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. 

Resistance to behaviour change

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 which could be used to explain resistance to, or implementation of, behaviour change. They are:

1. Knowledge
2. Skills  
3. Social/professional role and identity  
4. Beliefs about capability  
5. Beliefs about consequences  
6. Motivation and goals  
7. Memory, attention and decision processes
8. Environmental context and resources
9. Social influences
10. Emotion regulation
11. Behavioural regulation
12. 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.   

Stages of behaviour 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:

1. 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.  
2. 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.
3. Preparation: Intends to take action within the next 30 days and has taken some behavioural steps in this direction.
4. Action: Has changed behaviour for less than six months.Maintenance: Has changed behaviour for more than six months.
5. 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.   
   

Implementation Strategies

A recent 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). 

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