Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review.

BACKGROUND: Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.
METHODS: We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.
RESULTS: Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.
CONCLUSIONS: We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

This study provides a comprehensive scoping review of a diverse literature of facilitator roles and characteristics of facilitation from various disciplines.

Arksey and O’Malley’s (2005) framework was used to guide the scoping review process.

Grey literature was not included, nor did we conduct a quality appraisal of included studies as this is not part of a scoping review undertaking, and this may introduce the potential for publication bias. However, the scoping review enabled us to synthesise the breadth of literature that characterises the quantity, nature and extent of research evidence on facilitation and the roles undertaken to facilitate the uptake of evidence.

Introduction

Scholars describe the potential for evidence-based decision making to have a positive impact on patient outcomes.1 Implementing evidence (ie, research findings) into practice is a complex, multifaceted process that requires a proactive effort to encourage use at the point of decision making.2–4 Multilevel factors influence this implementation5; some of these include individual (eg, education, attitude),6–8 organisational/contextual,9–14 system14 and innovation-specific factors.15 Several knowledge translation (KT) theories exist that can be used to guide the process of getting research evidence into practice.16 In their Promoting Action on Research Implementation in Health Services (PARiHS) framework, Kitson and colleagues17 highlighted the importance of facilitation that, along with strong evidence and a context supportive of change, can lead to successful research implementation. Facilitation is a technique where an individual makes things easier for others, by providing support to help them change their ways of thinking and working.17 In their refined integrated framework i-PARiHS, facilitation is an active element that integrates the other core constructs: innovation, recipients and context.18

In the healthcare literature, a small body of conceptual work on facilitation has considered it a promising approach to implementing evidence into practice.17–21 Facilitation has evolved from a concept in the education and counselling literature22 to an implementation intervention in the healthcare and KT literature3 4 20 and has recently been situated in the organisational learning theory literature.23 The literature on facilitation roles and characteristics is growing.19 Thompson and colleagues delineated the similarities and differences between five roles that aim to influence a practice or behaviour change: opinion leader, facilitator, champion, linking agent and change agent, noting much ambiguity remains among these roles.24 Harvey and colleagues explored the purpose, roles, skills and attributes of facilitators, suggesting that the concept of facilitation is only partially developed.20 Dogherty et al updated Harvey et al’s20 literature review and reported that, in addition to facilitation as role and process, project management and leadership were important components of facilitation.19

Two reviews have been conducted specifically on practice facilitation, also described as outreach facilitation, where facilitators assist primary care physicians with research implementation and quality improvement projects.25 26 These studies found that practice facilitators were effective in improving practice processes and patient care outcomes,25 and primary care physicians were almost three times more likely to adopt evidence-based guidelines with practice facilitation.26 Although some preliminary evidence supports practice facilitation as an effective intervention to implement evidence into practice, facilitation as a construct requires further development and testing for its effectiveness in improving outcomes.

Implementation methods—such as facilitation—can be viewed as practice innovations. Rogers defined an innovation as an idea or practice that is perceived as new by an individual.15 He described five main attributes of an innovation: (1) relative advantage—the perception that an innovation is better or more beneficial than existing practice; (2) high compatibility—the perception that the innovation is consistent with existing values, beliefs and needs; (3) low complexity—the perception that the innovation is easy to understand and use; (4) trialability—the opportunity to try the innovation before making a decision about its adoption; and (5) observability—the extent to which the effects of the innovation are observed and communicated to others.15 Innovations with all of these qualities tend to be adopted more rapidly than other innovations.15

By treating facilitation as an innovation and healthcare providers as potential adopters, we can better understand how the roles and characteristics of facilitation may contribute to successfully implementing research into practice. Our review complements and extends the review by Dogherty et al27 which explored elements of facilitation based on an existing systematic review of the effectiveness of interventions to increase the use of practice guidelines in nursing. Our study adds to the evidence base on facilitation by describing the various roles and the characteristics of facilitation from the healthcare and management literature in the context of healthcare professionals that includes practice guidelines and other forms of research use, and the roles undertaken to facilitate the uptake of evidence. The research questions guiding this scoping review were:

What are the key facilitator roles identified in the literature?

What characteristics of facilitation contribute to research use by healthcare professionals?

Methods

We conducted a scoping review of the literature using Arksey and O’Malley’s framework to guide our review.28 Their scoping review framework has five stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarising and reporting the results; and an optional stage of a consultation exercise with stakeholders.28 We searched the following 10 electronic databases from the healthcare and management literature: ABI Inform (1970–2016), Business Source Complete (1886–2016), CINAHL (1982–2016), Cochrane Library (2003–2016), EBMR (1991–2016), Embase (1980–2016), Medline (in process and other non-indexed citations) (1950–2016), PsycINFO (1806–2016), Scopus (1960–2016) and Web of Science (1900–2016). We developed our search strategy with a research librarian who constructed expert searches tailored to each of the databases searched (box 1). Key terms and final search strategies were refined based on initial search results. For example, because our initial search revealed a large number of articles we decided not to search grey (unindexed) literature such as conference proceedings, dissertations, editorials and government reports. We manually searched reference lists of included papers to identify additional studies.

(facilitator* or facilitative or facilitation).tw.

facilitat*.ti. or reminder systems/

(academic detail* or educational outreach worker* or opinion leader* or change agent* or champion* or linking agent* or promotor* or knowledge broker* or enabler* or enabling or boundary spanner* or coach*).tw.

or/1–3

evidence-based practice/ or evidence-based dentistry/ or evidence-based medicine/ or evidence-based emergency medicine/ or evidence-based nursing/

(ebp or ebm or ebn or cpg* or best practice*).tw.

(evidence adj2 practice*).tw.

(guideline* adj2 (implement* or adher*)).tw.

guideline adherence/ or quality assurance, health care/ or benchmarking/ or guidelines as topic/ or practice guidelines as topic/

(quality adj1 (improv* or manag*)).tw.

‘diffusion of innovation’/ or technology transfer/

(research adj2 (‘use’ or utili?* or adopt* or implement* or disseminat* or uptake or transfer* or translat* or support)).tw.

(knowledge adj2 (‘use’ or utili?* or adopt* or implement* or disseminat* or uptake or transfer* or translat* or support)).tw.

(evidence adj2 (‘use’ or utili?* or adopt* or implement* or disseminat* or uptake or transfer* or translat* or support)).tw.

(innovation adj2 adopt*).tw.

or/5–15

4 and 16

facilitat*.mp.

18 not 17

‘outcome and process assessment (health care)‘/ or ‘outcome assessment (health care)‘/ or treatment outcome/ or ‘process assessment (health care)"/

quality assurance, health care/ or benchmarking/

Quality Control/

‘Delivery of Health Care’/og [Organization & Administration]

og.fs.

or/20–24

19 and 16 and 25

17 or 26

(comment or editorial or letter or news or newspaper article).pt.

27 not 28

Selection criteria

We included conceptual papers and empirical studies both quantitative and qualitative that met the following criteria: (1) facilitator roles, characteristics, facilitation processes and/or interventions were described; (2) facilitation focused on healthcare providers; and (3) facilitation focused on research use in practice. We excluded: non-English literature;* study protocols; articles that focused solely on facilitation directed towards patients; articles focused solely on computerised/automated reminder systems or decision support systems.

Selection process

Three team members independently screened one-third of the references for inclusion. Because of the volume of search results, we first excluded references based on irrelevant titles and abstracts. Approximately 10% of articles were screened together for training and reliability. The team met periodically prior to and during screening to ensure consistency between reviewers.

Data charting

We developed a data dictionary detailing information to collect, for consistency between reviewers throughout charting. Each reviewer was assigned one-third of the included articles and extracted the following data elements: citation, purpose, theoretical framework, study design/method, sample and setting, description of facilitation role, characteristics, process and/or intervention. We did not appraise the quality of data extracted as the aim of the scoping review was to identify facilitator roles and characteristics of facilitation from the literature.

Data analysis and synthesis

We conducted a content analysis of extracted data to identify facilitator roles and characteristics of facilitation. Next, we conducted a thematic analysis using extracted data to further identify characteristics of facilitation. Because we conceptualised facilitation as an innovation, in the final analytical step, we used Rogers’ attributes of an innovation as a framework to first sort and then to synthesise within each category our identified characteristics of facilitation.15 We did not report literature review papers that included studies cited in our scoping review in our roles or attributes results tables to avoid duplication.

Stakeholder consultation

We consulted with stakeholders early in analysis to inform and validate findings.28 Our decision-maker partner (CC) arranged for two study team members to meet with seven regional managers from a large healthcare organisation for feedback on the identified facilitator roles. These managers provided feedback on understandability, meaningfulness, and usefulness and relevance to practice of the facilitator roles.

Results

Our searches found a combined total of 38 488 references (table 1). After removing duplicates and adding 18 articles from our manual search, we screened 26 593 articles and identified 791 as potentially relevant. Of these, 195 met our selection criteria and were included in our review (figure 1). We report characteristics of included studies (see online supplementary file 1), followed by facilitator roles (table 2) and characteristics (attributes) of facilitation (table 3).

Table 1

Search results

Database	Search results
ABI Inform	1710
Business Source Complete	2100
CINAHL	2539
Cochrane Library	2
EBMR Central	161
Embase	10 453
Medline including Medline in process	7777
PsycINFO	3278
Scopus	5661
Web of Science	4807
Total	38 488

Figure 1

Screening process.

Table 2

Results: facilitator roles, n=150 articles

	Facilitation
	Internal					External			External-internal
	Informal	Formal
	Opinion leader	Coach	Champion	Facilitator			Boundary spanner
				Research facilitator	Clinical/practice facilitator[†]	Outreach facilitator	Linking agent	Knowledge broker	External-internal facilitators
Definition	A peer-nominated individual who informally influences individuals’ attitudes, professional behaviour, decision making, research use, clinically and educationally using their professional status to drive change	An individual who assists with making behaviour changes to improve performance and/or to use EBP through motivation, encouragement and positive reinforcement	A local visionary who uses expert knowledge to persuade others to adopt an innovation, idea or project	An individual who provides support to staff to strengthen their research skills and knowledge, and participation in research in a clinical setting	An individual who provides continuous (primarily) local assistance to others through a formal implementation process using peer support (eg, formal/informal education, shared learning and being a resource person)	Individuals external to the target organisation and/or practice (typically primary care) trained to assist others to improve performance (eg, uptake guidelines) through a formal implementation process using educational visits/AD/CQI	Individuals acting as intermediaries to span the boundary between research and practice to bring closer collaboration between the two systems	Intermediaries who build relationships between two communities, typically policymakers/decision makers and researchers, by sharing their expert knowledge and establishing communication channels	External facilitators (those external to the setting/off site) provided ongoing support to local facilitators implementing a practice change (eg, guidelines)
Key roles	Educationally influential about EBP35 36 42 61 63 65 110 142 180 188–190 Exert informal influence on individuals’ attitudes, behaviours and decision making60 61 68 180 191 Use professional status to drive change67	Provide feedback about research use76 138 192 Provide encouragement/motivation, positive reinforcement to use EBP75 76 Planning and goal setting73 193 Assist others with learning process73–75 192 Role model76 Build relationships73 76 138	Persuade others to adopt an innovation, idea or project37 40 44 46 48 77–79 133 136 143 150 153 159 170 184 194 Advocate change44 77 133 135 147 150 151 153 170 184 195 196 Motivate others52 153 159 163 194 197 198 Personal commitment to the project37 46 59 147 150 164 195 199	Facilitate research in a clinical setting39 80–83 158 160 161 177 182 200 201 Provide educational sessions about the research process39 80 81 161 182 Strengthen research skills of clinical staff39 80–82 Provide peer support for participation in research activities39 80–83 158 160 161 182 200 201 Establish local research programmes, committees/workshops/steering group80 160 182	Practice based30 32 45 51 84–95 98 99 101 134 137 140 141 152 169 173 202 203 Assess local needs for research use94 137 140 Identify modifiable barriers to change137 141 Identify resources for change30 137 140 141 152 Provide education, peer support, shared learning30 32 45 51 84–101 Monitor and evaluate practice change30 87 97 137 202 Serve as an ongoing resource person45 89 91 95 97 140 152 202 Some practice facilitators were external30 32 88 89 91 92 96 97 101 134 173	Guideline implementation/care delivery via educational outreach/AD visits (typically face-to-face)26 69 102–120 145 175 or CQI47 69 102 103 105 157 165 204 Provide feedback and support47 103 105 108 109 111 112 118 120 204 Provide audit and (performance) feedback102–106 115 117 145 175 Provide information/resources to promote uptake of best practice47 103 108 109 111 112 114 117 119 120 Build good working relationship between staff and facilitator112 145	Link research to practice29 123 Help bring together two systems24 29 Intermediary29 121 123 Help maintain links across professional, team, organisational boundaries122 123 Communicate information122 Help build relationships and networks for research-based change122 123	Intermediary between researchers and policymakers,124 125 128 decision makers/other stakeholders Catalyst for system change125 Promote research use in decision making43 125 126 128 171 205 Build networks,128 205 relationships of trust125 Facilitate learning and exchange of knowledge124–126 205 Establish communication channels124 125 128 Conduct environmental scan/needs assessment43 125 Knowledge management, capacity building, linkage and exchange activities128 171	External facilitators provided ongoing support (eg, guidance, assistance, being available) to internal facilitators41 49 56 57 129 130 Information sharing49 56 57 129 Build relationships57 Build capacity for improvement/change49 130
Training	Not trained for role42 60–67 142 190	May be trained for role75 138 or may not be trained for role192 193	May be trained for role37 46 48 133 135 206 or may not be trained for role52 59 163 164 194 195 199	Trained for role82	Trained for role30 32 93 94 98 100 134 137 140 178 202	Typically trained for role47 69 102–107 111 112 114 117–120	Trained for role24	Not trained for role,43 125 however, optimal training remains unknown43 and training needs may vary by setting171	External facilitators trained internal facilitators129
Key attributes and skills	Peer nominated42 60–68 Influential35 42 60 62 69 207 Credible/trustworthy62 68 Clinical knowledge/experience42 63 69–71 Role model180 Communication skills60 68 156 180	Negotiation skills73 193 Problem-solving skills73 76 Active listening and communication skills76 193 Leadership skills76 192	Expert knowledge of innovation40 52 164 179 199 Persuasive37 40 136 143 159 Mentorship skills77 135 143 153 179 Visionary37 163 Enthusiasm151 198 199 Creativity37 Driven151 and passionate about their work206 Communication skills40 59 159 208	Expert research knowledge/experience39 81–83 158 160 177 182 200 201 Leadership skills80 158	Expert knowledge in work area/clinical work experience30 45 84 86 87 90 91 93 94 98–101 140 141 152 Communication skills93 95 137 Credibile141 Empowering leadership style141 Reciprocal relationships between leaders (eg, managers) and facilitators203	Experienced/skilled practitioners (eg, physicians, nurses)26 69 102–105 112 119 175 204 Experience in management/business or health administration103 104 Knowledge­able112 204 Encourage others/provide positive reinforcement104 109 112 Approachable, flexible and available112 Credible112 204 Communication skills107	Strong critical thinking skills29 Strong interpersonal and communication skills29 Clinical credibility and research knowledge29	Expertise in both communities/cultures (research and policy)43 125 Skilled in interpretation/tailoring and application of knowledge43 124 125 Collaboration/networking skills124 Motivational skills43 Communication skills124 125 205	Organisational skills56 57 Relationship skills56 57 Communication skills56 57 Leadership skills56 57

AD, academic detailing; CQI, continuous quality improvement; EBP, evidence-based practice.

Table 3

Results: characteristics (attributes) of facilitation, n=133 articles

Rogers’ attribute of an innovation	Characteristics of facilitation	Illustrative examples from the literature
Relative advantage	Facilitation could be considered advantageous because it is described in the literature as a process for making change easier for others by: (1) encouraging assessment of current practice, (2) presenting ideas to others, (3) creating useful communication networks, and (4) providing support and resources to achieve goals	Encourages assessment of current practice Encourages the assessment of current practice/performance gaps4 32 101 140–142 Helps others understand gaps between the knowledge and practice of the target audience36 171 Helps individuals and teams to understand what they need to change and how they need to change it in order to apply evidence into practice17 101 145 146 Facilitation occurs in the context of a recognised need for improvement (eg, supports best practice)4 56 77 143–145 Presents ideas to others Introduces the existence of desirable new ideas and enhances the knowledge base about new ideas48 67 78 79 148 Creates useful communication networks Facilitates effective communication56 57 159 205 Establishes/navigates communication channels4 60 128 152 Networks with other health professionals about best practices143 180 205 Provides support and resources to achieve goals Facilitator as ongoing support or resource4 30 41 48 49 56 57 78 86 92 94 95 133 141 142 147–156 Offers or identifies resources to assist with the process of change32 33 44 78 142 151 156 190 198 Monitors progress.56 57 111 147 Builds organisational support for new practices151 157 Provides structure for learning33 Supports a goal-oriented process4 118
Compatibility	A key purpose of facilitation is to make change more compatible with existing practice. There are several characteristics of facilitation that promote compatibility with existing practice including: (5) mobilising existing knowledge and skills, (6) enhancing staff readiness for change and empowering staff, (7) supporting/promoting a culture for change, and (8) tailoring facilitation activities to local context, needs and circumstances	Mobilising existing knowledge and skills94 Enhances staff readiness for change; empowers staff Increases perceptions of professional acceptability and subjective norms35 Enables individuals and teams to analyse, reflect and change their own attitudes, behaviours and ways of working3 66 Facilitator belief that the change is needed59 76 Facilitator framed knowledge so that it was relevant to staff practice158 Empowers staff to be equal participants95 121 141 159 Supports and promotes a culture for change; creates a supportive climate; creates a vision for research use/evidence-based practice Creates a local climate in which research activities are encouraged128 130 160 Creates a culture to sustain the implemented change40 44 45 75 128 130 144 145 161 165 Addresses and develops organisational systems20 and infrastructure to facilitate success of the innovation148 153 Facilitator must understand the practical realities of healthcare and clinical settings99 164 Helps others make choices based on their own context134 Addresses individual concerns and helps others to change behaviour through the provision of information or evidence66 Creates and supports an organisational vision for evidence-based practice62 163 Tailors facilitation activities to local context, needs and circumstances Facilitator helps the group to consider and address the local issues that might negatively affect the use of the recommendations166 Facilitation activities tailored to local context, needs and circumstances49 50 56 61 75 103 142 150 165–171
Complexity	Facilitation can assist others with the implementation process. Facilitation capitalises on existing skills and (9) supports the development of new knowledge and skills, (10) requires facilitators to be trained or have experience with this role, (11) may comprise several strategies, and (12) is described as a bidirectional process that fosters relationship building	Supports the development of new knowledge and skills Supports the development of new knowledge and/or skills45 68 78 79 94 99 108 114 126 128 150 156 165 170 171 181 191 196 208 Helps staff to learn to access and/or appraise evidence to answer clinical questions and apply it to their practice21 52 83 122 161 200 Assesses and meets staff learning needs70 201 Guides the learners33 Facilitator training Ongoing support for the facilitator role18 48 56 57 82 94 129 209 Facilitators require training*32 37 46–48 68 69 102–107 118–120 129 133–139 Facilitators are experienced mentors,75 90 140 153 and must have a basic knowledge of the problems experienced by staff101 119 141 175 194 206 210 More than one facilitator (champion) was needed when an improvement required people to change behaviours151 Multiple components Use of multiple strategies (eg, reminders and a nurse facilitator)47 48 84 142 185 (eg, opinion leader education and audit and feedback)63 Bidirectional process Facilitation is proactive and dynamic211 Facilitation drives a process of change19 30 56 130 141; a two-way process of communication, building relationships/reciprocal relationships,203 and mutual goals and opportunities4 An iterative process in which the next step is informed by the conditions preceding it74 Flexible and purposeful4 A process of interactive problem solving4 56 73 Internal/external facilitation or a combination thereof3 17 18 20 21 49 146 176† Enabling approach3 4 20 21 146 176
Trialability	The literature provided some examples of facilitation interventions that were pilot tested on a small scale prior to full implementation	Pilot test; feasibility studies46 90 103 105 118 138 149 150 163 174 177–179
Observability	Observability reflects whether one can see the results of facilitation, that is, observing an individual using research as a result of facilitation. Observable characteristics of facilitation identified in the literature were: (13) facilitators encouraging others to role model the change (use of research evidence) and (14) maintaining momentum by reinforcing change	Role models the change33 45 56 68 78 86 99 126 180–182 Maintains the momentum and encourages/motivates staff in the process33 86 139 152 153 181 194 198 203 by reinforcing the change/75 108 109 184and supporting sustainability18 27

*Intervention studies.

†Theoretical literature—PARiHS framework/i-PARiHS.

Characteristics of included studies

Our sample included 130 primary research articles: quantitative (n=63), qualitative (n=39) and mixed methods (n=28) (used both qualitative and quantitative data collection methods). The remainder were descriptive papers (n=34), literature reviews (n=20) and theoretical/conceptual papers (n=11).

Over half of the research studies (n=85/130) included a mix of healthcare providers in their samples (eg, nurses and physicians); the remainder included a single healthcare provider group. Study setting was reported in 120 studies; the most frequent were hospitals (34%), primary care (23%) and other community-based facilities (18%). Less frequently cited were studies with more than one setting (13%), long-term care (8%), home care (2%) and symposiums (2%). For studies that also reported the country (n=120), most were conducted in the USA (29%), Canada (23%), UK (18%), Europe (10%) and Australia (9%). Some studies included more than one country (6%). A few studies were conducted in Africa (3%) and one in Singapore (1%) and Nicaragua (1%).

Nine definitions of facilitation were used (table 4). The definitions of facilitation from the PARiHS framework were the most frequently cited (n=19). A common thread in seven of the nine definitions is that facilitation is viewed as a process of providing support to enable change to occur.4 17 18 20 29–31 The other two definitions were notably different as they did not include process in their definitions. One article focused on relationships,32 the personal contact and support required, while the other article highlighted facilitation as a strategy for learning.33

Table 4

Results: Definitions of facilitation

First author/year	Definition of facilitation	Number of citations
PARiHS framework Kitson (2008, 1998)3 17	Facilitation is ‘a technique by which one person makes things easier for others’ (p 152). ‘The term describes the type of support required to help people change their attitudes, habits, skills, ways of thinking, and working.’ (p 152)	n=19
Harvey (2002)20	Facilitation refers to ‘the process of enabling (making easier) the implementation of evidence into practice’ (p 579). ‘Facilitation is achieved by an individual carrying out a specific role (a facilitator), which aims to help others.’ (p 579)
Bashir (2000)32	‘Facilitation uses personal contact between the facilitator and the professional to encourage good practice and better service organisation.’ (p 626)	n=0
Schwartz (2002)212	‘A process of enabling individuals, groups, or teams to work effectively together to achieve a common goal.’ (cited in ref 18, p 296)	n=1
Ferguson (2004)29	‘Facilitation involves helping others to identify questions of practice; providing support to enable others to meet specific goals, including research use; attending to the process of achieving those goals; and knowing the system in which change is proposed and implemented.’ (p 325)	n=0
Lekalakala-Mokgele (2005)33	‘Facilitation is both a method and a strategy for learning. Facilitation promotes critical thinking in the learners and both become reflective learners.’ (p 25)	n=0
Stetler (2006)4	‘Facilitation is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation is primarily a distinct role with a number of potentially crucial behaviors and activities.’ (Abstract paragraph 4)	n=4
Petrova (2010)30	‘Facilitation is the process of providing support to individuals or groups to achieve beneficial change’ (p 38). It has been described as ‘the provision of opportunity, resources, encouragement and support for the group to succeed in achieving its own objectives and to do this through enabling the group to take control and responsibility for the way they proceed.’ (p 38)	n=1
Dogherty (2010)19	‘Facilitation is viewed as both an individual role as well as a process involving individuals and groups.’ (p 86)	n=3

In 77/195 articles, a theory or conceptual framework(s) guided research or contextualised findings. Most frequently cited were the PARiHS framework17 (n=16), change theories (eg, Lewin’s theory of change)34 (n=10) and Rogers’ diffusion of innovation theory15 (n=10). Sixteen papers used more than one theory or framework.4 35–49 For example, papers citing the PARiHS framework had used it to: inform the decision to involve both external and internal facilitators41; conceptualise a nurse pain champion role40; guide design of a KT intervention for continuous improvement of patient care and evidence-based practice (EBP)38; and assist with the description of processes and outcomes of an EBP training programme.50 Examples of other frameworks used are Donabedian’s structure, process, outcome model37 51–54; Graham et al’s55 Knowledge to Action Framework41 48 56 57; and May et al’s58 Normalization Process Theory.59

Facilitator roles

We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Of note, overlap exists in the terms used to describe a clinical facilitator and a practice facilitator, and a practice facilitator and outreach facilitator. We describe conditions under which each role is considered most appropriate based on locality (facilitators located internal to the organisation, external, or combined external and internal) and formality (formal appointed role vs informal role). These nine facilitator roles expand (both in number and scope) those identified in previous reviews.19 20 24 For each role, we provide a definition, key features, training requirements, and key personal attributes and skills (table 2). As each facilitator role included change agent activities,24 we did not include change agent as a separate role.

Stakeholder feedback on the identified facilitator roles was positive and validated our findings. Stakeholders indicated that roles and characteristics were understandable and meaningful. They commented that understanding the key role and skills of each type of facilitator, and whether training was required, was useful in hiring processes.

A key goal and responsibility in all nine facilitator roles is to drive and motivate a practice change and to act as a resource for making the change. Overall, facilitator roles included attributes and skills such as credibility, trustworthiness, expertise, enthusiasm and good problem-solving and networking skills. Opinion leaders, coaches, champions, research facilitators and clinical/practice facilitators all work internally (locally) within the organisation. Two main features of opinion leaders as facilitators are: they are peer nominated42 60–68 and they are informal leaders who are influential because they are knowledgeable and experienced.42 63 69–71

Opinion leadership stems from medical literature71 and is based on diffusion of innovation15 and social influence theory.24 72 Opinion leaders have wide interpersonal communication networks60 61 and therefore have a key role in assisting others to recognise the need for improvement and communicating information about innovation within professional networks.42 Coaching has been used in the business/management literature as an approach to training,73 and more recently has been theoretically positioned in the context of EBP as a relational approach.74 A coach assists others with making a change particularly in guiding their learning during implementation using motivation, encouragement and positive reinforcement.75 76 A champion, whose role is also based on diffusion of innovation40 and social influence theory,24 is a local visionary who uses expert knowledge and vision to persuade others to adopt an innovation24 37 48 77–79; and help others to see the advantages of making a practice change and mentor them through the process.

Research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators were considered more formally appointed roles, and the majority of these facilitators were typically trained for their role. Research facilitators, described in the context of EBP, have expertise (research, clinical background) to support staff to strengthen their research skills, knowledge and participation in research in a clinical setting.39 80–83 A clinical/practice facilitator, also described in the context of EBP (eg, guideline implementation), provides ongoing education and support through the implementation process30 32 45 51 84–101 (though some were external). Facilitator roles considered external to the organisation included outreach facilitators, linking agents and knowledge brokers (the latter two being boundary spanner roles). An outreach facilitator assists healthcare providers (eg, those in primary care practices) through a formal implementation process (eg, using educational outreach visits/academic detailing/quality improvement).69 102–120 A clinical/practice facilitator or outreach facilitator role may be useful when staff are required to learn new skills for research implementation. The linking agent role is based on the concept of spanning the boundary between research and practice to bring about change.24 29 121–123 The knowledge broker role is based on the concepts of linkage and exchange (eg, establishing communication channels),43 116 124–126 knowledge management and capacity building (eg, builds relationships between two communities, typically policymakers and researchers).127 128 Recent studies focus on using external-internal facilitators based on the PARiHS framework—described as external facilitators (eg, research team members) supporting internal (local) facilitators to assist healthcare providers with implementing a practice change.49 56 57 129 130

Training requirements were a key distinguishing feature of the facilitator roles. External facilitators tended to be formally trained for their role but internal facilitators may or may not have received training. Only the opinion leader role was described as informal (with no training required).42 60–67 131 132 Of the 63 intervention studies, 24 identified training facilitators.32 37 46–48 68 69 102–107 118–120 129 133–139 Seventeen of these 24 studies described training components, with nine studies including length of training, ranging from 4 hours,107 40 hours,118 1–3 days68 102 137–139 to 6–7.5 months.32 106 Training components typically included course work (theoretical knowledge),37 47 102 119 120 or both course work and practical experience (skills training).32 48 106 107 118 137–139

In a recent article describing the i-PARiHS framework, Kitson and Harvey18 outline facilitator activities, and further identify three distinct facilitator roles: novice, experienced and expert facilitator. For example, the novice facilitator is skilled at clarifying tasks, and identifying key stakeholders; experienced facilitators support novices, assess system-wide activities and contextual issues, and develop skills in sustaining change; expert facilitators are positioned at a strategic level to provide project coordination and leadership for the initiative, and includes engaging stakeholders and political negotiation skills.18

Characteristics of facilitation

Within our sample of 195 articles, there were 133 articles from which we identified 15 characteristics of facilitation associated with research use by healthcare providers, and mapped these onto Rogers’ five attributes of innovation: (1) relative advantage (four characteristics), (2) compatibility (four characteristics), (3) complexity (four characteristics), (4) trialability (one characteristic) and (5) observability (two characteristics).15 Each of these attributes is described next and shown in table 3.

Relative advantage

Relative advantage is one of the strongest predictors of successful implementation and an innovation’s adoption rate, and was the most frequently cited attribute of facilitation in our review.15 The relative advantage or benefit of facilitation is that it involves a process for making change easier for others. We found four characteristics of facilitation considered advantageous to those involved in implementing research into practice: (1) encourages assessment of current practice; (2) presents ideas to others; (3) creates useful communication networks; and (4) provides support and resources to achieve goals. A facilitator can help healthcare professionals to identify gaps between knowledge and practice,4 32 36 101 127 140–142 and to acknowledge the need for improvement.4 56 77 143–145 Facilitators can assist others to understand the relative advantage of making a change,17 101 145 146 as well as the benefit of facilitation as an implementation innovation itself. A facilitator provides continuing support and identifies resources to help with the process, and monitors the change.4 30 41 48 49 56 57 78 86 92 94 95 111 133 141 142 147–156 For example, a facilitator builds organisational support for new practices151 157 and provides structure for learning.33

Compatibility

A key purpose of facilitation is to make change more compatible with existing practices. Several characteristics of facilitation promote compatibility of the change with existing practice including: mobilising existing knowledge and skills94; enhancing staff readiness to change and empowering staff3 35 66 76 95 121 141 158 159; supporting a culture for change20 27 40 44 45 62 66 75 99 128 134 144 145 148 153 160–165; and tailoring facilitation activities to local context (eg, social, cultural).49 50 56 61 75 103 142 150 166–171 For example, a facilitator understands the climate and practical realities of the organisation,27 99 128 160 164 and frames knowledge so that it is relevant to staff practice.158

Complexity

Facilitation supports the development of new knowledge and skills, requires facilitators to be trained or have experience with this role, may have multiple components, and is described as a bidirectional process that fosters relationship building. A complex intervention typically contains several interacting components.172 Most intervention studies in this review described a single intervention but interventions tended to be multifaceted, with several components or strategies typically delivered by a facilitator (eg, audit and feedback, consensus building).103 Eleven studies used multiple interventions (ie, more than one intervention arm),47 63 68 69 84 125 129 142 173–175 for example, reminders and a nurse facilitator,84 and opinion leader education and audit and feedback.63 However, facilitation as an innovation need not be complex. Facilitation is an enabling approach3 4 20 21 146 176 that can help reduce the (perceived or actual) complexity of a multifaceted intervention. Facilitation involves building trust and fostering mutual opportunities.4 30 74 Facilitators are experienced or are trained for their role to support others with implementation. The frequency and duration (dose) of facilitation varies; for example, some studies included daily facilitation for 3 months,90 monthly for 12 months,104 and on average 25 visits per site lasting 1 hour for 18 months.105

Trialability

The ability for potential adopters to test an intervention can enhance its adoption.15 We located examples of researchers who pilot tested a facilitation intervention (or its components) prior to full-scale evaluations.46 90 103 105 118 138 149 150 163 174 177–179 For example, in one study six nurses were trained for their facilitator role and gained experience conducting outreach visits in pilot general practices.105

Observability

Observability is seeing the results of an innovation, in our case being able to ascertain that individuals use research as a result of facilitation.15 Two characteristics of facilitation that reflected observability were facilitators encouraging others to role model the change33 45 86 99 126 180–182 and reinforcing the change (research use)75 108 109 183 184 and supporting sustainability.18 27 Some examples of role modelling included sharing examples of good practice68 and providing opportunities for formal shadowing.126 An example of reinforcing the change was a follow-up visit by a nurse facilitator to reinforce guideline implementation.109

Facilitation process

Although facilitation is identified in the literature as a process of enabling implementation of evidence into practice,19 20 few studies identified the actual process. Dogherty and colleagues outlined four stages of facilitation that include activities to facilitate research use in nursing: (1) planning for change, (2) leading and managing change, (3) monitoring progress and ongoing implementation, and (4) evaluating change.19 27 56 Elnitsky and colleagues141 described an internal facilitation process (within the organisation): learning the role of facilitator, assessing the culture, facilitating external programmes, negotiating and getting buy-in. They mapped this process to Dogherty and colleagues’ facilitation taxonomy (above) and subdomains of the PARiHS framework.155 Others have described facilitation as an interactive problem-solving process requiring supportive interpersonal relationships.4 Dogherty and colleagues185 described key factors to successful facilitation of EBP such as development of strategic partnerships, use of multiple strategies to effect change, and facilitator characteristics and approach (eg, leadership and team building skills). Barriers influencing the facilitation process were largely contextual constraints such as lack of engagement and resources and team functioning.

Discussion

Our review suggests that facilitation has become an important aspect of implementing research into practice, and has potential to be an effective innovation. Our literature synthesis advances previous reviews on facilitation by broadening our understanding of the roles of facilitators and the characteristics of facilitation.19 20 24 Our first research question addressed the key facilitator roles identified in the literature. We identified nine types of facilitator roles, the majority of which are formal appointed roles. Facilitators share a common goal of implementing an EBP change, and some roles share theoretical underpinnings—opinion leaders and champion roles are based on diffusion of innovation and social influence theory, and a linking agent and knowledge broker act as intermediaries/boundary spanners to bridge gaps. However, we have also highlighted some notable differences in these roles. Clearly, many facilitator roles are being used in healthcare systems. Our findings shed light on the variety, complexity and need for these roles. Policymakers can use these findings to design role statements and processes to impact outcomes for care providers and patients. Knowing the various types of facilitator roles can assist administrators and managers to implement a facilitator role that best supports change activities in their setting. For example, an outreach facilitator could be potentially useful in settings such as outpost nursing and home care. Boundary spanner facilitator roles may be most useful to bridge practitioners with internal and external stakeholders involved in planned change. The importance of external facilitators supporting internal facilitators in creating organisational facilitation capacity is highlighted in the literature.27 41 49 56 57 129 Building internal facilitation capacity may create sustainable infrastructures to support implementation activities designed for improving patient safety and quality of care delivery. Further research should be undertaken on external-internal facilitator roles as they may foster a more integrated approach to facilitating the use of research into practice.

Our second research question addressed the characteristics of facilitation that contribute to research use by healthcare professionals. Characteristics of facilitation are important because they identify those features that may potentially lead to greater success in implementing change. In the KT literature, the knowledge itself is typically considered the innovation. Studies have shown that facilitation itself should be operationalised as an innovation or tool used to influence implementation of other innovations (eg, guideline implementation via facilitation).32 46 51 63 69 75 103 105 107 109 136 Using Rogers’ framework enabled us to highlight characteristics of facilitation that may influence its adoption as an innovation.15 Relative advantage was the most frequently cited attribute of facilitation in our review. Rogers’ attributes of an innovation15 covered all of the results that we found and therefore it is confirmed to be a comprehensive model to describe characteristics of an innovation.

Further research could examine whether facilitation strategies with Rogers’ innovation attributes lead to successful implementation. For example, facilitation that is tailored to local context and offers ongoing support may be better received than a complex intervention. According to Greenhalgh et al, Rogers’ concept of reinvention (innovation adaptability) can be considered another innovation attribute that could lead to innovations being adopted more readily.15 186 Though we did not include the concept reinvention in our data analysis, three articles from our review described reinvention of the innovation as an important quality to enhance adoption.41 148 183 For example, Miller et al suggested designing a KT intervention with reinvention in mind, which involves knowing the attributes of the intervention that must be maintained for effectiveness183; this is important for adoption and sustainability of an innovation.41 Facilitators can assist with reinvention during implementation to individualise the innovation to better meet adopters’ needs.148 Reinvention as an attribute of an innovation could be explored in future reviews. Understanding these innovation attributes can lay the groundwork for well-designed and well-evaluated facilitation interventions to improve practice in healthcare delivery. However, we noted key gaps in the literature on the characteristics of facilitation. First, the process of facilitation remains unclear and largely implicit, which challenges descriptions of facilitation interventions for future study. Second, few studies were conducted in home care and long-term care settings, which is important to address as Canada and other countries are experiencing a shift in population demographics towards an ageing generation.

Two main limitations of our review, which may introduce the potential for publication bias, are that we did not include grey literature, nor did we conduct a quality appraisal of included studies as this is not part of a scoping study undertaking28 187 nor the purpose of our review. The scoping review enabled us to synthesise a breadth of literature that characterises the quantity, nature and extent of research evidence on facilitation187 and the roles undertaken to facilitate the uptake of evidence. Our search was further restricted to the English language. However, we tracked non-English language studies and could have included four of them. Our review was focused on research use specifically among healthcare professionals, which has a considerable body of literature that theorises, conceptualises and operationalises facilitation. While this diversity creates some inconsistencies in naming facilitator roles, it has a notable strength; the diversity of the disciplines that describe facilitator roles and characteristics of facilitation from various theoretical perspectives helps us to better understand facilitation.

High-quality rigorous studies are needed on facilitation to distinguish those characteristics or components that have greatest impact and effectiveness. While we did not assess rigour in this scoping review, others have noted a lack of rigorous studies evaluating facilitation.27 Our team is currently completing a systematic review to examine the effectiveness of facilitation as an implementation innovation in healthcare. Such work could also help to shed light on the process of facilitation, what facilitator role is best used and when, and what types of training are most effective for facilitators.

Conclusion

This scoping review highlights a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery. Implementing research into practice to improve patient care is complex and requires dedicated facilitators to support the change process. This scoping review advances the field of KT science by contributing to the evidence base needed to develop measures of facilitation and to design and test facilitation interventions for successful research use.