Practice Environment structural social patients other Potential Adopters knowledge attitudes skill Evidence-Based Innovation translation process innovation Transfer Strategies diffusion dissemination implementation Adoption decision use Outcomes patient practitioner economic

Background: Clinical practice guidelines have been a popular tool for the improvement of health care through the implementation of evidence from systematic research. Yet, it is increasingly clear that knowledge alone is insufficient to change practice. The social, cultural, and material contexts within which practice occurs may invite or reject innovation, complement or inhibit the activities required for success, and sustain or alter adherence to entrenched practices. However, knowledge translation (KT) models are limited in providing insight about how and why contextual contingencies interact, the causal mechanisms linking structural aspects of context and individual agency, and how these mechanisms influence KT. Another limitation of KT models is the neglect of methods to engage potential adopters of the innovation in critical reflection about aspects of context that influence practice, the relevance and meaning of innovation in the context of practice, and the identification of strategies for bringing about meaningful change. Discussion: This paper presents a KT model, the Critical Realism and the Arts Research Utilization Model (CRARUM), that combines critical realism and arts-based methodologies. Critical realism facilitates understanding of clinical settings by providing insight into the interrelationship between its structures and potentials, and individual action. The arts nurture empathy, and can foster reflection on the ways in which contextual factors influence and shape clinical practice, and how they may facilitate or impede change. The combination of critical realism and the arts within the CRARUM model promotes the successful embedding of interventions, and greater impact and sustainability. Conclusion: CRARUM has the potential to strengthen the science of implementation research by addressing the complexities of practice settings, and engaging potential adopters to critically reflect on existing and proposed practices and strategies for sustaining change. Background In recent years, knowledge translation (KT) and evidencebased medicine have gained currency in health research through emphasis on moving 'knowledge off the shelves and into practice, making it relevant and accessible to practitioners and patients' [1]. Clinical practice guidelines have been a popular tool for the implementation of best clinical evidence from systematic research to improve the quality of health care. However, it is now widely understood that guidelines do not automatically change pracPublished: 5 January 2009 Implementation Science 2009, 4:1 doi:10.1186/1748-5908-4-1 Received: 3 April 2008 Accepted: 5 January 2009 This article is available from: http://www.implementationscience. com/content/4/1/1 © 2009 Kontos and Poland; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.