Advancing the updated MRC Framework for developing and evaluating complex interventions with integrated implementation conceptual knowledge: An example using NeuroRehabilitation OnLine (NROL)

Abstract

Background Implementation involves complex interventions, hence the updated Medical Research Council (MRC) framework for developing and evaluating complex interventions (2021) is one approach implementation scientists could use to guide their research. However, despite extensive citations, there is limited evidence of how it has been used in its entirety and little integration with relevant implementation conceptual knowledge. To address this, we provide a novel example of using the updated MRC framework, uniquely demonstrating the potential for incorporating implementation science frameworks, strategies and outcomes. This example uses a telerehabilitation intervention, NeuroRehabilitation OnLine (NROL), implemented within an existing healthcare system. Methods Within a clinical-academic partnership we completed the MRC Framework checklist, and context was described using the updated Consolidated Framework for Implementation Research (CFIR). We used a deliberative process to operationalise the MRC phases: adaptation of NROL based on the ADAPT guidance and establishing feasibility of NROL through concurrent implementation and evaluation. Phases are described in two iterations: within a single service, then when scaled-up as a regional innovation. Stakeholders were involved throughout. Implementation strategies were identified using the CFIR-ERIC matching tool. Selected Proctor’s implementation outcomes were evaluated. Results The MRC framework provided a useful structure when applied iteratively to address key uncertainties for the implementation, and considerations for sustainability, of the complex intervention NROL. Context description was crucial for phase-specific considerations across iterations. An additional sustainment phase was added to the framework, reflecting that the value proposition discussions with decision-makers inevitably culminated in decision-points. This guided decision-making for NROL to be scaled-up. Implementation Research Logic Models were co-produced and iterated to depict programme theory and formalise integration of implementation conceptual knowledge. Conclusion We provide a novel example of the application of the updated MRC framework being described in full, and to our knowledge is the first to comprehensively integrate implementation conceptual knowledge. Synergistic in nature, the MRC framework benefitted the conceptualisation of implementation through use of its phases, and implementation science knowledge was useful in enacting the core elements within the MRC framework. In this example, we emphasised sustainability throughout and include a distinct ‘Sustainment’ phase to advance the MRC framework.