实施科学知识的实施：研究-实践差距悖论

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The challenges in improving health care are considerable, as are the efforts made to develop and deliver best practice (Grol, Wensing, Eccles, & Davis, 2013). Different interventions with evidence of effectiveness are continuously made available for potential improvement of health care. However, the difficulties in implementing and using such evidence are well known (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). The knowledge-practice gap in health care refers to the gap between scientific knowledge and its application in routine healthcare practice.

Implementation science has developed in the 2000s in response to this gap, with the ambition to generate knowledge to promote a better uptake of evidence for improvements in the quality and safety of health care. The body of implementation knowledge comprises a rapidly growing amount of empirical studies as well as countless theories, frameworks, and models, contributing to an understanding of factors associated with successful implementation of evidence-based interventions within a variety of settings (Tabak, Khoong, Chambers, & Brownson, 2012).

The multitude of empirical implementation studies, as well as theories, models, and frameworks developed in implementation science, reflect a growing evidence-based concerning implementation (Brownson, Colditz, & Proctor, 2018). However, despite the rapid progress of implementation science, the knowledge-practice gap in health care is still substantial, as shown in studies that describe difficulties in achieving desirable change in healthcare practice. Low rates of adoption and limited use of evidence-based interventions are persistent problems. Thus, the challenges of reducing the knowledge-practice gap still remain after more than two decades of research.

The aim of this editorial is to address the knowledge-practice gap by means of increasing awareness of a parallel knowledge-practice gap (i.e., the somewhat paradoxical gap between scientific knowledge concerning implementation and actual real-life implementation and use of this knowledge in healthcare practice).

This editorial is based on findings and conclusions presented in a doctoral thesis by the first author, which investigated the resemblance between available scientific knowledge on implementation and implementation strategies used in healthcare practice in three large improvement efforts in Sweden (Westerlund, 2018). An overall conclusion of the thesis was that there exists a parallel knowledge-practice gap between scientific knowledge on implementation and the use of this knowledge in implementation efforts in healthcare practice (Westerlund, 2018; Westerlund et al., 2017). The findings showed that implementation knowledge was not transferred to healthcare practice (and practitioners) to a sufficient extent, thus restricting the systematic use of implementation knowledge in practice.

Implementation science has a twofold aim: to produce knowledge sufficiently generalizable to contribute to scientific knowledge accumulation and to produce knowledge applicable for improved practice (Fixsen, Blase, & Van Dyke, 2019). The question of use, applicability, and impact of implementation science has been highlighted previously, and the need to make implementation science knowledge more relevant and widely disseminated has been called for in the literature (Armson, Roder, Elmslie, Khan, & Straus, 2018; McIsaac et al., 2018). Implementation knowledge is not taught in healthcare practitioners’ basic training and only seldom in continuing professional education. Although the literature on evidence-based implementation is expanding and courses are increasingly being made available, these do not focus on practical issues or guidance on how to actually use implementation science knowledge in implementation endeavors (Nilsen, Neher, Ellström, & Gardner, 2017). Ovretveit, Mittman, Rubenstein, and Ganz (2017) have noted that healthcare practitioners are not expected to be knowledgeable about implementation science.

Although implementation science is widely considered an applied science, the extent to which knowledge produced in this field is actually used by practitioners is not known. There are few empirical studies concerning if or how scientific knowledge on implementation is being used in healthcare practice (Armson et al., 2018). As implementation researchers, we need to ask ourselves if our research findings and evidence on implementation have reached the world of practice to a sufficient degree.

There are many analytical tools aimed at supporting researchers’ use of implementation science in their research endeavors (Simpson et al., 2013). When approaching the implementation knowledge field, phrases such as the following are frequently encountered:“Theories and frameworks enhance implementation research” and”inform study design and execution” (Tabak et al., 2012, p. 6) or“Scholars seeking to study implementation have over 60 conceptual frameworks to guide their work” (Birken et al., 2017, p. 2). The impression is that models and frameworks are developed to“help advance implementation science” (Damschroder et al., 2009, p. 2). Recently, the ImpRes tool was developed with the stated purpose to“support research teams in the process of designing implementation research” (King's Improvement Science, 2018, p. 1). These observations raise the questions of whether other researchers are the primary target audience of implementation science knowledge and the extent to which the knowledge produced in the field actually reaches beyond academia. To a large extent, knowledge produced in implementation science still seems to belong to the scientific community rather than practitioners to improve outcomes in health care (Armson et al., 2018; Ovretveit et al., 2017; Westerlund, 2018).

Considering the vast amount and variation of empirical studies of implementation efforts in many different healthcare settings, there is no question that the field of implementation science has produced knowledge on implementation of great relevance for potential use in health care. It seems highly plausible that a conscious and systematic use of scientific knowledge on implementation would be beneficial in change efforts in health care and would likely increase adoption and use of research-informed interventions to improve the quality of care. Hence, applying scientific knowledge on implementation in healthcare practice may help bridge the knowledge-practice gap in health care.

So-called”action models” such as Knowledge-to-Action (Graham et al., 2006) and Quality Implementation Framework (QIF; Meyers, Durlak, & Wandersman, 2012) have been developed to guide the translation of research into practice. The originators of the QIF introduced the concept of”practical implementation science,” which refers not only to the translation of implementation science knowledge into user-friendly resources but also to research and actions based on this translation. Meyers and colleagues stated that one of their goals was to”outline practical implications for improving future implementation efforts in the world of practice” (Meyers, Durlak, et al., 2012, p. 464). Deriving from the QIF, Meyers and colleagues developed what they referred to as a”practical implementation tool” and the Quality Implementation Tool. The aim was to assist practitioners and those providing support to practitioners in implementing interventions with better quality (Meyers, Durlak et al., 2012; Meyers, Katz et al., 2012). However, efforts like these with the explicit goal of narrowing the gap between the science and practice of implementation may not be sufficiently practice-friendly or ready to use. We do not know this because studies regarding their utility and usability do not exist.

In many ways, making use of implementation science knowledge could be viewed as an important implementation strategy with the potential to reduce the knowledge-practice gap in health care. However, studies are needed to explore and assess this assumption. We strongly recommend research efforts focusing on further development of the concept of”practical implementation science.” There is a need for research on the applicability and use of models and frameworks as well as additional focus on the question of how to develop and evaluate more user-friendly tools.

The rapidly growing body of evidence for implementation has the potential to bridge the knowledge-practice gap in health care. However, implementation science knowledge is still predominantly in the domain of researchers. For knowledge on implementation to facilitate bridging the knowledge-practice gap, it needs to be translated to user-friendly tools that are actually used by healthcare practitioners.

With this editorial, we hope to have raised awareness of the need for the implementation science society to reflect upon the question of how we can support the systematic use of implementation science knowledge among leaders and other practitioners in healthcare settings.

Implementation science was born out of a desire to bridge the knowing-doing gap (i.e., the gap between what is known and what is actually done in health care). It is a paradox if the knowledge produced in this field fails to reach the world of practice. For the practice of implementation to be furthered, we as researchers have an obligation to contribute to improved utilization and translation of the knowledge produced in the implementation science field.

全文翻译（仅供参考）

改善医疗保健的挑战是相当大的，开发和提供最佳实践的努力也是如此（Grol、Wensing、Eccles 和 Davis，2013 年）。不断提供具有有效性证据的不同干预措施，以潜在地改善医疗保健。然而，实施和使用这些证据的困难是众所周知的（Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004）。医疗保健知识-实践差距是指科学知识与其在日常医疗保健实践中的应用之间的差距。

为了应对这一差距，实施科学在 2000 年代得到了发展，其雄心是产生知识以促进更好地吸收证据以改善医疗保健的质量和安全。实施知识体系包括数量迅速增长的实证研究以及无数的理论、框架和模型，有助于理解与在各种环境中成功实施循证干预相关的因素（Tabak、Khoong、Chambers） , & 布朗森, 2012 )。

大量实证实施研究，以及实施科学中开发的理论、模型和框架，反映了越来越多的基于证据的实施（Brownson、Colditz 和 Proctor，2018 年）。然而，尽管实施科学取得了快速进展，但医疗保健领域的知识与实践差距仍然很大，如描述在医疗保健实践中实现理想变革的困难的研究所示。采用率低和循证干预措施使用有限是长期存在的问题。因此，经过二十多年的研究，缩小知识与实践差距的挑战仍然存在。

这篇社论的目的是通过提高对平行的知识-实践差距的认识来解决知识-实践差距（即，关于实施的科学知识与实际现实生活实施和在医疗保健中使用这些知识之间有些矛盾的差距实践）。

这篇社论基于第一作者在博士论文中提出的发现和结论，该论文调查了在瑞典的三项大型改进工作中，现有的实施科学知识与医疗实践中使用的实施策略之间的相似之处（Westerlund，2018 年）。论文的总体结论是，在实施的科学知识与在医疗实践的实施工作中使用这些知识之间存在平行的知识-实践差距（Westerlund，2018 年；Westerlund 等人，2017 年））。研究结果表明，实施知识没有充分转移到医疗实践（和从业者），从而限制了实施知识在实践中的系统使用。

实施科学有双重目标：产生足够普遍化的知识以促进科学知识的积累，并产生适用于改进实践的知识（Fixsen、Blase 和 Van Dyke，2019 年）。实施科学的使用、适用性和影响问题之前已经强调过，文献中呼吁需要使实施科学知识更加相关和广泛传播（Armson、Roder、Elmslie、Khan 和 Straus，2018 ; McIsaac 等人，2018 年）。实施知识在医疗从业人员的基础培训中不传授，也很少在继续专业教育中教授。尽管有关基于证据的实施的文献正在扩大，而且课程越来越多，但这些文献并不关注实际问题或关于如何在实施工作中实际使用实施科学知识的指导（Nilsen、Neher、Ellström 和 Gardner，2017 年） . Ovretveit、Mittman、Rubenstein 和 Ganz（2017 年）指出，医疗保健从业者不应该了解实施科学。

尽管实施科学被广泛认为是一门应用科学，但从业者实际使用该领域知识的程度尚不清楚。关于是否或如何在医疗保健实践中使用有关实施的科学知识的实证研究很少（Armson 等人，2018 年）。作为实施研究人员，我们需要扪心自问，我们的研究结果和实施证据是否已充分触及实践领域。

有许多分析工具旨在支持研究人员在他们的研究工作中使用实施科学（Simpson et al., 2013）。在接近实施知识领域时，经常会遇到以下短语：“理论和框架增强实施研究”和“为研究设计和执行提供信息”（Tabak et al., 2012 , p. 6）或“寻求研究的学者”实施有 60 多个概念框架来指导他们的工作”（Birken 等人，2017 年，第 2 页）。给人的印象是，开发模型和框架是为了“帮助推进实施科学”（Damschroder et al., 2009，页。2）。最近，ImpRes 工具的开发目的是“在设计实施研究的过程中支持研究团队”（King's Improvement Science，2018 年，第 1 页）。这些观察提出了其他研究人员是否是实施科学知识的主要目标受众以及该领域产生的知识实际上超出学术界的程度的问题。在很大程度上，实施科学产生的知识似乎仍然属于科学界，而不是从业者，以改善医疗保健的结果（Armson 等人，2018 年；Ovretveit 等人，2017 年；Westerlund，2018 年）。

考虑到在许多不同的医疗保健环境中实施工作的经验研究的数量和变化，毫无疑问，实施科学领域已经产生了与医疗保健潜在用途密切相关的实施知识。有意识和系统地使用有关实施的科学知识将有利于医疗保健的变革努力，并且可能会增加采用和使用以研究为依据的干预措施以提高护理质量，这似乎是非常合理的。因此，在医疗保健实践中应用科学知识可能有助于弥合医疗保健中的知识与实践差距。

所谓的“行动模型”，例如知识到行动（Graham et al., 2006）和质量实施框架（QIF; Meyers, Durlak, & Wandersman, 2012）已经被开发出来，以指导将研究转化为实践。QIF 的发起者引入了“实用实施科学”的概念，它不仅指将实施科学知识转化为用户友好的资源，还包括基于这种转化的研究和行动。Meyers 及其同事表示，他们的目标之一是“概述在实践世界中改进未来实施工作的实际意义”（Meyers, Durlak 等人，2012，页。464）。在 QIF 的基础上，Meyers 及其同事开发了他们所谓的“实用实施工具”和质量实施工具。目的是帮助从业者和为从业者提供支持的人以更高质量实施干预措施（Meyers, Durlak et al., 2012 ; Meyers, Katz et al., 2012）。然而，像这样的明确目标是缩小科学和实施实践之间的差距的努力可能不够实践友好或准备好使用。我们不知道这一点，因为不存在关于它们的实用性和可用性的研究。

在许多方面，利用实施科学知识可以被视为一项重要的实施策略，具有缩小医疗保健知识-实践差距的潜力。然而，需要研究来探索和评估这一假设。我们强烈建议着眼于进一步发展“实践实施科学”概念的研究工作。有必要对模型和框架的适用性和使用进行研究，并额外关注如何开发和评估更用户友好的工具的问题。

快速增长的实施证据有可能弥合医疗保健领域的知识与实践差距。然而，实施科学知识仍然主要存在于研究人员的领域。对于有助于弥合知识实践差距的实施知识，需要将其转化为医疗保健从业者实际使用的用户友好型工具。

通过这篇社论，我们希望提高对实施科学学会的认识，以反思我们如何支持在医疗机构的领导者和其他从业者中系统地使用实施科学知识的问题。

实施科学诞生于弥合知行差距的愿望（即，在医疗保健中已知与实际所做之间的差距）。如果该领域产生的知识未能到达实践世界，那就是一个悖论。为了进一步推动实施实践，我们作为研究人员有义务为改进实施科学领域产生的知识的利用和转化做出贡献。

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