Framework selection

Following the evaluation of these four frameworks, taking into consideration their key elements and functionality, the PARIHS framework was identified as being the most suitable for this study. The decision to use the PARIHS framework is predominately due to the following points that are central to this study;

1. Emphasis on high quality evidence – this is of particular importance within this study as a clinical guideline will be developed in order to test the elements of the PARIHS framework for cross cultural utility. As an integral part of the guideline development is the quality of the evidence and an assessment of this, the inclusion of evidence as a key component is pivotal as it is central to guideline development.

2. The prominence of context and culture within the framework – this is fundamental to this study as cultural translation of knowledge is a key element and therefore it is important that context and culture are acknowledged within the framework to be used. Therefore, whether culture and context are strong enough elements in the PARIHS framework will be ascertained.

3. An environment that is receptive to change and is promoted and supported by the presence of skilled facilitation (Rycroft-Malone et al., 2004 ). As the study focuses on the development of a clinical guideline, the receptiveness of the environment, in particular healthcare professionals, management and patients’ receptiveness to change is of importance in regards to the implementation of the guideline.

Thus as acknowledged by Ullrich et al (Ullrich et al., 2014) the three elements of context, facilitation and evidence are a reflection of the factors integral to knowledge

implementation and are therefore essential to this study.

In addition, the development of the PARIHS framework into a two stage process; stage 1 (evidence and context) produces data outputs which inform the intervention to be applied at stage 2 (facilitation) (Kitson Alison. L et al., 2008), suits the design of the study as the evidence will be presented within the context of Malta and discussion will be facilitated to create recommendations to be implemented.

41 With this in mind, it is important to note that this work uses the 2008 (Kitson Alison. L et al., 2008) version of the PARIHS framework. The reasons for this is are two fold; it was the most established version when work on this study commenced, it has been more

thoroughly tested and is shown to have both face and concept validity and conceptual integrity (Kitson Alison. L et al., 2008). The two versions that were developed following this, Rycroft Malone 2013 (Rycroft-Malone et al., 2013) and Harvey and Kitson 2016 (Harvey and Kitson, 2016), were developed post the commencement of this study. The i-PARIHS is a new iteration, recently published, by a sub-group of the original authors and for which these authors are currently requesting feedback (Harvey and Kitson, 2016).

The PARIHS framework (2008) will be used to guide the development of an evidence based clinical practice guideline and will be evaluated to ascertain whether it has cross cultural utility. The following points are a brief summary as to why the other three

model/frameworks were not chosen.

1. The OMRU is a practical model, targeted to a multidisciplinary audience, with an acknowledgement of culture under the key element of ‘practice environment’ i.e. context. However, the quality of evidence is assumed rather than being assessed. This latter component makes it less suitable when the quality of evidence is integral to the study.

2. The KTA can be used by a wide audience including the public, stakeholders, and multidisciplinary healthcare professionals. There is a strong emphasis on adaptation of information to the context, yet the quality of evidence is questionable. Again it is the lack of integrity regarding evidence quality that makes this framework less suitable. 3. The Stetler model was designed for clinical nurse specialists and project teams. It

includes a component referring to the ‘context’ and uses critical appraisal in the assessment of knowledge, yet overall it is prescriptive and complicated to use, not making it flexible enough for this study.

2.6.1

The contribution of this study

This study proposes to contribute to the literature on the use of the PARIHS framework in two areas. Firstly, it wishes to test the framework’s applicability for use in the adaptation of an evidence based clinical practice guideline. That is to say, it aims to see if the elements of the framework can inform the development of the guideline and extend to identifying the challenges and barriers of this process. Secondly, although the PARIHS framework has

42 been used internationally, this study wishes to explore its appropriateness for cultural translation and adaptation, thus testing the strength of the components of context and culture. Furthermore the opportunity will be taken to explore the interactions between the elements and the sub-elements and understanding whether each elements carries the same importance.

Following the review the research questions to be addressed are;

1. To explore the appropriateness and utility of the PARIHS framework, in the cultural translation and adaptation of an evidence based clinical practice guideline into clinical practice in the healthcare system in Malta2_.

2. To identify the challenges and barriers to successful cultural translation and

implementation to inform future cross cultural knowledge translation programmes. Central to this study is culture and the effect it has on the translation of knowledge into practice. Therefore the subsequent section is an exploration of culture, its breadth and complexity and relevance to the healthcare environment. As an outcome of this discussion, a definition of culture to be used in this study will be provided.