Introduction
Healthcare systems worldwide face mounting pressure to care for aging populations with complex care needs, amid existing challenges with workforce shortages and resource constraints across the care continuum from acute, community-based care and long-term care settings (Martin & Knowles, Reference Martin and Knowles2020). Despite extensive research demonstrating the importance and benefits of person-centred, integrated, coordinated, and holistic approaches for older adults, organizations continue to struggle with implementing and sustaining these models (Horgan, Reference Horgan2020). International implementation science literature has identified multiple factors that influence the successful adoption of evidence-based innovations in healthcare settings. These include intervention characteristics, such as the adaptability of care models to local contexts (Boustani et al., Reference Boustani, Alder and Solid2018); organizational elements, including leadership support and resource allocation (Estabrooks et al., Reference Estabrooks, Song, Anderson, Beeber, Berta, Chamberlain, Cummings, Duan, Hayduk, Hoben, Iaconi, Lanham, Perez, Wang and Norton2022); and external influences, such as political landscapes and policy frameworks (Brownson et al., Reference Brownson, Kumanyika, Kreuter and Haire-Joshu2021). When it comes to healthcare for older adults, these factors do not operate within discrete care sectors; rather, they manifest at multiple scales from local to national, and across the full continuum – from acute care, home and community-based care, and facility-based long-term care (McArthur et al., Reference McArthur, Bai, Hewston, Giangregorio, Straus and Papaioannou2021). Older adults’ care trajectories similarly routinely cross organizational and sectoral boundaries, fostering structural and fiscal impediments to research development, uptake, and translation (Ellen et al., Reference Ellen, Panisset, de Carvalho, Goodwin and Beard2017; McArthur et al., Reference McArthur, Bai, Hewston, Giangregorio, Straus and Papaioannou2021). It is also important to note that home and community-based care and support services, though highly critical for seniors’ health, are generally given insufficient weight or consideration when it comes to transformative system change and innovation (Clavet et al., Reference Clavet, Hebert, Michaud and Navaux2022; Giosa et al., Reference Giosa, Saari, Holyoke, Hirdes and Heckman2022; Johnson et al., Reference Johnson, Bacsu, Abeykoon, McIntosh, Jeffery and Novik2018).
Implementation Science (IS) is the scientific study of methods and strategies that facilitate the uptake of evidence-based practices and research findings into regular use by practitioners and policymakers (Eccles & Mittman, Reference Eccles and Mittman2006; Keith et al., Reference Keith, Crosson, O’Malley, Cromp and Taylor2017). Our research focuses on identifying specific facilitators and approaches for research uptake toward improving integrated care delivery and outcomes for older adults (Ellen et al., Reference Ellen, Panisset, de Carvalho, Goodwin and Beard2017; Sadler et al., Reference Sadler, Sandall, Sevdalis and Wilson2018). Drawing on tested IS approaches, the Consolidated Framework for Implementation Research (CFIR) is a conceptual framework that provides a comprehensive theoretical foundation for systematically assessing and understanding how multilevel contextual variables interact and influence research evidence uptake and implementation success (Damschroder et al., Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery2009; Keith et al., Reference Keith, Crosson, O’Malley, Cromp and Taylor2017). While research has illuminated various contextual factors, a critical knowledge gap remains in understanding which ones are most important, and how factors either facilitate or hinder evidence-based implementation practices, particularly in seniors’ healthcare (Brazil et al., Reference Brazil, Walshe, Doherty, Harding, Preston, Bavelaar, Cornally, Di Giulio, Gonella, Hartigan, Henderson, Kaasalainen, Loucka, Sussman, Vlckova, van der Steen, Achterberg, Visser, Fitzgerald and Dening2024; Sadler et al., Reference Sadler, Sandall, Sevdalis and Wilson2018). Healthcare organizations struggle with varying research cultures across care settings, compounded by high leadership turnover rates that disrupt institutional memory and relationship continuity (Adjognon et al., Reference Adjognon, Shin, Steffen, Moye, Solimeo and Sullivan2021). They also face fragmented systems that impede information flow, variable levels of collaboration and continuity of care (Kokorelias et al., Reference Kokorelias, Gould, DasGupta, Cass and Hitzig2022), and resource constraints that limit uptake and engagement in research partnerships (Adjognon et al., Reference Adjognon, Shin, Steffen, Moye, Solimeo and Sullivan2021; Bowen et al., Reference Bowen, Botting, Graham, MacLeod, de Moissac, Harlos, Leduc, Ulrich and Knox2019; Corry et al., Reference Corry, Carter, Doyle, McGlade, O’Halloran, Wallace and Brazil2022). Human resource challenges, evident across all health sectors, are especially significant in long-term care as made visible by COVID-19 (Estabrooks et al., Reference Estabrooks, Song, Anderson, Beeber, Berta, Chamberlain, Cummings, Duan, Hayduk, Hoben, Iaconi, Lanham, Perez, Wang and Norton2022; Smith & Johnson, Reference Smith and Johnson2023). Specific to palliative care, but likely extending to other areas, Collingridge Moore et al. (Reference Collingridge Moore, Payne, Van den Block, Ling, Froggatt, Gatsolaeva, Honinx, Pivodic, Miranda, Onwuteaka-Philipsen, van Hout, Pasman, Oosterveld-Vlug, Ten Koppel, Piers, Van Den Noortgate, Engels, Vernooij-Dassen, Hockley and Wichmann2020) argued that every intervention implemented and studied benefits from its own targeted implementation strategy, but cautioned that the specific strategies employed are generally not well documented or reported in the literature.
Beyond conditions and circumstances in the local context, the macro scale of the Canadian healthcare environment can be problematic for IS given its highly decentralized nature. Although the federal government provides funding to provinces through the Canada Health Transfer, provinces and territories are responsible for administering and delivering healthcare services within their own jurisdictions (Canadian Institute for Health Information, 2011). The result is high levels of variation in healthcare administration across the country. Within this varied large scale administrative landscape, implementation success requires navigating complex stakeholder networks of older adults, families, and multiple care providers across the continuum (acute, home and community-based, and long-term care) at the local scale (Di Pelino et al., Reference Di Pelino, Lamarche, Carr, Datta, Gaber, Oliver, Gallagher, Dragos, Price and Mangin2022). Recent studies highlight how siloed decision-making hinders cross-sectoral collaborations between health and housing for example, in the context of holistic person-centred care delivery (Flynn et al., Reference Flynn, Mrklas, Campbell, Wasylak and Scott2021; Smith & Johnson, Reference Smith and Johnson2023). In addition, regulatory frameworks often impede innovative, personalized approaches to specialized senior care (e.g., dementia) (Kothari et al., Reference Kothari, Boyko, Conklin, Stolee and Sibbald2015; Lalani et al., Reference Lalani, Fernandes, Fradgley, Ogunsola and Marshall2019).
The primary goal of our study was to understand how health-focused organizations take up research evidence to support integrated healthcare for older adults (Boustani et al., Reference Boustani, Alder and Solid2018; Flynn et al., Reference Flynn, Mrklas, Campbell, Wasylak and Scott2021). Addressing current knowledge-to-action implementation challenges for seniors’ healthcare innovation requires attention to both evidence uptake enablers and principles, and care delivery transformation lessons from real-world contexts. Informed by an extensive review of the IS literature, we draw on in-depth interviews with experts in seniors’ healthcare implementation and systems change to investigate the following research question: What practical approaches and strategies should healthcare organizations and policymakers employ to enhance evidence uptake and care delivery for improved healthcare for older adults?
Methods
Study design
We employed a qualitative research design using semi-structured expert interviews, guided by IS frameworks, notably CFIR (CFIR, 2023; Damschroder et al., Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery2009), and, to a lesser extent, the Standards for Reporting Implementation Studies (StaRI-65) (Carpenter et al., Reference Carpenter, Southerland, Lucey and Prusaczyk2022) to provide deep contextual insights into implementation facilitators and barriers. CFIR provides a comprehensive structure for examining implementation determinants across multiple organizational levels, while StaRI-65 offers guidance for reporting implementation strategies and outcomes specific to older adults in healthcare settings. Prompts were designed to elicit detailed information about implementation experiences, sensitive to the unique context of older adult care.
Research team characteristics and reflexivity
The research team comprised three academic researchers from a Canadian university (experts in gerontology, medical anthropology, nursing, and health geography), and one healthcare policy expert from the provincial health ministry. Among them, an experienced research associate was primarily responsible for data collection and analysis processes.
The team’s diverse positioning within academic and governmental organizations influenced the research process. The academic researchers’ theoretical knowledge helped frame the interview questions and initial coding structure, while policy perspectives provided crucial contextual insights for data interpretation. Through regular team meetings, members discussed the interview findings, challenged each other’s assumptions and biases, and validated the central themes for this paper.
To maintain reflexivity (Braun & Clarke, Reference Braun and Clarke2019), team members documented their perspectives throughout the research process, paying particular attention to how their institutional positions and disciplinary backgrounds might influence their interpretation of implementation challenges and opportunities. This reflexive practice helped ensure findings reflected participants’ experiences rather than researchers’ preconceptions.
Sampling strategy
Through purposive sampling, we identified 15 individuals with extensive experience in seniors’ healthcare implementation and systems change in Western Canada. The sample size and diversity reflected efforts to capture varied perspectives while ensuring analytical depth. The expert panel included ten healthcare decision-makers/leaders and five researchers with expertise in seniors’ health and implementation. Selection criteria included: (1) demonstrated experience in research uptake and mobilization; (2) leadership roles in seniors’ healthcare or relevant research areas; and (3) direct involvement in system change initiatives. The study is situated predominantly in British Columbia (BC), but includes two participants whose work was primarily conducted in Alberta. The geographic descriptor ‘Western Canada’ is used to protect the identities of a small and otherwise readily identifiable expert panel. BC delivers healthcare services through seven health authorities (five regional, two provincial), a governance structure that differs materially from Alberta’s consolidated single-authority model (Canadian Institute for Health Information, 2011). Both provinces thus represent distinct but complementary administrative contexts for examining evidence uptake and illustrate how governance structures shape – but do not determine – implementation capacity. Given the small expert panel, claims of sample diversity rest on the range of roles, sectors, and governance contexts represented rather than on numerical breadth. Participant characteristics are documented in Table 1 to allow readers to assess the composition of the sample directly.
Participant characteristics
Table 1. Long description
The table consists of six columns: I D, Province, Role/sector, Care setting, Identity, and Notes.
* D M 01 to D M 05: All are from B C, serve as Senior health-system leader/executives. D M 01, 02, 03, and 05 are in Long-term care, while D M 04 is in Home and community care. All are Disclosed.
* D M 06: From A B, Senior health-system leader/executive in Acute/system-level, Disclosed. Note: Works primarily in Alberta.
* D M 07: From B C, Senior health-system leader/executive in Long-term care, Disclosed.
* D M 08: From B C, Senior health-system leader/executive in Long-term care, Not disclosed. Note: Role generalized for confidentiality.
* D M 09: From B C, Health-system manager/director in Home and community care, Disclosed.
* D M 10: From B C, Health-system manager/director in Long-term care, Not disclosed. Note: Role generalized for confidentiality.
* R 01: From B C, Academic researcher in Long-term care, Not disclosed. Note: Role generalized for confidentiality.
* R 02: From B C, Academic researcher in Home and community care, Not disclosed. Note: Role generalized for confidentiality.
* R 03: From B C, Academic researcher in Long-term care, Disclosed.
* R 04: From B C, Academic researcher in Home and community care, Disclosed.
* R 05: From A B, Academic researcher in Long-term care/system, Disclosed. Note: Work primarily in Alberta.
Footer notes define D M as decision-maker/leader and R as researcher.
Note. DM = decision-maker/leader; R = researcher. Province reflects the primary jurisdiction of work directly relevant to this study. Identity disclosure refers to participant consent to be named in the associated technical report; the manuscript uses coded identifiers per its anonymization protocol. Role descriptions for non-disclosing participants are generalized to protect confidentiality.
Ethical considerations
The study received approval from the University of Victoria Human Research Ethics Board (Protocol #23-0385). All participants provided informed consent. Interview recordings and transcripts were stored securely and de-identified to ensure confidentiality.
Data collection
Semi-structured interviews were conducted via Zoom between November 2023 and January 2024. The interview guide (Appendix B) was developed by the core research team, incorporating diverse academic and health policy perspectives. Interviews were 60–75 minutes in length and were recorded with participant consent. The semi-structured interview guide included four main sections: (1) participant background and experience with system change, (2) knowledge of barriers to research implementation in seniors’ care, (3) identification of facilitators of successful implementation, and (4) priority areas for future evidence-building and knowledge translation in seniors’ healthcare.
Questions progressed from descriptive (e.g., roles and experiences) to analytical (e.g., implementation barriers and facilitators) and finally to evaluative and prospective considerations (e.g., priority setting and future directions for health system change). This structure allowed participants to draw on their diverse backgrounds while ensuring coverage of key research themes. The guide included primary questions and targeted probes, offering flexibility to explore emerging topics while maintaining focus on implementation factors and system change strategies. The interviewer (Anonymized for Review) adapted questions based on participants’ self-identified roles (e.g., healthcare practitioner, decision-maker, or academic) to capture role-specific insights and experiences.
Data analysis and Interpretation
We employed a framework analysis approach (Ritchie & Spencer, Reference Ritchie, Spencer, Bryman and Burgess1994), in which a pre-existing theoretical framework structures the initial coding, while ongoing coding remains open to inductive expansion. The analytic process proceeded in four stages. First, interview transcripts, imported into NVivo 14® (QSR International, 2023), were coded deductively against CFIR domains and StaRI-65 constructs (Carpenter et al., Reference Carpenter, Southerland, Lucey and Prusaczyk2022; CFIR, 2023), which provided structures for examining implementation factors – including intervention characteristics, organizational context, and external influences – and their specificity for older adults. Second, inductive open coding was undertaken to capture emergent themes not encompassed by applying the frameworks deductively, particularly themes reflective of the Western Canadian context. Third, the lead analyst and research team refined and consolidated codes into thematic categories through iterative team discussion, resolving interpretive disagreements by returning to the data and reaching consensus. Fourth, findings from the expert interviews were systematically triangulated with findings from a concurrent literature review through parallel coding in a shared NVivo 14® project, enabling identification of convergences, divergences, and complementary insights (Shenton, Reference Shenton2004; Stahl & King, Reference Stahl and King2020).
The literature component of this triangulation strategy was a rapid, quasi-systematic review (Richter & Dixon, Reference Richter and Dixon2023) conducted with assistance from a health sciences librarian. Search strategies deployed in Google Scholar and Scopus yielded 311 abstracts for review. Following a two-stage screening process, 103 articles were retained and imported into NVivo 14® alongside the interview transcripts. Sources were classified by care setting and theoretical orientation and coded using the same CFIR- and StaRI-65 informed framework applied to the interview data, permitting direct integration of literature and interview findings within a unified analytic environment. Contrary and ancillary perspectives from the literature were retained where relevant.
Regular team meetings throughout the analysis process facilitated peer review and discussion of findings, helping to minimize individual bias in interpretation. Team members actively questioned each other’s assumptions and interpretations during these discussions, strengthening the confirmability of our findings (Shenton, Reference Shenton2004). More specifically, the lead analyst presented preliminary code structures and thematic groupings at regular intervals; team members with policy and clinical expertise challenged interpretations that appeared to privilege academic framing over practitioner realities, and vice versa. Disagreements were documented and resolved by returning to transcript excerpts and, where relevant, to the parallel literature coding. Interview transcripts were verified for accuracy by returning them to participants for review and revision if necessary (Stahl & King, Reference Stahl and King2020).
Findings
Our analysis revealed how organizations mobilize research evidence to support integrated seniors’ care. We identified three interconnected elements (context, culture, and creativity) that are crucial considerations for implementation success and that demonstrate the complex relationship between evidence uptake and care delivery transformation: (1) Context: Local Conditions and Leadership; (2) Culture: Building a Collaborative Research Environment; and (3) Creativity: Adaptive Problem-Solving under Resource Constraints. Below, we detail illustrations of these three elements and their sub-components. Academic participant perspectives are designated as R, while healthcare decision-makers and leaders are designated as DM.
The findings were influenced by the CFIR domains most strongly represented in the data: the Inner Setting (organizational culture, structural characteristics, networks, readiness for implementation, and absorptive capacity for change), the Outer Setting (external policies and incentives, political motivations, and patient needs and resources), Intervention Characteristics (evidence strength and quality, adaptability, relative advantage, complexity, and intervention source), Characteristics of Individuals (knowledge and beliefs, self-efficacy, stage of change, and personal attributes), and finally Process (engaging, implementation leaders, planning, executing, and reflecting and evaluating). The CFIR Mapping Table (Supplementary File 1), produced from NVivo 14® coding outputs, documents these attributions in full, including representative quotations for each construct. Three constructs – political motivations, community and preventive care as a priority area, and the resource adaptation paradox – extended the framework inductively and are discussed below and in the Discussion.
Context: local conditions and leadership
The findings under this theme map primarily to the CFIR Inner Setting domain (emphasizing Structural Characteristics; Networks and Communications; Readiness for Implementation) and to the CFIR Outer Setting constructs of External Policies and Incentives and Political Motivations.
Adaptability to local context
Successful implementation of research evidence requires careful adaptation to local contexts, specifically by considering local organizational dynamics, resource availability, and population needs. Healthcare leaders emphasized this complexity: ‘Every single place has different access and resources… you really need to look at each individual community and figure out what the needs are and what the gaps are’ (DM08). Making and acting on decisions requires ongoing monitoring and adjustments by multiple stakeholders, including frontline staff, organizational leaders, and research partners. According to our participants, this seemed to be particularly true in rural contexts where resources and alternatives were more limited.
Several participants highlighted the tension between maintaining research rigour and responding to local realities. One senior leader (DM06) described a project where this tension manifested clearly: ‘We had the evaluation folks involved… and they reached into knowledge services… to get information, and you know it all fed in, but it wasn’t anywhere near coordinated. It wasn’t bought into. It wasn’t successful’. These experiences reflect the CFIR construct of Complexity: the perceived difficulty of multilevel coordination across siloed units and resources. DM06 also emphasized how implementation success requires more than just technical expertise: ‘We bring in facilitators who are skilled at facilitation, but they don’t know anything about our areas or what it is we’re trying to do, or the work… you almost need to teach facilitation to people as leaders who are going to be doing some of this work in order for it to be successful’. These perspectives highlight how successful implementation requires finding ways to combine methodological expertise with deep understanding of local contexts.
Consistent leadership support
Researchers and senior decision-makers report leadership turnover as a significant challenge for research implementation. One researcher described the practical implications: ‘The healthcare system has a big turnover itself of key persons; they change all the time… Sometimes the person who provides a letter of support for a grant, and who was involved in the original conversations, is replaced by the new person’ (R05). This pattern reflects the CFIR Structural Characteristics construct, specifically team stability (or its absence) as a driver of implementation discontinuity. A senior healthcare leader (DM06) noted the difficulty of sustaining research engagement across such leadership transitions: ‘I do mentor quite a few people [e.g., in systems related matters], but not in this particular area [research]… I haven’t found people who I can mentor in the same way [i.e., bridge the two] here’. This leader suggested that protected time for mentorship itself might help address the continuity challenge, while acknowledging competing demands that make this difficult. In some jurisdictions, as noted by R05, leadership turnover is built into organizational policy: ‘sometimes it’s even a declared policy that people in certain leadership positions can’t be there longer than a year or two, and then they have to turn over’. Such a policy approach highlights the challenges arising from how organizational systems naturally function and evolve over time in ways that hamper integrated, continuous planning cycles.
When consistent leadership support is present, it can positively influence implementation outcomes in seniors’ health. One embedded researcher described their experience: ‘I believe that the reason why we were able to implement … is because the person I report to is strongly supportive of research and implementation… even when sometimes the results [of research] don’t look like they want [them] to look’ (R01). This speaks directly to the CFIR construct of Readiness for Implementation: specifically, the dimension of leadership engagement as a prerequisite for sustained implementation effort. A CEO (DM10) demonstrated this kind of active leadership engagement through regular participation in research meetings: ‘I join a fair amount on a regular basis, which they tell me is quite unusual to have the CEO as part of that group, but it’s so integral to how we drive improvement across the organization’. These insights acknowledge the value placed on research culture discussed more fully in the next section, and wide engagement within the organization, as well as maintaining the flexibility to adjust course when evaluations turn up evidence that is contrary to expectations.
Interviews also provided important insights about the relationship between formal leadership and established staff dynamics, particularly in long-term care settings. As one decision-maker explained: ‘sometimes, you can have the best leader there, and because of the nature of how staffing in long-term care works … those that have been there the longest, have the power in terms of [influencing] staff’ (DM01). This observation highlights how successful implementation depends on a leader’s ability to effectively manage dynamic relationships and integrate the wider perspectives and influence of long-term staff members within decision-making for the organization.
Healthcare leaders and researchers identified significant variation in levels of research engagement across health regions and care settings, and emphasized that successful implementation of research evidence often hinges on deliberate efforts to establish a research culture within organizational environments.
Culture: building a collaborative research environment
The findings in this second theme map primarily to the CFIR Inner Setting constructs of Culture and Absorptive Capacity for Change, and to the CFIR Process constructs of Engaging and Implementation Leaders.
Research-positive culture
Embedded researchers are formalized in some health regions through various positions. One site created a ‘learning health system facilitator’ position designed to work across ‘seniors’ health, geriatric services, [and] research innovation’ (DM03). Other health regions had established embedded research positions in specialized areas such as mental health, substance use, and cancer care (DM10).
Specialized positions combining academic research expertise with operational understanding were highly valued. As one embedded researcher (R01) explained, understanding both academic and healthcare contexts is essential for ‘connecting the dots’ between research evidence and practical implementation. A senior healthcare leader characterized the required skillset for a research culture as ‘a pie chart’, with roughly half comprising knowledge broker skills, a quarter focused on understanding organizational culture and measurement, and the remaining quarter having awareness and understanding research perspectives (DM01).
Another healthcare leader (DM07) highlighted how some specialized healthcare centres establish strong research cultures when embedded researchers are integrated into daily operations. At the same time, this leader (DM07) recognized that operational demands in health regions often take precedence over research engagement, particularly among nursing staff compared to medical staff. Other participants emphasized that sustained research engagement requires protected time for research activities. Finally, researcher R05 explained that teams can also be ‘overburdened with research’ asks, alongside administrative requirements, requiring balanced approaches and making it difficult to properly engage with and implement new evidence-based practices.
With respect to the development and sustainability of a research culture, one researcher (R05) explained the attitudes at their site: ‘They have developed a culture of being part of that kind of research and not experiencing that as a burden. Like, it’s just part of their everyday work, and “we want to be part of it,” and “we’re going to benefit from it,” and “we’re going to translate that”’.
Long-term care was sometimes singled out by participants as having additional and particular challenges. DM01 reported that ‘part of the problem is that there hasn’t been a fulsome, supported approach to developing a research culture in long-term care’. Another leader described a successful example where a researcher became an integral advisor, helping staff implement evidence-based practices until they became ‘embedded into the fabric of the organization’ (DM07).
In general, participants emphasized that implementation requires sustained commitment to relationship-building, as vocalized by one senior leader (DM01), who said relationships must be maintained ‘before, during, after, and in-between research’ projects (DM01).
Home and community-based care: an underfunded implementation priority
A theme that emerged across multiple interviews and that maps to the CFIR Outer Setting construct of Patient Needs and Resources as well as to the inductive code of community and preventive care was the persistent gap between what is known about the benefits of home- and community-based and preventive seniors’ care, and what the system invests in. Several participants clearly articulated this gap.
DM09, a long-time healthcare leader, described the systemic problem directly: the BC system has ‘lost lower-level care and preventive care altogether’ despite ample evidence of its cost-effectiveness. This participant argued that a shift toward home and community-based evidence, framed explicitly in terms of reduced acute care costs, was necessary to make research actionable for government decision-makers: ‘every little data point you look at… everywhere you triangulate it’, the case for community investment becomes compelling, yet fiscal and political history and constraints prevent government from acting on findings it formally acknowledges.
An academic researcher with sustained home care research partnerships in BC (R04) pointed to the structural difficulty of translating community care research into practice: despite 27 publications from a decade-long project with Fraser Health, it was ‘not easy to draw a direct dotted line’ from the research to specific practice changes. Privacy legislation also prevented data linkage between workers and clients – a specific Outer Setting implementation barrier – and, in combination with health authority staff turnover, meant that research relationships must be rebuilt from scratch periodically.
From a determinants of health perspective, a senior leader (DM04) elaborated on the fragmentation between housing, health, and social care funding streams that prevents a coherent home and community care system from emerging: ‘you can have subsidies, but they’re hard to integrate’. This participant described how health authorities were effectively paying for acute care bed days that could be avoided through community investment but could not redirect those funds due to siloed accountability structures. This is a concrete illustration of the CFIR Outer Setting construct of External Policies and Incentives operating as a barrier.
DM08 provided the most detailed account of successful community-based implementation, describing how investing in frailty, palliative, and transitional care services in the community reduced hospital occupancy from a sustained 115% average to approximately 95% over three years. The success was predicated on executive-level commitment, evidence-based model fidelity, integrated embedding of resources into existing community teams, and continuous monitoring and evaluation – elements spanning the CFIR Process domain constructs of Planning, Executing, and Reflecting and Evaluating.
Taken together, these perspectives establish home- and community-based and preventive care as a domain in which the evidence–practice gap is especially pronounced, and in which the implementation levers identified across the other themes are urgently needed.
Creativity: adaptive problem-solving given resource constraints
The findings in this theme map primarily to the CFIR Intervention Characteristics constructs of Adaptability, Relative Advantage, and Evidence Strength and Quality, and to the CFIR Process constructs of Engaging and Implementation Leaders.
Time and space
Participants described how implementing research evidence required navigating fundamental tensions between research and operational perspectives and directives. Time scales were emphasized as one researcher explained: ‘in research you can take two or three years to finish your research project; in the healthcare system, it needs to be fast’ (R01). Successful implementation also required establishing feedback loops between research and practice while maintaining fidelity to evidence-based principles. One researcher reflected, ‘researchers need to be aware that the system will take pragmatic steps if [they] like that or not… [Research] information is only one small piece of the puzzle to make decisions for the system’ (R05).
Resource constraints posed ongoing challenges, particularly in academic settings where relationship-building activities may not be formally recognized (R03, R04). The solution of one health region was to establish mechanisms for protected research time, recognizing that ‘there’s no such thing in healthcare as buying out time’ for research without specific infrastructure (DM07).
Several health regions have also established research offices that actively facilitate connections between academic researchers and healthcare operations (DM03, DM07). For example, one health region maintains a research office with dedicated leadership to match researchers with opportunities and ‘make all the right connections internally’ (DM10). However, systems fragmentation often hampered the effectiveness of such structures (DM01, DM07, R03). As one participant noted, ‘There’s people doing the same documentation over and over again because they can’t share information. The client is being asked to share information multiple times as well’ (DM04).
Stakeholder engagement practices
Participants emphasized the importance of inclusive engagement extending beyond organizational leadership. One senior decision-maker (DM09) described how a health region, facing budget constraints, gathered public input for their strategic plan. By prioritizing perspectives from stakeholders with lived experience in socially deprived areas, they uncovered priorities that differed significantly from local leadership’s focus on infrastructure and employment. The resulting community-informed interventions led to meaningful improvements in health outcomes.
Early engagement of stakeholders is critical, as stated by one decision-maker who criticized projects where implementers were never involved in crafting research questions or early discussions, warning that such research risks ‘sitting on the shelf’ unused (DM07). This concern aligns with the CFIR construct of Intervention Source: innovations designed in isolation from local implementation contexts, without integration of practitioner knowledge, are systematically less likely to be adopted. Multiple participants emphasized the importance of looking beyond both research silos and healthcare system perspectives to ensure inclusion of diverse stakeholder viewpoints.
Interdisciplinary team operations
Implementing person-centred, integrated seniors’ care requires careful attention to team composition and support structures (DM03). One healthcare leader emphasized that investing in staff support through administrative assistance and education is crucial, while noting the importance of embedding these resources into existing teams to build connected networks of care rather than creating siloed services (DM08). This integrated approach was cited as being particularly effective in mid-sized communities where receptiveness to healthcare relationships between complementary disciplines and settings made them easier to establish.
Implementation relationships
Interviews revealed how effective evidence uptake for care implementation depends on engaging appropriate decision-makers. As one healthcare leader emphasized, implementers need to ‘understand who the true decision maker is…it’s usually higher up the food chain than you think’ (DM04). This reflects the CFIR Process construct of Engaging: specifically, the identification of formal and informal leaders whose engagement is necessary to unlock the organizational authority and resource access required for implementation. In a different vein, a researcher (R05) described alternative implementation pathways, for example, including partnerships with advocacy organizations that can ‘exert some pressure that I never could’ while maintaining credibility with system partners.
Overall, both researchers and decision-makers (R04, R05, DM06) emphasized the necessity of sustained engagement. One cited a long-standing elder care research program that illustrated this value, noting how research questions evolved over time through input from both frontline workers and government representatives over a 20-year period (DM06).
Evidence-informed system transformation
One health region initiative that demonstrated the interplay between research evidence implementation and care delivery transformation arose in a setting where the prospect of hospital overcrowding prompted the development and implementation of evidence-based community care alternatives instead of resorting to traditional solutions like increased bed capacity (R01, DM08).
Their implementation process exemplified crucial elements previously discussed. A research-positive organizational culture and supportive leadership enabled consideration of broader, outside-the-box, evidence-based alternatives. Multiple stakeholder groups were consulted and engaged in decision-making. The transformative work was further activated and mobilized through strategic knowledge exchange mechanisms, including embedded researchers and real-time monitoring to provide continuous feedback. Contextual realities of resource constraints meant that minimal monetary investments were available to motivate system change, but the overall result showed how crucial innovative solutions, evidence uptake, and system transformation were still achieved even under difficult circumstances.
Mapping our thematic findings to the CFIR framework (Supplementary File 1), we found that the domains of Inner Setting and Process were the most prominent, followed by Intervention Characteristics, and Characteristics of Individuals. The CFIR Outer Setting, particularly external policies and incentives and political motivations, were strongly articulated, but primarily as a barrier rather than a facilitator of implementation.
Several inductive themes extended or nuanced the framework: the identification of home- and community-based and preventive care as a chronically underfunded priority area, the finding that relationship continuity across leadership turnover constitutes a structural implementation problem that transcends any individual CFIR construct, and the ‘resource-adaptation paradox’ described below.
Discussion
Our interviews with experts and the review of the literature on IS indicate that evidence uptake is contingent on the relationships between researchers and knowledge users, and their abilities to maintain sensitivity and responsiveness to local contexts, and to navigate complex organizational dynamics. With effective and supportive leadership, organizations can harmonize these elements and foster adaptive, innovative, and responsive solutions to local conditions. The findings from this research are aimed at spurring dialogue about evidence uptake for improving and transforming seniors’ healthcare. They extend existing IS literature in three directions: (1) underscoring the complex interplay between organizational context and conditions; (2) noting the opportunities arising from establishing a collaborative research environment or community of practice and mechanisms to build and support a research culture; and (3) maintaining and exploring avenues for creative, flexible, innovative thinking and problem-solving based on the engagement of multiple stakeholder voices, particularly when options seem few and constraints many. In the current environment of long-standing system fragmentation and fiscal and human resource constraints, the important role of ongoing knowledge exchange, translation, and mobilization to improve healthcare for older adults cannot be overstated.
CFIR mapping: strongly represented and extended domains
The CFIR (Damschroder et al., Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery2009) provided a productive structure and conceptual framework for testing and extending the findings. Among the five domains, the Inner Setting was most extensively discussed, reflecting interviewees’ detailed accounts of organizational culture, leadership volatility, communication networks, readiness for change, and absorptive capacity. These constructs are particularly salient in seniors’ healthcare, where care is delivered across diverse and fragmented organizational settings – acute, home and community-based, and long-term care – each with its own research culture, resource base, and accountability structures.
The CFIR domain of Process was the second most richly represented, with all five constructs – Engaging, Implementation Leaders, Planning, Executing, and Reflecting and Evaluating – evident in the data. Notably, the construct of implementation leaders revealed a pattern specific to this context: the near-universal dependency on a single champion whose departure typically ended the implementation effort. This finding extends the CFIR’s treatment of champions by identifying single-champion dependency as a structural fragility, and not merely an individual variation.
Intervention Characteristics – specifically Adaptability, Relative Advantage, Evidence Strength and Quality, and Intervention Source – were clearly represented in our data, with participants consistently emphasizing that externally designed interventions with minimal co-development by practitioners had poor implementation success. Second, the persuasive framing of translatable evidence (e.g., quantitative bed-day savings) was as important as its technical quality.
The Outer Setting domain was prominently voiced but disproportionately recognized as a source of barriers: political motivations and funding cycle pressures were experienced as forces that override rather than enable evidence uptake. This finding is consistent with existing IS literature (Brownson et al., Reference Brownson, Kumanyika, Kreuter and Haire-Joshu2021), but is particularly impactful in the context of seniors’ healthcare, where demographic urgency collides with political incentives that favour immediate gains over sustained system investment.
Two additional inductive themes emerged in our findings that fell partially outside the CFIR framework. First, the ‘resource-adaptation paradox’ – the finding that resource constraints can sometimes catalyze rather than inhibit implementation innovation – is not directly captured by any existing CFIR construct, though it draws on elements of Adaptability and Absorptive Capacity for Change. Second, and specific to seniors’ healthcare, the articulation of home and community-based and preventive care as a chronically underfunded implementation domain extends the CFIR’s Patient Needs and Resources construct by foregrounding the political and structural mechanisms that perpetuate underinvestment despite clear evidence of need for, and benefit from, investment (Giosa et al., Reference Giosa, Saari, Holyoke, Hirdes and Heckman2022; Johnson et al., Reference Johnson, Bacsu, Abeykoon, McIntosh, Jeffery and Novik2018).
Context: local conditions and leadership
Our first recommendation underscores the need to understand the local context in as much detail as possible. Our findings support and complicate Estabrooks et al.’s (Reference Estabrooks, Song, Anderson, Beeber, Berta, Chamberlain, Cummings, Duan, Hayduk, Hoben, Iaconi, Lanham, Perez, Wang and Norton2022) emphasis on organizational culture by revealing distinct challenges to person-centred care in seniors’ healthcare contexts, especially where implementation must bridge acute care, home- and community-based services, and long-term care systems that are historically not well integrated. Smith and Johnson (Reference Smith and Johnson2023) emphasize how organizational culture is shaped by managerial support, departmental culture (values, attitudes and practices), and time allocation – factors with greater significance in seniors’ care settings where staff turnover is high, and where care needs are more complex and ongoing.
While the literature has emphasized leadership support (Damschroder et al., Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery2009), our study reveals how leadership turnover and varying research culture and engagement across care settings also significantly impact both evidence uptake and care delivery. Our findings argue that successful implementation in local contexts requires sustained leadership engagement, commitment, and continuity (formal and informal) at multiple organizational levels, extending beyond traditional top-down approaches, as noted in prior literature (Boustani et al., Reference Boustani, Alder and Solid2018). These findings align with Hu et al.’s (Reference Hu, Rowe, O’Mara, Bulger, Bleday, Groff, Cooper and Bernacki2023) identification of implementation success factors in seniors’ care: organizational champions and institution-level resource investments to foster successful adoption of evidence-based practices.
Our findings also extend Estabrooks et al.’s (Reference Estabrooks, Song, Anderson, Beeber, Berta, Chamberlain, Cummings, Duan, Hayduk, Hoben, Iaconi, Lanham, Perez, Wang and Norton2022) work on contextual elements by highlighting how leadership and decision-making innovation and autonomy interact to shape implementation outcomes, particularly the organizational dynamics linked to relationships between direct care staff in long-term care and ongoing workforce stability and autonomy challenges. The research-positive culture needed for implementation success further depends on the intersection of health equity considerations, feasibility, and acceptability within specific organizational contexts (Bornstein et al., Reference Bornstein, Baker, Navarro, Mackey, Speed and Sullivan2017).
Culture: building a collaborative research environment
Our second recommendation revolves around the importance of establishing a collaborative research environment or community of practice. Data from the literature and our participants revealed significant variation in research culture across settings. Evidence for implementation success depended on three key components: effective knowledge translation practices to bridge research-practice gaps, specialized, embedded knowledge broker roles combining research expertise with operational understanding, and institutional structures and funding that facilitate building and sustaining a research culture and engagement. These elements were most effective when organizations established formal mechanisms for protecting research time and incorporated sustainable models for research support. Pervasive challenges included system fragmentation and resource constraints, particularly in long-term care, which is a challenging environment due to resource and staffing pressures, and the complex profiles and needs of older adults (BC Care Providers Association, 2018; Kothari et al., Reference Kothari, Boyko, Conklin, Stolee and Sibbald2015; Sadler et al., Reference Sadler, Sandall, Sevdalis and Wilson2018).
Care delivery implementation relied heavily on inclusive stakeholder engagement beyond organizational leadership, attention to interdisciplinary team operations, and strategic implementation relationships. Successful implementation required engaging appropriate decision-makers while maintaining sensitivity to both formal power structures and informal leader networks (i.e., those who wield power not necessarily by position, but by personality and length of tenure). One highlighted example from our experts demonstrated how these elements work together in practice, showing how evidence-based alternatives can be successfully implemented even with resource constraints when supported by appropriate organizational culture, stakeholder engagement and knowledge exchange mechanisms.
Our research advances understanding of integrated knowledge translation in seniors’ healthcare (Gagliardi et al., Reference Gagliardi, Berta, Kothari, Boyko and Urquhart2016; Sadler et al., Reference Sadler, Sandall, Sevdalis and Wilson2018) by analyzing fundamental tensions between research and operational perspectives in care settings where needs are complex and urgent. Our findings correspond with research noting misalignments between research and practice timelines (Kothari et al., Reference Kothari, Boyko, Conklin, Stolee and Sibbald2015); however, we reveal deeper structural challenges in seniors’ healthcare contexts, emphasizing tensions between the need for rapid results and the demands of rigorous research integrity (Vingilis et al., Reference Vingilis, Noori and Shokoohi2020).
In addition, our findings challenge simplistic stakeholder engagement models in seniors’ care, revealing the complex interplay between formal and informal networks spanning multiple providers and settings. While prior research emphasized formal mechanisms (Keefe et al., Reference Keefe, Hande, Aubrecht, Daly, Cloutier, Taylor, Hoben, Stajduhar, Cook, Bourgeault, MacDonald and Estabrooks2019), our study demonstrates how successful implementation relies as much on informal relationships and networks, requiring broader end-user engagement – including older adults, families, and care providers – rather than solely organizational or local leader perspectives (Brownson et al., Reference Brownson, Kumanyika, Kreuter and Haire-Joshu2021; Di Pelino et al., Reference Di Pelino, Lamarche, Carr, Datta, Gaber, Oliver, Gallagher, Dragos, Price and Mangin2022). Our research also emphasizes the value of longitudinal relationships between researchers and those within clinical settings for spurring the implementation of evidence uptake and new knowledge development and exchange. This aligns with Flynn et al.’s (Reference Flynn, Mrklas, Campbell, Wasylak and Scott2021) observation that successful implementation requires breaking down silos and facilitating sharing among groups who might not otherwise interact, creating ‘cyclical reinforcement’ through continuous learning and ongoing adaptations. Networks of diverse stakeholders and collaborators can amplify the uptake of scientific evidence into decision-making processes, although there is still a gap in understanding the most effective practices for this (Garavito et al., Reference Garavito, Moniz, Mansilla, Iqbal, Dobrogowska, Bennin, Talwar, Khalid and Vindrola-Padros2024; McArthur et al., Reference McArthur, Bai, Hewston, Giangregorio, Straus and Papaioannou2021).
Creativity: adaptive problem-solving given resource constraints
Our third recommendation reinforces the critical importance of innovative thinking, problem-solving, and ongoing knowledge exchange for evidence uptake to fuel positive system change. This research extends understanding of how knowledge broker roles and institutional structures support implementation success in evidence uptake and care delivery within seniors’ healthcare. While previous research identified the importance of knowledge brokers (Vindrola-Padros et al., Reference Vindrola-Padros, Pape, Utley and Fulop2017), our study reveals how embedded researcher roles catalyze evidence integration into decision-making affecting older adults’ health and care. This aligns with Conklin et al.’s (Reference Conklin, Lusk, Harris and Stolee2013) characterization of effective knowledge brokers as boundary spanners who create relationships among groups with shared concerns, promote mutual understanding, facilitate knowledge exchange across social boundaries, and develop new capacity for collaboration.
Effective knowledge exchange depends on individual brokers and broader organizational frameworks, particularly in the complex landscape of seniors’ healthcare. Extending Bornstein et al.’s (Reference Bornstein, Baker, Navarro, Mackey, Speed and Sullivan2017) work on contextualized evidence translation, we demonstrate that successful implementation requires dedicated roles and appropriate alignment with supportive institutional structures. Chambers et al. (Reference Chambers, Luesby, Brookman, Harris and Lusk2010) identify interconnected functions for effective knowledge networks: sponsors, leads, brokers, information specialists, and network members. This multi-role approach facilitates analytical, technical, and relational activities that Conklin et al. (Reference Conklin, Lusk, Harris and Stolee2013) describe as necessary for thriving communities of practice.
The foundation for effective knowledge exchange lies in relationship-based implementation, particularly significant in seniors’ care where provider-patient-family relationships are central to care quality. Vingilis et al. (Reference Vingilis, Noori and Shokoohi2020) emphasize that successful knowledge-to-action requires an egalitarian partnership culture based on sensitivity, respect, freedom, trust, and ownership. Their identification of this cultural foundation as an ‘essential precondition’ reinforces our finding that technical exchange mechanisms must build upon strong relationship dynamics and partnership principles – especially crucial for person-centred seniors’ care.
Bringing it all together: the implementation interface where evidence meets practice
Research evidence implementation and care delivery implementation in seniors’ healthcare recognizes their bi-directional relationships, where one continuously informs and shapes the other, to challenge and advance IS understanding. Boustani et al.’s (Reference Boustani, Alder and Solid2018) agile implementation framework shows how research evidence shapes integrated care delivery, while care delivery experiences generate crucial real-world evidence. The example of a health region’s response to hospital overcrowding cited by interviewees, exemplified this dynamic: evidence and receptiveness to community-based alternatives informed care delivery transformation while generating new evidence about adaptation strategies. This aligns with Bowen et al.’s (Reference Bowen, Botting, Graham, MacLeod, de Moissac, Harlos, Leduc, Ulrich and Knox2019) findings on research-practice partnerships creating innovative and iterative learning cycles to advance both evidence implementation and care delivery improvements.
Our research revealed what we are calling a ‘resource-adaptation paradox’ in seniors’ care implementation. While resource constraints are widely acknowledged as barriers (Bornstein et al., Reference Bornstein, Baker, Navarro, Mackey, Speed and Sullivan2017), some of our findings suggest that these limitations can catalyze innovative adaptations of evidence-based practices. The hospital case and others reflected how organizations combining a research-positive culture with collaborative approaches, extensive stakeholder engagement, and knowledge exchange mechanisms can implement effective solutions despite significant constraints. This challenges assumptions that resource limitations are purely inhibitory, suggesting a more nuanced understanding of how innovation arises from organizational constraints. Our findings also extend previous human resources work (Estabrooks et al., Reference Estabrooks, Song, Anderson, Beeber, Berta, Chamberlain, Cummings, Duan, Hayduk, Hoben, Iaconi, Lanham, Perez, Wang and Norton2022) by highlighting the role of integrated information systems and organizational structures in knowledge uptake.
Successful implementation also depends heavily on organizational capacity to create effective bridges between research and practice. Knowledge broker roles are critical translators between evidence and operational realities (Van Eerd et al., Reference Van Eerd, Newman, DeForge, Urquhart, Cornelissen and Dainty2016), but must be integrated within existing structures and supported by leadership that values evidence and innovation.
In short, effective implementation approaches in seniors’ healthcare actively cultivate the research-practice interface rather than treating evidence implementation and care delivery transformation separately. When organizations successfully navigate this interface, evidence-based knowledge becomes integrated into their operational practices. One healthcare leader (DM07) illustrated this when describing how an embedded researcher’s contributions ‘became part of the fabric of the organization’, while the organization maintained the flexibility to adapt both evidence and practice to local contexts and needs.
Limitations and contributions
Several important limitations warrant consideration. Our expert selection process, drawing primarily from seniors’ healthcare networks in Western Canada, may have introduced selection bias favouring those engaged in research-practice partnerships focused on older adult care. While Western Canada’s distinct seniors’ care approaches provide valuable insights, this regional focus may limit broader generalizability. Additionally, varying local conditions during the study period may have influenced participants’ perspectives in ways not reflective of typical operating conditions.
Long-term care perspectives predominate in the coded data, reflecting both the composition of the sample and the sector’s salience in the Western Canadian IS conversation at the time of the study (Table 1). Critically, home and community-based care, while addressed by multiple participants, received less systematic attention in the analysis, and preventive care perspectives were underrepresented relative to their policy importance. Future research should deliberately recruit from home- and community-based and primary care settings to complement the long-term care focus evident here.
The study is situated primarily in BC, with two participants whose primary relevant work was conducted in Alberta. Readers should interpret findings with this provincial concentration in mind, particularly given the material differences between BC’s multi-authority governance structure, and Alberta’s consolidated model. The CFIR Mapping Table (Supplementary File 1) is an analytical product rather than a representative inventory; the constructs documented there reflect the concerns and experiences of this particular sample and should not be read as a comprehensive account of CFIR implementation in all seniors’ healthcare contexts.
Despite these limitations, the study makes significant contributions to evidence uptake in seniors’ healthcare. Our research advances understanding in three key areas. First, we emphasize the critical importance of co-linking evidence implementation and care delivery innovation as far as possible given complex interdependencies in seniors’ care contexts. Second, in addition to support for a collaborative research environment or community of practice involving a wide range of constituents, our research provides new insights into how complex stakeholder networks – including older adults, their families, seniors’ care providers, and community organizations – extend beyond traditional healthcare hierarchies to influence both evidence uptake and care delivery innovation. Third, we identify a ‘resource-adaptation paradox’ where, instead of immobilizing transformative action, constraints in seniors’ care settings can at times catalyze innovative adaptations when combined with a strong organizational and research culture and effective collaborations.
Consistency in themes across diverse participants and their alignment with IS literature suggests our findings offer valuable insights for understanding and improving evidence uptake and implementation in seniors’ care. Future research on transformative healthcare for seniors could examine (1) evidence implementation and care delivery interactions in different geographical contexts; (2) longitudinal studies of implementation processes; and (3) wider sharing of lessons learned from implementation experiences across organizations with varying stakeholder engagement levels.
Conclusion
This study enhances our understanding of how healthcare organizations implement research evidence to support integrated and transformational healthcare delivery for older adults. For healthcare organizations and policymakers, enhancing research uptake for care delivery transformation requires concrete strategies: ensuring knowledge broker roles are integrated within existing organizational structures and practices; developing comprehensive and sustainable funding models to support directed and independent research activities; supporting leadership in the fulfillment of their roles; and employing explicit mechanisms to protect time for research engagement and relationship building.
For integrated approaches to evidence uptake and care delivery transformation, organizations should develop implementation strategies that recognize how cultural, collaborative, and knowledge exchange elements interconnect. This integrated understanding is crucial in seniors’ healthcare given complex care needs, diverse stakeholder networks, varying administrative structures and directives, and the need for implementation approaches sensitive to local contexts and the evolving needs of older adults.
Looking forward, future research on how to transform seniors’ healthcare should examine how different combinations of implementation elements such as knowledge broker roles, collaborative networks, and institutional support structures can be strategically deployed based on local contexts, population needs, and resources. Such research should also focus on optimizing implementation approaches grounded in the priorities of stakeholder communities, particularly older adults and their families.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/S0714980826100877. Supplementary File 1: CFIR Mapping Table – Barriers and Facilitators to Research Uptake in Seniors’ Healthcare in Western Canada. This file contains the full CFIR mapping table produced from NVivo 14® coding outputs, organized by CFIR domain and construct, with codebook definitions, thematic summaries, and representative quotations.
Data availability
The data, analytic methods, and materials for this study are not publicly available. This study was not preregistered.
Acknowledgements
We would like to acknowledge the participation of our panel from Western Canada and thank them for their time and contributions to this project. They included expert professionals from both academic settings and health care leadership environments working in a Western Canadian context.
Financial support
This work was supported by Michael Smith – Health Research BC.
Competing interests
The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.
Ethical approval
This research was approved by the Institutional Review Board (Human Research Ethics Board) at the University of Victoria, Ethics protocol # 23-0385. Consent to participate was obtained in writing from each participant after explaining the study goals and objectives.
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