This construct captures linkages between the Inner Setting and entities in the Outer Setting, including partnerships, collaboratives, professional societies (Aarons, Hurlburt, and Horwitz 2011; Moullin et al. 2019), referral networks between health and social services (Flottorp et al. 2013), community-academic partnerships, advocacy groups (Moullin et al. 2019), contracts, technical assistance organizations (Aarons, Hurlburt, and Horwitz 2011; Raghavan, Bright, and Shadoin 2008), and access to regional data warehouses or membership in systems (e.g., integrated healthcare system, school district) (Nilsen and Bernhardsson 2019; Aarons, Hurlburt, and Horwitz 2011).
The original CFIR (Laura J. Damschroder et al. 2009) elaborated on this construct, recognizing that Inner Settings that support and promote external boundary-spanning roles are more likely to implement new practices quickly (Aiken, Bacharach, and French 1980; Baldridge and Burnham 1975; Barnsley, Lemieux-Charles, and McKinney 1998; T. Greenhalgh, Robert, et al. 2004; Kimberly and Evanisko 1981). Professional knowledge can arise from increased boundary-spanning activities (Damanpour 1991) and participation in professional group(s), as well as external training, are associated with implementation success (Simpson and Dansereau 2007).
There is a negative relationship between linkages with external entities and implementation until clear advantages of the innovation become apparent (Burns and Wholey 1993; T. Greenhalgh, Robert, et al. 2004). However, the relationship is positive once the innovation is accepted as the norm by others in the in/formal network (see Outer Setting: External Pressure) (T. Greenhalgh, Robert, et al. 2004).
In addition, the collective relationships of individuals in a setting with outer entities represent the social capital of the setting (Brehem and Rahn 1997; Gittell and Vidal 1998; Gladwell 2006; Leana and Pil 2006); increased bridging between the Inner Setting and the Outer Setting builds social capital (T. Greenhalgh, Robert, et al. 2004; Nilsen and Bernhardsson 2019).