The Implementation in Context (ICON) Framework: A meta-framework of context domains, attributes and features in healthcare
Authors: Squires Janet E. , Graham Ian D. , Santos Wilmer J. , Hutchinson Alison M. ,   The ICON Team, Backman Chantal , Bergström Anna , Brehaut Jamie , Brouwers Melissa , Burton Christopher , de Candido Ligyana Korki , Cassidy Christine , Chalmers Cheyne , Chapman Anna , Colquhoun Heather , Curran Janet , Varin Melissa Demery , Doering Paula , Rose Annette Elliott , Fairclough Lee , Francis Jillian , Godfrey Christina , Greenough Megan , Grimshaw Jeremy M. , Grinspun Doris , Harvey Gillian , Hillmer Michael , Ivers Noah , Lavis John , Li Shelly-Anne , Michie Susan , Miller Wayne , Noseworthy Thomas , Rader Tamara , Robson Mark , Rycroft-Malone Jo , Stacey Dawn , Straus Sharon , Tricco Andrea C. , Wallin Lars , Watkins Vanessa 
Published: August 2023

Background

There is growing evidence that context mediates the effects of implementation interventions intended to increase healthcare professionals’ use of research evidence in clinical practice. However, conceptual clarity about what comprises context is elusive. The purpose of this study was to advance conceptual clarity on context by developing the Implementation in Context Framework, a meta-framework of the context domains, attributes and features that can facilitate or hinder healthcare professionals’ use of research evidence and the effectiveness of implementation interventions in clinical practice.

Methods

We conducted a meta-synthesis of data from three interrelated studies: (1) a concept analysis of published literature on context (n = 70 studies), (2) a secondary analysis of healthcare professional interviews (n = 145) examining context across 11 unique studies and (3) a descriptive qualitative study comprised of interviews with heath system stakeholders (n = 39) in four countries to elicit their tacit knowledge on the attributes and features of context. A rigorous protocol was followed for the meta-synthesis, resulting in development of the Implementation in Context Framework. Following this meta-synthesis, the framework was further refined through feedback from experts in context and implementation science.

Results

In the Implementation in Context Framework, context is conceptualized in three levels: micro (individual), meso (organizational), and macro (external). The three levels are composed of six contextual domains: (1) actors (micro), (2) organizational climate and structures (meso), (3) organizational social behaviour (meso), (4) organizational response to change (meso), (5) organizational processes (meso) and (6) external influences (macro). These six domains contain 22 core attributes of context and 108 features that illustrate these attributes.

Conclusions

The Implementation in Context Framework is the only meta-framework of context available to guide implementation efforts of healthcare professionals. It provides a comprehensive and critically needed understanding of the context domains, attributes and features relevant to healthcare professionals’ use of research evidence in clinical practice. The Implementation in Context Framework can inform implementation intervention design and delivery to better interpret the effects of implementation interventions, and pragmatically guide implementation efforts that enhance evidence uptake and sustainability by healthcare professionals.