Translating Research to Practice

Allan Jette's May editorial (Phys Ther) is excellent and speaks to the issue most readers of this blog care passionately about: translating the evidence we have (verus that which always seems to be in motion) to evidence in practice.

Download EditorialJetteEBPPhysTher2005.pdf

Evidently this whole phenomenon of drag time from elucidating evidence to its eventual implementation has been noted and studied in the social sciences for some time now.  It is much more than just the reluctance of clinicians to overcome inertia, and has been described as the "diffusion of innovation" by Dr. Everett Rogers. Dr. Jette discusses Everett Rogers work that hightlights 3 primary influencers related to the speed of adopting innovation.  If we relate them directly to physical therapy intervention, they would be: 1) How interventions are percieved; 2) characteristics of people who adopt or reject the intervention; and 3) contextual factors such as leadership, managment, incentives, and communication. According to Rogers, all 3 must be addressed to accelerate adoption of intervention.

When evidence for a given intervention exists but is failed to be adopted, we must ask ourselves “why”?  It starts with us and these 3 factors are a good place to begin

Rob

Comments

[britt smith]

Rob,
Great comments. I read The Tipping Point last year and the author makes similar points about what does it take to 'tip' the balance towards change. Roger's work on who are 'innovators' and the sinusoidal curve of 'early adaptors' and the more resistant folks is very interesting. Jette is right on with the idea of changing the culture and the complexity of any venture in change.
Thomas Kuhn, who coined the term 'paradigm shift' in his book 'The Structure of Scientific Revolution', also noted that for a shift to occur in science, ultimately, a generation has to pass. His point is that the 'old guard', or us grey beards, need to retire, before the new 'paradigm' can be fully embraced by the next generation. I think this is at the bottom of the Choudhry et al. systematic review in Annals 2005, on experience & patient care: Older provider are at risk of providing inferior care!!![Choudhry NK, Fletcher RH, Soumerai SB.
Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005 Feb 15;142(4):260-73. Review. Summary for patients in: Ann Intern Med. 2005 Feb 15;142(4):I54.
PMID: 15710959]
The authors speculate that older physicians
are not keeping abreast of changes in the system...including EBP.
Short of (ex)terminating all the older PTs, we should make it an imperative to integrate skills/knowledge in EBP with every new PT, the schools should press the clinician/ed. coordinators to seek education in EBP and the association must make it our flag ship standard of practice (I believe 'hooked-on-evidence' attempts to get there).
Thanks, again.
Britt

[Dale Avers]

John, thanks for posting the link and comments re: Jette’s May editorial about the complexity of changing practice. I am thrilled that health care is finally becoming aware of the diffusion and adoption research. It will be interesting to see if an understanding of the principles of how innovation (ideas, practices, technology etc) is diffused and adopted will have an effect on the speed of adoption. It certainly is a start. I think a lot about how to change practice because that is why I got into teaching.

My journey through the diffusion and adoption literature (I used this theory as the underpinning for my dissertation on adoption of technology in PT education) has led me to recognize the power of belief – what an individual BELIEVES to be so. We humans hold our beliefs near and dear – and typically are loath to let them go. Perhaps it is the implication that in the letting go that we were wrong – or perhaps it is the fear of change. Whatever it is – belief trumps evidence! When I introduce EBP to the TDPT students I teach, it is the students that are heavily invested in their beliefs that have the most difficulty embracing the concepts and even need for EBP. I also recognize I have my own tightly held beliefs that I am loathe to release in the face of contradictory evidence (high-intensity strengthening for older adults is one of them) – so none of us are exempt from the belief phenomenon. Rogers (1995) describes this belief system as a predisposition of individuals to be open to ideas that are compatible with their beliefs, needs, interests, and existing attitudes. Individuals consciously or unconsciously avoid messages that are in conflict with their predispositions (p.164).

I think our strong belief system and unwillingness to let go of our beliefs is why it might take a generation before an innovation is wholly adopted. It seems to me that to truly change practice, we must get at those beliefs – recognize the tenuous foundation they are built upon (Turner 1997) and then make it “safe” to change beliefs and thus practice. This process requires an acceptance of the philosophy of androgogy (adult learning) and constructivism (every person creates his/her own reality and unique perspective borne from his/her experiences, culture, etc). If we can let go of the belief that learners are empty vessels that just need to be filled up with new knowledge; and recognize the real task in teaching and thus changing practice is to illuminate beliefs and errors in reasoning in a safe and respectful environment (Rogers 1982)– we might be able to create an openness to new ideas and perhaps even change.

I also believe personality has a lot to do with how new ideas and evidence are diffused and adopted. And since personality is one of the most stable features of we humans – this bears some consideration. Certain personalities – such as those who are more detail oriented, rigid, dwell in the past, care about the how rather than the why, and have a need for control (the SJ’s in Myers Briggs language or the “Golds” in the Color Temperament classification) are not going to embrace change as readily as those who are more impulsive, courageous (not rule bound), dissatisfaction with status quo, and care about the why more than the how (SP’s and Oranges); will be more amenable to embracing change. I’ll let you decide which personality tends to predominate in physical therapy. Rogers (1995) relates adopter characteristics as a factor of adoption. For example the early adopters would most likely be the later personality I just described while late adopters and laggards might be the former personality (Rogers, pp 264-265). Rogers (1995) alludes to another construct that is relevant here – homophily. Homophily is the concept that more effective communication (e.g. sharing of ideas) occurs among individuals who are more alike than different with regards to beliefs, background, education, etc. I think about how like people attract like people and I think of Rogers’ theory of homophily. A discussion that might be valuable would be how to create in people whose personalities might be more comfortable with status quo a need and desire to ask why and to embrace new ideas.

One last thought about the challenge of changing practice is the idea that individuals will be more open if they perceive a NEED to change. Some individuals develop a need when they hear of an idea (like EBP). But many others do not recognize they have a problem (ineffective practice) and therefore do not have a need to change. “Individuals will seldom expose themselves to messages about an innovation unless they feel a need for the innovation, and even if such individuals are exposed to these innovation messages, such exposure will have little effect unless the innovation is perceived as relevant to the individual’s attitudes and beliefs” (p.164). Whew! Lots more discussion needs to occur about how to create change in the face of these challenging assumptions. The more we know about diffusion and adoption the more we can be in creating real practice change. Thank you for bearing with this expression of my passion! I look forward to your comments.

Rogers, C (1982). Freedom to Learn for the 80’s. Merrill Publishing Co.

Rogers, E (1995). Diffusion of Innovations (4th Edition). The Free Press, New York.

Turner, P., & Whitfield, T. W. A. (1997). Physiotherapists' use of evidence based practice: a cross-national study. Physiotherapy Research International, 2(1), 17-29.