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Journal of Human Behavior in the Social Environment, 22:54–64, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1091-1359 print/1540-3556 online
DOI: 10.1080/10911359.2011.598828
Social Learning Theory and Behavioral Therapy: Considering Human Behaviors within the Social and Cultural Context
of Individuals and Families
ANNIE McCULLOUGH CHAVIS
Department of Social Work, Fayetteville State University, Fayetteville, North Carolina, USA
This article examines theoretical thoughts of social learning theory
and behavioral therapy and their influences on human behav-
ior within a social and cultural context. The article utilizes two
case illustrations with applications for consumers. It points out
the abundance of research studies concerning the effectiveness
of social learning theory and the paucity of research studies re-
garding effectiveness and evidence-based practices with diverse
groups. Providing a social and cultural context in working with
diverse groups with reference to social learning theory adds to the
literature for more cultural considerations in adapting the theory
to women, African Americans, and diverse groups.
KEYWORDS Social learning theory, behavioral therapy, human
behavior, social context, cultural context, environment, effective-
ness, evidence-based practice, African Americans, diverse groups
INTRODUCTION
Social learning theory is one of the most recent approaches to addressing people in need and applying the theory to human problems within a social context. The utilization of the theory as an applicable approach to change human behaviors began in earnest in the 1950s. Its use in the social and behavioral sciences as a mental health intervention grew in popularity in the late 1950s as interest in insight-oriented approaches waned. Social learning
Address correspondence to Annie McCullough Chavis, Department of Social Work, Fayetteville State University, 1200 Murchison Road, Fayetteville, NC 28301, USA. E-mail:
54
Social Learning Theory and Behavioral Therapy 55
theory is one of the most influential theories of learning and human devel- opment and is rooted in many of the basic concepts of traditional learning. The theory focuses on learning that occurs within a social context, and it considers that people learn from one another (Ormond, 1999); however, the theory adds a social element. It proposes that people can learn new information and behaviors by observing other people. Thus, the use of observational learning, imitation, or modeling explains a wide variety of human behaviors using social learning theory and approach. Behavioral therapy has its roots and basic principles within social learning theory.
Centered upon principles of learned behavior that occurs within a social context, behavioral therapy focuses upon the principles of classical condi- tioning developed by Ivan Pavlov and operant conditioning developed by B. F. Skinner. Coady and Lehmann (2008) note that Pavlov (1927) demon- strated that, through association in time and space, the sound of a bell could have the effect of cuing a dog to produce a biological reaction of salivation— classical conditioning/learning. B. F. Skinner (1953, 1974) documented that when behavior occurs, whatever follows it (the consequences of behav- ior) can either increase or decrease the frequency, duration, or intensity of the behavior (Coady & Lehmann, 2008). Albert Bandura (1977) added to the development of the therapy by exploring the role of cognition and emphasizing that people learn vicariously. Burman (1997) states behavior therapy is an approach to psychotherapy based on learning theory that aims to treat psychopathology through techniques designed to reinforce desired and extinguish undesired behaviors. Today, with the thrust for evidence- based practice and measurable results, behavioral therapies are widely used to change general as well as dysfunctional behaviors such as depression, anorexia, chronic distress, substance abuse, anxiety, obesity, phobia, pas- sivity, obsessive behavior, self-mutilating behavior, anger disorders, mental retardation, and alcoholism (Mehr, 2001). The explanation of these behaviors is largely based upon culture. Culture is a major factor in explaining and intervening in human behaviors.
Culture shapes human behavior and the social environment. The social environment of today is one of many challenges and warrants the use of evidence-based practices that focus on culture to meet the needs of con- sumers seeking help with problem behaviors. All individuals are social beings and carry within them their cultural experiences that affect all aspects of behavior. This article focuses on two case illustrations and discusses learned behaviors, the usability of social learning theory, and behavioral therapies within the social and cultural context. The cultural context refers to the environment and cultural influences but recognizes that society, community, and cultural heritage, values, beliefs, thinking, and traditions affect individ- uals and families (McCullough-Chavis & Waites, 2004). For this article, the social and cultural context includes the culture, community, family, school, work, and all systems within the social environment of consumers. The article
56 A. McCullough Chavis
concludes with a discussion of the importance of social learning theory and approaches to usability with individuals from varied cultural backgrounds such as African Americans and women.
LITERATURE REVIEW
Interventions and Effectiveness
Social learning interventions and behavioral approaches to changing human behaviors are among the most studied and reported in the literature. Ac- cording to Mehr and Kanwisher (2007), persons conduct more controlled outcome research on behavioral therapies than on any other psychotherapy due to the use of scientific methods and the ability to measure outcomes using evidence-based practice techniques and instruments. Behavioral ther- apy points toward the new emphasis in the social sciences on empiricism (observable evidence) in evaluating the outcomes of intervention with chil- dren, adults, couples and families (Mehr & Kanwisher). They state the surge in the therapy movement toward efficiency, research-supported methods, and evaluation of outcomes is a credit to behaviorists, and there is evidence that these approaches do change behaviors. Uses of the approaches in systems or settings include public school programs for emotionally handi- capped children, residential programs for people who are mentally retarded, residential and outpatient programs for children identified as mentally ill, and juvenile and adult corrections facilities (Mehr & Kanwisher). In many settings and systems, behavioral therapies are the primary approaches employed to change unacceptable learned behavior in children and adults. Therefore, the service delivery environment, with its focus on outcome indicators and evidence-based practice, owes a great debt to behaviorists who remain the most proficient group of practitioners in measuring intervention outcomes (Granvold, 1994).
Behavioral therapies are efficient therapies, and several research studies document effectiveness for a wide range of behaviors. Mehr and Kanwisher (2007) postulate that the effectiveness of behavioral approaches seems well documented, particularly for consumers who have behavior problems that use behavioral approaches. Weisz, Hawley, and Doss (2004) statistically examined 236 published randomized trials on treatment for youth (ages 3–18 years) spanning the years 1962 through 2002. They found that across various outcome measures, 80% of treated youngsters improved after treatment more than those not treated. Behavioral treatments proved more effective than non-behavioral treatments regardless of client age. Mehr and Kanwisher (2007) report that a major positive feature of behavioral strategies is that a majority of their proponents are thoroughly indoctrinated in the scientific method and extremely concerned with proving whether the techniques of
Social Learning Theory and Behavioral Therapy 57
behavioral therapy work. Therefore, many behavioral studies, and particu- larly controlled studies, support the claims of significant behavior evalua- tions and evidence-based practices claims. Prochaska and Norcross (2007) describe several meta-analyses conducted on adults, couples, and families concerning the effectiveness of behavioral therapy that produced similar results. For example, in a 1983 study conducted by Norcross and Wogan (cited in Prochaska & Norcross), behavior therapists reported seeing clients less frequently and for a shorter duration than psychotherapists of other persuasions, and only 7% of their clients, on average, had more than a year of treatment.
Literature documents the use of behavior approaches to deal with per- sons in individual, group treatment and family settings. Mehr and Kanwisher, (2007) discuss a 1986 study, reported by Nardone, Tryon, and O’Conner, on a cognitive-behavioral group treatment for reducing impulsive-aggressive behavior in adolescent boys in a residential setting for boys. During the course of the project, the frequency of impulsive-aggressive behavior on the part of the boys declined dramatically. However, during a follow-up period, the therapist discovered that the positive gains slowly eroded and disappeared within 5 weeks. With more focus on evidence-based practices, this finding clearly emphasizes the need for maintenance reinforcement programs after behavior therapy programs.
Other studies point to the use of social learning theory as a family intervention. Kilpatrick and Holland (2009) suggest that social learning theory utilization as a family intervention is particularly effective with families that have issues with internal and external environmental factors. They report that families who experience high levels of disruptions and communication problems and families that have children in difficulty with social systems within the community are a few examples of intervention utilizing social learning theory. In other studies as cited in Kilpatrick and Holland (2006, 2009); Sayger, Horne, and Glaser; Sayger, Horne, Walker, and Passmore; and Szykula, Sayger, Morris, and Sudweeks measured the effectiveness of social learning family interventions with children with behavioral disorders and their families in a variety of settings. The results, according to the authors, have been remarkable, with significant decreases in negative behaviors of children in the study and subsequent increases in positive behaviors both at home and in school.
The literature review suggests social learning and behavioral interven- tions are effective in changing human behaviors across several environmental settings in treating children, adults, and families. The theory and approaches have a strong research and evidence-based background that demonstrate effectiveness within the social context of human behaviors. However, the literature does not provide sufficient information concerning effective inter- ventions with all target groups, particularly diverse groups such as women, African Americans, and people of color consumers. Today, any efforts at
58 A. McCullough Chavis
interventions and problem resolutions must be in tune with the distinctive culture, values, and community customs of all consumers within their social and cultural context.
Understanding theory and the impact of behaviors on human devel- opment are collectively a part of interventions in the social and behavioral sciences. For example, in social work, the influence of theory driving practice is evident, and all the social sciences expound evidence-based practices as sufficiently interrelated to outcomes pertaining to human behaviors within the social context. To illustrate the relationship concerning human behaviors, theory, and behavioral interventions, two case illustrations discuss the need for changes in human behaviors. The two cases demonstrate how to use social learning theory and behavioral approaches with different individuals and families in different settings and disciplines, and particularly in social work.
Case Illustrations
The case illustration of Paula demonstrates the use of behavioral therapy in a public school setting. The second case illustration (of Jamaal) exemplifies the use of social learning theory in a family intervention case with an emphasis on social work.
Paula, age 10, is one of five students in an exceptional classroom. Her disruptive behavior prevents her from being in a regular classroom. Paula’s behavior disrupts the learning environment due to her hyperactivity and impulsivity. She constantly squirms in her chair, snaps her fingers, taps her feet, talks loudly to the other students during class, and gets up and moves about the classroom without permission instead of listening and following instruction from the classroom teacher or teacher assistant.
Paula is the oldest child of John and Megan Head. She has an 8-year-old brother, Tim, who attends the same elementary school in a regular class. The parents report no major behavioral problems with him but state that Paula has difficulties remaining in her seat while eating as well as when the family watches television or engages in most family activities. They use time-out techniques when these disruptions occur. They expressed concerns about Paula’s behavior and often inquire from the school about her behavioral and educational progress.
In this case illustration modified and adapted from Mehr (2001), in order to help Paula change the undesirable classroom behaviors, the teacher, teacher assistant, school psychologist, and social worker met several times and decided to implement a behavioral treatment plan with Paula. After several discussions, they targeted two behaviors for change: talking to other students and leaving her seat without permission. The focus of intervention was observation and recording of the behaviors, verbal counseling, verbal praise, and loss of playtime because of breaking these two rules. If Paula
Social Learning Theory and Behavioral Therapy 59
spoke or left her seat without permission, the aide reminded her of the loss of playtime for rule breaking. If Paula behaved acceptably, she received verbal praise. The primary person responsible for the behavioral program was the teacher aide, and for a day, she observed Paula and recorded how often she disrupted the class concerning the targeted behaviors. The disrupted behaviors occurred 25 times during the 1 day of observation before any intervention.
The next week, the teacher aide informed Paula of the program and the consequences if the two disrupted behaviors occurred. At the end of each class period when Paula did not speak out or leave her seat without permission, she earned a gold star beside her name on the board. At the end of the day, she could take a gold star home to her parents if she earned stars in more than half of the classroom sessions. At the end of the week, Paula was down to eight disruptions a day and showed much progress as recorded by the teacher’s aide. The next week, the aide added another behavior to change and explained the addition to Paula. By the end of the second week, Paula was down to four disruptions a day, and after another week, Paula took home a gold star each day. Some days there were one to no disruptions, and this change continued for the remainder of the school year. More sig- nificantly, Paula’s schoolwork improved with the improvement in behavior, and the positive changes continued until Paula did not need gold stars to maintain her behavior. Using pre-data and data during the intervention, the case of Paula illustrates the application of principles of learned behavior. It shows that humans can learn to change undesirable behavior with behavioral therapy and evidence-based practice within a social context.
Modified and adapted from Kilpatrick and Holland (2006), the second case illustration of Jamaal exemplifies the use of social learning theory in a family intervention case. This case illustrates the use of treatment goals consistent with the principles of the theory.
Jamaal, a 22-year-old African American man, is gay and the only child of Joe and Mary Jones. After graduating from college, he returned home to live and work as a high school teacher.
Jamaal’s parents are highly religious and do not approve of Jamaal’s sexual orientation or his homosexual relationships. They will not converse with Jamaal about his sexual orientation or relationships. They believe in intimate heterosexual relationships and that God condemns any other rela- tionships. Jamaal is very close to his parents and expresses concern about their denial or disapproval of his relationships. He desires the acceptance of his choice of relationships and sexual orientation by his parents. Jamaal believes in God but has concerns about being gay and being accepted within his social environment. Many in his family, church, and extended family are homophobic.
Other family members suspect that Jamaal is gay but are not quite sure of his sexual orientation, so he selects and guards his communication with
60 A. McCullough Chavis
extended family, except for his cousin, James. Although Jamaal interacts with James more than with other extended family, Jamaal has never revealed any information regarding his sexual orientation or ambivalent feelings about be- ing gay or non-acceptance by his parents to James. However, Jamaal suspects that James is aware of his sexual orientation. His parents avoid the subject and are consistent in their disapproval. Jamaal feels lonely, ashamed, angry, and isolated. Consequently, he is having considerable difficulty managing his needs for intimacy. The negative social pressure he feels from his family and social environment is burdensome and depressing.
Jamaal came to counseling seeking assistance in learning how to manage his intimacy, his loneliness, and his shame, anger, and pain. Additionally, he needs help learning to accept his homosexuality and help with communi- cation skills to assist in facilitating meeting other persons. There is also a need to learn new ways of conversing with his parents and family members concerning their homophobia and his sexual orientation.
In this case illustration, the focus of intervention is with Jamaal and his parents as they are experiencing difficulties with an ineffective family structure and boundaries (Kilpatrick & Holland, 2006), which could inhibit problem solving (homosexuality, intimacy, communication, and feelings of shame, pain, anger, and confusion). The communication within the family as dictated by the family rules is weakening by unrealistic expectation and appears complicated by these rigid family rules and family roles. There is also confusion within the family and clearly with Jamaal. This confusion limits the family’s capacity to overcome their life challenges and feelings of insecurities, dissatisfaction, and discomfort with the level of intimacy within the family and the environment (Kilpatrick & Holland, 2006). The family operates as a closed family system concerning family rules, boundaries and communica- tion, and dealing with Jamaal’s sexual orientation. Also, Jamaal’s communica- tion is poor regarding his feelings, and he finds it difficult to maintain intimate relationships. Utilizing social learning theory, it would be very appropriate and useful to work with Jamaal and his family concerning the following goals as stated by Kilpatrick & Holland (2006) and modified for this case:
1. Learn to develop coping strategies to manage fear and loss (son’s sexual orientation, family, and son’s acceptance of sexual orientation) within the social and cultural context;
2. develop skills and knowledge concerning self-control to manage, family, life, and the social environment of extended family and religious family more effectively; and
3. help in communication skills that will permit family rules, roles, and boundaries to be more open and that will allow greater means and ways of expressing feelings, meeting people and sharing with family and friends that includes the cultural context in meeting the unique style, life experiences and worldview of the family.
Social Learning Theory and Behavioral Therapy 61
Social learning theory interventions are appropriate for use with Jamaal and his family. Cognitive thoughts, beliefs, and development of communication skills from a cultural perspective are major focal points of intervention with Jamaal. The case also focuses on appropriate learned behaviors by normal- izing the problems of the family and focusing on strengths within the social and cultural context. Social learning theory and behavioral approaches are applicable in a variety of environments and disciplines.
DISCUSSION AND IMPLICATIONS
Social learning theory offers a structured and learned approach to dealing with a variety of behavioral concerns in many different disciplines and settings. Although I discuss only two case illustrations, this article presents the importance of treating and focusing on learned behaviors using theory and strategies in an effort to change behaviors from a social and cultural context. The target population of the two cases consisted of a female consumer and an African American male consumer from diverse groups. The question of the applicability of the theory and approaches with diverse groups is a major criticism and of concern to this author and others. Kilpatrick and Holland (2009) state that in some cultural groups, the specific approaches used in social learning theory are not valued or endorsed; rather, they appear as being white, middle class, or incompatible in other ways with many cultural groups. Although behaviorists expound empowerment and concrete changes of consumers, the research rarely addresses cultural, multicultural, or African American issues, despite important theoretical contributions made by Cheek (1976) and Kantrowitz and Ballou (1992).
Cheek, a pioneer in assertive training, was one of the first behaviorists to generalize behavior theory specifically to counseling with African Americans. He demonstrated the validity of behavioral concepts with African American clients and supplied a culturally relevant view to the therapy. Cheek affirms that assertive behavior varies between African American and white cultures and that both groups need to understand the frame of reference of the other (Ivey, Andrea, Ivey, & Simek-Morgan, 2002). The work by Cheek had particular implications for women.
Kantrowitz and Ballou (1992) suggest that the behavioral focus on indi- vidual skill training could neglect social issues and support dominant group values. They assert that assertiveness training is an example of evidence- based treatment and will probably meet with the approval of the sexually harassed woman, and the social norm of women’s duty to protect themselves is not seriously questioned. The women’s distress is temporarily reduced, but the social status quo of the dominant society is also decisively protected. That is, necessary social change does not occur.
62 A. McCullough Chavis
Even though the literature cites the wide use of social learning theory and behavioral therapies, a careful examination of the literature found a paucity of information to support effective and evidence-based application with women, African Americans, and diverse groups. A wide array of behav- ior therapies applying the principles is applicable for use with these groups, but what is not as clear is whether substantially conducted research studies prove efficacy and effectiveness. Empirically, behavioral therapies yielded a great deal of effective therapies, and some took into account the culture and worldview of African Americans and others, but according to Cheek (1976), behaviorists should not seek to ‘‘make African Americans White’’ or to have women think like men but to recognize the perspective and worldview of different groups. His pioneering works demonstrate how to use the approaches effectively with African American clients when modified to meet the client’s unique style, life experiences, and worldview.
The worldview and culture of African Americans and other diverse groups are uniquely different from the dominant group. Nobles (1973) argues that the African view of ‘‘self’’ is contingent upon the existence of others, oneness of being, and a balance and harmony with all things. McCullough- Chavis and Waites (2004) contend that the cultural context is an important aspect of individuals and families. Thus, a criticism of social learning the- ory and behavioral therapies from a cultural perspective is the somewhat exclusion of diverse cultures and an African view of ‘‘self.’’ If Cheek can demonstrate effectiveness with African American consumers when adjusted to meet the consumer’s unique linguistic style and life experiences (Ivey et al., 2002) and Kantrowitz and Ballou with women, then behaviorists should consider these adjustment and adaptations when working with consumers from diverse groups.
CONCLUSION
This article presents two case illustrations and focuses on the importance of human behaviors within the social environment. The literature points to evidence-based practice and the effectiveness of the theory and approaches. However, the author believes that in order to make an unmitigated claim of effectiveness and aggregate evidence-based practice, those utilizing the theory and approaches must prove their effectiveness through more research with other groups as demonstrated with the dominant group. The social en- vironment of today is a multicultural environment, which warrants the use of culturally focused evidence-based practices to meet the needs of consumers seeking assistance with problem behaviors in a variety of environmental settings and disciplines. In addition, the Code of Ethics for social workers states there is a responsibility to ‘‘understand culture and its function in
Social Learning Theory and Behavioral Therapy 63
human behavior and society, recognizing the strengths that exist in all cul- tures’’ (National Association of Social Workers, 1996, p. 9). Thus, it is critical and imperative that social workers, practitioners, counselors, sociologists, psychologists, educators, and behaviorists practice more from a culturally focused perspective. In order to be effective, professionals must acquire further knowledge and skills about the cultures, values, beliefs, practices, and worldviews of individuals and families who come from different and varied cultural backgrounds. This article and its use of two case illustrations offer a structural and practical approach to dealing with human behaviors within the social and cultural context. It helps professionals understand and intervene appropriately and effectively with consumers from various cultural backgrounds.
REFERENCES
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
Burman, S. (1997). An agenda for social work education and practice: A multi- theoretical approach in intervention planning. Journal of Teaching in Social
Work, 15(1/2), 81–95. Cheek, D. (1976). Assertive black : : : : Puzzled white. San Luis Obispo, CA: Impact.
Coady, N., & Lehmann, P. (Eds.). (2008). Theoretical perspectives for direct social
work practice: A generalist-eclectic approach. New York, NY: Springer. Granvold, D. (Ed.). (1994). Cognitive and behavioral treatment: Methods and appli-
cations. Pacific Grove, CA: Brooks/Cole. Ivey, A., Andrea, M., Ivey, M., & Simek-Morgan, L. (2002). Theories of counseling
and psychotherapy: A multicultural perspective (5th ed.). Boston, MA: Pearson. Kantrowitz, R., & Ballou, M. (1992). A feminist critique of cognitive-behavioral
therapy. In L. Brown & M. Ballou (Eds.), Theories of personality and psy- chopathology: Feminists reappraisals (pp. 70–87). New York, NY: Guilford.
Kilpatrick, A., & Holland, T. (2006). Working with families: An integrative model by level of need (4th ed.). Boston, MA: Pearson.
Kilpatrick, A., & Holland, T. (2009). Working with families: An integrative model by level of need (6th ed.). Boston, MA: Pearson.
McCullough-Chavis, A., & Waites, C. (2004). Genograms with African American families: Considering cultural context. Journal of Family Social Work, 8(2), 1–
19. Mehr, J. (2001). Human services: Concepts and intervention strategies (8th ed.).
Boston, MA: Allyn & Bacon. Mehr, J., & Kanwisher, R. (2007). Human services: Concepts and intervention strate-
gies (10th ed.). Boston, MA: Allyn & Bacon. National Association of Social Workers. (1996). Code of ethics. Washington, DC:
NASW Press. Nobles, W. W. (1973). Psychological research and the black self-concept: A critical
review. Journal of Social Issues, 29(1), 11–31.
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Ormond, J. E. (1999). Human learning (3rd ed.). Upper Saddle River, NJ: Prentice-
Hall. Pavlov, L. P. (1927). Conditioned reflexes: An investigation of the physiological
activity of cerebral cortex. London, England: Oxford University press. Prochaska, J. O., & Norcross, J. C. (2007). Systems of psychotherapy: A transtheoret-
ical analysis (6th edition). Belmont, CA: Thomson: Brooks/Cole. Skinner, B. F. (1953). Science and human behavior. New York, NY: MacMillan.
Skinner, B. F. (1974). About behaviorism. New York, NY: Random House. Weisz, J. R., Hawley, K., & Doss, A. (2004). Empirically tested psychotherapies for
youth internalizing and externalizing problems and disorders. Child & Adoles- cent Psychiatric Clinics of North America, 13, 729–815.
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www.elsevier.com/locate/bodyimage
Available online at www.sciencedirect.com
–38
Body Image 5 (2008) 28
Review article
Social learning theory and cognitive behavioral models
of body dysmorphic disorder
Fugen Neziroglu a,*, Sony Khemlani-Patel
a , David Veale
b
a Bio-Behavioral Institute, Great Neck, NY, United States
b Institute of Psychiatry, Kings College, London, United Kingdom
Received 14 June 2007; received in revised form 3 January 2008; accepted 5 January 2008
Abstract
Contemporary cognitive behavioral models of body dysmorphic disorder are reviewed, whereby the first by Neziroglu and
colleagues emphasizes conditioning processes and relational frame theory and the latter by Veale emphasizes information
processing. A brief review of the existing cognitive behavioral therapy research follows the presentation of the models. The majority
of publications on BDD continue to deal with phenomenology and epidemiology, and much more research on cognitive behavioral
treatment is needed. Treatment research should be geared towards testing elements of the models explicated in this article, and
randomized controlled trials are greatly needed.
# 2008 Elsevier Ltd. All rights reserved.
Keywords: Body dysmorphic disorder; Cognitive behavioral treatment; Classical and operant conditioning; Information processing; Social
learning
Introduction
Cognitive behavioral theories explain the possible
mechanisms involved in a disorder and at best why
certain feelings and behaviors are maintained, but not
necessarily how and why they develop. Theories for the
development of body dysmorphic disorder (BDD) have
been put forth by both Veale (Veale, 2004; Veale et al.,
1996) and Neziroglu (Neziroglu, 2004; Neziroglu,
Roberts, & Yaryura-Tobias, 2004) Although these two
models are specific to BDD, they incorporate many of
the elements of Cash’s general cognitive social learning
model of body image disturbance (2002, 2008). Cash’s
model discusses how historical factors (cultural
socialization, interpersonal experiences, physical char-
* Corresponding author. Tel.: +1 516 487 7116;
fax: +1 516 829 1731.
E-mail address: [email protected] (F. Neziroglu).
1740-1445/$ – see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bodyim.2008.01.002
acteristics, and personality attributes) lead to the
development of body image perception and attitudes
that elicit emotions and behaviors that are then
maintained via negative reinforcement. Perception
traditionally refers to body size or shape estimations
while attitude refers to self-evaluations (i.e., body
satisfaction) and investment (e.g., importance one
places on appearance). The attitudes or schemas
regarding one’s appearance contribute to emotions,
beliefs, and behaviors related to body dissatisfaction.
Neziroglu’s model emphasizes evaluative and
operant conditioning as well as the role of relational
frames in developing BDD related beliefs. Veale’s
model emphasises the role of imagery, attentional biases
and effortful cognitive processes such as ruminating. At
times, in order to explicate the models, it will be
necessary to diverge and explain related phenomena
such as relational frame theory since its application to
disorders is relatively new and not well understood.
F. Neziroglu et al. / Body Image 5 (2008) 28–38 29
A cognitive behavioral model based on classical
(evaluative) and operant conditioning
Childhood operant conditioning
Early experiences which positively reinforce an
individual for physical appearance may play an important
role in BDD development. In clinical interviews with
individuals with BDD, Neziroglu, Roberts, and Yaryura-
Tobias, 2004 reported that for a significant portion of
BDD individuals, appearance was one of, if not the most
salient factor reinforced during their childhoods. These
experiences may function to reinforce a sense that
appearance is ultimately important to the exclusion of
behavior (e.g., comments such as ‘‘Wow, you are the
tallest kid on the team,’’ or, ‘‘You were wonderful on
stage and you looked so good,’’ rather than, ‘‘You played
the flute so well during the school concert’’). Although
not all BDD individuals were positively and/or inter-
mittently reinforced for their overall general appearance,
many were reinforced as children or adolescents for a
particular body part, height, cuteness, poise, weight, and/
or body shape. Often, individuals with BDD report
being in the ‘‘attractive’’ crowd in school, early dating
success, and other childhood and adolescent experiences
where the importance of appearance is highlighted and
exaggerated.
Early life experiences need not be positive to have an
impact. BDD individuals report a significantly greater
incidence of emotional and sexual abuse (Didie et al.,
2006; Neziroglu, Khemlani-Patel, & Yaryura-Tobias,
2006a). Other kinds of trauma, such as car accidents
resulting in scars or skin conditions (acne or psoriasis),
are reported to result in unnecessary attention to
appearance. Aversive early experiences (for example
teasing, neglect, bullying) may condition the individual
to the negative affect he/she may experience when
observing body parts in later life (Cash, Winstead, &
Janda, 1986; Osman, Cooper, Hackmann, & Veale,
2004; Rieves & Cash, 1996; Veale, 2004; Zimmerman
& Mattia, 1999). Research has shown that peer teasing is
positively correlated with body dissatisfaction even in
elementary school children (Smolak, 2002). Cash et al.
(1986) found that women and men who reported being
teased or rejected by their peers for their appearance
during childhood were more body dissatisfied as adults
than non-teased controls. Similarly, Cash (1995)
reported that teasing severity was highly correlated
with a more negative body image. In adolescence,
perception of overall physical appearance appears to be
the most important factor in global self-esteem,
especially in industrialized nations (Levine & Smolak,
2002). Experiences such as the ones mentioned above
may build core beliefs regarding the value of attrac-
tiveness.
Social learning
Vicarious learning occurs by observing others being
reinforced positively or negatively for a particular belief
or behavior (Bandura, 1977). One can learn that
physical attractiveness leads to rewards. This is perhaps
most salient in the media and popular culture. It is
difficult to find an unattractive lead female television or
movie star. Recent reality shows capitalize on this
entertainment theme: unattractive women must undergo
a radical transformation in order to win her ‘‘prince
charming.’’ In addition, children and adolescents are
taught that physical attractiveness is necessary for
success and are bombarded by advertisements for
cosmetic products and surgery to achieve this goal.
Besides the individual’s socio-cultural environment,
one’s immediate environment and family can provide
numerous learning opportunities as well. This type of
vicarious learning gives the individual further con-
firmation that appearance is an important trait valued in
society. For example, Rieves and Cash (1996) found
that there is an association between daughters’
recollections of their mothers’ earlier body image
attitudes and the daughters’ own current body image
experiences. In addition, they found that sibling social
comparisons were found to influence self-appraisal of
appearance, whereby having a more attractive sibling
may foster unfavorable self-evaluations, and a less
attractive sibling may enhance self-appraisals of
appearance. It appears, however, that direct comments
about body, weight, and eating are stronger sources of
parental influence than parental modeling (Levine &
Smolak, 2002). How do the above mentioned factors
contribute the development of BDD?
Symptom development through classical and
evaluative conditioning
Evaluative conditioning is similar to classical
(Pavlovian) conditioning with the latter referring to
conditioning of physiological responses and the former
to conditioning of liking or disliking a stimulus or
stimuli. They are very similar although the usage of
language that is unique to humans allows for some
differences. It is not within the scope of this paper to
discuss similarities and dissimilarities between the two.
For a review, see De Houwer, Thomas, and Baeyens
(2001). For the most part, the two have been used
F. Neziroglu et al. / Body Image 5 (2008) 28–3830
interchangeably in the psychological literature with the
term classical conditioning used more often.
BDD might begin with classically or evaluatively
conditioned experiences. Aversive events involving one’s
physical appearance, such as being teased, abused, or
reaching puberty earlier may serve as unconditioned
stimuli (UCS) since they cause an unconditioned
emotional response (UCR) such as anxiety, depression,
disgust, or shame. The UCS can cause an aversive
reaction and then when paired with a neutral stimulus
(CS) elicit the same reaction. In other words, the teasing,
abuse, and so forth, becomes associated with a word or
body part (an aversive stimulus; CS) that is then also
evaluated as negative. Therefore, both the UCS and CS
evoke emotions such as anxiety, disgust, and so forth.
The following is an illustration of classical or
evaluative conditioning. You are teased about your big
head (UCS) and you feel ashamed (UCR) and thereafter
you dislike or feel ashamed (CR) of anything you
associate with your head such as your hairline (CS:
evaluative conditioning). Because the teasing is eval-
uated to be aversive, all paired associations are also
deemed to be aversive. In other words, your hairline (CS)
is associated with teasing of the head (UCS) and both take
on a negative valence and elicit the same response of
shame (CR).
It can be hypothesized that (1) a biological predis-
position, (2) early childhood reinforcement history, and
(3) vicarious learning are necessary prerequisites for the
development of BDD. These factors may cause a
particular individual to have an increased sensitivity to
this type of classical or evaluative conditioning event,
since many individuals experience body-focused nega-
tive life events and do not develop a body image disorder.
A diathesis-stress model is important in explaining the
predisposition of some but not all individuals under these
circumstances.
Information processing/development of belief
system based on relational frame theory
Classical conditioning in humans is radically
different than it is for all other animals because of
our ability to think and verbalize our thoughts. We will
briefly explain this difference in order to explicate how
BDD individuals develop certain cognitions and
emotions. We explained above how BDD individuals
could develop certain aversive reactions to appearance
through conditioning. We further propose that role
language plays a significant role within this condition-
ing paradigm. Understanding this role requires that we
first explain the development of relational frames and
relational frame theory (Hayes, Strosahl, & Wilson,
1999).
Bi-directional stimulus relations
Only for humans, does a word and the actual item or
event enter into a bi-directional stimulus relation
wherein each can equally stand for the other. For
example, the word ‘‘cookie’’ and the actual cookie are
equal for humans because of our ability to use language.
We do not need to see the cookie in order to anticipate
getting a cookie. Simply hearing the word ‘‘cookie’’ is a
powerful enough stimulus, as the word and the food are
equally powerful reinforcers.
Animals require a direct experience with an object
for learning to occur; they learn about events that
predict the onset of something (e.g., Show a cookie, say
‘‘cookie’’ and dog salivates). However, a human child
can learn that touching a hot stove will burn without
having direct experience with a hot stove. Our ability to
use language allows us to learn about things even if we
have never experienced the particular events.
In addition, for animals, the order in which the word
‘‘cookie’’ is said and the presentation of the actual
cookie is important. The word ‘‘cookie’’ has to be said
before the cookie in order for the animal to learn that the
word and the actual object are the same. In humans,
however, the word ‘‘cookie’’ could be said either before
or after the child eats the cookie. We can then also teach
a child that a cookie is similar to a muffin and eventually
both words, cookie and muffin, will elicit the thought of
a cookie and muffin even though the child has never
seen a muffin. Humans can learn after the fact; in other
words, they are taught once an event has occurred
whereas other animals need to have the event precede
the onset of the response. This bi-directionality is the
most important defining feature of human language and
cognition and explains why evaluative conditioning can
occur and why arbitrary associations can be made.
Relational frames
Another important feature of human language and
cognition involves the emergence of complex networks
of related events. The ability to think relationally allows
us not only to make predictions, similar to other animals
via classical conditioning, but allows our mind to
generate various other relations. Relational responding
is established during early language training by
teaching relational frames. We learn that things that
are ‘‘similar.’’ We learn temporal and causal relations –
‘‘before and after’’ and ‘‘if/then.’’ We learn comparative
and evaluative relations – ‘‘better than’’ and ‘‘bigger
than.’’ Relational frame theory seeks to explain the
F. Neziroglu et al. / Body Image 5 (2008) 28–38 31
generative nature of language and cognitions. It draws
from both classical and operant conditioning to explain
various thoughts and emotions.
Language assists classical conditioning by stimulat-
ing complex networks of associated ideas, images, and
evaluations. For example, a child could learn that
having a pimple (UCS) is associated with disgust
(UCR), and later any blemish (CS) elicits disgust (CR).
The word pimple is similar to blemish, acne, bumps on
face, or unsmooth face, and thus those similar words
alone can elicit the same aversive affect (i.e., classical
conditioning via the relational frame of coordination or
similarity). Words that connote similar concepts conjure
up similar thoughts. This is why a BDD individual may
respond with aversive affect to any event or word that
reminds him/her of a similar situation. For example, if
he/she has a disgust reaction at one point to a pimple,
anything similar to it may elicit the same reaction by
thinking about it, even if it no longer exists. If one had
been teased about his/her big head, then the word ‘‘big’’
could have an aversive feeling. Likewise, any similar
associated body part (hairline/hair) could elicit the same
response.
Arbitrary and non-arbitrary connections
Relational frame theory (Hayes, Barnes-Holmes, &
Roche, 2001) would also suggest that as human beings,
language enables us to make arbitrary and non-arbitrary
connections among events and therefore develop certain
beliefs based on these associations. In other words, due
to language we think about the future, make plans, and
we are able to evaluate and compare outcomes.
Relational frame theory suggests that as human beings
we use language as a way of making connections that
may or may not be factual. Furthermore, as these
associations are often communicated rather than
experienced directly, faulty associations are rarely
tested and thus not likely to be extinguished. For
example, many people avoid consumption of raw eggs
due to early instructions to do so, despite the low risk of
salmonella infection today through this source. This
habit of avoidance persists because of verbally imposed
negative reinforcement. It is not difficult to see how
pathological habits may develop in a predisposed
individual, when health is attributed to the continued
and excessive practice of similar rules. Perhaps in the
case of BDD, persons make arbitrary associations
between appearance, social success, and/or undesirable
human traits. For example, a child may hear a parent
make a comment about someone who is difficult to
invite over to the house because she is a finicky eater.
However, at the same time the parents may comment
that this child is so cute and pretty and it is a shame she
is so difficult at meal times. The child may learn that
people will put up with unpleasantness (finicky eating
behavior) when the person is pretty. The child may in
fact start comparing herself with her friend to see if she
is just as pretty or prettier in order for people to accept
her as well.
In addition to having language and cognitions elicit
emotions, thoughts can take on meaning. For example,
if you think of swallowing you may have a neutral
response, but if you think of spitting and saving your
saliva and swallowing it later, you may have a disgust
reaction. This demonstrates that through language, we
make arbitrary associations and have certain emotional
responses to those thoughts. As early as 22–27 months,
human children are able to understand the complex
interrelationships among events even if they are not
specifically taught each relationship (Lipkens, Hayes, &
Hayes, 1993). As soon as we are able to think, we
arbitrarily relate events that may occur together or
events that we associate with past events. Therefore,
there may be either direct conditioning of the CS and
UCS or conditioning via the mediation of language. As
the CS is paired with the CR, a set of cognitions are
strengthened. Information is processed at this time, and
a set of beliefs initially introduced through early life
experiences continues to be reinforced. These beliefs
may center on thoughts such as, ‘‘if I am attractive I will
be more likely to obtain what I want,’’ ‘‘being attractive
is the most important thing in the world,’’ ‘‘I need to be
noticed,’’ ‘‘life is not worth living unless I am
attractive,’’ and so forth. It is also during this time
that attention is drawn to the perceived defective body
part. Selective attention to the defective part leads to
more focus on the defect and thus a strengthening of the
conditioning process.
Information processing research in BDD
Recent research suggests that individuals with BDD
perceive, process, and recall information in their
immediate environment in biased ways. BDD research-
ers have suggested that this predisposition may play a
further role in how early life experiences are processed
and stored, contributing to the development and
maintenance of BDD (Buhlmann & Wilhelm, 2004).
Studies have found that individuals with BDD over-
focus on details rather than global image (Deckersbach,
Savage, & Phillips, 2000), selectively attend to
emotional stimuli, especially BDD-related words
(Buhlmann, McNally, Wilhelm, & Florin, 2002), and
interpret ambiguous social, general, and BDD-related
F. Neziroglu et al. / Body Image 5 (2008) 28–3832
situations as threatening as compared to individuals
with OCD or other controls (Buhlmann, Wilhelm, &
McNally, 2002). Furthermore, BDD individuals may
also have difficulty identifying emotional expressions
of other individuals (Buhlmann, McNally, Etcoff,
Tuschen-Caffier, & Wilhelm, 2004), and rate more
expressions as contemptuous in self-referent situations
(when they imagine themselves in the scenario)
(Buhlmann & Wilhelm, 2004) and thus believe
others are looking at them in a disapproving manner
(ideational reference).
Higher-order conditioning
It is through higher-order conditioning that we can
explain how multiple body parts may become foci of
concern. BDD symptoms secondary to the patient’s
primary concern may be accounted for by such
conditioning. The patient observes himself in the mirror
and believes that the shape of his ears causes him to look
disgusting. Then, he turns his attention to his hairline
around his ears and – not surprisingly – continues to feel
disgust. From this point forward, the he may experience
disgust when examining this area of his hairline. If such
phenomena occur due to higher-order conditioning, it
follows that these secondary concerns would be of
secondary importance to the patient, in that higher-order
conditioned stimuli produce less of a conditioned
response than lower-ordered conditioned stimuli. In fact
it is quite common for individuals with BDD to be
preoccupied with more than one body part. Research has
found that individuals are typically dissatisfied with up to
three body parts, with one usually causing the most
distress (Khemlani-Patel, 2001; Neziroglu, Khemlani-
Patel, & Yaryura-Tobias, 2006b).
Higher-order conditioning may be direct or occur
through relational framing. For example, initially a child
is taught to see an object, then hear its name, and then say
its name. Later the child can hear the name and point to
the object. Once the object-word and word-object
relation is explicitly trained (relational training) then
derived relational responding emerges. If a child is taught
‘‘These are your nose, mouth, and ear,’’ then the child can
identify the facial part when asked ‘‘Where is your nose,
mouth, and ear?’’ even in the absence of differential
reinforcement for doing so. This derived, arbitrarily
applicable relation is referred to as ‘‘relational frame’’
and it is brought under the control of contextual cues
through a process of differential reinforcement. After the
history of reinforcement, a derived relation emerges
without reinforcement; as human beings we can
generalize to novel situations without direct reinforce-
ment of these situations by using what we have learned in
the past. Thus, if a person has a disgust reaction to
pimples and then equates pimples with blemishes,
elevations on the skin, or redness or any other arbitrary
relation, then new facial abnormalities can elicit the same
response. This is similar to higher-order conditioning
whereby the CS is paired with another CS and thus
evokes the same response.
Maintenance of symptoms through operant
conditioning
BDD is maintained via operant conditioning princi-
ples, specifically negative reinforcement, whereby
aversive emotions are reduced or prevented by avoidance
and safety seeking behaviors (e.g., checking, camoufla-
ging). Cash (2002, 2008) refers to these avoidance
behaviors as self-regulatory processes that function as a
coping mechanism to avoid, escape, or manage body
image discomfort, and these evasive actions are
maintained via negative reinforcement. BDD patients
may engage in behaviors such as camouflaging,
reassurance seeking, mirror checking or avoiding,
excessive grooming, and avoidance of social or public
situations in an attempt to reduce disgust, anxiety, or
negative feelings in general.
At times the individual may like the way he/she
looks. In the case of mirror checking, the occasional,
random positive feedback he/she receives from looking
in the mirror results in encouraging the patient to
continue mirror checking. Intermittent reinforcement is
more resistant to extinction, meaning that if individuals
remember occasionally checking the mirror and liking
what they see in the past, they may continue to engage in
mirror checking for a long time even though they
infrequently get good results.
In addition to these compulsive behaviors, indivi-
duals with BDD compulsively compare their specific
body parts with those of others, often concluding that
they are less attractive. Theories of social comparison
(Festinger, 1954) or social ranking (Allan & Gilbert,
1995) have been applied to body dissatisfaction.
Thompson and colleagues (Heinberg & Thompson,
1992; Thompson, Heinberg, Altabe, & Tantleff-Dunn,
1999; Thompson, Reed, Brannick, & Sacco, 1991)
suggest that higher levels of comparison are associated
with more body dissatisfaction, particularly if compar-
ison is made to target persons who are considered more
attractive. Heinberg and Thompson (1992) described
this as ‘‘upward’’ (as opposed to ‘‘downward’’)
comparison comparing self to targets considered
more attractive, and ‘‘particularistic’’ comparison (as
F. Neziroglu et al. / Body Image 5 (2008) 28–38 33
opposed to ‘‘universalistic’’), comparing self on the
basis of specific factors such as age, gender, and specific
body features of the target. Cash (2008) used the term
‘‘unfair to compare’’ to describe a cognitive error
involving biased appearance comparison, in which
people selectively compare themselves to people whom
they regard as being more attractive. The role of social
comparison has not been studied in BDD specifically.
However, we can apply the principles of relational
frame theory and hypothesize that individuals with
BDD have a relational learning history whereby
comparative and evaluative frames have been classi-
cally conditioned.
In conclusion, the behavioral model of BDD
developed by Neziroglu and colleagues suggests that
a biological predisposition paired with early learning
experiences (through both direct reinforcement of
attractiveness as well as social learning) make
individuals vulnerable to classical and evaluative
conditioning experiences which can lead to BDD
symptomatology. Also, relational frame theory may
help us explain how certain thoughts elicit certain
emotions and behaviors via relational responding. Some
pairings are arbitrary and not clearly identified; it is a
matter of how events are associated based on the
learning experience of the person. BDD behaviors are
maintained via negative reinforcement.
Cognitive behavioral model of BDD based on
information processing
Although we have touched upon how some aspects
of how BDD is maintained and the role of social
comparisons and avoidance behaviors, now we will
further explicate them. We will especially expand upon
the factors involved in BDD’s maintenance. In addition,
we will consider the view of oneself as an aesthetic
object and how this view leads to effortful cognitive
processes such as ruminating, social comparing and
self-attacking.
Veale (2004) had extensively discussed the view of
oneself as an aesthetic object and the importance of
external representations triggering negative appraisal of
one’s body image and then negative affect and
rumination. In this regard, BDD has some links to
the social phobia literature (Hackmann, 1998) where the
emphasis is on perceived negative appraisals of others.
The self as an aesthetic object
Veale (2004) hypothesized that external events or an
intrusive thought activate a distorted mental image. The
process of self-focused attention increases the aware-
ness of the image and specific features within the image.
Individuals with BDD view themselves as an aesthetic
object and thus various external events (e.g., looking in
a mirror or seeing a picture of one’s self) or an intrusive
thought (e.g., ‘‘Why is my nose too crooked?’’) may
trigger a process of self-focused attention. The outcome
of this is the ‘‘self as an aesthetic object.’’
The four main components of the self as an aesthetic
object are: (a) mental imagery, (b) self-focused
attention, (c) beliefs about the importance of self-
focused attention, and (d) the lack of a self-serving bias.
Mental imagery
The outcome of self-focused attention is that
individuals with BDD experience mental imagery or
a ‘‘felt’’ impression of how they appear to others from
an observer perspective (Osman, Cooper, Hackmann, &
Veale, 2004). When individuals are asked to draw a
picture of an impression of how they look to others, they
are attempting to reproduce their mental imagery or
‘‘felt impression.’’ This is regarded as central to the
experience of BDD as it drives the subsequent
appraisals and response. Individuals with BDD and
social phobia may use the observer perspective partly to
distance themselves from and avoid emotion associated
with negative evaluative experiences by others. The
observer perspective may therefore become a main-
taining factor through continued avoidance of emotion.
Self-focused attention
When anxious, a person can be in one of two possible
modes, an orienting (‘‘fight’’) mode or a defense
(‘‘flight’’) mode (Mogg & Bradley, 1998). In the
orienting mode, a person scans the environment for
threats and may be more sensitive or hyper-vigilant to
signals of danger. Thus, in BDD persons may be
comparing their appearance with others to determine
their social standing in relation to others. When a threat
is imminent, such as being physically close to a person
who is perceived as more attractive, BDD individuals
are more likely to resort to a safety-seeking, protective
behavior, such as camouflaging, avoiding eye contact,
or escaping the situation. In this mode, attention may be
directed towards the source of safety (e.g., an escape
route) and avoiding the threat (e.g., being self-focused,
keeping one’s head down, and avoiding eye contact).
It is hypothesized that a person with BDD is
excessively self-focused on aversive imagery and verbal
associations, thus preventing accurate observations of
other’s reactions which prevent the disconfirmation of
fears of negative evaluation. A person with BDD might
F. Neziroglu et al. / Body Image 5 (2008) 28–3834
appear to lack social skills as a result of these biased
social observations, which in turn may generate a
negative reaction in others that the individual experi-
ences as a negative reaction to their appearance rather
than their behavior. When the individual is alone, there
are usually difficulties in concentration because the
attentional capacity may be taken over by the
constructed image and negative appraisals of one’s
appearance. Often the individual is unable to process
external information or feedback about his or her
appearance. In less severe cases, there appears to be
some attentional capacity to external information so that
the image may be less stable and associated with doubts
about how the person appears to others. In this case, the
individual may feel driven by a need to know exactly
how he or she looks. Such persons might be rewarded
only with certainty while looking in a mirror and
focusing on what they see (rather than an impression of
how they look). However, the longer one looks in the
mirror, the more self-focused he/she becomes, the
worse he/she feels, and the more it reinforces his/her
view of being ugly and defective. When there is no
external reflection available, individuals seem to use
their image or ‘‘felt impression’’ as an internal mirror
and way of checking how they look. The unintended
consequence is the creation of further doubt, preoccu-
pation, and at times confusion about how their
appearance might alter from day to day or hour to
hour. Drawing from the model of social phobia (Clark
et al., 1995), BDD individuals in social situations shift
to being self-focused in order to monitor and check their
appearance from their image. The presence of others (or
indeed a reflective surface) will induce the process of
appearance comparison and switching between their
internal image and that of another face or their own
reflection.
Meta-cognitions about self-focused attention
The beliefs about the process of self-focused
attention are unexplored. Clinically, individuals with
BDD report that their motivation for self-focused
attention is to check on how they appear to others,
similar to checking in a mirror. Thus, while their
attention is directed towards safety, they are also
monitoring how much of a threat they are in and
mentally preparing for possible humiliation or rejection.
Self-serving bias
Another form of selective attention occurs when it is
directed externally at one’s representation in a picture or
mirror. Individuals with BDD may then experience an
increase in depth and ‘‘hyper-reality.’’ They appear to
have lost their self-serving bias (or ‘‘rose tinted glasses’’)
in self-judgments of attractiveness. Jansen, Smeets,
Martijn, and Nederkoorn (2006) first identified this
phenomenon in individuals with eating disorders. The
body image of eating symptomatic participants and
controls were compared with inter-subjective evaluations
of their own and others’ bodies. Both groups rated the
headless bodies of eating symptomatic individuals as less
attractive. Contrary to the eating symptomatic indivi-
duals, the control group rated their own bodies as more
attractive than others had rated them. The study suggests
that the problem in eating disorders is not a distorted body
image but a lack of one—that is, the lack of a self-serving
body image bias. This study has not yet been replicated in
BDD. However, Lambrou (2006) found that BDD
individuals were similar to art and design student
controls and both groups were superior to non-art
controls in their self-estimations of aesthetic proportions.
They were able to switch attention to focus on a photo of
self, another person, or a building and come to a ‘‘better’’
aesthetic judgment than non-art controls. In keeping with
the view of the self as an aesthetic object, perhaps
individuals with BDD are more accurate than distorted in
their body image perceptions.
Negative appraisal of body image
Individuals with BDD appraise and aesthetically
judge their body image negatively in a process of
activating assumptions and values about the importance
of appearance. In BDD, appearance has become over-
identified with the self and at the center of a ‘‘personal
domain’’ (Veale, 2002), similar to Cash’s (2002, 2008;
Cash, Melnyk, & Hrabosky, 2004) concept of appear-
ance investment or schematicity. An idealized value
occurs when one of the values develops into such over-
riding importance that it defines the ‘‘self’’ or identity of
the individual or becomes the very center of a personal
domain. The idealized value in BDD is usually the
importance of appearance of certain features, but other
values may include social acceptance, perfectionism,
symmetry, or youth. Such values will reinforce
processing of the self as an aesthetic object, and in
social situations, as a social object (Clark et al., 1995).
Without these idealized values, it might be possible to
adapt to a body image in the way that some individuals
with a disfigurement may accept themselves and
become less self-conscious (Lansdown, Rumsey, Brad-
bury, Carr, & Partridge, 1997). What is not known is
whether the importance of appearance and the
assumptions about a defect have developed before or
after the experience of mental imagery. In other words,
F. Neziroglu et al. / Body Image 5 (2008) 28–38 35
in the absence of mental imagery of appearing defective
and believing it as truth, would the person hold such
beliefs and assumptions? Alternatively, have such
assumptions developed as a consequence of the mental
imagery and will they subside once the person no longer
views such imagery as truth or they are no longer
preoccupied and distressed by such imagery?
Rumination and appearance comparison
A further vicious cycle in maintaining preoccupation
and distress in BDD is the process of appearance
comparison and rumination. The outcome of such
processes tends to be further evaluations and appraisals.
Appearance comparison
As discussed above, individuals with BDD exces-
sively compare their feature perceived as defective to
others. Many patients report compulsively collecting
magazine pictures, videotapes of particular media
celebrities, or photographs of themselves at an earlier
age in order to compare/contrast their appearance.
Appearance comparison is a core factor in the
development and maintenance of body image problems
(Thompson et al., 1999) and is not specific to BDD.
In BDD, it is hypothesized that selective attention to
mental imagery and specific features prevents individuals
with BDD from obtaining a representative or accurate
view of the appearance of others. This process is likely to
contribute to excessive focus on overall and specific
features of appearance, and the resultant mental imagery.
These factors are proposed to maintain negative beliefs
and exaggerated ideals relating to appearance (in terms of
both self-evaluation and perceived evaluation by others),
and exaggerated beliefs about the importance of overall
appearance and specific features in terms of identity.
Rumination
Individuals with BDD use effortful cognitive stra-
tegies such as ruminating, worry, and self-attacking in
response to thoughts. They are trying to solve the wrong
problem by responding to intrusive thoughts and images
and as a result maintain the preoccupation and distress.
The ruminative process suggests a further feedback loop
in which engagement and trying to solve the appraisals
and evaluations of one’s appearance further contribute
to preoccupation and distress.
Emotion
Emotions in BDD are complex and will depend upon
the appraisal of the situation and event and subsequent
behavior. The emotions include (a) internal shame (or
self-disgust) when the individual compares and ranks
his or her appearance as lower than others; (b) external
shame and anticipatory social anxiety based on
judgments about how others are likely to scrutinize,
humiliate, or reject the individual; (c) depression and
hopelessness at the individual’s failure to reach his or
her aesthetic standard; (d) anger and frustration at
oneself for damaging one’s appearance (e.g., ‘‘do it
yourself’’ surgery, skin-picking) and others not under-
standing or agreeing with their concerns; and (e) guilt
and shame at damaging one’s appearance by oneself or
through cosmetic surgery.
Avoidance and safety-seeking behaviors
Avoidance and safety-seeking behaviors in BDD are
generally engaged in by the individual for various
functions. These include avoiding thinking about a body
part or feature, altering appearance, camouflaging,
distracting attention away from a feature, reducing
uncertainty or distress, and avoiding situations or
activities that activate increasing self-consciousness and
imagery. Thus, there is another negative feedback loop.
Safety behaviors may briefly decrease distress or
uncertainty but are counter-productive and increase
self-consciousness, preoccupation and distress. Further-
more, safety behaviors (a) involve enormous mental
effort and attention which means less capacity for
external information, (b) often lead to further monitor-
ing (e.g., mirror checking to determine if the camou-
flage is ‘‘working’’), (c) may objectively make one’s
appearance worse (for e.g., skin-picking), and (d)
increase attention by others to one’s appearance (for
e.g., a person hold ups his/her hand against the face).
All safety-seeking behaviors are a major main-
tenance factor in the preoccupation and distress of
BDD, and much clinical creativity may be required to
help individuals cease using safety behaviors. Simi-
larly, individuals will require exposure to situations
avoided without their safety behaviors and with
maximum attention on tasks and the environment
(rather than the self).
Summary
Many similarities exist between Neziroglu and
Veale’s models, and Cash’s nondisorder-specific model.
They emphasize the impact of early life experiences and
social learning in the development of body image
beliefs and attitudes. These include parental role
modeling, interactions with peers and family, aversive
F. Neziroglu et al. / Body Image 5 (2008) 28–3836
experiences such as teasing and bullying, and media
influences. All models attempt to explain avoidance
behaviors, negative emotions, and selective attentional
biases. Perhaps the only divergent point between the
BDD models is the emphasis placed by Neziroglu and
colleagues on conditioning and social learning as being
central in the development and maintenance of BDD,
and it views the problem more from a field perspective.
On the other hand, Veale and colleagues emphasize to a
greater degree the importance of cognitive processing,
imagery from an observer perspective, and the role of
safety-seeking behaviors.
Cognitive behavioral treatment of BDD
Treatment research
The cognitive behavioral treatment research for
BDD consists largely of case studies or case series
investigating treatment efficacy with little control of
treatment format, length, and inclusion/exclusion of
medications (Neziroglu & Khemlani-Patel, 2002) and
with few randomized controlled studies. Despite the
lack of rigorous methodology, overall CBT seems to be
an effective treatment modality. It is unclear whether
either component alone is effective.
Some studies have attempted to investigate the
differential effectiveness of the treatment techniques
for BDD. It appears that cognitive therapy alone
(Geremia & Neziroglu, 2001) has positive results, as
does exposure and response prevention (ERP) alone
without the addition of other techniques (Campisi, 1995).
Studies comparing ERP alone to a combination of ERP
and cognitive therapy found that both therapy formats
resulted in significant gains in BDD symptoms, anxiety,
and depression with no significant differences between
the groups (Khemlani-Patel, 2001). Another case series
of five patients with BDD were treated with cognitive and
behavioral therapy in a crossover trial indicated that
behavioral therapy was more effective in reducing
symptoms as compared to cognitive therapy (O’Grady,
2002). Group CBT also seems to hold promise, with
patients improving on BDD symptom measures (Rosen,
Reiter, & Orosan, 1995; Wilhelm, Otto, Lohr, &
Deckersbach, 1999).A recent meta-analytic study found
that CBT and serotonergic reuptake inhibitors improve
BDD symptoms and decrease depression with modest
effect sizes (Williams, Hadjistavropoulos, & Sharpe,
2006). Psychological treatments had higher effect sizes
than medication, with no differences between CBT and
behavioral therapy alone. Beyond the BDD treatment
literature, a review of CBT for body image dissatisfaction
found that stand alone CBT is successful in improving
various facets of body image and associated psychosocial
functioning (e.g., self-esteem and social anxiety) (Jarry
& Berardi, 2004). A meta-analysis of stand-alone CBT
for body image dissatisfaction (Jarry & Ip, 2005) found
that CBT is an effective treatment but produces the
weakest effects for body image investment, which is
particularly crucial for BDD since patients tend to be
highly appearance invested (Hrabosky et al., 2008).
Many published articles have alluded to the difficulty
in treating BDD. Spontaneous remission rates are
extremely low (Phillips, Pagano, Menard, & Stout,
2006) and quality of life does not seem to improve post-
treatment (Khemlani-Patel, 2001; Phillips, Menard,
Fay, & Pagano, 2005), suggesting that treatment
strategies should continue to be investigated. In fact,
in a recent study (Hrabosky et al., 2008) patients with
BDD, as compared to anorectics, bulimics, and clinical
controls, reported exhibited greater body image
disturbance, more investment in their appearance for
self-worth, and a more deleterious impact of body
image on quality of life.
As the models above suggest, examining the role of
early life experiences, early operant conditioning,
modeling, and the role of language in the development
of beliefs may enhance traditional CBT. Rather than
directly challenging the existence of the perceived
defect, individuals can be taught to modify the
attentional biases, and to cease effortful cognitive
processes such as ruminating, self-attacking, and
comparing. Behavioral experiments are used to test
predictions during exposure without rituals. Incorpor-
ating the role of imagery and self-focused attention, the
link with early experiences, and the lack of a self-
serving bias can also be valuable components. This type
of dialogue can assist in the process of engagement and
validating the experience of BDD. Second, when
assessing individuals, more negative self-beliefs about
the self can be accessed via imagery and from earlier
memories than via verbal techniques (Osman et al.,
2004). There are a number of strategies for modifying
the meaning of the image by historical reviews or re-
scripting an image especially for teasing, bullying, and
sexual trauma (Arntz & Weertman, 1999) or the beliefs
about the imagery (Layden, Newman, Freeman, &
Morse, 1993; Smucker, Dancu, Foa, & Niederee,
1995). Thus the strategy is to develop a different
relationship with the image so that it is no longer
regarded as truth but just a ‘‘picture in one’s mind’’ that
was constructed over time. This strategy is reflected in
Cash’s (2008) mindfulness and acceptance approach to
body image CBT.
F. Neziroglu et al. / Body Image 5 (2008) 28–38 37
It may also be helpful to train individuals with BDD
to increase the degree of attention away from self-
referent information towards tasks or towards the
environment. This strategy has been described for social
anxiety (Bogels, Mulkens, & De Jong, 1997; Wild,
Hackmann, & Clark, in press) and health anxiety
(Wells, 1990). The principle of increasing attention on a
task such as shaving or combing one’s hair can also be
applied to mirror retraining (Veale & Riley, 2001) or
routine activities such as walking down a street and
becoming more aware of the environment from a field
perspective.
Given the potential arbitrary associations occurring
in BDD, the incorporation of acceptance and commit-
ment therapy (ACT) into the CBT protocol may teach
individuals to recognize that language and cognitions
cause us to formulate arbitrary relations and experience
pain even without external stimuli. We can sponta-
neously think about being teased and feel upset even if
we are out enjoying ourselves on vacation. A discussion
of how ACT is derived from relational frame theory is
beyond the scope of this article (see Eifert & Forsyth,
2005), but it is suffice to say that language may
perpetuate our suffering. ACT focuses on a contextual
functional analysis, acceptance rather than avoidance of
aversive experiences, and diffusion from language. The
aim is to act in personally valued directions and not
according to the idealized value placed on appearance.
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Medical Care Research and Review 69(3) 294 –315
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436348MCQ69310.1177/1077558711436348McAl earney et al.Medical Care Research and Review
This article, submitted to Medical Care Research and Review on May 6, 2011, was revised and accepted for publication on December 28, 2011.
1The Ohio State University, Columbus, OH, USA 2École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland 3Nationwide Children’s Hospital, Columbus, OH, USA
Corresponding Author: Ann Scheck McAlearney, ScD, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Cunz Hall 224, 1841 Neil Avenue, Columbus, OH 43210, USA Email: [email protected]
The Role of Cognitive and Learning Theories in Supporting Successful EHR System Implementation Training: A Qualitative Study
Ann Scheck McAlearney1,2, Julie Robbins1, Nina Kowalczyk1, Deena J. Chisolm1,3, and Paula H. Song1
Abstract
Given persistent barriers to effective electronic health record (EHR) system implementation and use, the authors investigated implementation training practices in six organizations reputed to have ambulatory care EHR system implementation “best practices.” Using the lenses of social cognitive and adult learning theories, they explored themes related to EHR implementation training using qualitative data collected through 43 key informant interviews and 6 physician focus groups conducted between February 2009 and December 2010. The authors found consistent evidence that training practices across the six organizations known for exemplary implementations were congruent with the tenets of these theoretical frameworks and highlight seven best practices for training. The authors’ analyses suggest that effective training programs must move beyond technical approaches and incorporate social and cultural factors to make a difference in implementation success. Taking these findings into account may increase the likelihood of successful EHR implementation, thereby helping organizations meet “meaningful use” requirements for EHR systems.
McAlearney et al. 295
Keywords
ambulatory care, electronic medical records, medical informatics, qualitative, training
Background
Although evidence is still emerging, the potential for electronic health record (EHR) systems to improve quality and coordination of health care is widely recognized (e.g., Bates & Gawande, 2003; Chaudhry et al., 2006; Corrigan, Donaldson, Kohn, Maguire, & Pike, 2001; Goldzweig, Towfigh, Maglione, & Shekelle, 2009; Hillestad et al., 2005; Holroyd-Leduc, Lorenzetti, Straus, Sykes, & Quan, 2011). Key opportu- nities include process standardization, improved medication safety and management, enhanced coordination of care within and across provider settings, and better adher- ence to evidence-based guidelines for disease detection and treatment.
Yet despite these potential advantages, physicians and health care organizations have been slow to adopt EHR systems in ambulatory care settings (Catharine & Sisk, 2005; DesRoches et al., 2008; Gans, Krawlewski, Hammons, & Dowd, 2005; Hing, Hall, & Ashman, 2010; Hsiao et al., 2009). In a recent survey of physicians, only 13% reported having an EHR system in their office, and of those, only 4% noted having “fully functional” systems that moved beyond a record-keeping function to provide tools for electronic ordering of tests and/or the clinical decision support necessary to influence quality of care (DesRoches et al., 2008). However, with the recently enacted American Recovery and Reinvestment Act of 2009, physicians practicing in outpa- tient settings will soon be required to demonstrate both the implementation and use of fully functional EHR systems in order to meet federally defined “meaningful use” requirements (Blumenthal, 2009; Blumenthal, 2010; Blumenthal & Tavenner, 2010; White House, 2004).
Recent research has repeatedly highlighted the challenges of EHR implementation across health care organizations (e.g., Ford, Menachemi, Huerta, & Yu, 2010; Jha, DeRoches, Karlovec, & Joshi, 2010; Kaplan & Harris-Salamone, 2009; McGinn et al., 2011; Scott, Rundall, Vogt, & Hsu, 2005; Yoon-Flannery et al., 2008; Zandieh et al., 2008). In ambulatory settings, many factors contribute to slow EHR adoption rates and low levels of system use (e.g., Bates, 2005; Ford, Menachemi, Peterson, & Huerta, 2009; Lee, Cain, Young, Chockley, & Burstin, 2005; Simon et al., 2007; Ludwick & Doucette, 2009). For instance, resistance to EHR adoption and use can result from a poor understanding about the specific features of the EHR system, thus impeding proper integration of the technology into work practices.
Studies of successful EHR implementation have consistently recognized the impor- tance of training in the implementation process (e.g., Anderson & Stafford, 2002; Ash & Bates, 2005; Brokel & Harrison, 2009; McAlearney, Robbins, Hirsch, Jorina, & Harrop, 2010; Whittaker, Aufdenkamp, & Tinley, 2009). Researchers have begun to identify training factors important to successful EHR implementation such as timing training to coincide with implementation (Anderson & Stafford, 2002; Lorenzi, Kouroubali, Detmer, & Bloorosen, 2009; Whittaker et al., 2009), targeting training to
296 Medical Care Research and Review 69(3)
users’ needs (Lorenzi et al., 2009; Whittaker et al., 2009), and providing knowledgeable on-site support (Anderson & Stafford, 2002; McAlearney, Song, et al., 2010; Terry et al., 2008). Some studies have also examined the relative benefits of different training approaches (Carr, 2004; Poe, Abbott, & Pronovost, 2011; Terry et al., 2008), while broader investigations have shown that users who receive excellent training and obtain hands-on experience with an information technology (IT) system will adopt more real- istic expectations about what the IT will be able to do (Cheney, Mann, & Amoroso, 1986). Yet, in practice, finding the time to adequately train clinicians working in busy ambulatory care settings to use new information technologies and adapt to new work- flows is not easy.
Consensus has also been emerging that beyond technical issues, sociological and cultural factors contribute to many of the barriers to health information technology (HIT) implementation projects (e.g., Kaplan & Harris-Salamone, 2009; McGinn et al., 2011). In practice, then, employing an HIT implementation training strategy that takes these sociological and cultural factors into account may help reduce implementation barriers. However, we know little about whether or how sociological and cultural fac- tors are accommodated in EHR training programs.
As part of a larger study investigating “best practices” in ambulatory EHR system implementation (McAlearney, Song, et al., 2010), we initiated additional data analyses to learn more about training practices within health care organizations known to have exemplary ambulatory EHR system implementations. We were particularly interested in exploring how sociological and cultural factors might be involved in these organiza- tions’ training activities that were designed to promote successful ambulatory EHR system use.
New Contribution Our research contributes to the literature in several ways. First, our study contributes to the development of management theory related to HIT and EHR system implemen- tation training practices. Although many studies on EHR implementation have identi- fied training as an important consideration, our study examines these training practices in the context of cognitive and adult learning theories. By framing our analyses using these theoretical lenses, this study helps improve our understanding about training features that lead to successful EHR implementation and makes impor- tant strides toward helping organizations predict what may work best for EHR train- ing, given their different organizational contexts. More practically, our study contributes to management practice by identifying key elements of EHR system implementation training that can facilitate the successful implementation and use of EHR systems in ambulatory health care settings.
Conceptual Framework We drew on concepts from social cognitive theory and situated cognition theory (from adult learning theory) to frame our study of training practices within the ambulatory
McAlearney et al. 297
EHR system implementation process. These theories helped us develop five propositions related to the importance of training in promoting meaningful use of EHR systems. We describe our propositions and the supporting theoretical concepts below.
First, social cognitive theory (Bandura, 1986) postulates that individuals will be more likely to change behavior if they value the outcomes associated with the change. Conversely, they will not change behavior if they perceive that the change will pro- duce unfavorable consequences. In the case of EHR system adoption, an individual’s values are influenced by his or her unique, preconceived assumptions and expectations about the EHR system. These expectations thus establish the framework that will color subsequent interactions with the EHR system. We are then led to propose the following:
Proposition 1: EHR system training programs that emphasize the positive potential of EHR systems to produce positive outcomes (e.g., improved patient safety) will contribute to better learning outcomes and meaningful use of EHR systems.
Second, social cognitive theory also incorporates the concept of self-efficacy, the individual’s belief about his or her capability to control events affecting his or her life. Self-efficacy is an important determinant of human motivation and action. In the context of EHR implementation, social cognitive theory would predict that individu- als with high self-efficacy visualize success and believe that they have the ability to master use of the EHR; this idea can be extended to suggest that with this knowledge, an individual is more likely to adopt the changes required in transitioning to an EHR system. From a practical standpoint, this suggests that training programs that include opportunities for learners to observe others using the EHR system, and those that provide active learning activities, should enhance the learning process because they give learners opportunities to develop positive perceptions about their own abilities related to using the EHR. Higher self-efficacy will thus contribute to persistence with EHR use, despite obstacles that arise during system implementation.
Along these lines, the adult learning theory (e.g., Merriam & Caffarella, 1999) of situated cognition (Brown, Collins, & Duguid, 1989; Lave & Wenger, 1991) posits that one’s learning context influences learning outcomes. This suggests that knowl- edge evolves not only through formal learning activities such as training programs but also through the context and culture in which they are delivered. A review of literature conducted by Robey, Boudreau, and Rose (2000) examined the impact of situated cognition on IT implementation and concluded that organizational learning occurs as a result of the combination of formal, classroom learning and activities situated in the context of the work place. Together, these theoretical constructs of self-efficacy and situated cognition lead us to propose the following:
Proposition 2: EHR system training programs that incorporate observation and active learning activities will contribute to better learning outcomes and meaningful use of EHR systems.
298 Medical Care Research and Review 69(3)
Another key element of social cognitive theory is the notion of social persuasion. Social persuasion that includes observing the performance of others, verbal persua- sion, and associated social influences contributes to self-efficacy (Bandura, 1986). Therefore, when learners observe others successfully using the EHR, their efficacy expectations are increased because of their corresponding beliefs that they also pos- sess the capabilities to master the EHR system. In our context, this occurs if the learner is influenced by social persuasion, best exhibited through positive behavior modeling by the trainer (Compeau & Higgins, 1995), and also occurring through role modeling from peers in the work environment. Positive behavior modeling conveys information about the predictability of the events and demonstrates effective strate- gies to deal with challenging situations. Translating this theoretical insight into practice, then, identification of champions and super-users, in addition to explicitly involving clinical leaders and skilled training coordinators, are essential components of training efforts. We thus propose the following:
Proposition 3: EHR training programs that identify positive role models, includ- ing clinical leaders, persuasive champions, super-users, and skilled training coordinators, will contribute to better learning outcomes and meaningful use of EHR systems.
Robey et al.’s (2000) work on situated cognition and organizational learning also led them to conclude that an organization’s past experience with IT positively affects subsequent IT implementations—as long as leaders and participants reflected on past experiences and used these situations as learning opportunities. This important con- clusion leads us to propose the following:
Proposition 4: EHR training programs that recognize an organization’s past experiences with IT implementation and encourage participants to reflect on these experiences will contribute to better learning outcomes and meaningful use of EHR systems.
Finally, the theory of situated cognition suggests that learning involves much more than the acquisition of technical knowledge; it is also the result of an individ- ual’s interactions with members within a community of practice and within their shared environment. This theory places learning in the context of social relation- ships, focusing on the social interactions that provide a framework in which learning occurs. Thus while individuals are participating in learning activities and are generat- ing meaning associated with the new knowledge, shared meaning is also developed as these individuals share learning experiences and relate to one another as members of the community. This is clearly important in the case of technology adoption as the impact of the social system or community of practice can play a large role in facilitat- ing or impeding the learning process (Lave & Wenger, 1991). In practice, then, this concept suggests that training programs should take into account the unique needs
McAlearney et al. 299
and characteristics of diverse user groups (e.g., nurses vs. physicians vs. office staff), or different communities of practice. This leads us to our final proposition:
Proposition 5: EHR training programs that take into account the characteristics and assumptions of a particular community of practice will contribute to bet- ter learning outcomes and meaningful use of EHR systems.
Method Research Design
We designed an extensive qualitative study (Crabtree & Miller, 1999; Miles & Huberman, 2004) to conduct this exploratory research. Using a multiple–case study approach (Yin, 1994), we examined the perceptions of clinical and administrative representatives involved in EHR system implementations in six health care organiza- tions identified as having “best practices” in ambulatory EHR system implementa- tion.
We used several criteria to generate an initial list of “best practice” sites, including (a) receipt of a Healthcare Information Management Systems Society Annual “Davies” Award for Ambulatory EHR within the past 5 years and (b) recognition as a “Most Wired” hospital by the Hospital & Health Network’s (HHN) annual benchmark sur- vey. We considered these awards as a proxy indicator to identify health care organiza- tions that were on the leading edge of successful ambulatory EHR implementation and attempts to achieve meaningful use. Specifically, Davies award winners are selected through a competitive process in which applicants document that an EHR system is in use for more than 75% of the organization’s patient population, that there has been a “transformation” in the provision of care (e.g., linkage across care sites), and that the EHR system is used for clinical decision-support (Healthcare Information and Management Systems Society, 2011). HHN’s “Most Wired” award is based on an assessment of health system progress in adopting and integrating technology in four areas: infrastructure, business/administrative management, clinical quality and safety, and care continuum (Hospitals & Health Networks, 2011).
We further narrowed our list of study sites based on feedback from a project advi- sory committee comprised of representatives from industry and academia with exper- tise in health IT, and based on our additional study criteria wherein we sought to ensure geographic and organizational variability across the sites to be studied. With six sites in our final study sample, we found that we were able to observe sufficient replication of themes across sites to draw conclusions, consistent with the standards of case study research (Yin, 1994).
From an EHR system implementation perspective, all six of the sites used some version of a “big bang” approach to implementation in which the key functions of the EHR system (e.g., scheduling, clinical documentation) went live at once within a sin- gle practice; however, implementation across practices within a single health system
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Table 1. Overview of Case Study Sites’ Training Approaches
Site
1 2 3 4 5 6 Comments
Pre-implementation training approaches Classroom training X X X X X X • All conducted within 1-3 weeks prior
to go-live E-learning X • Physician training ranged from 8 to
16 hours per physician Competency testing X X • Physicians “Pre-Load” charts X X X • Use of clinical scenarios X X X • EHR “Go-Live” and ongoing support approaches IT department trainers X X X X X • Most sites used internal IT
department “trainers” who moved from one implementation to the next
Vendor support X • One site hired temporary staff for each implementation; one site used vendor support
Temporary support staff X Trained super users X X X Formal “optimization” or
follow-up sessions X
Note: EHR = electronic health record.
was sequential. With respect to training practices, all the sites offered some combina- tion of pre-implementation group training (e.g., classroom or e-learning, on-site sup- port at the time of EHR “go-live”), and then various approaches to ongoing support and training (e.g., help desk, follow-up sessions). Table 1 presents additional detail about the six sites and their EHR system training approaches.
Data Collection We conducted a total of 43 in-person or telephone key informant interviews across the six sites between February 2009 and December 2010. Key informants included orga- nizational leaders and administrators (n = 23), IT personnel and trainers (n = 13), and physicians and other clinicians (n = 7). In addition, we held six focus groups com- prised of 34 generalist and specialist physicians. Physician participants included both attending (n = 22) and resident (n = 12) physicians.
Interviews were conducted using a standardized interview tool including semis- tructured interview questions and follow-up question probes about barriers and facilitators of EHR implementation and use. One section of the interviews included questions about training and user support that are the focus of these analyses. Interviews
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lasted 30 to 60 minutes. One study investigator conducted each interview with a sec- ond investigator in attendance. Focus groups were guided by a standardized focus group guide that covered topics related to EHR implementation and use and included questions asking about the implementation training process. Focus groups lasted 60 to 90 minutes. One study investigator moderated each focus group, with a comoderator available to assist. All interviews and focus groups were recorded and transcribed verbatim. No informant approached for this study refused to participate. This study was approved by the institutional review board of The Ohio State University.
Analyses Interview transcripts were reviewed and coded by members of a research team com- posed of the lead project investigator and three research assistants. The research team first developed a “coding dictionary” that included a list of codes and definitions for each. This initial list of codes was based on the questions included in the interview and focus group guides. All members of the research team next individually coded three common transcripts, then met to compare and discuss individual coding deci- sions to clarify and finalize codes and definitions. Coders met periodically throughout the coding process to ensure consistency in coding and review any new codes that emerged, consistent with a grounded theory approach (Glaser & Strauss, 1967; Strauss & Corbin, 1998). We used the Atlas.ti software program (Scientific Software Development, 2009) to support the coding process.
For the research we report in this article, we used both deductive and inductive methods to analyze the subset of data initially coded as associated with EHR system “Training.” These data included comments that made reference to training activities before, during or after EHR implementation.
First, we used a deductive approach whereby we applied our theoretical framework to evaluate our five propositions about EHR system training in the ambulatory setting. This analysis included an assessment of whether a proposition was supported both within and across sites. We considered a proposition to be supported within a site if there was evidence from at least two different informants from the site that supported the proposition. We considered a proposition to be supported across sites if we found supporting evidence in at least four of our case study sites. If a proposition was sup- ported across three of the six sites we considered it to be partially supported across sites. Our final conclusions as to whether a proposition was supported are based on the across-site analyses (i.e., support by at least eight informants across at least four of the six sites).
Second, we used inductive methods in which we sought common themes across the sites with respect to “best practices” in EHR system training. We characterized some- thing to be a “best practice” if it was observed in at least three of our case study sites, and described by multiple informants (i.e., three or more) within those sites as a best practice. Finally, we assessed the degree to which these “best practices” then mapped back to our conceptual framework.
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In specifying our propositions we describe our outcomes of interest as “learning outcomes” and “meaningful use” of EHR systems. However, because this study of training practices was conducted as a secondary analysis within a broader study of best practices in EHR implementation, we did not specifically ask questions that would enable us to assess a direct link between training practices and either learning out- comes or “meaningful use” per se. Instead, we consider our selection criteria as a valid proxy for “meaningful use of EHR systems” because (a) all the organizations selected for study had been recognized for successful EHR system implementations and (b) EHR introduction had included some transformation of care processes. Furthermore, as few organizations, to date, have achieved “meaningful use” of EHR systems (e.g., Jha et al., 2010), we believe that our study of these industry leaders can provide valuable insight for organizations seeking to achieve true meaningful use. In addition, with respect to “learning outcomes,” wherever possible we focused our analyses on informant comments that indicated that a training practice was, in fact, linked to successful learning.
Results We found that our conceptual framework, based on social cognitive and situated cog- nition theories, provides useful insight into successful training practices for ambula- tory EHR system implementation. We present our findings below in the following sections: (a) Insight from Conceptual Frameworks and (b) Best Practices in Ambulatory EHR System Implementation Training.
Insight From Conceptual Frameworks Using our established criteria for assessing each proposition both within and across sites, we found support for four of our five propositions, described below and sum- marized in Table 2.
Proposition 1: Positive potential of EHR systems. We proposed that training programs emphasizing the positive potential of EHR systems to produce positive outcomes would contribute to better learning outcomes and meaningful use of EHR systems (Prop- osition 1). This proposition was fully supported in only one of our sites. We found additional evidence that “positive potential” was specifically incorporated into train- ing initiatives in two other sites; however, because this evidence did not meet our standard for within-site support, we classified this proposition as not supported in our study.
Proposition 2: Observation and active learning. We proposed that training programs that incorporate active learning would lead to better learning outcomes and meaning- ful use of EHR systems (Proposition 2). This proposition was widely supported with evidence across all six sites. We found that all our study organizations intentionally attempted to build confidence among users about their abilities to use the EHR system appropriately and effectively, thus providing support for this proposition. The benefits
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Table 2. Support for Propositions
Propositions Exemplary Quotes
Proposition 1: Training programs that emphasize the positive potential of EHR systems to produce positive outcomes will contribute to better learning outcomes and meaningful use of EHR systems (Not Supported: 1 site)
“The vision that we’d outlined related to electronic medical records as the tool to help get you there.”
Proposition 2: Training programs that incorporate observation and active learning activities will contribute to better learning outcomes and meaningful use of EHR systems (Supported: 6 sites)
“We suggest that providers also preload [their charts]. They’re part of the preload training.”
“We have this thing called the playground so they could go in and play.”
“So the more realistic we can simulate [a patient interaction], the better the training has become.”
“We had champions . . . somebody that’s really engaged and knowledgeable and a positive role-model.”
“Those folks [super-users] were identified. . . . They’d go to training early before their colleagues and then they’d cycle back through training two more times to serve as trainer helpers or what we call ‘floaters.’”
“Making sure that you select champions . . . your nursing champion, your super-users, and your physician champion so that you get them onboard.”
“The implementation process went smoothly because we were able to learn from each site. We did a lot of lessons learned that, by the end, we were able to shorten out time on site to support them by a week.”
“We have learned from the inpatient side that we translated over to the outpatient side, is that dedicated support people and making that path of contact as easy as possible is a big positive for the clinicians. We’ve translated that as best we can to the ambulatory side.”
“They would go back and help them figure out now, how do you use this system in your work environment? And how are you going to change your workflow? . . . It depends on who’s actually working in this environment, what you can and can’t do.”
“Also, probably half way through the implementation we started a bunch of user groups.”
“The clinical trainers are clinicians and I feel strongly that they need to be able to speak the language of the people that they’re speaking, and understand the real world of the physician, or nurse, or med tech, or pharmacist, and so forth.”
Proposition 3: Training programs that identify positive role models, including clinical leaders, persuasive champions, super- users, and training coordinators, will contribute to better learning outcomes and meaningful use of EHR systems (Supported: 4 sites)
Proposition 4: Training programs that recognize an organization’s past experiences with IT implementations and allow participants to reflect on past experiences will contribute to better learning outcomes and meaningful use of EHR systems. (Partially Supported: 3 sites)
Proposition 5: Training programs that take into account the characteristics and assumptions of a particular community of practice will contribute to better learning outcomes and meaningful use of EHR systems (Supported: 4 sites)
Note: EHR = electronic health record.
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of active learning were broadly recognized, as illustrated by comments from infor- mants such as “Like any software system, you really learn to use it by using it,” and “You’ve just got to do it in the practice, that’s the way you really learn.”
Two specific active learning approaches that were used to train clinicians in several of the sites were scenario-based training and preloading of patient records. With scenario-based training, clinicians were presented with a typical patient scenario, and then given the opportunity to interact with the record as if it were a real patient. With “preloading,” physicians were required, or encouraged, to abstract a number of patient charts and then use that information to create an electronic record, thereby gaining familiarity with the electronic documentation process, and seeing how the information from the paper record would be translated into the electronic environment. Although this approach was viewed as valuable, several of the sites indicated that it was often difficult to get physicians to spend time preloading, particularly if they were in a busy clinic with high productivity expectations.
The application of active learning principles was also evident in the use of strong on-site user support as a learning resource during the “go live” period in which the practices transitioned from paper records to the EHR system. All the sites in this study offered some type of intensive training-based support during the actual EHR imple- mentation “go live” (e.g., on-site support staff). While sites withdrew intensive on-site support after their initial “go live” phases, they all continued to provide some mecha- nism (e.g., a telephonic help line) to support users’ needs to access knowledgeable resources and enable continued learning in practice.
Proposition 3: Positive role models. Our third proposition posited that training pro- grams that leverage the skills of clinical leaders, persuasive champions, super-users, and training coordinators would contribute to better learning outcomes and meaning- ful use of EHR systems. This proposition was supported by evidence in four of our six study sites. Informants from these organizations suggested that the identification of clinical leaders, champions, and super-users to serve as role models and first-line resources for their colleagues was an important contributor to training success. Pro- viding an example of how one of these skilled users modeled learning behavior, the medical director of one clinic described how he
ran our own workshops. . . . I did this on my own . . . and a fair number of [physicians in the practice] came. And I think it contributed to our transition being successful. In fact, they used our clinic as a model for what we need to do for future offices.
An informant in another site explained, “The most you can do is find a good physician champion, find a strong practice leader to set expectations up front.”
Proposition 4: Recognition of past experiences. We proposed that EHR training pro- grams that recognized organizations’ past experiences with IT implementation would result in better learning outcomes and meaningful EHR use (Proposition 4). We found partial support for this proposition based on evidence in three sites. In these sites, EHR
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system training efforts took advantage of both individuals’ past experiences with tech- nology and the organizations’ experiences with prior IT implementation. For instance, an informant at one site that had previously implemented an outpatient EHR reported that “some people had experience with implementing the previous [EHR]. So having those people retained into this project is valuable.” At the organizational level, there was strong evidence that the case study organizations drew on their experiences from one implementation “go-live” to the next, subsequently improving training and other implementation processes based on that experience.
Proposition 5: Communities of practice. We also found support for our proposition (Proposition 5) that training programs that consider the shared assumptions, knowl- edge, and expectations within communities of practice in the EHR system implemen- tation training process will contribute to better learning outcomes and meaningful use of EHR systems. In four of our six sites, informants reported that training programs were tailored for specific subgroups within the ambulatory care practice setting, thus effectively recognizing these smaller “communities” with their unique needs and expectations. Training was then delivered that was appropriate for the different com- munities of ambulatory EHR system users (e.g., physicians vs. nurses vs. clerks). This was observed most frequently when organizations segregated physicians for training. In these four sites, clinicians were widely recognized as the most challenging group to train and the community most likely to benefit from a training approach that targeted their unique needs.
Best Practices in Training for Ambulatory EHR Implementation We identified seven “best practices” in EHR system training across the study organi- zations. These practices and our assessment of how they correspond to our conceptual framework are described below and summarized in Table 3.
Obtain organizational commitment to invest in training. In all six of the sites, the entire EHR implementation process was driven by strong leadership commitment and a vision toward transforming care and improving quality through effective use of the EHR (McAlearney, Song, et al., 2010). We found that this broad, underlying organi- zational commitment to the EHR system was an important factor in the study organi- zations’ willingness to invest in training, and informants across sites commented that training was valued in their organizations as a critical component of successful EHR implementation. This finding is consistent with our proposition (Proposition 1) that a focus on the positive benefits of the EHR system could lead to training success, even though evidence that this focus was explicitly included in training programs was lim- ited in our study. As one organizational informant explained, the EHR system was “the tool to help get you there”—toward the achievement of quality improvement and patient safety goals; thus, “The organization has to be ready to commit that time for the clinicians to say, ‘Alright, instead of seeing patients for the next two hours, go do this.’”
Assess users’ skills and training needs. Informants at all our sites recognized that some potential EHR users, mainly clinicians, did not have basic computer literacy and skills.
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Table 3. Key Components of Best Practices in EHR Implementation Training
Key Component (Proposition) Representative Verbatim Quotations
1. Obtain organizational commitment to invest in training (Proposition 1)
“We have been very, very fortunate that our leadership understands the value and importance of education and insuring a quality implementation, and so we’ve set a pretty high bar on training.”
“To do this right, to give people a fighting chance when you went live, that it would not fail for lack of training, we made these additional commitments to training and development.”
2. Assess users’ skills and training needs (Proposition 2)
“One of the things that we have learned is that sometimes we need to give computer training to people before we even start the EMR. We have the trainers go out and show them how to use a mouse and show them how to do things like that.”
“We require that every single user completes our training and passes a competency exam, which is not just a cognitive test that is not multiple choice, but rather a demonstrated competency that you can show that you know how to use this system to do your respective role.”
3. Select appropriate training staff (Proposition 3)
“Some came from a clinical background and learned the technical aspect and some were technical. . . . And the mix is actually very nice because you can then target certain end users to match with certain educators.”
“We figure it’s easier to teach training skills than it is to teach clinical vocabulary and to understand the life of a clinician.”
4. Match training to users’ needs (Proposition 5)
“The other significant thing is that we are very direct in how much training . . . if you are a registration person, how much training do you have to do, what’s the timing of the training, and how much practice do you need before go-live? So you know, it’s a very succinct process.”
“We would train them on the functionality of the system, which gave us the ability to bring groups. We could merge clinics together, for example and bring folks from multiple sites into one class and train them.”
5. Use multiple training approaches (Propositions 2, 4, and 5)
“We do classroom training, we do one-on-one training.”
“There were also computer-based learning modules that were available that we were actually required to work on as well.”
“We probably spent around 8 hours of classroom training per physician and then they had to practice some on their own.”
6. Provide training support throughout implementation (Proposition 2)
“‘Red coats’ that were experts on how to use [the EHR system] would be in the clinic for at least 2 weeks. Then they would be on for a period of time after in smaller numbers to help out people who needed help.”
“During the first couple of days everyone is on the high. By about day 3 they are crying, and then they are back. Some people handle it better than others. You go with this cyclical thing. . . . So it is a transition period.”
7. Retrain and optimize (Propositions 2 and 4)
“They have 1-month and 3-month optimizations . . . they do have sessions where you can go back and meet with people from [the vendor].”
“We’ve actually been doing optimization after all the clinics went live, maybe 6 to 10 weeks. But now, a lot of them, it’s a year past go-live and we’re still out there doing the optimization . . . We’re kind of continually doing it.”
Note: EHR = electronic health record.
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Several of the sites recognized this need and developed pre-implementation skills assessments. As one informant explained,
We had them take the PC assessment . . . have they ever used a mouse? There was this really simple assessment. And you could then identify who struggled with that. And then you’d kind of know who you needed to work with, just from a PC skills assessment.
Assessments of the users’ comfort with and confidence using HIT helped the trainers customize basic training to ensure all users built competence using technologies prior to focusing specifically on the EHR system; this effort to build users’ skills and confi- dence is consistent with our proposition related to self-efficacy (Proposition 2).
Select appropriate training staff. Although IT and/or vendor staff were responsible for the training programs overall, none of the sites we studied depended solely on IT experts to support their training function. There was widespread recognition among our informants that people prefer learning from similar others, particularly clinicians. One informant suggested that organizations should “build an army of physicians— physician super-user-champions that are passionate about the system and are savvy on a computer system and are good educators” to ensure excellent training across the ambulatory setting. Our sites largely favored using clinicians as trainers and/or super- users. As one informant explained of trainers, “They need to be able to speak the lan- guage of the people that they’re teaching and understand the real world of the physician or a nurse or a med tech or a pharmacist and so forth.” These efforts enabled role modeling, encouraged peer-to-peer exchange, and fostered trust between trainers and learners, approaches that were consistent with the notion of social persuasion (Proposition 3).
Match training to meet users’ needs. Another key to successful training appeared to be consistent with the notion of “communities of practice” (Proposition 5) in which the sites recognized that different groups have unique perspectives and needs and developed training initiatives accordingly. For instance, one interviewee explained how the trainers
would go back and help them figure out now, how do you use this system in your work environment? And how are you going to change your workflow? . . . What type of staff do you have employed . . . because it depends on who’s actu- ally working in this environment, what you can and can’t do.
Use multiple training approaches. All our sites used a variety of different training approaches, including classroom-based didactic training, e-learning modules, hands- on learning methods such as scenario opportunities to practice with mock patients, and intensive one-on-one support in the ambulatory care setting. In all these organizations, the training content and approaches were both tailored to the specific needs of the learners (e.g., clinicians; Proposition 5), had evolved over time as the organization
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learned from one implementation to the next (Proposition 4), and included a strong emphasis on hands-on learning, whether as part of a training session or during actual system implementation (Proposition 2).
Provide training support throughout implementation. All the sites in our study provided training and support to users during all phases of the implementation process. In gen- eral, this training support was composed of a combination of didactic and practical pre-implementation training followed by intensive on-site support during the actual EHR “go live,” with accessible, ongoing support thereafter (e.g., help desk). In all these phases our sites’ training approaches appeared to recognize the value of learning in practice (Proposition 2) by incorporating hands-on learning during pre- implementation (e.g., scenarios) and to recognize the need for continuing training sup- port to facilitate active learning during the go-live period. As one informant explained,
We tend to probably overstaff during support coverage and then usually after a few days, they say, “Okay, you can cut back, you can cut back.” But so we only do it when they’re telling us to cut back. We’re not leaving them.
Retrain and optimize. The sites in our study all conducted follow-up training and efforts to “optimize” EHR system usage at set intervals following the initial imple- mentation. These efforts were largely based on the idea that users needed to first learn the basics of the EHR system, and then, after a period of active use, would be both ready and motivated to enhance their skills. This common approach recognizes the importance of learning in practice (Proposition 2). One informant commented,
We go back after at least seven days of go-live support. Every physician sits down with a trainer and goes through a skills checklist. They have optimization sessions, and they come back and teach some new things. We invest a lot in our physicians and we do feel that that’s part of what makes us a best practice.
Several sites established formal mechanisms (e.g., committees, user groups) to rou- tinely identify user problems, troubleshoot and share solutions, and/or identify further training opportunities; this approach is consistent with recognizing the value of learn- ing from past experiences (Proposition 4).
Discussion/Conclusions The importance of training in facilitating EHR system implementation and, ideally, helping health care organizations make progress toward “meaningful use” of their systems cannot be overemphasized. While training has been identified previously as an important factor in other studies of EHR implementation (e.g., Anderson & Stafford, 2002; Ash & Bates, 2005; Brokel & Harrison, 2009; Lorenzi et al., 2009; McAlearney, Song, et al., 2010; Whittaker et al., 2009), our study contributes to this literature by providing insight into the underlying sociocultural factors that affect learning processes and influence EHR implementation training processes.
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We drew on social cognitive theory and the adult learning theory of situated cogni- tion to develop five propositions about training factors that would lead to better learn- ing outcomes and meaningful use of EHR systems. Three of our five propositions (Propositions 2, 3, and 5) were fully supported by evidence from our study of health care organizations known to have had exemplary EHR implementation processes, thus suggesting that training initiatives that incorporate active learning (Proposition 2), the use of role models (Proposition 3), and recognition that different “communities of practice” have different training needs (Proposition 5) will be most successful. Our findings are consistent with the results of previous studies that have shown that an individual’s learning curve and rate of increasing efficiency in using an EHR system is directly related to her/his degree of exposure to the technology (Poissant, Pereira, Tamblyn, & Kawasumi, 2005), prior research that has described the value of champi- ons and/or role models, for example, peer coaches (Hoyt & Yoshihashi, 2010; Poe et al., 2011), and studies that have emphasized the importance of providing knowl- edgeable on-site support (Anderson & Stafford, 2002; McAlearney, Song, et al., 2010; Terry et al., 2008) and targeting training to users’ needs (Lorenzi et al., 2009; Whittaker et al., 2009) in facilitating HIT implementation.
Furthermore, although only partially supported, we found evidence that training programs that recognize and build on previous IT implementation experiences may be positioned to contribute to better learning outcomes and “meaningful use” of the EHR systems (Proposition 4). This evidence is aligned with results of prior studies that have emphasized the importance of users’ expectations and prior experiences with HIT (e.g., Dennehy et al., 2011; McAlearney, Song, et al., 2010; McGinn et al., 2011; Terry et al., 2008) in facilitating EHR implementation.
Our proposition about the importance of emphasizing the positive potential of EHR systems (Proposition 1) did not meet our criteria for support, although there was some supporting evidence in three of our sites. We considered several potential explanations for this lack of full support. First, in a previously published study of EHR implementa- tion using the same sample, we found that leaders within the study organizations had (a) consistently articulated the positive potential of the EHR system to reduce medical errors and improve patient safety as part of organizational efforts to engender broad support for the EHR implementation initiative and (b) partnered with physician cham- pions who were deployed to achieve buy-in and support among their colleagues for initial EHR adoption (McAlearney, Song, et al., 2010). Thus, in the context of this current study of EHR training activities, it is possible that messages about the positive potential of the EHR system had already been widely disseminated and, by the time of the training, were perhaps accepted as part of the context for implementation. Second, our limited evidence may be a reflection of limitations in our methodology. Because our sites were selected as leaders in EHR implementation, they may have had greater than average support for this initiative, thus reducing the need to emphasize its importance in training. Finally, it is also possible that the importance of emphasizing the value of the outcomes associated with a change (here, the “positive potential” of the EHR system), while consistent with social cognitive theory, may not be necessary in the
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case of successful EHR training, particularly when the trainee has no choice about whether to adopt the technology or not. In the case of our study organizations, once the health system decided to implement ambulatory EHR, the end-user physicians either had to learn to use the EHR or leave the organization. Our findings suggest that more training-specific research is needed to determine how emphasizing the positive aspects of the technology can contribute to successful EHR training in different contexts.
We also identified seven best practices in EHR system implementation training that were observed across our six case study sites. We found a strong link between these identified best practices and the theoretical tenets underlying our propositions; this congruence further supports the applicability and value of these theories for improving our understanding about training features that can contribute to successful EHR sys- tem implementation training efforts. Furthermore, in light of increasing evidence sug- gesting that beyond technical factors, sociocultural factors must be recognized and accommodated in EHR implementation efforts (e.g., Kaplan & Harris-Salamone, 2009; McGinn et al., 2011), our study results can provide insight about how these fac- tors can be taken into account.
Ames, Ciotti, and Mathis (2011) warn of the errors associated with less successful EHR system implementation efforts that were rushed in order for organizations to qualify to receive American Recovery and Reinvestment Act stimulus funding. Of particular concern were organizations’ decisions to provide minimal amounts of train- ing in attempts to reduce costs. Yet as these authors report, “The surest path to mean- ingful use may not be an accelerated implementation if rework, poor quality, and organization-wide chaos are the end results” (Ames et al., 2011, p. 73). Our research suggests that paying attention to the training process itself is of paramount importance for organizations seeking successful EHR system implementation and “meaningful” system use in ambulatory care settings.
Study Limitations First, while our propositions and research approach were structured to improve our understanding of the factors associated with training practices that contribute to better learning outcomes and meaningful EHR system use, our study was not designed to definitively assess this linkage. Instead, this link is implied in our selection of sites that are recognized leaders for successful EHR implementation and have therefore successfully trained users. Furthermore, operationalizing “meaningful use” as a spe- cific outcome remains elusive as consensus regarding a standard definition has not yet been realized (e.g., Jha, 2010).
Second, our focus solely on organizations with successful EHR implementations limits the scope of our conclusions. While our extensive qualitative database enabled us to learn from the perspectives of both clinical and administrative key informants in a geographically and organizationally varied sample of ambulatory care settings, a comparison was not made with organizations that had experienced difficulties with ambulatory EHR system implementations. Such a comparative approach might have
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led to greater insight regarding the relative benefit of specific practices. Nonetheless, our findings—based on rich evidence across six varied organizations—provide strong preliminary evidence regarding successful training practices.
Third, as with any case study research, we are limited in our ability to broadly gen- eralize the findings from this study, although the rigor of our methods certainly sup- ports their validity. Finally, as our data were collected after EHR system implementation had occurred in these sites, this approach could have contributed to recall bias as key informants were asked to reflect on training activities that had occurred several months before the interviews. We mitigated this potential bias by gathering data from multiple informants who were involved in different aspects (i.e., clinical and administrative) of the EHR implementations we studied, but acknowledge the retrospective nature of this data collection process as another potential limitation.
Suggestions for Future Research Future research can extend this study to analyze best practices in EHR system imple- mentation training from larger, more varied samples of ambulatory care settings. In addition, as the use of EHR systems in ambulatory sites becomes more widespread, future studies can examine the value of specific training practices identified in this article such as training of training staff themselves, skills assessment for users, or retraining activities. Finally, future opportunities to investigate EHR training practices using study designs that are longitudinal and quantitative will make important further contributions to our understanding in the area of EHR system implementation train- ing, especially in the context of meaningful use of EHR systems.
Acknowledgments
We are grateful for the participation of all of our study sites and key informants and for the research assistance provided by Maria Jorina, Annemarie Hirsch, Emily K. Knecht, and Trevor Young, all of whom were affiliated with The Ohio State University during the study. We are also grateful to the anonymous reviewers and the journal editor for their helpful suggestions.
Authors’ Note
An earlier version of this article was accepted for presentation at the 2011 Academy of Management Meeting in San Antonio, Texas.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We are grateful to the Center for Health Management Research that funded a portion of this study.
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