Research areas
Many of these research areas are interlinked. The CERAG offered exemplar questions within each of them in order to illustrate key issues. The processes suggested in the subsequent recommendations will further elaborate and prioritise the content of this agenda.
Context
The impact of context on implementation is important, and systematic study of the attributes of context (and their role and modifiability) that form barriers or facilitators to implementation is needed. The responsiveness of context is important in order to understand (and influence) culture and other attributes of organisations as well as the individuals within them and their interests related to implementation of new knowledge. The role of context in intervention development needs to be better understood.
Behavioural determinants and evaluation of change strategies
Successful implementation of new knowledge should be built on an understanding of the determinants of behavioural change and maintenance of behavioural change in individuals and organisations. Such understanding would allow the rational development and testing of implementation interventions. This should include the systematic development of interventions and trials across a range of conditions and NHS settings. These could include the study of the organisational embedding of new interventions, the effectiveness of healthcare system interventions, as well as evaluation of delivering new models and methods of care. There is a need for studies examining the methods of optimising the content and methods of delivery of interventions.
Evaluations should use a range of (and often a combination of) research designs and methods (e.g., cluster randomized trials, quasi-experimental designs, and qualitative studies).
Testing of theory in Implementation Research
Theory is underused in Implementation Research. There needs to be considerable work on understanding available theories, on the testing and development of theories, and on how to operationalise theory. This work should not be restricted by disciplinary perspectives, worldview, or area of application.
Knowledge attributes and knowledge generation – features related to uptake
Research is needed on the important attributes of new knowledge and how these influence its uptake (or not). This would include the attributes of and applicability of what is regarded as evidence by different individuals and in different contexts.
Decision makers have problems accessing, appraising, adapting, and applying research evidence. The increasing recognition that implementation of evidence from individual studies may be misleading, either due to bias in their conduct or random variations in findings, has led to greater emphasis on knowledge syntheses as the basic unit of implementation. Knowledge syntheses interpret the results of individual studies within the context of global evidence thus increasing the 'signal to noise ratio' of implementation activities and increasing the likelihood of their success. Knowledge syntheses provide the evidence base for other implementation vehicles such as patient decision aids, clinical practice guidelines, or policy briefs.
Systematic review activities (guided by relevant theory) need to be supported systematically to ensure their continued development. Important areas activity include: compiling and maintaining a register of systematic reviews of Implementation Research; updating overviews of reviews of professional behaviour change interventions; conducting systematic reviews of methods to improve the implementation of clinical research findings in routine settings; workshops on conduct and use of knowledge syntheses targeted to different stakeholders.
Cross-cutting issues
Methodology
Across all of the areas above there will be important methodological issues that need to be identified, investigated, and resolved. These include:
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The area of Implementation Research needs a common understanding of terms. Important areas of research include: the development of one or more taxonomies of barriers to implementation, mediating mechanisms and pathways; standardised measurement approaches for key elements of the taxonomy; a suite of reporting guidelines for different types of Implementation Research.
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All of the areas pose measurement challenges, such as the development of process and outcome methods and measures for relevant constructs.
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Is there a 'core set' of measures that will be applicable to most settings, or is each combination of patient team and organisation conceptually unique? The idea of a core set of measures offers greater potential for accumulation of knowledge.
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What are the pros and cons of using proxies for behaviour, such as written or web-based vignettes that simulate clinical behaviours?
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The incorporation of economic analysis within Implementation Research is not necessarily methodologically challenging, but it is very uncommon and should be encouraged and supported.
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An explicit examination of the pros and cons of the use of routinely available data to assess implementation. This would include the availability of data and the specificity of data in relation to the implementation of research evidence. Are there situations where there is sufficient routinely available data for economic modelling to demonstrate the viability or otherwise of certain behaviour change strategies? How complex can and should such modelling become?
Implementation Research across different areas of clinical practice
Implementation Research will be conducted in a range of clinical areas. This needs to be done in a way that ensures contribution to an incremental understanding of implementation. Research in one clinical area should generate ideas and understanding that can be drawn on in other clinical areas.
Knowledge infrastructure for Implementation
This links to 'knowledge attributes', (above) and is addressed in the UK by initiatives such as the NHS National Library for Health, the Cochrane Collaboration and Social Care Online. Nonetheless, the process recommended below could formally set out the knowledge infrastructure for implementation. This would be an important exercise in making explicit the content of an infrastructure (staff, skills, and resources), its scale, and its degree of current (and future) integration into routine healthcare.
Sustainability
The consideration of sustainability permeates the research agenda. It is important to have a healthcare workforce that can sustain implementation in the clinical setting as a matter of routine. It is important that we learn more about the organisational/contextual factors that enable the sustained use of evidence in practice. It is also important to have a research workforce that can sustain the area of Implementation Research.
Within research itself it is important to examine attributes of sustainability (within individuals, teams, and organizations) and to develop methods to examine whether the effects of interventions are sustained over time.
Communication strategy/engagement with the NHS
As part of integrating implementation and Implementation Research within the NHS it will be vital to develop an explicit communication and engagement strategy.
Workforce issues
Capacity to do implementation
How should the NHS workforce (clinicians/practitioners and managers) be trained (at both undergraduate and postgraduate levels) in order to optimise their ability to implement new knowledge (without doing harm, overspending, giving more to one patient than another, while also stopping ineffective practices)?
What are effective engagement strategies to involve the workforce in implementation?
What are the important attributes of the workforce that enhance knowledge use and implementation in healthcare settings?
How can these attributes be sustained both within individuals and organisations?
Capacity to do Implementation Research
Capacity to do research into implementation is limited both within the UK and internationally. The NIHR needs a strategy of building capacity at all levels of the researcher career. Given the time that it takes to build experience in this area NIHR needs a cadre of experienced senior investigators who can direct programmes of research.
A funding strategy should also train junior researchers to be capable of developing into independent researchers (this should be linked with experience Implementation Researchers). This could involve a mix of PhD studentships and fellowship awards.
Attributes of research teams addressing this agenda
Addressing this research agenda will be an inherently multi- and inter-disciplinary endeavor. No one practice or academic group or discipline will bring all the necessary attributes to address the research agenda. The range of required disciplines will vary within and across the various areas of the research agenda, but is likely to include some of Implementation Research, sociology, health psychology, health economics, and statistics.
Implementation and evidence of benefit from clinical and public health interventions
It will most often be the case that the Implementation Research agenda will be applied to areas where there is a clear understanding of appropriate clinical care or public health practice. In some areas there will be insufficient published evidence to inform a clear, shared understanding of optimum practice; in such instances the research agenda should address the need for evidence of efficient clinical and public health practice.