Team-based research appraisal activities among allied health in
rural and regional health
services
Dr Olivia A. King1,2,3
Dr Rosalie A. Boyce1,2,4
- University Hospital Geelong
- South West Healthcare
- Monash Centre for Scholarship in Health Education
- The University of Queensland Office of Sponsored Research
Abstract
Rational and aim
Health services are expected to provide evidence-informed care and
services. Journal clubs have been the mainstay of evidence appraisal
activities for many clinical teams however the translation of findings
to changes in clinical practice are less certain. The current study
examines the operationalization of evidence appraisal activities by
allied health teams in a regional and rural area and their connection to
practice change.
Method
A cross-sectional online survey of allied health managers and team
leaders across three health services in a regional and rural area in
Victoria, Australia. Participants were asked to describe the evidence
appraisal activities undertaken within their teams with respect to
operational factors such as the approach, forum, frequency and platform.
Participants were also asked about their perceptions of the capacity
within teams to undertake evidence appraisal, impact of the activities
and the importance of different stakeholder groups in the clinical
practice change process.
Results
Sixteen allied health managers or team leaders responded to the survey.
Almost all teams engaged in some form of regular evidence appraisal
activity, either within a unidisciplinary or multidisciplinary format.
Features of the activities varied however participants commonly reported
the perceived impact of such activities on clinical practice was
moderate or low. Participants considered themselves, as managers and
their clinicians key to identifying the need for, and leading changes to
clinical practice.
Conclusion
Allied health teams regularly engage in evidence-appraisal activities in
regional and rural health services. While impact of these activities on
clinical practice remains unclear, the findings of this survey study
suggest the impact is moderate at best. A region-wide approach to
team-based evidence appraisal activities underpinned by research
translation framework(s) may improve the impact of these activities on
clinical practice.
Keywords
Allied health, evidence-based practice, research translation, journal
club
Introduction
Appropriate and timely translation of research evidence into clinical
practice is central to health service capacity development strategies in
both developed and developing countries,
worldwide.1-4 Research
translation is a non-linear process by which the best available evidence
is adopted, adapted to the local context and implemented into practice
with a view to improve service efficiency and effectiveness and
ultimately, healthcare
outcomes.5,
6 Successful and sustained research
translation relies on appropriate adaptation of research evidence to the
local context, leadership (and followership), adequate resources,
organisational support and engagement with stakeholders beyond the team
driving translation.5,
7-9 Research translation is a complex and
social process.5,
7, 10
Health services with a vibrant research culture and high levels of
clinician research capacity are associated with evidence-informed care,
perform more relevant clinical and health service research and increased
clinician job satisfaction and
retention.4,
11-14 Research capacity encompasses an
array of individual skills and competencies which contribute to
proficiency in key research activities. For this paper, three key
domains to define individual healthcare professionals’ research capacity
are identified: 1) research consumption (i.e. the reading and appraising
of research evidence); 2) research activity (i.e. actively undertaking
research and thereby generating relevant research evidence) and 3)
implementing research evidence to change clinical practice in accordance
with the best available evidence).4,
14-16 Developing individuals’ skills in
these three domains enhances organisational research capacity leading to
increased service and system-wide adoption and implementation of
evidence-informed healthcare
practices.17
Clinicians’ skills in research evidence consumption rely on their
ability to identify a clinically-relevant knowledge gap, search for and
identify relevant research evidence, read, comprehend and critically
appraise the evidence to inform their decision to adopt and apply the
findings in clinical practice. A critical finding limiting the appetite
of allied health clinicians for research engagement and consumption is a
decline in confidence in their evidence-based practice skills, including
critical appraisal within five years of commencing clinical
practice.18
Evidence consumption activities can be undertaken individually, within a
uniprofessional or a multiprofessional setting. Journal clubs have been
an institution among health professionals since the late 1800s and have
provided a forum for team-based evidence consumption. Touted as a means
to support and promote evidence-based practice, little is known about
the features of journal clubs that influence practice
change.19 Despite the
enduring nature of the journal club format, there is no assurance or
systematic methodology for ensuring that it translates into clinical
practice review and change. Evidence is notably lacking that high-level
research consumption skills influence successful and sustained research
translation.9,
19
While efforts to enhance research capacity have historically focused on
the skills required to competently consume and conduct healthcare
research,16 attention
has recently turned to the mechanisms by which research knowledge is
mobilised or translated into practice and the capabilities required of
health services and clinicians to facilitate this.9,
14, 20 In
the Australian context, investment in allied health research translation
capacity development has been increasing over the last decade and
includes the recent establishment of allied health service situated
researchers to support research translation in
Victoria.14,
21 Allied health represents more than a
quarter of the healthcare workforce in
Australia22.
Professions included in allied health may number more than twenty,
depending on the jurisdiction, but typically include disciplines such as
speech pathology, dietetics, podiatry, physiotherapy, occupational
therapy, social work.23
Recent research has focused on new formats for journal clubs to improve
practice change outcomes for allied health. For example, Wenke and
colleagues measured the effectiveness of an enhanced journal club format
compared with the traditional format, with teams of allied health
clinicians. However, the results indicated that further research
needed.24 The purpose
of the current study is to elucidate how team-based evidence appraisal
activities are operationalised by allied health teams in regional and
rural health services, to influence and inform research translation. The
study serves as a precursor to establishing processes to promote
research translation capacity development in health services across the
region.
A key contextual feature to note is that infrastructure supporting
allied health research in the region is comparatively underdeveloped
with respect to major hospitals in metropolitan areas and other regions.
Anecdotal evidence collected from allied health clinicians and managers
within the region identified two areas of perceived weakness:
- Structures and processes governing team-based evidence review and
appraisal were inconsistent
- review and appraisal activities did not consistently inform
systems-level clinical practice change.
Managers and team leaders expressed a desire to ensure clinical practice
was aligned with contemporary, evidence-based guidelines and make
efficient use of the time allocated for clinical appraisal activities.
Methods
To gain an understanding of the processes and systems in place, as well
as perceptions of the role of such processes in informing practice
change, a survey of allied health managers and leaders of teams with
allied health clinicians was undertaken. The use of survey methodology
provided anonymity for participants to disclose perceived inadequacies
in team-based evidence appraisal activities and processes.
The survey study was conducted across three health services and between
May and August 2019. The decision to restrict the survey to manager and
team leader levels was to capture formal and organisationally approved
evidence appraisal activities. Furthermore, the study was seeking to
assess the manager and team leader satisfaction with the translational
output from appraisal activities rather than those of frontline staff.
The survey (available on request) was sent to 27 allied health managers
or team leaders. Ethics approval was obtained from the region’s largest
health service research office. Responses to close-ended questions the
and free text responses were analysed and summarized
descriptively.25
Results
Sixteen allied health team or program managers responded to the survey.
All participants are allied health discipline managers or managers of
programs or teams of which allied health clinicians are members. The
survey asked questions which relate to team characteristics and
activities. One question asked participants about their perceptions of
the impact of clinical evidence appraisal activities undertaken within
and by their team. Due to concerns about the identifiability of
participants and teams, very few demographic questions were included.
Participant and team
characteristics
Sixteen allied health team or program managers responded to the survey.
The size of the teams represented varied, with five participants
representing teams of between 10 and 20 clinicians and another five
representing teams of more than 30 clinicians. Four participants
represented a team with less than 10 clinicians and two had between 20
and 30 clinicians. Therefore, the respondents represent at least 280
allied health clinicians.
Nine of the participants described their team as being unidisciplinary
(which may include allied health assistants) and seven participants’
teams were multidisciplinary. More than half (n = 9) of the participants
had completed their most recent qualification over 10 years ago, four
had completed a qualification within the last five years, two within the
last six to 10 years and one participant was currently undertaking a
further qualification.
Types of clinical evidence appraisal activities
Participants were asked to select the clinical evidence appraisal
activities that their teams engage in, from a pre-defined list. They
were given the opportunity to select “other” and describe the
activity. Participants were able to select all applicable activities and
among the eight types of activities, there were 52 selections. Two
participants indicated that they were not aware of any organized or
regular evidence appraisal activities in their teams. Table 1 shows the
most commonly employed approaches to team-based clinical evidence
appraisal.
Table 1 Clinical evidence appraisal activities according
to team
type
One participant indicated that they were not aware of any organized or
regular activities, one indicated that individual team members engaged
in activities with teams outside of theirs (only) and one indicated that
they (manager) engaged in evidence appraisal privately or as part of
formal study. Of the participants whose teams do engage in team-based
evidence appraisal activities (n = 13), all engage in multiple types of
activities.
Forums and media for evidence appraisal
activities
Participants were asked to select from a list, the forums within which
clinical evidence appraisal occurs. Participants were also asked to
select the medium utilized. For both questions, participants could
select all that apply and had the option to select and describe
“other”. Tables 2 and 3 present the types of forums and media
according to team sizes. Most teams reviewed and appraised clinical
evidence within regular team meetings or during meetings which are
scheduled in response to the identification of clinical or service
issues. See Table 2.
Table 2 Team size and forums for conducting clinical
evidence appraisal
activities
The most commonly utilized medium is face-to-face meetings (n = 14),
followed by email (n = 6) and video- or teleconference (n = 4). See
Table 3.
Table 3 Team size and media utilised to conduct team-based
clinical evidence appraisal
activities
Frequency of evidence appraisal activities and team member
attendance
Participants were asked to indicate how frequently team-based clinical
evidence appraisal activities are undertaken (single answer option) and
typical team-member attendance. More than one third of the teams
represented meet quarterly (n=6), a quarter met monthly (n=4) and the
remaining teams represented meet every two months (n=2) or every six
months (n=1). Two respondents selected not-applicable and one did not
answer.
Half of the participants (n=8) indicated that typically most team
members attend clinical evidence appraisal activities, a quarter (n=4)
indicated that some of the team members attend regularly and the
remaining responded that all attend regularly (n=2) or not applicable
(n=2).
Perceived levels of expertise within the teams and impact of
evidence appraisal
activities
Participants were asked to indicate their perception of the level of
capacity or expertise within their teams, with regard to clinical
evidence appraisal. The majority of participants indicated that they had
adequate (n = 7, 44%) or very good (n = 6, 38%) capacity or expertise
within their teams to undertake clinical evidence appraisal activities.
There were no participants that indicated they had excellent capacity
and few indicated they had inadequate capacity (n = 2, 13%) or very
poor capacity (n = 1, 6%).
Participants were also asked to indicate their perceived impact of the
clinical evidence appraisal, where the following definitions, for the
purpose of the current study, were applied:
- High impact: activities regularly result in stimulating and fruitful
discussions and positive changes to practice
- Moderate impact: activities often result in stimulating and fruitful
discussions but do not regularly lead to changes to practice
- Low impact: discussions tend to be superficial and do not lead to
changes to practice
The majority of participants indicated that their activities were
perceived to lead to moderate impact (n = 8, 50%), fewer perceived high
impact (n = 4, 25%), low impact (n = 3, 19%) and for one participant,
this question was not applicable.
On interrogating the data, there did not appear to be any patterns in
the type or size of the team and the perceived impact of evidence
appraisal activities. This is likely due to the small number of
responses. Interestingly, there did not appear to be any link between
teams with higher levels of evidence appraisal expertise and a higher
impact of their activities.
Descriptions of evidence appraisal activities and how these
inform changes to clinical
practice
Fifteen participants responded to two open-ended questions which asked
them to (1) describe the clinical evidence appraisal activities which
take place within their teams and (2) how these activities inform
decisions and actions to change clinical practice.
In response to the first question, several participants described having
a structured process in place, which is led by a designated person
(either the manager / team leader or a senior clinician with an interest
in research or a clinical area). Others described more ad hoc approaches
to reviewing evidence, based on current and emerging trends and issues.
Responses to the second question were also varied. Several participants
did however, speak about establishing small working groups to effect
clinical practice changes in response to evidence and a perceived need
to address clinical or service issues.
Who is best placed to identify the need for clinical practice
change and who is best placed to lead the endeavour?
Participants were asked to rank the importance of the list of
stakeholders / factors below from a pre-determined list, with respect to
their role in (1) identifying the need for clinical practice change and
(2) in leading the implementation of changes. Consumers were not listed
as a stakeholder group, as it is implied that through consumer stories,
experiences and adverse events involving consumers, the need for changes
to clinical practice will be highlighted by one of the above-listed
stakeholders. For example, receiving and acting on consumer feedback is
incorporated in the work of the Safety and Quality team. Further, the
purpose of the study was to examine the appraisal activities and their
impact of the frequency of change to practice, rather than to understand
how consumers are involved in identifying the need for appraisal
activities.
Participants were asked to use a ranking of 1 to indicate which
stakeholder group was considered to be most important in identifying or
leading the need for changes to clinical practice. Those considered
least important were ranked 10. Therefore, the stakeholder group or
factor with the lowest sum were considered most important.
Table 4 Stakeholder group or factor most important in
identifying the need for changes to clinical practice
Table 4 shows, the participants ranked managers or team leaders, and
clinicians as the most important stakeholder group in identifying the
need for changes to clinical practice. Policy directives and important
Safety and quality teams were also considered very important.
Similarly, Table 5 shows that participants ranked managers or team
leaders and clinicians as the most important groups in leading changes
to clinical practice. Senior managers, project workers and safety and
quality teams were also considered important.
Table 5 Stakeholder group most important in leading
changes to clinical practice
Discussion
The respondents represented 16 teams of least 280 clinicians from three
health services across the Region. This is approximately 40% of the
allied health workforce in the employing institutions Allied health
teams, both unidisciplinary and multidisciplinary, take different
approaches to appraising clinical evidence within their teams and there
are no clear patterns according to team composition. There is variety
with respect to the types of activities, forums and media used to
appraise the clinical evidence, the frequency at which these activities
are undertaken, typical attendance, perceived expertise within the teams
and impact of such activities in terms of changes to clinical practice.
Most of the participants who reported having team-based processes to
review and appraise clinical evidence in place, frequently described
themselves (i.e. as the manager or team leader) to be the leader of such
processes. Of the participants that reported having a team-based
approach to discussing and planning changes to clinical practice in
place, the establishment of small working groups was commonly described.
The size or disciplinary profile of the teams does not appear to
influence the types of activities undertaken or any of the other
aforementioned factors.
The majority of participants (n = 12, 75%) perceive the impact of their
various evidence appraisal activities to be either low or moderate; that
is, these activities seldom lead to positive changes to clinical
practice. That is, regardless of perceived capacity, engagement and
expertise, team-based research consumption rarely leads to changes in
clinical practice. This resonates with Hitch and colleagues’ (2019)
observations that knowledge and research consumption skills are rarely
the key predictors of clinicians’ or teams’ ability to translate
research into practice. This highlights the need for a different
approach to promoting evidence-informed clinical practice.
On ranking the importance of the different groups and factors in terms
of identifying the need for change to clinical practice and then again
in leading changes to clinical practice, participants pointed to
managers / team leaders (i.e. themselves) and the clinicians within
their teams. This adds weight to the argument for ongoing investment in
research translation support and resources in health
services.4,
26-28 Moreover, that managers themselves
were identified as central to the clinical practice change process
reflects the findings of previous research on the factors influencing
middle managers’ commitment to driving clinical practice
innovation.29 The
authors found that the two most important factors were managers’
perceptions of the ease of implementation and of the likely benefits on
patient outcomes.
Clinicians and managers are aptly placed to identify the contextually
relevant enabling and constraining factors influencing research
translation endeavors.8,
9 Indeed, the results of the current
study indicate that allied health managers and team leaders consider
themselves and the clinicians in their teams aptly placed to identify
the need for practice change and to lead the practice change
process. However, support to identify relevant, high quality guidelines
and evidence appropriate for clinical teams and areas is enhanced by the
presence of, or ease of access to, resources including experienced
researchers as knowledge brokers or
facilitators.24,
30
While the evidence supporting the impact of traditional team-based
evidence appraisal activities on clinical practice remains weak, it is
clear that for allied health, journal clubs as a concept represent the
mainstay of research and quality improvement activities. They are
conducted regularly: quarterly in more than one third of cases,
generally well-attended: most team members attending regularly in half
of the teams represented and using a number of different platforms.
Accordingly, efforts to develop research translation capacity within
allied health clinicians, teams and health services more broadly, can
leverage off the enduring commitment to and engagement with, these sort
of activities. The focus however, can be shifted from research
consumption (review, appraisal and judgment of the worthiness of
published research), to a process guided by one of the numerous research
translation frameworks that have proven effective in identifying and
address the various factors impeding the successful and sustained
translation of research into clinical practice, on a systems
level.31,
32
There are several implications for practice emanating from the current
study. The traditional journal club can be revitalized, refocused and
rebranded as a research translation group or contemporary clinical
practice club. Membership, frequency of meetings and platforms should
remain as they are so as to ensure the current level of engagement,
however the focus should be placed on translation discussions with the
support and guidance of a suitably qualified clinician-researcher or a
skilled translation lead.
Limitations and future
direction
This study has several limitations. The findings are based on a small
sample of 16 allied health managers and team leaders. Further, the
survey tool utilized is not validated. However, it is important to note
that it was designed to enable the researchers to attain an accurate
illustration of the various team-based research consumption activities
across the region to form the basis of research capacity development
activities. The definitions related to impact (i.e. high, moderate,
low), were employed for the purpose of the survey and it was beyond the
scope of the study to measure or make claims about impact, or to
generate a definition of impact with respect to research appraisal
activities.
The findings of the survey study nonetheless, provide a baseline against
which subsequent research translation capacity building strategies and
efforts in Rural and Regional areas, can be measured. The study also
sets the scene for investing in resources to support the identification
of key areas of focus for research and the opportunity to take a
concerted, region-wide approach to research translation.
Conclusion
Team-based evidence appraisal activities continue to occur regularly in
most allied health teams. The size, composition of the teams, forums,
platforms and frequency of activities varies across teams. Attendance is
reportedly strong and perceived capacity to undertake evidence appraisal
is adequate. Notwithstanding, perceived impact on changes to clinical
practice is consistently low. Managers are aptly placed to identify and
lead innovation in healthcare practices. With supportive infrastructure
including evidence-based frameworks, there are clearly opportunities for
research translation activities and capacity development strategies in
allied health to leverage off existing and well-subscribed to forums,
and to introduce a systematic and regional approach to identifying the
need for, and leading innovative, evidence-informed clinical practice
change.
Acknowledgements
We would like to thank the Directors of Allied Health from the
participating health services for supporting the study. We particularly
thank Kait Brown for her feedback on an earlier version of the paper. We
also acknowledge and thank the participants.
References
1. Pickstone C, Nancarrow S, Cooke J,
et al. Building research capacity in the allied health professions.Evidence & Policy . 2008;4(1):53-68.
doi:10.1332/174426408783477864
2. Ekeroma AJ, Kenealy T, Shulruf B,
McCowan LM, Hill A. Building reproductive health research and audit
capacity and activity in the pacific islands (BRRACAP) study: methods,
rationale and baseline results. BMC Med Educ . 2014;14(1):121.
doi:10.1186/1472-6920-14-121
3. Gill SD, Gwini SM, Otmar R, Lane
SE, Quirk F, Fuscaldo G. Assessing research capacity in Victoria’s
south‐west health service providers. Aust J Rural Health .
2019;27(6):505-513. doi:10.1111/ajr.12558
4. Hitch D, Lhuede K, Vernon L, Pepin
G, Stagnitti K. Longitudinal evaluation of a knowledge translation role
in occupational therapy. BMC Health Serv Res . 2019;19(1):154.
doi:10.1186/s12913-019-3971-y
5. Braithwaite J, Churruca K, Long JC,
Ellis LA, Herkes J. When complexity science meets implementation
science: a theoretical and empirical analysis of systems change.BMC Med . 2018;16(1):63. doi:10.1186/s12916-018-1057-z
6. May CR, Johnson M, Finch T.
Implementation, context and complexity. Implementation Science .
2016;11(1):141. doi:10.1186/s13012-016-0506-3
7. Greenhalgh T, Wieringa S. Is it
time to drop the ‘knowledge translation’metaphor? A critical literature
review. J R Soc Med . 2011;104(12):501-509.
doi:10.1258/jrsm.2011.110285
8. Greenhalgh T, Papoutsi C. Spreading
and scaling up innovation and improvement. BMJ . 2019;365:l2068.
doi:10.1136/bmj.l2068
9. Hitch D, Pepin G, Lhuede K, Rowan
S, Giles S. Development of the translating allied health knowledge
(TAHK) framework. Int J Health Policy Manag . 2019;8(7):412.
doi:10.15171/ijhpm.2019.23
10. May CR, Johnson M, Finch T.
Implementation, context and complexity. Implement Sci .
2016;11(1):141. doi:10.1186/s13012-016-0506-3
11. Matus J, Walker A, Mickan S.
Research capacity building frameworks for allied health professionals–a
systematic review. BMC Health Serv Res . 2018;18(1):716.
doi:10.1186/s12913-018-3518-7
12. Williams C, Miyazaki K, Borkowski
D, McKinstry C, Cotchet M, Haines T. Research capacity and culture of
the Victorian public health allied health workforce is influenced by key
research support staff and location. Aust Health Rev .
2015;39(3):303-311. doi:10.1071/AH14209
13. Jonker L, Fisher SJ, Dagnan D.
Patients admitted to more research‐active hospitals have more confidence
in staff and are better informed about their condition and medication:
Results from a retrospective cross‐sectional study. J Eval Clin
Pract . 2020;26(1):203-208. doi:10.1111/jep.13118
14. Department of Health and Human
Services. Victorian allied health research framework. Accessed
06/09/2020,
https://www2.health.vic.gov.au/health-workforce/allied-health-workforce/allied-health-research
15. Slade SC, Philip K, Morris ME.
Frameworks for embedding a research culture in allied health practice: a
rapid review. Health Res Policy Syst . 2018;16(1):29.
doi:10.1186/s12961-018-0304-2
16. Kislov R, Waterman H, Harvey G,
Boaden R. Rethinking capacity building for knowledge mobilisation:
developing multilevel capabilities in healthcare organisations.Implement Sci . 2014;9(1):166. doi:10.1186/s13012-014-0166-0
17. Harding K, Lynch L, Porter J,
Taylor NF. Organisational benefits of a strong research culture in a
health service: a systematic review. Aust Health Rev .
2017;41(1):45-53. doi:10.1071/AH15180
18. Klaic M, McDermott F, Haines T.
How soon do allied health professionals lose confidence to perform EBP
activities? A cross‐sectional study. J Eval Clin Pract .
2019;25(4):603-612. doi:10.1111/jep.13001
19. Wilson M, Ice S, Nakashima CY, et
al. Striving for evidence-based practice innovations through a hybrid
model journal club: A pilot study. Nurse Educ Today . May
2015;35(5):657-62. doi:10.1016/j.nedt.2015.01.026
20. Wenke RJ, Tynan A, Scott A,
Mickan S. Effects and mechanisms of an allied health research position
in a Queensland regional and rural health service: a descriptive case
study. Aust Health Rev . 2018;42(6):667-675. doi:10.1071/AH17086
21. Hulcombe J, Sturgess J, Souvlis
T, Fitzgerald C. An approach to building research capacity for health
practitioners in a public health environment: an organisational
perspective. Aust Health Rev . 2014;38(3):252-258.
doi:10.1071/AH13066
22. Allied Health Professions
Australia. What is allied health? Allied Health Professions Australia.
Accessed 06/09/2020, https://ahpa.com.au/what-is-allied-health/
23. Nancarrow SA, Young G,
O’Callaghan K, Jenkins M, Philip K, Barlow K. Shape of allied health: an
environmental scan of 27 allied health professions in Victoria.Aust Health Rev . 2017;41(3):327-335. doi:10.1071/AH16026
24. Wenke RJ, Thomas R, Hughes I,
Mickan S. The effectiveness and feasibility of TREAT (tailoring research
evidence and theory) journal clubs in allied health: a randomised
controlled trial. BMC Med Educ . 2018;18(1):104.
doi:10.1186/s12909-018-1198-y
25. Cooksey RW. Descriptive
Statistics for Summarising Data. Illustrating Statistical
Procedures: Finding Meaning in Quantitative Data . Springer;
2020:61-139.
26. Wenke R, Mickan S. The role and
impact of research positions within health care settings in allied
health: a systematic review. BMC Health Serv Res . 2016;16(1):355.
doi:10.1186/s12913-016-1606-0
27. Moran A, Haines H, Raschke N, et
al. Mind the gap: is it time to invest in embedded researchers in
regional, rural and remote health services to address health outcome
discrepancies for those living in rural, remote and regional areas?Aust J Prim Health . 2019;25(2):104-107. doi:10.1071/PY18201
28. Cooke J, Gardois P, Booth A.
Uncovering the mechanisms of research capacity development in health and
social care: a realist synthesis. Health Res Policy Syst .
2018;16(1):93. doi:10.1186/s12961-018-0363-4
29. Urquhart R, Kendell C, Folkes A,
Reiman T, Grunfeld E, Porter G. Factors influencing middle managers’
commitment to the implementation of innovations in cancer care. J
Health Serv Res Policy . 2019;24(2):91-99. doi:10.1177/1355819618804842
30. Coates D, Mickan S. The embedded
researcher model in Australian healthcare settings: comparison by degree
of “embeddedness”. Transl Res . 2020;218:29-42.
doi:10.1016/j.trsl.2019.10.005
31. Damschroder LJ, Aron DC, Keith
RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of
health services research findings into practice: a consolidated
framework for advancing implementation science. Implement Sci .
2009;4(1):1-15. doi:10.1186/1748-5908-4-50
32. Keith RE, Crosson JC, O’Malley
AS, Cromp D, Taylor EF. Using the Consolidated Framework for
Implementation Research (CFIR) to produce actionable findings: a
rapid-cycle evaluation approach to improving implementation.Implement Sci . 2017;12(1):15. doi:10.1186/s13012-017-0550-7