Examples include multifaceted obesity interventions in middle school settings, HIV prevention programs in local health departments and cancer risk reduction programs in African-American churches. The more complex the health promotion program, the greater the potential utility of the theory for studying implementation processes and outcomes.
A theory uses concepts and arguments to describe a causal change of events that produce an outcome of interest. When putting something new into use, the immediate outcome of interest is initial use or early use.
Benjamin Schneider and Karen M. Barbera
A theory of implementation, therefore, uses concepts and arguments to predict or explain how courses of action taken to put an idea, decision, procedure or program into use result in observed patterns of initial use or early use. A theory of implementation can be distinguished from a program theory, a program planning model and a theory of innovation adoption and diffusion. A program theory predicts or explains how a program works or is supposed to work [ 48 ]. It explains how or why program activities i. An implementation theory predicts or explains implementation success.
It explains how or why implementation activities e. A good program theory can explain how and why a comprehensive worksite health promotion program reduces cancer risk, yet say little about how or why some organizations implementing such a program achieve more consistent, high-quality and appropriate program use than others do. A program planning model is a tool designed to help researchers and practitioners identify high-quality programs, prioritize program options based on population needs and interests and develop a plan for program implementation and evaluation [ 49 , 50 ].
A program planning model is not intended for use as a theory of implementation. It does not offer a set of concepts and arguments that can be translated into testable hypotheses to predict or explain how or why different implementation activities produce differences in program use or outcomes.
Instead, a program planning model is intended as a practical guide. It describes step-by-step procedures for program development, deployment and evaluation. While valuable for guiding practice, a program planning model has limited usefulness for guiding implementation research. Finally, a theory of innovation adoption is distinguishable from a theory of implementation. Adoption, according to Rogers [ 46 , p. Implementation is the process the course of action of putting an innovation into use.
As Rogers [ 46 , p. But implementation involves overt behavior change as the new idea is actually put into practice.
Most studies of innovation diffusion blur the distinction between the cognitive decisional aspects of adoption and the behavioral aspects of implementation. In organizations, those who make the adoption decision often are not directly involved in implementing the decision.
Moreover, implementation itself often involves collective behavior change by many employees. Thus, in organizations, the adoption—implementation gap can be quite substantial. In a sense, a theory of implementation picks up where a theory of adoption leaves off. It seeks to explain and predict what happens after the adoption decision takes place. We regard the implementation of comprehensive worksite health promotion programs as an organizational act and view the successful implementation of such programs as an organizational issue. We focus on the organizational level of analysis—and, hence, offer an organization-level theory of implementation—for three reasons.
The authority to decide whether or not an organization will adopt a comprehensive worksite health promotion program rests in the hands of a few individuals, usually senior managers [ 51 ]. The hierarchical structure and division of labor found in many organizations often produce a differentiation of decision makers, program implementers and program users.
This differentiation, in turn, generates organizational dynamics relevant to a theory of implementation.
Second, implementing a comprehensive worksite health promotion program is a collective endeavor; it is not something that individual employees can do independently or without assistance. Due to job specialization and task interdependence, implementation activities e.
An Introduction to Theory, Research, and Practice
Organizational issues such as administrative coordination, resource allocation and technical support are germane to a theory of implementation. Collective benefits result from collective program use. Even the personal benefits that individual employees realize depend to some extent on collective program use. Protection from workplace accidents, for example, can depend on collective use of safety procedures. Continued availability of program components e. When collective use is important, it makes sense to conceptualize implementation effectiveness as organization-level construct and focus attention on organization-level determinants.
Organizational Climate and Culture: An Introduction to Theory, Research, and Practice
These two groups may overlap in whole, in part, or not at all. We view a comprehensive worksite health promotion program as a complex innovation.
A complex innovation is a new idea, practice, program or technology whose implementation requires collective action and whose use entails collective behavior change. Figure 1 depicts our theory of implementation. We propose that effective implementation is a function of the organization's readiness for change, the quality of the implementation policies and practices that the organization employs, the climate for implementation that results and the degree to which targeted employees perceive innovation use as congruent with their values.
Organizational benefits result from effective implementation provided the innovation was initially efficacious and remains so during implementation. Implementation outcomes, in turn, have implications for continuing and future implementation efforts.
Download Organizational Climate and Culture: An Introduction to Theory Research and Practice
To illustrate the theoretical constructs associated with implementation effectiveness, we consider the national Working Well Trial, the largest federally funded worksite cancer prevention trial in the United States — We use the Working Well Trial to provide a common frame of reference and to reduce the level of abstraction in the model description that follows.
Organizational readiness for change refers to the extent to which targeted employees especially the implementers are psychologically and behaviorally prepared to make the changes in organizational policies and practices that are necessary to put the innovation into practice and to support innovation use. As noted earlier, implementing complex innovations usually entails making a host of interrelated changes in organizational structures and activities.
In the Working Well Trial, for example, implementing the smoking intervention entailed organizing an employee advisory board EAB ; identifying the original smoking policy if one existed and its level of enforcement; drafting new, more restrictive smoking policies that were state-of-the-science and acceptable to the EAB; creating a communication plan to inform employees of the new policy and the consequences associated with violations of the policy; implementing the new policy by distributing no smoking signs; removing ashtrays; installing smoke detectors; informing visitors of the new policy; monitoring compliance with the policy; enforcing the policy; conducting educational campaigns to raise awareness of the risks of secondhand smoke; and offering a variety of smoking cessation opportunities to assist smokers who may be prompted to quit as a result of the new policy e.
Organizational readiness to make changes such as these is reflected in the level of change commitment and change efficacy. Similar to Bandura's notion of goal commitment [ 53 ], change commitment refers to targeted employee and management's shared resolve to pursue courses of action that will lead to successful implementation. We emphasize shared resolve because implementing complex innovations involves collective action by many people, each of whom contributes something to the implementation effort. This implies that greater variability in change commitment reflects less readiness for change.
As with change commitment, we emphasize shared beliefs and collective or group-referenced capabilities because implementation entails collective action among interdependent individuals and work units. As Bandura and others note [ 56—58 ], efficacy judgments refer to action capabilities; they are not about outcome expectancies or assessments of knowledge, skills or resources [ 56 ]. Change efficacy is higher when people share a sense of confidence that collectively they can implement a complex innovation e.
Organizational readiness for change is innovation specific. An organization can exhibit high readiness with respect to one innovation and low readiness with respect to another. That larger social contextual influence prompted employers to consider implementing more restrictive smoking policy changes, thus putting the organization at a level of high readiness to change. However, during that same time period, many of the same organizations were not aware or concerned about having healthy foods available in the cafeteria or vending machines.
Thus, they exhibited low readiness to change related to access to healthy foods while exhibiting a high level of readiness to change the smoking policy. We posit that organizations that exhibit high readiness are more likely than those that exhibit low readiness for change to initiate the changes in organizational structures, policies and practices that are necessary to support innovation use and to do so more effectively.
Implementation policies and practices refer to the plans, practices, structures and strategies that an organization employs to put the innovation into place to support innovation use [ 38 ]. Implementation policies and practices are the means by which an organization assimilates an innovation in order to achieve an acceptable level of operational, cultural and strategic fit. The assimilation process, as others have noted, entails a mutual adaptation of the innovation and the organization [ 52 , 59 ].
Some implementation policies and practices are temporary measures that intentionally or naturally disappear when the organization reaches desired levels of innovation use. Others remain in place long after the implementation phase in order to support and reinforce continued innovation use.
The Working Well Trial smoking intervention illustrates a variety of interrelated implementation policies and practices that worksites can employ to deploy a worksite health promotion program and support program use. In addition, budget redeployment to support the program and its implementation was carried out. Because fit is context dependent, the specific implementation policies and practices needed to support putting an innovation into practice and support its use may vary considerably by innovation and across organizations.
For example, training may be essential when asking cafeteria workers to change recipes so that healthier foods can be served in the cafeteria. However, training may not be necessary to enact a restrictive smoking policy. Likewise, for a given health promotion program e.
Generally speaking, the more implementation policies and practices, the better However, the presence of some high-quality practices and policies may compensate for the absence or low quality of other policies and practices.
For example, high-quality in-person training might substitute for poor-quality program manuals. Finally, different mixes of implementation policies and practices can produce the same results [ 45 , 60 ]. Following Klein and Sorra, we posit that an organization's implementation policies and practices influence innovation use by shaping the organization's implementation climate.
Through interactions with each other and with implementation policies and practices, targeted employees develop a collective sense of the organization's priorities and sanctioned means for achieving those priorities [ 60—62 ]. Colloquially, an organization's implementation climate offers targeted employees answers to the following questions. Are we expected to do this? Can we in fact do this e. And, if we do this, what will happen? For example, organizations can strengthen the implementation climate by making sure that targeted employees have easy access to high-quality training, technical assistance and documentation all of which enhance knowledge and skills ; engaging employees in decision making about innovation design and implementation e.
Organizational Climate and Culture by Mark G. Ehrhart -
Like organizational readiness for change, implementation climate is innovation specific. An organization can have a strong implementation climate for one innovation and a weak implementation climate for another.
The same might be true for specific interventions in a comprehensive worksite health promotion program. In the Working Well Trial, for example, some worksites established a stronger implementation climate for the smoking intervention than for the nutrition intervention [ 11 , 28 ]. WellWorks-2, a related worksite health promotion trial, reported similar variability in implementation climate related to norms about nutrition, occupational exposures and smoking interventions [ 18 ].
This specificity is what differentiates implementation climate from more general constructs like organizational climate or organizational culture [ 38 , 63 ]. Implementation effectiveness is an organization-level construct that refers to the aggregated consistency, quality and appropriateness of innovation use within an organization [ 38 , 39 , 41 ].