Evaluation Clinical Practice - 2017 - Rapport - The Struggle of Translating Science Into Action Foundational Concepts of
Evaluation Clinical Practice - 2017 - Rapport - The Struggle of Translating Science Into Action Foundational Concepts of
DOI: 10.1111/jep.12741
ORIGINAL ARTICLE
1
Professor, Centre for Healthcare Resilience
and Implementation Science, Australian Abstract
Institute of Health Innovation, Macquarie Rationale, aims, and objectives “Implementation science,” the scientific study of methods
University, Australia
2
translating research findings into practical, useful outcomes, is contested and complex, with
Research Fellow, Centre for Healthcare
Resilience and Implementation Science,
unpredictable use of results from routine clinical practice and different levels of continuing
Australian Institute of Health Innovation, assessment of implementable interventions. The authors aim to reveal how implementation
Macquarie University, Australia science is presented and understood in health services research contexts and clarify the
3
Postdoctoral Research Fellow, Centre for foundational concepts: diffusion, dissemination, implementation, adoption, and sustainability, to
Healthcare Resilience and Implementation
progress knowledge in the field.
Science, Australian Institute of Health Innova-
tion, Macquarie University, Australia Method Implementation science models, theories, and frameworks are critiqued, and their
Correspondence value for laying the groundwork from which to implement a study’s findings is emphasised. The
Professor Frances Rapport, Centre for
paper highlights the challenges of turning research findings into practical outcomes that can be
Healthcare Resilience and Implementation
Science, Australian Institute of Health successfully implemented and the need for support from change agents, to ensure improvements
Innovation, Macquarie University, Level 6, 75 to health care provision, health systems, and policy. The paper examines how researchers create
Talavera Rd, Macquarie University 2109,
implementation plans and what needs to be considered for study outputs to lead to sustainable
Sydney, New South Wales, Australia.
Email: [email protected] interventions. This aspect needs clear planning, underpinned by appropriate theoretical para-
digms that rigorously respond to a study’s aims and objectives.
Funding information
National Health and Medical Research Council, Conclusion Researchers might benefit from a return to first principles in implementation
Grant/Award Number: APP1054146
science, whereby applications that result from research endeavours are both effective and readily
disseminated and where interventions can be supported by appropriate health care personnel.
These should be people specifically identified to promote change in service organisation, delivery,
and policy that can be systematically evaluated over time, to ensure high‐quality, long‐term
improvements to patients’ health.
KEY W ORDS
evidence‐based health care and policy, health services research, implementable research findings,
implementation science
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2017 The Authors Journal of Evaluation in Clinical Practice Published by John Wiley & Sons Ltd
advancing implementation science; and (3) what is persistently With this in mind, in 2008, Rabin et al recommended returning to
interfering with the smooth implementation of research evidence first principles in implementation science, to clarify the evidence‐base
into practice. We offer suggestions for researchers to consider when of an intervention. We would argue that the same applies today,
planning a research study regarding what might improve the impact almost a decade later. We need to remind ourselves of implementation
of their study findings through stronger implementation plans. As a science’s foundational concepts and develop research strategies
contested and complex topic, with unpredictable uptake of research according to these concepts. We need to discuss their incorporation
findings into routine clinical practice, and different levels of assess- right at the outset of a rigorous health services research design,
ment and evaluation, it is vital that we take the time to visit the basic recognising that this will help us to understand more about the form
precepts of implementation science and the theoretical propositions that new knowledge takes, and how to bring new knowledge to the
underlying the production of strong research outcomes. We hope awareness of others. In describing the foundational concepts of
to provide researchers with a yardstick against which to consider implementation science in the section that follows, we wish to
whether their research has clear and extensive scope. If we can get highlight that the foundational concepts are critical elements of a
it right, this can support the design of new interventions into health successful implementation process.
care services to bring about longer‐lasting impact and better value‐ Foundational concepts, which underpin an intervention’s proven
for‐money, in spite of fluctuations in service delivery, system organi- efficacy and effectiveness, are said to fall within 5 distinct categories:
sation, and economic growth and decline. (1) diffusion, (2) dissemination, (3) implementation, (4) adoption, and (5)
sustainability1 (see Figure 1 for the authors’ visualisation of Rabin’s foun-
dational concepts). There are slight variations to this schema, most nota-
2 | F O U ND A T I O N A L T H E O R E T I C A L bly, the categorisation provided in Roger’s “implementation science
C O N C E P T S I N I M P L E M E NT A T I O N S C I E N C E model,”7 which includes “evaluation” and “institutionalization.” We
would also emphasise the point, as other scholars of implementation sci-
Implementation science, dissemination and implementation (D&I),1 evi- ence have, that context is crucial to successful adoption, take‐up, and
dence‐based interventional dissemination,2 and implementation spread.11-13 Additionally, as Stetler et al11 and Øvretveit13 remind us,
3
research, is a basket of terms that refers to the application of effective we must not only consider the different environments where we want
and evidence‐based interventions, in targeted settings, to improve the to ensure implementation can take place but also that context and envi-
4
health and well‐being of specific population groups. Implementation ronment influences much that is important. However, if we take for the
science is the scientific study of methods that take findings into practice, moment the 5 categories Rabin et al1 presented, we can consider them
while “effective implementation” refers to the process whereby an as a comprehensive suite of core components that together support an
actionable plan is appropriately and successfully executed. Both the sci- intervention. Each has a powerful message to deliver, and together can
ence and the implementation elements inspire new knowledge produc- act concertedly to influence the development of implementation sup-
tion and its dissemination.5 Implementation science enables questions port tools such as guidelines, programmes, projects, and policies.
to be asked about whether, and if so how, an intervention can make a “Diffusion,” while loosely defined in many studies, is the notion that
difference to a patient’s life or to the practice of a health care delivery ideas, behaviours, and practices spread out in a relatively unfocused
team, and whether bringing new knowledge into one setting automati- way, through informal and formal communicative channels, over time.7,6
cally, or with effort, enables its applicability in another. Answers to these Most experts see diffusion as relatively passive, where little targeted
kinds of questions can encourage better, more targeted service provi- planning takes place. In effect, diffusion, as a foundational concept, is
sion and policy development, and help to remind us of the need to part of “a diffusion‐dissemination‐implementation continuum”1 and as
foreground patient care and its delivery with rigorous evidence. a result, whether researchers are directly involved in how behaviours
The literature suggests that evidence‐based interventions must be and practices are dispersed through a system or not, diffusion, when it
appropriately disseminated (knowledge translation), to the right audi- occurs, is to a considerable extent, emergent and spontaneous.14
ences (knowledge targeting), implemented at the right time (knowledge “Dissemination” is “an active approach to spreading evidence‐
fidelity); and following dissemination, successfully adopted (knowledge based interventions to a target audience via determined channels using
take‐up) and evaluated (knowledge assessment), to clarify the extent planned strategies.”1 The “planned” and “targeted” components of
6,7
to which they are effective (knowledge results). When this works well, dissemination are often underpinned by strategic thinking about how
outcomes can affect both policy and practice, and can be measured in to reach as wide an audience as possible, efficiently and effectively,
terms of their long‐term sustainability and translational effect (knowl- and in the least possible time, while leaving the basic structures and
edge evaluation).8 However, there are multiple challenges to effective processes that make dissemination feasible undisturbed.15
dissemination in health services research, not least the ability to commu- “Implementation” is both “an ideal and an endeavour.”8 For an
nicate and move research findings beyond the scope of an immediate ideal, it captures research evidence and applies it to practice, reaching
project to influence health care delivery systems and procedures, and out, through science or social science, with a message about systems‐
long‐term policy initiatives and sustained, ubiquitous practice change or organisation‐based levels of change. As a practice, translating
(knowledge spread). Other challenges include how evidence can best research into implementable procedures “recognizes that these stages
be defined, the context within which evidence may be successfully do not happen automatically, often to no great extent, and sometimes
implemented, and how to keep evidence relevant within rapidly adap- not at all.”8 When implementation fails, it can leave behind a legacy
8-10
tive, changing health care systems. not just of wasted economic resources but also at worst, of systems
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RAPPORT ET AL. 119
upheaval, affecting health professionals at various levels, and successfully applied and embedded. That an intervention, once
impacting on patient care. When genuine implementation is implemented, should be sustainable is said to create “a feedback
successful, it can affect whole systems or services, positively loop that cycles through the action phases” of an intervention16,21;
improving practice and optimizing patient care. We have presented a a feedback loop that demands monitoring, adoption, and extended
graphic representation of the difference between the attempt to turn uptake phases, so that with each cycle, the intervention becomes
research into implementable procedures (the implementation more firmly entrenched within a system. However, for something
stage; ideal and endeavour) and the genuinely successful implementa- to be sustainable, it is not enough to just measure the success
tion of an intervention (the effective implementation stage; the of its evidence base. It also needs to take account of the real‐
successful endpoint) in Figure 1. In effective implementation, all the world environment setting.2 This aspect of sustainability
component parts come together to impact on the system or service; cannot be underestimated. Recognising the demands of different
in effect, this is the central focus around which all other component health care environments and their complexities adds to our
parts circle. When unsuccessful, challenges to the service or understanding of the resources necessary to sustain uptake and
individuals must be addressed quickly, but this can be delayed as a the initial commitment necessary for people to get involved
result of the complexities of health care service organisation and in the first place.17 We can bring this together in a conceptual
delivery, often leaving patients’ needs unmet.8 model. Figure 1 depicts the interrelationships between the core
“Adoption” is the degree of uptake of new ideas, behaviours, concepts.
practices, and organisational structures. As we have seen, adoption It is important to emphasise that, as outlined in Figure 1, these
is dependent on the context within which implementation of an components act connectedly and are integrated and should not be
intervention or diffusion or both have taken place, and in turn, the perceived as acting interdependently of one another. To make this
context is influenced by the practices and attitudes of those working point, in Figure 1, we present them in a circle, to give each an equal
within a particular organisation, the experiences of those presiding weight and position and to reinforce the point that they are bound to
over organisational design and activity, and organisational structure one another as cohesive elements of 1 effective implementation,
and processes.14,26 Also at play are the resources at the disposal of rather than as discrete elements within a pecking order or hierarchy.
those wishing to mobilise activity. These include the material It is also worth noting that the directionality indicated in Figure 1,
resources, the aptitudes of staff, and “the policies and incentives, where 1 component leads on to the next, can change. For example,
networks, and linkages”14,26 that affect how information is used by adoption may come before implementation, not after, if the intention
adopters. to implement is dependent on the success of the adoption of an
“Sustainability” is the logical endpoint of implementable intervention. Ordering of components is dependent on circum-
interventions, once new knowledge and the intervention have been stances, settings and situations.
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120 RAPPORT ET AL.
3.1 | Models for advancing the implementation of science. These are often known as “research‐to‐practice” theories.18,7
evidence‐based interventions For example, SCT was developed as a broad‐based conceptualisation
for understanding clinical behaviour change. It is widely used in
In 2012, Tabak et al24 undertook a detailed review of models spe-
implementation science, originated in psychology, but is now applied
cifically used in D&I research and published in peer‐reviewed
in other fields, to explain implementation outcomes.18 Social cognitive
journals. Focusing on 61 models, derived across disciplines such
theory is helpful for understanding the determinants of clinical
as Health Services Research, Nursing, Public Health, and Medical
behaviour and can support a clearer picture of “cognitive processes
Science, including models presenting “innovation, organizational
involved in clinical decision‐making and implementing EBP (evidence‐
behaviour, and research utilization,” Tabak et al24 categorised each
based practice).”18,7 While originally designed to examine behaviour‐
model according to construct flexibility, dissemination or implemen-
change at an individual level, SCT is now also used for its applications
tation angles, and a socio‐ecological framework. In listing all 61
to wider groups of health care professionals’ to examine aspects of the
models, Tabak et al24 hoped to raise awareness of the diverse
efficacy and effectiveness of practice.
range and scope of these models, but in effect, highlighted their
In 2008, Godin et al25 undertook a systematic review of
extensive degree of overlap, arguing that there was some scope
behaviour change studies and factors that influenced health care
for having a model in place in 1 discipline that could be used in
professionals’ behaviour using SCTs, the first systematic review of
another. They also identified the value of models for a wider
its kind for clinically related behaviours. They identified 72 studies
understanding of implementation constructs. This final use of models,
that provided information on the determinants of intention, and 16
defined by Nilsen18,3 as “process models,” is said to be suitable for
on the determinants of behaviour, referencing, in particular, “The
describing or guiding “the process of translating research into
Theory of Reasoned Action,” and “The Theory of Planned Behaviour.”
practice.”
They argued that prediction of behaviour and action was predi-
Of the 61 models of Tabak et al,24 most were already in
cated not only on determinants of intention (such as role beliefs
existence, used extensively in 1 discipline, and presented exactly as
and moral norms) but also on the type of health care professional
they had been designed, while others were adapted for use for
involved in the research, individual characteristics of professionals
different applications or contexts, or adopted across different
involved, social influences impacting on their involvement, and
disciplines. In the latter case, the use of a preexisting model was said
methodologically: eg, context, sample size, efficacy, and objective/
to be highly beneficial and supportive of the notion that a model has
subjective measures. Since this work, Cane et al26 have presented
generalizability and multiple uses. Adaptation of a previously adopted
an integrative theoretical framework for behaviour change research
model to suit a new study’s needs was also said to develop
and tested its validity for cross‐disciplinary implementation. Their
confidence in the model’s prevalidated measures and allowed for
“Theoretical Domains Framework” has been well tested across
further testing and assessment. The suite of models of Tabak et al24
health care systems and aims to bring about positive behaviour
included those supporting transfer, dissemination, and improvement,
change.
such as a “‘Model for Locally Based Research Transfer Development’
and a ‘Model for Improving the Dissemination of Nursing Research.’”
The models predominantly covered either dissemination or 3.3 | Determinant frameworks for evaluating success
implementation strategies but not generally both and spanned an
Determinant frameworks have been cited as 1 way of evaluating
extensive and varied topic base, such as health promotion, improving
the variables of success and are valuable in understanding the
health services research dissemination, coordinating implementation,
influences on implementation outcomes.18 They are not theories
policy process, knowledge infrastructure, social marketing, patient
and cannot clarify how change has taken place. However, they
safety, technology transfer, and evidence‐based practice in public
can be used to explain the outcomes of implementations, such as
services.
behaviour change in health care professionals or professional
For Tabak et al,24 it was not only the model that was important but
adherence to, and uptake of, clinical guidelines. Determinant
also whether there were measures in place to define and assess the
frameworks are useful in defining both dependent and independent
model’s constructs, so that it could be rigorously operationalized.
variables influencing implementation outcomes. They can draw links
Many of the models did not include construct measurements;
between dependent variables and can highlight barriers between
however, indicating that standard measurement development is still
variables that hinder interdependence and therefore have an
somewhat in its infancy. Without greater awareness of reliable and
impact on implementation. They can bring to others’ awareness
valid measures, an assessment of common constructs cannot take
the strengths and weaknesses of implementable outcomes and
place, resulting in, for example, shortcomings in information about
can assist with the design and execution of implementation strate-
outcomes and units of analyses.24
gies regarding, for example, changes to clinical guidelines. Meyers
et al23 undertook a synthesis of the critical steps in the implemen-
tation process, including postimplementation steps such as those
3.2 | Implementing new knowledge in health
necessary to realise determinants of success. They undertook a
services research: the example of SCT detailed review of implementation frameworks (based on empirical,
Some theories have been specifically developed to underpin new theoretical, and conceptual work), detailing 14 specific aspects,
knowledge and its take‐up in practice, through implementation phases, or “steps” to the implementation process, derived from an
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122 RAPPORT ET AL.
assessment of 25 frameworks.23 The review related to the imple- and resulting outcomes. Having covered core ideas about theories,
mentation of evidence‐based programmes across literature sources models, and frameworks, we turn to considering aspects of
target populations and innovation types. Their results emphasised translation.
the need for clear implementation structures built in to a study
from the outset. In relation to postimplementation assessment,
implementation frameworks were described in terms of the need 3.4 | Translating health services research findings
for “Ongoing Structure Once Implementation Begins” and to improve into practice
future applications (italics and capitals in original).23 Meyers et We have emphasised the importance of health services researchers
al23 defined the final phases of implementation frameworks as ensuring that appropriate theories, models, and frameworks are in
important for clarifying (1) that progress had been made in the place to give support to their implementable study outcomes. We
implementation for the benefit of all stakeholders involved; (2) a have discussed the value of returning to first principles, to define
retrospective analysis of implementation had been undertaken; (3) the core concepts of implementation science and clarify an inter-
assessment of strengths and weaknesses embedded in the vention’s evidence base.1 Yet even with all of this in place, sustain-
process was underway; (4) testing and modification of the imple- ing positive change to systems, processes, and behaviours seems
mentation was possible, according to (5) self‐reflection and difficult to achieve, while new policy or practice initiatives within
critical awareness, and the reconceptualisation of what quality the health services do not always withstand the test of time.27
23
implementation should look like. Meyers et al highlighted that We have described elsewhere how challenging it is to plan for
between frameworks, there was substantial agreement about the the translation of knowledge into practice, particularly around
steps and phases necessary for successful implementation and transitional care programmes.28 In the final sections of this article,
evaluation (the determinants of success), with framework devel- we would like to raise a selection of the most pressing problems
opers valuing health services researchers may face, highlighting what may be
getting in the way of progressing long‐term implementation plans
“Monitoring implementation […] developing buy‐in and a before considering how these may be alleviated and where we
supportive organizational climate […] technical go from here.
assistance […] feedback mechanisms […] the creation of
implementation teams […] and the importance of
building organizational capacity.”23, p.471 4 | LANGUAGE AND TRANSFORMATION
Their work emphasised the importance of ongoing monitoring Challenges surrounding implementation, and creating a science of
and evaluation for positive impact of the implementation process implementation in health services, are particularly noticeable when
it comes to clarifying shared understandings of the terms used to Box 2. Suggestions for overcoming some of the
describe the implementation process.28 This is exacerbated by a lack challenges of implementation science
of transformative vision and planning that would allow health
services researchers to achieve their research aspirations. Grol and
Challenges Overcoming Implementation Science Challenges
Grimshaw29 have alluded to this when they say: “sometimes the
Lack of common Common language is essential. Terminology
step from best evidence to best practice is simple; however, most
language must be consistent and used consistently
of the time it is not, and we need various strategies targeting within and across adopting groups,
obstacles to change at different levels.” To achieve long‐lasting organisations, and settings. Common
language is imperative for the sustainability
change in the delivery of health services to patients, according to of an intervention and the clarity about
appropriate care delivery models, systems, and practices, we need new structures and processes.
a common language. A language that is clear enough to withstand Short‐termism Characteristics of the adopting organisation
and adopting community should be not
knowledge translation in all its variation and to overcome semantic only recognised but also considered in
nuance, which often gets in the way of implementation, leading to terms of the longer‐term sustainability of
the intervention. This includes an
misunderstandings around what people are attempting to do and organisation’s size, complexity, and
hoping to achieve. readiness for change.
Terminology can drive a wedge between researchers and ser- Lack of The ability of an adopting organisation or
transformative community to share transformative goals
vice providers, researchers and service users, and researchers and
goals will be defined by the attitudes of the
policy developers, who need to understand one another to bring adopting organisation. These can be
about wider service reorganisation and practice improvements. considered in relation to individual and
group concerns, individual and group
When there is semantic disjuncture, miscommunication is rife. This adopters, the ability of an organisation to
is not helped by the fact that health services researchers see come on board early or late in the
adoption process, and the motivation
implementation science in different ways. For some, it is the expressed for implementation to be a
synthesis of evidence into practice. Others concern themselves success.
with integrating medical advances into trials, and still others define Lack of shared Context and rationale for delivery must be
agenda clearly understood and agreed by all
it as the preemptive strategies for ensuring the translation of constituencies for successful
knowledge, such as (1) undertaking systematic literature reviews; implementation to occur.
(2) designing new technologies; and (3) changing infrastructure Inappropriate Fit of methodology to aims and objectives of
methodologies the implementation process and
support.5,29-32 Semantic nuance adds a further dimension of
implementation outcomes must be
complexity to an already tricky issue and can problematize recognised at the study design stage and
underpinned by an evidence‐base.
dissemination plans.
We have highlighted earlier that some cornerstone concepts of Lack of embedded Evaluation frameworks should be in place as
evaluation plans part of new research design, ready to be
implementation science are defined by very specific terms with applied at the appropriate stage in the
which researchers need to familiarise themselves, if they wish to implementation process, for evaluation
purposes. Evaluation frameworks provide
design a rigorous study: (1) diffusion, (2) dissemination, (3) imple- a clear structure to evaluating
mentation, (4) adoption, and (5) sustainability. Yet how many of implementation endeavours.
these terms are clearly understood by those stakeholder groups Language unable Language must be able to withstand the test
to withstand of time, thus, if terminology around
who will be called upon to play an integral role in the implementa- the test of time implementation strategy or evaluation
tion process, and without that clarity, how can their value as part framework is refined, this must be through
agreement with all stakeholders and
of that process be best communicated? The language of implemen-
researchers involved, for the common
tation science needs to be consistent yet accessible to all. For this good.
to be successfully achieved, researchers must err on the side of
overexplanation, forming close ties with all stakeholder groups so
that language can be widely adopted and consistently understood.
The language of implementation science must be accessible and
communicative, to benefit not only other researchers but also prac- 5 | W H E RE D O WE G O F R O M H E RE ?
titioners and other stakeholder groups involved in the implementa-
tion process. So where do we go from here? We suggest that it is time for
Finally, health services research designs should have high translation endeavours to turn a corner, for health service researchers
aspirations to be transformative. Research that is bereft of trans- to contend with a lack of consistency and clarity. Researchers should
formative goals, grounded in the here‐and‐now, and underpinned consider whether they have taken into account how they will obtain
by inappropriate methodologies can lead to inconsistent outcomes evidence about research impact and ensure scientific rigour when they
that lack integration into practice and often lack an embedded design their research studies.33 They should include the user
evaluation plan. We summarise these concerns in Figure 3, perspective, to inform health care professional opinion,34 and create
suggesting some ways of overcoming or managing these concerns patient‐centred outcome indicators that favour a more thorough
in Box 2. outcome‐evaluation nexus.35
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124 RAPPORT ET AL.
A number of approaches may work concertedly to address the cur- it is necessary to also identify “purveyors” of change,37 who offer
rent problems faced in implementing interventions for longer‐term support to initiatives through their vision of the wider picture (see
change and to manage more effectively system capacity and scope. Figure 4). Purveyors of change can ensure a programme or practice
Alongside redesigned policy initiatives, contending with common goals has integrity and fidelity for the situation or setting within which it is
and shared agendas, and identifying champions of translational effect envisaged. Purveyors of change can be instrumental in ensuring that
6
may help overcome problems of translational research. Champions others will persevere with implementation in spite of any problems
of translational effect (who come in many guises, eg, “boundary faced along the way. In effect, they are identified to
spanners”36 are people who are recognised for their ability to engage
thoroughly with all stakeholder groups, include patients in consultation • Develop implementation measures that offer stakeholders
around implementing study outcomes, and utilise data to serve whole practical feedback as implementation embeds;
population groups—incorporating a vision for wider‐population impact. • Influence groups of future purveyors, with the knowledge and
Champions of translational effect should be cognizant of a proposal’s skills they have acquired that are necessary to carry implementa-
evidence base and be clear about its intended impact, be aware of tion forward; and
strategies to overcome problems that occur along the way to successful
• Engage policy makers and managers with the notion of successful
implementation, be supportive of indicators that measure success
implementation, looking forwards not backwards, to a future of
holistically, and be able to manage and monitor progress.29 Preparing
effective practice, and well‐supported patients.37
for change, by having champions of translational effect on board, within
the right setting for implementation, and with appropriate resources in
place to see implementation through, is critical for success. However, In the end, researchers may need to consider the value of
championing translational effect is a process that also needs overseeing, recommending and supporting the redesign of policy initiatives, with
by “change agents.” Change agents are people who can bridge the initiatives that are broad enough to manage research and system
divide between research outcomes and stakeholder groups.8,12 Finally, capacity and scope.8,33 Policy initiatives should be in line with patients’
overview of the challenges researchers face when they wish to translate 2. Brownson RC, Fielding JE, Maylahn CM. Evidence‐based public
health: a fundamental concept for public health practice. Annu Rev
science into action and offer some key concepts in implementation sci-
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nity to go into any great depth on a wide number of critical elements of 3. Palinkas LA, Aarons GA, Horwitz S, Chamberlain P, Hurlburt M,
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10.1007/s10488‐010‐0314‐z
offering a summation of a complex topic, we have only been able to
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6. Naylor MD, Feldman PH, Keating S, et al. Translating
time, lay the grounding in implementation science’s basic principle, and
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7. Rogers EM. Diffusion of innovations. New York: Free Press; 1995.
7 | C O N CL U S I O N
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