SeeHearSpeak Podcast

00:00:11 Tiffany Hogan: Welcome to See Hear Speak Podcast Episode 42. This is a bonus episode in which I talk to my collaborator Rouzana Komesidou about Implementation Science. If you’ve ever wondering, what is implementation science? then this is a great short episode for you to learn a bit about it. In full disclosure this episode was created to provide basic content to prepare attendees who have enrolled in a2 day virtual conference we are sponsoring atthe end of April, focused on Implementation science in communication sciences and disorders (however the content is accessible for those in many fields). After listening if you are interested in attending, registrations open until this Monday April 18th at info.mghihp.edu/isforall, which I’ll link in the show notes and on the podcast website. After April 18ththe content will still be available to view for a reduced price. Big shout out to the conference committee (you know who you are) for thoughtfully planning a conference that actively engages participants online, which is no small feat in the age of pandemic-induced zoom fatigue. Speaking of the pandemic, Rouzana and I recorded in person, which was a treat. However, you may be able to hear our masks crinkling a bit as we talk. After listening to this episode, don’t forget to check out the website, www.seehearspeakpodcast.com,to sign up for email alerts for new episodes and content, read a transcript of this podcast, access articles and resources that we discussed, and find more information about our guests.

00:02:10 TH: Welcome to See Her Speak podcast, and I'm going to start by having Rouzana Komesidou introduce herself.

00:02:14 Rouzana Komesidou: Hi, my name is Rouzana Komesidou. And I am a researcher and lecturer at MGH Institute of Health Professions, working with Tiffany at the SAiL Literacy Lab. My work focuses on implementation science and trying to bring implementation science into schools to improve service delivery and outcomes for children with communication disorders.

00:02:33 TH: So today, we're going to talk about implementation science. So what is implementation science?

00:02:40 RK: Implementation Science is formally defined as the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice to improve the quality and effectiveness of health services. In other words, implementation science studies how we can improve the implementation of evidence-based practices to maximize outcomes in the populations that we serve, and in our case, people with communication disorders. But to do that, we have to first understand what are the needs in a setting, whether evidence-based practices exist to address those needs. If they do exist, do clinicians implement them? And most importantly, do they implement them successfully? If not, why that is, what are the barriers to implementation? How can we improve implementation? But also, if something is done successfully, how can we continue capitalizing on it?

00:03:33 TH: So, some people may think, this is what most research is focused on. However, we know there's this continuum of research. And something that is often cited is that study that says that there's 17 years for only 14% of research to get into practice. So even if research can be implemented into practice, we see that there's this gap, and it isn't being implemented into practice.

00:03:59 RK: Right. Yeah. And that's exactly it. And I think in this case, we have to think about context and how that matters, and what factors within that context will influence how well we're gonna implement something.

00:04:10 TH: That makes good sense. And then also I remember you telling me one time and I really being interested in this study that showed that it's really the connection between the research and the context that drives whether that research is going to be implemented. The more that the research takes into account the context upfront, the more likely the research will happen in clinical practice.

00:04:31 RK: Right. And conducting research that takes context into consideration, if possible, from the beginning, so we can accelerate that translation of research findings.

00:04:42 TH: So based on our work, we see that there are several things to consider when we do this implementation science work. Can you tell us about those?

00:04:49 RK: Yes. So there are several aspects that we have to consider when we do that type of work. One of them are the factors that influence uptake in clinical or educational settings, and whether they act as barriers and facilitators. In implementation science, we have frameworks called determinant frameworks that allow us to systematically examine factors related to the program itself. The recipients of services, the providers, the clinicians, the inner setting, and the outer setting. Few examples are programs quality of evidence and adaptability, clinicians' knowledge and how well they apply that knowledge, demographics, local resources, time is a big factor, workload, whether the leadership is engaged in the process, what funding opportunities we have, but also what policy is there to support this translation process. Another thing that we have to consider is the process we follow to make implementation happen. This is usually, in the literature, reflected in phases or stages. We have, for example, exploration and preparation phases where we're exploring a need and preparing at all levels for its implementation. Then we are focusing actively on implementation and we pay attention to what's happening and we also try to solve problems that may arise.

00:06:15 RK: And eventually all that is coming together to support multiple iterative cycles, where we continuously improve our processes because our goal is sustainability. We need to ensure that what we're doing will help our programs to stay in the settings and benefit the recipients of the services. During that process of implementation, we have to think about what strategies or techniques we're gonna use to promote adoption, implementation, and sustainability. A few examples of strategies can be assessing for barriers and facilitators to better understand the factors that contribute to implementation, developing an implementation plan, building partnerships, adapting any intervention, training and coaching, and centralizing data management systems. And of course, we have to consider outcomes, implementation science helps us evaluate outcomes related to implementation, for example, whether a program is appropriate, it's visible, whether it costs a lot. We have to look at outcomes related to the services we provide, for example, whether they're people-centered and equitable, or, of course, outcomes related to the individuals receiving those services, their symptomatology, their function, and whether they are satisfied by those services.

00:07:30 TH: This makes good sense. And I think even on that research continuum, where we think about doing, for instance, a randomized control trial, where we're trying to see if something is efficacious, we can always think about sustainability at the endpoint. So I have that experience in working in the language and reading research consortium. We developed an intervention to stimulate language comprehension in children. And we were running a randomized control trial. But along that way, when we were developing the intervention, we were constantly thinking about if this does show efficacy, how could this be implemented quickly and easily within a context? So even though we were doing a randomized control trial to determine the effectiveness of the intervention, we were consistently making small decisions that then would make sure that the intervention match the context that it was going to be placed in.

00:08:26 TH: So as a concrete example, during this intervention, we were... Our vision is that if it was effective, that teachers would be implementing it into their ELA block, so their English language block. And so we worked with teachers upfront while we were developing it, to say, What would... How much time would you be able to give? Is this a 20-minute intervention, a 30-minute intervention? Does this need to be in a large classroom or a small group? All of these decisions were made upfront with our... What were called stakeholders, so our stakeholders in that case were the teachers that were going to be implementing this intervention. So we made all these decisions, and then we ran the randomized control trial and we showed effectiveness. And then because we made those decisions upfront, we didn't have to do a ton of tweaking after we showed that it was efficacious. We had more of a direct match into the context, so that really... Having that sustainability in mind right upfront was, I think, really critical to making sure that it would be implemented in the context in which it was intended to be implemented.

00:09:27 RK: Yeah, you brought up a very beautiful example of maximizing contextual fit for our programs, and this should be the model that we frame our work, because I think oftentimes in the way that frameworks are laid out, we see sustainability towards the end, and this doesn't imply that we shouldn't focus on sustainability from the beginning, because if we don't, then we're gonna arrive at a point where it's gonna be difficult to help the program stay and continue benefiting those who receive those services. So that was a great example, and that shows that it is important to consider sustainability from the beginning of that process.

00:10:06 TH: Because we all know great study [0:08:00.8] ____ that really... We look and think, how is that ever gonna be implemented? It doesn't take into account the frameworks and barriers and context that it's going to be implemented. Another thing that you mentioned was these strategies, and I think all of the components you mentioned here are really the heart of the science behind implementation science. So with those strategies in mind, if you talk and say, Okay, this is the barrier that we have, then we can have some strategies, and these models are so great because they give you some ideas about what those strategies would be. I know for us, we've seen that in implementing our language screener that we had the sense that the teachers didn't understand fully why to do it, which could impact then the fidelity and follow-through, and try to work with the district to try and work best. Of course, we know that's not the be-all, end-all, but it's just one example of a strategy, I think, to negate this barrier of understanding the why of why we're doing something.

00:11:12 RK: And you bring up a good point about training educators and helping them increase their knowledge and skills, which as you said, shouldn't be the only thing that we do, because we do have to have processes where we actively are working on different other elements that may influence implementation. In our case, for example, another thing was to make sure that our data is centralized and people can use the data to inform their instructional approaches, their interventions, so creating data management systems in large school districts is quite some work and a very important one if we, again, think about sustainability.

00:11:50 TH: I think too, it's... The partnerships are so important, 'cause when I first started doing research in this area, I really had the eye towards only scientific rigor, so I wanted to make sure that I was... Had a research question, answer the hypothesis, find out what the answer is, and then I thought I would just publish that and then practitioners will pick it up and they would adapt it to their context somehow. If they knew how to adapt, I thought, Oh, educators, SLPs, teachers, they would know how to do it best in their context. But what I realized with learning more about implementation science and really pushing into that in my own work is that you then work upfront with those partners instead of just saying, "Well, that's not my area. I don't know how to do that. I'm just gonna leave that to the professors.

00:12:37 RK: I don't have the time.

00:12:38 TH: I don't have the time, I don't... To do this. Now, I think working with you on implementation science is really the key, is those partnerships upfront, listening to those partners to make those decisions that will create sustainability, so you do it right upfront.

00:12:54 RK: Yes, and I think that's one of the themes of our coming conference, to create those spaces where we could have those partnerships from the beginning. But you are bringing up the problem that frames the need for this work and why do we need implementation science in CSD. And thinking of that problem, I think we have to think it as two-fold that leads to the same overall issue, and that is implementation remains the biggest challenge in our field. First, you described something that we often see where research knowledge doesn't always reach practice, and there are a few reasons of why that is. Again, if we look at that continuum from basic science to scale up in implementation, much of our work lacks those translation and implementation aspects. And another reason is accessing. I think we still do that, we still run studies, publish our findings, write beautiful manuscripts, present in scientific conferences, and somehow we may have this naive perception that clinicians will take that information and directly apply it to their context. But we see that that's not really happening.

00:14:06 RK: And when thinking about access, is accessing an article, for example, of course, it's not behind a pay wall, which we know that is quite problematic and even in our own field, but also how well the clinicians are accessing the content in those articles and whether they see the immediate application to their settings. And even if they do, I think we still need deliberate efforts to bring implementation science into our settings and to ensure that the systems that clinicians are working are ready to receive a new programming or practice and sustain it.

00:14:43 TH: That makes good sense. I think we also tend to not realize that researchers have their own language, so when I'm writing a research article, even if I'm writing it with the intent that it will actually be implemented in practice, I'm still writing to my scientific peers. So, there's a lot of jargon in the articles. Those are the reviewers of our articles. Right?

00:15:05 RK: Yeah, yeah.

00:15:06 TH: So, I'm writing to them and somehow it becomes a secret language with full of jargon, and it doesn't make a lot of sense to then expect people who are dealing with their own barriers to then pick up that article and somehow be able to just translate this code. Even if they've had great training and evidence-based practice, it's really on us to think about how to shake hands better and communicate that. And this podcast is really a big part of that because I could write these articles, even if I did write them to practitioners, let's say I did say, "I'm gonna write this article for practitioners," first off, I'm not a practitioner, so even though I'm writing for practitioners, I don't exactly know what's happening in that context. That's first. Second...

00:15:46 RK: You're making assumptions.

00:15:47 TH: I'm gonna make a lot of assumptions, and I'm speaking for them as opposed to partnering with them. And then I also think that with the podcast, it's been eye-opening. I've written articles that have gotten a lot of "citations," but I never get feedback, I never really understand, but with the podcast, I have people tell me, "Oh, I understood that in a different way, or access that article." So I think it's really on us as scientists and also really thinking about as practitioners working together, and that's a big part of what we wanted to do for this conference.

00:16:19 RK: Right, and yeah, [0:14:12.8] ____ our methods of dissemination, but also working again closely with them to apply the findings into practice. Another thing I think we have to think about is that, yes, research doesn't reach practice, but also sometimes research doesn't reflect practice because it is often created without practice in mind, and you and I have seen this in our own work, that context really matters.

00:16:47 RK: It's not enough for us to create effective interventions. The real question is whether they will fit into routine settings and benefit those who need them, and if they don't fit, how do we make them fit? Where clinicians work, how the systems are operating, what barriers do they face, what facilitators exist, what are the characteristics and needs? All that will determine how well an evidence-based program will be adopted and maintained over time.

00:17:15 RK: I think we've seen this even more recently during the pandemic, where we had to continue working with limited resources in highly constrained settings, and in one of our recent publications, we kinda told the story of that type of work, where we are partnering with a local school district and suddenly we had to go from in-person intervention to online intervention, and we had to make some quick decisions, how to pivot to online intervention, how to adapt our materials, and how to ensure that even within that adaptation process, we are keeping the effectiveness of the program intact and benefiting our students. So we tell that story, and it's an example of context mattering in this type of work, because again, you have this effective intervention, but if something radically changes in your context, then you really need to think about how you're gonna make that fit happen and continue supporting the needs of your partners.

00:18:19 TH: That's right. That's a great example, I think, and many are doing that in the pandemic, adaptation was a key word.

00:18:26 RK: Yes, yes, we are forced to do that, I think.

00:18:28 TH: Exactly. So, we've talked a bit about the research continuum, can you speak more about that research continuum?

00:18:34 RK: Yeah. So, if we're thinking about research, we have different stages that research goes through, starting from basic experimental work, going to efficacy and effectiveness studies, and then towards the end of that continuum, thinking more about translation and implementation. And I think we have to closely see where our research falls into that continuum and try to focus more on those translation, on implementation aspects.

00:19:02 RK: I'm not saying that it's not important to have basic work or efficacy and effectiveness studies, but I think we have to also try to have more of both, what we call hybrid studies where we can still evaluate the effectiveness of an intervention, but at the same time, look at the context and focus on what we're gonna do, all the processes that we have to set to prepare the context to receive the program. And the example from Lark that you just mentioned is a great example of that because that's what you did, you had a hybrid study and focusing on both because eventually you want to accelerate that translation piece. But I think in that continuum, we have to consider clinical needs from the beginning, researchers and clinicians should be able to work together to develop programs that will eventually fit in practice settings and are meaningful to them and the populations they serve. And it is more cost effective. And you recently published a paper with Hugh Catts, where you were talking about prevention and how much money that saves in comparison to traditional models, and the same concept applies here, if we work together from the beginning where we almost co-design or co-develop programs that will be beneficial to them and their populations, we can accelerate this translation process and start addressing that research to practice gap.

00:20:33 TH: And that makes so much sense. And we just talked about this research to practice gap, and we often hear this referred to, but we have started to talk about the practice to research gap.

00:20:41 RK: You're right, yeah.

00:20:42 TH: 'Cause you might be thinking, if you're listening to this and you're a practitioner of any sort, you might think, "How do I fit into implementation science?" But this research to practice gap puts more weight on the research, right? So research to practice, but what we're thinking here too is that we need to think about practice to research, and that means that practitioners make their voice heard so that then research can accommodate what's happening in practice, it can consider what's important in clinical practice. So practitioners play a valuable, critically important role in implementation science, because there, we're thinking about how we can address this practice to research, research to practice gap.

00:21:21 RK: Right, right.

00:21:22 TH: And it's really more of a secular aspect, so we don't wanna put the burden on clinicians to translate and implement what researchers do, it's really that researchers need to also listen to clinicians to understand what the problems are and what are the barriers and facilitators in a context so then we can create research that has the most maximal impact on outcome.

00:21:45 RK: Right. And I think also thinking that the evidence that is coming out from practice looks different than what we have from research. And we have to take that into consideration and to change some of the ways that we do research studies and looking at needs in different settings and populations, because if we don't, then we will continue having large populations remaining undiagnosed like children with a long-term language disorder. And you and others wrote so much about the negative consequences that arise from lack of identification and support, such as limited education, employment opportunities, high risk for mental health problems, high risk for suicide, sexual abuse, and contact with the justice system. And we will also continue perpetuating systemic racism, white-centered practices, and inequity, preventing many people from accessing health services and opportunities to thrive.

00:22:43 RK: I think we see this in our work every day. Many programs we currently use were developed with some groups in mind and left out entire communities, people of color, people from different cultures, people who speak other languages, people who speak other dialects, we see this with the screening work that we do. And this is serious because we... At the same time that we're advocating that we're trying to address these problems and we're trying to eliminate them, we are also contributing to them, and we can't really pretend that we're actively addressing those problems if, for example, we are dedicating a couple of lines in our paper saying that, "Future work needs to address the needs of diverse populations." I've done it, and I'm also guilty, and I think that's a problem there, and we have to recognize that and really find more active approaches to address that gap, but also increase accessibility to services for all people, especially those who've been left out a lot.

00:23:40 TH: Absolutely, I'm absolutely guilty of that myself, and it's because I've gone into situations where I say to a school district, "Okay, I have a grant, and I'm only going to study these children in your district." But I've really been trying to think more with you, Rouzana, thinking about how do we address all children in the district, how can we deal with that what we often think of as is the messiness of real life, right? Implementation science allows you to have the tools to deal with that, because that's real life, that's what we need to be focusing on. In the meantime, without these meaningful changes in our research and in the practice to research gap that we're focusing on, the clinicians are just continuing to face these serious obstacles in their work, and we are discussing barriers, and we see these barriers, but if we don't address them, we're just gonna see that downward spiral of job dissatisfaction, burnout, and just a constant disconnect. And then also a feeling of insecurity and frankly, shame when educators are told, "You're not reading the research, you don't know what's in it, what's going on with you?" When really we have to work together as a team.

00:24:50 RK: Yeah, I think your last point is so important because it kinda takes us to what we need to do to start addressing these problems and really work together to eliminate that research to practice gap, and it's about blaming, we really need to stop the blame. We need to stop saying, "Clinicians don't do this, they don't do that. They don't apply this successfully." And we have to understand that it's not just on clinicians, it's on all of us, how we're gonna address this research to practice gap. And also consider that they do, as you said, they don't have the capacity in many cases to take our research findings and apply them in their practice, because of all those constraints they face, so it has to be collective effort. And I think something that we're gonna try to do in this conference is also show that clinicians actually do a lot that fits the definition of implementation science, they assess their context, they seek evidence-based practices, they adapt, they evaluate, and we have to also take advantage of that, strengthen those processes with more systematic approaches to allow some clinical practice to inform research, going back to that practice to research pathway that we want to establish.

00:26:05 TH: Practitioners are the ultimate implementation scientists.

00:26:08 RK: They are, they truly are, and I think they just... We need to recognize that and empower them to do that. Something else I think we have to think within that system perspective is how we can align our systems to support access to services for people with communication disorders, because that's what implementation science helps us to think about, about the context, about the larger systems that come together to determine implementation of services and access to those services. And in line with that, I think we have to look at communication problems as a public health issue and take advantage of existing knowledge around public health and tools in implementation science that can help us to evaluate context and coordinate multiple systems.

00:26:53 TH: Well, this brings us to think about the conference, why did we put together the conference? And our field in speech language pathology also referred to as Communication Sciences and Disorders, we have really been focusing on implementation science for some time, so there was an initial conference in 2014 put on by the ASHFoundation. We've had many people in the field who've been thinking about this for some time.

00:27:16 RK: We had special issues.

00:27:19 TH: Special issues in journals, we've had... ASHA Foundation has had research grants focused on clinician-researcher partnerships. There's been training opportunities that have been funded through ASHA and ASHA Foundation on implementation science. So, there is a movement just in general, also to help clinicians to see themselves as implementation science or clinician scientists in programs. And within ASHA, with this conference, what makes it unique is, upfront, we decided we would have a focus solely on speech language pathology, communication sciences and disorders, so all of the speakers have experience in communication sciences and disorders, and so that's what makes this conference unique. Also, it's unique in the sense that we wanted to focus on paring clinicians and scientists together and being in the same space, so we can talk about the same clinical problems, how we’re doing with them together, and then you, with your partner Carla, have been working on really thinking about how to actively engage in a conference online.

00:28:26 TH: We’ve all been doing Zoom online for a long time, so it can get so tedious. And so, we wanted to make sure this was something that participants walked away and had the notes that said “Ok I can take this and apply this to my own clinical problem.” So, there’s activities throughout the two days, that really address these. And the speakers themselves are really selected to showcase first our speakers focus on equity really which is at the center of implementation science, cause it addresses all people that need services. And then we have some of the major change makers in our field that are doing implementation science for some time, writing about it. They’re gonna talk about the history and their own experience with implementation science. We also then have someone who’s really been thinking a lot about implementation science in her own area and how to learn more about implementation science.

00:29:18 TH: We have a focus on resources. We also have a discussion about the frameworks that can be used in your work and we have a discussion about social media and how to translate in a more valuable way the research that’s being done. And clinicians also really speaking through social media to not only other clinicians but scientists that are listening to what’s going on there. And then we have a few opportunities to showcase some of the work that’s happening in particular here at MGH and our surrounding community to say this is how we’ve applied it. We also have, I think we have, it’s over 40 short talks that are gonna be given from those around the world who are practicing implantation science. Yeah so we have some of those that we call lightning talks that are 10 minutes long.

00:30:03 TH: So it is exciting to think about, you know, a way to bring together and educate so many people that are interested in implementation science. And I think another part of it is that we wanna bring together community cause we have some things in the works to get people together after the conference as well to just keep the momentum going. You know that forward momentum is something we absolutely need as you said, it’s really important.

00:30:27 RK: Yeah, and you know I think in addition to this type of opportunity like conferences and opportunities to get together, especially with clinicians and listen to them and hear their stories, I think we also need more training opportunities, more education opportunities. I see it in my own work as an early career investigator, but I also see it as a lecturer with my students, in the master SLP program. There is a need to bring that content in to our clinical doctorial training and any other opportunities after that to strengthen our knowledge and skill development. As an early career investigator, I think we also need to think about funding opportunities because that’s something that I’m currently struggling with right now. I think there’s this perception that only established researchers like yourself can do this type of work and it seems that funding systems reflect that. Which on one hand, I definitely understand why that is happening but also if we keep discussing and trying to take actions about doing this type of work and addressing the research to practice gap we definitely need to think about more funding opportunities for early investigators like myself to explore that work and bring it into schools and to hospitals.

00:31:50 TH: Yes, I mean I think you know you coming in and having interest in implementation science and really helping me make some tweaks to the work I’ve been doing which was always focused on sustainability but really pushing into the frameworks and focusing on the science aspect too of measuring fidelity and outcome in a way that documents this context of various facilitators. It’s been hugely important to the work that’s been done, and I think it’s something that makes me realize that you really don’t have to wait. You can jump into this at any point in your career and any point in your practice. You can jump into implementation science with actually a few tweaks, these are important tweaks. It’s really a way of thinking about your work and research and your practice.

00:32:37 RK: I think it’s important that you say that. It’s good as an early career investigator to hear something like that coming from you as an expert and a leader in the field. And I’ve been lucky to be here, to work with you and you’ve really established processes in allowing me to innovate. But I think that’s not the case for many others in the similar position. So, it’s good to hear that we can innovate and we can get into implementation science and do this type of work.

00:33:07 TH: I’m just really excited about this conference. I just want to say to our listeners that I look forward to meeting you all, spending two days discussing and brainstorming on what Rouzana and I just love, which is working with clinicians to make sure the research is put into practice. I often say that it takes a village to do anything, and it really does take a village to do implementation science. And I really am hopeful that this conference will be our village.

00:33:33 TH: Thank you for taking the time to listen. Thank you for coming on Rouzana and talking about implementation science.

00:33:37 RK: Thank you for having me I’m also excited and I look forward to seeing you all in our conference.

00:33:44 TH: Check out www.seehearspeakpodcast.com for helpful resources associated with this podcast including, for example, the podcast transcript, research articles, and speaker bios. You can also sign up for email alerts on the website or subscribe to the podcast on Apple Podcasts or any other listening platform, so you will be the first to hear about new episodes. Thank you for listening and good luck to you, making the world a better place by helping one child at a time.

00:34:20 TH: Ok ready?

00:34:22 RK: Bap, bap bap, yes.

00:34:23 TH: Ok you’re ready. Let’s lock the door just in case. I always worry someone’s gonna bust in.