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Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
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4

Applying Implementation Science Concepts to Case Studies

Objective: To provide opportunities for participants to use implementation science.

In this session of the workshop, participants worked together in small, interprofessional groups on an implementation science activity about simulation-based education (SBE). Soicher began by defining SBE as “a teaching strategy that complements traditional training with actual patients and enables students and health professionals to learn in ways that eliminate risk to patients” (McCaughey and Traynor, 2010, p. 827). She noted that SBE may also involve working with simulated patients using various forms of technology. SBE is well studied, and evidence suggests that it improves a wide range of outcomes, including psychomotor skills, problem solving, critical thinking, clinical reasoning, judgment, clinical confidence, self-efficacy, motivation, and situational judgement (Burton and Hope, 2018). SBE can be delivered using high-fidelity or lower-fidelity simulation, said Soicher. High-fidelity, she added, means the simulation is as close as possible to the intended context (e.g., clinical setting), and lower-fidelity simulations take place in contexts (e.g., the classroom) that are dissimilar to the intended context.

Soicher listed best practices for conducting SBE, which included:

  • Prebriefing: Learners are prepared for the content and aware of the ground rules for the simulation.
  • Design: Simulation is purposefully and intentionally designed to meet identified objectives and to optimize students’ experience.
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
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  • Facilitation: Specific facilitation methods are matched to the learning needs of the learner.
  • Debriefing: Students are given time for feedback or guided reflection about the experience.
  • Operations: There are systems and infrastructure in place to support and maintain SBE.
  • Objectives: Clear learning objectives have been identified that learners should be able to achieve after participating in the SBE experience.

Questions that need to be considered when implementing SBE, said Soicher, include:

  • What debriefing mode works best and under what conditions?
  • How does learner motivation affect the acquisition and retention of skills in simulation-based activities?
  • How do characteristics of the environment affect learning in simulation, such as onsite vs. offsite, individual vs. group, peer vs. multidisciplinary, timing vs. frequency, and procedure embedded vs. isolated?
  • How can institutions address operational scale issues to ensure their educational outcomes are being achieved and sustained? For example, can portable systems operated by a small team of full time, well-trained simulation experts lead to effective outcomes (Ferguson et al., 2020; Issenberg et al., 2011)?

SETUP OF BREAKOUT GROUP ACTIVITY

With the background of implementation science and SBE in mind, Soicher walked workshop participants through a logic model meant to guide their breakout group discussions (Figure 4-1). The model included a section for Determinants, which Soicher explained are the barriers and facilitators to implementing a practice. Implementation Strategies is a way of thinking about how “we get people to do the thing,” she said, while Mechanisms describe why a specific strategy actually results in an outcome. Soicher noted that for the purposes of the breakout group, the Mechanisms category would be skipped, as there is little information in the literature about this area. Finally, the category of Outcomes includes measures of acceptability, feasibility, and adoption, as well as measures of end goals such as efficiency, patient-centered care, and equity.

The breakout groups were tasked with filling out the logic model using their own example of an SBE activity (e.g., use of simulation for disaster preparedness). Soicher noted that while some components of the model

Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Image
FIGURE 4-1 Implementation Research Logic Model.
NOTE: EBI = evidence-base intervention.
SOURCE: Smith et al., 2020, presented by Soicher on June 8, 2022.
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×

may vary depending on the example or setting, others would be consistent; for example, questions about the willingness of faculty to implement SBE would likely be relevant in all groups. Brooks underscored the value of this activity for giving participants an opportunity to put new ideas into practice. Soicher’s presentation on implementation science was full of great information, he said, but participants were not yet empowered with the tools to do it. This activity allowed participants to apply this information and identify practical strategies to implement it.

In addition to a blank version of the logic model, breakout groups were given lists of potential factors in each area, drawn from the literature (see Appendix E for this and other workshop materials). For example, within the category of Determinants, the list included characteristics of the intervention (e.g., cost), the outer setting (e.g., policies and incentives), the inner setting (e.g., readiness for implementation), individuals (e.g., self-efficacy), and process (e.g., engaging stakeholders). The breakout group participants were encouraged to choose one or two variables that would be important to assess or measure within each category. The benefit to using a standard set of variables with common terminology and measures, said Soicher, is that it makes it possible to compare the results of different studies. In Soicher’s review of the literature, a common critique was that studies did not use the same measures for variables, which made it difficult to synthesize the results into a cohesive picture.

Workshop participants broke into groups and discussed the logic model and the use of implementation science in HPE then reconvened in the larger group.

DISCUSSION OF BREAKOUT GROUP ACTIVITY

Jessani welcomed participants back and led a discussion by asking a series of questions.

What were some the “a-ha” or “lightbulb” moments that arose while filling out the logic model and during your conversations about it?

The process of going through the logic model together, in an interprofessional group with diverse perspectives, was very helpful, said Shawna Hudson, professor at Rutgers Robert Wood Johnson Medical School. While her group focused on disaster preparedness, participants emphasized different potential areas for SBE, such as new learners or continuing education. Going through the steps together and having cross talk was a major benefit of the exercise, she said. Gail Jensen, vice provost for learning and assessment, professor of physical therapy, School of Pharmacy and Health Professions, Creighton University, said that her group had a lot of discussion about the return on investment in implementation and the importance

Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×

of a philosophical grounding and shared values and beliefs behind the implementation of a new practice.

Darrin D’Agostino, provost and chief academic officer, Texas Tech University Health Science Center, reported that his “a-ha” moment was a realization that higher education is shifting away from “achieving nuggets of information” toward applying information and that any innovation in education—whether SBE, flipped classrooms, or other approaches—should be focused around this shift. An “a-ha” moment for Kim Dunleavy, clinical associate professor and director of community engagement and professional education, University of Florida Department of Physical Therapy, came when looking at implementation outcomes for various stakeholders; this activity “crystallized” the importance of centering students as the biggest and most important stakeholders in education. Patricia Cuff, director of the Global Forum, remarked that while filling out the logic model, her group realized the importance of including as many details as possible about how an intervention was implemented. Soicher agreed with this realization and said the description of the process of implementation “needs to be detailed so it is useful to somebody else wanting to adopt the same process.”

What challenges did you encounter in thinking about implementation science and working through the logic model?

Soicher shared that participants in her group sometimes “got lost” in the diagram when trying to determine where an aspect of the intervention should go. For example, “involving students in the design of SBE” might be an intervention characteristic, or it might be part of the implementation process. Soicher emphasized that there is “no one right way to categorize” parts of an intervention, and where they go in the logic model depends on one’s perspective and goals. Jessani agreed and noted that some items in the logic model might even contradict each other, such as fidelity and adaptability, both of which may be relevant in different ways in different contexts. This emphasizes the importance of documenting and describing the exact process of implementation and what choices were made and why, she said.

One participant said it can be challenging to meet the needs of a group of learners who come to the table with different experiences, training, perspectives, and styles. When filling out the logic model, she realized the complexity of finding interventions that are evidence based but also flexible enough for a diverse group. Kathlene Camp, assistant professor at the University of North Texas Health Science Center, shared that another challenge that arose during her group’s discussion was how to effectively measure student outcomes. For example, she said, preintervention and postintervention measures of confidence may not accurately capture the effect of an intervention because students sometimes are very confident until “they get into the weeds” and realize they know less than they thought they did. Effect may

Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×

not be able to be measured immediately at the end of the intervention, she said, and it may be necessary to reevaluate at a later point in time. Soicher agreed and said there is very little longitudinal follow-up with students to measure the effectiveness of a pedagogical practice. Unfortunately, she said, research is limited by resources, so the evidence base for the long-term effect of interventions is not as robust as we would like.

Hudson noted that it was challenging for her group to decide whether to focus on outcomes for students or clinical outcomes; HPE tends to focus on learners, but ultimately these learners will affect clinical outcomes. Soicher shared that her group, in contrast, began by focusing on clinical outcomes and worked backward from there. Hudson also commented on the process of filling out the logic model, describing it as iterative: as some pieces get refined, other parts need to be revisited and revised. Despite the challenges that arose during these conversations, said Jessani, the process of thinking through implementation was “not completely out of the realm of what many educators are already doing.” The process was a different way of thinking, she confirmed, but perhaps it was not as hard as she imagined.

Does this process of thinking through the implementation of a practice have relevance in the multiple settings of HPE (e.g., clinical, classroom, community)?

Educators often perceive the clinical environment as the “Wild West” and feel they have little control over what students do or learn there, said Kimberly Lomis, vice president for undergraduate medical education innovations at the American Medical Association. However, there are opportunities for educators to implement a framework in order to guide clinical learning. For example, she said, there could be an expectation that students starting a new rotation meet with a supervisor to talk about their educational objectives and what sort of feedback they would like to receive. Implementation science would be critical in putting a system like this in place, given the complexities of the different settings and different stakeholders involved. While it is simpler to think about using implementation science in the classroom setting, said Lomis, it could be enormously useful in building a bridge between education and practice.

Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Page 21
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Page 22
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Page 23
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Page 24
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Page 25
Suggested Citation:"4 Applying Implementation Science Concepts to Case Studies." National Academies of Sciences, Engineering, and Medicine. 2023. Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26783.
×
Page 26
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Exploring the Use and Application of Implementation Science in Health Professions Education: Proceedings of a Workshop Get This Book
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Implementation science bridges the gap between research and medical practice, investigating aspects of practice and pedagogy that make the strategies successful for future use. By introducing and training leaders, faculty, and health workforce researchers in implementation science, health professions education institutions can build capacity for evidence-based practices.

The National Academies Global Forum on Innovation in Health Professional Education held a workshop series to introduce the concept of implementation science to health professional educators to consider its potential use in the classroom. Speakers provided a foundation for discussion of the role of implementation science in health professions education and provided methods for educators interested in applying these recommendations to scale. This Proceedings of a Workshop highlights the presentations and discussions that occurred at the workshop.

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