Demystifying the implementation of mental health strategies in education

Georgina Livingstone
Welcome everyone and thank you for joining us for this special event hosted by Be You. My name is Georgina Livingston, and I'm the Be You National Operations Manager with headspace. I'm introducing our event today. I'd also like to hand to my colleague Louis to introduce himself.

Louis Hamlyn-Harris
Hello, everyone! I'm Louis Hamlin Harris. I'm the Be You Executive Manager for Early Childhood Australia and, George, I'm going to leave the rest of the intro to you, but I will be back towards the end of the event for a Q&A with Robyn. So, looking forward to it.

Georgina Livingstone
Thanks, Louis.
A little bit of tech advice as we begin. If you need any tech support throughout this event, please visit the Zoom help centre, using the link in the chat which you should be able to see now.
Before we kick off, I would like to acknowledge that I'm joining you today from the lands of the Yuggara and the Turrbal people of Meanjin, and that Aboriginal and Torres Strait Islander people are Australia's first people and traditional custodians. We value their connections, identities, and continuing connection to country, waters, kin, and community. 
I'd also like to recognise that National Reconciliation Week began yesterday, and the theme this year is bridging now to next, reflecting the ongoing connection between past, present, and future. So, today we pay our respects to elders, past and present, and are committed to making a positive contribution to the wellbeing of Aboriginal and Torres Strait Islander young people by providing services that are welcoming, safe, culturally appropriate, and inclusive.
Today's presentation is mostly about implementation science. There will be some elements presented around mental health and wellbeing, though, so when we talk about mental health, sometimes feelings or thoughts or reminders might come up, and sometimes these can be challenging. So, we ask you to just please be aware of anything that might come up for you and have a plan about who and how you can reach out to someone for support if you need it.
Be You has a range of wellbeing tools and fact sheets to support educators that you can find on our website. In the chat, you'll also find a link to a mental health services and support resource that you can download and display in your learning community, if you'd like to.
A little bit about us, Be You aims to transform Australia's approach to supporting children and young people's mental health in early learning services and schools. Our vision is for all learning communities to be positive, inclusive, and responsive. A place where every child and young person, educator, and family, is empowered to achieve their best possible mental health and wellbeing. 
You can check out our free, evidence-informed tools and resources they are  designed to fit within your learning community's already existing framework, so there's nothing extra that you need to do to start using Be You. It's free, federally funded by the Department of Health and Aged Care, and it's delivered by Beyond Blue in collaboration with Early Childhood Australia and headspace.
So, with no further ado, I'd like to officially invite Robyn Milden to the stage. The stage that Robyn's already on. You can see her on your screen Now. Robyn is internationally recognised in the field of research translation, and implementation science, and program and policy evaluations. She has a PhD and is the founding Chief Executive Officer of the Centre for Evidence and Implementation, a global social purpose organisation with offices across the world. Robyn's work has helped to advance the implementation of better evidence in policy and practice settings, improving the quality and effectiveness of health, education, and human services. 
She's an author, a visiting Associate Professor at the Yong Loo Lin School of Medicine with the National University of Singapore. She's also an Adjunct Associate Professor at Monash Uni and is the Chair of the Evidence and Implementation Summit.
Robyn's a very busy woman, so we're very fortunate to have her with us today, as we give Robyn a virtual round of applause and welcome her. I'll also let you know that you can use the Q and A function for questions, and Robyn will save some time at the end to respond. So please join me in welcoming Robyn. And over to you, Robyn.

Robyn Mildon
Thank you. Thank you very much. I cringe often at when people read my bio. I'm not as fancy as that sounds. So, I want to acknowledge the traditional owners of the land. I'm coming to you from today the land of the Wurundjeri people of the Kulin nation and pay my respects to elders, past, present, emerging, and acknowledge it always was and always will be, aboriginal land.
I apologise for the angle of my camera. We have an office in London, and I got back yesterday and did a very dumb thing and left my computer on the plane. So, your colleagues have been very kind helping me set my phone up. So, I'm very appropriately sitting on the floor of my house. Coming to you on my phone. So again, apologies if the sound or the visual isn't what it should be. And I'm very grateful for being invited to give this talk this morning. 
It's an important topic. It's a topic obviously very close to my heart, and I very much enjoyed working with Be You over a number of years now, trying to see what we can do to support better implementation of things that can improve the lives of the people that we are here to serve. So next slide.
So just a tiny bit about centre for evidence implementation. We are about 9 years old now. Based in Melbourne, work in a number of countries. And do a number of things to try and accelerate the use of best practice, knowledge and evidence in the way policies designed in the way services are designed. 
Next slide.
So, in a very fast, maybe 40-ish minutes to leave time for questions. I'm literally going to provide a 101 of implementation science. So, everything you need to know in in a very short space of time. So, apologies if the content is a little bit dense. But there's plenty of things that you can read or email me about later. 
Next slide.
So why focus on implementation, and how can it help?
Next slide.
So this is a very it's an old one, but a good one, and those of you that have seen me give talks before, have probably seen me say, and heard me say this a number of times, but you can't benefit from something you just don't receive. And that's why focusing on implementation really matters. 
A number of things, innovations, programs, policy practices, show some evidence that they can improve the lives of children, young people, and the communities that we work with. But if literally they don't get them in the way that they're intended, we don't benefit from them at all. 
Next slide.
So, for a really long time well, not too long, I suppose, but for some time we focused researchers, academics in general have focused on what works. So, trying to figure out what are the things that we can do. So, in the context that you're all working can address student wellbeing. And generally, that's called sort of evidence, based practices. And it's delivered by professionals. Sometimes even volunteers, or whoever within a school setting or outside of the school setting to try and improve outcomes. However, we've paid much less attention on how to implement these practices. Well, so that we again benefit from the research that's being done.
Next slide. 
And it's taking way too long.
So, there is a very famous study, those of us that work in implementation often quote, which talks about it takes on average, this might be a little bit slower now. Sorry. It might be a little bit faster. But 15 to 17 years, for something we know can support people's wellbeing. 
Now, in becoming business as usual, in the way that we deliver services, whether it be a school setting and early childhood setting, or a hospital community service. If you think about this in an early childhood context, we know the first five years are super important in terms of laying good foundations for the wellbeing of kids. That means three generations of young people are missing out on something that they could benefit from now. And so, implementation and our focus on implementation and looking at implementation research is dedicated to trying to close that gap.
Next slide.
And so, if you just think about implementation science, and sometimes I don't use the word science, because it can be a little bit off putting. But implementation science in this context is the study of how research findings can close that gap can be implemented to be best practice business as usual in school and early childhood settings. 
Implementation practice is just the application of that research in the way that we do business. So, it's the implementation. It's the story. It's the implementation of research in practice in school and early childhood settings.
To try again to close that 17-year gap.
Next slide.
Sometimes language can also get in the way of closing the gap and making progress together. So just to help a little bit. A number of years ago we used to talk about the diffusion of innovation. And that is the generally a little bit that ‘ohhh.’ It's the unplanned, very passive kind of ‘spray, and pray’ approach, if you like, to spreading what can really support mental wellbeing, mental health in early childhood and education. 
So, we generally call that diffusion so sort of letting it happen. Helping it happen is the next step up where it's a little bit what I'm doing with you today. 
It's targeted distribution of information and materials for a very specific reason. Implementation science and applying that in practice is the ‘making it happen’ bit. It's the use of strategies to adopt and integrate interventions and change practice patterns in specific settings. So, it's a very deliberate, focused attempt to better implement things we know can well, things, we hope will improve wellbeing of the people that we are working with next slide and implementation really matters.
So, research has produced enormous amount of interventions in mental health and wellbeing for young people, for children, for young people and for adults. In fact, you can see from this slide here some colleagues of ours identified over 500 different evidence-based interventions that had been identified in the research. 
However, a number of these aren't implemented at all. Or implemented at such a low dose or low intensity that we don't benefit from them at all. And that, if you know, given the context that all of you work in, you know, is an emergency. It's an emergency. And it's up to us to figure out, how can we best build on what research has shown to work well for children and young people and get that implemented effectively.
Next slide.
And I'm sorry, I'm not able to drive my own slides. 
So why does implementation fail.
Next slide, please. 
So, one of the reasons that we've seen, and you can, you can see in research evidence why implementation fails is often something about the innovation itself. So, when I'm using the term innovation, I'm often talking about a program, a policy. A clinical guideline. So, I'm using the word very broadly. But often we'll be brought in to support implementation, and we have to go back and look at the model, the approach, the innovation itself. And if it's not clear what that thing is, or what the model's trying to achieve. If it's not clear what changes are meant to occur to result in some improvement. 
Or it's unclear. What the evidence is to support the changes that the model is looking for. It is very, very difficult to get effective implementation. And again, effective implementation. What I mean. There is something become goes from being new to business as usual.
So, implementation starts by looking at the ‘what’ from the beginning.
Next slide.
Implementation often fails when we don't understand the context in which we're implementing. So unfortunately, and for people that have seen me speak before, I'm repeating myself a little bit. But there are a number of rep frameworks and implementation science. And I don't think we've been, as implementation scientists, been as helpful as we can as there are too many frameworks.
This particular one is called the Dynamic Sustainability Framework. I like to just call it the ‘three eggs,’ and what it's trying to demonstrate is we have to find the fit. 
So, you'll see in the little red egg. And this is in a health context. It's not necessarily speaking to schools or only childhood settings. But I think the concept still works. So, you have your intervention, your innovation, your practice, your program, and that will have components. Things that teachers or early childhood workers need to be doing. 
There'll be some outcomes you're trying to address. But that really needs to fit within the practice setting that you're delivering, whether it be a school and early childhood setting, all the different multiple early childhood settings, which, of course, there isn't one version as many. And those arrows should be going two ways. So, you're really wanting to think about. I have my watch what I'm delivering that in a particular place. And we need to find the fit because there's different staff that might be there. There are information systems that organisation might have a particular culture, a particular climate, but that also needs to fit with the broader ecological system. That is the policy setting the way funding is delivered, the way both early childhood and schools need to operate in different jurisdictions across Australia.
So, a lack of understanding of the context in which you're delivering something can often lead to very significant implementation failure. 
So again. Two arrows, finding the fit bit next and not including stakeholders in the planning process. Or indeed, in all the phases of implementation. And I can't emphasize this enough. And I took this for granted. 
Early in my career. People with an interest in outcomes of the project or the work that you're trying to do need to be consulted and included in the entire implementation process. Folks that have something to lose or benefit from the work should also be involved in the implementation of all phases of what you're doing or anyone that's going to be affected by the project. So not including stakeholders, and I can't emphasise this enough is almost always leads to implementation failure. And we can often tell when we start working with different sites across Australia. 
I will, or my team will ask, you know, ‘Tell me a little bit about the stakeholder consultation and what you've done.’ If it's only been done once, this is sort of a one and done activity we're going to have lots of issues with implementation. So, it's a very genuine activity that needs to be valued; funded properly and given the time it needs.
We also have pay now or pay later. 
So, poor planning in an implementation project no matter how well intended that implementation is, will lead to very poor implementation. And you'll see it next to it in the way we use implementation frameworks. The planning phase is essential. And sometimes a little bit of a privilege. But I can talk you through how we tried to accelerate that, but pay now or pay later, if we don't do well, well done. Planning 
Next slide, next slide. I suppose demystifying implementation.
Next slide.
So, this goes back to my point on context, implementation science recognises that not only do we need a ‘what’ so that can be. Again, the program, the policy, the clinical guideline, the innovation. But that needs to be paired with very effective implementation. The how and we need to understand the context and be adapting for that context. So, it enables the what and the how to work well together to get improved outcomes. That looks super simple, that diagram. It's not that simple, I know. But I think in the past we went straight from the ‘what’ to ‘outcomes,’ and we didn't often think about the how or the context that we're implementing in.
Next slide. 
And so really, good implementation, again, is informed by your ‘what.’ So that can be, again, I'm using different terms here, it could be evidence-informed practice, evidence-based program innovation, clinical guideline. Plus, the how active and effective implementation will lead to positive outcomes. 
But also, to be really good at implementation,  you're wanting to systematically think through what are the things that are getting in the way, and what are the things are helping implementation from the start. So, that's the barriers and labels box at the top.
So, you're thinking about your ‘what;’ your ‘how;’ what's getting in the way, and what's helping. And you're trying to decrease the amount of barriers you're having and increase the things that are helping you to get to those positive outcomes.
Next slide. 
So many things influence implementation in education and early childhood settings. So, I should put that in the in the title there. Leadership attitudes of leaders, skills of leaders. And I don't mean leaders in a hierarchical sense. Anyone in some sort of leadership role can be a barrier or can facilitate implementation, and the resources that you have. Any kind of organisational stress or financial pressure that you might be under management types of tolerance for change. A culture of experimentation and taking risks. Those are all things, again, that can help or hinder implementation.
Next slide.
And this is one of my favourite quotes ‘the use of effective interventions without implementation strategies is like serum without a syringe the cure,’ is available, but the delivery system is not gone. 
Are there days where we can use training as our sole implementation strategy to try and get change into the settings that we work in. Training is super important but ineffective on its own to get the result. So again, we're really wanting to think through what our delivery system is to better enable the work that we're trying to do.
Next slide 
Implementation scientists do love a framework and a model. This one I just wanted to share. Because it's a very good way to think through behaviour change. So, all implementation efforts need systems change. But they also need humans to do something different. So, COM-B (COM-B Behavioural Framework), developed by Susan Mitchie, who's up at the University College in London. She's been working on this model for a really long time, so it's called COM-B. If you Google it, you'll see it come up in enormous amount of studies in all settings, education, health. Public health, early childhood.
But what's important for our conversation now is what she's been able to show is, that behaviour change needs three things to happen. 
One people need the capability to do the innovation. They need the skills, the resources, the money, the time, the information support to be able to do the thing. And that's often developed through training and coaching down the bottom there. 
They also need the opportunity to do it. So, in my career we've done enormous amount of training over years in various evidence-based models, particularly around child mental health.
But no matter how good that training is, if, when the people we're working with go back into the setting, and they have no opportunity to implement the model,  it won't be implemented. No matter how motivated they are, no matter how capable they are. 
So there needs to be an opportunity within the setting that you're working to be able to do the innovation. 
And then, in addition to that, people need motivation to do it, so they need to think or understand that the new thing they're doing is possibly better than the old thing that they're doing and feel quite motivated to do it. So, for good behaviour change when we're trying to implement, not even something brand new, maybe something just slightly different, we people need the capabilities to do it. They need the motivation, but, importantly, they need the opportunity to do it in the setting that they're operating in.
Next slide.
This is another implementation framework. So, this is more looking at beyond behaviour change to how you can carefully think through implementing something in the setting that you're working in. So, this is, I should have had the reference on there. 
This is developed in the US around veterans’ mental health. I like this because most implementation frameworks have phases. Some have three, some have four, some have five (phases). This has three, and it's a very simple framework to use when you're trying to plan and promote better implementation of the model that you're working with. 
It has a nice pre-implementation phase. So, this is what is the problem? 
Who are the stakeholders and what are best practices? 
So, this framework assumes that you don't already have a model that you want to be implementing. Then it goes to the implementation phase, which is what implementation strategies will we be using? What adaptations or resources do we need to do that? And how will we know (if) we're successful? So, what data will we use to be to be able to measure how successful we'll be. And then the wonderful sustain phase. And you can see the term veterans use there. How do? How do people benefit? What is the impact on clinicians and who owns the process. 
And often in any implementation process, you're moving across these phases, often and sometimes working in between them. At the same time, the reason I like implementation frameworks is when you're planning. It gives you all a similar language to use when you're working together to think through how you're going to move the idea to effective implementation.
Next slide.
Again, this is another example of a very simple framework. This one has four phases. This is more common in education and early childhood work. Again. You often have your preparation phase, which framework before had pre implementation. You have your early implementation phase. You're trying to figure out what's your plan. Full implementation, sustainment. Most research and implementation has shown that no matter which way you go, you often naturally go through these phases just sometimes we're not doing it as intentionally as we would like to be doing next slides.
This is another example. Again, too many frameworks and implementation science, apologies. We developed this some time ago for the Education Endowment Foundation in the Uk, who were trying to promote the importance of consciously thinking about implementation to schools across the United Kingdom. And you again can see there's four phases. 
We have our ‘explore phase’ here. Where we're thinking about what it is we're trying to change. What does the evidence say we could do to change, to affect that change? And how best can we do that in a feasible way. 
You see our ‘prepare phase.’ This one's talking a little bit about getting ready. Get getting the site ready, preparing your implementation plan. 
You have your ‘deliver phase.’ Most people think the delivery phase is implementation. Again, you can see implementation really starts right from the beginning of thinking about what you want to do, and then your ‘sustainment phase.’ 
You don't have to follow all of the steps within each phase to the letter. But it's just, (that) there are common steps that implementation science has shown. If we do these things in this particular order, we may be more effective than if we just didn't. And again, didn’t use training as our sole implementation strategy. 
Next slide.
Now sorry for a Wednesday at 1030 in the morning Melbourne time earlier in Perth and Adelaide and Darwin. 
But one thing that's really good to focus on when you're thinking about implementation is ‘what are the things that are going to get in the way,’ and ‘what are the things that are going to help? 
So again, I mentioned it earlier. Barriers and facilitators, CFIR implementation of commonly known as the Consolidated Framework for Implementation Research, is a framework that was developed by a woman named Laura Damn Shorter a number of years ago, and a lot of us use it when we're trying to think through ‘what are the barriers and ‘what are the facilitators’ to implementation? And ‘how will we overcome them? 
Laura did a great job of developing CFIR, because she took all of the frameworks, that ever existed in looking at what are the barriers and facilitates implementation, and she put it into one. the CRIR, thus the word consolidated. And she takes into account a number of things, I think are important. So, if you see here, the framework calls out the outer setting and the things that can help or get in the way of good implementation. For example, financing. She also takes into account the inner setting. So, things within the practice setting that can either help or hinder implementation. You can see some of them laid out there. 
She also does a really nice job looking at the innovation of the model itself, and what things can be helpful, or what things can get in the way. How adaptable is it? How trainable is it? Can it? How much does it cost? Is it too complex? So that's the thing in the green box. 
She also takes into account the implementation process itself. How? How well was the planning process done? How many strategies are we using? And where we able to tailor them, how engaging was it? And then. In addition to that, the individuals who need to do the implementation, which you can see down the bottom characteristics of what they're able to do, skills and capability of doing it. Going back to COM-B, level of motivation. 
There's a really cool thing called relative advantage that she has named in CFIR, and that is the concept that somebody believes the thing that they were doing before was better than the new thing or the adaptive thing. They're being asked to do so. If they don't feel like there's an advantage to it often you won't get very effective implementation. So, you're really wanting to make sure you're doing good stakeholder engagement from the beginning to overcome any issues like that.
Next slide, please.
Implementation strategies. 
So, if we put frameworks in one bucket, and that's the phases and stages of implementation. In our planning phase that's where we build our implementation plan and our implementation plan is made up of implementation strategies. A wonderful colleague of all of ours globally, Byron Powell, who's referenced down there at the bottom for his PhD. He suffered for all of us and went and looked at all the implementation strategies that have ever been studied in implementation research and started to categorize them. And he came up with over 80 and a lot of us try and stick. So, these are Expert Recommendations for Implementation Change or ERIC. A lot of us try and use these implementation strategies when we're doing our implementation plans or doing some implementation research to see what's effective. So that we can compare things globally, and they loosely fell in these buckets. 
So, developing stakeholder relationships, there are a number of strategies you can do engaging the service users, financial strategies, of course, changing infrastructure, something we don't often think about training and education. A must, but again, training by itself insufficient to get the effect, other supportive practice; interactive assistance that can be apps, it can be reminders. 
There's a great thing called audit and feedback. Which has been studied a lot in healthcare and is something that we've only utilized in education and early childhood in terms of a very simple, low, cost way of checking whether we're implementing in the way that we intended, and if not, providing some very supportive feedback to try and improve the level of implementation. 
Evaluation. We cannot understand how well we're implementing without data. So, it doesn't mean evaluate from an evaluation point every time. But you need some form of data monitoring to understand ‘are we reaching the people that we intended to reach?’ ‘Are we implementing in a way that we thought?’ And are we getting some sort of outcome that is what we were hoping to get. 
It's very, very difficult to do good implementation work without that. Unfortunately, we ask people to collect too much data which is underused, and I think puts the front line (staff) for sure off collecting data. But it's very important we do. And it's very important that we're pragmatic about it. And then it's meaningful to the people that need to use it. 
And then, in addition to that tailoring and adapting an intervention. I mean, it's we used to talk about implementing with fidelity. Well, we still do actually not used to but really, what implementation research has shown is that we need to do some level of adaptation to better understand how to find that fit like the three-egg diagram.
Next slide.
And just to build on that, this is another way of looking at the slide before, with a little bit more detail under each of the categories of implementation strategies. So, you can see under the support practice staff, we need to adapt the roles people have. Sometimes we need to develop relationships with other support organisations that can help implement. 
One of the very well researched and effective strategies for implementation is to have an intermediary or a group come in and help the practice setting implement it. It doesn't mean the practice setting doesn't mean anything's wrong, but we are wanting to build a sort of a good coalition of trained implementation consultants which you have on Be You. Who are able to come in and provide whatever assistance they can to help develop implementation plans. Using all sorts of strategies. You can see there's assessing for readiness to identify the barriers. You can see there's a monitoring system. 
What I would say about implementation strategies, though, is sometimes we have a tendency, particularly in high income contexts. To overdo the amount of implementation strategies we need. And what we've seen is some amazing research in other low resource contexts, where, because out of necessity, they only implement… It's, we call it. How low can you go? So, what's the least amount of implementation strategies you can put in place to get the effect, which is why basic data monitoring is really important. 
So again, not using too many implementation strategies from the start, because I don't think a system can cope with that, and particularly the settings that most of you are likely working in education / early childhood. You just don't have time. It's one of the harder settings to do implementation work because of the focus on being in in the classroom or in the setting most of the time. So, you really want to be quite careful. 
Pick the implementation strategies that have good evidence behind them, but also only add, if you need to. If you're not getting the sort of implementation outcomes you want.
Next slide.
And again, I think you'll get a copy of these slides. These are just more examples, implementation strategies with a bit more description for you there. So, identifying preparing champions. A fantastic strategy. There's a lot of good evidence, mostly in healthcare. But I think it would still apply in education, early childhood that identifying key people who are prepared to really focus on the implementation of the innovation. 
Understand the innovation well and can act for champions. For it is a very effective implementation strategy. And it's been shown in multiple studies to result in more effective implementation. 
Local consensus discussions. I mean, I think that would be quite normal within the systems, recruiting training all of the things. But again, I would encourage any setting that's trying to focus on better implementation, to just take it slow and do some of the easier implementation strategies to see if you can get an effect before you complicate too much. Training, dynamic, promoting adaptability. Again, that sometimes is controversial with some program developers, who feel that you really need to stick to the way that the program was designed, initially. I hadn't seen that done over a long period of time. And a lot of implementation research is again arguing that there needs to be, find some adaptive, oh, my gosh! adaptability to fit with the context.
 Next slide. 
And I'm sorry for those of you. that this is me trying to encourage you to measure. Not put you off at all. 
So, this diagram. Here Enola Proctor developed this a number of years ago. Mainly because she was arguing about measuring implementation outcomes. As, in addition to children and family outcomes. So again, health setting, a lot of implementation research has come from health. So, we're transferring it over to education setting. 
But what I like about this is, it talks about ‘the what.’ So that's your Be You framework, the how? That's the implementation strategies you want to use to implement Be You in the setting that you work in. And then just some examples of ways you can measure. 
Are you implementing in a way that you thought? And are you getting some outcome? And some of these you probably do already in your setting, for example, acceptability. It would be very unusual to not measure how acceptable is the innovation to the people that need to implement it for the people that are supposed to benefit from the implementation. How much does it cost? How feasible is it if something isn't feasible. It's very difficult to get good implementation at all. So, if you're able to measure a few implementation outcomes and child family and young people outcomes, that just gives you a terrific start. 
And again, this isn't saying, measure all of these things. It's just saying, don't forget. Don't go straight from the innovation to the outcome, with no measurement in the middle of how are you able to validate what you're doing? But even better, how are you able to adapt and fix what you're doing. 
A lot of good implementation research and implementation practice. Really argues in a very compelling way that, we shouldn't keep doing something for a very long time that we have no evidence that it works. So again, just some very pragmatic outcomes that is, are meaningful to the setting that you're implementing in.
Next slide.
So, this is a little bit of a summary, the implementation isn't a ‘one and done’ thing. It occurs in phases and stages. So, you would have seen from the previous slides. Again, some implementation frameworks have three, some have four (phases), but it's not something that's you just deliver training and you're done. So, that’s really the research has shown us that that is not effective at all. It requires an assessment of needs prior to selection of innovation. Now, in this case, you have your innovation. That is Be You. So, selection isn't really necessary. But other things that you might do further on in the work that you're doing. You do need to do a good assessment of what's needed in the setting that you're working. What are the outcomes you need to achieve to improve the lives of people that you're working with. And what is the most effective innovation to do that.
It depends on the readiness of individuals. So, if you think about COM-B, which I spoke to before. People being (and) having the capability to do it. I mean the motivation and having the opportunity. Which is essentially what readiness is, is very important, not only people, but organisations as well.
So, an organisation having the opportunity to do something. The capability and the motivation matters just as much as if, as individuals. Individual people do. 
It always requires adaptation. Again, that is a little bit controversial. Because, you know, some, as I said, earlier program developers do like people to implement with some level of fidelity. But context really matters. Some adaptations and careful adaptation are often needed. We need to build the capability among all the stakeholders that are involved in the in the implementation effort, not just teachers or not just and even principals or leaders in early childhood settings. It takes everybody to have some capability to know what you what you're able to implement. No matter what it also entails, developing some infrastructure to support implementation, using training as the sole strategy to implement, and not changing things around that people who are getting training is utterly ineffective. So, we need some infrastructure to support the people who need to do the implementing part. I have to use my phone to. [moves phone camera]
And that last point goes to again, the sort of point I'm trying to drive home quite clearly is it needs monitoring. It needs some basic pragmatic monitoring of are we reaching who we thought, who we wanted to reach? Are we implementing in a way that we thought. And are we getting some sort of outcome.
Next slide.
And if you really liked this, we are having a conference in October in Melbourne called the Evidence and Implementation Summit. We've been doing it for about 12 years. Now. It focuses on a lot of this of introduction to implementation science. I've given you and it focuses a lot on how to do good evidence and evaluation. It's an event for policy makers. It's event for practitioners. It's event for researchers. We put a lot of thought into it. So, join us if you can, in October.

Louis Hamlyn-Harris
Robyn, thank you so much. It was a fantastic presentation, and I've been following the Q. And A. With much interest. And there's been lots of really great conversation and questions we've got just probably right on about 10 min for Q&A, maybe a little bit more. So, I'm going to try to do some synthesis and get to the major themes. 
I loved something you talked about, which was the how low can you go principle? And we've had a lot of questions about time. This is something we see reported really, really, consistently that the biggest barrier that educators experience to implementation is a lack of time and often related to that is the sense of competing priorities. We're trying to do lots of different things, and we just don't have the time for them all. So, I wonder what are some of the strategies we might consider to work around that very simple barrier of just not having enough time.

Robyn Mildon
It is such a good question, and some of the hardest implementation work we've done is in education and early childhood settings because of that, because of the need to be, you know. In the classroom, in the in the setting. So, I would highly encourage, of course, everyone's going to have to have training. So we just accept that if there is any possibility, and I think Be You has done some really creative ways to do this, coaching post training in the setting is a very, very effective strategy, like it's if I could give up anything I would give up training, and I would just do coaching in the setting, while people need to be using the skills that they're developing.
But again, the use of champions, that's a very low resource, easy strategy to put in place. 
The easiest, audit and feedback. So that's a little underrated outside of health settings. But when done well, and unfortunately, I've seen it done a few times where it's it comes across as compliance, which it shouldn't be, so you're checking to see if people are complying to implementing the thing as planned. So you don't want to do that. You want to have a check to see if things are being implemented in the way you thought, but when they're not, provide very supportive feedback to enable people to implement it a little bit clearer. 
So those are also low-cost implementation strategies. 
One of the things that really works well, but I think is very, very hard to do in education and only (in) childhood settings is implementation teams. So, people working together to think through how, what is the implementation plan you could put in place and then monitoring how that's going. That has been very difficult to do in a number of settings. 
We've worked in again because of time, but we found creative ways of having buying people dinner and asking for a little bit of their professional development time, so, we can work with them on plans. I would recommend those, and the research evidence behind them is so strong. And then, if it's not working, you do, you will need to add on also advocating for some sort change in the way schools and early childhood settings are run to give the people that need to do the implementing more time out of the direct service delivery to be able to plan better. But I mean that's a long way off.

Louis Hamlyn-Harris
I want to pull on that thread that you started there around monitoring and evaluation. We've actually had a really good batch of questions about evaluation. And it's interesting. I tend to think, actually, that educators and teachers have a lot of expertise in evaluation. But we often call it assessment, or we call it documentation. I wonder what are some really simple indicators are, we might look at to assess whether our implementation is successful, and I think people are also curious…‘how do we balance?”… you know the things we can count with those more qualitative under storytelling measures.

Robyn Mildon
Oh, again, I would just stick with reach, implementation, and outcome. So, reach in that I mean you reach is a is you would have that already because of the way that you’re implementing naturally in the settings that you're working in. So, you would, you would know, (the) reach that you would have with students or young children.
Implementation is a little bit harder, because… just say with some modules from Be You. Ticking, that a module has been read or done is an implementation. It's just ticking that the thing's been done. So, it's finding more creative ways of implementing some of the recommendations that are in Be You within the classroom. And that can be done just through a little self-assessment, that can be done peer to peer so people pairing up and observing each other. And then one outcome. Just any, I plead for any outcome, because there's no point measuring implementation. If you're not measuring whether or not, you're getting positive outcomes. And the worst thing that could happen is we're getting outcomes that make no difference, or, in fact, unintentionally do more harm. So, we don't want those two things occurring at all.
To make things easier for those of you working in these settings is hopefully recommendations around, what data could be monitored are being provided, rather than people having to come up with it themselves over and over again. So, we also advocate for that. But again, the system has a little bit of a tendency to over measure things. So, if we all think of the amount of data we're being asked to put in, that is likely not used in a meaningful way.
So, if you're able to give up some of the assessments or and use more meaningful data to understand implementation outcome. That would be amazing. But I would make try and make it easy on the system and provide that data. two sites. And I bet you, there'll be some sites already doing it really well. So also sharing that across implementation consultants that would be excellent.

Louis Hamlyn-Harris
I want to talk about stakeholders. I think you've made it so clear that you ignore stakeholders at your peril. Right? Yeah, earlier is the better in terms of bringing stakeholders into the into the process. I wonder how we might think about kind of really embedding that kind of consultation. Sometimes co-design process into the planning process kind of from the beginning, how we might think about including the broader community. So, children and families alongside our colleagues, and we've had just now a really interesting spin on that question, which is, how do we manage that kind of stakeholder engagement, when there might be conflicting ideologies or conflicting priorities.

Robyn Mildon
Oh, my! Gosh!
I know. I mean, there's a great implementation framework called Paris. And I like it because it's called Paris, firstly, but and one of the things that so Joe Rycroft Malone developed this framework a long, long time ago in a nursing context. But one of the things that framework showed, was facilitation and skilled facilitation of stakeholders with conflicting views or not is a very effective implementation strategy.
So, I often say, most of implementation work is facilitating, so facilitating groups of people to come up to a consensus, facilitating groups of people to understand what it is that we're trying to do. Facilitating language and power, so people understanding, you know, certain words that are used and what they mean, and who's got power in the room, and who doesn't have power in the room.
I think really good facilitation, overcomes conflicting ideologies, because in the end a good facilitator can get to some, get to some point. And, in fact, in the Paris framework it lays out what good facilitation skills look like. So, you can train for it. So, you can train people to be good facilitators of stakeholders, even again, with conflicting views. In saying all that sometimes it just doesn't work like humans, you know, just I've been in plenty of projects where you know just certain sites have opted to step out of the process because they don't agree with the particular model that people are trying to implement, and that that just is what it is sometimes.
But I would encourage all the implementation consultants that are here, that I think you're working with later on to really hone your facilitation skills because it's It makes things a lot of help more helpful. And it makes stakeholders you're working with enjoy the process more. In fact, somebody said to me recently they hated the term stakeholder. I was trying to remember what else they were using, or maybe it was in the prep. We did for this.

Louis Hamlyn-Harris
It may have been me. 

Robyn Mildon
It could have been me. Maybe it was you. But so then I was trying to come up with another term, like people just say people. But yeah, no good facilitation, is what I would recommend.

Louis Hamlyn-Harris
We're getting so many great last-minute questions; it’s making my job difficult. But I think we've got time for one more, and we've had a really good little cohort of questions around adaptation, and someone just framed this beautifully. Just now. They talked about the adaptation versus fidelity hustle, right? So, adaptations are balancing act because you've got to keep the things about the initiative or the program that matter or that are essential. But you've also got a translate it, or it's never going to work. So, I wonder, how do we find the sweet spot.

Robyn Mildon
Well, this is only the shoulders of the people developing the innovation. They should be clear what are the essential components. And we don't do that very well, for education or childhood settings they should be clear. These are the things that need to be implemented or need to be in the thing that makes the outcome positive. And here's the things you can change. And ideally, anyone developing a model, an approach and innovation should do that. Which means they should know what's in and what can be adapted. There’s a great scale up study in the US around, I think it was mental health. Where they were really clear on the things that, that no matter what state what site you're in, you had to implement certain things in a way that the program said. Because the research showed that it would be effective if you did that. But then they let them do all sorts of adaptation of other things, and then ask them, ask the sites to give feedback to the developers about what they adapted and what results they got.
So yeah, I think it's quite difficult, and a lot for sites to be asked to do adaptation, and be kind of held to it unless they're getting some guidance on what are the essential bits of it? And I think people designing or developing things need to get a lot better at that. Because I, when and again in my time I've seen a lot of things being implemented, where I would say 50% of it was unnecessary. And probably made a lot more work for people on the ground. Where they could have got an equivalent effect, by doing a little less, almost. If you don't have that guidance from developers, then it's just using the most experienced practitioners you can find to help with the adaptation. A lot of people that have been working in the field for a long time would know, or some recent graduates depending on what their, what their training is. But it's there is no magic, sweet spot. There just is the fact that you have to do some adaptation. It's just not realistic to be implementing the same thing in the same way in every place, with such a diverse country that we have.

Louis Hamlyn-Harris
And I think, Robyn, you've spoken a couple of times just now to the value of having a human being you can talk to and call on the phone and have some conversations, which is exactly what our Be You consultants are for.

Robyn Mildon
Oh, yeah, we do have this vision. We have this vision that everybody will have implementation teams the way you have IT teams. That it's like, it'll be so normal eventually. Because it's a it's a, you know, that intermediary work is super important. So, it's the Be You implementation consultants are there for.

Louis Hamlyn-Harris
That's right, Robyn. We're at time. But thank you again, that was such a useful overview of kind of the what and the why of implementation science. I think you've taken some really big ideas and frameworks, but you've made them really practical and grounded. So, thank you for joining us. We really appreciate it.
Robyn Mildon
And I want you all to know I'm sitting on the floor.

Louis Hamlyn-Harris
You are. I feel very comforted by it. It's very early childhood.

Robyn Mildon
Literally I am on the floor. It's quite funny.

Louis Hamlyn-Harris
I also want to let everyone know that Be You offers a really great range of implementation tools and resources. So, we've got an implementation cycle of our own. That's specific to making change around mental health and wellbeing.
We have a set of bite sized implementation modules, which we actually collaborated with Robyn and her team on putting together. And of course we offer our Be You consultant team, and I'm really hopeful that people in attendance will pick up the phone or send an email off to their consultant afterwards, and so that you can have some of these, follow up conversations and unpack some of these topics in a bit more depth.
We would really love your feedback about today's event, but also about what other topics you'd like us to explore. So, you should see a very short feedback poll on your screen right now. We're really grateful to you for filling it out. That kind of feedback is really helpful. Please keep an eye (out). It's how we evaluate. 

Robyn Mildon
No, no, somebody just sent me a very nice text offering to buy me a chair.

Louis Hamlyn-Harris
Please keep an eye out for the post event email, which will have a certificate of attendance, but also a link to today's recording. So, if you'd like to revisit the material or pull up Robyn's slides, that's the best way to do it. As Robyn mentioned, a small group of attendees are going to join us afterwards for a follow up, masterclass, so you'll know if you're a part of that already. We're going to take about a 15 min break, and then just follow the link in your email to join us there for everyone else. Thank you so much for coming, and we hope to see you again.

Robyn Mildon
See you.

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