Abstract
BackgroundEvaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method. While implementation depends on clinicians and managers changing a variety of behaviours, psychological theories of behaviour and behaviour change are seldom used to try to understand difficulties in implementation or to develop interventions to overcome them.ObjectivesThis study applied psychological theory to examine explanations for difficulties in implementation. It used a theoretical framework derived from an interdisciplinary consensus exercise to code interviews across 11 theoretical domains. The focus of the study was a National Institute for Health and Clinical Excellence's Schizophrenia guideline recommendation that family intervention should be offered to the families of people with schizophrenia.MethodsParticipants were recruited from community mental health teams from three United Kingdom National Health Service (NHS) Trusts; 20 members (social workers, nurses, team managers, psychologists, and psychiatrists) participated. Semi-structured interviews were audio-taped and transcribed. Interview questions were based on the theoretical domains and addressed respondents' knowledge, attitudes and opinions regarding the guideline. Two researchers independently coded the transcript segments from each interview that were related to each theoretical domain. A score of 1 indicated that the transcript segments relating to the domain did not appear to contain description of difficulties in implementation of the family therapy guidelines; similarly a score of 0.5 indicated possible difficulties and a score of 0 indicated definite difficulties.ResultsCoding respondents' answers to questions related to the three domains 'beliefs about consequences,' 'social/professional role and identity,' and 'motivation' produced the three highest total scores indicating that factors relating to these domains were unlikely to constitute difficulties in implementation. 'Environmental context and resources' was the lowest scoring domain, with 'Emotion' scoring the second lowest, suggesting that these were likely to be areas for considering intervention. The two main resources identified as problems were time and training. The emotions that appeared to potentially influence the offer of family therapy were self-doubt and fear.ConclusionThis exploratory study demonstrates an approach to developing a theoretical understanding of implementation difficulties.
Highlights
Evaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method
In the United Kingdom (UK), an evaluation of 12 pieces of "tracer" guidance published by The National Institute for Health and Clinical Excellence (NICE) found variable implementation with pharmacological interventions, such as the taxanes and orlistat showing higher levels of implementation than procedures such as hearing aids, implantable cardioverter defibrillators, or laparoscopic surgical procedures [5]
This paper describes the use of the theory-based implementation interview (TBII) to understand the difficulties in implementing the family intervention recommendation within NICE's Schizophrenia guideline in three UK National Health Service (NHS) Mental Health Trusts, as a preliminary step to designing efforts to overcome them
Summary
Evaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method. Evidence-based guidelines are produced in large numbers across the world to improve standards of health care and reduce inequalities in access to effective treatments. Despite widespread circulation and publicity of such guidelines, they are often not implemented effectively, with the result that there is a substantial gap between evidence and practice, and best health outcomes are not achieved [1,2]. In the UK, an evaluation of 12 pieces of "tracer" guidance published by The National Institute for Health and Clinical Excellence (NICE) found variable implementation with pharmacological interventions, such as the taxanes and orlistat showing higher levels of implementation than procedures such as hearing aids, implantable cardioverter defibrillators, or laparoscopic surgical procedures [5]. A review of quality of care studies from the United Kingdom (UK), Australia and New Zealand primary care concluded that "in almost all studies the process of care did not reach the standards set out in national guidelines or set by the researchers themselves" [6]
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