Implementation in action
2. What is implementation science?
Implementation science is the study of methods and strategies to promote the uptake of evidence-informed practices into 'business as usual', with the aim of improving service quality (Eccles & Mittman, 2006). Evidence-informed programs and practices are incorporated into 'business as usual' at very different speeds and there is often a gap between what we know works and what's being done in practice. There are many reasons for this. Sometimes the research is difficult to access and translate into a real-world environment; sometimes the evidence-informed program or practice is not a good fit for the local context; sometimes the service provider or staff are not interested in making changes to how they work; and sometimes there are barriers relating to the broader operating context, such as funding models. The field of implementation science aims to close this gap between research and practice.
2.1 Why is good implementation important?
When your program or practice implementation is high-quality, the children and families receiving your services are more likely to benefit from your service.
Many agencies and service providers now try to select and deliver programs and practices using the best available research evidence (i.e. those proven to be effective, based on well-designed evaluation studies) and best practice. Having an effective program or practice is necessary for good client outcomes. However, it is not sufficient. Using programs and practices with a strong evidence base is important, but two common pitfalls contribute to their potential not being realised:
- only focusing on 'what' program or practice to use, and ignoring 'how' the program or practice will be implemented
- failing to consider influencing factors (such as enablers and barriers) that impact your ability to initiate and sustain the program or practice.
You need to consider all these factors - the 'what', the 'how' and the influencing factors - to achieve the best outcomes for children and families, as illustrated in Figure 1.
Figure 1: Factors to consider when improving client outcomes
2.2 What are the key concepts of implementation science?
This section explains some key concepts of implementation science. We'll highlight key ideas, themes and assumptions used throughout this guide.
Implementation frameworks explain the different stages and activities you'll use when implementing a program or practice. Theyprovide a map and shared language for the implementation process. Many are applicable across a wide range of settings - though some are better for particular types of interventions, or focus on different aspects of implementation. During the past 20 years, researchers have developed many implementation frameworks (Albers, Mildon, Lyon, & Shlonsky, 2017; Moullin, Sabater-Hernández, Fernandez-Llimos, & Benrimoj, 2015; Tabak, Khoong, Chambers, & Brownson, 2012).
Our guide outlines an implementation framework that integrates relevant concepts that are common across existing frameworks frequently used in the child and family service sector (see Chapter 3 for more information).
Implementation happens in stages. It is a process that unfolds - it's not a single event. Your implementation model should guide you through the different steps in your implementation process. It should help you decide when to focus on each implementation activity - though the exact order of activities should not be fixed. Ideally, you should tailor your implementation process to your needs and context. And while implementation does happen in stages, the stages don't always end exactly as another begins. The process isn't always linear. For example, timeline and funding pressures may mean that you need to move fast and cause stages to overlap (with activities from two different stages happening at the same time). You may also experience setbacks that mean you need to revisit a previous stage before you can progress further. For example, staff turnover may mean you no longer have enough practitioners trained in the program or practice, resulting in a 'pause' on service delivery while you recruit and/or train additional staff.
This guide outlines four stages (see Chapter 3 for more information):
- Engage and explore
- Plan and prepare
- Initiate and refine
- Maintain and expand.
Implementation enablers and barriers
Implementation enablers increase the likelihood a program or practice will be successfully implemented. Enablers can include support from an organisation's leadership, and the program or practice being a good fit for target children and families.
Implementation barriers make the implementation process more challenging. Barriers can include a lack of resources to deliver a program or practice, and low confidence in the program or practice among the people delivering it. However, you shouldn't give up on your implementation simply because you face barriers. It's normal to experience barriers. Your implementation will be successful if you can identify and overcome barriers early in the process. You should continually monitor the enablers and barriers, as different influencing factors will emerge during different stages of implementation. The process of assessing and identifying enablers and barriers is described in Chapter 4.
Implementation strategies are techniques that improve the adoption, planning, initiation and sustainability of a program or practice (Powell et al., 2019). They are the 'how to' components of the implementation process and are used to overcome barriers.
So how do you decide which implementation strategies to use? Sometimes there is existing evidence showing which implementation strategies are likely to be useful for implementing your particular program or practice. Or, if you're implementing a manualised program (i.e. a program which has been developed with a structured, detailed manual that you usually need to buy a license for), the program developers may require you to use particular implementation strategies. If you don't have any suggested implementation strategies, you can tailor your strategies based on the barriers you've identified and experienced in your program or practice.
For example, in Stage 1 (engage and explore) a key barrier may be a lack of information about the needs of the children and families who participate in your service. You can overcome this barrier by compiling agency or service provider data, such as demographics; client goals at baseline; child and family feedback; and outcomes for families when they exit your program. During Stage 2 (plan and prepare), when you've already decided what to implement, a barrier might be that staff lack the right experience and skills to implement the new program or practice. You can overcome this by providing staff with interactive, skills-based training and post-training technical assistance, such as coaching.
Chapter 5 explains how to identify and choose implementation strategies.
Implementation pace and planning
We don't provide a recommended timeline for a high-quality implementation process, as it always varies depending on your circumstances and context. However, it often takes two to four years for a well-structured program to be fully implemented. The timeline and duration of your implementation process will depend on the complexity and adaptability of your program or practice; the context of your implementation; and other influencing factors, such as policy and funding priorities.
It's important for your agency or service provider to prioritise your implementation planning and preparation activities. Common pitfalls include:
- not investing enough time or resources during the early stages of implementation
- attempting to implement too many new programs and practices at once
- not reprioritising resources from an 'old' to a 'new' initiative.
Investing adequate time and resources during the early stages of implementation will reduce your efforts later down the track. This short-term pain will result in long-term gain.
Implementation leaders and champions
Implementation leadership is the level of support leaders provide to implementation efforts. Leadership can come from people who have formal organisational authority and can mandate and create change (including executive leaders, middle management and team leaders), as well as from champions of the specific program or practice who have informal influence in the organisation (including practitioners or other staff). The benefits of having implementation leaders and champions are undisputed and should not be underestimated (Aarons, Ehrhart, & Farahnak, 2014; Aarons, Ehrhart, Farahnak, & Hurlburt, 2015; Aarons, Ehrhart, Farahnak, & Sklar, 2014; Aarons et al., 2016). Effective implementation requires support, involvement and communication from leadership. Leaders define the vision for your implementation. They also set expectations for staff behaviours and performance; allocate resources for your implementation efforts; and determine how the implementation is perceived throughout your organisation.
Indicators of high-quality implementation
To see how well your implementation process is going, you need to monitor your 'implementation outcomes' (Proctor et al., 2011). Implementation outcomes are the effects of using your implementation strategies. They are indicators of the quality of implementation. For example, you can monitor how acceptable your program or practice is to staff who are delivering it; how feasible the program or practice is in your context; and the fidelity of program delivery (i.e. whether the program has been implemented as intended. See Chapter 5.3 for more detail). Figure 2 illustrates the relationships between the 'what' (the evidence-informed program or practice), the 'how' (implementation strategies), and implementation and client outcomes.
In summary, using relevant implementation strategies will improve the quality of your implementation (as shown by improved implementation outcomes). This, in turn, improves client outcomes. This shows just how important it is to monitor implementation quality, as well as client outcomes.
Consider this scenario: You evaluate a new program by assessing the outcomes for children and families, and you find no beneficial effects. Unless you also assess the implementation outcomes, it's unclear if the program had no effect because it was poorly implemented (e.g. lack of program buy-in or fit; or program components were skipped or not delivered as intended), or because it's a truly ineffective program.
Figure 2: The relationships between implementation strategies, implementation outcomes and client outcomes
Source: Adapted from Lewis (2017), Lyon and Bruns (2019), Proctor et al. (2011) Adapted from Lewis (2017), Lyon and Bruns (2019), Proctor et al. (2011)