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EDITORIAL

Implementation models: applicability across research, implementation, culture and context

Stewart, Derek PhD

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doi: 10.1097/XEB.0000000000000268
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The Joanna Briggs Institute (JBI) Model for Evidence-based Healthcare is a whole-of-health model that brings together healthcare needs, research generation, synthesis, transfer and implementation while accounting for diverse contexts and evidence types.1 This editorial explores congruity between models complementary to subcomponents of the JBI model, using recent research examples, and explores cultural adaptability, then concludes by revisiting the JBI perspective on Evidence Implementation with its three components of context analysis, facilitation of change and evaluation of process and outcome in relation to the case studies reported in this issue.

Evidence synthesis, understanding contextual issues, identifying factors likely to influence change, engaging with key people, committees and organizational leaders, planning, informing, motivating and soliciting support are key to aspects of practice development and implementation.1 This is then followed by planned and systematic evaluation, reflection and further planning. This editorial describes the application of these approaches of evidence synthesis, translation and implementation to developments in pharmacy practice in Qatar.

Evidence of effectiveness, safety and acceptability has guided implementation of nonmedical prescribing.2–5 Both legislation and evidence are key to informing successful and sustained implementation, and requires commitment at the highest organizational and political levels.6,7 In spite of the accumulation of evidence of effectiveness, safety and acceptability, and organizational and political will, transfer to practice across settings or geographic regions is rarely seamless. Adopting relevant theory and theoretical frameworks as part of action planning may help to alleviate these complexities.

One such framework is the Consolidated Framework for Implementation Research (CFIR). The CFIR is a five domain synthesis of models, theories and frameworks that facilitate translation of research findings into practice (Table 1).8Table 1 summarizes the five CFIR domains and associated constructs which can influence implementation hence can be used in action planning similar to JBI Getting Research into Practice (GRiP), but with increased emphasis on engaging stakeholders’ perspectives and considering organizational characteristics.

Table 1 - Consolidated Framework for Implementation Research domains and construct descriptions
Domain Constructs
Intervention characteristics Intervention source, evidence strength and quality, relative advantage, adaptability, trialability, complexity, design quality and packaging, cost
Outer setting Patient needs and resources, cosmopolitanism, peer pressure, external policy and incentives
Inner setting Structural characteristics, networks and communications, culture, implementation climate, readiness for implementation
Characteristics of individuals Knowledge and beliefs about the intervention, self-efficacy, individual stage of change, individual identification with organization, other personal attributes
Planning Planning, engaging, executing, reflecting and evaluating

Implementation studies of the transition to pharmacist prescribing in Qatar illustrate the connectedness between qualitative study of the perspectives of key stakeholders in strategic positions of policy influence. The interview schedule was constructed from an extensive literature review and CFIR to ensure comprehensive coverage of potential implementation factors. Findings demonstrated specific issues to be considered including: tailoring the specific model of pharmacist prescribing to the needs of Qatar (innovation characteristics); collaborating with other countries that have successfully implemented pharmacist prescribing (outer setting); aligning more to the goals and ambitions of Qatar, and considering more the readiness for implementation (inner setting); enhancing pharmacists’ confidence to undertake prescribing (characteristics of individuals); and developing robust processes and associated governance standards (process).9 A further Delphi study determined the levels of agreement amongst key stakeholders on a framework for the potential implementation of pharmacist prescribing, the results of which are now informing the development of an education and training program, licensing requirements, models of care and governance standards.10 Demonstrable value in the implementation was achieved through local change and the roll out of education programs to embed and sustain the changes. Basing practice change on the synthesis of evidence derived from high-quality studies, supported by political drive and implementation theory, can support translation of innovation across countries and settings.

This issue of JBI Evidence Implementation includes a number of important evidence-implementation case studies based upon the JBI evidence-based healthcare model, demonstrating that strategies such as education to inform and sustain practice change have cross-model potential for localized implementation that is specific to the needs of local culture and context. These and other JBI implementation studies investigate and report what works in highly localized settings, using the JBI Practical Application of Evidence System and GRiP; readers of this issue will be interested in the implementation studies with ‘clinician friendly’ practice change strategies.11,12

Acknowledgements

Conflicts of interest

The author reports no conflicts of interest.

References

1. Jordan Z, Lockwood C, Munn Z, Aromataris E. The updated Joanna Briggs Institute Model of Evidence-Based Healthcare. Int J Evid Based Healthc 2019; 17:58–71.
2. Stewart D, Jebara T, Cunningham S, Awaisu A, Pallivalapila A, MacLure K. Future perspectives on nonmedical prescribing. Ther Adv Drug Saf 2017; 8:183–197.
3. Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016; 11:CD011227.
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7. Scottish GovernmentAchieving excellence in pharmaceutical care: a strategy for Scotland. 2017; Edinburgh:The Scottish Government, Available at: http://www.gov.scot/Resource/0052/00523589.pdf. [Accessed October 2020].
8. Damschroder L, Aron D, Keith R, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4:50.
9. Jebara T, Cunningham S, MacLure K, et al. Key stakeholders’ views on the potential implementation of pharmacist prescribing: a qualitative investigation. Res Social Adm Pharm 2020; 16:405–414.
10. Jebara T, Cunningham S, MacLure K, et al. A modified-Delphi study of a framework to support the potential implementation of pharmacist prescribing. Res Social Adm Pharm 2020; 16:812–818.
11. Khalil H, Kynoch K, Hines S. Interventions to ensure medication safety in acute care: an umbrella review. Int J Evid Based Healthc 2020; 18:188–211.
12. Khalil V, Wang W, Charlson L, Blackley S. Evaluation of prescribing patterns of nonsteroidal anti-inflammatory agents in a tertiary setting. Int J Evid Based Healthc 2019; 17:164–172.
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A video commentary on implementation project titled: How do health professionals prioritise clinical areas for implementation of evidence into practice? The commentary is provided by Andrea Rochon RN, MNSc, Research Assistant, Queen's University, Ontario, Canada