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This article provides effective ways to change professional behavior in education. It discusses factors and barriers that influence change, as well as dissemination and implementation interventions based on research. The interventions range from multi-faceted approaches to continuous quality improvement, and include evidence-based strategies such as academic detailing and feedback. The article also explores barriers to adherence to guidelines and offers insights on how to overcome them.
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Effective ways to change practice Judith Mackson Education and QA Program Manager
Improving practice • Identify factors/barriers likely to influence the proposed change in professional behaviour • Choose dissemination and implementation interventions - based on these factors - based on relevant research
Interventions to improve Rx • Range of interventions effective • Trials in a range of settings • Multi-faceted interventions targeting different barriers more likely to be effective than single interventions • Use continuous quality improvement principles
Clear messages describing the desired behaviour • Reinforcement and repetition • Adequate resources and appropriate skills
Evidence-based interventions • Mailed educational material alone • generally ineffective • Academic detailing (educational outreach) • generally effective • Ongoing feedback • generally effective
Interventions cont’d • Reminder systems (manual or computer based) • ? Insufficient evidence • Group education • ? Insufficient evidence • Use of opinion leaders • ? Mixed results • Identify and recruit
Using feedback • Feedback which includes specific recommendations for change more effective than general feedback describing current practice • Individual behaviour identified
Regulation and processes • Restrictions, forms, approval etc
Getting guidelines into practice • Evidence-based, authoritative, local ownership • Guide to quality care • Accessible where prescribing decisions made
Barriers to adherence to guidelines • Lack of awareness or familiarity • Lack of agreement - specific or general • interpretation of evidence • credibility of authors • beliefs re benefits vs risk/cost • applicability to patient • Lack of outcome expectancy - belief will result in improved outcome
Barriers cont’d • Lack of self-efficacy (belief one can perform the guideline recommendation) • Lack of motivation/inertia of previous practice • External/practical barriers • convenience/ease of use • time constraints • lack of reminder systems
Barriers cont’d • Patient-related barriers • Environmental barriers eg lack of resources, organisational constraints • Other: discomfort with uncertainty, industry promotion, opinion leaders with non-EB opinions, compulsion to treat Cabana MD et al. Why don’t physicians follow clinical practice guidelines? JAMA 1999;282:1458-1465
Points to consider • Did the DUE identify barriers to prescribing according to guidelines? • Is further research necessary eg focus group? • Develop messages in collaboration with prescribers • Tailor the message/educational activity for the prescriber eg junior RMO vs specialist
Further reading • Dartnell J. Activities to improve hospital prescribing. Aust Prescr 2001;24:29-31 • NHS Centre for Reviews and Dissemination. Getting evidence into practice. Eff Health Care 1999;5:1-16 • Oxman AD. Can Med Assoc J 1995;153:1423-41 • Cochrane Reviews • Thomson O’Brien MA et al. 2000 • Thomson MA et al. 2001 • Fremantle M et al. 2000 • Cabana MD et al. JAMA 1999;282:1458-1465
