The Process of Implementing Evidence in Practice
3). Identifying barriers and enablers to change
A series of barriers to change (and their corresponding enablers) may be contributing to the evidence-practice gap. Barriers include limited knowledge and skills, beliefs and attitudes of professionals and clients, role expectations, and organisational factors such as lack of equipment or transport.
Time spent investigating possible barriers and enablers will not be time wasted. Often professionals think they know why a treatment is not being used often, for example lack of time or a ‘poor’ attitude. However, the lack of knowledge and awareness about existing evidence is remarkably common, and should not be underestimated. Similarly, professionals who do not view a treatment or testing procedure to be part of their work role are displaying another attitudinal barrier, which will impact on practice changes.
Techniques available for identifying barriers include use of a survey, interviews with staff or clients, a focus group with staff or clients, or a medical record audit.
In the Kramer and Burns example (2008), clinicians completed the Provider Attitude Survey, a 27-item instrument which assesses clinician knowledge, awareness and attitudes toward CBT and manualised treatments in general; current practices using CBT; and intentions to initiate CBT in the next six months. At the close of the CBT training, clinicians also completed a 9-item survey to assess satisfaction with the instruction, attitudes toward CBT and level of comfort with CBT initiation. Investigators also collected qualitative data through field notes of discussions with managers and records of supervisory sessions with treating clinicians. The authors identified a series of barriers for the implementation of CBT.
Kramer and Burns (2008) grouped the barriers as follows:
Acceptance, resources, availability, appropriateness, adherence
Clinicians comments on acceptance: “The ones for me that understood and accepted this (CBT) the best were the parents that were in treatment themselves, kind of the treatment-savvy parents.”
Openness to EBP and/or CBT, Caseload Mix, Coping skills, Competence, Learning style
Clinicians comments on openness: “I wanted to have that skill set under my belt, because I did come from that psychodynamic developmental and more relational kind of stuff, so I wanted something more concrete.”
Effectiveness, complexity, Training/tools, Compatibility, Adaptability
Clinicians comments on effectiveness: “I knew it was a very good tool for depression.”
Learning environment, Resources, Target population, Morale, retention, leadership
Clinicians comments on the learning environment: “To have all these kids (on my caseload) and to stop just to come here for a three-hour training once a month, but we’re supposed to keep our productivity.”
The external environment
Competing requirements, Opportunities
Clinicians comments on competing requirements: “It (the paperwork) is excessive…I can tell you I’m not gonna stay in this job. Because it’s just ridiculous…I would start crying if I started to calculate it (the number of hours spent on paperwork.)”
Kramer T, & Burns B. (2008). Implementing Cognitive Behavioural Therapy in the real world: A case study of two mental health centres. Implementation Science;3:14.