From Evidence to Impact: Implementation Science with Dr. Jeremy Grimshaw

Dr. McGavock: [00:00:00] Welcome back to the Emerging Scholar Podcast. I'm your host, Dr. Jon McGavock from the University of Manitoba, and I'm thrilled to have you back for season two. Last season, we took you on a journey through your first year of research training, covering everything from crafting great research questions to understanding the foundations of both quantitative and qualitative methods.

Dr. McGavock: We met incredible scholars, explored fundamental concepts, and built a roadmap to help you navigate your early research career. This season, we're going deeper. If season one was about laying the foundation, season two is about mastering the craft. We're taking those methods we introduced and really unpacking them, diving into the nuances, the challenges, and exciting new possibilities that each method has to offer.

Dr. McGavock: Throughout this season, you'll meet a remarkable team of both established and emerging scholars with expertise across a diverse array of approaches, from natural experiments that reveal causal insights into real-world [00:01:00] settings, to qualitative inquiry grounded in social justice, the complexities of implementation science, and yes, my personal favorite, causal inference.

Dr. McGavock: Each episode will introduce you to researchers who are pushing the boundaries, asking bold questions, and making novel and important scientific discoveries. First, we're celebrating Canadian research excellence, showcasing incredible work happening right here at home. Second, we're emphasizing the critical importance of patient engagement in shaping research that truly matters across a range of scientific methods.

Dr. McGavock: And finally, we're championing curiosity, the essential spark that drives all great science and keeps us asking what if and why. Whether you're designing your first research study, wrestling with methodological challenges, or simply passionate about rigorous and meaningful research, this season is for you.

Dr. McGavock: So let's dive in, stay curious, and continue building the skills that will shape your own scientific journey Welcome back, everyone, to the Emerging Scholar Podcast. And a distinct difference from previous episodes is that you [00:02:00] will not only hear my voice throughout this episode, you will hear the voice of one of the grad students in my lab, soon to be, hope to be, definitely one day will be Dr.

Dr. McGavock: Nika Klaprat. Nika, welcome to the show.

Nika Klaprat: Hi. It's good to be here. Yeah, as you said, I'm a doctoral student in your lab, but also at the College of Community and Global Health at the University of Manitoba. So I'm really excited to learn from this experience today and, and get to talk to Dr. Grimshaw.

Dr. McGavock: And one of the big reasons why we invited you today to co-host with me is that we're doing an implementation science research project with scientists from across Canada.

Dr. McGavock: You want to talk a little bit about that project that we're working on that's funded by the Canadian Institutes of Health Research?

Nika Klaprat: Sure, happy to. The project overall is looking at the built environment and specifically protected cycling spaces. So we're interested in how we build these spaces to get people active and involved in active transportation.

Nika Klaprat: Our big question is focusing on why some of those trails have been implemented really well and support more [00:03:00] people to use them to get to work or school or wherever else they need to get to, whereas other ones see a little bit less cycling traffic on them. So trying to use implementation science frameworks to understand what drives those differences.

Dr. McGavock: Awesome. And one of the pioneers in this field is Dr. Jeremy Grimshaw. We reached out to Dr. Grimshaw to see if he could come in and talk about his experience within implementation science, the history of implementation science in Canada. You seemed pretty excited when I said Dr. Grimshaw was coming in.

Dr. McGavock: What are some of the things you hope to learn from Dr. Grimshaw in this episode?

Nika Klaprat: Yeah, I was really excited. Dr. Grimshaw is a huge name in the field of implementation science in Canada, and he's, has a number of publications that I've read in the past year or so. So it's really helped to clarify some of the, the basics about the field, but I'm really excited to learn from him on other applications of implementation science and medicine or otherwise, depending on where the conversation goes.

Nika Klaprat: Kind of understand how implementation science [00:04:00] evolved from the evidence-based practice movement into what it is today and the various ways that you can use these theories, models, and frameworks in research to support health.

Dr. McGavock: Awesome. I couldn't agree more. I feel like we dove into this because we had a pretty interesting question that required implementation science methods to answer it.

Dr. McGavock: Unfortunately, depending on who I ask- I don't have a clear definition for what implementation science is , and I'm really hoping that Dr. Grimshaw can clarify a few things for us, and using his own experience and his broad reach in this field, maybe dial in a few key themes for what implementation science is, when do we use it, and how can it be used to inform effective implementation of the evidence that we know is working.

Dr. McGavock: Really looking forward to this interview. Thank you so much, Nika, for coming in. Now it's time for Dr. Grimshaw

Dr. McGavock: Welcome everyone to the Emerging Scholar [00:05:00] Podcast. My name's Jon McGavock. I'm one of the hosts, and today, for the first time in the history of the Emerging Scholar, I have a co-host. Would you like to introduce yourself?

Nika Klaprat: Sure. Hi everybody, I'm Nika Klaprat. I'm a doctoral student at the University of Manitoba, and I'm happy to join the podcast today.

Dr. McGavock: Awesome. Thank you, Nika, and today we are very fortunate to have Dr. Jeremy Grimshaw with us to talk about the topic of implementation science. This is an emerging field worldwide, I would say, and the Canadian Institutes of Health Research has considered this a top priority for future research in Canada.

Dr. McGavock: And every time that I talk about implementation science, one name pops up as the Canadian figure for this, and it's yourself, Dr. Grimshaw. Thank you so much for making time. Can you tell us a little bit about who y- you are and how you came into this space?

Dr. Grimshaw: Sure. So first of all, thanks for the invitation to talk today.

Dr. Grimshaw: So I come from the UK originally. I grew up about halfway between Manchester and Liverpool, and although I didn't have any sort of medicine in the family, I basically did [00:06:00] a medical degree in Edinburgh. But when I went to medical school, I always wanted to be a family doctor in my hometown. That was my passion.

Dr. Grimshaw: And when I was exposed to research in university, it always seemed like, yeah, I could see how it's intellectually interesting, but it really didn't speak to me in terms of something that would have a more immediate social value to, to the patients and communities we were working with. So I, after I finished my MD, I went to do family practice training, and I had the great fortune to organize a national GP trainee conference.

Dr. Grimshaw: In the UK every year, there's one conference where basically about 300 or 400 trainees got together and I could invite these heroes of mine, people whose papers I'd written and really enjoyed, and just met these amazing scientists. So one of them was someone called Peter Townsend, who's a professor of social policy at Bristol, and he was one of the founders about basically the recognition of health inequities in the UK.

Dr. Grimshaw: There [00:07:00] was Muir Gray, now Sir Muir Gray, who at that time was a director of public health in Oxford and was working with family practices to provide facilitation to them to improve their cardiovascular care. And also a GP from Edinburgh called-- Oh, I'm gonna get his second name wrong. Roy something. I apologize to him.

Dr. Grimshaw: But he was the person who just by doing careful epidemiology in his practice, I think gave some of the first compelling evidence that, um, HIV was a, basically a bloodborne infection. He had a high number of drug injectors in his population. It's very early days of HIV. Just by actually understanding what people did, needle sharing and other things, he was able to track and show that people who shared needles were more likely to get HIV.

Dr. Grimshaw: But what was impressive about them is that they're all doing work that seemed to have some almost immediate value and utility to the societies that they were engaged with. And so that kind of led me into the [00:08:00] idea that I could potentially do some research. I still thought I wanted to be an academic family practitioner, but I was advised to go and do a PhD.

Dr. Grimshaw: So I went to do a PhD in the health services research unit in Aberdeen, which was about trying to improve referrals from family docs to specialists. We tested four different interventions. None of them worked. Um, but I wasn't put off remarkably enough.

Dr. McGavock: Yeah.

Dr. Grimshaw: But it was an example of basically being able to do rigorous research on how do we change professional practice.

Dr. Grimshaw: The other thing that happened was my PhD supervisor was, was asked to do a book chapter on how to evaluate guidelines. And so he pulled me in to help him, and we started to try and identify published evaluations of guidelines. And even though my PhD supervisor had been working in the space for probably about 10 years, we could only identify a handful.

Dr. Grimshaw: And what happened is we started to try and find them. We found more and more and more. So [00:09:00] by the time the book chapter came out, we had 18. And I-- it was kind of like then just an itch. And people who've been involved in a systematic review will recognize this, that basically you keep turning over rocks and you find more creepy crawlers that could be papers that go into a review.

Dr. Grimshaw: And so we kind of continued to do this, and eventually we published a systematic review of 61 evaluations of guidelines, dissemination, implementation strategies that was published in The Lancet in 1993.

Dr. McGavock: Wow.

Dr. Grimshaw: And at the time, the kind of prevailing view was that doctors had to die or retire if you wanted to change practice.

Dr. Grimshaw: People would ju-- you just couldn't do anything.

Dr. McGavock: Yeah.

Dr. Grimshaw: And what was very clear is that in this review, and it was very early and by today's standards very, very rudimentary systematic review. But what was clear is that actually guidelines, if they're appropriately developed, disseminated, and implemented, could lead to changes in practice.

Dr. Grimshaw: The vast majority, I think 57 out of 59 studies looking [00:10:00] at process of care showed some improvements in process of care measures, and nine out of 11 studies that looked at outcomes of care showed improvements. So those two things together kind of consolidated the idea that The implementation process is something that we can study and to learn how to do it better.

Dr. Grimshaw: Again, a lot of the view is a bit like that famous graph where you've got physicists and there's algebra on one side of the blackboard, algebra on the other, and it's like something magic happens here. Mm-hmm. So I think we could look into what the magic is, and we could try and do something about that. So we started to think about, yeah, what we end up calling implementation science because that's what I used in the Lancet review, and it seemed to make sense about very active approaches to try and improve practice.

Dr. Grimshaw: And in 1997, we actually got some funding from Aberdeen University to establish the Aberdeen Centre for Implementation Research, which I don't think anyone was thinking of that at the time. But it's very much about the problem we're trying to solve is that there's a gap between what we [00:11:00] know the evidence says and what we actually achieve, and that has n- been a consistent finding of health services research probably over the last...

Dr. Grimshaw: well, over the last 50 years. And so the key issue is how do we support healthcare professionals, healthcare systems to provide care that is evidence-based and patient-centered. So that was kind of my introduction to implementation science.

Dr. McGavock: So a couple of things that I've noticed over my career that there's something in the water in the UK in terms of taking clinicians and making them unbelievable clinician scholars, and I would love to know a little bit more about that.

Dr. McGavock: The fact that you coined implementation science at a time when the evidence base was not that great. I've heard people say, I think it was Cochrane himself saying, you know, "Things only change after gray-haired white men die," kind of thing, right? And it sounds like it was the same thing with implementation science, that people are so grounded in [00:12:00] this way of doing things that, sure, a guideline's gonna come out or a new randomized controlled trial's gonna come out, but you know what?

Dr. McGavock: I've always done it this way. I don't think I'm gonna change. As someone who maybe defined the term implementation science and started the, the first research group, how would you-- as for a resident or grad student coming in, how would you define implementation science now, and why would you say that it's important for a student or a resident to get involved?

Dr. Grimshaw: So first of all, can I just make a correction? Even though I used implementation science in the, the large review, it, the, there was stuff bubbling around in the s- in the air. So fundamentally though, I think evidence or implementation science is trying to understand how to address more effectively these evidence to practice gaps.

Dr. Grimshaw: And yeah, it actually covers a wide range of different topics. It's going from, well, what should we be doing? And that's where I think systematic reviews and guidelines come out, and they help us understand the content of what we should do. We've [00:13:00] made huge strides in the last 30 years to then trying to understand the extent to which we have these evidence practice gaps, and there are lots of descriptive studies around that.

Dr. Grimshaw: My good colleague, Janet Squires, in 2023 published a review in the CMAJ of all the sort of studies of appropriateness in Canada. And unsurprisingly, Canada is just not any better, but no worse than anywhere else in the world. What we see globally is about 35% of patients don't get care that the evidence would suggest is needed, and about 15 to 20% of people get either care that is obsolete or even harmful So the next phase is trying to understand, well, why?

Dr. Grimshaw: If you think about this from a clinical perspective, you know, we've got this gap, and then the next thing is the diagnosis. And so what we need to do is say, "Well, how do we understand what the problem is?" And the challenge with this is it's very rarely a single problem. I think if you went back historically, everyone assumed that this was a knowledge problem, so all you have to do is give doctors and nurses better knowledge, and they'd be perfect [00:14:00] clinicians.

Dr. Grimshaw: And that is clearly wrong now, and it was never right. Yeah. But you know, one, one of the things that I see implementation of sciences, it, it's a fundamental issue is that challenge is behavior change of individuals who are working in busy and chaotic systems. When we think about behavior change, suddenly we recognize there are many things that drive our behaviors.

Dr. Grimshaw: Knowledge is just one of those. So I worked a lot with health psychologists, and particularly professor of s- health psychology at London, Susan Michie. And if people want to follow up on her work, she's published a paper on the Theoretical Domains Framework and the COM-B frameworks. Nika is smiling. She's heard of those.

Dr. McGavock: Yeah.

Dr. Grimshaw: And, and basically that gives us a lens that says this can-- collectively, this is what psy- psychology says about influence behaviors. The other side, though, is you also have behaviors that are embedded into these complex and chaotic surroundings. And so also being able to look at this in a multilevel way is not just about what drives our individual behavior, it's [00:15:00] also what is the space we're in.

Dr. Grimshaw: What's the social space? Do our patients expect us to do this? Do our colleagues expect us to do this? And so one of the sort of, you know, what-- I mean, I think one of the major challenges that healthcare systems have not been designed to support evidence-based practice. If anything, they often kind of work against it a little bit.

Dr. Grimshaw: And so e- if you've got well-meaning, highly intentional clinicians, it may be very hard in their day-to-day clinical space because of the kind of issues in the environment and also the chaos. One of the other things we're recognizing a lot is I think that a lot of our human behaviors are habits. Human beings don't try to think or try not to think, rather.

Dr. Grimshaw: Because thinking takes up a lot of energy.

Dr. McGavock: Mm-hmm. So

Dr. Grimshaw: we spend most of our time trying not to think and preserving our brain for when we really have to think.

Dr. McGavock: Yeah.

Dr. Grimshaw: So our day-to-day lives, the way that we manage that is by creating habits. You know, the classic [00:16:00] habit is if you were, say, driving home from work, you get into the car, you get out of the car at home, and you have no recollection of what's happened in between 'cause you've not had to use the sort of thinking bit of your brain.

Dr. Grimshaw: Unless it's an accident, and then you have to think, "Oh my goodness. Okay, what's a detour? How do I do X, Y, or Z?" When clinicians go into a clinical environment, they don't stop being human beings. They continue to be human beings, and so this fundamental idea about I can develop habits will make my life a bit easier is, you know, what drives a lot of clinical behavior.

Dr. Grimshaw: And it works a lot of the time. You know, when I go into emerge with my crushing chest pain, I don't want an emerge doctor thinking through the differential diagnosis from a 101 and what would be the appropriate investigations. I want them just to act.

Dr. McGavock: Right.

Dr. Grimshaw: And most of the time it works. But habits are really hard to change.

Dr. Grimshaw: And so, you know, basically-- And most of our attempts so far have largely ignored this as a habit issue. So [00:17:00] implementation is this multilevel multi-challenge, and trying to understand what the drivers are and where the margins we can intervene to try and improve them is a key element of implementation science.

Dr. Grimshaw: And then, I mean, I've done a lot of trials of implementation strategies. I think I've done about 60 cluster randomized trials at this point of time. And, you know, one of the challenges is that the-- when we're seeing any improvements in implementation science or i-in implementation effort, they're often smallish.

Dr. Grimshaw: The median effects across a broad range of quality improvement interventions in Cochrane is about probably a four to eight percent absolute improvement. And so one of the challenges there is if you didn't use something like a randomized control trial, you could basically be misled by non-specific effect or other biases.

Dr. Grimshaw: Yeah. And it'd be very hard to have confidence that your intervention led to this. And so the arguments for randomized control trials in implementation science are the same as they are in all other aspects of healthcare and other areas of human enterprise. [00:18:00] The effects you try to detect are often small to modest.

Dr. Grimshaw: We have a very incomplete, actually much worse complete-- worse knowledge about what are the potential confounders in implementation science. So I wouldn't even know how to correct an observational study in implementation science. I just don't know what you'd think about for that.

Nika Klaprat: Yeah.

Dr. Grimshaw: And third, you know, if we want healthcare systems to invest in implementation approaches and they invest in the wrong thing, the opportunity costs are large.

Dr. Grimshaw: So implementation trials, key components. And then the final thing is we need to actually ensure that we are looking at the global evidence base, so doing systematic reviews of implementation trials to say, in general, do things work or do they not work? I don't know if that answers your question.

Dr. McGavock: I think that does.

Dr. McGavock: I'm just gonna summarize before I hand it over to Nika. But let's say systematic reviews of randomized control trials in a pediatric endocrinology clinic suggest we should get all kids A1Cs down to below 7.5%. We do, and then we do a quality improvement [00:19:00] study of clinics across Canada. We find some are hitting those targets, some are not.

Dr. McGavock: You know, 80% of their patients are meeting that criteria. In other centers, it's 30. So we-- the evidence is there. Now we've got a practice gap that they're not achieving it. Next question: Where are the barriers to implementing that? Putting on a white coat and a stethoscope doesn't dehumanize you. You're still gonna make mistakes.

Dr. McGavock: Things are gonna be hard. You're having discussions with parents and kids about trying to, uh, change those behaviors. Someone identifies some key barriers to clinicians trying to adopt that and then says, "Hey, let's test this intervention. Let's do a randomized control trial, see if you can change your behavior while you're in the clinic, and we're gonna see whether or not that brings your clinic's measure from 60% up to 70%."

Dr. McGavock: And most of the time, when we do those interventions, it's about, you know, a 3 or 4% improvement, but that's actually a lot. And without that randomized control trial to show that the implementation strategy worked, we don't know whether or not we can reduce the barriers in the right way.

Dr. Grimshaw: The perfect summary

Dr. Grimshaw: said it [00:20:00] succinctly.

Dr. McGavock: All right. And we definitely need more research in that space. Over to you, Nika.

Nika Klaprat: So in a similar note, I really appreciate and think it's super important that you're acknowledging the complexity of the systems and individual habits and the humanity of physicians, because I think that's often a forgotten piece, is that we think physicians are above the rest of us in the fact that they can make mistakes, which, I mean, that's just not fair.

Nika Klaprat: Not fair to them,

Dr. McGavock: for sure.

Nika Klaprat: I'm sure you as a physician yourself, you bring in a lot of your own clinical experiences into des- designing your research projects, and a lot of the listeners of the Emerging Scholar podcasts are also physicians or emerging physicians in this space. So can you talk about some of it- those examples of how maybe you've brought in your own clinical experiences or maybe you've seen something in a hospital or clinic-based setting that has inspired a project of yours in terms of implementation science and implementing scientific evidence?

Dr. Grimshaw: I stopped doing clinical practice about [00:21:00] 30 years ago. I trained as a GP. I did a PhD. I was still practicing when I was doing my PhD training. And at some point in time, it became apparent that I don't think I could be a good GP and spend half my time doing research. And so I- Mm-hmm ... either had to give up research or I had to give up practice.

Dr. Grimshaw: And at the time, there were very few people doing high-quality, rigorous research, particularly in the space I was interested in.

Nika Klaprat: Right. And

Dr. Grimshaw: I went that way. Um, I still pretend that I'm a physician. And it's quite remarkable how little has changed in medicine, that I can still largely busk it in a room with individuals.

Dr. Grimshaw: But when I'm putting together... An implementation project will often start is a clinician will come into a room with a really interesting problem, like the one Jon just said. "Yeah, this is something we've been struggling with. Yeah, have you got anything that you might be able to help with?" And so, you know, what we would normally do is we try and build up...

Dr. Grimshaw: This research is always [00:22:00] interdisciplinary. You need the clinical experts. You need the content experts and also people who live giving care in that environment. I always see myself probably now as being a bit of a conductor. I kind of understand each section of the orchestra and what... Yeah, and I can talk to each of them, but I can't play the trombone or, you know, the violin.

Dr. Grimshaw: So I feel like I need to have enough skill set to be able to engage with the work and understand the big picture of this. But typically, in the groups, we'll often have people come from a Royal Health Services research perspective. We'll have behavioral scientists and system scientists, statisticians, economists.

Dr. Grimshaw: And it's bringing those teams together. But normally, it's a clinician coming in with a good idea. If you want an example, there is a professor of stroke nursing in Australia called Sandy Middleton. And when she finished her PhD, she was interested in Trying to explore whether if you could optimize stroke care, nursing [00:23:00] care for stroke patients in stroke units, would that lead to further improvements?

Dr. Grimshaw: We already know that providing care for stroke patients in stroke units is a very, very good system for improving patient outcomes What Sandy was interested in is there's good evidence, not randomized evidence, but good epidemiological evidence, that if a patient with a stroke spiked a temperature in the first 72 hours, or spiked a glucose in the first 72 hours, or were given something to eat or drink without doing a swallowing assessment, they had a worse outcome.

Dr. Grimshaw: And so Sandy's question was, what would happen if you could improve these fairly fundamental, straightforward aspects of nursing care and management? So we ended up doing a cluster randomized control trial, and we randomized 19 stroke units in New South Wales and Australia. The intervention was actually basically team-based problem-solving in the intervention hospitals.

Dr. Grimshaw: Going in and sort of saying, "Here's what the guidelines say. What are the kind of issues that you need to do if you want to get that going here?" So some of the things [00:24:00] about, say, the glucose monitoring is there weren't enough pumps, insulin pumps, in the wards. Or, yeah, basically standing orders wouldn't allow nurses to prescribe insulin for this basis, and so the teams would actually develop local solutions for that.

Dr. Grimshaw: But the upshot of this is that, uh, the primary outcome was a composite of death or severe disability at three months, which is fairly standard in stroke care or stroke research, and we demonstrated a 16% absolute improvement in mortality. It, it was virtually no change in mortality at that time. But in sort of basically severe disability, meaning that probably 16% of the patients got home, otherwise would have went into long-term care.

Dr. Grimshaw: Wow. We followed up those patients for five years, and there's about a 4% absolute reduction in death amongst the intervention sites. So I mean, again, this is a really, really thoughtful nurse-

Dr. McGavock: Mm-hmm ...

Dr. Grimshaw: who moving as a nurse researcher, but just had this kind of, "Well, what would happen if we put this together?"

Dr. Grimshaw: There's a very good stroke research community in Australia [00:25:00] that was very supportive of the young nurse researcher to do this, and that's gone on to change pra- practice in Australia. Globally, we did a big European implementation project in the, you know, the Eastern Europe and the transitional states. So yeah, typically someone comes into the room with a problem.

Dr. Grimshaw: It's not that I'm sitting there thinking of great problems to solve. Yeah, I'd love it if someone comes and they've got this really challenging problem. And the last 20 years I've been in the Ottawa Hospital Research Institute in Canada, and I am surrounded by clinicians who are great researchers in their own right, but also have great problems to solve.

Nika Klaprat: Okay. Yeah, that's an excellent example. Thank you for offering it. So it sounds like... You were saying that was a clustered randomized control trial, and that seems like a really attractive, efficient approach to understanding the factors that influence implementation of evidence into practice, is incorporating them into a cluster RCT.

Nika Klaprat: So it sounds like you would agree with that. Is that, is that a common thing that you like to [00:26:00] build in?

Dr. Grimshaw: So normally we wanna do our diagnostic process before we think about what the solution, the prescription might be. So normally we would do some form of structured inquiry across a range of representative sites and professionals to understand what's going on.

Dr. Grimshaw: So that kind of is, is a first stage. Once we've got... And what we like to do is sort of basically make sure we have a very clear logic model. Yeah, we identify this is a barrier, this is how we're gonna try and address it, and then develop an intervention. I think when we come to test the interventions, for the vast majority of implementation interventions, it makes sense to do this in a cluster trial.

Dr. Grimshaw: So when we randomize patients in, say, a clinical trial, we are l- expecting very little contamination across patients. So it's not that someone's gonna go to s- someone next door and basically give them information about what's going on. If you randomized patients when you try a test as an intervention at the clinician level, there is a real danger of [00:27:00] contamination.

Dr. Grimshaw: And there's some very interesting early work from the '80s that showed that basically there's some trials, I think, from Boston, that showed that if you did a patient trial of a QI intervention, this-- in that case it was reminders. What happened is that the intervention group improved, but there was actually a sort of a parallel increase in the control arm.

Dr. Grimshaw: And the idea was that if a clinician has been prompted or reminded that they should test someone's blood pressure, and with an intervention patient, the control patient comes in next, they're not gonna forget that knowledge. Yeah. It's gonna be there.

Dr. McGavock: They're human.

Dr. Grimshaw: Yeah. And there's, so there's really- ... the evidence.

Dr. Grimshaw: They are human.

Dr. McGavock: Yeah.

Dr. Grimshaw: So many interventions actually operate at a, a social cluster or unit level, and so we have to randomize at that level when we're testing these. One of the challenges is that cluster trials are statistically inefficient. So if you've got a cluster trial with 10 units and 3,000 patients in total, that isn't the same as having a [00:28:00] 3,000 patient individual patient trial.

Nika Klaprat: Yeah. Right.

Dr. Grimshaw: So they are really complex to organize, and they have a very different feel and anatomy to individual patient trials and, you know, they are, they-- we are often struggling to get enough clusters to allow us to build th- those up. But I don't think I've ever done an individual patient trial. I think it's just been we have to do it this way 'cause it just makes-

Dr. McGavock: Yeah

Dr. Grimshaw: methodical sense. Um-

Dr. McGavock: Yeah, and the, the changes are at the, the system level or, like, at the clinic level. Just building on that, in that trial, did you actually look at some of the implementation factors, like, to try to make a more efficient cluster RCT, where you were like, in addition to measuring the endpoint, are we gonna see nurses you have to detect in that first 72 hours a spike in glucose, right?

Dr. McGavock: Like, how are you gonna measure that? And if they miss it on a rotation or whatever, we need to know that. So did you incorporate some of those identification of barriers while the intervention was being rolled out?

Dr. Grimshaw: Sandy applied her first grant having done a PhD to the [00:29:00] NHMRC in Australia, which is equivalent to the CIHR.

Dr. Grimshaw: And the NHMRC really is interested in did the outcome improve. And so this trial, the primary action with the NHMRC was did the outcome improve, yes or no? When we were talking about this, it was like, well, we actually need to know much more about did our intervention change behaviors? Did the change in behaviors lead to the improvements in outcome?

Dr. Grimshaw: And so we-- Sandy went and found ways of getting additional money that would basically allow her to do the process eval.

Dr. McGavock: Okay.

Dr. Grimshaw: And what we're kind of able to show is that there was a difference in the extent to which nurses were measuring and starting appropriate treatment in the intervention arm versus control arm.

Dr. Grimshaw: Implementation behavior change outcomes. And the argument here is very much about, well, how strong is the clinical evidence that links the behavior change to the outcome? So that if we wanted to look at, say, a trial of deep vein thrombosis prophylaxis, and we wanted to have [00:30:00] reduction in DVTs as an endpoint, we'd probably have to randomize certainly North America, all of it.

Dr. Grimshaw: Just because of how infrequent DVTs are.

Dr. McGavock: Yeah.

Dr. Grimshaw: Yeah. But DVT is one of those areas where we have such good evidence that DVT prescription reduces this. And so if you're doing a trial, you know it's gonna be much more efficient to basically demonstrate do you get an improvement in the behavior, which is your proximal outcome, and then you can model it onto the likely clinical implications.

Dr. Grimshaw: And within implementation science, someone called Geoffrey Curran, who's a pharmacist from the US, I can't remember his school, I apologize, Geoffrey. But he introduced the idea of hybrid trials.

Dr. McGavock: Right.

Dr. Grimshaw: Which is basically a way of trying to deal with this, where you may have-- where you've got really solid evidence about this clinical practice leads to improvement.

Dr. Grimshaw: Maybe you don't have to worry about measuring the outcome. If you're just doing a clinical trial, you can still learn about implementation. So I mean, again, there's a lot of thoughtful people working in the space. A colleague in Australia [00:31:00] published a sort of guide to implementation trials in the BMJ three or four years ago.

Dr. Grimshaw: I'm one of the authors of it, but I think it's very different to your traditional patient clinical trial. And so if you're looking for this stuff, make sure you're also trying to embed yourself in that and not just... I've learnt a lot from the clinical trial literature, but I've had to learn lots of other things and social evaluation literature and other things are probably as useful.

Dr. McGavock: Yeah. We're gonna put links to that. And that was sort of my intro was Curran and others have published on these hybrid designs. Yeah. I think they're super efficient. I wanted to get your take on that. And I think if you can get information for both the implementation and the behavioral change at the same time, it just speeds up that translation to knowledge into practice.

Dr. Grimshaw: It may depend on the w- whether you're powering on both of those.

Dr. McGavock: Mm.

Dr. Grimshaw: So if you're doing a DVT prophylaxis trial and you want to power a reduction of DVT or, God forbid, PEs, then, you know, basically you've not got a cat in hell's [00:32:00] chance. You could power it for the prescription of DVT prophylaxis.

Nika Klaprat: Yeah.

Dr. Grimshaw: You could still measure the clinical intervention, and you could look to see whether you are getting a directional effect that's of the order you might anticipate.

Dr. Grimshaw: But I think frankly the most statistically efficient design would be if you are largely trying to just change the clinician's behavior. I think what Geoffrey says is, well, where there's sometimes where you don't have that link is as strong, in which case you should definitely collect both. And there's a real issue about where do you power it on?

Dr. Grimshaw: Do you power it on the patient outcome? Do you power it on the behavior change outcome? I mean, like all things, when you design any study, you're making a whole range of somewhat arbitrary decisions.

Dr. McGavock: Mm-hmm.

Dr. Grimshaw: It's probably in the eye of the beholder. You know, I normally say when you're designing a trial there are many good options.

Dr. Grimshaw: There's probably one or two stupid ones. But you're often trying to make a judgment about what would be the most useful trial design for where we are in the knowledge base, and there'll be some, some objectivity in that. Actually, [00:33:00] I, and I can give you another great example if you're, if you're interested in that.

Dr. McGavock: Absolutely. And then we're gonna transition to the theoretical frameworks guiding this.

Dr. Grimshaw: Okay. So there is, there are meta-analyses in Cochrane from about 1995 showing that selective decontamination of the gut reduces the mortality by about, I think it's about 5% in intensive care units. I mean, that's a huge effect.

Dr. Grimshaw: It has not been routinely implemented in Canada, Australia, the UK, and you know, when you talk to clinicians in those settings, what they say, and also the microbiologist in their settings say, "Well, they were done in low resistance settings, the Netherlands, other places. We're really worried that you might get an immediate patient benefit, but if that increases a- antimicrobial resistance in the local ecosystem for micro- microbiological ecosystem, that could do much more harm."

Dr. Grimshaw: And there is a prof, an intensive care specialist in Sunnybrook called Brian Cuthbertson, who was originally in Aberdeen. We didn't [00:34:00] overlap, so I didn't know him then. But he was very interested and said, "Well, should we do some implementation research? Should we try to move this forward?" And it was really unclear where the equipoise was.

Dr. McGavock: Mm-hmm.

Dr. Grimshaw: If there was no equipoise in the clinical setting, yeah, an implementation trial would be great. But if there's substantial equipoise in the clinical space, then maybe we have to do another clinical trial. So we did a Delphi approach where we actually surveyed, you know, basically intensivists in all three countries and with also microbiologists and others in the, from those settings.

Dr. Grimshaw: And what came across is that there was considerable equipoise about whether selective decontamination of the gut would be helpful. And part of that was actually the trials that were summarized in 1995 were sort of done, you know, in the '80s and '90s. Intensive care has got a lot better, thankfully. But also this idea about risk, and virtually none of the trials looked at the impact on the local [00:35:00] microorganism resistance So Brian pivoted and designed a cluster trial, 'cause you need to do a cluster trial if you are looking at the effect on the microbiology.

Dr. Grimshaw: Mm-hmm. And basically sort of worked with colleagues in the UK, Canada, and Australia to do a cluster trial that was powered to really be able to say something meaningful about the microflora. And so that was an example where there was genuine equipoise, and that question needed to be addressed before we could move to implementation.

Dr. Grimshaw: This should be out sometime soon. Mm. Watch this space. We'll see what it says. But I think there's that kind of issue that you're judging about what's the uncertainties about this? Where do we not know? What are the gaps in knowledge, and what do we need to do at this point in time? Whenever I go to conversations, and particularly when we're using the knowledge translation language, I would often say, "Well, where's the K?

Dr. Grimshaw: Tell me there's a good enough K- ... to even encourage us to go to KT." Yeah,

Dr. McGavock: yeah. '

Dr. Grimshaw: Cause otherwise we're wasting your time and the time of the clinicians you're engaging with. So-

Dr. McGavock: [00:36:00] Mm-hmm ...

Dr. Grimshaw: uh, that's a kind of interesting space.

Dr. McGavock: And if you didn't acknowledge the equipoise and you just went straight into that cluster RCT, you might have very low uptake of that intervention.

Dr. McGavock: Yeah. And then you have no idea what happened. We're gonna do a podcast on David Sackett's CMAJ Physiological Statistics. It's a must-read, I think, when you're in this space to try to understand, like, how you're designing your trial- Yeah ... and have enough people, have enough endpoints, that kind of thing.

Dr. McGavock: However, on the equipoise point, I think it depends on what you believe the barriers are, which I think leads to frameworks. And Nika, you're-

Nika Klaprat: Yeah ...

Dr. McGavock: you're, like, our local framework expert. Oh. And-

Nika Klaprat: Oh, hardly.

Dr. McGavock: Yeah, very pa- Nika's very passionate about frameworks. And can explain it in really nice ways to our team here at-

Dr. McGavock: the Children's Hospital.

Nika Klaprat: Well, thank you for that. So I guess the way I think about it is now that once you've... I like the way you said, "Give me a good enough K." Once you have a good enough K and you're trying to implement that K into practice, we've kind of touched on this a little bit throughout the conversation, but you've mentioned, like, COM-B and Theoretical Domains Framework [00:37:00] and Susan Michie's work.

Nika Klaprat: So because implementation science draws from so many disciplines, you mentioned that you were the conductor of, of this grand orchestra, so I'm a trainee and I'm very much at the beginning stages of learning in this space, and many of our listeners will be in the same position as me. So how do you suggest trainees decide on research frameworks and methods?

Nika Klaprat: And there's so many to draw from, and I'm in the starting phases of planning my thesis. I was sat down by a committee the other day, and they asked me what framework I should be using. I was like, "There's a thousand," so I'm trying to figure out which one fits my project best. So I guess any advice on that to trainees who are in a similar position who might be interested in implementation science and research?

Dr. Grimshaw: Yeah. So anyone who's interested in tracking this back, I think in 2006, Martin Eccles and myself, with colleagues, published a paper in the Journal of Clinical Epidemiology about why theory could be helpful in this space. It was published as a variance in dissent. So my really [00:38:00] good friend Andy Oxman basically published the dissent.

Dr. Grimshaw: Yeah. We said, "So a theory could be helpful." He said, "Theory's bunk." And we still, we still talk about this when we meet. And, you know, I, I'm not sure we've shifted our, either of our views very well. But at that time, we basically sort of said what, you know, what good theories are basically a current accumulation of what the evidence tells us about a particular phenomena.

Dr. Grimshaw: So most theories aren't, you know... So Jon could go into the bar tonight, it's a Friday evening, and he could have a great theory by midnight based on, I don't know, some fanciful blah. The way that theory is built though is actually by observing, testing, and building theory. So theory represents a cumulative knowledge of what we currently think at this point in time.

Dr. Grimshaw: It doesn't mean that the theories are right. And in fact, basically we would anticipate in science, in 20 years' time, even if we've got the perfect theory now, it should be improved. Einstein gave us general [00:39:00] relativity, but we now have physics, now quantum gravity. Science should involve in these things. But the benefit of using theory was potentially it allowed you to be confident that you were building upon some body of knowledge and expertise.

Dr. Grimshaw: Often there may be standard ways of measuring the theoretical constructs, which are helpful, and it gives you something of a standard language. So if we're talking about Bandura's social cognition model, and we talk about self-efficacy, someone else will say, "Okay, I know what you mean." So we thought the theories would be really helpful, and also there could be a link to behavior change.

Dr. Grimshaw: So that was a very early approach to trying to, to look at that. One of the other major criticisms or problems with theories, as you said, there are thousands of theories out there. Most of them are not worth the paper they're written on. Um-

Dr. McGavock: That's my problem with i- implementation science. There's too many theories.

Dr. Grimshaw: So I think there are probably three or four frameworks that probably really, at this point in [00:40:00] time, worth while looking at.

Dr. McGavock: All right.

Dr. Grimshaw: Uh, there's a whole range of reasons. One is that the academic consensus are you should develop a theory. If you apply to the NIH as well as in the US, don't know now, you'd have to do something, you would actually develop a new theory rather than, "I'm gonna test what we already know."

Dr. McGavock: Mm.

Dr. Grimshaw: And so you get lots of theories that are incrementally different or use slightly different language, but they're not necessarily really different. When we started thinking about theory and working with psychologists, we say, "Well, which theory is the best?" And they said, "Oh, we don't know." "Do you ever test them head-to-head?"

Dr. Grimshaw: They're, "Oh, no. No. No. Why would you do that? You got this school over here, you got that school over there. No, we just sort of allow each other to sort of work in our little worlds or skirmish at the edges."

Dr. McGavock: You either cheer for Manchester or you cheer for Liverpool. Yeah, right? Like, you pick your theory based on what you're closest to, right?

Dr. Grimshaw: Yeah, absolutely. So I think you can start to sort of say, "Here are what would make a good theory." And there's a [00:41:00] colleague who's a relatively new professor in Montreal called Guillaume Fontaine. He did a postdoc with me, and there is a paper in press in Implementation Science that includes over 6,600 different theories and models and frameworks that are in this space.

Dr. Grimshaw: But also what we've started to say, "Well, how could you actually help you choose what it is? What are the kind of decision rules you need f- to do for that?" So I think some of the issues are to what extent is the actual development of the theory good? If it's, you know, Jon McGavock's midnight Friday night theory-

Dr. McGavock: Guinness theory

Dr. Grimshaw: yeah, even though he's a brilliant guy, come on. If this is something that has been built cumulatively, there has been replication studies that seem to suggest that it's k- has an ongoing benefit, that could be helpful. You might wanna think about spec- you know, are there issues that are specific to the context you're working within?

Dr. Grimshaw: But I think one of the areas of profusion is everyone develops a new theory for their particular setting or [00:42:00] context, and again, it just creates noise. Many of the mid-level theories basically should talk about generalizable factors that influence our behaviors. So I think you should probably try and use something which is more at a mid-level.

Dr. Grimshaw: I think there'll be people who would argue with that, but I think that's what you should probably do. You should maybe think about, you know... Some theories are descriptive, normative. Rogers' diffusion of innovation is a descriptive theory. We keep watching this, we see the same phenomena. Doesn't tell us how to change that phenomena.

Dr. Grimshaw: So I think you want to try to identify theories that are predictive and also can help you think about behavior change. You know, from Rogers' theory, we've managed to then desi- design and think about opinion leaders, but that was a huge body of work. And I think o- over time there'll be better empirical evidence, particularly in implementation science.

Dr. Grimshaw: There has been in the last 15 years increased use of theory, which on one level is good, but we're struggling to come together as a field and say, "Okay, what have we learned? And what are the weaknesses of [00:43:00] this theory? What can we do with that theory?" So that's something that in the field you have to do.

Dr. McGavock: Mm-hmm.

Dr. Grimshaw: If you are do- choosing something for your PhD, the theories that, and I'm probably gonna upset colleagues here, the theories and slash frameworks that I think have- Most credence at the moment in the field would be Professor Susan Michie, Theoretical Domains Framework or COM-B, and she's moving forward with the Human Behavior Change Project.

Dr. Grimshaw: From the US, CFIR, and from UK psych sociology, Carl May, with the Nor- Normalization Process Theory. I would maybe start... Uh, that'd be my shortlist, and then actually we'll go back and have a look. Okay, they don't work, or they're not gonna be appropriate here, or we don't think they're helpful, you know, do something else.

Dr. Grimshaw: But I think going to, to find something that sounds very clever but has been, you know, published 10 years ago and never cited, you're gonna spend all your time trying to work out what it means and how you operationalize it as opposed to how can we advance our knowledge about the use of this theory. I have, for a long time, argued that we need more theory but less theories.[00:44:00]

Dr. McGavock: Um, and I

Dr. Grimshaw: was

Dr. McGavock: giving

Dr. Grimshaw: a keynote for the first NIH Dissemination Implementation Conference. There's a wonderful paper by Robert West, who's a UK health psychologist, published probably in 2005, around there, 2006. He looked at transtheoretical model of change. This is a stage change process that says we go from pre-contemplative to contemplative to action to change to maintenance.

Dr. Grimshaw: And Robert basically said, "Well, theoretically it doesn't make sense. Empirically, if you look at trials that try transtheoretical approach versus other approaches, doesn't make a big difference." And he basically said, this theory is... A- and it's so dominant in public health- Mm-hmm ... that it's getting in the way of progress.

Dr. Grimshaw: We need to kill it.

Dr. McGavock: Wow.

Dr. Grimshaw: And the great thing is, so the jour- it's things in addiction. The great thing is there are 10 different responses, and half of them were people who loved it, loved Robert's argument, and

Dr. Grimshaw: half of the people hated it. Yeah. And at the NIH conference, I actually argued that theoricide [00:45:00] is good. Test theories to destruction. That's what science should do.

Dr. McGavock: Mm-hmm.

Dr. Grimshaw: You know, my sense, and Nika, you, uh, Jon, you may have different insights on this, is that, you know, it does seem like there is at least two stages in human behavior.

Dr. Grimshaw: One is, do I intend to do something? Second is, okay, if I intend to do something, how do I act upon that? That does seem to be quite a real sort of difference. But I think we actually constantly need to be testing theories and trying to poke holes in them rather than just assuming that they're right or whatever, and I think that's quite hard if you're doing this just getting into the field.

Dr. Grimshaw: But I think as you mature in the field, you really need to make sure you're being, you know, critically what you do.

Dr. McGavock: And now just to add to that, I think that was great. We are alienating a lot of my colleagues, so we just tore down the theory of behavior change shaska. I don't know what's gonna happen here.

Dr. McGavock: I don't know how many emails we're gonna get about this, but I love that because it's challenging status quo. Now, my other thing that we discuss a lot is if we're talking to knowledge users, [00:46:00] people are gonna implement this information, and they tell us right away what their barriers are. I think one approach, too, is to line up your theory of behavior change with what the knowledge users have identified.

Dr. McGavock: And sometimes it's, yeah, it's our behavior. Sometimes it's a system, right? Thinking about CFIR, there's external pressures, there's internal pressures. Thinking about the NIH right now, your framework has to align with Robert F. Kennedy for some reason, right? So do you consider the, we call it methodological coherence, where your framework is gonna define how you measure things and what you measure so that you're actually testing that theory in the real-world setting and then identifying some of those barriers in your science?

Dr. Grimshaw: I mean, completely. One of the things I said beneficial about use of some theories is they have well-developed measurement systems.

Dr. McGavock: Mm-hmm.

Dr. Grimshaw: If you don't have a well-developed measurement system a- and you've got, you know, a theory built, made of multiple constructs, your first step is actually say, "Well, can we actually operationalize the theory in a valid and reliable way?"[00:47:00]

Dr. Grimshaw: So it's almost about your, your measure development. I mean, so one of the issues about the theoretical domain framework, people criticize it 'cause it, it allows for contextual and environmental factors to come in, but it probably doesn't fully capture them. The danger is that the kind of more these other, the models that may look at that don't particularly necessarily capture what's happening at this other level.

Dr. Grimshaw: And it's a multilevel issue. It's not that one is right or one is wrong. It's like they should be additive. I think if you kind of completely disregard it, unless you had really solid proof that if we use that, it doesn't work, I don't think we should go into turf wars. We should be sort of saying, "Okay, let's actually explore."

Dr. Grimshaw: Carole Estabrooks, who's one of Canada's leading nurse researchers- Mm-hmm ... in Edmonton.

Dr. McGavock: Yep.

Dr. Grimshaw: She and I had this conversation when I came to Canada. Carol was largely looking at the, the organizational level. I was looking at probably more the individual clinician level, and it's like we both need to do this.

Dr. McGavock: Yep.

Dr. Grimshaw: And then we can talk and see how we link them up. Yeah. That's what we need to do. Yeah. Rather than, rather than kind of thinking if you only sort of think about system-level stuff, there are so many examples about, oh, we changed the [00:48:00] system and people... You know, nothing happened, or it's not what happened, or there are unanticipated consequences.

Dr. Grimshaw: But you also need to think about the behavioral change stuff if you're trying to do that, and it may be that quite often where people come up with system ideas, they actually don't reflect what the barriers are that people face that, that need to be addressed. One of your comments, Jon, I know we need to wrap up, but was that when people tell you what the barriers are- Our experience is that if you ask people often in management or middle management, even the kind of professional leaders in middle management, "Well, what do you say the problems are?"

Dr. McGavock: Mm-hmm.

Dr. Grimshaw: And then we ask the frontline staff, completely different. And so something that makes sense at an organization level may not make any sense whatsoever when you're dealing with people who are, you know-- My experience of clinicians-- When I was doing my, you know, hospital residences and training, I at least normally had time to go and have a pee.

Dr. Grimshaw: And most days I could grab lunch. And now if I hear colleagues, you know, the [00:49:00] pressure is so hard, and that's the reality they live in.

Nika Klaprat: Mm-hmm.

Dr. Grimshaw: And so I think we need to understand that reality and try and work with them and around them, support them, make it easy to do the right things, and we need both levels of insight.

Dr. McGavock: Yeah. Mm-hmm. That's excellent. I think one thing that's really important moving forward is this potential impact of AI and digital tools in the implementation science field. Residents always come to me, they want to do QI projects. What's quality improvement, right? And I would say implementation science is QI science.

Dr. McGavock: It's the empirical quality improvement, right? Mm-hmm. And so if you're thinking of quality improvement, you should think about this because this is the right way to do it. If you were to talk to a trainee about QI versus implementation science, would you differentiate the two? And then the second question would be: Where does AI fit into all this?

Dr. Grimshaw: So I think QI and implementation science have different purposes. Quality improvement, the emphasis is [00:50:00] on-- or the question on is, can we improve things within our local setting? And the proof-- I mean, and often when you're doing that, you probably need less robust evidence. Mm-hmm. You can do it before or after.

Dr. Grimshaw: Oh, this kind of happened when we did this, and that's probably good enough locally for us to work it through. Implementation science is trying to develop generalized knowledge that will be relevant in other settings. You require probably greater rigor in terms of what gets done, and often, you know, you need more than one unit.

Dr. Grimshaw: So if you want to do QI in one unit in a hospital, then it's actually quite hard to think how you might do that in implementation science perspective. There is something called improvement science, which I don't understand what the, the difference is. It drives me crazy that we have these two terms. But I think the issue about science versus practice, science is trying to generate generalizable knowledge.

Dr. Grimshaw: Practice and AQI practice is trying to make a difference. So I think there's those two things, but I think people should understand what those differences are to work through. I think [00:51:00] AI- is already improving our clinical understanding and knowledge. But, you know, it's still a doctor who has to prescribe.

Dr. Grimshaw: It's still a nurse who would have to go and do things. And so I, at this point in time, if AI is informing human beings about what they should do, and those human beings have some degree of autonomy, it's back to a behavior change problem. I don't think it fundamentally changes that kind of key issue at the heart of implementation.

Dr. McGavock: Mm-hmm. Mm-hmm.

Dr. Grimshaw: If we got to the stage where we were having your family doctor was a chat box, and the chat box said- Yeah ... "Oh, well, go, go pick up this prescription over there."

Dr. McGavock: Yeah.

Dr. Grimshaw: Yeah, okay, that would change it. But at this point in time, yeah, I think it's a really helpful tool. There are many times over my career where people have argued we just get slightly better knowledge, then all the implementation issues will fall apart or go [00:52:00] away, but they don't.

Dr. McGavock: No. It's

Dr. Grimshaw: not a knowledge issue. So I think that AI will have huge benefits in medicine, but i- if healthcare is still administered and delivered by human beings, there will be an implementation challenge.

Dr. McGavock: Mm-hmm. Excellent. That really puts that into a nice perspective for me.

Nika Klaprat: Yeah, that was really great. And thank you so much.

Nika Klaprat: This has been a really good chat. I've learned a lot. I'm really excited to be able to try and take the knowledge you've shared with us today and use it in my own work. Thank you for that. I'm wondering if there's anything else that we should know about implementation we haven't talked about yet. We've looked into some of your recent work, and seems to be a little involved in, like, deimplementing low-value care and choosing wisely.

Nika Klaprat: So if you want to speak to any of that or, or anything else that comes to mind.

Dr. Grimshaw: Yeah. I think initiatives like Choosing Wisely have focused attention on low-value care, but it's not new. Idea, their trial was [00:53:00] published in The Lancet in, I think, two thousand and one, which was how to reduce low value. We didn't call it that at the time, but how to reduce sort of large redundant knee and back X-rays in primary care.

Dr. Grimshaw: So, you know, basically, this has always been part of the implementation puzzle. I think what Choosing Wisely did, and it's a bit like what patient safety did, is they shone another light on a particular problem area. And Wendy Levinson, who is the lead of Choosing Wisely Canada and a global leader, deserves a huge amount of credit for that.

Dr. Grimshaw: So what it so-- and I suddenly was kind of, okay, well, here's something where, you know, we're doing-- we're wasting resources, we're doing patients harm, and now we know we're also harming the environment. We should do something about that.

Dr. McGavock: Mm-hmm. So

Dr. Grimshaw: I got involved in Choosing Wisely Canada probably about five or six years ago, and it's been really interesting.

Dr. Grimshaw: I mean, some of the issues are, is deimplementation similar or different to implementation? What can we take from implementation science? Do we have to build a completely new science? My starting point, and it's not changed, is no, they're actually highly related. One of my colleagues, Andrea Patey, [00:54:00] who's at IWK, and for her PhD, she looked at, well, do theories distinguish between stopping and starting a behavior?

Dr. Grimshaw: And apart from operative learning, they don't. Do people use different interventions if they are trying to stop or start a behavior? In general, not particularly. So it doesn't feel like the field is making a big difference in that. Having said that, I think there are probably slightly different barriers, uh, that we need to address with deimplementation and implementation.

Dr. Grimshaw: And some of these go back to, say, cognitive biases. So human beings feel much better if they act, even if they got it wrong, God forbid the patient dies, than if they didn't act and the patient died. So we're kind of quite action-oriented. Um, and so that's very different from where you're trying to get people to start a behavior, 'cause fundamentally, we should just do this.

Dr. Grimshaw: We've always done this. This is what's going on. So I think we're starting to understand this. You're trying to get a more nuanced understanding about Whether implementation, deimplementation are [00:55:00] so different, my guess is that there are differences, but there's a huge overlap. What I think the focus on deimplementation and choosing wisely gives is just a really important area and it's shining a light saying we need deimplementation/implementation in this space.

Dr. Grimshaw: We want choosing wisely to make a difference in Canada to the citizens, the healthcare systems, those healthcare s- professionals and systems to try and enact the choosing wisely recommendations. So I think it's opened a space That was never as prominent. And as I said, Choosing Wisely Canada is an international leading group, and Wendy Levinson is really the star of the world in this setting.

Dr. McGavock: That's great. And yeah, I think if you're a pediatric resident and you're wondering, "Why are we doing that X-ray for that kid who came in with croup?" Even before we gave them dex or, like, just after we gave them dex and you're like, "Why are we doing that?" That's... Those are great questions. One of our topics of- of choice is, like, where do you find those great questions?

Dr. McGavock: And I feel like groups like that, Choosing Wisely, are [00:56:00] identifying some great gaps that you can dig into and dive into. And this is really important. I think that really opened my eyes and helped me actually clarify a lot of the muddiness that I had with implementation science. Our lab is moving into this in the space of the built environment, where cities are implementing protected bike lanes.

Dr. McGavock: Every city worldwide. Paris is, like, decommissioning entire roadways and protect them for bike lanes. And they could have huge health impacts, and we're trying to understand on our end, like for Nika's thesis, what are some of the implementation factors- Yeah ... that are influencing behavior change? And it's always nice to hear that we are humans, and we work with humans, and humans are making important decisions.

Dr. McGavock: And it's important for us to have more than knowledge guiding this, right? And being able to pick apart where humans are making errors and whatnot. So this is really good for me. I think it's an exciting area of research. I think CIHR really nailed it by saying we should be emphasizing this. I really wanna thank you a lot.

Dr. McGavock: I wanna thank Nika. Any other final comments, Nika? [00:57:00]

Nika Klaprat: Not much. I really liked your focus on being multidisciplinary, and I think we see a lot of that in our work, too, in this built environment space working with city planners. Like, we wouldn't be able to know half the questions to even ask without having them on our team.

Nika Klaprat: So that's a very critical piece to this IS world that I think is important to build into it moving forward.

Dr. McGavock: And our evidence comes from natural experiments, not randomized control trials, 'cause you can't randomize people to their neighborhood or randomize neighborhood and elements of the

Dr. Grimshaw: neighborhood.

Dr. Grimshaw: You can, you can randomize neighborhoods. You can randomize a whole range of stuff. But actually- Yeah ... I live in both the causal experiments and the experimental, and there's a whole range of reasons. But there's hundreds, if not thousands, of cluster randomized trials that randomize more socially intact areas.

Dr. McGavock: Love it. Okay. And we'll point residents, trainees into your papers, things like that. If there's any other resources or groups that trainees should be looking to if they're really passionate about this work, let us know, and we'll add that to the website.

Dr. Grimshaw: Okay. That's great. All right. Thanks a lot for today.

Dr. McGavock: Take care. Thank you very much. Thank you very much. Really appreciate it. Take care.[00:58:00]

Dr. McGavock: Wow, that was fantastic. Jeremy Grimshaw has had a lifetime of experience working in this field. He could have gone in any direction, and I thought that was a perfect way to summarize his use of implementation science, how he's using implementation science to guide The application of best practices in the form of guidelines into clinical practice.

Dr. McGavock: For his origin story, it's shocking that he had to choose between clinical medicine and doing research.

Nika Klaprat: Yeah, it just shows how much work, what he was doing in the field, and how he's pushed it further throughout the past few decades.

Dr. McGavock: And I'm always impressed when a clinician moves into that space to say, "I really care about working with patients.

Dr. McGavock: However, I really think I can make a huge difference here in this field." And so the fact that he dedicated his career to advancing implementation science, doing it here in Canada, and helping us [00:59:00] understand you can't just take the evidence, put it in a guideline, and expect that everyone's gonna use it.

Dr. McGavock: The second thing for me that really resonated was that he uses RCTs as a tool in implementation science. So when I look at his Google Scholar and his resume, he's involved in so many RCTs, and for me, the history went like this: You do an RCT, other people do RCTs, we meta analyze them, we put them into guidelines, and then you read those guidelines and you apply them.

Dr. McGavock: But he's using RCTs after the guidelines have been printed and published and put out there and then running RCTs to see what's the best way for us to implement those guidelines. Any thoughts or takeaways from you, Nika, on that approach?

Nika Klaprat: Yeah, I think just building on that, I really appreciated how he covered hybrid trials and talked about how you can put those two things together, in certain contexts anyways, to advance both sides of that coin at the same time, both advancing the intervention itself and understanding how efficacious it [01:00:00] is, but also how it can be effective in an implementation standpoint.

Nika Klaprat: So putting those two things together really made a lot of sense, and the way he described it cleared up a lot of that part for me as well.

Dr. McGavock: Yeah, and I don't think that's something that we talk to trainees about very often. We'll tell you that there are RCTs, and then there are other methods, and rarely do we say to trainees, "Well, you could actually do an RCT and at the same time measure how it was delivered, taking a look at different outcomes related to the implementation of it at the same time as you're measuring the efficacy of it."

Dr. McGavock: So I agree. I'm with you on that one. That was really great. Then I guess my final takeaway was related to the story that he gave around identifying barriers in a stroke unit and saying, from the people working on that floor, "How do you see? What are the main challenges for you taking what we consider best practice, putting that into practice in your own unit to [01:01:00] try to improve the outcomes of the patients that you're serving?

Dr. McGavock: And then after you've identified those gaps, well, let's design an RCT to try to address them." And so I felt like- It resonated with me, and I think our project touches on this a little bit too. You've gotta talk to the people that are doing it.

Nika Klaprat: Yeah, for sure.

Dr. McGavock: You gotta talk to the people that are actually implementing guidelines, or in our case, the city planners that are designing cycling trails.

Dr. McGavock: Without that input, we don't really know how to design that RCT or how to design that next intervention.

Nika Klaprat: Yeah, I would agree. And I also really liked when he spent some time talking about having less theories, but more theory guiding our work. I've never really thought of that balance before, but as we've talked about a few times, there's so many theories that go into implementation research as a field that sometimes it's hard to work through them all.

Nika Klaprat: But having less numbers of theory, but more theory actually guiding the bulk of the rationale behind your work is really important, and I appreciated his coverage on that.

Dr. McGavock: Yeah. I think that's [01:02:00] something that we're seeing with almost every scientist we interview, that you start with a question, you develop a theory that lines up with that question, and then your methods follow.

Dr. McGavock: This is a field that is just full of theories. And I guess far too often people are not choosing any theory and just saying, "This is implementation science." So I agree with you that that was another great takeaway for me. We are gonna put all of the links in the show notes to Dr. Grimshaw's publications, summaries of, of implementation science, a little bit of our own work maybe.

Dr. McGavock: Any final thoughts, Nika, for people entering into the implementation science space?

Nika Klaprat: I would say visiting those resources would be a good place to start. Yeah. But definitely take it slow and make sure you have a deep understanding. You can start understanding where the evolution came from. I think Dr.

Nika Klaprat: Grimshaw really talked about that in good detail, so understanding where something comes from can help you understand a trajectory of where it's going and how you can use it in your own work.

Dr. McGavock: Is there a [01:03:00] paper or resource that's really helped you in this journey as you're putting your work together that helped just clarify the complexity of this overall area of implementation science?

Nika Klaprat: Yeah. It's... There is one paper, it's by Per Nilsen in 2015. It's a taxonomy of the different implementation science models, theories, and frameworks that are used, and they present the theories in five different categories, and it really helps me wrap my mind around how different theories are being used, can be used, and what types of projects should be informed by each type.

Nika Klaprat: So that would be the primary paper I usually refer people to first.

Dr. McGavock: Is that the paper that informed that beautiful slide that you presented to me-

Nika Klaprat: That would be the one, yes ...

Dr. McGavock: framed. Yeah. Awesome. I think we should actually take that slide, put it as a JPEG, and put it in the show notes.

Nika Klaprat: Yep. Happy-

Dr. McGavock: That- ... to

Nika Klaprat: provide it.

Dr. McGavock: Awesome. Perfect. That absolutely helped me clear a number of things up. So hopefully we will have Nika back to talk about other aspects related to implementation science, because we only really scratched the surface. And [01:04:00] thanks again, Nika, for coming out.

Nika Klaprat: Happy to be here. Thanks for your chatting.

Dr. McGavock: The Emerging Scholar podcast was recorded in the UMFM studios located at the University of Manitoba in Winnipeg, Manitoba, Canada. This is Treaty 1 territory, the original homeland of the Anishinaabe, the Ininew, and on the national homeland of the Red River Métis. Manitoba is also homeland to the Anishininew, the Dakota Oyate, and the Dene peoples.

Dr. McGavock: We acknowledge that our water is sourced from Shoal Lake 40 First Nation. As a settler scientist working in health research, I acknowledge TRC Call to Action Number 18, that health inequities between Indigenous and non-Indigenous people are the direct result of colonization. Winnipeg is the center for reconciliation in Canada, and where we are speaking from today is at the crossroads of Canada's history and Canada's future.

Dr. McGavock: We are three kilometers away from one of the most sacred meeting grounds for Indigenous people on the [01:05:00] plains and within Turtle Island. We are also several kilometers away from one of the last residential schools in the province. We are working collectively on reconcili-action with youth, elders, and community leaders to heal from the trauma of colonization, past and present, honor the original treaties, and create a Canada that addresses and eliminates the inequities and injustices of the past and present to create a future for Indigenous children to live and thrive.

Dr. McGavock: On behalf of the team at the Emerging Scholar podcast, we wanna thank Osani Balkaran for the great production for our opening and closing themes. We also wanna thank UMFM 101.5, especially our executive producer, Jared McKetiak, for technical assistance and production on this project. We also wanna thank all of our guests for the discussion and the insight that they've provided.

Dr. McGavock: Once again, thank you for listening. Be sure to subscribe to the Emerging Scholar podcast on Apple Podcasts, Spotify, and [01:06:00] umfm.com.