Research related to evidence-based programs and practices
When evaluating the intervention research literature, distinctions often are made between practices and programs. However, practices and programs share a great deal of common ground with respect to implementation. Practices often are seen as simpler procedures that can be adopted for use when and where appropriate by individual practitioners. It is expected that practitioners might make use of many evidence-based practices in the course of providing treatment (Chorpita et al., 2002). However, successful implementation of clinical practices has not been a simple matter.
For example, a major implementation effort has been underway in medicine to reduce research findings and best practices to "clinical guidelines" that can be used by medical staff to eliminate errors, reduce variability, and improve consumer outcomes. Mittman, Tonesk & Jacobson (1992) found that, "Modifying health practitioners' behavior to conform more closely to practice guidelines and other recommended practices has proved to be a difficult task" (p. 413).
DeBattista, Trivedi, Kern, & Lembke (2002) concluded that, "Even when guidelines are carefully implemented through intensive physician education or well publicized through distribution or publication, their use and influence in clinical practice remains elusive…Evidence suggests that even if a physician adheres to a guideline initially, adherence often diminishes over time" (p. 662).
Similarly, Saliba et al., (2003) assessed nursing home clinicians’ adherence to the Agency for Healthcare Research and Quality (AHRQ) pressure ulcers guidelines. The study found adherence to only 41% of the fifteen guidelines and 50% adherence to the 6 key recommendations. According to the authors, variation in implementation of guidelines was found to be evident even among nursing homes with the same owners and reimbursement structures. Sheldon et al., (2004) examined patient records in a national survey of implementation of nine practice guidelines in England. They found evidence that 2 of the 9 guidelines were being implemented generally. They also found that managerial, financial, and clinical perspectives often did not support changes in physician behavior (e.g., changes in health care funding, competing priorities, funding deficits, staff shortages, staff turnover, professional bureaucracies that effectively resist change and external influences from network partners) and were barriers to effective implementation.
Nevertheless, evidence-based practices have been implemented successfully. Perlstein (2000) evaluated a multi-component approach to the implementation of a practice guideline for bronchiolitis. Implementation was successful when training for medical staff was followed with daily rounds by the clinical coordinator to prompt and reinforce use of guideline principles (coaching). The clinical coordinator was a respected person with high credibility, was dedicated to assuring use of the guideline, and had the authority to remove barriers to implementation at the practice level. Similarly, Perry (2003) assessed a multi-component approach to the use of clinical practice guidelines for nutritional support in acute stroke. In this study, training of medical staff (teaching combined with practice sessions to develop skills), use of opinion leaders, and audit and feedback were coupled with a project coordinator who was trained in change management, critical appraisal skills, and methods to embed evidence-based practices.
In summary, from an implementation point of view, it appears from these studies that practices share many components of programs. That is, specific practices are embedded in an organizational context and each must be accounted for if implementation is to be successful. It seems that evidence-based practices and programs occupy two sides of the same coin and appear to have similar requirements for successful implementation.
