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IMPLEMENTATION PROJECT

How do health professionals prioritize clinical areas for implementation of evidence into practice? A cross-sectional qualitative study

Wenzel, Lisa-Anabell BSc1; White, Jenni PhD, MMSc(OT), BAppSc(OT)1; Sarkies, Mitchell N. PhD, BAppSc(Phty)1,2,3; Morris, Meg E. BAppSc(Physio), MAppSc, PhD, FACP4; Carey, Leeanne BAppSc(OT), PhD, FAOTA, FOTARA5,6; Williams, Cylie BAppSc(Pod), MHlthEd(HlthProm & Ed), PhD1,7; Taylor, Nicholas F. PhD4,8; Martin, Jenny PhD9; Bardoel, Anne PhD, MBA10; Haines, Terry P. BPhysiother (Hons), G Cert Health Economics, PhD1

Author Information
doi: 10.1097/XEB.0000000000000217

Abstract

What is known about the topic?

  • Generating evidence that is better matched to the needs of health professionals and decision-makers could reduce the evidence to practice gap in healthcare.
  • Previous studies have explored research implementation priorities focused on specific clinical specialties. But few have explored prioritization across specialties.
  • Allied health are typically organized by profession across clinical specialties in the hospital setting, placing this group in a potentially ideal position to identify research implementation priority areas and lead efforts for practice change.

What does this article add?

  • Allied health professionals prioritize clinical areas as high priority for implementation of evidence into practice based on 10 reasons.
  • There is potentially misalignment between priorities of clinicians and those of the health system.
  • Allied health professionals varied in the type and application of evidence used to support clinical practice claims and of effectiveness.

Background

Internationally, there is a widespread move towards implementing evidence-informed policy and practice in healthcare.1 Dissemination of research findings through journals, conference presentations and clinical practice guidelines do not lead to contemporaneous changes in clinical practice or improved patient outcomes.2,3 One reason for this is that research does not always address questions of relevance to health professionals and decision-makers.4 Generating evidence that is better matched to the needs of patients, health professionals, policy-makers and health services is posited as a means of reducing the evidence to practice gap.5–7 Specifically, one approach to better align practice change efforts with the needs of stakeholders is to systematically identify high-priority areas for implementation of evidence into practice. Previous studies exploring research implementation priorities have focussed on specific clinical specialties, such as maternal health care, the diagnosis and management of lung cancer patients and post stroke aphasia management.8–10 However, there is a gap in relation to studies that have explored prioritization across specialties, potentially limiting the ability of decision-makers to target resource allocation in an environment of competing demands for finite health resources.

Allied health professionals are often organized according to profession (discipline) but provide services across a range of clinical specialties (e.g. oncology, orthopaedics, neurology).11 Together with medical practitioners and nurses, allied health professionals play a vital role in optimizing safety, quality of care and patient outcomes within the health system.12,13 This group of professions includes but is not limited to: physiotherapy, occupational therapy, speech pathology, dietetics, social work and podiatry14; comprising over 25% of the Australian healthcare workforce, with over 200 000 allied health clinicians delivering over 200 million episodes of care annually.12,15 This size, research capacity and diversity across clinical specialties places allied health professionals in an ideal position to identify research implementation priority areas and lead efforts to change practice.16–18 However, to date, there is a paucity of research attempting to identify criteria for prioritizing allied health implementation efforts.

Across allied health, nursing and medicine, there is a body of evidence illustrating the research and evidence-to-practice gap priorities for these professions.19–23 Yet, little is understood about why health professionals consider one area more important than another. Without a better understanding of how health professionals make these decisions, it is possible that the implementation of research into practice will follow the priorities of the individuals that initiate practice change activities. A study by Davis et al. (2018) explored the identification of allied health research priorities within a health service organization, finding that areas related to an individual's personal work and department were prioritized but the self-reported reasons for prioritization related to anticipated intervention effectiveness, improvements in patient outcomes and service efficiency.24 It is important to understand how these priorities are determined, as efforts to implement research evidence into practice are increasingly encouraged to align with the priorities of health professionals. Ideally, this could ensure the better informing of resource allocation towards the implementation of research evidence into policy and practice.

The current study aims to identify and understand the reasons why allied health professionals think certain areas of healthcare service provision are a high priority for implementation of evidence into practice.

Methods

The current study used a cross-sectional, online-based survey design. Eligible participants included allied health professionals working in service provision, managerial and academic roles within public or private health services, governance agencies and universities across regional, rural and metropolitan settings in Australia. Monash University Human Research Ethics Committee approved the conduct of this research (project ID: 12800).

Survey

An online survey was developed in Qualtrics (Qualtrics, Provo, Utah, USA) and comprised 20 questions (Appendix 1, http://links.lww.com/IJEBH/A29). Open-ended questions were used to identify potential areas for practice change and to determine how allied health professionals justified these areas of priority or need. Furthermore, participants were asked to describe the amount of resources currently allocated to the suggested area of practice and the amount of resources that they think should ideally be allocated. The survey focused on three areas: first, commencement or increase of service delivery; second, cessation or decrease of service delivery; and third, substitution of service delivery. Participants were able to progress through the survey without providing a response to every question if they could not identify an area of practice they felt required changing in each context. The survey was initially designed by a subgroup of the investigators (L.W., T.H., J.W. and M.S.) and was subsequently reviewed and refined by the remaining investigative team drawn from a range of different professional groupings.25 Changes were made based on feedback to improve the clarity and wording of the questions and options for given answers.

Procedure

An invitation email included the link to the survey and an explanatory video informing participants about the study aim and provided participation instructions. The explanatory video was used to motivate people to take part in the survey but was not mandatory to watch to start the survey. There are no data available on the number of times the video was accessed. A convenience, snowballing sampling approach was used to recruit participants initially accessed from an existing email distribution list (previously created by the research team as part of a larger research agenda).25,26 The email distribution list included around 197 individuals who were asked to forward the email invitation to other colleagues who were eligible to participate to access as many allied health professionals as possible. A reminder email was sent to the participants 1 week prior to closing of the survey. Data collection occurred between April and May 2018, determined as a priori based on project timelines for the earlier mentioned larger research agenda. The majority of responses were obtained shortly after the initial invitation, with a small number of additional responses received after the reminder email. Implied consent was obtained by virtue of survey completion.

Data analysis

Each survey response was analysed verbatim. Microsoft Excel (Microsoft, Redmond, Washington, USA) was used to manage the survey data and compare the responses. A qualitative content analysis approach was employed. This analysis approach allows for large amounts of data to be reduced to concepts that describe the research phenomenon.21 At the level of initial coding two researchers (L.W. and T.H.) independently read the responses multiple times and made notes towards emerging categories. The next step was conducted collaboratively, with the researchers refining their initial comments into preliminary codes, and descriptive labels were given.27 Following regular meetings and discussion, codes were abstracted to a higher level to form categories and a descriptive column was inserted into the spreadsheet. Latent themes were deductively derived from categories inspired by common factors observed in making service changes. We negotiated any researcher-perspective differences; and, if necessary, regrouped and recoded until reaching consensus. Our final step examined relationships between categories to form themes.

Results

There were 149 surveys commenced, and the final sample comprised 146 completed surveys from allied health professionals working in service provision, managerial and academic roles. Three participants commenced the survey but did not complete beyond the demographics section of the survey, so these were excluded from subsequent analyses. Of the 146 respondents, 131 (90%) indicated that they completed the survey on behalf of themselves, compared with 15 (10%) respondents who indicated they were completing the survey on behalf of the organization they worked for. Participant characteristics are set out within Table 1.

Table 1
Table 1:
Participant characteristics

In total 104/146 (71%) respondents suggested areas of practice with a high priority for commencement and provided reasons concerning the commencement or increase of service delivery. A total of 102/146 (70%) respondents stated how many resources are currently allocated and their perception of an ideal resource allocation for this service. In relation to suggested areas of practice with a high priority to be ceased, 28/146 (19%) respondents made suggestions and provided reasons for the cessation or decrease of service delivery. Concerning these areas, 26/146 (18%) respondents stated how many resources are currently allocated and their perception of an ideal resource allocation for this service.

Finally, 52/146 (36%) respondents suggested areas of practice that should be substituted with a different approach and provided reasons concerning the substitution of services. Concerning these areas, 44/146 (30%) respondents stated how many resources are currently allocated and their perception of an ideal resource allocation for this service.

The number of suggestions reflects the number of respondents, as each respondent made only one suggestion for each answer given. Ten themes emerged that underpinned reasons respondents felt that their nominated areas of practice change were a high priority or need for change. The number of suggestions reflects the number of respondents, as each respondent made only one suggestion for each answer given. The individual themes and associated quotes are shown in Table 2. The themes are listed below and explained in further detail:

Table 2
Table 2:
Examples of quotes for the key themes and priority drivers for practice change

Closing policy/recommendation/guideline-practice gaps

Closing a policy/recommendation/guideline-practice gap was cited when classifying an area of practice change as a high priority for change. One respondent, for example, highlighted the need for screening and treatment of patients [respondent (r.) 19, physiotherapist]. At times, the source of the recommendation was not given, whereas in other responses, a specific citation was provided (r. 53, physiotherapist). In these instances, the evidence-base of the referenced guidelines was not discussed or critically appraised.

Closing evidence-practice gaps

Perceived evidence-practice gaps were described as a high priority for change. The majority of respondents referred to evidence supporting a practice that was currently not being employed but felt should be employed (r. 14, occupational therapist). Few respondents provided details of the evidence, and when provided, the level of evidence hierarchy was varied. For example, one respondent provided reference to a randomized control trial and a systematic review of control trials (r. 58, dietitian) compared with another respondent who provided a trial protocol, for which the results were not yet available (r. 28, psychologist).

Improving access through potential change

The current theme captured the need to improve patient access to allied health services. These responses mainly focused on two situations where access could be an issue. The first description was of a person who could theoretically access a service, but was not presently doing so in a timely manner (r. 22, physiotherapist). The second description related to situations where a person was presently unable to access a particular type of service was another priority for service change (r. 42, diversional therapist).

Perceived cost-effectiveness of service delivery

A different explanation toward prioritizing efforts for practice change involved improvements in service efficiency in the context of value for money/cost-effectiveness of service delivery. Respondents referred to two broad approaches for improving efficiency. The first related to the reduction of work duplication (r. 84, occupational therapist). The second approach for improving efficiency related to delegation and substitution of tasks from allied health professionals to allied health assistants (r. 57, allied health assistant). Some responses relating to improved efficiency were complicated, in that the productivity of an individual or health professional group may have improved, but possibly without broad increased (or with diminished) efficiency for the health service (r. 13, social worker). In this example, the request for more administrative staff to complete this paperwork was not accompanied by a sacrifice of social work positions to offset the additional investment in administrative positions.

Improving allied health effectiveness

Another reason for practice change was based on claims relating to how effective a given intervention was anticipated to be for the patient or the patient's family and/or the community as a whole. This theme differed from the theme of ‘Closing evidence-practice gaps’, as respondents appeared to focus on the magnitude of perceived benefit rather than the presence of an evidence-practice gap. Many respondents believed that a different approach to care would have a positive effect on the patient's health outcome such as functional independence, cardiorespiratory fitness, in mental health, pain, spacticity, pressure injury or infection rates. One respondent stated, ‘increasing podiatry service delivery will prevent foot ulceration and avoidable amputations and reduce inpatient stay’ (r. 72, podiatrist). Furthermore, respondents suggested different approaches to care to prevent future admissions or readmissions to hospital (r. 92, dietitian). Regarding the patient's family, respondents believed that a different approach to care would increase the provision of support for families (r. 14, occupational therapist). Concerning the community as a whole, respondents also argued that more effective approaches would impact the magnitude of costs/benefits to the community (r. 21, physiotherapist).

Imbalance between supply and demand

Priorities often centred on perceived imbalances in service supply and demand. This included scenarios where there was a high demand for unmet specific services or an insufficient supply not meeting the current demand. High demand was either determined by patients’ health conditions (r. 53, physiotherapist) or driven by policy (r. 5, dietitian). This policy, if enacted, would create a supply demand imbalance with a greater demand for service than presently available. Regarding supply, most respondents described an insufficient supply of allied health professionals to perform a particular role commonly being performed (r. 56, physiotherapist). A similar category of response related to insufficient practitioners in a role not ordinarily provided in that setting (r. 28, psychologist). Other statements towards insufficient supply were based on the lack of practitioners’ skills (r. 48, physiotherapist). Some respondents based insufficient supply on the lack of physical facilities (r. 14, occupational therapist). Suggestions of supply increase were common without the mention of resourcing to fund this supply (e.g. a redistribution of resources).

Amount of resources involved

Another theme emerged based on the justification of the amount of resources involved. Some respondents provided details on the amount of change needed relative to the current level of resources (r. 108, social worker). Other respondents justified the need for change by providing the absolute amount of change needed compared with the current level (r. 101, occupational therapist).

Extent of the health problem

Respondents who justified the need for practice change on the extent of the problem, provided two reasons. Some respondents provided examples of priority areas for the health of Australians such as growing obesity rates (r. 52, dietitian). Other respondents highlighted the increasing magnitude of the problem that is likely to occur in the future, such as aged care (r. 45, social worker).

Areas of allied health care futility

Some respondents identified allied health services considered to be futile forms of care as a high priority for cessation or replacement. Respondents suggested discontinuing with the current approach to care, to offer treatments that show (in their opinion) a measurable benefit (r. 7, physiotherapist).

Equality of workload for allied health professionals

Respondents, who based their reasons on the equality of workload, mainly focused their statements about a perceived inequality of workload distribution (r. 24, physiotherapist).

Discussion

Allied health professionals appear to prioritize areas for practice change on the justifications that changes will improve outcomes for patients, lead to more efficient service delivery models, improve access to services, rebalance supply and demand, address large problems within our community, address large gaps between policy and/or evidence and current practice, reduce the futility of care provided and/or improve the equality of workload across health professionals. However, hidden deeper within these overarching themes are some inconsistencies between what respondents stated, and what might happen in real-life. This indicates that greater dialogue between health service decision makers and allied health professionals may be of benefit so allied health can understand the priorities of decision makers and the evidence they find persuasive when trying to drive service improvements from the ground up.

The current study provides insights into real-life decision-making of health professionals. Inconsistencies between respondent statements and real-life practice may have been masked within these overarching themes. For example, respondents spoke about the need to improve productivity of professions to improve efficiency. They suggested transferring some tasks to others without mentioning where the time and resources to support task delegation would come from. Without evidence supporting resource allocation or reallocation, less efficient service models may be employed. Respondents were more likely to suggest areas and reasons for commencement or increase in service delivery. Only 52/146 (35%) respondents suggested a practice change involving substitution, and half as much suggested a practice for cessation. This is perhaps not surprising as the concept of disinvestment in health care services is still relatively new. Research designs to specifically address the withdrawal and reallocation of services are still emerging.28–30

The current study identified several reasons why allied health professionals think certain areas of practice are a high priority for change. Some themes echo key factors already known about allied health managers’ resource allocation decisions.31 Factors held in common included: extent of the problem, access to services, the effectiveness and efficiency of services under consideration, the relationship to policies, guidelines and recommendations, and different professional groups’ workloads. A key point of difference to this previous work was that allied health managers considered reputational risks to their organization when making resource allocation decisions.31 This was not identified as a reason why a practice change could be considered a high priority in the current study. Similarly, allied health managers also considered the degree of stakeholder support for changes.31 Again, this was not elicited within this current study. It is possible that participants considered these themes, but they were not considered a reason as to why the change should be a priority.

Allied health managers have reported finding, sourcing and using research evidence to inform decision making as difficult and time consuming. Yet evidence-practice gaps were cited as the key priority driver for change.31 Our current study found that allied health referred to evidence as a part of their justification for change; however, the robustness of the evidence cited was variable, and some responses were highly questionable. Barriers to using evidence to inform decision-making have previously been identified including lack of skills concerning searching and evaluating research findings, and perceived lack of time to find and evaluate relevant evidence. In spite of this, respondents to this survey frequently cited evidence-practice gaps as the key priority driver for change.32–34 This contrast indicates that allied health professionals may know that evidence should be driving practice change, but feel ill equipped or under supported to enact an evidence-based approach to changing practice. Previous research has found that allied health professionals lose confidence related to using and critically analysing published research in under 5 years of commencing clinical practice.35 Routine support should be provided to allied health managers towards the implementation of evidence-based practice and we posit that access to, and use of, a growing number of implementation strategies be utilized to promote evidence-informed policy and management decisions in healthcare.1,36

Strengths and limitations

The study sample for this survey represents the opinions of a diverse cross-section of the allied health professional workforce in Australia. A varied range of age, experience, level of qualification and profession provides an insight into prioritization for implementation of evidence into practice across the health care workforce. Importantly, the survey not only captured perceptions around evidence-to-practice gaps for the commencement of new services, but also the removal and substitution of services. This is important, as initiatives including the Choosing Wisely campaign are increasingly focussed on the deimplementation or disinvestment of low value health care service provision.37,38 There are also limitations that need to be considered in this research. We received less than 150 respondents for this survey, who were accessed via an existing email distribution list as part of larger research agenda.25 The true denominator for our response rate is unknown due to the use of a snowball sampling approach. Furthermore, professionals with an interest in practice change may have been more likely to participate in this survey. Consequently, the representativeness and generalizability of our findings to the broader population of allied health practitioners and managers in Australia may be limited. We asked the respondents to list evidence supporting their statements in some of the survey questions; as a result this may have prompted respondents to cite evidence-practice gaps as a reason as to why the change should be a high priority. For this reason, we have not sought to use the frequency of responses in this survey as a measure of relative importance of each theme. However, our results provide an in-depth analysis allowing a rich exploration of how health professionals prioritize areas for practice change.

Conclusion

The current study adds to a knowledge base informing evidence on decision-making in allied health. Despite growing resources and frameworks for planning and measuring progress, we suggest that future research must ensure that resources and effort spent trying to change practices in allied health are targeted. Such research should determine if a more systematic approach can help ensure that efforts to change practice are focused on areas where high levels of evidence are present and where the economic impacts of the changes proposed are considered. Such a systematic approach could potentially generate economies of scale in the searching and synthesis of literature to support relevant practice change, to incorporate stakeholder concerns in this process and to generate economic models of likely impact.

Acknowledgements

Conflicts of interest

The authors report no conflicts of interest.

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Keywords:

allied health; behaviour change; implementation; practice change; qualitative analysis

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A video commentary on implementation project titled: How do health professionals prioritise clinical areas for implementation of evidence into practice? The commentary is provided by Andrea Rochon RN, MNSc, Research Assistant, Queen's University, Ontario, Canada