The Action Cycle represents activities or actions required for effective implementation of knowledge. The seven phases of the cycle are not sequential. To address a KT issue, one can start at any phase, and can also move between the phases of knowledge creation and the action cycle.

Identify problem/ Determine the know/do gap/ Identify, review, select knowledge refers to identifying a problem that should be addressed; this may involve comparing what the current practice is, with what should be in place, in order to determine a gap that ought to be closed. Resources for identifying a problem or gap:

Determining quality:

  • Appraisal of Guidelines for Research and Evaluation (AGREE) tools
    • Used for the development, reporting and appraisal of clinical practice guidelines and health systems guidance documents
    • Website: https://www.agreetrust.org/

Adapt knowledge to local context refers to adapting the knowledge to a particular setting, taking into consideration the population, available resources, political climate, etc. Resources for adapting guidelines:

  • CAN-IMPLEMENT
    • Interactive planning resource
    • Developed in response to barriers and facilitators experienced by Canadian cancer care groups engaging in guideline adaptation using the ADAPTE process
    • Article describing the development of Can-Implement: Harrison MB, Graham ID, van den Hoek J, Dogherty EJ, Carley ME, Angus V. Guideline adaptation and implementation planning: a prospective observational study. Implement Sci. 2013;8:49.
    • Available for purchase here: https://www.nursingcenter.com/evidencebasedpracticenetwork/canimplement.aspx?id=1917711

Assess barriers/facilitators to knowledge use refers to identifying potential barriers and facilitators to using/implementing knowledge.

Methods for assessing barriers and facilitators:

  • Surveys
  • Focus groups
  • Interviews
  • Observations
  • Review of records

Resources/tools for assessing barriers and facilitators:

  • Theoretical Domains Framework (TDF)
    • Comprehensive, theory-informed approach for identifying determinants of behaviour
    • 33 theories relevant to implementation were identified and grouped into domains to create the original version of the TDF
    • Validation assessment resulted in an updated version of the TDF that consists of 14 domains
    • Article describing the development of the original framework: Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26-33.
    • Article describing the validation evaluation and presenting the revised framework: Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.
    • Article to help guide application of the TDF: Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.
  • Consolidated Framework for Implementation Research (CFIR)
    • Framework used to guide development and adaptation of health-related interventions
    • Consists of constructs across five domains: intervention characteristics, outer setting, inter setting, characteristics of individuals, and process; individuals assess whether constructs will hinder or support implementation success in a particular setting
    • Various tools are available on the CFIR website: https://cfirguide.org/tools/
    • Article describing the development of the framework: 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. Implement Sci. 2009;4:50.
    • Systematic review assessing use of the CFIR and providing recommendations for future use: Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72.
  • BARRIERS to research utilization scale
    • 29-item scale to assess clinicians’ and administrators’ perceptions of barriers to research use in practice
    • Used extensively in nursing
    • Permission to use: http://barriers.web.unc.edu/distribution/permission/
    • Article describing development and assessment of the scale: Funk SG, Champagne MT, Wiese RA, Tornquist EM. BARRIERS: the barriers to research utilization scale. Appl Nurs Res. 1991;4(1):39-45.
    • Systematic review evaluating the usefulness of the scale: Kajermo KN, Bostrom A, Thompson DS, Hutchinson AM, Estabrooks CA, Wallin L. The BARRIERS scale-the barriers to research utilization scale: a systematic review. Implement Sci. 2010;5:32.
  • Promoting Action on Research Implementation in Health Services (PARiHS) Framework
    • Framework to inform implementing research into practice
    • Examines interactions between three factors that inform research use: evidence, context and facilitation
    • Article introducing and describing the framework: Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care. 1998;7(3):149-58. (https://qualitysafety.bmj.com/content/7/3/149)
    • Review assessing the framework’s practicality and challenges with its use: Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci. 2008;3:1.
  • Alberta Context Tool (ACT)
    • 56-item survey, to measure organizational context; informed by the PARiHS framework
    • Intended to support implementation of interventions in busy clinical or public health settings
    • Request access here: https://trecresearch.ca/alberta_context_tool
    • Article describing the development and assessment of the tool: Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton PG. Development and assessment of the Alberta Context Tool. BMC Health Serv Res. 2009;9:234.

Select, tailor, implement interventions refers to planning and implementing an intervention. Resources for selecting, tailoring the implementing interventions:

  • Expert Recommendations for Implementing Change (ERIC) Tool
    • This Matching Tool was developed to guide users in choosing implementation strategies based on the results of a CFIR context assessment
    • Available on CFIR website: https://cfirguide.org/tools/
  • Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework
  • Standards for Reporting Implementation Studies (StaRI)
    • The 27-item StaRI checklist can help to assess suggested implementation strategies and interventions
    • Publication reference: Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ et al. Standards for reporting implementation studies (StaRI): explanation and elaboration document. BMJ Open. 2017;7.
  • Relevant article: Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57(4).
  • Relevant article: Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterizing and designing behaviour change interventions. Implement Sci. 2011;6:42.
  • CIHR webpage, “Selecting, Tailoring and Implementing KT interventions”: http://www.cihr-irsc.gc.ca/e/43793.html

Monitor knowledge use refers to tracking and recording uptake of the KT intervention. Examples of monitoring include observation and active measurement.

Evaluate outcomes refers to measuring whether the KT intervention is positively influencing the desired outcomes. Resources for evaluation:

Sustain knowledge use refers to maintenance of intervention activities to sustain the desired outcomes. Resources regarding sustainability of knowledge use:

  • National Health Service (NHS) Sustainability Model and Guide
  • Dynamic Sustainability Framework
    • Proposes continued learning and problem solving, ongoing adaptation of interventions, and expectations for ongoing improvement
    • Article: Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Impl Sci. 2013;8:117.
  • Relevant article: Wiltsey Stirman S, Kimberly J, Cook N, Calloway A, Castro F, Charns M.  The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci. 2012;7:17.