Synthesising theoretical frameworks in practice

Background: Despite the rapid advances in genomic medicine, few studies incorporate implementation science theoretical frameworks, focussed on macro-level factors, or attempt to develop evidence-based strategies for enhancing implementation. While experiential learning has its place, using theory can reduce the time required for implementation, identify generalisable implementation strategies and encourage widespread learning. However, identifying a theoretical framework that accounts for multiple levels of change is challenging. As synthesis becomes more complex, combining frameworks may be beneficial. The implementation of genomics in Australia is an exemplar case. As a pre-cursor to targeted intervention development, we examined individual clinician-level behaviours alongside broader influences on service provision to identify factors affecting implementing genomics in the clinical setting. Methods: Working with Australian Genomics and Melbourne Genomics, we interviewed 37 people with experience of genomics in clinical practice: i) non-genetic medical specialists, using the Theoretical Domains Framework (TDF), and process mapping to examine behaviour within four target behaviour areas: Ensuring appropriate patients receive genomic testing, Test ordering and interpretation, Providing results to patients, and 'Mainstreaming' care; and ii) service level decision-makers using the Translation Science to Impact (TSci) framework phases: Preadoption, Adoption, Implementation and Sustainability. Ethical review was provided by Melbourne Health (HREC/13/MH/326). Aligned with the TDF, the COM.B model facilitates the identification of barriers and enablers according to Capability, Opportunity and Motivation. Combining the TDF and TSci allows the development of intervention design using matched Behaviour Change Techniques (BCTs) across all phases of implementation for different aspects of the genomic testing process. Findings: The interviewees identified the need for agile knowledge gathering (opportunity) and infrastructure to support the evolving genomic knowledge base (capability). Clinicians focused on getting ‘hands on’ experience (capability) and developing corporate knowledge (motivation). At a service level the concept of ‘value’ (motivation) and organisational focus on day-to-day care (opportunity) were prominent themes. Implications for D&I Research: This study demonstrates the need to select frameworks that enable assessment of factors affecting implementation at an individual level that cover the entire implementation process and incorporate service/organisational factors. Our approach shows that in complex settings, a combination of frameworks can be harnessed to facilitate implementation.