The inter-play between facilitation and context in the promoting action on research implementation in health services framework: A qualitative exploratory implementation study embedded in a cluster randomized controlled trial to reduce restraint in nursing homes

Aim: To explore the inter-play between external facilitation and nursing home contexts relative to intervention outcomes. Background: The Promoting Action on Research Implementation in Health Services framework is frequently used to theoretically inform implementation and research in nursing and recent reviews indicate high face validity for health services. However, the inter-play and relationship between framework sub-elements of evidence, context and facilitation and the prospective utility in non-English speaking contexts warrant further illumination. Design: In an overarching single-blind cluster-randomized controlled trial, we applied participatory action research and ethnography from August 2011-June 2015 to evaluate a standardized education intervention to reduce restraint and agitation in nursing home residents living with dementia. The trial results are published elsewhere. Methods: Prospectively informed by the PARIHS framework, a research team and eight facilitators participating in dual roles as action researchers designed, implemented, and evaluated the intervention. How contextual factors influenced the facilitation processes were explored in focus group interviews (1), reflection notes (84) written by the facilitators' after each education session, ethnographic field studies (6 homes), and co-analysis workshops (5). Directed content analysis was used to analyse data. Results: Clinical leaders taking roles of internal facilitator influenced the success of implementation, while complex and fluctuating context elements determined whether restraint use was reduced-or not. The PARIHS framework was found to be relevant in a non-English nursing home setting, albeit some elements merit further conceptualization. Conclusions: Our findings confirm the prospective utility of the PARIHS framework for implementation in a non-English context, particularly the notion of implementation processes as dynamic and multifaceted.