The difficulty of change: A new challenge for the new decade
As a health services researcher, I investigate the science of evidence implementation. My current research focuses on identifying factors which influence practice and behaviour change when implementing evidence into practice. For the last two years, my research has focussed on engaging with physiotherapists, chiropractors, patients and funders to evaluate evidence implementation strategies for whiplash management in South Australia. I identified structural (access to evidence), process (how to integrate evidence) and philosophical (what is evidence?) barriers to implementing evidence. I then developed targeted strategies to overcome these barriers. I would like to take this opportunity to reflect on my journey over the last two years, both as a researcher interested in the science of evidence implementation and also as a clinician wanting to engage with evidence.
Evidence is a widely used term. It is used in law and order when prosecuting, in welfare when determining eligibility for social benefits and in education when establishing competencies. The term evidence is also relevant to health, as decisions in health care should also be informed by evidence. Ideally, this evidence should be sourced from current research, rather than consensus opinion. In health care, the philosophy of integrating evidence into practice is called evidence based practice. Evidence based health care is an important as it can facilitate the delivery of safe and high quality health care services and positively impact on outcomes. However many popular health practices are still not based on research evidence. In other words, a gap exists between research evidence and clinical practice. This gap can potentially lead to poor quality, unsafe, costly and harmful health care practices.
Examples of evidence practice gaps include antibiotic prescription for the common flu, soft collar prescription for whiplash injury and routine X-rays for low back pain. Research evidence has shown that wearing a soft collar is harmful and staying active promotes recovery in whiplash. Yet, clinicians’ practice and behaviour does not match this evidence. It is important to note that this is not a new problem. The acceptance of the practice of consuming citrus fruits to treat scurvy took more than two centuries!
Throughout my two years researching evidence implementation in South Australia, it became very clear that clinicians are sceptical of researchers. The phrase "sitting in ivory towers” was used by some clinicians to describe researchers. My perception was that many clinicians considered researchers as being far removed from their everyday lives in clinical practice and therefore struggled to engage with them. This issue became obvious even at the commencement of my project. While I had built in many redundancies for sampling, it became apparent that recruiting clinicians to participate in my project was becoming increasingly difficult. As a researcher, I was routinely told that clinicians needed to be supported in their evidence implementation journey. And yet, even though I was providing clinicians with an opportunity to participate in an evidence implementation project, with freely available support and resources, I was still finding it difficult to engage the interest of clinicians. In addition to perceived philosophical differences, there were also pragmatic barriers (such as time, resources and ongoing commitment to participate in a research initiative). Addressing these disjoints and prompting engagement between researchers and clinicians became paramount. This was achieved through ongoing consultations, discussions and addressing barriers for participation.
As evidence implementation aims to address practice and behaviour change in clinical practice, it became vitally important that key stakeholders had "buy in”, and were cognisant of, the need for change. Failure to do so could significantly impact any evidence implementation initiative as stakeholders may be satisfied with current practice and status quo. For this project, there were a number of stakeholders including patients, clinicians, funders, administrators. From a researcher perspective, this was achieved through recognised processes such as stakeholder mapping, focus groups (where key stakeholders discussed their perspectives of current evidence-practice gaps and the need for change), audit and feedback. By undertaking these comprehensive processes, clear evidence-practice gaps were identified and the need to address practice and behaviour change could be demonstrated. In the initial stages of the initiative, the importance of striking a good balance of "push and pull” also became apparent. Clinicians should recognise the need for change, and be receptive to it (pull) and change should be supported by stakeholders via targeted strategies (push). Without equilibrium between push and pull, and if one outweighs the other, the evidence implementation initiative was likely to fail.
The importance of context in implementing evidence became apparent to me early in the project. As clinicians’ operate in a rapidly changing environment, elements of care that were considered to be of high priority one day could be dropped the next. This often occurred when changes within the practice (such as staff leaving), personal issues (moving interstate) and changing referral patterns meant implementation initiative were not considered a priority. As a researcher, I had to regularly communicate with clinicians, seek updates and try to mitigate barriers that arose as a result of changing contexts. As highlighted before, for any evidence implementation initiative, it is vitally important that all stakeholders have a uniform understanding and agreement about implementing evidence into practice. During the roll out of this initiative, it became clear that although most participating clinicians based their practice on evidence, they were often not supported by their fellow health professionals. In many instances there were differing expectations from other clinicians on how whiplash patients should be managed. This created confusion and angst between clinicians, patients and funders. Therefore, despite a comprehensive stakeholder mapping and analysis, this issue remained a real problem throughout the project.
From a clinical perspective, I was able to witness firsthand the challenges that confront clinicians when trying to implement evidence into practice. For many clinicians, ambiguities continue to persist regarding what actually constitutes "evidence”. In my previous editorial, I discussed the misconceived perceptions and warped realities of evidence based practice; common among some groups of clinicians. These misconceptions were palpable among clinicians involved in the project. Furthermore, the access to evidence remains a persistent barrier for clinicians wishing to implement evidence into their practice. Many had limited access to databases and were uncertain about the process of accessing synthesised evidence (such as systematic reviews and clinical practice guidelines). As part of this research, I was able to spend many days visiting clinicians at their practices. This provided a unique insight into a number of factors which influence clinicians’ behaviour and clinical practice. These factors included perspectives of referrers and funders, existing administrative processes, patient expectations, interplay between health professionals within a clinical setting, media, model of service delivery, just to name a few. For example, the current fee-for-service model of healthcare facilitates the ongoing provision of care with no incentives to facilitate guideline-based care. I also observed historical practices and traditional health hierarchies, which were so well entrenched that they could be not amended easily, continued to play a deterring role. If sustained and successful behaviour and practice change are to be achieved, clinicians need to be supported in curtailing the influence of these factors.
While the past two decades have witnessed a metaphoric rise of the need for evidence based practice in health care, at grassroots level, making it happen continues to face several barriers. As a new decade dawns on us, it is important that we, as heath care stakeholders, take the challenge of evidence implementation seriously and acknowledge the difficulty of change (achieving behaviour and practice change). The science underpinning evidence implementation is growing, with new research shedding insights on how best to achieve and sustain behaviour and practice change. Now is the opportune time to put into practice these findings that are emerging from this unique branch of science. The challenge that confronts us, in this new decade, is making it happen, rather than merely paying lip service to evidence based health care.
Kumar S. The difficulty of change: A new challenge for the new decade. The Internet Journal of Allied Health Sciences and Practice. 2011 Jan 01;9(1), Article 4.