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framework maintained facilitation as a component, but further highlighted facilitation as the “active ingredient” in the implementation process (Harvey & Kitson, 2015a, p. 47). Innovation, recipients, and the inner and outer contexts are ‘integrated’ through facilitation (which is

purposeful and planned) by individuals with the unique skills to create practice change (Kitson & Harvey, 2015). Within i-PARIHS, the main characteristics of facilitation included involvement of key stakeholders, participant ownership, providing feed-back at the time of performance, empowerment, and enablement of individuals within the organization. Kitson and Harvey (2015, p. 75) have identified the differences between “being a facilitator” and “doing” facilitation and these terms have their roots in the early PARIHS terminology of skills, roles, and attributes as sub-elements of facilitation. Attributes of ‘being a facilitator’ included someone who is fearless, resilient, curious, and patient. ‘Doing facilitation’ includes establishing rapport and trust with individuals, building a cohesive and effective team, teaching, and creating a learning

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facilitators need to be flexible and have the ability to adapt how they facilitate relative to the particular innovation, recipients, and context.

One of the major critiques of the PARIHS framework was that facilitation was difficult for individuals and teams to use in everyday settings (Stetler et al., 2011). As a result of this, a “pathway’ was created in which facilitators move through the process of starting out as novice facilitator towards becoming an expert facilitator. Novice facilitators need to be supported by individuals who have more experience in facilitation and should be mentored by an expert facilitator. Experienced facilitators should work under the supervision of expert facilitators, and the role of the expert facilitator is to provide coaching and guidance to other facilitators within the system or organization. The idea of support for facilitators has been echoed by other researchers (i.e. Dogherty, Harrison, Graham, Vandyk, & Keeping-Burke, 2013; Harvey & Lynch, 2017).

Harvey and Kitson (2015a) have conceptualized the implementation process in the i- PARIHS framework as a continuous spiral. For the facilitator, their journey begins in the middle of the spiral in which they focus their attention on the innovation and the recipients. As the implementation process continues, their focus moves outwards through the inner context (at the local and organizational level) towards the outer context. The facilitator will examine different factors related to the innovation, the recipients, and the contexts, and identify what activities need to be completed for each construct. Harvey and Kitson (2016) hypothesized that as the facilitator progresses through the spiral, they move from the more concrete skills of facilitation (e.g., project management skills) towards those that require more complex skills and experience. 1.6.2 Characteristics, Skills, and Attributes of Facilitators

1.6.2.1 Facilitation in health care settings. Janes, Fox, Lowe, McGilton, and Schindel Martin (2009) conducted one of the few studies related to facilitation within LTC settings. Their study was designed to explore the factors that impact on whether or not nursing staff use research in their practice through facilitation, from the perspective of the facilitators. Participants

identified individual factors related to the facilitator’s approach and traits, and the emotionality and intellectual capacity of the receivers (nursing staff). The three factors related to the approach of the facilitator were framing, engaging, and bridging. Facilitator traits included flexibility, experience, and emotional maturity. Characteristics of receiver emotionality were defined as feelings, motivation, and attitude.

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According to Janes et al. (2009) participants identified leadership, culture, and workload as contextual factors that impact on the implementation of evidence-based practice. Managers must support the use of research in practice through role modelling and being enthusiastic. Leaders must also ensure that there is a positive relationship between nursing staff and administration. In addition to strong leadership, an organization must promote a culture of practice change, and arrange for staff to have time away from their workload to be able to focus on ways to implement research in their clinical practice. Many of the factors identified at the individual and contextual levels were affective and relational (Janes et al., 2009). Working in LTC homes is not an easy job. It is challenging, unpredictable, and often very stressful. When staff react to these conditions with negative feelings and attitudes, the chances of changing practice decreases.

Within the PARIHS framework respect, empathy, and credibility of facilitators are identified as factors that are likely to increase the chance of evidence being implemented in practice. Janes et al. (2009) suggest that engagement, framing, and experience are linked to the characteristics defined in the PARIHS framework; however, the framework does not address the emotional maturity of the facilitator. Janes et al. agree with Harvey et al. (2002) that it is not known what facilitation skills are required in LTC homes and that there is very little consensus about the most effective method of facilitation for helping staff effectively implement research findings in their daily practice. “Empowering styles of leadership and emancipatory approaches to facilitation require further research in the interest of promoting the social interactions within LTC homes most conducive to nursing staff utilization of best practice knowledge” (Janes et al., 2009, p. 174).

Dogherty et al. (2013) proposed that the subject of facilitation is not well defined in Canada. They suggested that there are many individuals across the Canadian health care system who play a facilitator role and use facilitation skills as a part of their job but are not referred to as official “facilitators.” Researchers do not have a good understanding of the role or the function that nurses play in facilitating evidence-based practice. To delve further into this unknown area of nursing practice, Dogherty et al. invited 20 nurses from across Canada to discuss their

experiences as facilitators in relation to implementing evidence-based practice. Few of the nurses within this study identified as being “facilitators” and many other titles were used in place of facilitators (e.g. Clinical Leader, Advanced Practice Nurse, or Project Lead). This is a similar

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finding to that of Harvey and Kitson (2015a) and Harvey and Lynch (2017) who believe that facilitation can be done by many individuals within an organization, in contrast to earlier conceptualizations of the facilitator as a formal role (Harvey et al., 2002).

The attributes, skills, and characteristics that the nurses identified as leading to successful implementation in the study by Dogherty et al. (2013) were similar to what Kitson and Harvey (2015) and Janes et al. (2009) identified in their research on facilitation. Flexibility, resilience, credibility, relationship building skills, using multiple facilitation strategies, engaging individuals and teams, not shying away from conflict, and relying on positive communication skills were just a few of the areas in which Dogherty et al., Kitson and Harvey, and Janes et al. overlap in their research related to facilitation. Although Dogherty et al. (2013) did not officially use the terms innovation and recipients as used in the i-PARIHS framework, they described three important factors that impact successful implementation that would fall under these two constructs: the development of partnerships and engagement of key stakeholders, importance of the issue (e.g., is the innovation being implemented meeting a need or a problem identified by staff), and

characteristics of the evidence. Dogherty et al. (2013) found that the factors related to the context (another i-PARIHS construct) were those that had a negative impact on successful

implementation (e.g. lack of resources, conflictual relationship throughout the organization, staffing issues, lack of evaluation). These authors recommended that prior to implementing evidence-based practice into an organization, facilitators should recognize that there will be contextual issues and establish a plan to overcome these barriers prior to the start of the implementation process.

1.6.2.2 Refinement of facilitation in health care. Dogherty et al. (2014) conducted a