Increasing Access to Organization Theories for Implementation Science
Sarah A. Birken1* 
Linda K. Ko2 
Mary Wangen3 
Cheyenne R. Wagi1 
Miriam Bender4 
Per Nilsen5 
Mimi Choy-Brown6 
Alexandra Peluso1 
Jennifer Leeman7- 1Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
- 2Washington School of Public Health, Health Systems and Population Health, Seattle, WA, United States
- 3UNC Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
- 4Sue & Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
- 5Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- 6School of Social Work, College of Education and Human Development, University of Minnesota, St. Paul, MN, United States
- 7School of Nursing, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
Background: Organization theories offer numerous existing, highly relevant, yet largely untapped explanations of the organizational dynamics underlying evidence-based intervention (EBI) implementation. Rooted in ideas regarding power, autonomy, and control, organization theories can explain how and why organizations adopt, implement, and sustain EBI use. Although they have gained visibility, organization theories remain underused in implementation research, perhaps due to their inaccessibility to implementation scientists. To improve access to organization theory among implementation scientists, we summarized organization theories with relevance to implementation science.
Methods: Led by the Cancer Prevention and Control Research Network (CPCRN) Organization Theory for Implementation Science workgroup, we employed a modified Delphi process to reach a consensus among 18 experts at the intersection of organization and implementation science regarding organization theories with relevance to implementation science. From texts that described the organization theories, using standardized abstraction forms, two investigators independently abstracted information regarding constructs, propositions regarding how or why constructs might influence implementation, the potential relevance of organization theories' propositions for implementation, and overviews of each theory. The investigators then reconciled discrepancies until reaching consensus. A third investigator reviewed reconciled abstraction forms for accuracy, coherence, and completeness.
Findings: We identified nine organization theories with relevance to implementation science: contingency, complexity, institutional, network, organizational learning, resource dependence, sociotechnical, and transaction cost economics. From the theories, we abstracted 70 constructs and 65 propositions. An example proposition from institutional theory is: “Coercive, mimetic, and normative pressures contribute to organizations…within an organizational field [becoming increasingly similar].” These propositions can be operationalized as levers to facilitate EBI implementation.
Conclusions: To increase use in the field, organization theories must be made more accessible to implementation scientists. The abstraction forms developed in this study are now publicly available on the CPCRN website with the goal of increasing access to organization theories among an interdisciplinary audience of implementation scientists through the CPCRN Scholars program and other venues. Next steps include consolidating organization theory constructs into domains and translating the resulting framework for use among researchers, policymakers and practitioners, aiding them in accounting for a comprehensive set of organization theory constructs thought to influence EBI implementation.
Introduction
Implementation scientists increasingly acknowledge that evidence-based intervention (EBI) implementation is influenced by organizations' internal and external settings (1, 2). Constructs relating to organizations' internal and external settings (“organization-level constructs”) are reflected in many implementation science theories, models, and frameworks (TMFs). For example, the Consolidated Framework for Implementation Research includes organization-level constructs that could influence implementation such as external policies and incentives (3); Promoting Action on Research Implementation in Health Services includes physical, social, and cultural context that impacts on implementation (4); and the Theory of Innovation Implementation includes access to financial resources as a potential influence on implementation (5–8). Although implementation TMFs include organization-level constructs, they do not comprehensively conceptualize organizations' internal and external settings, which are multifaceted, and implementation TMFs lack nuanced explanations of how and why implementation is influenced by dynamics within and among organizations. Without clear understanding of organization-level constructs' influence on implementation, the potential to leverage organization-level constructs (e.g., restructuring; incentives) to facilitate implementation will remain unrealized (3, 9–11).
Organizations manage implementation by exerting power—i.e., the ability to wield resources to manage implementation in ways that will benefit the organization (e.g., resisting or embracing implementation) (12). To manage implementation, organizations exert many forms of power (e.g., legitimate, coercive, expert), and organizations may exert power horizontally (e.g., strategic relationships within a health system) and vertically (e.g., controlling decisions within government or accrediting bodies). The power that organizations exert to manage implementation can be explained using organization theories. Organization theories describe, explain, and predict complex influences within and across organizations (13). Thus, organization theories have the potential to account for dynamics related to power that organizations exert (e.g., policies, funding, contracts) to manage implementation. Organization theories' history is described in detail elsewhere (14). Briefly, organization theories are rooted in ideas regarding power and associated constructs including structure, autonomy, control. Organization theories explain, for example, how and why organizations come to exist, die, perform as well or as poorly as they do, including organizations' power to adopt, implement, and sustain innovations—or to resist adopting, implementing, or sustaining innovations. Organization theories have been widely used in other fields such as education, public management, and health services research (15–18). Since our initial call for organization theories' use in implementation science (14), the application of organization theory in implementation research has remained limited (19).
Organizational theory remains largely unused and unfamiliar to implementation scientists (14). The field of implementation science has been significantly shaped by the work of many health psychologists, who may view implementation through the lens of psychology, which predominantly focuses on individual-level cognitive constructs thought to influence behavior (e.g., attitudes, beliefs, motivation). These experts have introduced implementation science to a host of psychological theories, which emphasizes the individual's deliberation and rational decision-making process (e.g., Social Cognitive Theory, Theory of Planned Behavior, Health Belief Model). Advances in psychological theories have supported their use in implementation science, for example, through the development of the Theoretical Domains Framework (TDF), which synthesizes 33 psychological theories into 14 domains. Of note, constructs within psychological theories relating to analytical levels beyond individuals (e.g., the TDF's environmental context and resources) remain conceptualized as they relate to individual behavior.
In contrast to the individual focus of psychological perspectives, the analytical level of organization theories is typically the organization or organizational field (e.g., health system). For example, implementation climate, a construct from the Theory of Innovation Implementation, must be measured from the perspective of the organization rather than the individual (20). However, empirical studies in implementation science often collect data from individuals; the challenge of capturing collective-level influences may provide a further explanation as to why organizational theories are not used to the same extent as individual-level theories (21).
To increase the accessibility of organization theories, and thus contribute to more comprehensive, nuanced conceptualization of organization-level constructs in implementation science, our study summarized organization theories and their relevance to implementation science. Our overarching goal is to support the use of organization theories in implementation science by, for example, supporting the selection of strategies that target organization-level constructs that influence implementation.
Methods
This study was guided by the Cancer Prevention and Control Research Network's (CPCRN) Organization Theory for Implementation Science (OTIS) workgroup (22). CPCRN is a national network of academic, public health, and community partners who work together to reduce the burden of cancer. The OTIS workgroup's overarching mission is to advance the science of implementation by increasing access to organization theory. In meetings that were held monthly or as needed, OTIS workgroup members, who have expertise at the intersection of implementation and organization science, offered perspectives on the purpose, methods, and analysis, and interpretation of the data collected. The study described below employed a modified Delphi process (23–25) to reach a consensus among experts at the intersection of implementation science and organization theory (25) in (1) a survey regarding organization theories relevant to implementation science and foundational texts that described them; (2) a process of developing a standardized form in which to present our findings; and (3) a process of abstracting information from the texts into the form. We describe each of these steps in detail below and in Figure 1.
Figure 1. Data abstraction process.
Survey to Identify Organization Theories Relevant to Implementation Science
Sample and Recruitment
SB and JL, each of whom have expertise at the intersection of implementation and organization science, drew upon their professional networks to identify other experts at the intersection of implementation science and organization theory. SB and JL invited a total of 31 experts working in academic or government institutions in the US, Canada, and Europe to participate in the survey via email, repeating contacts until experts indicated whether they were willing to participate. The survey was deemed not human subjects research by the Institutional Review Board of The University of North Carolina at Chapel Hill.
Data Collection
The survey was designed to elicit participants' perspectives on (1) which organization theories may be relevant to implementation science, (2) foundational texts that described organization theories identified as potentially relevant, and (3) texts that demonstrated theories' application in implementation science. To promote understanding of which organization theories may be relevant to implementation science, the survey defined ‘organization theory’ and ‘implementation science’ and listed 12 organization theories that we, as experts at the intersection of organization and implementation science, identified as potentially relevant to implementation science. Participants were asked to review the list and identify theories that should either be added or removed. We also asked participants to select one or more of the theories with which they were most familiar. For each theory they selected, participants were shown a list of texts (61 across the 12 theories) that SB identified as potentially relevant to the theory based on a PhD-level course on organization theory at The University of North Carolina at Chapel Hill. Based on the list of texts, participants were asked to evaluate texts' relevance to describing the theory and to identify additional texts describing the theory generally and it application to implementation science. We administered the survey between July 31, 2018 and November 29, 2018 via Qualtrics (Provo, UT), multifunctional online survey software.
Analysis
OTIS workgroup members collaboratively reviewed survey findings. Based on the feedback from survey respondents, theories and texts were added or eliminated.
Theory Abstraction Form Development
Based on our collective expertise in theory, OTIS workgroup members developed an initial standardized abstraction form. We then hosted a pre-conference meeting at the 12th Annual Conference on the Science of Dissemination and Implementation in Health (26) on December 4th, 2019 to solicit feedback on the form from additional experts in the field. The objective of the meeting was to identify an optimal approach to synthesizing organization theory abstractions into something that would be useful to implementation researchers. Topics of discussion included project background, proposed use, options for distilling the information into a usable format, conceptual level, potential outcomes, and any additional theories not addressed by the survey participants, followed by next steps for the project. Detailed notes were taken during the group discussions and reviewed by the project's leadership team, with the goal of further refining the abstraction form to meet the needs of implementation researchers. We then pilot tested the forms by creating three forms for sample organization theories and applied the theories to three case studies of colorectal cancer screening interventions (27). Institutional Theory, Transaction Cost Economics, and Contingency Theory were applied to the case studies. For each theory, outer setting-level determinants and propositions were defined. The process of applying the forms allowed us to revise them to promote usability. For detailed information on this process, see Leeman et al. (26).
Abstraction of Data From Theories
The data abstraction process took place over multiple steps (Figure 1). Two OTIS workgroup members abstracted data regarding each theory. First, both members of each pair independently entered data into the abstraction form using information derived from texts identified in the survey as relevant to the theory. Second, pairs met to reconcile discrepancies in abstracted data until consensus was reached. Third, one member of each pair integrated data into a single abstraction form for each theory.
To enhance the validity of the data included in each abstraction form, we recruited experts who participated in the survey to provide feedback on a theory with which they were familiar. We offered participants a $100 honorarium to edit the forms and respond to the following questions: (1) Does the abstracted theory qualify as an organization theory (defined in the survey as, “Organizational theories explain phenomena such as change by explaining relationships between organizations and their environment”)? (2) Does the information on the form reflect the experts' understanding of the theory's tenets? (3) Is any key information missing from the form? (4) Are the claims about the theory's application to implementation science reasonable? We then engaged OTIS workgroup members to provide feedback on the forms with respect to (1) ease of use and quality of formatting, (2) ease of understanding and quality of language use, (3) resonance with members' work, (4) relevance to members' work, (5) relevance to implementation science, and (6) accuracy. The abstractors for each theory were responsible for incorporating feedback into abstraction forms, consulting with the leadership team as needed. Finally, we edited each form for consistency, word choice, and formatting and sought final approval from the OTIS workgroup.
Results
Survey
Eighteen experts participated in the survey (58% response rate).
Sixteen theories were identified in the survey: 12 listed in the survey for participants' assessment, and four that participants identified (Figure 1). From the 16 theories, we excluded seven because they represented perspectives rather than theories with falsifiable hypotheses (n = 5: Models of Change, Theory of Practice/Coordination, Adaptation Theory, Strategic Management Perspective, and Resource-based View of the Firm) or were not organization theories (n = 2: Behavioral Theories and Innovation Theory). The texts that experts identified as relevant to each theory are listed in Table 1.
Table 1. Foundational texts by theory – results of the survey.
Theory Abstraction Forms Development
The initial form draft included the following sections: (1) summary of the theory, (2) key constructs, (3) proposed relationships among key constructs, (3) bounds of theory, (4) implications for implementation, and (5) implications for implementation strategies. After abstracting data from the foundational texts, we revised the forms' sections based on discussion among a total of 12 experts, including OTIS workgroup members and external experts who attended the pre-conference meeting at the 12th Annual Conference on the Science of Dissemination and Implementation in Health. In that process, we identified the need for example applications to implementation science and criticisms, and we renamed the sections for clarity. The resulting final draft of the form included the following sections: (1) theory overview (changed from ‘summary of the theory’), (2) example application to implementation science, (3) constructs and definitions (changed from ‘key constructs’), (4) propositions (changed from ‘proposed relationships among key constructs’), (5) relevance to implementation science (changed from ‘implications for implementation’), and (6) criticisms and/or bounds on the theory (changed from ‘bounds of the theory’).
Abstraction of Data From Theories
The final abstraction forms describe nine organization theories and their potential relevance to implementation science. Across the theories, we abstracted 70 constructs (Table 2) and 65 propositions. Below, we offer an overview of the data included in each section of the abstraction form and examples of each section from one of the included theories. Supplemental Files - Abstraction Form contains information in each abstraction form organized by section.
Table 2. Organization theory constructs and definitions.
Theory Overview
The theory overview section provides a brief orientation to the theory's basic tenets. For example, the overview of transaction cost economics theory is: ‘Organizations incur costs as a result of planning, implementing, and enforcing transactions with other organizations. Organizations strive for greater efficiency by implementing governance structures that will minimize transaction costs.’
Example Application to Implementation Science
In this section, we provide full citations of empirical studies that used the organization theory. For example, for complexity theory, we provide references for two studies: Braithwaite et al.'s (32) 2018 empirical analysis of systems change and Colón-Emeric et al.'s (33) 2017 cluster-randomized trial of an intervention to improve staff interactions around fall prevention in nursing homes.
Constructs and Definitions
In the constructs column of this section, we list each construct from the theory. In the definitions column, we provide a definition of each construct from one or more of the foundational texts, often with practical examples. For example, organizational learning theory includes the construct ‘explicit knowledge,’ which is defined as ‘facts and information that can be codified (e.g., in policies and procedures)’ (34).
Propositions
In this section, each proposition includes at least two constructs and posits relationships among those constructs. In the case of each theory, multiple propositions are listed. Examples of propositions from resource dependency theory include: ‘competition increases uncertainty and decreases stakeholders’ willingness to adopt or implement new strategies' and ‘decreased munificence requires organizations to reduce their dependence on some resources and/or find alternative resources.’
Relevance to Implementation Science
Each statement of relevance to implementation science includes an implementation outcome and a construct from the theory. For example, sociotechnical systems theory proposes that implementation may be facilitated by optimizing organizational, social, and technical subsystems. Network perspective proposes that direct and indirect ties, network density, cohesion, embeddedness, and flexibility among organizations influence the diffusion, dissemination, adoption, scale-up, and spread of evidence-based practices (35).
Criticisms and/or Bounds on the Theory
This section lists full references for any articles that critique the theory or suggest contexts or conditions under which the theory may or may not apply, as well as examples of criticisms or bounds. For example, in her 1981 paper, Claudia Bird Schoonhoven (36) argues that contingency theory's statements are ambiguous and that the relationships it hypothesizes are of ambiguous functional form.
Discussion
This study sought to summarize organization theories and their relevance to implementation science. Using expert-developed and –refined abstraction forms, we synthesized nine organization theories that collectively include 70 constructs and 65 propositions with relevance to implementation science. Our objective in developing the forms was to increase implementation scientists' access to organization theories. To that end, we have posted OTIS abstraction forms on the CPCRN website (22). In achieving our objective, we have made publicly available a subset of the many published organization theories that may be relevant to implementation science, introducing implementation scientists to a more comprehensive set of constructs relating to organizations' internal and external settings and nuanced explanations of organization-level influences on implementation. Increasing access to organization theories gives implementation scientists the opportunity to incorporate perspective on the power that organizations exert to adopt, implement, and sustain innovations—or to resist adopting, implementing, or sustaining innovations. The nuanced perspective that organization theories offer to implementation science is documented in several extant studies [e.g., (27, 37)]. For example, Leeman & Mark (38) applied Transaction Cost Analysis to understand health plans' decisions to exert their power to improve chronic illness management by employing a centralized team of case managers vs. incentivizing clinics to redesign the way they provide care. The benefits of applying organization theory to implementation science has also been documented (27). The increased access to organization theories that the forms offers has the potential to extend the perspective that organization theories offer more broadly in implementation science.
The organization-level constructs that we identified in our study can be used to expand the relatively limited scope of constructs represented in, for example, the CFIR's inner and outer setting domains and the TDF's environmental context and resources domain. Collectively, the CFIR's inner and outer setting domains include nine constructs, and the TDF's environmental context and resources domain includes four constructs (39). Thus, OTIS substantially broadens implementation science's conceptualization of organization-level constructs by describing 70 constructs that go beyond the organization-level constructs included in extant implementation TMFs.
OTIS abstraction forms include constructs not represented in extant implementation TMFs such as uncertainty, power, complexity, and competition. OTIS abstraction forms can be used to complement the CFIR's organization-level constructs, which are based in part on other theories, models and frameworks, and in part on evidence. The 65 OTIS propositions describe, explain, and predict relationships between organization-level constructs and implementation. OTIS abstraction forms may also enhance understanding of the relationship between the TDF's organization-level constructs, which are based in psychological theories intended to conceptualize individual behavior, with organization theories, which are specifically designed to conceptualize organization-level phenomena that influence implementation. Future work that directly maps OTIS constructs and propositions onto organization-level constructs in extant implementation TMFs is needed to broaden extant TMFs' conceptualization of organization-level constructs and to explain how organization-level constructs influence implementation.
In addition to integration with extant implementation TMFs, we hope that implementation scientists find that the abstraction forms themselves enhance their work. Implementation scientists may use the forms to develop basic understanding of organization theories relevant to implementation science; define included constructs; identify propositions and potential relevance to implementation science; and understand criticisms and/or bounds on the theories. We hope that information regarding organization theories will promote high-quality theory application in implementation science. That is, exposure to OTIS abstraction forms may help implementation scientists to evaluate whether a given organization theory is relevant to their work and, if so, to apply the theory knowledgeably and appropriately. This is an important contribution given evidence that implementation scientists have been found to superficially and inappropriately apply theories, models, and frameworks (40); appropriate theory application is essential for the selection of strategies, as theory identifies the mechanisms by which strategies produce outcomes (41). Indeed, our work has already enhanced implementation science. For example, one OTIS workgroup member applied resource dependency theory to conceptualize aspects of organizations and resources that may have been impacted by the COVID-19 pandemic (42).
There are several limitations to this study. First, our Delphi approach was limited to our network of colleagues with scholarship at the intersection of organization theory and implementation science. We may have failed to recruit participants who could have suggested theories, texts, or perspectives not reflected in our resulting abstraction forms. Second, the respondents represented a geographically-limited group of implementation scientists, only covering the U.S., Canada, and Western Europe. Third, despite our attempts to methodically abstract relevant constructs and propositions from foundational texts, we may have omitted information from the abstraction forms. Third, we may have failed to include relevant organization theories. To address this, we regard the abstraction forms that we have compiled as living documents to be revised and augmented through implementation scientists' careful review, critique, and application.
To further promote access to organization theories for implementation science, the forms have been added to the CPCRN website (22). We will also incorporate the forms into the CPCRN Scholars program with the goal of increasing knowledge and access to organization theories among an interdisciplinary audience of implementation scientists. The forms may be useful for other implementation science training programs and we hope by sharing them in these spaces, we can increase their use by implementation scientists. We are in the process of consolidating the organization theory constructs into domains and translating the resulting framework for use among policymakers and practitioners. The resulting OTIS framework may help implementation scientists to consider a more comprehensive set of factors in organizations' internal and external environments as well as determining which organization theories are relevant to their work. Finally, the forms that we developed may be useful for adding organization theories that are identified in the future, or for efforts to summarize TMFs at other levels (e.g., teams; communities).
Conclusions
Organization theories offer implementation researchers numerous existing, highly relevant, yet largely untapped explanations of the organizational dynamics underlying the implementation of evidence-based practices. To advance the use of organization theory among implementation scientists, we summarized organization theories most relevant to implementation science. To promote the theories' relevance to the field, we invite implementation scientists to review, critique, and apply the forms, and to contribute their resulting feedback to the OTIS workgroup for incorporation into these living documents.
Data Availability Statement
The original contributions presented in the study are included in the article/Supplementary Materials, further inquiries can be directed to the corresponding author/s.
Author Contributions
The authors confirm contribution to the paper as follows: Study conception and design: SB, LK, and JL. Data collection and analysis and interpretation of results: SB, LK, MW, MB, PN, MC-B, and JL. Draft manuscript preparation: SB, LK, MW, CW, MB, PN, MC-B, AP, and JL. All authors reviewed the results and approved the final version of the manuscript.
Funding
This publication was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award with 100 percent funded by CDC/HHS (Cooperative Agreement Number U48 DP006400). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.
Author Disclaimer
The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Acknowledgments
We would like to thank all of those who took part in the surveys and development of the abstraction forms. Additionally, we would like to thank Barbara Baquero and the members of the CPCRN OTIS workgroup for their contributions.
Supplementary Material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frhs.2022.891507/full#supplementary-material
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Keywords: organization theory, constructs, propositions, adoption, implementation, sustainment
Citation: Birken SA, Ko LK, Wangen M, Wagi CR, Bender M, Nilsen P, Choy-Brown M, Peluso A and Leeman J (2022) Increasing Access to Organization Theories for Implementation Science. Front. Health Serv. 2:891507. doi: 10.3389/frhs.2022.891507
Received: 07 March 2022; Accepted: 08 June 2022;
Published: 30 June 2022.
Edited by:
Erin P. Finley, United States Department of Veterans Affairs, United StatesReviewed by:
Danielle D'Lima, University College London, United KingdomMegan B. McCullough, University of Massachusetts Lowell, United States
Copyright © 2022 Birken, Ko, Wangen, Wagi, Bender, Nilsen, Choy-Brown, Peluso and Leeman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Sarah A. Birken, sbirken@wakehealth.edu