Evaluation of behavioural change strategies

Several systematic reviews of a broad range of interventions to improve health professional practice in general,^{2, 5–7} and nursing practice specifically,⁸ have been conducted. Although most reviews reported some improvement in practice, the importance of the change was not always clear.

One systematic review has focused specifically on the effectiveness of continuing nursing education,⁸ and covered complex interventions as well as traditional activities such as lectures. The author concluded that overall, continuing education was effective in improving practice, although it was not possible to ascertain the importance of these changes from the published review.

Other reviews have focused on specific interventions such as audit and feedback,⁹ educational outreach visiting,¹⁰ and computerised decision support,¹¹ or a specific targeted behaviour, for example, immunisation,¹² or a particular practice setting (eg, primary care).¹³ A recent “overview” of systematic reviews concluded that passive dissemination of information alone (even information viewed as important) was insufficient to improve the practice of physicians, although it may increase knowledge or create awareness (table 1⇓).¹⁴ Behaviour change strategies which have shown an impact on practice include, prompts on patient charts¹⁵ and workshops that include interaction among participants.¹⁶

A taxonomy of interventions to improve practice has been developed by the Cochrane Collaboration on Effective Professional Practice (CCEPP).¹⁴ This is an international group of people interested in preparing and maintaining systematic reviews of the effectiveness of interventions that influence professional practice. A complete description of CCEPP's scope and methods can be found in the Cochrane Library.¹⁷

Getting research into practice

Getting research into practice is not as simple as choosing an intervention and hoping for the best. Aside from the intervention itself, mediating factors include the characteristics of the patient and the practitioner and the desired behaviour change.^{18, 19} Getting practitioners to start doing something new, such as routinely asking patients if they smoke, may require a different strategy than that used to get practitioners to stop doing something they do frequently. Furthermore, administrative or financial policies may exist within organisations and settings that act as disincentives to improving the practice of individuals.

Interventions should ideally be tailored to an individual's stage of change, and should address administrative barriers where appropriate.²⁰ For example, health professionals might already be aware of the need for cervical screening and may not require an educational intervention, but they may need a prompt on the patient's chart. If, however, practitioners lack information, awareness, or skills, then strategies such as educational workshops that involve a high degree of interaction might be effective.

Planning for improving practice

As professionals, we need to develop systems of scrutinising our practice with a view to self improvement. An initial needs assessment can be accomplished using strategies such as self reflection, reading, and discussions with respected peers. However, two studies have shown less impact on performance if clinicians choose their own topics for further learning, and more impact if lower preference topics were studied.^{21, 22} It may be that practitioners tend to choose topics in which they have the greatest interest and are already quite knowledgeable.

The next step is to choose a learning activity, and there may often be a discrepancy between the health professional's preference for a style of continuing education and what might be most effective in actually improving practice. Tassone and Speechley found that Canadian physiotherapists preferred short courses,²³ while Covell et al reported that physicians preferred reading.²⁴ Yet, poorly designed courses and reading alone may have little impact on practice.

Reading materials can be useful if they are evidence-based. Secondary sources such as this journal are ideal because they only present high quality research, and provide a commentary on each abstract by a clinician. The Cochrane Library is another important evidence-based source of information and should be available in medical and nursing libraries.¹⁷ Table 2⇓ contains suggestions for matching the need for learning with different educational strategies.²⁵ Although short “courses” are popular, practice is likely to improve if lectures are minimised and a high level of reflection and interaction is encouraged.¹⁶ Other sources of information about behavioural interventions can be found in the CCEPP.¹⁷

Completion of a formal or informal educational activity, although important, is likely to be insufficient on its own to improve practice. Changing behaviour is a complex process, and clinicians may revert back to usual practices unless the new behaviours are reinforced.²⁰ Individual nurses should attempt to identify practical barriers to change, which need administrative/organisational support, and then attempt to influence existing managerial or quality improvement structures to address these barriers.

The gap between research and practice is not merely the consequence of nurses failing to keep up to date.²⁶ Changing behaviour is complex, involves many systems, and is unlikely to be solved solely by educational strategies.²⁷ Other efforts such as organisational supports and resources that encourage nurses to participate in research projects,^28–30 to connect with larger networks,^{31, 32} and to gain experience with critical appraisal tools and journal clubs³³ are important considerations and should not be overlooked.