JCPSLP Vol 23 Issue 2 2021

service delivery. Within the ImpSci framework approach, the starting point may be to gain insights into the variability in current practice, as well as perceived—and actual— constraints to the adoption of the new practice/s. Since services are necessarily delivered within a multidisciplinary and often cross-agency context, wider stakeholder consultations would usually include referral agents, as well as onwards referral providers. These consultations in both QI and ImpSci paradigms need to negotiate competing priorities and address aspects of the organisational culture. What specific insights can ImpSci contribute to SLP practice? While there are general benefits to ImpSci research in understanding and addressing the barriers to evidence use in practice, there are specific challenges that SLPs face that ImpSci may help us to address. One relates to the questions that become highly relevant when an SLP determines that a change is needed to their current clinical practice on the basis of evidence; specifically, questions about transferability and about acceptability. First, we might ask whether the (usually very specific) clinical population and the (often highly resourced) intervention protocol used in the research is realistically transferable to our clinical setting. Do we have these clients and the time/ resources/ funding or staff to implement this evidence based intervention as presented in the literature? Clinical caseloads include patients with complex profiles, and from demographics that do not necessarily closely match the stringent inclusion criteria of the published studies. Alongside this, the published intervention protocols are often unrealistic for clinical contexts. Second, we might ask whether the intervention is acceptable from the perspectives of both the service users and the health care professionals. Do we want to do this? Would patients be interested in this intervention? These questions are related—for example, if the evidence proposes daily intervention at a clinic, we need to ask both whether this is feasible to provide and acceptable to those receiving it to attend daily for the intervention. At best (or worst), we might choose to selectively adapt variations of validated interventions. Adaptations to the intervention could include changes to the format or setting for the session delivery, adding or skipping elements of the intervention; changes to the pacing or timing; re-ordering the sequence or substituting elements of the programme; or “drift” from the intervention protocol (Stirman et al., 2013). These ad hoc adaptations may render the interventions less, or wholly, ineffective. At worst (or best) we might choose to ignore the unfeasible and unacceptable evidence as presented, and continue with our current practice. ImpSci approaches provide us with another way. Rather than ignoring the changes that are needed to implement the evidence, or ignoring the evidence altogether, ImpSci helps us to explore these adaptations and the impact of these. For example, ImpSci evaluations may include exploring practitioners’ opinions on the feasibility of length and intensity of intervention that could be possible within their own routine clinical practice (Morris et al., 2020; Rycroft-Malone et al., 2004; Stetler et al., 2011). These approaches can also objectively measure the range of adaptations made by experienced practitioners when they begin to implement new therapy interventions within real-world settings, including all the relevant factors related to the intervention itself (content/duration/frequency etc), as well as the context for delivery (service user demographics,

practitioner characteristics, environment) (Carroll et al., 2007). This enables a clear differentiation between the intended delivery and the actual delivery of the intervention. ImpSci framework approaches support the identification of both context and content modifications that may influence the effectiveness of the intervention (Stirman et al., 2013), which can subsequently be explored through both observed and self-reported adaptations to the intervention delivery. There is a distinction between unwarranted modifications, versus adaptations that are consistent with the intended delivery of complex interventions within a range of feasible fidelity; an issue that is an ongoing methodological challenge within the field of ImpSci (Stirman et al., 2012). ImpSci studies measure the effectiveness of the implementation of the new practice (intervention fidelity), as well as the effectiveness of any specified strategies that were put in place to assist the adoption and maintenance of the practice change. We believe that these types of ImpSci studies are both highly relevant and necessary to SLP practice at this point. We have a growing body of strong, well-conducted research that requires precisely this type of interpretation to enable successful implementation into practice. The past few years has seen a slow but steadily growing discussion of ImpSci models across allied health research (including Lynch et al., 2018; Morris et al., 2020) and in speech pathology specifically (including Campbell & Douglas, 2017; Douglas & Burshnic, 2019). These papers exhort the value of ImpSci, but also recognise a number of factors that contribute towards the relatively slow adoption of this field of science across health care disciplines. In common with much of health care research, and with the evidence base for allied health disciplines in particular, our traditional research focus has been on evaluating the efficacy of interventions. This is valuable and necessary, but the research agenda of exploring how best to implement evidence into practice has been largely ignored, and we are seeing across all areas of health care that this is needed. Without ImpSci, we risk having a lot of strong evidence that we can’t use clinically or can only use with modifications that potentially negate the efficacy. Influencing the research priority agenda to secure substantive investment for ImpSci studies across all aspects of communication and swallowing science will be a challenging and long battle ahead. However, without this investment, without seriously considering how we shift some of our precious (and scarce) research resources towards demonstrating how to implement the interventions that we know to be effective, there is a danger that we may miss an important opportunity for change in our profession. EBP is as important as ever, but with ImpSci, we have the opportunity to create a better return on our research investment into the efficacy of interventions, to harness evidence in a new way that leads to greater clinical effectiveness, with greater societal impact and improved scientific reputation for our professional practice. The responsibility for shaping this future knowledge base for practice does not rest exclusively with the researchers, but also needs practitioners, service managers and policy leads to demand the publication of implementation studies that realistically reflect the rapidly evolving contexts in which SLP services are delivered. In this issue Given the above need, we welcome the discussions in this issue that include an ImpSci focus and tell us more about where and how our efforts can be focused. There are two

56

JCPSLP Volume 23, Number 2 2021

Journal of Clinical Practice in Speech-Language Pathology