Applying the updated MRC framework for developing and evaluating complex interventions with integrated implementation conceptual knowledge: an example using NeuroRehabilitation OnLine

Abstract

Background: The updated 2021 UK Medical Research Council (MRC) Framework offers a valuable guide for implementation scientists to navigate the challenges of the development and evaluation of complex interventions. However, despite extensive citations, there is limited evidence of how the MRC Framework has been used in its entirety and limited integration with relevant implementation conceptual knowledge. To address this, we demonstrate the application of the updated MRC Framework 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 the 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 the feasibility of NROL through concurrent implementation and evaluation. Phases are described in two iterations: within a single service and then when scaled up as a regional innovation. Stakeholders were involved throughout. Implementation strategies were identified using the CFIR-Expert Recommendations for Implementing Change (CFIR-ERIC) matching tool. Proctor's implementation outcomes were selected for the evaluation.

Results: The MRC Framework provided a useful structure when applied iteratively to address key uncertainties for implementation. Stakeholder co-production was integral to all phases, in both 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. Logic Models were co-produced and iterated to depict programme theory and formalise the integration of implementation conceptual knowledge.

Conclusion: Synergistic in nature, the MRC Framework benefitted the conceptualisation of implementation through the use of its phases, and implementation science knowledge was useful in enacting the core elements within the MRC Framework. This example of application will be directly relevant to the field of rehabilitation and build transferable knowledge to enrich implementation research and practice.

Keywords: ERIC strategies; Proctor's outcomes; context; determinant framework; implementation research logic model; rehabilitation; scale-up; sustainability.

Figure 1

“Updated MRC Framework for developing and evaluating complex interventions”. Context, any feature of the circumstances in which an intervention is conceived, developed, evaluated, and implemented; programme theory, describes how an intervention is expected to lead to its effects and under what conditions—the programme theory should be tested and refined at all stages and used to guide the identification of uncertainties and research questions; stakeholders, those who are targeted by the intervention or policy, involved in its development or delivery, or more broadly those whose personal or professional interests are affected (that is, who have a stake in the topic)—this includes patients and members of the public as well as those linked in a professional capacity; uncertainties, identifying the key uncertainties that exist, given what is already known and what the programme theory, research team, and stakeholders identify as being most important to discover—these judgments inform the framing of research questions, which in turn govern the choice of research perspective; refinement, the process of fine tuning or making changes to the intervention once a preliminary version (prototype) has been developed; economic considerations, determining the comparative resource and outcome consequences of the interventions for those people and organisations affected. Reproduced with permission from “Framework for developing and evaluating complex interventions” by Skivington et al., licensed under CC BY 4.0.

Figure 2

Advanced MRC Framework. Overview of the application of an advanced MRC Framework, showing two iterations: as a single-service intervention and regional multi-service innovation for NROL, NeuroRehabilitation OnLine. Advancements to the updated MRC include a sustainment phase. Integrated implementation conceptual knowledge includes ERIC, CFIR, and IRLM.

Figure 3

NROL Logic Models. Co-produced logic models showing two iterations: as a single-service intervention (a) and regional multi-service innovation (b). NROL, NeuroRehabilitation OnLine; NHS, National Health Service; CFIR, Consolidated Framework for Implementation Research; ERIC, Expert Recommendations for Implementing Change; SOP, standard operating procedure; SSNAP, Sentinel Stroke National Audit Programme.