Abstract
Despite advancements in occupational therapy research, the widespread research-to-practice gap continues to delay how quickly evidence-based practices are implemented in real-world clinical settings. Implementing research in practice is a complex process that mandates attention from all occupational therapy stakeholders; however, researchers are uniquely positioned to help minimize the 17-yr lag between scientific discovery and the implementation of research findings into practice. Our article serves as a response to Marr’s (2017) Centennial Topics article, which proposed that purposeful efforts are needed to advocate for implementation research in occupational therapy. We provide an implementation science research agenda informed by concepts from the implementation science literature and suggest how researchers can structure methodologies to examine implementation-related outcomes and strategies. We provide explanations of gold-standard implementation outcomes and offer several recommendations for how researchers can report and disseminate implementation research findings to occupational therapy stakeholders.
Balas and Boren (2000) are often cited as having discovered that it takes an estimated 17 yr for 14% of research findings to be used in health care practice. This lag between empirical discoveries and the actual implementation of these discoveries by practitioners and health care organizations is known as the research-to-practice gap, and it has been well documented in the health literature (Bauer et al., 2015; Brekke et al., 2007; Morris et al., 2011). Although rigorous experimental studies may be deemed efficacious in highly structured research settings, perhaps the more pressing challenge now is determining how best to integrate evidence-based practices (EBPs) into real-life therapy environments (Corcoran, 2006; Reagon et al., 2008).
Marr’s (2017) Centennial Topics article in the American Journal of Occupational Therapy proposed that purposeful efforts are needed to advocate for implementation research in occupational therapy. In this article, we expand on Marr’s proposal and suggest an implementation science (IS) research agenda to narrow the research-to-practice gap, thereby enhancing the quality of therapy delivered by occupational therapy practitioners in a range of health care settings.
Various scholars have suggested ways in which the emerging field of IS can inform research translation to practice (Clark et al., 2013; Marr, 2017; Upton et al., 2014). Although some researchers have proposed recommendations to increase the uptake of EBPs in the clinic (Damschroder et al., 2009; Lin et al., 2010), empirical research that examines the most effective strategies (e.g., workshops, peer mentoring, journal clubs, protocols) for implementing evidence in occupational therapy practice settings is limited.
Implementation Science
IS is defined as “the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services” (Eccles & Mittman, 2006, para. 2). To date, social work, nursing, medical, and public health researchers have been at the forefront of IS research (Clark et al., 2013). Scholars in the IS research field have developed models and designed studies to examine specific barriers, facilitators, and strategies that influence how evidence is implemented in practice (Damschroder et al., 2009; Proctor et al., 2011) through the following IS research methodologies (Curran et al., 2012):
Preimplementation: exploratory or descriptive studies used to identify barriers or facilitators to EBP use and understand gaps in the quality of care delivered to clients
Observational: naturalistic studies used to determine the extent to which EBPs are being implemented in practice settings
Interventional: experimental studies used to test how implementation strategies (e.g., training workshops with coaching compared with online training modules) affect EBP use
Effectiveness–implementation hybrid: studies that examine the effectiveness of an EBP (e.g., constraint-induced movement therapy) in addition to assessing implementation outcomes (e.g., feasibility, fidelity, sustainability).
Although occupational therapy stakeholders have acknowledged the value of implementing EBPs in the clinical setting, less is understood about how to conduct IS research and measure implementation outcomes. In the United States and internationally, implementation-related scholarship in occupational therapy is often labeled translational research, practice-based evidence, or knowledge translation (Clark et al., 2013; Marr, 2017). Although none of these terms is entirely inaccurate in describing IS research, the occupational therapy profession could benefit from a clear explanation of how IS research can complement the occupational therapy scholarship that has informed existing EBPs.
To understand the unique value of IS research, one must first understand the translational research continuum. Abernethy and Wheeler (2011) described the science of translating research into practice through T blocks. In the T1 block, the focus is primarily on basic science research with initial testing in humans or, in some cases, animal species; the T2 block consists of human clinical trials research; and the T3 block examines clinical practice and implementation research (Khoury et al., 2007). To apply these T blocks in occupational therapy research, T1 research would, for example, include studies examining the effects of neuromuscular electrical stimulation (NMES) on arterial blood flow in the poststroke hemiparetic upper extremity (UE; Huang et al., 2014); T2 research would then investigate how NMES can improve the motor function of patients with UE hemiparesis (Hsu et al., 2010); and T3 research would determine how feasibly NMES could be adopted in the clinical setting, including the costs associated with training practitioners in how to implement NMES with stroke survivors. Although randomized controlled trials, found in the T2 block, are highly regarded in occupational therapy research, T2 research should be complemented by IS (T3) research to minimize the time lag between T2 discoveries and the actual use of such discoveries in practice.
Implementation Research Agenda
Scholars across disciplines have acknowledged that IS research is necessary to effectively enhance the adoption of evidence into practice (Clark et al., 2013; Döpp et al., 2015; Samuelsson & Wressle, 2014; Upton et al., 2014). However, acknowledging the value of IS research is only the first step in narrowing the research-to-practice gap. Marr (2017) noted the need for more effective integration of research into practice and specifically called for an implementation research agenda. Occupational therapy researchers in academic and clinical settings are well positioned to take active steps to narrow the research-to-practice gap through purposeful IS research efforts. However, IS research is still evolving, and understanding its complexity requires specialized training and mentorship. To narrow the research-to-practice gap, we first encourage collaboration between occupational therapy and IS scholars to conduct high-quality studies specifically designed to enhance the adoption of EBPs in practice settings. Just as researchers often consult with statisticians to assist with data analysis, implementation scientists can provide consultation and guidance on how to structure implementation-related methodologies.
The occupational therapy profession has made great strides in establishing evidence-based interventions and best practice guidelines. The rising impact factor of the American Journal of Occupational Therapy is one metric that indicates the advancement of rigorous, cutting-edge research being produced by occupational therapy scientists, practitioners, and students. In their collaboration with IS researchers, we propose that occupational therapy scholars acknowledge the value of measuring actual implementation outcomes. Proctor et al. (2011) developed a taxonomy of implementation outcomes that is considered to be the gold standard of measurement in the IS field. These eight outcomes are adoption, acceptability, appropriateness, costs, feasibility, fidelity, penetration, and sustainability. This taxonomy of outcomes can be measured by means of retrospective chart reviews, administrative data, surveys and questionnaires, focus groups and interviews with key stakeholders, observations of practice patterns, and fidelity checklists. Comprehensive descriptions of the implementation outcome taxonomy and measurement options can be found in the full article published by Proctor et al. (2011).
The evidence supporting effective implementation strategies continues to grow with contributions from interdisciplinary fields (Kirschner et al., 2018; Powell et al., 2015). Broadly defined, implementation strategies are the techniques used to promote the adoption of EBPs into a real practice setting. Select implementation strategies and their descriptions are as follows:
Assess for readiness and identify barriers and facilitators: Evaluate an organization’s or a group of practitioners’ readiness to implement EBPs and the associated factors that may influence implementation.
Conduct local consensus discussions: Include practitioners and other stakeholders in discussions that address whether the chosen EBP is important and appropriate for a given setting.
Develop a formal implementation blueprint: Develop an implementation plan that includes all goals, outcomes, and strategies being addressed. Use and update this plan to guide the implementation effort over time.
Identify early adopters: Identify practitioners or administrators at a local site who have already adopted an EBP and learn from their experiences when applying the EBP in practice.
Promote adaptability: Identify the ways in which an EBP can be tailored to meet client needs while preserving fidelity (Powell et al., 2015).
Samples of implementation strategies examined in the occupational therapy literature have included educational workshops, chart audits, follow-up consultations, standardized training modules, coaching, and fidelity vignettes (Colquhoun et al., 2017; Juckett & Robinson, 2018; Lin et al., 2010). However, the details related to the dosage, parameters, intensity, and frequency of these implementation strategies have not always been clearly reported. Although we strongly encourage researchers to test effective strategies for implementing EBPs into the clinical setting, implementation scientists (e.g., Proctor et al., 2013) also encourage researchers to specify the details of their strategies so that occupational therapy stakeholders can replicate them with their target audiences, such as practitioners, supervisors, and administrators. Samples of previously studied implementation strategies and recommendations for reporting these implementation strategies are described in Table 1.
Implementation Strategy Reporting Recommendations
Note. From Proctor et al. (2013).
Research examples are adapted from Döpp et al. (2015) to include hypothetical examples for all reporting criteria.
Implementation Science Research Agenda: Action Steps
To begin to support the adoption of EBPs across occupational therapy practice settings, we propose the following four action steps geared to academic and clinical researchers:
Consider collaborating with researchers who have specialized training in IS. Translating knowledge into practice is complex, and collaborations with IS researchers have the potential to expedite the integration of research into practice. The 17-yr research-to-practice gap has been the result of passive implementation efforts, whereas collaboration and active efforts through implementation teams have led to as much as 80% of research being implemented in just 3 yr (Balas & Boren, 2000; Fixsen et al., 2001).
Collaborate with practitioners who understand the daily challenges and opportunities related to implementing EBPs into routine care. Identifying barriers and facilitators to implementation is the first step in understanding the types of implementation strategies that can be leveraged to support the incorporation of research into practice.
Design empirical studies that purposely measure any of the eight gold-standard implementation outcomes suggested by Proctor et al. (2011). Measuring the outcomes of adoption, acceptability, appropriateness, costs, feasibility, fidelity, penetration, and sustainability is a critical step in understanding the extent to which an EBP can be implemented in practice.
When testing implementation strategies (e.g., audit and feedback, EBP champions, interactive in-services), we encourage researchers to consistently specify the components of their implementation strategies on the basis of the reporting recommendations offered by Proctor et al. (2013; Table 1).
Conclusion
The research-to-practice gap is an ongoing professional issue that needs to be addressed. Although we have acknowledged the importance of implementing EBPs in practice, we must now take our conversations about implementation to the next level and begin to empirically examine how to facilitate the use of EBPs by occupational therapy stakeholders. Future discussions and research efforts can be supported by concepts, nomenclature, and frameworks from the IS field. Our IS research agenda offers four action steps that can help focus researchers’ attempts to narrow the widespread research-to-practice gap and expedite the uptake of EBPs and promising interventions. Through the infusion of IS research concepts into occupational therapy research, we can begin to lay the groundwork for the effective and efficient integration of EBPs into real-world clinical settings with a range of client populations.