Understanding the rollercoaster of contextual influences on the spread of practices

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Within our Implementation Science Group at PenCLAHRC, we’ve been exploring how evidence-based practices implemented in one hospital can be spread to other departments or hospitals in the South West of England. In theory, this sounds simple. Why wouldn’t other places make improvements to care found to work well elsewhere? In actual practice, as quite often can be the case, the experience was not quite so straightforward. So, we sought to study in real-time how context can critically influence the spread of practices – helping in some places and hindering in others.

Working with the South West Academic Health Science Network (SW AHSN), we studied, using qualitative methods, two collaborative projects seeking to spread improvements to healthcare in acute settings: the emergency treatment of acute ischaemic stroke (also involving the South West Cardiovascular Strategic Clinical Network) and the implementation of Patient-Initiated Clinics. We wanted to understand how the differences in context within six hospitals (for acute ischaemic stroke) and three departments in one hospital (for Patient-Initiated Clinics) influenced progress in the spread of these particular practices in healthcare.

To help us explore the influence of context we were informed by one of the many frameworks available in the field of implementation science: the Consolidated Framework for Implementation Science (Damschroder et al 2009). This offered us a taxonomy to develop insights into the factors present and influencing, positively or negatively, the spread of these evidence-based practices. Three of the domains were particularly useful for considering contextual factors: the outer setting, inner setting and the characteristics of individuals.

For the spread of stroke treatment improvements and the Patient-Initiated Clinics intervention, our analysis highlighted the following important contextual influences.

At the macro-level of context (e.g. focus on patients, national and regional influences) we found these influences playing a role:

  • Whether there was competitive pressure to improve as other organisations/teams had already done so.
  • Whether patients’ needs were known, and prioritised, and if implementing the new practices was viewed as beneficially meeting their needs.
  • An absence of national and regional incentives and policies to drive/support uptake.

We found the most influential factors occurred at the meso-level context (e.g. organisation, department and team) and included:

  • Whether the change to practice was a viewed as a priority or strongly needed by each organisation/department.
  • How ready for change was each organisation or department. Particularly if there were skilled and engaged leaders, a stable team, and the available resources (i.e. money, space, and time).
  • Whether, in each setting, could attract, involve and engage key individuals and locate a champion to act as a catalyst/driver for spreading the practice locally.
  • An ability to be flexible (i.e. about timescales and approach) and persist in response to barriers encountered within each organisation/department.

And we found these influences at the micro-level of context (e.g. key individuals within a setting):

  • What key individuals know of and believe about an improvement and intervention.
  • The perceived value key individuals placed on making a change to current practice.

From our work, we generated lessons in the form of questions. These may help to identify contextual factors that could influence future efforts to spread evidence-based practices. We note a need to consider how differing contextual factors and levels interact with each other.

We also identified other factors that influenced uptake. How key people viewed the strength of evidence underpinning the change, and the benefit of external support from university-researchers and, for the stroke project, a quality improvement manager. We identified some challenges too. For example, how to ensure the sustainability of improvements and interventions over time so they become routine healthcare practice.

One of our main lessons was for those involved in spreading these practices to be prepared for hard work and expect the unexpected. So, it’s a bit like being on a rollercoaster! This makes sense when we consider each healthcare setting will have their own demands and complexities that impact on the uptake of improvements and interventions. We will be working with the SW AHSN on how we can build on these lessons to influence future efforts to spread practice. To read more about our study, here’s our project page.


Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science. 2009;4:50. doi:10.1186/1748-5908-4-50

Pfadenhauer L, Rohwer A, Burns J, Booth A, Lysdahl KB, Hofmann B, Gerhardus A, Mozygemba K, Tummers M, Wahlster P, Rehfuess E. Guidance for the Assessment of Context and Implementation in Health Technology Assessments (HTA) and Systematic Reviews of Complex Interventions: The Context and Implementation of Complex Interventions (CICI) Framework [Online]. 2016. http://www.integrate-hta.eu/downloads

The Health Foundation. Perspectives on context: a selection of essays considering the role of context in successful quality improvement. London: The Health Foundation. 2014. health.org.uk/sites/health/files/PerspectivesOnContext_fullversion.pdf