Editorial: Clinical implementation to optimise outcomes for people with brain conditions

While clinical implementation has received greater focus over recent years, there are still crucial gaps and inefficiencies in the time taken and rigour with which evidence is translated into clinical practice to optimise outcomes for people with brain conditions. It is often said that it takes an average of 17 years between generating new evidence and implementing that into practice (Morris et al. 2011). Some have questioned the accuracy of the 17-year figure – for example, there are variable definitions used to determine when implementation has occurred – but whether the time is 17 years or half that, it is too long for people with brain conditions to wait to access the best available care and support. Additionally, if we fail to implement interventions that we know are effective, we are wasting the enormous time and resources required to collect that evidence in clinical trials.

There are a range of issues underpinning this implementation problem. The conceptualisation or delivery method of the assessment, intervention, resource, or service model may not be fit for purpose for the clinical or cultural context. Related to this, relevant stakeholders – including people with lived experience of brain conditions, clinicians and service funders – are often not genuinely or purposefully included in the design of the implementation process. When it does occur, implementation is often done without guidance from a theory or framework. This is exacerbated by the lack of clear clinical competency frameworks and training methods to ensure clinicians are delivering the assessment or intervention technique effectively (Wong et al. 2023). Commonly, there are inconsistencies between the delivery of a technique in research and how it used in practice. Finally, low-resource settings or marginalised populations are often overlooked and under-served in research, particularly our Aboriginal and Torres Strait Islander populations. The processes of culturally secure translation and knowledge exchange need to be better understood to ensure clinical implementation meets the needs of these populations.

The papers included in this collection serve as instructive examples on how these issues can be addressed to optimise clinical implementation in our field. The collection commences with two studies that seek to understand barriers and facilitators to support for the needs of children with acquired brain injury (Keetley et al. 2024; Knight et al. 2024). These studies exemplify the use of systematic approaches from the outset to inform and plan for intervention development and implementation, aiming to optimise a smooth transition from research to practice. Similarly, Drake et al. (2024a) determined the adaptations required to an existing digital education resource for the Australian context to increase the likelihood of a successful implementation. Several of the studies showed the value of including clinician and lived experience perspectives throughout the knowledge-to-action cycle. Three studies (Carminati et al. 2024; Drake et al. 2024b; Hwang et al. 2024) co-designed resources, interventions and implementation strategies with key stakeholders including clinicians and people with lived experience, ensuring they are fit for purpose for the context of the planned implementation. Authentic engagement with clinicians and service managers (‘change champions’) was recognised by several authors as a critical component for sustainable changes in clinical practice. Health professional perspectives were collected by Ingram et al. (2024) to inform best practice in post-stroke coordinated discharge planning. The development of a clinician competency framework to guide stroke clinicians providing stroke care in aphasia rehabilitation (Baker et al. 2024) provides important guidance in the implementation of effective clinical service delivery. Trevena-Peters et al. (2024) describe training methods used to upskill occupational therapists in providing evidence-based activities of daily living (ADL) retraining for individuals with traumatic brain injury (TBI), highlighting the importance of training clinicians to deliver best practice. Wheatcroft et al.’s (2024) study exemplifies the a priori use of implementation theory to guide practice change in occupational therapists’ cognitive assessments. Cubis et al. (2024) show how a clear implementation framework can inform policies necessary to meet the housing support needs of people with multiple sclerosis. Finally, and importantly, Drew et al. (2024) outline the processes followed to ensure culturally safe translation of their Healing Right Way program for Aboriginal people with brain injury.

The implementation initiatives reported in this special collection cover a variety of interdisciplinary clinical processes and services as well as specific assessment and intervention techniques for people with a variety of brain conditions. Clinical processes and services include goal setting (Knight et al. 2024), discharge planning (Ingram et al. 2024), rehabilitation for Aboriginal people with brain injury (Drew et al. 2024), school participation (Keetley et al. 2024), education provision (Drake et al. 2024a), peer support video resources (Drake et al. 2024b) and housing support (Cubis et al. 2024). Specific assessments and interventions include cognitive assessment (Wheatcroft et al. 2024), ADL retraining (Trevena-Peters et al. 2024), assessment and support for sexual dysfunction (Hwang et al. 2024), psychological support for people with aphasia (Baker et al. 2024) and positive behaviour support (Carminati et al. 2024). While some of these studies focused on implementing already-developed interventions into practice, many focused on identifying barriers and facilitators, developing new interventions or adapting existing programs or interventions. These efforts to plan for implementation lay the groundwork for future successful translation of processes and interventions into practice.

A common limitation seen in implementation research is the failure to draw on implementation models as guiding frameworks (instead retrofitting models to explain findings at study completion). The use of theories, models and frameworks to identify behavioural determinants (commonly identified as barriers and facilitators) is known to be crucial. Nearly a decade ago, Nilsen (2015) proposed a taxonomy of five categories of theories used in implementation science: process models, determinant frameworks, classic theories, implementation theories and evaluation frameworks. While evaluation frameworks may be applied at the completion of an implementation program, process models (including the Knowledge-to-Action Framework, as applied by several studies in the collection), determinant frameworks (including the Theoretical Domains Framework (TDF), which was the most commonly applied framework in the collection), classic theories (including the Social Cognitive Theory and the Theory of Diffusion) and implementation theories (including the Capability, Opportunity, Motivation and Behaviour (COM-B) theory, as applied in several studies, usually in combination with the TDF) are all suitable options to guide the implementation research from inception. A priori use of a framework or theory supports the researcher to hypothesise a relationship between potential determinants and enables the design and execution of implementation strategies to change behaviour within a clinical service. Such use of theory should not be seen as an afterthought for publication but rather as a key first step in any implementation study.

We hope that these papers inspire and guide the successful implementation of evidence-based practice to optimise outcomes for children and adults with brain conditions. To do so requires us to connect, communicate, collaborate and advocate. With this intention, we conclude with a call to action to researchers, clinicians, services, funders and policymakers.