From Research to Clinical Practice
Assessing the implementation of INSPIRE's Palliative Rehabilitation Intervention
Translating research to everyday healthcare practice depends not only on trial results, but also on the environment and context in which these results will be put into action.
With a wealth of new research to address gaps in modern healthcare, how can we best measure and overcome barriers to implementing new practices? This was a core discussion when the INSPIRE project, an EU-funded initiative trialling a rehabilitation intervention for individuals with cancer-related disability and palliative care needs, was first being proposed in 2021. It became clear that our palliative rehabilitation intervention would need to account for factors and barriers that might affect its implementation across international healthcare systems.
Implementation science, a relatively new field garnering increasing interest, was recognised as a way of bringing our novel intervention/s from blueprints into reality. This science aims to understand the most effective pathways to translate research into practical application. It seeks to identify the contextual factors of the “real world” that will influence how an intervention can work in specific environments. Think of it as a bridge between knowing what works and actually doing what works in real-world settings. Within the INSPIRE project, evaluating how successfully the intervention is delivered across our clinical sites is central to the evaluation of the intervention overall.
What is implementation effectiveness?
A crucial question in this field is how we conceptualise and evaluate successful implementation. Distinguishing between implementation effectiveness and intervention effectiveness is essential to translate research from the “laboratory” to everyday healthcare. In developing the INSPIRE palliative rehabilitation intervention, we sought a methodology to evaluate both forms of effectiveness. This involved examining the potential effects on patients’ quality of life, while also identifying barriers and facilitators to future implementation into routine clinical practices, whether economic, social factors or otherwise. To this end, INSPIRE is adopting the approach of Proctor et al (2011), who proposed a taxonomy of indicators, or metrics for evaluation, to evaluate the implementation of an intervention. Among these indicators are whether the intervention is acceptable, appropriate, sustainable, feasible, and faithful to the intervention plans. Within INSPIRE, we have chosen to evaluate these 5 indicators to investigate whether the intervention is ultimately delivered as planned.
Who are the key players for in implementation?
To account for real world variance, implementation evaluation encompasses the entire system in which the intervention is to be used. It is important to consider not only the perspectives of patients receiving the intervention, but also perspectives of all stakeholders involved. To this end, INSPIRE will be evaluated from the perspective of patients, their families, and healthcare professionals delivering INSPIRE, including nurses, physiotherapists, and occupational therapists as well as physicians referring patients to the trial who are under their care. This evaluation will also involve institutional representatives, such as hospital managers, department heads, and rehabilitation managers, as well as financial teams who will assess the cost-effectiveness of implementing the intervention in their institution.
How is implementation evaluated?
The methodology used in implementation research generally relies on a multimethod survey that uses scaled questionnaires, and personal reflections, to evaluate programs, interventions, and policies under evaluation. Questionnaires involve general statements about the intervention (e.g., “This intervention seems appropriate for my health condition”) with responses ranging from 1 (“completely disagree”) to 5 (“completely agree”). Personal reflections are extracted from interviews with participants asked to discuss and develop their views on the intervention using open-ended questions (e.g., “What is your opinion about your health status and condition?”, “how appropriate is the intervention for individuals with cancer?”). This method is applied at different levels, the patients, the professionals involved in the intervention and the institution within which the intervention is implemented. This process will raise valuable questions during the research process and inform the development of INSPIRE with a level of scrutiny that might otherwise be missed in the traditional outcome measurement of a randomised controlled trial.
Evaluating how successfully a novel intervention is implemented is a necessary element of modern healthcare. By embedding implementation evaluation from the start of the project, INSPIRE seeks to generate key learnings about the process not only for palliative rehabilitation but for future healthcare initiatives. If you are interested in conducting implementation studies, we recommend that you refer to Nilsen’s (2015) article, which helps you grasp the theoretical underpinnings of this science – and soon to our own INSPIRE methodology article!
Resources
Here are some handy resources for you to learn more about implementation science:
- Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation science, 10 (53). Doi: 10.1186/s13012-015-0242-0
- Proctor, E., Silmere, H., Raghaven, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and policy in mental health, 38 (2), 65-76. doi: 10.1007/s10488-010-0319-7
Julia Romeyer is an occupational therapist with a master’s degree in clinical research employed at Hospices Civils de Lyon and a PhD Student on the INSPIRE project. As part of INSPIRE, Julia is responsible for the process evaluation of the INSPIRE intervention. You can read more about Julia from her INSPIRE’s Monthly Researcher post.
