2020/02/14 by Charlotte A Sharp, Laura Swaithes, Benjamin Ellis +2 · 1 citation
Health Professions · #Primary Care and Health Outcomes #Health Policy Implementation Science #Interprofessional Education and Collaboration
paper · pdf · doi:10.1093/rheumatology/keaa088
openalex publication_date 2020/02/14 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
It is estimated that 85% of healthcare research is ‘wasted’, avoidably, due to inadequacies in research design, conduct and dissemination [1]. Such inadequacies in implementing healthcare research lead to health, economic and opportunity costs. A major review investigating the use of healthcare research identified two ‘gaps’ in research translation, the first being between bench and bedside and the second relating to ‘implementing … products and approaches into clinical practice’ [2]. So, whilst we know there is a problem in this area, what can the growing field of research into implementation do to help healthcare professionals, patients and carers improve outcomes and quality of care? Implementation is the practical process of embedding knowledge (in the form of usable innovations) into real-world clinical practice. A range of techniques or methods known as implementation strategies aim to optimize the process [3]. The Council for Allied Health Professionals Research has recently launched its Top 10 Tips for Implementation [4]. They feature some of the key ingredients necessary for successful uptake of innovations such as: leading across boundaries; patient and public involvement and engagement; theories, models and frameworks; capturing impact; and measuring success. Acknowledging real-world conditions (rather than controlling for them) and recognizing context are fundamental components of implementation [5]. The academic field of implementation science attempts to develop a systematic approach to undertaking and evaluating implementation strategies, and has been defined as ‘the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services’ [6] (p.1). Implementation science has emerged in acknowledgment of the second translational gap, aiming to address the challenging process of ensuring that the best available evidence is adopted in practice [7]. The resulting models, frameworks and theories (see Nilsen, 2015 [8] for a useful review), implementation scientists argue, help us to plan, understand and evaluate the factors that influence the degree to which an evidence-informed intervention is implemented with fidelity (i.e. being true to the original intervention design) or not. They may also help us to understand whether implementing aspects of an intervention, rather than a carbon copy of the original intervention, might still have benefits for patients and carers, health care professionals, and services. Fig. 1 illustrates some of the factors that may need to be considered when implementing research into practice. Factors affecting knowledge mobilization Factors affecting knowledge mobilization Knowledge mobilization is regarded as a key ingredient for successful implementation and can be described as ‘a proactive process that involves efforts to transform practice through the circulation of knowledge within and across practice domains’ [9]. Knowledge mobilization (the dominant terminology in the UK) has other names such as knowledge transfer, translation or utilization, and is synonymous with the phrase ‘integrated knowledge translation’ in Canada. Endless debates and navel gazing about exactly which word or phrase should be used can be frustrating, not only for academics keen to get on with advancing the field, but also for healthcare professionals and patients keen to use these approaches to improve patient care. Central to the philosophy of knowledge mobilization are collaboration and coproduction, in which ongoing development of partnerships between research producers and users (such as healthcare professionals, commissioners, patients, the public, policymakers and managers) enable clinical, commissioning and socially relevant questions to be produced and addressed jointly [5, 10]. By involving key stakeholders at all stages of the research from priority setting research questions through to implementation, potential barriers to implementation may be identified, overcome or circumnavigated, in turn influencing whether and how research is eventually embedded in practice. Examples of organizational collaborations between academia and healthcare providers worldwide include the Department of Veterans Affairs in the United States (US), and the United Kingdom’s (UK) National Institute for Health Research’s (NIHR) Applied Research Collaborations (formerly the NIHR Collaborations for Leadership in Applied Health Research and Care) and Knowledge Mobilization Alliance, which focus on implementing research into practice. Dual roles for those who span boundaries is another strategy that supports the understanding of the complex context of healthcare, whilst fostering relationships that may facilitate knowledge to action via communication between key stakeholders [5, 11]. Individuals such as these, who sit across one or more organizations, can facilitate the sharing of knowledge, skills and ideas; demonstrate a greater understanding of different contexts; and create more joined up networks. As an example of the contribution of implementation science to clinical practice, the award-winning Enabling Self-management and Coping with Arthritic Pain through Exercise (ESCAPE-pain) programme is a clinically and cost-effective intervention for knee and hip osteoarthritis (OA), now implemented across 260 sites in the UK [12]. It integrates education on self-management with an individualized exercise programme for each participant. A report by the King’s Fund describes the challenges of the adoption and spread of evidence-based innovation in the NHS, including ESCAPE-pain, highlighting the conflicting drivers and agendas between academic and commissioning stakeholders [13]. This includes stakeholders adapting the innovations for local use and fitting programmes into the local context, which illustrate the iterative, contextual nature of implementation. Furthermore, complex funding creates disconnects between commissioners and providers, and some contracts leave little room for flexibility of service provision without compromising funding or contract review. Conflicting drivers and agendas between academic and commissioning stakeholders can frustrate implementation efforts, illustrating the need for key stakeholders to work together throughout the knowledge mobilization journey to optimize the implementation of research. The Strengthening and Stretching for People with Rheumatoid Arthritis of the Hands (SARAH) trial demonstrated the effectiveness and acceptability of the addition of an individualized hand exercise programme to usual care [14]. Despite the trial’s success and integration of the intervention into policy (NICE guidance), neither its uptake, nor the fidelity of its implementation, are guaranteed, and further work focussing on its implementation is underway. Whilst this intervention requires behaviour change for patients and therapists, which in itself contains many challenges, system-wide change may be even more complex to implement. For example, the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-e) [15] aims to implement a model of supported self-management into clinical practice, including a package of written patient information, model consultations, training for professionals and quality indicators of OA care. Despite an active and engaged international community of practice, challenges encountered include: the complexity of managing projects across partnering countries and systems; cultural differences requiring adaptation to innovations; and contractual agreement required to share anonymized clinical audit data for evaluation purposes. There is wide recognition that publishing alone is not sufficient to promote research such that it will gain traction in practice. Working to improve the impact of research includes the collaborative approach outlined above, as well as integrating activities that might mobilize knowledge within the research design itself. Different formats for knowledge sharing may better suit different audiences, using a language and style familiar to those whose needs they aim to address. Finally, identifying a range of networks and vehicles for mobilizing the knowledge (including peer networks, professional organizations, public groups, credible champions, academic journals, or a combination) may optimize the process. What can the growing field of research into implementation do to help healthcare professionals improve outcomes for patients? Whilst the risk of using contentious and ambiguous terms (e.g. knowledge mobilization) may alienate those working closer to the coal-face, the principles underlying these fields of academic endeavour are ones that can improve all our practice. We all want to improve the healthcare we provide, but overwhelmed systems and perverse incentives often make it more difficult for us to enact this in practice. The approaches highlighted by implementation research, including paying attention to collaborative working, context, human relationships and different communication styles, arguably can be applied to many aspects of healthcare, including quality and service improvement initiatives. Implementation science may remind us of the importance of applying these common sense principles to our everyday practice. If we do this when co-designing services with patients, developing policy, commissioning agendas or undertaking primary research, then both the research undertaken by academics, and the care provided by healthcare professionals, should be more relevant and meaningful. This in turn may help us all drive up the quality of care for patients. C.A.S. is supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester. The views expressed are those of the authors and not necessarily those of the NIHR, the NHS or the Department of Health and Social Care; L.S. is funded by an NIHR School for Primary Care Research Fellowship; K.D. was part-funded by a Knowledge Mobilisation Research Fellowship (KMRF-2014–03-002) from the NIHR, the NIHR Applied Health Research Collaboration West Midlands, and is an NIHR Senior Investigator. Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript. Disclosure statement: N.W. was involved in the development and testing of the ESCAPE-pain programme, which was funded by the Arthritis Research Campaign. K.D received funding from EIT Health to establish the JIGSAW programme of work. L.S. was part-funded by EIT Health to conduct a knowledge mobilisation PhD. The other authors have declared no conflicts of interest.