If evidence based practice and clinical guidelines are such great ideas, why is it not embraced by all in health care?
While there are many reasons for this, one of the primary reasons is that changing health care practices can be quite difficult. There is increasing research evidence which highlights key issues in implementation of evidence into clinical practice and below are summaries of some seminal research published in this area.
Theoretical Domains Framework
Dr. Susan Michie and colleagues in United Kingdom undertook research which aimed to identify theoretical constructs for use in implementation of evidence based practice (Michie et al., 2005). The findings from this research identified twelve domains (Theoretical Domains Framework) which could be used to explain resistance to, or implementation of, behaviour change. They are:
- Social/professional role and identity
- Beliefs about capability
- Beliefs about consequences
- Motivation and goals
- Memory, attention and decision processes
- Environmental context and resources
- Social influences
- Emotion regulation
- Behavioural regulation
- Nature of the behaviour
These domains provide valuable insight into potential barriers, and enablers, in implementing evidence in clinical practice. It is important to identify barriers when considering implementing evidence in clinical practice so that interventions can be tailored to overcome these barriers. Several types of barriers currently exist when implementing evidence in clinical practice. These range from an individual perspective to organisational and social contexts. From an individual perspective, barriers can be reported in terms of knowledge, attitudes, awareness, motivation to change and behavioural issues. From an organisational perspective, barriers can include limited resources, existing historical structures and processes of care, etc. From a social perspective, barriers can relate to leadership, culture of workplace and opinion of peers, etc. Barriers can also exist in the form of patients' perspectives (i.e. patients' expectations) and existing economic circumstances, such as fee-for-service models, etc.
Since this publication, there have been many iterations of the Theoretical Domains Framework with the most recent being Huijg et al (2014). Based on this research, the Theoretical Domains Framework includes 18 domains. The 18 domains are knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, belief about consequences, intentions, goals, innovation, socio-political context, organisation, patient, innovation strategy, social influences, positive emotions, negative emotions, behavioural regulation and nature of behaviour.
Transtheoritical/stages of change
Clinician readiness to adopt guideline recommendations reflects their readiness to consider behaviours, and change these behaviours if necessary. For over a decade, six stages of behaviour change have been described (Transtheoretical model of behaviour change) as underpinning individuals' capacity and motivation to change (Prochaska et al., 1992a,b). The key elements of the trans-theoretical stages of change, outlined by Gambling and Long (2006, pp 119) are:
- Pre-contemplation: No intention to take action within the next six months,aims to move the person by subtle consciousness raising to think about behavioural change.
- Contemplation: Intends to take action within next six months. Key processes of consciousness raising and dramatic relief. Aims to shift the balance of factors in favour (pros) and against (cons) in adopting the beneficial behaviour.
- Preparation: Intends to take action within the next 30 days and has taken some behavioural steps in this direction.
- Action: Has changed behaviour for less than six months.Maintenance: Has changed behaviour for more than six months.
- Termination: Overt behaviour will never return and there is complete confidence that the patient can cope without fear of relapse. No remaining need for the educational support/intervention.
Theory of planned behaviour
This is a theory which links beliefs and behaviour. The Theory of Planned Behaviour (TPB) has its origins in Theory of Reasoned Action and is intended to explain all behaviours over which people have the ability to exert self-control. A critical part of this theory is the behavioural intent. There are six constructs to TPB namely attitudes, behavioural intention, subjective norms, social norms, perceived power and perceived behavioural control. This theroy was developed by Icek Ajzen.
Theory of diffusion of innovation
This theory was popularised by Everett Rogers and he argues that diffusion is a process by which an innovation is communicated through certain channels over time among participants in a social system. This theory proposes that the spread or diffusion of ideas about a new practice could be achieved through harnessing the influence of opinion leaders and change agents. Rogers highlights four main elements which will influence the spread of new idea. They are innovation itself, communication channels, time and social system. Rogers highlights various categories of adopters such as innovators, early adopters, early majority, later majority and laggards. The process of diffusion relies on human capital and as humans and human networks are complex, some critics of this theory suggest that it is extremely difficult and almost impossible to measure exactly what causes adoption of an innovation.
A synthesis of systematic reviews identified the effectiveness of a range of published strategies used to implement guidelines (Prior et al., 2008). This review highlighted that multipronged implementation strategies are required for greatest effectiveness in guideline uptake. Effective strategies were reported as educational (such as continuing medical education), educational meetings and interactive educational sessions (either face to face, or using multimedia or the internet), educational outreach ('academic detailing'), which typically consisted of practice visits by educators, and audit, feedback and peer review.
The use of mass media dissemination strategies is controversial. Reminder and decision support systems and local opinion leaders have been shown to be effective in maintaining clinician interest after a guideline has been implemented. Patient-specific interventions interventions designed to influence practitioner behaviour via information provided to patients) are also effective, although the best way to influence patients is yet to be determined. Specific interventions may be more effective for clinicians at different stages of behaviour change, particularly when introducing guideline-based recommendations which require radical changes in practice behaviours (Michie et al., 2005).
Cane J et al. (2012).Validation of the Theoretical Domains Framework for use in behaviour change and implementation research. Implementation Science, 7:37.
Gambling T. & Long AF (2006): Exploring patient perceptions of moving through the stages of change model within a diabetes tele-care intervention. Journal of Health Psychology 11(1): 117-128.
Huijg JM et al. (2014). Measuring determinants of implementation behaviour: Psychometric properties
of a questionnaire based on the Theoretical Domains Framework. Implementation Science, 9:33.
Michie S, Johnston, Araham C, Lawton R, Parker D & Walker A (2005): Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality and Safety in Health Care, 14: 26-33.
Prior M, Guerin M, Grimmer-Somers K (2008) The Effectiveness of Clinical Guideline Implementation Strategies - A synthesis of systematic review findings. Journal of Evaluation in Clinical Practice, 14(5): 888-897.
Prochaska JO, DiClemente CC, Norcross J (1992a) In search of how people change: Applications to addictive behaviours. American Psychologist, 47 (9): 1102-1114
Prochaska JO, Norcross J, Fowler JL, Follicj MJ, Abrams DB (1992b) Attendance and outcome in a work site weight control program: processes and stages of changes as process and predictor variables. Addictive Behaviours, 17: 35-45.