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Clinical

Implementing evidence-based practice: A model for change

Nicola Ann Plastow is Lecturer in Occupational

Therapy, Mary Seacole Building, Brunei

University, tJxbridge, Middlesex UB8 3PH

Correspondence to: N Plastow

Nicola Ann Plastow

Evidence-based practice is a cruciai part of professional conduct for practicing allied health

professionals. Rosenberg and Donald (1995) identified the well-recognized four steps to evidence-

based practice, which include identifying the clinical question, finding and critically evaluating the

evidence and finally implementing the evidence.

To date there is a wide variety of literature available describing evidence-based practice and

methods of critically evaluating the literature, however, there are few articles describing how to

promote change on the basis of evidence found.

This article aims to outline a modei for changing practice for health professionals at all levels of

practice. The model uses broad organizational development and project management principles. It is

applicable for managing change both within organizations and at an individual level and will be useful

to a range of allied health professionals.

Key Words: Evidence-based practice, deveiopment, change management

Plastow N (2006) Implementing evidence-based practice: A model for change. Int J Ther Rehabii 13(10): 464-9

E vidence-based practice is 'a process of turning clinical problems into ques- tions and then systematically locating, appraising and using contemporaneous

research findings as the basis for clinical decisions' (Rosenberg and Donald, 1995). Sackett ct al (1996) added that:

'The practice of evidence-based medicine means integrating individual ciinicai expertise with the best avaiiabie external clinical evidence from systematic research'.

The use of evidence can therefore assist occupa- tional therapists and other allied health profession- als to make decisions in clinical practice based on the best available evidence (Bannigan, 1997; Lloyd- Smith, 1997; Taylor, 1997).

A broad range of literature is now available to allied health professionals detailing methods of searching for the evidence as well as a variety of models for critical appraisal (Finlay 1997; Law, 1998; Sackett et al, 2000; Dorsch, 2003). Few arti- cles, however, offer practical advice for change management based on the evidence gathered, either for organizations or for individtial therapists.

This article aims to outline a model for change, developed by the author, using broad organizational development and project management principles (Figure J). The model can be used both by clini- cians who are implementing an evidence-based

intervention for a particular client, or by managers who want to implement evidence-based practice across a department. This article will describe the process the author used as an occupational therapist in an older people's mental health service. The pro- posed plan was to implement a reminiscence group in a residential home as an intervention for depres- sion for a particular resident, Mary (pseudonym).

IMPLEMENTING THE EVIDENCE

Initiate change Allied health professionals identify a number of barriers to evidence-based practice (Metcalfe et al, 2001; Palfreyman et al, 2003; Roulstone et al, 2004; Tempest et al, 2004), which reduce the momentum for change. The first hurdle in changing practice is to actually initiate the change process. Change can be initiated by a number of factors including raising the awareness of the need to change prac- tice, identification of variations of practice across an organization, or awareness of a new intervention or technique (Bury, 1998). In the authors case, the aim was to identify the best non-pharmacological treatment for Mary.

Identify change required The next step is to clearly state the change that is required. This ensures that the process of change is managed efficiently. The author aimed to imple-

464 International Journal of Therapy and Rehabilitation, October 2006, Vol 13, No 10

ment a 1-hour reminiscence group for five resi- dents, including Mary, at the care home once per week for 6 weeks. This proposed outcome was con- cise, meastirable, achievable and had a stated maxi- mum time for change to occur.

Conduct diagnostic analysis Stakeholder analysis: Stakeholder analysis is a three stage process. First the specific people or groups who are affected by or have an interest in the change are identified. In the authors setting the peo- ple most likely to be affected were identified as the

Figure I. Evidence based practice: a model of change

therapist (author), the therapy assistant, and Mary. The wider multi-disciplinary team was also affected by and interested in the new intervention.

The level of multi disciplinary team (MDT) inter- est in a proposed change depends on the nature of the change, how well the team is integrated, and how much pressure there is in the team to work inter-professionally. The staff and other residents at the home would also be affected by the planned intervention, although some more than others.

At the second stage of stakeholder analysis, the required actions of each stakeholder needs to be

Initiate change

Identify change

Conduct diagnostic analysis

Stakeholder analyisis

Factors affecting uptake

Attitudes and readiness for

change

Force-field analysis

Select and plan the right intervention

Plan and prepare intervention

Evaluation methods

Design implementation strategy

Clinical guidelines

Educational approaches

Audit and feedback

Outreach Conferences

Service user involvement

Local opinion leaders

Implementation cycle

Plan for individual

Identify change for next time Do intervention

VjV—I Reflect on success

Evaluate success

Plan future actions

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identified. At the third stage, approval and support for implementing the change in practice should be gained from all people identified as stakeholders, in order to improve the chances of successful imple- mentation (Beckhard and Harris, 1987; Oldfield, 2001). Assess factors that may afTect implementation: Once all the stakeholders have been identified, othei' factors that may affect implementation need to be considered. These may include the support for the intervention in the literattire, its adaptability to indi- vidual clinical practice, how easy it is to implement and the risk of its use to patients or clients.

Other factors to consider include the change's compatibility with the philosophy and practice of the person leading the change, and with wider health agendas such as the National Service Frameworks, National Institute of Health and Clinical Excellence (NICE) Guidelines and clinical governance. Change that clearly reflects the wider health agenda is more easily justified to clinicians and managers who are acting as stakeholders. Assess attitude and readiness for change: Clinicians involved in any proposed change will have different attitudes and approaches towards change, which in turn affects their readiness to change (Prochaska and DiClemente, 1986; Camall, 2003; Dobson, 2004). Those involved need to understand the reasons for the change in practice, its likely benefit for service users, and its suitability to the service provided. They also need to be confident that implementing evidence-based practice will be successful.

Four different approaches to change have been identified by Rogers (1983): 1. Innovators are those who are constantly looking

for ways to improve practice and will usually be the clinician who is driving the change forward.

2. Early adopters will usually be enthusiastic about change and will have a commitment to improving practice.

3. The early majority may be a little skeptical about the change but will support the process of change if they have confidence in it.

4. Finally, there is the late majority who are usually reluctant to change.

Changing practice can be very intimidating for those involved. Small changes to practice may only require one 'innovator; and a few 'early adopters' to make the change happen, however, with bigger changes there is likely to be a larger 'early majority' who need a little convincing.

If confidence about the change is needed, 'innova- tors' need to keep their enthusiasm while influencing the 'early majority'. When implementing evidence- based practice there will always be those who will not change their practice or accept alternative prac-

tice from others (Rogers, 1983). Acknowledging that it is impossible to keep everyone happy will ensure that the change still occurs, despite a small number of protesters. If a large number of the stake- holders take a 'late majority' attitude to the change proposed, it may be more successfiil if the change is introduced in smaller, more acceptable steps.

Changing and developing practice will occur at different paces depending on the various stake- holders' attitudes to change. In the authors case, the change in practice was relatively small and only required the author and the therapy assistant to drive the change forward. The rest of the MDT were supportive of innovative practice, but needed to be presented with the evidence that had been found to support the use of a reminiscence group for depressed residents. Force field analysis: There are factors that will both encourage and hinder change (lies and Sutherland, 2001). Once the need for change has been identi- fied, a force field analysis can be conducted (Paton and McMalman, 2000). This is the process through which the strengths, weaknesses, opporttmities and threats facing the proposed change are identified and diagrammatically represented as forces for change and forces against change. In the authors project it was useflil to consider all the stakeholders in order to identify potential stumbling blocks so that they could be tackled in a planned and system- atic way.

Once the diagnostic analysis has been completed, the implementation of the evidence should be planned in more detail, considering all the factors already identified.

Select and plan the right intervention During this step of the process, an implementation or intervention plan is developed, and evaluation meth- ods selected, based on the best available evidence. Planning and preparation: During the planning and preparation stage it is useflil to consider from the evidence gathered the best method of delivering the change or intervention. If a change in therapeu- tic practice is planned it may be useful for the thera- pist to consider the following factors: • How many sessions of the new intervention will

be required • The ideal dtiration of each session • Each session's content • Which staff members need to be involved in the

delivery of the new intervention. Each of these factors was taken into account when the author wrote the statement of the change required. Evaluation methods: When introducing some- thing new, it is important to measure outcomes in order to demonstrate the efficacy of clinical prac-

466 International Journal of Therapy and Rehabilitation, October 2006, Vol 13, No 10

tice. The authors previous search and evaluation of the evidence highlighted the potential benefits of the reminiscence groups - and also how others had measured the effectiveness of sitnilar groups.

Evaluation should be as broad as possible, indicat- ing improvement in symptoms, functional perform- ance and quality of life for therapeutic interventions. For all interventions, the client's level of perform- ance both before and after the intervention needs to be measured in order to ensure that the intervention is actually leading to change.

For the intervention in question, the author planned to use the BASDEC (brief assessment schedule in the elderly cards) to assess depression (Yohannes et al, 2000), the mini-mental state exami- nation to assess cognitive function (Folstein, 1983), the MOHOST (model of human occupation screen- ing tool) to assess overall occupational performance (Kielhofher, 2002), and the group activity form to evaluate changes in level of group participation (Thorgrimsen et al, 2002). All these needed to be completed both before and after the series of remi- niscence groups.

Design implementation strategy For successful implementation, barriers identified in the force field analysis need to be addressed (Bury 1998; Effective Health Care, 1999). During the planning and strategy stage, each of the clinicians, service users and carers that have been identified as stakeholders should be interviewed about their knowledge of the planned intervention, their level of interest in the planned change, and the resources that they require and their availability. In the next stage the relevant approaches for change need to be identified and the materials required should be prepared.

Using a range of strategies targeted at the barriers to change leads to more effective change (Effective Health Care, 1999). Different strategies employed by the author included clinical guidelines for the treatment of depression in older people, informal education about the benefits of reminiscence, dis- cussing the planned intervention with the resident' gaining the support of the home manager and out- reach to other organizations, such as the authors collaboration with the local authority culture and history project. Other useful strategies can include formal in-service education, audit and feedback and involving service users. Ciinical guidelines: Utilization of clinical guide- lines, such as the NICE guidelines for depression (2004), increases confidence and skills and reduces fear of ridicule, as evidence is clearly available to support the planned intervention. For the project in question, NICE recommended psychological treat- ment focused on depression for 6-8 sessions for

people with mild to moderate depression, and also advocated the evaluation of social support inter- ventions for those who are vulnerable, for exam- ple, care home residents. Clinical guidelines are now freely available through the National Electronic Library for Health (2006). Educational approaches: Educating other staff, particularly those who are reluctant to adopt change, can address a range of barriers to change. Different methods of education suit different situ- ations and learners (Wall, 2000). Education can be formal, with lectures, workshops and small group sessions (Chambers, 2000); or informal with individual members of staff. In the authors case informal education and making journal articles supporting the intervention available in the MDT office was helpful.

Education can also occur through experiential learning where staff observe or are involved with the new intervention, while the clinician carries it out (Alsop and Ryan, 1996). This occurred par- ticularly in the care home as some care staff either observed from a comfortable distance or, in one case, asked to be involved in a group. Audit and feedback: The need for evidence-based practice within teams can be highlighted through the process of audit and feedback (Mugford, et al 1991; Bury, 1998). Audit of previously used inter- ventions can provide a baseline against which future performance can be measured (NHS Modemization Agency, 2002b). Service user involvement: When using new or innovative clinical interventions, it is essential to involve both the service user and carers, within a partnership approach. In this study, Mary was pre- sented with verbal information regarding the use and effectiveness of the planned intervention (Btiry, 1998). The author then discussed Mary's response to being in a group, and the different options avail- able. These included: • Which residents Mary wanted to include in the

group • Where the group should be held • The most appropriate time of day for the group

to take place. Where problems were identified, such as the availability of a quiet group room, solutions were explored. Further information was also provided such as the content of the discussion of the reminis- cence groups.

This approach empowered Mary and enabled her to make choices about her care, influence the reac- tions of staff to the new intervention, and improve her own health outcomes (NHS Modernization Agency, 2002).

Following the choice and execution of imple- mentation strategies, clinicians can evaluate the

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effectiveness of these and can prepare for imple- mentation of the intervention.

Implementation cycle At this point significant effort and time should have been taken to ensure that the planned change can occur without the stirfacing of major problems. For small scale change like the authors project, many of the above steps were considered only briefly, how- ever, for substantial organizational change, adequate planning and preparation is vital for success.

Implementation of a change in practice should occur through an implementation cycle based on the principles of action research: plan for individ- ual change, do intervention, reflect on success and identify change required in the future (Figure J). This is a style of research that aims to generate new knowledge, improve practice and enhance critical clinical reasoning (Bowling, 1997; Berwick, 1998; Meyer, 2000; Taylor, 2000; Darwin et al, 2002) while improving the relationship between theory and practice (Darwin et al, 2002).

Completing change in small cycles on a case- by-case basis, starting with Mary, allowed for adaptation of the new intervention to her own cir- cumstances. This process could then be repeated in future with other referrals to the MDT who lived in different care homes and who had different indi- vidual circumstances (Berwick, 1998).

EVALUATING THE OUTCOMES

In evaluating the outcome of implementing evi- dence-based practice, it is useful to consider both the sustainability and spread of the new interven- tion. Evaluation in the authors study occurred by asking two questions: • Did the intervention happen as planned? • What was the effect of the reminiscence sessions? The original objective of the reminiscence group was to implement a 1 -hotir reminiscence group for five residents, including Mary, at the care home as a non-pharmacological intervention for depression. This was meant to happen once a week for 6 weeks (NHS Modemization Agency, 2002b).

In this intervention only five of the six sessions took place, as Mary was feeling unwell one week, and the number of participants fluctuated. To evalu- ate the effect of the reminiscence sessions before and after scores on the clinical evaluation tools were compared. Mary showed improvement in all but the MMSE score.

Evaluation can occur in the short term such as with this individual resident, but should also occur over a longer period of time, as more of the same interventions are carried out with other service users. Short-term evaluation could help convince

the early majority, who have been skeptical about the change, that the new intervention is working for the client group. Evaluation over a longer period of time will provide more reliability as to whether the change implemented is leading to better outcomes for all of the service users involved.

Sustainability In order for the change to be sustainable over time the stakeholders should continue to see the benefits of the intervention. This can be achieved through feedback to the stakeholders at appropriate intervals using the longitudinal data recorded and includes the changes implemented, other progress made, challenges or issues that have arisen and future planned actions (NHS Modernization Agency, 2002c).

Spread Spread is the extent to which the learning and change applied during the implementation is adopted by other parts of the organization (NHS Modemization Agency 2002c). Spread is dependent on the readiness for change within the organiza- tion and how willing people are to adopt change. Spread can also occur through the development of clinical guidelines based on evidence-based prac- tice, research, publication and clinical audit. Each of these activities in tum supports future evidence- based practice. Using reminiscence groups as an intervention for depression was discussed within the occupational therapy in-service training, but in this case did not spread to other parts of the men- tal health service because of their existing service delivery models.

CONCLUSION

Evidence-based practice can be complex to imple- ment. However, with adequate planning and prep- aration, support from most stakeholders and the identification and removal of barriers to change, it can be successful. Success can be achieved by fol- lowing a model of change which includes: • Initiation and identification of change; • Diagnostic analysis of the factors affecting

change • Selection and planning of the most appropriate

intervention • The design of an implementation strategy • Following an implementation cycle • Evaluating success and planning for the future. This has been demonstrated with the example of a reminiscence group in a care home as an interven- tion for depression.

The benefits of the successful implementa- tion of evidence-based practice include improved

468 International Journal of Therapy and Rehabilitation, October 2006, Vol 13, No 10

health outcomes for service users and their carers, increased skill and knowledge for therapists and increasingly efficient and effective service provi- sion within the NHS.

With these benefits, all allied health profession- als should aim daily to deliver practice that is based on the best available evidence.

Conflict of interest: none.

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KEY POINTS

Evidence-based practice involves identifying a clinical question, finding and critically evaluating the evidence, implementing these findings into clinical practice and evaluating the outcome.

Evidence can be implemented at an individual and organizational level using organizational development and project management pnnciples.

Implementing change successfully occurs through a process of initiating and identifying change, planning for change and implementing it on a case by case basis.

Evaluation should include the effectiveness of the change for service users, the sustainability of the change in practice as well as its spread to other parts of the organization.

Change based on the best available evidence leads to measurable improvement for service users and carers, therapists and their employing organization.

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