Are Implementation Frameworks Like Toothbrushes or Screwdrivers?
By Dr. Julia E. Moore, Executive Director
4-min read
What if we thought of implementation science frameworks as tools in our toolbox?
My husband is a car mechanic and a fixer of all things. My youngest son (who is 7 years old) sees the world very much like his dad. He wants to understand how things work, loves taking things apart, and loves building things. I often hear my husband say things like, “This is a diagnostic tool, I hook it up to the computer that’s inside of the car, and it gives me a code. That code tells me what’s going on in the car, that way I can figure out how to fix it”, or, “This screw has a star shape, it needs a Phillips head screwdriver.” Essentially, he’s teaching our son how every tool in his toolbox has a purpose.
Interestingly, so much of implementation science seems grounded in the use of theories, models, and frameworks (Nilsen, 2015), yet as a field, we have not done a great job explaining the purpose of each “tool” in our toolbox.
Are implementation frameworks like toothbrushes or screwdrivers?
For years, people have joked, “Implementation frameworks are like toothbrushes; everyone wants one, but they don’t want to use anyone else’s.” Now that frameworks are being increasingly used in implementation practice and support, that no longer seems to be the case. The people we talk to are eager to use someone else’s framework. But they struggle to figure out which one to use or complain that a framework doesn’t work or isn’t helpful. But we’ve started to wonder – maybe it’s not the framework that isn’t working. My husband recently said, “You can’t cut wood with a screwdriver. You can’t hammer a nail with a wrench – well, it might work, but it won’t be pretty”. Are we trying to do the same thing with some of our implementation frameworks?
Imagine how much easier picking a framework would be if it were easy to understand its purpose and function. Imagine what would happen if we used appropriate frameworks to guide our implementation practice and research. Imagine what it would feel like if frameworks were always helpful tools instead of barriers to getting things done.
That’s our goal – to make using frameworks feel much more accessible!
Reasons to use implementation frameworks
Lately, a lot of conversations about implementation frameworks have focused on the number of them (it’s true there are a lot of frameworks out there). But this sort of distracts us from what’s really important—the value frameworks provide.
Frameworks describe factors that predict something. While there are many frameworks (lists can be obtained from systematic reviews and interactive online tools), only a small subset is frequently used.
So why would we use an implementation framework? Frameworks help us organize information, deepen our understanding, and consider aspects of implementation in ways that we might not have before.
Types of implementation frameworks
To accomplish our goals of deepening our understanding and organizing information, we need to pick the right framework for the right job. Not all implementation frameworks do the same thing.
Some frameworks are designed to help us think about individual-level barriers and facilitators – the Theoretical Domains Framework is our go-to framework for this! Looking for tips on mapping barriers and facilitators to frameworks? Here are 5 tips that can help.
When we want to unpack organizational and system-level barriers and facilitators, we often use the Consolidated Framework for Implementation Research.
If you want to track adaptations, people find the FRAME and FRAME-IS are helpful frameworks.
If you want to explore the different types of outcomes, RE-AIM and Proctor’s implementation outcomes are commonly used.
This is far from an exhaustive list of all the frameworks and reasons we might use one, but it illustrates the different purposes or functions a framework might serve. The key is figuring out what you are trying to achieve and then finding a framework that will help you achieve that goal.
We introduce frameworks to people every week. When we first start, there is often a light eye-roll or big sigh—almost as if people are thinking, “Oh, you are teaching me another useless tool.” But once people start using a framework, the most common thing we hear is, “This is great; it’s mostly aligned with how we were already thinking about things, but there are these 2 or 3 factors that we had not even thought about that are game changers for us. But we might change some of the language to make it sound more like us.” We think this is a huge win! It means we helped them learn that framework’s purpose and, at the same time, expanded the way they think about implementation.
So, maybe it’s time we stop thinking of implementation frameworks like toothbrushes and start thinking of them like screwdrivers, hammers, and wrenches; each one has a purpose. We just need to make sure we’re properly explaining that so that when we need to reach for one, we reach for the appropriate one and don’t feel overwhelmed or confused while doing so.
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