From Core Components to Guiding Principles: Reframing Implementation Fidelity
By Dr. Julia E. Moore, Executive Director
5-min read
There have been many new developments, directions, and areas of interest in implementation science and practice lately. To us, it feels like spring; new ideas are blooming everywhere.
The shift away from binary thinking in the field and towards exploring nuance is exciting. Fidelity and adaptation are beautiful examples of this. It has been a long time since we have heard arguments exclusively for fidelity or exclusively for adaptations. There now seems to be a deep recognition that there needs to be some level of both fidelity and adaptation.
Here at TCI, we are deeply passionate and enthusiastic about understanding how to better support people in making adaptations. We have written about this topic, recorded podcasts, and are currently revising and updating our Map2Adapt tool.
Fidelity and adaptation: The role of core components
One of the most interesting recent discussions is about better defining the adaptations that people are implementing. We have participated in several conversations, attended presentations, and discussed how one way to navigate the nuances of fidelity and adaptations is to define better which aspects require fidelity and what can be adapted.
For many years, people have discussed “core components. " Conceptually, this idea makes sense, but people struggle to define these core components in practice, which leads to difficulty finding the right fidelity-adaptation balance.
We have been excited about the idea of thinking about fidelity to the “principles.” Principles often serve as the basis of people's actions, how they engage in relationships and the processes they design. When we are making adaptations, we typically aren’t looking to make adaptations to the underlying principles.
What does that mean?
Defining the THING and the 7 Ps
Let’s begin by establishing a few definitions, which we explored in more depth in this article. We'll start by considering the concept of the THING. Here is Geoff Curran's definition of the THING from this infamous implementation science article.
For many people, the THING is a program, a guideline, or a policy. Although the THING is defined in some ways when people dig into the nuance, it has often not clearly outlined all the people who need to do something differently (which we call the WHO) and what they are being asked to do differently (which we call the WHAT).
We use the 7 Ps to unpack WHAT people are asked to do differently. We usually start by identifying every WHO, and then for each WHO, we collaboratively describe WHAT they are being asked to do differently. We find that the 7 Ps help us think about those WHATs. Here are descriptions of each of the Ps.
Programs: A set of coordinated activities to accomplish a specific goal (e.g., a pre-packaged evidence-based program)
Practices: The application of an idea or belief (e.g., guideline recommendations)
Policies: Legislative/regulatory decisions made to ensure that specific actions can be taken within a legal/regulatory framework (e.g., policies with regional policymakers and service providers to improve transitions in care)
Procedures: A set of instructions or sequential activities that help guide a specific action (e.g., a screening tool)
Pills: Refers broadly to any drugs that might be used to improve outcomes (e.g., a medication)
Products: Tools or resources that guide people in accomplishing activities/goals (e.g., an online learning platform or app).
Principles: Beliefs/philosophies that guide action (e.g., using an equity-based approach to support underserved groups)
Note that sometimes we call it the 6 Ps when talking to an audience (like schools) where “pills” don’t seem appropriate.
Principles: One of the most important of the 7 Ps
One Ps we have grown to love is “principles.” Every program has underlying principles, but these are often not explicitly stated and described. In fact, people often select the THING they are implementing based on the principles that that THING embodies. Sometimes, when a THING is not a good fit, it’s because the underlying principles are not aligned with the setting or the audience. Essentially, the principles help connect people to the WHY of implementation.
Lately, we have seen several examples of people clearly defining the principles. In some cases, these were the principles for the THING; in others, people defined principles for specific WHATs. For example, while there might be general principles of the THING, the principles for leadership might look different than those of the personal support worker, given their various roles in an initiative.
As we navigate clearly defining which adaptations are potentially positive and which are potentially detrimental, we’ve been excited about the idea of having fidelity to the principles. That also allows us to more clearly outline what can be adapted.
In many settings, professionals have a certain degree of freedom in how they engage and interact. Consider the autonomy that teachers have in teaching students, or that social workers have in providing support to families, or the way nurses interact with patients and their families. When the guiding principles are clearly defined, it is easier for individuals to embody and apply them, whether following specific practices, policies, or procedures.
In fact, many protocols, procedures, practices, and policies are designed to embody principles in action without actually defining and sharing those underlying principles. When people define those principles, the entire experience of describing what’s being implemented and what people are being asked to do differently looks pretty different. It feels much less prescriptive and more about aligning people’s values and goals and how they show up and do their work.
Here are some examples of principles that we have seen:
We are meeting people where they are at
We cultivate connection over correction
We are strengths-based
This is the new way of work
We see so much potential in it – always defining the underlying principles of the THING and, when appropriate, the principles of the WHATs for each WHO.
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