Challenges in implementing evidence-based practice ...

i\/lenlaFlearl-r Besearchafd Pohcyf,,laking

Challenges in implementing evidence-based practiceinto mentalhealthservices Franl< P Deane,TrevorP Crowe,RobertKing,DavidJ Kavanagh andLindsayG Oades

This paper highlightschalenges r jmptementjng ne_Ia 'eakl_ po cJ a. d sArvi.. oe.\el level. tl descibes an attemptio fosiergrealerappticaijonoi fecovery-orientaled princlpes and praciiceswithrn menlal healih services. Nonrvlthsiand ng a hghty s r 0 0 0 . l ' v ao o l i c ye . v i o r ^ e n . .s r o r g s L p p o f . - o re-vce adrrr slr.io.s,ard an ellh-sas-ic s(afl r o c o o ' r s Le ol r o i r i r g .a p p c a d o ro r l ^ F- 3 - r g d r a sLooorl tool: was weaker har afi.pa(ed ThF p a o e e v d l u a _ el hse d s s e r nr l d l o ' rr i a r a q d , t r r . ( . elernentslo promolesusialnedadoptionof irnovations. Organisationaland proceduralchanges are reouied bebre nerral heal ooliciesa e sysleralica y impementedln placilce. Aust HealthRev20061 30(3):tos 309

lt ,s No octous_) Dt.ccrr I jo "_.u - .ha appropnac innolarioG in memal health care are Lakenup and rounlely implememed.rProblernsol diftusion are essendallyrhe same as those found n o r g r s a ro r 5 g 6 F . ' . Ldrrg Ld or .4 tngs - For effectir€ and susraineble tus.minarior, innorarioroneedro:116 .

o B o i : d L o r a" c

d . r : ,

, . T o b t " r " S u o o o r. r o - o o - n e o g 'e "nJ " \ .doD.e- pe"d

Ffank P Deane,PhD,Profe$or Tfevor P Crow€, PhD,AsociateFelow LindsayG Oades,PhD,SenlorLecturcf llawdm ln*iiule for Mentl Helth, llniveisityol Wollongong,Wo longong,Nsw Robert King, PhD,AsociareProfe$or DavidJ Kavanagh,PhD,Prdlesor UniveBiryotQueensand,Depadh€ntor Psychiairy. Conesponden.e: D. FEnk P Deane,llawar€lo*irurelor faenb Health,Univ€fsityolWollongohg, Nonnfi€dsAv€nue B-idirg )2. wo'o1so 8 NSw 2r2]. rdeane@uowedu.;-

Ausrrala. Heallh ReviewAlgusi 2006 vo 30 No 3

spread suppon by middle management and staff increaseseffectivenessand susrainabiLi.t ! B" o. .:.en " + "". o p,. .e . d e-i. ,ooled ,rr o onp6 o wir o erro . o i o n 1 e 3 " "o , n o n l . i . e o o , - . o u p . " r B. .or '"i...ed L o 1 " r " . . " " q . r _ 8 r " \ k l ] . d g h . .r l elficacy for their implemeniation t Have appropnate resourcesfor implemenutror, ". in. lud 'g ,1 -.., .o u" I . a md re\t'ardrng fidelir): r Be acceptedby cols-umers -hL D,o" . .". e.ra ronel ,; "r.€mD o p'elen ." prr. pe h, L.a Tradirionalh menral health sernces hare iocused on sFrprom reducrion and improved rcle fu- o i,g Ho^" er. -" s .rro.r" \o ond.

005

l4enta Healh

Researchand Polcy N/]aklng

'"-

dop.. 008 \H\tD , % PLn .00 pnmary pmciple that A recovery one ation should dnve senice deLverr' . An honf descnbes . . a way of Lil'1nga satrsilng, hopetu| dd coninbumg lie evenmrh limitations caused by iLLness. Recoveryinvolves&e development ot new meanng and tultose n oneSIife as one grows beyond the catasmthic efiecB ol Adoption ol fiis goal and ils rouone application ar Pq - o' e "oi r '" J |-,jlf P\ ema[on oI oDjectlves and practrces._ -r .ud ",. ". \" | ,pl- r"-,. .o ,j of the CollaborariveRecol'eryliaining Program D r P . w h i h p r o v d e - r . r . 1 n gd r d . p p o ool ro,r' , " , rFrl\ ".If-o *p . el recovery based car€ wilh people afected by chronjc mental illness, who have hish levels oI unmer need and re.tuire ongoing care. The ob" .'. d r'''Brot " oTDI ongn €

M

o

J

lb

t

P

ed o pofr"r ofg,."Lo

ao.

Methodology/sequence of events D"", ot' r. ronJe o R\' h"

pLLal,reoejr'J.nd e 'p1" " ] \ odP l" otrbo? /e ReLo " . "e c. -. beo 'g o ' .r rr "r'- ! o-qdr

\.':",o:"oe oC o o'"qb o l2-monlh booner sessions.Sessionsused manL o ' ot gurdrngpr .- p e " ,ortu ing colaborarion in clinical and suppon work. ' o r L " " d people \r1th chmnic or rccuning mental rllness; a

, g or.ron. rr, .lL'..rrnCo . b..r. ."..," r"d o " \-. or'l a g o u o u - g% e - , , . 1 d - , s . , B I n d . - . .

workers were given related honrwork assignrp Fl ne , r,d 'n.... . ppo ool' o goals. fomlulate 306

Setting/participant5 Pa ii'pating organisadons were pubLicsector menraLhealt\ seFrces fron lour separatearea ",j& "n " ,nd o.80.€... oB, , lions prondng suppon servicesfor peoplewith , . 1- . f . o , 1o ., e, ( our c u , , J , \ o r , \ " . o \ . , " d n dQ . e eL a lrid). Panicipaiingorganisationsdemonst.ate.L p - a j "b. o i b , g d , 1 d o ' u b . r: . other resourcestowardsimplementation.ParticL pation of lvorkers and clients.wasvaluntary The L d y p o ' o o- 4 . " d , * es|edsull, who ihen panicrpatedin the training "-^

.....

.-.1 .".-"rp;

""hhlp

,l,prL

lnitial naff rccruitmenr and training imPa.t Depoe ol" PTD ,i -g mrnagement and indilrdual paticipmt levels and partrclpadon was high across all parher serices. Serics requested addidonal tmhhg for s.aff - .l"rr.o .-" o.o,1 re.ar."d r pjkl a 0 0 " i r o , r J s g o ne > .e. .oa^ o ker, h,r/e been .ri ned "nd bo h lonnal "nd ,d , "d d " G. 1"d . :nlonnal teedb o r , r u r g wr rpa. o b,r'n '. 'rd po i " . 'p" I/ r'.la.oro,at.|1Ud".o e.o\el orientaredpnctrce 1l Iftplementorion

of opplied skils in .lini.ol

Procti.e The primary ailn of ilnplemetuation was !o have clixcians use the skils leamed in ihe initiat Z'day I n , . p o i l . . , r p , j . r" t. % l .."neo rF.. l\.*!r .".d. p . , j- . " h . C " r , h , be ott l r " p - o g, r d " n p r " d , o r d d r " . .h e r " ) d i r e ' . , - . " ^ . , . - , " . , . r l ' , "f n l " - " " ' " , ' . Manogement and staff commitment ghl o 'tet - . r a d l e t o n " dr o l P " ' w1!h naliona1 objectirs, and had stong organisa r . o, n'D € r or c . . p p o r . . . d s Senior managemenr and team leaders were i \o \ed d€ " opu'g nDl" r | ,o p,o.p ? lor fieir sites. Staff m€elings e:'?ressed strcng . p p oI l o I p og!n. i",rn ',d" . ,ldPo AlstralianHeallhFeviewAlgusl 2006Vol30 No3

;,1

il

?l

\4entaHeath Research and polcy lr4aklng , d , r , r g d o ^ r l i e . . " , r " , d e r p . ., y " g " . e ro suppo4implememaflonin pracdce. consistency with .utrent pradke CR]? components vere designedro be hrglly con 'r, "-- Lhed ing rerd e.t,hwo p...ri.e. adossa rangeof senice conlaxlE.A focuson goal olrru g,-d ro or.g " . hgrdy o15 en. r . e pl.tuLrgp! €.,€ ,hd h-"o u "L1 erv," Tne porn. fo o ".-La'jonard Bo", DL- r". -. n.DDpdo"ro he ro. -" t. ofll, assessmecyclesthat reponedlywec usedrn pa ticlparing govemmenrorganjsahonsi as well, our asr.ssments reLiedheauiy on exismgm€asures,Au ot.he o gan r o , nad.rre?e..,..o Ih, L. . a , ' r.so d i o i l o n g , ' r . a 6 - r .l..o,g rl.e rc". . ou: o 16 no pb,,€a .n no.l senicet $Ane fie demandsol CRtvIprocedurcs may be morc denundmg &an usual pnctice, we r , " A P o; o c r b . o ,ng." r b e ro assessed consumers to rhreeper clnician. Aeor .ommunication' The trainjngp.oceduresand rheir eraluadonssug gestedthat rhe rr"hjng was effecrive.Clinicians u - € p r o \ a d " d\ , , d n , . o a s . , \ n o . o idarionof tnidng, andeachsrrehadprojecroficer suppo[ to .eiilorce rajnng and provideguldance w]tn respecrro Lmptememarron.

the 400 memalhealih rcrkers who were rrainea, only aroundhalf agreedro formaity pa icipaie m |he voLunraryevaluarion,and most paniciparing wort ersrecmtedtusionecLienl.Concemsabour additionalnarkloadand compern1g demandson tim€, clains of rarelyworkrng long term vlrh consumers, and pereivedlack ol organisational suppo were commonly ciiecLnasoru for non_ participationor low clienr numb€rs.lvbrker abo indicaied rhe projec!! exrrapapenvorkprevented further recrutnent. One rcasonfor rhe percep tion of addirionalbuden \a?srhar rcurineou! come assessmenLs otren were nor completed . o n ,r e - d eo D " c . w p " " . € q . " ment (paniculrrly in ihe govemmemseNices) Prelimimry eridence also suggesredfiar tess lhan half the clienrspanicipating in rhe prognm were nahng regular activeuse of lhe key goaL selting and homework acriury laols. Allecdoial repo s to ste coordimrcrsjndicaredrhar dlb

.l " ".,"d . " -t" o "o t eF .o , !h 1p"i processes, ralher ihan clienr rsisrance !o fiexr However rhe degree of CRM appLicarior ]nay be an underestimale, sirce anecdo.al e\,,ldencesuggesred that some parflopanrs who lvele applPng cRx,I processesdid noi record rhem or did nor nuke them availabl€ lo fie evaluarion.

Discussion Resources to supportimplemenrotiot Eachclinician was provided'ffirh goal and home vork plannng fo]ms which were carbonaredn o d e o D o v i d €' . e .. . . a , o l a r p e r ( . , o p , e s c i zged o r"q-^ goaiplar .nc progressat teammeedngs.

Consumerocceptonce Consuhaiion nlth consumer groups and rhe con sumer-driven philosophy of rhe program suggesred '! o . ,-r€' uo ld . e' e dpproj. d\oul dbv-t-o e e 1 - r a . r " . L d dd . o n < L a - , " p . € setuative on fte Implementarion Comminee who was a strong advocarefor d:reprcgram. D - , o , d , r e b D - r , a g" t f o r e w]&%ho ]""i'!-

.re'p "erc oiJt npr".-,"O

Australia.NealthBeviewAugust2006Vo 30 No3

Poor upake of specificskjls hghlighls rhe cballenge 1or sust3jning evenrelallvely ninor modifications ro wo* pnctices among t\e menral healLhworkforce. ln rctrospect,much more vas neededn our prqecr to increde rhe succss of implemeniaiion and clunged practice Cle,Ih Lherea.e major chaltenges s'nh rega.d to upcke md lransfer of rminng to Dractrce" &aI need io be addressed. Nlore strucFr.e may have been needed ro suppon orgarosattonalchange. Becker er a1" descnbe rhe role of the erecutrve direcror in communicaring a recovery ideolog/ dd chdge middle managersard senior clinical staff to suppon fiis vision. They emphasrse&e need for niddle managersro nor only r - d p ' ) r d h " r o d e r ,b u r o o . r " r e r \ i . €ffectively and aaecutechange wiih clnicians and oiher srakeholdels.In L\e cunent srudy implemen

- Research MentalHeath andpo icyMakng

lal]on mal have been grearer if fieE were regular " ."v s ol D ogrlp. n iD " e .Lo'on b/ .enromanagemenr {e8, panicjpanr recmirment, file audrt md if d]€re werc formal stncruzes ro renew lideLF)'to CRM ll1team meeoigs and casercvievr's. Team leaderccould be rraned to praise €arh adop te$ of CRM. Establishmenrof CRI{ supervlsion, or integradon of CR\4 imo eaislr.rg snpenTisionn,a) also have increded implemdtauon. lmplemenration jr ihe contart ol researchsenos mded messag€sro paricipams Implemenlatlon ourside a researchcontexr embles lit operanon of quahry managemenr mechanisms. mcludrng boLtl fornal and inlormal clinjcian pertormance " p o f u i " , B r o n - b | ] 1 '1 h - a , - q u r p ' € n . ! o . . m o l e a F , o o . r * e " r . . D o . o c o i€ . r l p . s . e partlopanr auLonomy md do nor peml! anl, hnd or co€rcrve pracnces, even those rhar w.ou1d be slandard in rourine serice mmagemen.. TLjs meaft ihat ciinicians could easiiy percejve the pqect as an oprional "add on" to rcurine pracrice rather rhan core business, despire clear organisa

(eventhoughinfonnal audlrsof iles indicaradrhar ohenlhs vas nor the case) Consisrency wrh pe.ceivedroleswzsa problem in some seffices For a{ample, . P d

b o

" e

- . P - D . o , -

" h " r " e . g o a to a n r 6 e L ! v " " , L r -" l , i . d . h p p o rr o r r e , non-govemmenrorgalrsatronswho used CRM w:: clinical,, seffices. Mosr peopLe lelrenns wr|n chronLcand recuning menraldrsorderssucn as schizophr€riaacluall receivesimilar r}?es oj casematrugemmtand sefficeshom both .ctjni.a, and "disabilry $,rppor! providers. Argumems aboutwho provldedwhar servicesaddedto chal lengesfacedIn rhis projecr 1,5recognisedby the cune NMHB' rhereis a needio bnng rogerhera ollelse mge o1Sorernmen!andnon_govemmen! organjsaiioff jf rve are ro be succesJutin maleog slgniticantmenlal heahhrcforms. Roleboundarl, Bsuescreaienujor challenges lor suchreiorms. Whle rhe e\ldence suggestsrhar lhe rraini.Lg was sound,preuous researchsuggestsrhar vorl{ L o Da n s ' o o -rr o r g o" {e_.r There appearedro be a high ievel of sr,rpporr forcedby arremptsto use the sk s. ln the cuner( tor CPJP in meedngs bur it is also possibterhar prqect, somepar[clpants did nor apply the sk s rhrs projecr sufkred from scepticismconcernnLg imed J" \ rrd ni l-v" J...ea born.h-i. the relevanceol researchlindings ro reat_wortd ser-encacyand their fideliry ro CRMprorocots. practice, or lhe belief lhar endence basedpiac_ Resourcerssueswere also raisedri thrs projecr. rces arc passing fads rha!.wiil be quickty Pe*aps routine record keepins should incLude replaced with somerhing etse ra rhe evaluation both proc€ssand ourcomemeasuresElaong ro ,e| r'e r.Pedad ol -r.n o recovery values (eg, self derermjnarion,rllowrh stali on the ground, becauseol concems abour potentrat).15 Foreaample, ttreconsumers, ;overr thrcats to auronomy or chnical vision and goals could be documenred,with coa_ ,professional sumersgNen copresand encouragedro add com, 'CoDsistency wft curenl pmcrices was also an me s. However, our obseffarionssugg€stLha. rssue aspecG ot our ptamrng werc flawed, because mdeLyaddingsuch a lonn ro proceduni requre we reted on what stall said &ey atready djd, or on mentswill nor ensurerharit is used:modtoring 01 what managerssaid rhey were rcquired ro do, nfter rususeand inc.ndvesfor usewili be needed. |tlan vertrng whar they adualiy did in practrce,bl Other resourceusuesareraisedby fie needfo( reguLarbiatiending reamneedngs, and audihng Fles sustainabrliltSeveratother menralheatrhserlrces a]ld acriviq, rccoijs. A r\.,1ew ot worktoad anJrim. and non-govemmemorgamsadons tave requesred managememby dinicrtuT coutd atso have inJonned CRTPbasedon earlypromisingnndrnss the proo'.n rorru .ho o r.e o"en , or F . in,e . $"m ius beenlnegmtedinro someof dreumversq gnted lnto exjsling 6]e sjrsremsnrher rld beints o.ogJor bo.l d " I n \?F.rvo, Woltongo, g r, d !1ewedas -exdas. Some cii cians indicaredthal lne U- .€c r) ol Q-"iLl. o b. rlu co- n" they drd nor complere goal ptanning tomls becausc addressdr need.of disring pro\,,lde$inctudlnga |hey aheady complered orgsnisartonat care ptans raprqry expancrnEnon-govemmenrorganisation 308

I

I

i

I t

Australian Heatth Feview Augusl2006 vol30Nos

a

Menta Heath - Fesearchand PolicyUak ng

^ o r U o r 'e d e l t io or'" O Boug w 'e . *er.r..nd ro d o.e o o-v op" " n 4 - - e J . o L e r ' o L . d ' o d r L i g\ " d n dr l _ar"n o r g e L l- i F . o r . p - p e !-;.der.of con5:umeFas parr of lhe t.aning leam, th€re n a 'eed o -,h.n8 o n s u .e d d o c ' e s o n p o o t l " - ? ] e p o " h p a r l a " d r " a ' 4 8 o , D o o j " .m d ) J o p e J -o dl uq'o o \ \ . # D o a . . s L he,pp ,uo- o Lr- rume .) .e practices could assis! lhrs across serices €covery (es, assessmemr6). Recover,vself emluado;

Conclusions i " o n . l o m o . ' L t u lo r . f ' g ) 1 , 1 n " o . e r e , n d " P g , "nr g o'"'lp. " "\"ffp'l hilpgp fo. ,o ao)roqpd mentadon ol 1nental health pohcy Even when rhere is high congruence with natlonal policy p'ort" " Lg\ strong pariicipeflon in n"ining and only moderate \arg" ro u" . p ,r'r ' i npl" | "n ,j' on rn o. L"\ ro oe J>' Pd L " ie ,phT'rr'ior " q u ' r ' " r l o ' .^ Do4 r,nc€ 'e P o .r ' , d e s € " o u ) r - . .tr n r. .tsr c- svFn ro.s ,,idaon o oa:l orF , u . o o , ) . D o b n e . o h e L r e r e n to q t J o a cocideration. Given L\e hkelihood thar there qnl be some vio]ation of frdelity, we need to build interventios L\at will remain eftective even when jmpleme alion ls less than opliruL . o L d"-lorb "mBdL "Fe \" d-rru. ,o1 o r tug aelrq ,er J .J lnteNorion is possibLe.oHorvevea we need to rdec ano aseniru or b . ard U , B o o aD ? . . . e b e o ' e . o i € o shon'€rm intuatftes bring long |erm imprcvements

Acknowledgements This proiect was co.d!.ted as pa oj the Alstfalan ' "q o "o ve-l. -" , . r,. .e rplNlhid d ros o4t. ':o . d - o o J " n \ - V P C ' r " e o M e n" h ' " I P " T A Grant(+ 2r 9327)a.d by pairnerorganisatons.

Competing interests I e auTo . 06 d p ho' t!6r \o,6

i I

t-

o o.roolino ir leid

Vol30 No 3 Augusl2006 AustraianHealh Review

References I (avaaAh DJ Piatkowska O Ca D eial Applicallo..i - o rn a o : . " b e" o a . . ' - . o p , d ni.e b. e - r-d oi'.f '. q- ^ AuslPsy.hol1993t2ar1a1-e 2 Kei. KJ KnighiAP nnovarion implenenratonovercom n9 the cha enge Cun Dn PsychatSci2nat tu:243 6 3 FogeEEM D iruson.f i.novauons.5s ed NewYod