Encouraging evidence uptake  

Changing practice does not often occur just because evidence becomes available. Translating research evidence into practice requires deliberate and planned effort. Implementation focuses on actively supporting the uptake of evidence-based interventions and practices.

The related but different activity of implementation research (science) is 'the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice'. [1,2]


Implementation

Implementation aims to increase the use of interventions and practices for which there is evidence of effectiveness. This might be in response to a current lack of programs or to replace programs that are not working or are less efficient. Studies of implementation have evolved from an initial focus on service and client outcomes to recognition of the importance of implementation outcomes (each defined below). [2,4] 

  • Implementation outcomes - acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability
  • Service outcomes - efficiency, safety, equity, patent-centeredness, timeliness
  • Client outcomes - satisfaction, function, symptomatology.

In Proctors' model, implementation outcomes are defined as 'the effects of deliberate and purposive actions to implement new treatment, practices, and services.' [3] Examination of this helps us to understand what facilitates or blocks success of an implementation strategy which in turn affects both service and client outcomes. In clinical terms it tells us what works in practice based on effectiveness of the implemented change and expands on this to capture the contextual factors contributing to a successful outcome.


Some of the skills you will need to develop and where you can find help to build skills include: [4]
  • Understand knowledge translation and dissemination activities: How to interpret research findings for various audiences and uses, understand synthesis and implementation strategies.
  • How to be a knowledge broker: ability to act as a bridge between evidence and implementation; applying knowledge translation strategies to facilitate the flow of knowledge, improve practice and policy and increase research findings’ uptake.
  • Understand the context: knowing “how things really work” in your local context, and the applicability and adaptability of evidence to the user context.

Understanding how implementation fits in to the process of taking evidence to practice helps. Sometimes it can be difficult to understand what is meant by implementation and implementation science. Curran [5] has created a teaching slide to help health professionals understand what implementation does. Implementation simply looks at how best to help people and organisations do the thing needing to be implemented. 


What implementation does

When defining implementation science, [5] some very non-scientific language can be helpful....

  • The intervention/practice/innovation is THE THING
  • Effectiveness research looks at whether the THE THING works
  • Implementation research looks at how best to help people/places DO THE THING
  • Implementation strategies are the stuff we do to try to help people/places DO THE THING
  • Main implementation outcomes are HOW MUCH and HOW WELL they DO THE THING

Used under the Creative Commons Attribution 4.0 International License Copyright, BioMedCentral


Implementation strategies

The Cochrane Collaboration's Review Group on Effective Practice and Organisation of Care has identified four broad categories of implementation strategy interventions targeted at either: healthcare organisations, healthcare recipients, healthcare workers, or specific types of practice, conditions or settings. Many of these are widely used in practice, and a large number of systematic reviews have examined their effectiveness. The Rx for Change Interventions Database (Canadian Agency for Drugs and Technologies in Health) identifies a staggering body of literature that attempts to identify what interventions work and in what circumstances.

There is no strategy suitable for all circumstances, and what works best will depend on the intervention, the setting, the people involved and what resources the project has. Improving the reporting of implementations tudies wil help us build our understanding of what works in what contexts. [2] The Standards for reporting Implementation Studies (StaRI) statement will lead to comparable studies that will help in this regard. Nevertheless, Wensing recommends working creatively to plan a cost-effective mix of approaches tailored to the local setting, relying where possible on methods that have worked elsewhere in similar situations. [5]


It is worth noting that there have only been a few KT and Implementation theories, models and frameworks used in end of life studies. [7] Palliative care specific models such as the Evidence-based Model for the Transfer and Exchange of Research Knowledge (EMTReK) are now emerging. [8]

Queensland Health has a video on implementing a practice change and the different strategies you might consider depending on local circumstances. 

Plan the implementation! Possibly the most important element of implementing change is to actually plan the implementation, rather than assume it will automatically happen on the strength of the identified need or the evidence alone.


Wensing [6] emphasises the importance of planning. First, there should be a good basis for change. This could be new scientific knowledge, or perhaps a particular problem or best practice is identified. Second, the implementation should be planned (when, where, how, and by whom the implementation will occur). Clearly outlining the advantages of change, and solutions for any possible disadvantages also helps. [5] A diagnostic analysis can reveal the target group and behaviours, and identify barriers and facilitators to change. In common with dissemination, program logic models and theories of change are useful tools in planning implementation programs.

Principles

The general principles of planning are similar across different projects and circumstances but include: [9]

  • Plan development
  • Testing
  • Adapting and scheduling
  • Evaluation and organisation of the implementation.
Barriers and facilitators

Implementation effectiveness with different KT strategies varies. How well the barriers to implementation can be overcome has been identified as a key factor in success. [2]

Characteristics of successful innovations include: [6]

  • Compatibility with existing norms and values
  • Opportunity to try them out
  • A clear and easily accessible format
  • Co-design and opportunity to adapt to local situation

Identifying factors or determinants that might facilitate or block change is important because targeting these can result in a more effective implementation strategy. [6]


Tools such as Identifying Barriers to Evidence Uptake (NICS) and How To: Implement Change Successfully (113kb pdf) (University Hospitals Bristol, UK) may be useful in your clinical implementation project. Planning for change can benefit from input from theories on implementation of change. Visit the pages on theories of change for an overview of how these can help facilitate stakeholder involvement and uptake of change.


Knowing whether your organisation is ready to implement change is a key consideration when planning for change. A range of tools are available to help with your assessment of readiness to change. The Canadian Knowledge Translation Program has a useful Decision Support tool to help you choose which one to use. 

  1. Eccles MP, Mittman BS. Welcome to Implementation Science [editorial]. Implement Sci. 2006 Feb;1:1. https://doi.org/10.1186/1748-5908-1-1
  2. Barwick M, Dubrowski R, Petricca K. Knowledge translation: The rise of implementation (1.32MB pdf). Washington, DC: American Institutes for Research. 2020 Nov.
  3. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65-76. doi: 10.1007/s10488-010-0319-7.
  4. Mallidou AA, Atherton P, Chan L, Frisch N, Glegg S, Scarrow G. Core knowledge translation competencies: a scoping review. BMC Health Serv Res. 2018 Jun 27;18(1):502. doi: 10.1186/s12913-018-3314-4.
  5. Curran GM. Implementation science made too simple: a teaching tool. Implement Sci Commun. 2020 Feb 25;1:27. doi: 10.1186/s43058-020-00001-z.
  6. Wensing M, Grol R, Grimshaw J, edtiors. Improving Patient Care: The Implementation of Change in Health Care [Internet]. 3rd ed. Wiley–Blackwell; 2020. [cited 2022 May 19].
  7. Strifler L, Cardoso R, McGowan J, Cogo E, Nincic V, Khan PA, et al. Scoping review identifies significant number of knowledge translation theories, models, and frameworkswith limited use. J Clin Epidemiol. 2018 Aug;100:92-102. doi: 10.1016/j.jclinepi.2018.04.008. Epub 2018 Apr 13.
  8. Payne C, Brown MJ, Guerin S, Kernohan WG. EMTReK: An Evidence-based Model for the Transfer & Exchange of Research Knowledge-Five Case Studies in Palliative Care. SAGE Open Nurs. 2019 Jul 26;5:2377960819861854. doi: 10.1177/2377960819861854.
  9. Grol R, Wensing M, Eccles M, editors. Improving patient care: the implementation of change in clinical practice. Oxford: Elsevier; 2005.

Last updated 04 May 2022