As screening and targeted treatment therapies in cancer have improved over the last 25 years, so have cancer survival rates. The American Cancer Society reports 2.9 million fewer deaths in 2017 compared with numbers in 1991.1 Rates of decline exceed 50% for lung, prostate, and colorectal cancers, while breast cancer mortality rates have declined by 40%.1 Individuals are living significantly longer after a cancer diagnosis, with more than 26 million individuals living beyond a cancer diagnosis in the United States.1 With the increased number of survivors, it is imperative that evidence-based practice (EBP) be gold standard within cancer rehabilitation programs.
While practicing medicine, or rehabilitation, based on scientific evidence dates back to the 19th century, Sackett2 is credited with the modern EBP movement. Advocating for conscientious and judicious use of evidence in patient care decision making, Sackett2 proposed the 3-legged stool of EBP: evidence, clinician expertise, and the patient's needs. Yet, studies report that, without a plan for implementation, it can take upward of 17 to 20 years to implement research findings into clinical practice, with greater than 50% of innovations never actually making it into practice.3 Researchers and clinicians in rehabilitation will benefit from an understanding of implementation science (IS) and knowledge translation in order to optimize the integration of EBP into the clinical setting in a timely manner.4,5
Many terms are often used interchangeably in the literature to describe optimization of the uptake of evidence into clinical practice, including knowledge exchange, knowledge transfer, knowledge utilization, knowledge translation, knowledge mobilization, research utilization, research uptake, dissemination and implementation, and IS.5–10 The term “knowledge translation” (KT) was developed by the Canadian Institute of Health Research and has been adopted by several other APTA Academies.11 KT describes the complex system of relationships between researchers and knowledge users to synthesize, disseminate, exchange, and ethically apply research findings but lacks guidance in how to implement knowledge.11,12 Knowledge translation has been criticized because it is a passive term that suggests knowledge is translated or passed into the hands of those who need to use it. Historically, researchers create knowledge and then publish it in the hopes that readers will put this knowledge into practice. Knowledge translation does not sufficiently describe a process in how to adopt a new intervention at the individual or system level.12 This gap is addressed by IS. “Implementation science” is a much more dynamic term that focuses on how interventions work in real settings, how to improve them, and how to sustain them.13 It provides a framework for identifying barriers and facilitators to the uptake of the desired behavior and engages stakeholders of multiple levels into the process.13 This contrasts with KT, which traditionally stops at the interface of researcher to those who uptake the knowledge. Without full guidance in how to navigate the barriers to implementation, which can include lack of adaptability of the intervention to a clinical population, organizational or individual resistance to change, or disruption in workflow, successful implementation may not be feasible.13 The term “knowledge implementation” more accurately reflects both IS and KT; this terminology is used throughout the article to encompass the breadth of KT and IS.
THE IMPORTANCE OF KNOWLEDGE IMPLEMENTATION
The growth in oncology rehabilitation research parallels the increase in the number of survivors. In a bibliometric analysis of the landscape of cancer rehabilitation research, the number of published studies in cancer rehabilitation has increased 4-fold since 1992, from fewer than 400 per year to in excess of 1600 published studies, for an 810% increase.14 The question that arises, given the sheer amount of information being produced on a consistent basis, is how do these findings make their way into clinical practice? Knowledge implementation provides both a process to create change and a method to measure the effectiveness of the change. What is needed, then, is for clinicians and researchers to work together for change. The purpose of this article is to describe IS, key frameworks, and strategies of knowledge implementation and to identify barriers and facilitators to implementation of contemporary research into clinical practices. The secondary purpose of this article is to demonstrate its application for the Academy of Oncologic Physical Therapy.
IMPLEMENTATION SCIENCE THEORIES AND FRAMEWORKS
Implementation science is a complex and dynamic process composed of a myriad of theories, models, and frameworks to guide the process of implementation of research and knowledge into practice. Nilsen6 have categorized these theoretical approaches into 3 basic aims, which include “(1) describing and/or guiding the process of translating research into practice; (2) understanding and/or explaining what influences implementation outcomes; and (3) evaluating implementation” (Figure 1). The first aim describes process models that strive to provide structure to the implementation process.6 Many are linear, while some acknowledge the complex relationships between the steps in the process.6 The second aim captures the theoretical approaches that address the influences on implementation. Several of these theories have origins outside the field of IS and address behavioral change, while others were created within the field of IS and address the barriers, facilitators, context, and adaptation of the intervention to improve success.6 Strategies or behavior change interventions are required to encourage key stakeholders, including patients, providers, clinics, systems of care, communities, and organizational leadership, to participate in the process.13,15 Barriers are determinants that hinder the uptake of EBP, while facilitators enable it.6 Context, however, lacks a standard definition. Despite this, many frameworks have commonly described context to include the surroundings or conditions in which the intervention is being integrated and address the need to adapt the knowledge to this context for successful implementation.5,6,16,17 Finally, Nilsen's6 third aim encompasses theories that focus on evaluation of the implementation process so that stakeholders can measure the success of their efforts.
It is difficult to select the most appropriate approach for any given intervention or clinical setting as theories, models, and frameworks cannot effectively be used in isolation to identify the different influences on implementation.5,6,18 Understanding the basic underpinnings of IS and how this can provide a path forward for moving evidence into practice in oncology rehabilitation is important to achieve success in knowledge implementation. Two frameworks are presented here that provide guidance to clinicians and researchers in oncology rehabilitation who are interested in embarking upon IS projects. The Knowledge-to-Action (KTA) framework provides a logical structure and process to plan IS projects. Overlaying the Consolidated Framework for Implementation Research (CFIR) on the KTA framework offers a comprehensive methodology to identify barriers and facilitators and evaluation of the project. Both frameworks embody all 3 of the Nilsen and colleagues6,16 aims of IS—describe the process, understand the influencers, and evaluate the success of implementation.
PROPOSED IMPLEMENTATION SCIENCE FRAMEWORKS
The KTA framework is a process model that was refined by Graham and colleagues19 in 2006 to assist health care professionals conceptualize knowledge creation into knowledge application (Figure 2). Knowledge creation is at the center of the framework represented as a funnel, with knowledge becoming more refined and thereby more useful to stakeholders. At the top of the funnel is knowledge inquiry, which represents the large body of primary studies or information of variable quality that have been published or presented. Knowledge synthesis embodies the critical analysis of existing knowledge and can take the form of systematic reviews, meta-analyses, and meta-syntheses, such as the Academy of Oncologic Physical Therapy EDGE Task Force publications recommending best standardized outcome measures by patient problem (ie, fatigue, balance, etc). Finally, the most refined form of knowledge at the base of the funnel is knowledge tools or products. Journal clubs, clinical practice guidelines (CPGs), and care pathways are practical examples of knowledge tools. Once knowledge has been created, the next step of the KTA framework is to facilitate uptake and application of the knowledge or putting evidence into practice. In order for knowledge to be effectively translated into the clinical setting, Graham and colleagues19 propose that knowledge producers tailor their activities to the needs of potential users throughout this knowledge creation funnel.
Knowledge application, or the action cycle, comprises the periphery of the KTA framework (Figure 2), which is a dynamic and iterative process leading to implementation of knowledge. The action cycle was derived from a comprehensive review of planned action theories, frameworks, and models that are intended to increase the likelihood of the uptake of EBP and was distilled to several common themes to simplify the process. The KTA framework is presented in a circular path because the process of translating knowledge into practice is rarely linear. It is a dynamic process that considers feedback from the key stakeholders between the knowledge creation and action phases and within the action phases.
Initially, the key stakeholders need to identify the problem that needs to be addressed, followed by identification, review, and selection of EBP that may address the problem. Similarly, the key stakeholders may become aware of an EBP and determine that implementation of that EBP may be valuable in improving health-related outcomes (ie, a newly published CPG). To increase the likelihood of successfully implementing the chosen EBP, key stakeholders need to adapt the EBP to their clinical setting and identify barriers and facilitators to using the EBP.20–23
Once the EBP has been implemented, it is critical that use of the EBP be monitored. Key stakeholders need to define what constitutes knowledge implementation so that appropriate evaluative methods can be implemented to measure the success of the EBP in a given clinical setting. If the implementation process was unsuccessful, barriers to implementation need to be analyzed to determine whether new adaptations to the EBP are needed to optimize uptake of the EBP. Stakeholders should consider whether there was inadequate consideration of adaptation to the local context (setting/individuals) and/or unexpected barriers and facilitators that were encountered during implementation of the knowledge. In this phase, it can be determined whether the barriers can be overcome to increase successful implementation in the future. The final phase of the KTA cycle is sustaining utilization of the EBP. Sustainment is often one of the most difficult phases as new barriers can arise over time, making it challenging to maintain organizational change. Ideally, the sustainability phase should set in motion a feedback loop that cycles through the action phases to provide the stakeholders with a method to ensure the EBP continues to be implemented.19
Consolidated Framework for Implementation Research
The CFIR is a determinant and evaluation framework that was developed to identify factors that can influence the implementation and effectiveness of an intervention.17 It is a synthesis of existing frameworks and theories from multiple disciplines including psychology, sociology, organizational change, and IS that use distinct constructs and consistent terminology.5,17,24 The CFIR does not propose to determine whether an intervention works; rather, it assists in identifying what works in a specific environment and why it works.25
The CFIR comprises 5 domains including intervention, inner and outer settings, individuals, and the process of implementation (Figure 3).17 Each domain is made up of a variety of constructs that are believed to influence implementation. While each of the domains will interact with each other, the CFIR does not specifically identify how each interacts with the others.17 The CFIR is an adaptable framework where stakeholders can select the most appropriate constructs that are relevant to their project. Appendix 1 (see Supplemental Digital Content, available at: https://links.lww.com/REHABONC/A26) presents each CFIR domain, the corresponding constructs, and detailed definitions of each construct. The first CFIR domain, intervention, is related to the EBP that is being implemented. Each intervention comprises 2 components, the core and adaptable periphery, which encompass the essential parts of the EBP as well as the elements that can be adapted to the context of implementation.17 Adaptability is a critical component of implementation of an EBP. Without it, the EBP will likely not be implemented because of its poor fit with the clinical setting and lack of buy-in from the key stakeholders.17 Patients seen in the rehabilitation setting tend to be highly complex and do not mirror the study population in a well-designed clinical trial. Physical therapists rely on high-quality evidence when making treatment decisions. Without the ability to adapt these EBPs to a broader patient population, implementation will likely be unsuccessful.
The inner and outer settings consist of the contexts where the implementation process will occur. The outer setting includes the context within which an organization is housed encompassing economic, political, and social contexts.17 In the rehabilitation field, this could include challenges with reimbursement, documentation, and billing for services.26 The inner setting embraces the structural, political, and cultural contexts in which the process of implementation will occur.17 According to Sabus and Spake,26 physical therapy “practices that value innovation and successfully implement innovation must have internally supportive elements.”(p114) In other words, the culture and leadership of the organization must support the challenges and disruption that go along with implementation of new EBP. The implementation will likely be more successful if it is in line with the mission, vision, and values of the organization.26
The individuals involved in implementation are those who will be advocating for and implementing the adoption of the EBP. Individuals wield a certain amount of power when it comes to implementation.17 Individuals are not always predictable and they must be willing to accept the EBP for it to be successful. Their perceptions, values, experiences, and levels of confidence will influence the success of organizational change that comes from implementing new processes and workflows.26 It is well documented that behavioral change can be difficult.26–29 Ensuring that an individual is truly ready for change may lead to greater success of implementation.
The last domain is the actual process of implementation. This stage is iterative in nature and includes the planning of implementation, engagement of key stakeholders, executing the implementation, and evaluating the process. When done appropriately, this process can result in successful implementation of the EBP into the organizational setting.17 Organizations will benefit from a champion who can dedicate oneself to driving the implementation process. The champion is responsible for educating key stakeholders and gaining support for the implementation of a new EBP. Execution of the implementation plan can be formal or informal. However, the presence of a more formalized, objective process, such as described by the KTA cycle, will allow for a more thorough and accurate evaluation of the implementation.17
Hybridization of the Frameworks
We propose that using a hybrid version of the KTA and CFIR when designing and executing implementation projects will provide stakeholders with stronger and targeted tools to increase the likelihood of successful implementation of EBP. Where the KTA framework identifies the steps in translating evidence into practice, the CFIR can assist with identifying factors that influence implementation as well as measure the effectiveness of the implementation. The hybridization table (Figure 4) combines both frameworks to align the CFIR domains and constructs with the KTA process.
In the KTA funnel, knowledge creation takes center stage. Using the CFIR constructs such as evidence strength and quality within the intervention characteristics domain ensures that the knowledge inquiry and synthesis within the KTA framework use quality evidence that is applicable to the situational need. Systematic reviews of the literature and CPGs provide recommendations that assist clinicians in making informed decisions based on the strength of the evidence, the benefits and harms of interventions, the assessment of bias within studies, and alternative options to action.30 By overlaying the CFIR construct of evidence strength and quality on the KTA step of knowledge creation, there is an assurance that the evidence gathered for use in implementing change is targeted to the area of interest and meets the standard of scientific rigor (Figure 4).
Identification of the problem, and selection of the appropriate knowledge to manage the problem, is the start of the action cycle of the KTA. Examples of knowledge that could be selected include adopting a recently published CPG implementing EDGE highly recommended outcome measures or a recommended practice such as prospective surveillance of a problem encountered by patients with cancer. This stage is enhanced through the CFIR domains and constructs illustrated in Figure 4. In this part of the process, there may be outer setting influences such as peer pressure or external policy and incentives to adopt specific knowledge. There are also influences of the intervention characteristics and opinion leaders in this phase of the KTA cycle.
Once the knowledge has been selected, stakeholders will want to adapt the knowledge to local context. The KTA cycle is not always linear, so stakeholders may want to combine this step with the next two, assessing barriers to knowledge use and tailoring the knowledge, to enhance the chance of the knowledge being successfully implemented. This part of the KTA cycle is essential in creating targeted and tailored solutions to the identified problem. The CFIR framework provides resources to enrich these steps. Intervention characteristics are important to consider, such as complexity, cost, and adaptability of the intervention. The influences of the inner and outer settings, such as patient needs, compatibility of the intervention to the organization culture, and learning climate, should be considered. And finally, the characteristics of the individuals and the process of implementation need to be accounted for. The personal attitudes of change, identifying implementation leaders and champions to engage the rest of the stakeholders in the process, are pivotal to the success of implementation. This is important as implementation of change comes with costs, both time and resources; taking these steps increases the odds of success that can provide an impetus for further change.26
Making permanent change in practice patterns is similar to developing a new habit: repetition of the correct pattern reinforces the action. The KTA framework addresses this by monitoring the use of knowledge and evaluating the effect of the intervention, with continued evaluation and assessment of the facilitators and barriers. These steps lead stakeholders to the next KTA step, sustainment of the intervention. The CFIR again provides depth and guidance to successfully accomplish these steps. Implementation leaders need to identify a process of implementation that includes reflection and evaluation to be able to measure whether the knowledge implementation goal has been met. If the goal has not been met, inner setting–driven organizational incentives and feedback could provide improvement in implementation of the desired knowledge. Given that less than 50% of all new knowledge is translated into practice, providing clear pathways for knowledge implementation is not only important but also critical.3
A Call to Action
The Academy has the opportunity to be at the forefront of changing practice patterns through the adoption of the KTA and CFIR models to study and execute knowledge implementation. Standard 4.6 of the Commission on Cancer requires that organizations have policies and procedures for rehabilitation that is on-site or by referral.31 It is essential that oncology rehabilitation professionals have the opportunity to optimize the quality of life and function of individuals treated for cancer that is bolstered by the use of EBP.32 Here, we make recommendations and a call to action for oncology rehabilitation researchers and clinicians to work together to improve the rate at which oncology physical therapy knowledge is implemented into practice. These recommendations are intended to be guidelines as clinical practice patterns, employments, frameworks, and resources will vary. Use of these guidelines provide a path and common language to accomplish the goals of knowledge implementation. They are to (1) identify opportunities; (2) engage stakeholders; (3) measure successes; and (4) educate for knowledge implementation.
Identifying current practices that do not align with EBP requires knowledge of what the evidence supports. In the KTA model, this step begins with searching and summarizing the literature related to the practical area of interest. Once the ideal is identified, current practices can be evaluated against what is recommended in the literature to find out where the process is not aligned and to identify what barriers to change exist. Practical solutions that address both the mismatch between practice patterns and evidence and address the barriers to implementation can then be implemented. Having a basic understanding of the evidence for oncology rehabilitation is critical. Attending scientific conferences, hosting journal clubs, and keeping abreast of the current literature all facilitate identifying opportunities to implement evidence-based change.
Involving stakeholders in the knowledge implementation process provides 2 distinct advantages. The first is buy-in. With stakeholder engagement, the chances of successful change increase.26,33 Second, stakeholder involvement ensures a comprehensive evaluation of the current situation to identify barriers and facilitators, tapping into the respective expertise of these individuals. Continued stakeholder involvement is essential to ensure that solutions address all possible barriers. The CFIR model is especially useful in evaluating stakeholder position and input. Together, the proposed solution and its effect will be greatest with stakeholder involvement.
Measuring the success of sustainable utilization of EBP is vital to closing the gap in knowledge creation to knowledge implementation. While this can be done with internal quality improvement frameworks to record and assess change, the ideal is to partner with clinical researchers who possess the knowledge and unique skill set necessary to design, implement, and analyze the results of projects. This step is also essential in sharing what is learned in a public forum so that others engaging in such projects can learn from the past experiences of others. Rehabilitation Oncology is committed to publishing quality research studies in IS to further the dissemination of knowledge.
Educate for Knowledge Implementation
Knowledge implementation is the heart and soul of increasing the uptake of EBP. Doctor of Physical Therapy education programs must adopt the inclusion of CPGs, and high-quality systematic reviews and meta-analyses into the curriculum, so that students are learning EBP up front. Understanding how to implement knowledge is just as important. The Academy encourages and supports inclusion of IS training at some level in the Doctor of Physical Therapy curriculum in EBP. Future clinicians must understand the implementation process in order to effect change. Practicing clinicians are encouraged to learn about IS through conferences or workshops or reaching out to the Academy's Implementation Science Work Group. Partnering clinicians and researchers in this realm is essential as well. There is limited evidence for the effect of implementation of knowledge in oncology rehabilitation, and this area is in need of study.
By following these recommendations, the Academy has real opportunity to effect significant change in the cancer rehabilitation landscape. With an increased recognition of the importance of rehabilitation after cancer diagnosis, the growing number of individuals with cancer, and the emerging science of implementation study, now is the time to act.
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