Section 4.1: Planned Action Theories
Ian D Graham
Jacqueline M Tetroe
KT Theories Group
KT Theories Group members
Doug Angus, University of Ottawa; Melissa Brouwers, McMaster University; Barbara Davies, University of Ottawa; Michelle Driedger, University of Manitoba; Martin Eccles, Newcastle upon Tyne; Gaston Godin, University of Laval; Ian D. Graham, seconded from University of Ottawa to the Canadian Institutes of Health Research , Jeremy Grimshaw, University of Ottawa; Karen Harlos, University of Manitoba, Margaret Harrison, Queen's University, Sylvie Lauzon, University of Ottawa; France Légaré, University of Laval; Louise Lemyre, University of Ottawa; Jo Logan, University of Ottawa, Jessie McGowan, University of Ottawa; Marie Pascal Pomey, University of Montreal; Nicole Robinson, Carleton University, Dawn Stacey, University of Ottawa; Jacqueline Tetroe, the Canadian Institutes of Health Research, Michel Wensing, University of Nijmegen.
Key Learning Points
- Data on the validity and transferability of planned action theories are limited.
- A planned action theory can focus implementation efforts and provide all stakeholders with a common script or understanding of the action plan.
What is a planned action theory and why do we care?
A planned change (prescriptive) theory:
- Is a set of logically interrelated concepts that explain, in a systematic way, the means by which planned change occurs;
- Predicts how various forces in an environment will react in specified change situations;
- Helps planners or change agents control variables that increase or decrease the likelihood of the occurrence of change.
Planned change, in this context, refers to deliberately engineering change that occurs in groups that vary in size and setting.
Classical theories of change
- Describe change but were not specifically designed to be used to cause or guide change in practice;
- Can be quite informative and helpful for identifying the determinants of change;
- Are passive; they explain or describe how change occurs;
- But – researchers, policy makers, and change agents tend to be more interested in planned change theories that are specifically intended to be used to guide or make a change.
- We undertook a focused literature search of the social science, education, management and health sciences literature.
- The literature search yielded 78 articles that were subject to data abstraction by two reviewers.
- Thirty one planned action theories were identified and subjected to a "theory analysis", which is a useful process for determining the strengths and limitations of theories and to determine similarities and differences between them.
Steps in a theory analysis:
- Determine the origins of the theory (i.e. Who developed it? Where are they from? What prompted the originator to develop it? Is it inductive or deductive in form? Is there evidence to support or refute the development of the theory?).
- Examine the meaning of the theory (what are the concepts and how they relate to each other?).
- Analyze the logical consistency of the theory (Are there any logical fallacies?).
- Define the degree of generalizability and parsimony of the theory.
- Determine the testability of the theory.
- Determine the usefulness of the theory.
Description of the theories
- The 31 theories identified by our search were published between 1983 and 2006. Of these, 16 were interdisciplinary, 6 were from Nursing, 2 were from Medicine, 2 from Social Work, and one each were from HIV/AIDS Prevention, Occupational Therapy, Family Planning, Health Education and Health Informatics literature.
- The intended foci for these theories were:
- Social work;
- The theories were most commonly derived from the literature, followed by research, or the experience of the originators.
- Most (21/31) of the identified theories have not yet been tested empirically.
- The model by Graham and Logan has demonstrated face and content validity through use in a number of unpublished studies and implementation projects.
- Same is true for Green's model, which was used to conduct systematic baseline-diagnostic interviews with asthma patients treated in the emergency room or as outpatients.
We examined all of the components in each of the theories in order to determine commonalities and to develop a framework to compare the focus of each of them. This sifting exercise resulted in 10 action steps with some steps having sub actions and each theory could then be analyzed as to whether or not it addressed each action category.
The 10 Action Steps
- Identify a problem that needs addressing (n=19)
- Identify the need for change (n=22)
- Identify change agents (i.e. the appropriate actors to bring about the change) (n=15)
- Identify target audience (n=13)
- Link to appropriate individuals or groups who have vested interests in the project (n=15)
- Review the evidence or the literature (n=21)
- Adapt the evidence and/or develop the innovation (n=11)
- Assess barriers to using the knowledge (n=18)
- Select and tailor interventions to promote the use of the knowledge (n=26)
- Implement the innovation (n=22)
- Develop a plan to evaluate use of the knowledge (n=14)
- Pilot test (n=11)
- Evaluate the process to determine whether and how the innovation is used (n=19)
- Evaluate the outcomes or impact of the innovation (n=20)
- Maintain change- Sustain ongoing knowledge use (n=11)
- Disseminate results of the implementation process (n=7)
Observations / Conclusions
- No theory included all of the action steps and no action step was included in all of the theories.
- Some theories focus more on evaluation, for example, others on identification of the problem and their barriers to implementation.
- In choosing a planned action theory to guide implementation efforts, we would advise careful review of the component elements and how they have been coded into action categories and determine which theory is the best fit for the context and culture in which you are working.
Regardless of the selected theory (or whether you choose to use the list of action categories as a kind of "meta-theory") documenting experiences with the model will advance understanding of its use and provide information to others who are attempting a similar project.
- Planned action theories need to be tested empirically to be useful.
- More research is needed to determine the relative advantage of one theory over another.
- Research is needed to determine which elements of the planned action theories are important under what circumstances.
- Theory driven implementation can further the study of knowledge translation by providing a framework in which we can:
- understand the change process;
- see which implementation components were successful and which were not.
- For each action category in the knowledge to action cycle, there could be a host of theories from multiple disciplines to draw on for guidance.
List of Identified Planned Action Theories
- Ashford J, Eccles M, Bond S, Hall LA, Bond J. Improving health care through professional behaviour change: introducing a framework for identifying behaviour change stragegies. British Journal of Clinical Governance 1999;4(1):14-23.
- Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Intervention mapping: Designing theory and evidence-based health promotion programs. California: Mayfield Publishing Company; 2001.
- Benefield LE. Implementing evidence-based practice in home care. Home Healthc Nurse 2003 Dec;21(12):804-9.
- Craik J, Rappolt S. Theory of research utilization enhancement: a model for occupational therapy. Can J Occup Ther 2003 Dec;70(5):266-75.
- Dearing J. Improving the state of health programming by using diffusion theory. Journal of Health Communication 2004;9:21-36.
- DiCenso A, Virani T, Bajnok I, Borycki E, Davies B, Graham I, et al. A toolkit to facilitate the implementation of clinical practice guidelines in healthcare settings. Hosp Q 2002;5(3):55-60.
- Dixon DR. The behavioral side of information technology. Int J Med Inform 1999 Dec;56(1-3):117-23.
- Doyle DM, Dauterive R, Chuang KH, Ellrodt AG. Translating evidence into practice: pursuing perfection in pneumococcal vaccination in a rural community. Respir Care 2001 Nov;46(11):1258-72.
- Dufault M. Testing a collaborative research utilization model to translate best practices in pain management. Worldviews on Evidence-based Nursing 2004;1(S1):S26-S32.
- Feifer C, Ornstein SM. Strategies for increasing adherence to clinical guidelines and improving patient outcomes in small primary care practices. Joint Commission Journal on Quality & Safety 30(8):432-41, 2004 Aug.
- Fooks C, Cooper J, Bhatia V. Making research transfer work: Summary report from the 1st National Workshop on Research Transfer Issues, Methods and Experiences. Toronto: ICES, IWH,CHEPA; 1997 Feb.
- Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can J Nurs Res 2004 Jun;36(2):89-103.
- Green LW, Kreuter MW. Health promotion planning: An educational and ecological approach. 3 ed. Mountain View, CA: Mayfield Publishing Company; 1999.
- Grol R, Grimshaw J. Evidence-based implementation of evidence-based medicine. Joint Commission Journal on Quality Improvement 1999;25(10):135-40.
- Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004 Mar 15;180(6 Suppl):S57-S60.
- Herie M, Martin GW. Knowledge diffusion in social work: a new approach to bridging the gap. Soc Work 2002 Jan;47(1):85-95.
- Hickey M. The role of the clinical nurse specialist in the research utilization process. Clinical Nurse Specialist 4(2):93-6, 1990.
- Hyde PS, Falls K, Morris JA, Schoenwald SK. Turning knowledge into practice. Boston: The Technical Assistance Collaborative Inc.; 2003.
- Kraft JM, Mezoff JS, Sogolow ED, Neumann MS, Thomas PA. A technology transfer model for effective HIV/AIDS interventions: science and practice. AIDS Educ Prev 2000;12(5 Suppl):7-20.
- Lavis JN, Robertson D, Woodside JM, McLeod CB, Abelson J. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q 2003;81(2):221-2.
- Lundquist G. A rich vision of technology transfer: technology value management. Journal of Technology Transfer 2003;28:265-84.
- Motwani J, Sower VE, Brashier LW. Implementing TQM in the health care sector. Health Care Manage Rev 1996;21(1):73-82.
- Moulding NT, Silagy CA, Weller DP. A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. Qual Health Care 1999;8:177-83.
- National Health and Medical Research Council. How to put the evidence into practice: implementation and dissemination strategies. Canberra: Commonwealth of Australia: National Health and Medical Research Council; 2000.
- Pape TM. Evidence-based nursing practice: to infinity and beyond. J Contin Educ Nurs 2003 Jul;34(4):154-61.
- Proctor EK. Leverage points for the implementation of evidence-based practice.
- Roberts-Gray C, Gray T. Implementing innovations: a model to bridge the gap between diffusion and utilization. Knowledge: Creation, Diffusion, Utilization 1983;5(2):213-32.
- Rosswurm MA, Larrabee JH. A model for change to evidence-based practice. Image J Nurs Sch 1999;31(4):317-22.
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