Implementation Science

Introduction[edit | edit source]

The need for rehabilitation services in health systems has increased with a subsequent desire to implement evidence-based practices (EPB).[1] Rehabilitation professionals utilise evidence-based practice (EBP) when making intervention decisions based on the best evidence available.[2] It is a widely held belief among healthcare care practitioners that it is critical to know why, what and how an intervention works in different settings [1].  A key factor guiding EBP is including the patient in the decision-making process. Family norms, traditions, cultures and personal beliefs should play a role in the intervention choice. Research supports EBP has better outcomes with patient participation.[2] In addition to patient involvement, practitioners need to take into account costs, resources in the community and the nature of the healthcare system.[2]

Challenges to Implementing EBP[edit | edit source]

Rehabilitation intervention evidence is growing every day. Principles and guidance on rehabilitation interventions are increasingly available such as:

  1. NHS Commissioning Guidance for Rehabilitation
  2. World Health Organization Package of Rehabilitation Interventions Information Sheet [1]

Despite the wealth of information, the uptake of this evidence into practice is a slow process, especially in lower-middle income countries.[1] The translation from clinical research to clinical practice can take anywhere between 10-20 years. [3]Some of the barriers causing this delay are listed below:

  • Patient preference for an intervention
  • Time demands of healthcare professionals
  • Skills of practitioners, including lack of research skills [4]
  • Confidence of practitioners
  • Belief in intervention by healthcare professionals
  • Clinical trials may not transfer to clinical settings
  • Resources of health facility
  • Informational overload by healthcare professionals
  • Institutional support [3] [5]

In lower-middle income countries (LIMCs), the need for quality interventions is higher, however, the capacity to implement is much lower than in resource-rich countries.[6] Grimmer et al. (2019) [7] has described the challenges lower-middle income countries face to implementing EBP which are described below.

System level challenges[edit | edit source]

  • Limited awareness & understanding of evidence-based rehabilitation interventions
  • Limited quantification of existing rehabilitation services, workforce & service utilisation
  • Lack of specific government policy, strategic planning, legislation., funding for rehabilitation services across health system level (primary, secondary & acute)[7]

Health Care Provider level challenges[edit | edit source]

  • Lack of mandate to provide evidence-based rehabilitation interventions
  • Limited rehab workforce and capacity (awareness, skills) to treat, competing priorities and heavy workloads
  • Lack of coordination between services
  • High re-imbursements for non-evidence-based rehabilitation interventions[7]

Patient level challenges[edit | edit source]

  • Logistics of rehabilitation services
  • Affordability of rehabilitation services
  • Knowledge & attitudes to interventions
  • Health problem or condition specific factors[7]

Key Terms[edit | edit source]

  1. Implementation: The term implementation refers to the use of any strategies to adopt and integrate evidence-based interventions to change practice patterns[1]
  2. Implementation Science: The study of methods to promote the uptake of research and evidence-based practices into routine practice. Other names used include dissemination and implementation research, knowledge translation, knowledge-to-action, and continuous quality improvement in learning health systems.[1]

Implementation Science[edit | edit source]

Without a detailed implementation plan, it takes an average of 17 years for research evidence to be implanted into routine clinical practice.[5] This tremendous lag time prompted the development of implementation science which studies the process used to disseminate health information and merge it into clinical practice.[1][5] [8][9] Implementation science has many different layers and the following terms will describe each component:

  1. Implementation research: broad term referring to research by not only the provider but the organization and policy levels of healthcare[8]
  2. Implementation practice: rehabilitation leaders implement evidence based research and adatpting to different contexts and settings[1]
  3. Implementation strategies: how to strengthen the implementation, adoption and sustainability of EBP
  4. Implementation Facilitation: guide rehabilitation professions regarding identifying and addressing implementation challenges and utilising positive outcomes[1]
  5. Implementation outcome: effects of adopting the new interventions into practice[1]

In summary, implementation science is concerned with the uptake and implementation of EBP. It strategically, de-implements “low-value” care while expanding effective evidence interventions.[1]

Implementation Frameworks[edit | edit source]

As the implementation science field has grown, many frameworks have been developed to provide pathways for implementation. Frameworks clarify the core constructs of each step and phase providing accessibility to all involved in the implementation effort. [10] The aim of frameworks is to blend disciplines and combine insights from different approaches. [11]

Below are a sampling of various implementation frameworks and their links categorized based on their target goal:

Frameworks focused on: what steps to take to implement a new EB intervention

  1. EPIS Framework
  2. Knowledge-to-Action-Cycle
  3. Getting to Outcomes Model

Frameworks focused on: what differences would there to implementing a new EB intervention

  1. Consolidated Framework for Implementation Research (CFIR)
  2. Theoretical Domains Framework
  3. Integrating Promoting Action on Research Implementation in Health Services (I=PARIHS)

Framework focused on: how to make changes happen:

  1. Normalization Process Theory

Frameworks on: what effects the implementation strategies are having

  1. RE-AIM – which stands for (Reach, Effectiveness, Adoption, Implementation and Maintenance
  2. Precede-Proceed Model of Health Program Planning & Evaluation
  3. Consolidated Framework for Implementation Research (CFIR)

Many of these various frameworks are not used in isolation as they often are used together.[1]

Implementation Facilitation Mindset[edit | edit source]

Implementation facilitation is a multi-stage process that encompasses pre-implementation, implementation and sustainment. Facilitators implementing EBP adhere to three key factors:

  1. Intervention: the program or practice they want to adopt, scale up or spread; Questions they consider: Is there strong evidence for the intervention? Does this intervention have an advantage?
  2. Context: the setting that will either enable or hinder the implementation; Questions they consider: Is there a readiness and openness for change to implement this new intervention? Will this new intervention receive support from senior management and organisational leadership?
  3. Stakeholders: who are the key implementation players for the intervention (policymakers, organisational managers, or frontline rehabilitation professionals); Questions they consider: What knowledge, skills, and beliefs exist with stakeholders What resources and time are available amongst the stakeholders?

Summary[edit | edit source]

Implementation facilitation describes how to administer implementation science while identifying barriers and creating solutions to have a supportive sustainable evidence-based clinical practice or programs.[1]

Resources[edit | edit source]

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Naccarella, L. Implementation Science Course. Plus. 2022
  2. 2.0 2.1 2.2 Portney LG. Foundations of clinical research: applications to evidence-based practice. FA Davis; 2020 Jan 16.
  3. 3.0 3.1 Novak I, te Velde A, Hines A, Stanton E, Mc Namara M, Paton MC, Finch-Edmondson M, Morgan C. Rehabilitation Evidence-Based Decision-Making: The READ Model. Frontiers in Rehabilitation Sciences. 2021:51.
  4. Ibikunle PO, Onwuakagba IU, Maduka EU, Okoye EC, Umunna JO. Perceived barriers to evidence-based practice in stroke management among physiotherapists in a developing country. J Eval Clin Pract. 2021 Apr;27(2):291-306.
  5. 5.0 5.1 5.2 Lynch EA, Chesworth BM, Connell LA. Iimplementation—The missing link in the research translation pipeline: is it any wonder no one ever implements evidence-based practice? Neurorehabilitation and neural repair. 2018 Sep;32(9):751-61.
  6. Yapa HM, Bärnighausen T. Implementation science in resource-poor countries and communities. Implementation Science. 2018 Dec;13(1):1-3.
  7. 7.0 7.1 7.2 7.3 Grimmer et al (2019). A South African experience in applying the Adopt–Contextualise–Adapt framework to stroke rehabilitation clinical practice guidelines. Health Research Policy and Systems;17(1):1-14.
  8. 8.0 8.1 Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. An introduction to implementation science for the non-specialist. BMC psychology. 2015 Dec;3(1):1-2.
  9. Cabassa LJ, Baumann AA. A two-way street: bridging implementation science and cultural adaptations of mental health treatments. Implementation Science. 2013 Dec;8(1):1-4.
  10. Moullin JC, Dickson KS, Stadnick NA, Albers B, Nilsen P, Broder-Fingert S, Mukasa B, Aarons GA. Ten recommendations for using implementation frameworks in research and practice. Implementation science communications. 2020 Dec;1(1):1-2.
  11. Huybrechts I, Declercq A, Verté E, Raeymaeckers P, Anthierens S. The building blocks of implementation frameworks and models in primary care: a narrative review. Frontiers in Public Health. 2021;9.