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“Rational Refusal,” a missed opportunity to look at a broader definition of successful (non)implementation

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For many years, we have generally assumed that evidence-based practices should be implemented across all settings where they can possibly be delivered.  Indeed, many of our implementation trials have posited that among the sample of clinical or community settings that would receive an implementation strategy to support the integration of a specific intervention, the closer to full implementation across all sites that the strategy would yield, the better off science and practice would be.

Amidst a new year of resolutions, let us explore resolving the following: 100% implementation may be too high.  There are a multitude of reasons why interventions do not fit the practice settings to which they are targeted, be it culture, climate, structure, resources, population need, or any other factor affecting the fit between the intervention and the local context.  While many of our implementation strategies seek to overcome these barriers and promote implementation, to what degree are we allowing for the circumstances in which the mismatch is too great and should not be overcome?  We have already seen a similar field start to grow, that of “de-implementation,” where decisions to cease specific practices may augment our understanding of the ongoing fit within service settings.

Here, we inject a new term—“rational refusal,” the idea that there are certain circumstances through which the decision not to implement is arguably the right one, in many cases a response to the factors listed above.  We have often assumed, by and large, that a decision not to implement is going against the rationality of the evidence that supports its use.  Rational refusal suggests that evidence-based decision-making may indeed result in implementation rates lower than full saturation. 

The shift argued here is that success of implementation strategy may be more complicated than the question of whether a practice was implemented; it may be that success is related to the ability of a local site to determine, based on all evidence, whether a sufficient benefit will occur from implementation, given the range of characteristics of interventions, practices, and stakeholders within.  If implementation strategy is defined in this broader way, we may have strategies that are wise enough to support where “rational refusal” is the optimal decision.

This concept would greatly benefit from the wisdom of our research, practice and policy communities.  We are interested in your views of whether there is salience to this notion of “rational refusal,” whether there may be helpful scientific questions that push us to consider optimal levels of implementation for given practices, and whether decision-support tools may pave the way for improved decision-making across all manners of implementation science outcomes. Take part in the discussion below.