Amanda Watson (Penn ’26): Expanding Our System-Change Toolkit; Nurses Learning About Implementation Science

This summer, I attended the 2024 Implementation Science Institute hosted by the Penn Implementation Science Center (PISCE) and Master of Science in Health Policy research (MSHP) at the University of Pennsylvania.

The institute was led by PISCE’s Executive Director, Dr. Meghan Lane-Fall, and featured speakers from Penn Nursing, including Drs. Amanda Bettencourt and Katelin Hoskins. The four-day seminar series gave a broad overview of important implementation science topics and featured small group break-out sessions that helped attendees put the concepts into practice. My key takeaways from this experience: (1) learning about implementation science can provide a forward-thinking perspective to nurse scholars; and, (2) the combination of high-quality, actionable qualitative research and implementation science can have an impact on the way nurses change the health care system.

To summarize implementation science very briefly, it is a relatively young and rapidly growing field with a primary goal of closing evidence-to-practice gaps through behavior change.

Scientists utilize a variety of theories, models, and frameworks (TMFs) to identify determinants, implementation strategies, and mechanisms of change. They measure both perceptual outcomes (e.g. acceptability and feasibility) and behavioral outcomes (e.g. fidelity and sustainment). Embedded in every step of the implementation process is the social ecological model (SEM). In order to achieve success and promote equity in implementation it is critical to address individual, inner-setting, and outer-setting determinants. Equally important is the engagement of “affected communities” (used in place of “stakeholders”). While the field is continuing to evolve, implementation scientists rely on evidence and strategies that will help meet people where they are in order to bring about positive change.

Implementation science is quickly gaining traction in nursing research, understandably so. Many nurses are inspired to get PhDs because of the evidence-to-practice gaps they see in their fields of practice. I was drawn to implementation science by my interest in palliative care for heart failure patients. We have this “thing” (how implementation scientists refer to their evidence-based practice) that we know has a positive impact on patients’ lives, yet it is underutilized in this population. There are many cited reasons for this gap. A literature review published in 2020 showed that stigma for patients and clinicians, terminology, prognostic difficulty, and a lack of trained specialists contribute to the underutilization of palliative care for heart failure patients.¹ To address the lack of trained specialists, I proposed that one way to close the gap and increase access to care for these patients would be the implementation of nurse-led palliative care clinics.

Because I have never practiced in palliative care or heart failure, my evidence-to-practice gap wasn’t one I had experienced as a health care provider, rather, a trend I had noticed and read about in the literature. Both at the summer institute and as a student in the Foundations in Implementation Science course, offered through the Perelman School of Medicine, I found myself surrounded by peers who were actively engaged in practice and brought their lived evidence-to-practice gaps to the table. I saw my gap and proposed solution as “hypothetical” in comparison to others like an anesthesiologist working on better patient handoffs or a pediatric nurse practitioner wanting to increase prescribing of antiplatelet therapy for pediatric LVAD patients in their hospital.

Here’s how I put a positive and productive spin on this “hypothetical” implementation exercise: while I am not actively looking to implement nurse-led palliative care clinics, my current learning and theory-generating work is shaped by an understanding of how I can implement this kind of change in the future. The pure act of learning about implementation science is highly beneficial to any nurse researcher that intends to be a system changer. A sign of a flourishing scholar is one’s ability to think abductively. By adding foundational implementation science knowledge to my system-change toolkit, I tend to keep TMFs, implementation strategies, and the SEM in mind when working on projects.

Implementation science may also be the push qualitative researchers need to bridge the gap between conducting their work and seeing change in the real world. High-quality qualitative research should have results that are actionable. We should strive to generate theoretical models that can then be implemented in practice.

There are certainly parallels between actionable qualitative research and implementation science. For instance, both require scholars to move past the use of simple “barriers and facilitators.” Qualitative methodologists have pointed out that the barriers and facilitators approach, which favors universally desirable outcomes and binary thinking, is actually “at odds with the rich understanding of context and complexity needed to respond to the challenges faced by health services and public health.”² Although sometimes referred to as barriers and facilitators, in implementation science these characteristics and qualities are called determinants and are identified at multiple levels ranging from individuals to an organizations and beyond. It has been recognized within the field that “implementation is a multidimensional phenomenon, with multiple interacting influences.”³ Rather than taking a binary approach to characteristics and qualities of individuals or organizations, it is paramount that determinant frameworks take a systems approach. This approach helps the researcher understand that they are looking at an integrated whole made up of not only the sum of its components but also the relationships between and among them. While they don’t use the same terms, the overall message of both qualitative and implementation methodologists is that simply identifying things that help and things that hurt does not do enough to address the complex issues that we are trying to change within the health care system.

Nurses who have a strong interest in being change-makers in health care should seriously consider learning about implementation science and integrating it with actionable qualitative research. Although I consider my plans to engage in work that will increase access to nurse-led services in rural and underserved communities as an end-goal, this background in implementation science has brought a forward-thinking mindset to my current projects. My qualitative, theory-generating work will no doubt reflect what I have learned from this Institute and I look forward to my future as both a nurse scholar and implementation scientist.

References

(1) Romanò, M. (2020). Barriers to early utilization of palliative care in heart failure: A narrative review. In Healthcare (Switzerland) (Vol. 8, Issue 1). MDPI AG. https://doi.org/10.3390/healthcare8010036

(2) Haynes, A., & Loblay, V. (2024). Rethinking barriers and enablers in qualitative health research: Limitations, alternatives, and enhancements. Qualitative Health Research, 34(14), 1371–1383. https://doi.org/10.1177/10497323241230890

(3) Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science: IS, 10(1), 53. https://doi.org/10.1186/s13012-015-0242-0