Too much theory and not enough practice? The challenge of implementation science application in healthcare practice

Connecting Practice to Data: Implementation Strategies to Increase Collection of Core Outcome Measures in an Inpatient Rehabilitation Facility

OBJECTIVE

To describe a quality improvement project aimed at increasing collection of a "Core Set" of functional outcome measures in an inpatient rehabilitation facility (IRF), characterize implementation strategies used across 4 study phases, and evaluate program adoption and maintenance.

SETTING

A 30-bed brain injury unit of a 132-bed IRF.

PARTICIPANTS

Participants included physical therapists (5 full-time, 2 part-time, and 30 hourly as needed) and 764 individuals with traumatic brain injury (TBI) who received care during the project period.

DESIGN

In this descriptive observational study, we operationalize implementation strategies selected for 4 project phases: Exploration, Preparation, Implementation, and Sustainment. We define each implementation strategy using the Expert Recommendations for Implementing Change and report on program adoption and maintenance.

MAIN MEASURES

Adoption (proportion of TBI-related admissions with completed outcome measures) and maintenance (adoption over 4 years).

RESULTS

Preparation phase strategies focused on local adaptations, education, environmental preparation, and collaboration with informatics. Implementation phase strategies included reminders, feedback, champions, and iterative adjustments. Sustainment strategies focused on integration into standard practice. Adoption increased postinitiation for all measures except one. Despite improvements, a notable portion of measures remained incomplete. Increases in outcome measure collection were maintained for 2 to 4 years, but a significant decline in paired admission and discharge scores suggests a reduced ability to monitor change over time.

CONCLUSIONS

This study provides an example of a clinically driven quality improvement project and selected implementation strategies used to increase the collection of standard outcome measures in IRF. By leveraging the Expert Recommendations for Implementing Change framework, we aim to enhance comparability with similar efforts elsewhere. The results demonstrate the program's successes and challenges, highlighting the need for interdisciplinary clinical and research collaboration to support the translation of knowledge between research and clinical practice and inform meaningful improvements in care across TBI rehabilitation.

Organizing the dissemination and implementation field: who are we, what are we doing, and how should we do it?

Two decades into its tenure as a field, dissemination and implementation (D&I) scientists have begun a process of self-reflection, illuminating a missed opportunity to bridge the gap between research and practice-one of the field's foundational objectives. In this paper, we, the authors, assert the research-to-practice gap has persisted, in part due to an inadequate characterization of roles, functions, and processes within D&I. We aim to address this issue, and the rising tension between D&I researchers and practitioners, by proposing a community-centered path forward that is grounded in equity.We identify key players within the field and characterize their unique roles using the translational science spectrum, a model originally developed in the biomedical sciences to help streamline the research-to-practice process, as a guide. We argue that the full translational science spectrum, from basic science research, or "T0," to translation to community, or "T4," readily applies within D&I and that in using this framework to clarify roles, functions, and processes within the field, we can facilitate greater collaboration and respect across the entire D&I research-to-practice continuum. We also highlight distinct opportunities (e.g., changes to D&I scientific conference structures) to increase regular communication and engagement between individuals whose work sits at different points along the D&I translational science spectrum that can accelerate our efforts to close the research-to-practice gap and achieve the field's foundational objectives.

The effectiveness of knowledge-sharing techniques and approaches in research funded by the National Institute for Health and Care Research (NIHR): a systematic review

BACKGROUND

The National Institute of Health and Care Research (NIHR), funds, enables and delivers world-leading health and social care research to improve people's health and wellbeing. To achieve this aim, effective knowledge sharing (two-way knowledge sharing between researchers and stakeholders to create new knowledge and enable change in policy and practice) is needed. To date, it is not known which knowledge sharing techniques and approaches are used or how effective these are in creating new knowledge that can lead to changes in policy and practice in NIHR funded studies.

METHODS

In this restricted systematic review, electronic databases [MEDLINE, The Health Management Information Consortium (including the Department of Health's Library and Information Services and King's Fund Information and Library Services)] were searched for published NIHR funded studies that described knowledge sharing between researchers and other stakeholders. One researcher performed title and abstract, full paper screening and quality assessment (Critical Appraisal Skills Programme qualitative checklist) with a 20% sample independently screened by a second reviewer. A narrative synthesis was adopted.

RESULTS

In total 9897 records were identified. After screening, 17 studies were included. Five explicit forms of knowledge sharing studies were identified: embedded models, knowledge brokering, stakeholder engagement and involvement of non-researchers in the research or service design process and organisational collaborative partnerships between universities and healthcare organisations. Collectively, the techniques and approaches included five types of stakeholders and worked with them at all stages of the research cycle, except the stage of formation of the research design and preparation of funding application. Seven studies (using four of the approaches) gave examples of new knowledge creation, but only one study (using an embedded model approach) gave an example of a resulting change in practice. The use of a theory, model or framework to explain the knowledge sharing process was identified in six studies.

CONCLUSIONS

Five knowledge sharing techniques and approaches were reported in the included NIHR funded studies, and seven studies identified the creation of new knowledge. However, there was little investigation of the effectiveness of these approaches in influencing change in practice or policy.

[Implementing systematically: To what extent can implementation science make an educational contribution to health care practice?]

BACKGROUND

Implementation science is currently struggling with the challenge to translate its findings into implementation practice in health care. Therefore, it is of interest to explore to what extent advanced trainings are relevant for health care practice to support knowledge circulation, and what needs to be considered in their design.

DESIGN OF EDUCATIONAL INITIATIVES AND TRAINING

Internationally, numerous initiatives have emerged in recent years to make implementation science more accessible to health care implementers. They focus, in particular, on the development of curricula for actors in health care practice and the widespread implementation of these qualification programs. In German-speaking countries, the interest in health services research is particularly evident at the level of Master's degree programs to make implementation science accessible to health care. However, these efforts need to be complemented by a participatory, needs-oriented and theory-based approach to advanced training for implementers in health care practice. This will enable the required competencies to be addressed on different levels of training and the further development of training formats.

DISCUSSION

Recent literature shows that implementers in German-speaking countries can benefit from a training program tailored to their needs. International experience in the field of advanced training in implementation science for health care practice allows us to derive essential components for the development of advanced training for the German-speaking region.

Trust in embedding co-design for innovation and change: considering the role of senior leaders and managers

PURPOSE

In this viewpoint article, the authors recognize the increased focus in health systems on co-design for innovation and change. This article explores the role of leaders and mangers in developing and enhancing a culture of trust in their organizations to enable co-design, with the potential to drive innovation and change in healthcare.

DESIGN/METHODOLOGY/APPROACH

Using social science analyses, the authors argue that current co-design literature has limited focus on interactions between senior leaders and managers, and healthcare staff and service users in supporting co-designed innovation and change. The authors draw on social and health science studies of trust to highlight how the value-based co-design process needs to be supported and enhanced. We outline what co-design innovation and change involve in a health system, conceptualize trust and reflect on its importance within the health system, and finally note the role of senior leaders and managers in supporting trust and responsiveness for co-designed innovation and change.

FINDINGS

Healthcare needs leaders and managers to embrace co-design that drives innovation now and in the future through people - leading to better healthcare for society at large. As authors we argue that it is now the time to shift our focus on the role of senior managers and leaders to embed co-design into health and social care structures, through creating and nurturing a culture of trust.

ORIGINALITY/VALUE

Building public trust in the health system and interpersonal trust within the health system is an ongoing process that relies upon personal behavior of managers and senior leaders, organizational practices within the system, as well as political processes that underpin these practices. By implementing managerial, leadership and individual practices on all levels, senior managers and leaders provide a mechanism to increase both trust and responsiveness for co-design that supports innovation and change in the health system.

Models and approaches for building knowledge translation capacity and capability in health services: a scoping review

BACKGROUND

Building healthcare service and health professionals' capacity and capability to rapidly translate research evidence into health practice is critical to the effectiveness and sustainability of healthcare systems. This review scoped the literature describing programmes to build knowledge translation capacity and capability in health professionals and healthcare services, and the evidence supporting these.

METHODS

This scoping review was undertaken using the Joanna Briggs Institute scoping review methodology. Four research databases (Ovid MEDLINE, CINAHL, Embase, and PsycInfo) were searched using a pre-determined strategy. Eligible studies described a programme implemented in healthcare settings to build health professional or healthcare service knowledge translation capacity and capability. Abstracts and full texts considered for inclusion were screened by two researchers. Data from included papers were extracted using a bespoke tool informed by the scoping review questions.

RESULTS

Database searches yielded 10,509 unique citations, of which 136 full texts were reviewed. Thirty-four papers were included, with three additional papers identified on citation searching, resulting in 37 papers describing 34 knowledge translation capability building programmes. Programmes were often multifaceted, comprising a combination of two or more strategies including education, dedicated implementation support roles, strategic research-practice partnerships and collaborations, co-designed knowledge translation capability building programmes, and dedicated funding for knowledge translation. Many programmes utilised experiential and collaborative learning, and targeted either individual, team, organisational, or system levels of impact. Twenty-seven programmes were evaluated formally using one or more data collection methods. Outcomes measured varied significantly and included participant self-reported outcomes, perceived barriers and enablers of knowledge translation, milestone achievement and behaviour change. All papers reported that programme objectives were achieved to varying degrees.

CONCLUSIONS

Knowledge translation capacity and capability building programmes in healthcare settings are multifaceted, often include education to facilitate experiential and collaborative learning, and target individual, team, organisational, or supra-organisational levels of impact. Although measured differently across the programmes, the outcomes were positive. The sustainability of programmes and outcomes may be undermined by the lack of long-term funding and inconsistent evaluation. Future research is required to develop evidence-informed frameworks to guide methods and outcome measures for short-, medium- and longer-term programme evaluation at the different structural levels.

From pilot to a multi-site trial: refining the Early Detection of Deterioration in Elderly Residents (EDDIE +) intervention

BACKGROUND

Early Detection of Deterioration in Elderly Residents (EDDIE +) is a multi-modal intervention focused on empowering nursing and personal care workers to identify and proactively manage deterioration of residents living in residential aged care (RAC) homes. Building on successful pilot trials conducted between 2014 and 2017, the intervention was refined for implementation in a stepped-wedge cluster randomised trial in 12 RAC homes from March 2021 to May 2022. We report the process used to transition from a small-scale pilot intervention to a multi-site intervention, detailing the intervention to enable future replication.

METHODS

The EDDIE + intervention used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide the intervention development and refinement process. We conducted an environmental scan; multi-level context assessments; convened an intervention working group (IWG) to develop the program logic, conducted a sustainability assessment and deconstructed the intervention components into fixed and adaptable elements; and subsequently refined the intervention for trial.

RESULTS

The original EDDIE pilot intervention included four components: nurse and personal care worker education; decision support tools; diagnostic equipment; and facilitation and clinical support. Deconstructing the intervention into core components and what could be flexibly tailored to context was essential for refining the intervention and informing future implementation across multiple sites. Intervention elements considered unsustainable were updated and refined to enable their scalability. Refinements included: an enhanced educational component with a greater focus on personal care workers and interactive learning; decision support tools that were based on updated evidence; equipment that aligned with recipient needs and available organisational support; and updated facilitation model with local and external facilitation.

CONCLUSION

By using the i-PARIHS framework in the scale-up process, the EDDIE + intervention was tailored to fit the needs of intended recipients and contexts, enabling flexibility for local adaptation. The process of transitioning from a pilot to larger scale implementation in practice is vastly underreported yet vital for better development and implementation of multi-component interventions across multiple sites. We provide an example using an implementation framework and show it can be advantageous to researchers and health practitioners from pilot stage to refinement, through to larger scale implementation.

TRIAL REGISTRATION

The trial was prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Essential content for teaching implementation practice in healthcare: a mixed-methods study of teams offering capacity-building initiatives

BACKGROUND

Applying the knowledge gained through implementation science can support the uptake of research evidence into practice; however, those doing and supporting implementation (implementation practitioners) may face barriers to applying implementation science in their work. One strategy to enhance individuals' and teams' ability to apply implementation science in practice is through training and professional development opportunities (capacity-building initiatives). Although there is an increasing demand for and offerings of implementation practice capacity-building initiatives, there is no universal agreement on what content should be included. In this study we aimed to explore what capacity-building developers and deliverers identify as essential training content for teaching implementation practice.

METHODS

We conducted a convergent mixed-methods study with participants who had developed and/or delivered a capacity-building initiative focused on teaching implementation practice. Participants completed an online questionnaire to provide details on their capacity-building initiatives; took part in an interview or focus group to explore their questionnaire responses in depth; and offered course materials for review. We analyzed a subset of data that focused on the capacity-building initiatives' content and curriculum. We used descriptive statistics for quantitative data and conventional content analysis for qualitative data, with the data sets merged during the analytic phase. We presented frequency counts for each category to highlight commonalities and differences across capacity-building initiatives.

RESULTS

Thirty-three individuals representing 20 capacity-building initiatives participated. Study participants identified several core content areas included in their capacity-building initiatives: (1) taking a process approach to implementation; (2) identifying and applying implementation theories, models, frameworks, and approaches; (3) learning implementation steps and skills; (4) developing relational skills. In addition, study participants described offering applied and pragmatic content (e.g., tools and resources), and tailoring and evolving the capacity-building initiative content to address emerging trends in implementation science. Study participants highlighted some challenges learners face when acquiring and applying implementation practice knowledge and skills.

CONCLUSIONS

This study synthesized what experienced capacity-building initiative developers and deliverers identify as essential content for teaching implementation practice. These findings can inform the development, refinement, and delivery of capacity-building initiatives, as well as future research directions, to enhance the translation of implementation science into practice.

Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana

BACKGROUND

Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra.

METHODS

This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT).

RESULTS

Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility.

CONCLUSIONS

This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.

Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review

BACKGROUND

Computerized clinical decision support systems (CDSSs) are essential components of modern health system service delivery, particularly within acute care settings such as hospitals. Theories, models, and frameworks may assist in facilitating the implementation processes associated with CDSS innovation and its use within these care settings. These processes include context assessments to identify key determinants, implementation plans for adoption, promoting ongoing uptake, adherence, and long-term evaluation. However, there has been no prior review synthesizing the literature regarding the theories, models, and frameworks that have informed the implementation and adoption of CDSSs within hospitals.

OBJECTIVE

This scoping review aims to identify the theory, model, and framework approaches that have been used to facilitate the implementation and adoption of CDSSs in tertiary health care settings, including hospitals. The rationales reported for selecting these approaches, including the limitations and strengths, are described.

METHODS

A total of 5 electronic databases were searched (CINAHL via EBSCOhost, PubMed, Scopus, PsycINFO, and Embase) to identify studies that implemented or adopted a CDSS in a tertiary health care setting using an implementation theory, model, or framework. No date or language limits were applied. A narrative synthesis was conducted using full-text publications and abstracts. Implementation phases were classified according to the "Active Implementation Framework stages": exploration (feasibility and organizational readiness), installation (organizational preparation), initial implementation (initiating implementation, ie, training), full implementation (sustainment), and nontranslational effectiveness studies.

RESULTS

A total of 81 records (42 full text and 39 abstracts) were included. Full-text studies and abstracts are reported separately. For full-text studies, models (18/42, 43%), followed by determinants frameworks (14/42,33%), were most frequently used to guide adoption and evaluation strategies. Most studies (36/42, 86%) did not list the limitations associated with applying a specific theory, model, or framework.

CONCLUSIONS

Models and related quality improvement methods were most frequently used to inform CDSS adoption. Models were not typically combined with each other or with theory to inform full-cycle implementation strategies. The findings highlight a gap in the application of implementation methods including theories, models, and frameworks to facilitate full-cycle implementation strategies for hospital CDSSs.

Planning and implementing practice changes in Ontario maternal-newborn hospital units: a secondary qualitative analysis

BACKGROUND

Moving evidence into practice is complex, and pregnant and birthing people and their infants do not always receive care that aligns with the best available evidence. Implementation science can inform how to effectively move evidence into practice. While there are a growing number of examples of implementation science being studied in maternal-newborn care settings, it remains unknown how real-world teams of healthcare providers and leaders approach the overall implementation process when making practice changes. The purpose of this study was to describe maternal-newborn hospital teams' approaches to implementing practice changes. We aimed to identify what implementation steps teams take (or not) and identify strengths and potential areas for improvement based on best practices in implementation science.

METHODS

We conducted a supplementary qualitative secondary analysis of 22 interviews completed in 2014-2015 with maternal-newborn nursing leaders in Ontario, Canada. We used directed content analysis to code the data to seven steps in an implementation framework (Implementation Roadmap): identify the problem and potential best practice; assemble local evidence; select and customize best practice; discover barriers and drivers; tailor implementation strategies; field-test, plan evaluation, prepare to launch; launch, evaluate, and sustain. Frequency counts are presented for each step.

RESULTS

Participants reported completing a median of 4.5 of 7 Implementation Roadmap steps (range = 3-7), with the most common being identifying a practice problem. Other steps were described less frequently (e.g., selecting and adapting evidence, field-testing, outcome evaluation) or discussed frequently but not optimally (e.g., barriers assessment). Participants provided examples of how they engaged point-of-care staff throughout the implementation process, but provided fewer examples of engaging pregnant and birthing people and their families. Some participants stated they used a formal framework or process to guide their implementation process, with the most common being quality improvement approaches and tools.

CONCLUSIONS

We identified variability across the 22 hospitals in the implementation steps taken. While we observed many strengths, we also identified areas where further support may be needed. Future work is needed to create opportunities and resources to support maternal-newborn healthcare providers and leaders to apply principles and tools from implementation science to their practice change initiatives.

Stewardship 2.0: Embracing elements of implementation science to enhance everyday antimicrobial Stewardship efforts

This article explores the utility of implementation science (IS) as a method to promote the effective uptake of antimicrobial stewardship processes. Elements of IS can be readily incorporated into QI work and used as a platform to extend stewardship reach. As stewards are stretched to do more, IS can be a potential vehicle to ensure that our collective work is impactful, sustainable, and contributes more broadly to clinically relevant improvements.

Evaluating the translation of implementation science to clinical artificial intelligence: a bibliometric study of qualitative research

Introduction

Whilst a theoretical basis for implementation research is seen as advantageous, there is little clarity over if and how the application of theories, models or frameworks (TMF) impact implementation outcomes. Clinical artificial intelligence (AI) continues to receive multi-stakeholder interest and investment, yet a significant implementation gap remains. This bibliometric study aims to measure and characterize TMF application in qualitative clinical AI research to identify opportunities to improve research practice and its impact on clinical AI implementation.

Methods

Qualitative research of stakeholder perspectives on clinical AI published between January 2014 and October 2022 was systematically identified. Eligible studies were characterized by their publication type, clinical and geographical context, type of clinical AI studied, data collection method, participants and application of any TMF. Each TMF applied by eligible studies, its justification and mode of application was characterized.

Results

Of 202 eligible studies, 70 (34.7%) applied a TMF. There was an 8-fold increase in the number of publications between 2014 and 2022 but no significant increase in the proportion applying TMFs. Of the 50 TMFs applied, 40 (80%) were only applied once, with the Technology Acceptance Model applied most frequently (n = 9). Seven TMFs were novel contributions embedded within an eligible study. A minority of studies justified TMF application (n = 51,58.6%) and it was uncommon to discuss an alternative TMF or the limitations of the one selected (n = 11,12.6%). The most common way in which a TMF was applied in eligible studies was data analysis (n = 44,50.6%). Implementation guidelines or tools were explicitly referenced by 2 reports (1.0%).

Conclusion

TMFs have not been commonly applied in qualitative research of clinical AI. When TMFs have been applied there has been (i) little consensus on TMF selection (ii) limited description of selection rationale and (iii) lack of clarity over how TMFs inform research. We consider this to represent an opportunity to improve implementation science's translation to clinical AI research and clinical AI into practice by promoting the rigor and frequency of TMF application. We recommend that the finite resources of the implementation science community are diverted toward increasing accessibility and engagement with theory informed practices. The considered application of theories, models and frameworks (TMF) are thought to contribute to the impact of implementation science on the translation of innovations into real-world care. The frequency and nature of TMF use are yet to be described within digital health innovations, including the prominent field of clinical AI. A well-known implementation gap, coined as the "AI chasm" continues to limit the impact of clinical AI on real-world care. From this bibliometric study of the frequency and quality of TMF use within qualitative clinical AI research, we found that TMFs are usually not applied, their selection is highly varied between studies and there is not often a convincing rationale for their selection. Promoting the rigor and frequency of TMF use appears to present an opportunity to improve the translation of clinical AI into practice.

Exploring the intersection of hermeneutics and implementation: a scoping review

BACKGROUND

An enduring challenge remains about how to effectively implement programs, services, or practices. Too often, implementation does not achieve its intended effectiveness, fidelity, and sustainability, even when frameworks or theories determine implementation strategies and actions. A different approach is needed. This scoping review joined two markedly different bodies of literature: implementation and hermeneutics. Implementation is usually depicted as focused, direct, and somewhat linear, while hermeneutics attends to the messiness of everyday experience and human interaction. Both, however, are concerned with practical solutions to real-life problems. The purpose of the scoping review was to summarize existing knowledge on how a hermeneutic approach has informed the process of implementing health programs, services, or practices.

METHODS

We completed a scoping review by taking a Gadamerian hermeneutic approach to the JBI scoping review method. Following a pilot search, we searched eight health-related electronic databases using broadly stated terms such as implementation and hermeneutics. A diverse research team that included a patient and healthcare leader, working in pairs, independently screened titles/abstracts and full-text articles. Through the use of inclusion criteria and full-team dialogue, we selected the final articles and identified their characteristics, hermeneutic features, and implementation components.

RESULTS

Electronic searches resulted in 2871 unique studies. After full-text screening, we retained six articles that addressed both hermeneutics and implementing a program, service, or practice. The studies varied widely in location, topic, implementation strategies, and hermeneutic approach. All addressed assumptions underpinning implementation, the human dimensions of implementing, power differentials, and knowledge creation during implementation. All studies addressed issues foundational to implementing such as cross-cultural communication and surfacing and addressing tensions during processes of change. The studies showed how creating conceptual knowledge was a precursor to concrete, instrumental knowledge for action and behavioral change. Finally, each study demonstrated how the hermeneutic process of the fusion of horizons created new understandings needed for implementation.

CONCLUSIONS

Hermeneutics and implementation have rarely been combined. The studies reveal important features that can contribute to implementation success. Implementers and implementation research may benefit from understanding, articulating, and communicating hermeneutic approaches that foster the relational and contextual foundations necessary for successful implementation.

TRIAL REGISTRATION

The protocol was registered at the Centre for Open Science on September 10, 2019. MacLeod M, Snadden D, McCaffrey G, Zimmer L, Wilson E, Graham I, et al. A hermeneutic approach to advancing implementation science: a scoping review protocol 2019. Accessed at osf.io/eac37.

Stakeholder Perspectives of Clinical Artificial Intelligence Implementation: Systematic Review of Qualitative Evidence

BACKGROUND

The rhetoric surrounding clinical artificial intelligence (AI) often exaggerates its effect on real-world care. Limited understanding of the factors that influence its implementation can perpetuate this.

OBJECTIVE

In this qualitative systematic review, we aimed to identify key stakeholders, consolidate their perspectives on clinical AI implementation, and characterize the evidence gaps that future qualitative research should target.

METHODS

Ovid-MEDLINE, EBSCO-CINAHL, ACM Digital Library, Science Citation Index-Web of Science, and Scopus were searched for primary qualitative studies on individuals' perspectives on any application of clinical AI worldwide (January 2014-April 2021). The definition of clinical AI includes both rule-based and machine learning-enabled or non-rule-based decision support tools. The language of the reports was not an exclusion criterion. Two independent reviewers performed title, abstract, and full-text screening with a third arbiter of disagreement. Two reviewers assigned the Joanna Briggs Institute 10-point checklist for qualitative research scores for each study. A single reviewer extracted free-text data relevant to clinical AI implementation, noting the stakeholders contributing to each excerpt. The best-fit framework synthesis used the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework. To validate the data and improve accessibility, coauthors representing each emergent stakeholder group codeveloped summaries of the factors most relevant to their respective groups.

RESULTS

The initial search yielded 4437 deduplicated articles, with 111 (2.5%) eligible for inclusion (median Joanna Briggs Institute 10-point checklist for qualitative research score, 8/10). Five distinct stakeholder groups emerged from the data: health care professionals (HCPs), patients, carers and other members of the public, developers, health care managers and leaders, and regulators or policy makers, contributing 1204 (70%), 196 (11.4%), 133 (7.7%), 129 (7.5%), and 59 (3.4%) of 1721 eligible excerpts, respectively. All stakeholder groups independently identified a breadth of implementation factors, with each producing data that were mapped between 17 and 24 of the 27 adapted Nonadoption, Abandonment, Scale-up, Spread, and Sustainability subdomains. Most of the factors that stakeholders found influential in the implementation of rule-based clinical AI also applied to non-rule-based clinical AI, with the exception of intellectual property, regulation, and sociocultural attitudes.

CONCLUSIONS

Clinical AI implementation is influenced by many interdependent factors, which are in turn influenced by at least 5 distinct stakeholder groups. This implies that effective research and practice of clinical AI implementation should consider multiple stakeholder perspectives. The current underrepresentation of perspectives from stakeholders other than HCPs in the literature may limit the anticipation and management of the factors that influence successful clinical AI implementation. Future research should not only widen the representation of tools and contexts in qualitative research but also specifically investigate the perspectives of all stakeholder HCPs and emerging aspects of non-rule-based clinical AI implementation.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42021256005; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256005.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33145.

Implementation Methods and Research for a Post-truth World with Growing Inequities

The purpose of this article is to consider the changing context for implementation research and practice and new approaches which might now be more relevant for some implementation objectives. Factors that hindered implementation of evidence-based practices before the COVID-19 pandemic was an anti-science culture, strengthened by different media and appeals to emotion and identity. The article questions how effective are the rational-cognitive and individual models of change that frequency informs our research and practice. It describes challenges we face and considers methods we could use that might be more effective, including research-informed narrative methods, participatory research and practice, especially with culturally and linguistically diverse peoples, and adaptive implementation.

What implementation strategies are relational? Using Relational Theory to explore the ERIC implementation strategies

The identification and use of implementation strategies in implementation research and practice have strengthened our understanding of the implementation process as well as the causal pathways between mechanisms, strategies, and implementation outcomes. Although these contributions have advanced the application of strategies, there is still a need to learn more about how strategies might integrate relational exchanges and interactions. The inclusion of critical perspectives has been limited in implementation science, and theories such as Relational Theory can expand our understanding of the relational nature of implementation and enhance rigor through alternative theoretical applications. This study applied Relational Theory through a qualitative directed content analysis of the 73 Expert Recommendations for Implementation Change (ERIC) implementation strategies and examine relational components in strategy descriptions. Three reviewers used the structured approach to review and categorize the implementation strategies based on the Relational and Transactional Strategy Continuum measure, which operationalizes types of interactions, exchanges and alliances. Relational alliance strategies are those in which there is mutual growth and accountability, frequent interaction, shared power, and potential vulnerability. Operational alliances include forms of working exchanges between parties with balanced transactional and relational features. Operational alliances can be somewhat interactive in nature, with minor exchanges and limited accountability. Transactional alliance strategies are mostly uni-directional, influenced by power differentials, and do not require mutual growth, commitment, or exchange; thus, the power of growth is inherently one-sided. Results from the review suggest more implementation strategies with relational alliance features (highly relational, n = 17, semi-relational, n = 19) compared to transactional (highly transactional, n = 9, semi-transactional, n = 10) and 18 strategies coded as operational alliances. The qualitative review revealed opportunities to further expand how relational exchanges are considered within the implementation strategies descriptions, as well as the role of actors and power dynamics within strategy exchanges. The Relational and Transactional Strategy Continuum measure can help practitioners and researchers consider the sequencing, pairing, and impact on outcomes of different types and combinations of strategies in implementation practice and research. Additionally, the measure can support reflection on strategies that promote positive alliances, frequent connections, bi-directional communication, and power sharing.

The use of patient experience feedback in rehabilitation quality improvement and codesign activities: Scoping review of the literature

Objective

To characterize the literature, reported enablers, and gaps on the use of patient experience feedback for person-centered rehabilitation quality improvement and codesign activities.

Design

Scoping Review.

Data sources

Scientific databases (PubMed, CINAHL, Rehabdata, Scopus, Web of Science, ProQuest), website searches (e.g. Beryl Institute), snowballing, and key-informant recommendations.

Methods

Two independent reviewers performed title and abstract screenings and full-text reviews. Eligibility focused on English-language, peer-reviewed (all time) and gray literature (last five years) that used patient experience feedback in rehabilitation improvement activities. The aims, settings, methods, findings, implications, and reported limitations were extracted, followed by content analyses identifying reported enablers and gaps.

Results

Among the 901 unique references and 52 full texts reviewed, ten were included: four used patient experience surveys for improving patient experiences; six used codesign methodologies to engage patient feedback in service improvement activities. Implementation enablers included securing managerial support, having a structured methodology and facilitator, using efficient processes, engaging staff experiences, and using appreciative inquiry. Reported study gaps included limited follow-up, low sample sizes, analytical limitations, lack of reported limitations, or narrow range of perspectives (e.g. not from people with severe impairments).

Conclusion

Few examples of the use of patient experience feedback in quality improvement or codesign activities were found in the rehabilitation literature. Patient experience improvement activities relied exclusively on retrospective survey data, which were not combined with often more actionable forms (e.g. qualitative, real time) of patient experience feedback. Further research might consider design of activities that collect and use patient experience feedback for rehabilitation service improvements.

Promises and pitfalls in implementation science from the perspective of US-based researchers: learning from a pre-mortem

BACKGROUND

Implementation science is at a sufficiently advanced stage that it is appropriate for the field to reflect on progress thus far in achieving its vision, with a goal of charting a path forward. In this debate, we offer such reflections and report on potential threats that might stymie progress, as well as opportunities to enhance the success and impact of the field, from the perspective of a group of US-based researchers.

MAIN BODY

Ten mid-career extramurally funded US-based researchers completed a "pre-mortem" or a group brainstorming exercise that leverages prospective hindsight to imagine that an event has already occurred and to generate an explanation for it - to reduce the likelihood of a poor outcome. We came to consensus on six key themes related to threats and opportunities for the field: (1) insufficient impact, (2) too much emphasis on being a "legitimate science," (3) re-creation of the evidence-to-practice gap, (4) difficulty balancing accessibility and field coherence, (5) inability to align timelines and priorities with partners, and (6) overly complex implementation strategies and approaches.

CONCLUSION

We submit this debate piece to generate further discussion with other implementation partners as our field continues to develop and evolve. We hope the key opportunities identified will enhance the future of implementation research in the USA and spark discussion across international groups. We will continue to learn with humility about how best to implement with the goal of achieving equitable population health impact at scale.

A Home-Based Dyadic Music-with-Movement Intervention for People with Dementia and Caregivers: A Hybrid Type 2 Cluster-Randomized Effectiveness-Implementation Design

Background

Integrating evidence-based music-with-movement into routine practices for people with dementia requires effective implementation strategies. The objectives of this study were to evaluate the clinical efficacy of the intervention and to examine the effectiveness of the implementation strategies in promoting home-based adoption.

Methods

This was a cluster randomized controlled trial adopting a clinical effectiveness-implementation hybrid design. The 12-week music-with-movement intervention aims to promote the well-being of people with dementia and their caregivers. Clinical outcomes were assessed to evaluate the efficacy of the intervention. These included the symptoms of anxiety and depression of people with dementia; caregivers' perception of their stress and the positive aspects of caregiving; and the quality of the dyadic relationship. Caregivers, staff, and volunteers were interviewed and objective figures on reach and adoption were collected to reflect the outcomes of the implementation.

Results

Compared to the waitlist control, there was a significant reduction in the anxiety and the symptoms of depression of those in the intervention group. There was also a significant reduction in the perceived stress level of the caregivers. Six focus group interviews were conducted. The intervention and the appropriateness of the implementation strategies were perceived positively by the dyad participants, the staff of the centres, and volunteers. Of the collaborating centres, 57% continued to use the intervention and, after six months, served six times more people than were recruited in this study. Over half of the participating families continued to use the intervention for at least six more months.

Conclusion

Music-with-movement interventions showed promise for improving the well-being of people with dementia and their caregivers. Effective strategies facilitated the implementation process, such as integrating communication technology to provide instant support and involving volunteers in engaging the collaborating centres and families. This study sheds light on perceptions of the intervention, and on its scalability for a broader population.

Trial Registration

NCT03575026, Registered 2 July 2018.

CODESING DE APLICATIVO CUIDATIVO-EDUCACIONAL PARA PESSOAS COM INSUFICIÊNCIA CARDÍACA: IDEAÇÃO, PROTOTIPAGEM E CO-IMPLANTAÇÃO

RESUMO Objetivo descrever o processo de ideação, prototipagem e co-implantação do protótipo de aplicativo cuidativo-educacional à pessoa com insuficiência cardíaca em vulnerabilidade, seus familiares/cuidadores e equipe de saúde. Método estudo metodológico, com cinco fases: Constructo; Ideação; Prototipagem; Co-implantação e Adequação, realizadas de setembro de 2020 a julho de 2021. A equipe do Codesign envolveu 72 atores (15 pacientes com IC, 19 familiares/cuidadores, 35 profissionais da saúde, dois pesquisadores e um designer e desenvolvedor), que contribuíram com dados linguísticos e visuais. Resultados foi produzido o protótipo InCare®, representado pelo fluxograma de interação do usuário e esboços estruturais. Foram definidas cores para composição das telas e escolhidos recursos do protótipo, com delineamento da descrição, proposta e requisitos funcionais. O aplicativo envolveu temáticas relevantes (definição da doença e vulnerabilidade, etiologia, classificação, sinais e sintomas, cuidados diários e abordagens paliativistas, tratamentos, alimentação, atividade física e redes de suporte, benefícios) e aglutinou funcionalidades conforme necessidades e preferências da equipe, sendo considerado inovador e um incentivo ao autocuidado. Conclusão O Codesign permitiu a ideação de recursos, conteúdos, esboços das telas, fluxo do usuário, prototipagem e nome do protótipo, em processo criativo e participativo, para promoção da saúde da pessoa com insuficiência cardíaca em situação de vulnerabilidade em saúde.

Is implementation research out of step with implementation practice? Pathways to effective implementation support over the last decade

Background: There is growing interest in the lived experience of professionals who provide implementation support (i.e., implementation support practitioners). However, there remains limited knowledge about their experiences and how those experiences can contribute to the knowledge base on what constitutes successful and sustainable implementation support models. This study aimed to examine pathways of implementation support practice, as described by experienced professionals actively supporting systems' uptake and sustainment of evidence to benefit children and families. Methods: Seventeen individuals with extensive experience providing implementation support in various settings participated in semi-structured interviews. Data were analyzed using qualitative content analysis and episode profile analysis approaches. Iterative diagramming was used to visualize the various pathways of implementation support practitioners' role reflection and transformation evidenced by the interview data. Results: Findings highlighted rich pathways of implementation support practitioners' role reflection and transformation. Participants described their roots in providing implementation support as it relates to implementing and expanding the use of evidence-based programs and practices in child and family services. Almost all participants reflected on the early stages of their careers providing implementation support and described a trajectory starting with the use of "push models," which evolved into "pull models" and eventually "co-creation or exchange models" of implementation support involving both technical and relational skills. Conclusions: Developing an implementation support workforce will require a deeper understanding of this lived experience to prevent repeated use of strategies observed to be unsuccessful by those most proximal to the work. The pathways for implementation practice in this study highlight impressive leaps forward in the field of implementation over the last 15 years and speaks to the importance of the professionals leading change efforts in this growth.

Plain Language Summary

Over the past few years, professionals in the field of implementation science have identified a growing gap between implementation research and implementation practice. While this issue has been highlighted informally, the field is lacking a shared understanding and clear way forward to reconcile this gap. In this paper, the authors describe how professionals providing implementation support have shifted their implementation practice over time through systematic observations of what works (and what does not work) for supporting and sustaining evidence use in service systems to improve population outcomes. The authors share the impressive leaps forward made in the field of implementation practice - from didactic training to responsive and tailored implementation strategies to co-created and relationship-based implementation solutions. The paper concludes with a call to action to the field for the creation of a virtuous learning cycle between professionals conducting implementation research and professionals providing implementation support to change practice as a way to produce a more robust and relevant science of implementation.

CODESIGN OF A CARE-EDUCATIONAL APP FOR PEOPLE WITH HEART FAILURE: DESIGN, PROTOTYPING AND CO-IMPLEMENTATION

ABSTRACT Objective to describe the process corresponding to the design, prototyping and co-implementation of a care-educational app prototype for vulnerable people with heart failure, their family members/caregivers and the health team. Method a methodological study with five phases: Construct, Design, Prototyping, Co-implementation and Adaptation, all performed from September 2020 to July 2021. The Codesign team involved 72 actors (15 patients with HF, 19 family members/caregivers, 35 health professionals, two researchers and a designer and developer), who contributed with linguistic and visual data. Results the InCare® prototype was produced, represented by the flowchart corresponding to the user's interaction and structural sketches. Colors were defined to compose the screens and the prototype resources were chosen, outlining the description, proposal and functional requirements. The app involved relevant themes (definition of the disease and vulnerability, etiology, classification, signs and symptoms, daily care measures and palliative approaches, treatments, diet, physical activity and support networks, benefits) and gathered functionalities according to the team's needs and preferences, being considered innovative and encouraging for self-care. Conclusion codesign allowed designing resources, contents, screen sketches, user flow, prototyping and prototype name, in a creative and participatory process to promote the health of people with heart failure in vulnerable health situations.