Practitioner Attitudes Toward Evidence-based Practice: Themes and Challenges

Abstract The widespread successful implementation of evidence-based practices (EBPs) into community mental health settings will require a thorough understanding of practitioner attitudes toward these approaches. This study reports on the results of two community mental health practitioner focus groups investigating attitudes toward EBPs, perceived challenges to implementing EBPs, and recommendations for researchers interested in facilitating EBP use in community settings. The participants were child and adolescent mental health professionals (N=19) from two community mental health centers. The focus groups were taped, transcribed and coded for themes. Major themes included concerns regarding the applicability of some research supporting EBPs, a desire for a greater emphasis on the therapeutic relationship, and the need for flexibility within treatment protocols. Themes are discussed within the context of the recent movement toward implementing EBPs in community settings and recent research related to focus group themes.     

Consumer and Family Views on Evidence-Based Practices and Adult Mental Health Services

Evidence-based practice (EBP) is an important construct in mental health services. Though much has been written about them, there is little in the literature that fully explores consumers’ and family members’ views regarding EBPs. Using a focus group methodology, this study asked the question “What are consumers’ and family member’s views of EBPs within the larger context of their mental health service needs and their experiences with the mental health service system?” Results indicate that consumers and families have limited knowledge of EBPs, are generally supportive of EBPs, but have questions and concerns that are grounded in systemic and contextual considerations.     

Predictors of Practitioner Self-reported Use of Evidence-Based Practices: Practitioner Training,Clinical Setting,and Attitudes Toward Research

In light of the recent movement toward evidence-based practice (EBP) in mental health services, practitioner adoption of EBPs in clinical settings has emerged as an important area for study. This paper reports on the results of a national online survey of mental health practitioners in an attempt to identify correlates of self-reported EBP use in practice. The survey consisted of 214 mental health practitioners from 15 states drawn from a diverse set of clinical settings and representing a variety of theoretical orientations. The results indicated that practitioner training (i.e., taking a class in EBPs), the perceived openness of the clinical setting toward EBPs, and the practitioner's attitudes toward treatment research were significant predictors of self-reported EBP use. The relationship between clinical setting and EBP use was partially mediated by attitudes toward treatment research. Negative attitudes toward treatment research partially mediated the relationship between practitioner training and self-reported EBP use. The findings are presented within the context of efforts to increase EBP use in clinical settings and implications for clinical training, treatment research, and EBP dissemination efforts are discussed.     

Mental Health Provider Attitudes Toward Adoption of Evidence-Based Practice: The Evidence-Based Practice Attitude Scale (EBPAS)

Mental health provider attitudes toward organizational change have not been well studied. Dissemination and implementation of evidence-based practices (EBPs) into real-world settings represent organizational change that may be limited or facilitated by provider attitudes toward adoption of new treatments, interventions, and practices. A brief measure of mental health provider attitudes toward adoption of EBPs was developed and attitudes were examined in relation to a set of provider individual difference and organizational characteristics. METHODS: Participants were 322 public sector clinical service workers from 51 programs providing mental health services to children and adolescents and their families. RESULTS: Four dimensions of attitudes toward adoption of EBPs were identified: (1) intuitive Appeal of EBP, (2) likelihood of adopting EBP given Requirements to do so, (3) Openness to new practices, and (4) perceived Divergence of usual practice with research-based/academically developed interventions. Provider attitudes varied by education level, level of experience, and organizational context. CONCLUSIONS: Attitudes toward adoption of EBPs can be reliably measured and vary in relation to individual differences and service context. EBP implementation plans should include consideration of mental health service provider attitudes as a potential aid to improve the process and effectiveness of dissemination efforts.     

The Role of State Mental Health Authorities in Managing Change for the Implementation of Evidence-Based Practices

The evidence-based practice demonstration for services to adults with serious mental illness has ended its pilot stage. This paper presents the approaches states employed to combine traditional policy levers with more strategic/institutional efforts (e.g., leadership) to facilitate implementation of these practices. Two rounds of site visits were completed and extensive interview data collected. The data were analyzed to find trends that were consistent across states and across practices. Two themes emerged for understanding implementation of evidence-based practices: the support and influence of the state mental health authority matters and so does the structure of the mental health systems.     

Informal Role Expansion in Australian Mental Health Nursing

PURPOSE.  This study aims to determine the extent to which community mental health nurses are currently practicing beyond the traditional scope of nursing practice .
DESIGN AND METHODS.  A self-administered questionnaire was distributed to community mental health nurses in Victoria, Australia.
FINDINGS.  The majority of participants reported routine involvement in practices that would normally be considered beyond the scope of nursing practice, such as prescribing, ordering diagnostic tests, and referral to specialists.
PRACTICE IMPLICATIONS.  The extent to which the current mental health service system is dependent upon nurses transgressing professional and legal boundaries warrants further study. Psychiatrists and community mental health nurses need to work collaboratively to understand their respective knowledge and skills and to be clear about how they take responsibility for client care.     

Confirmatory Factor Analysis of the Evidence-based Practice Attitude Scale (EBPAS) in a Geographically Diverse Sample of Community Mental Health Providers

The Evidence-Based Practice Attitude Scale (EBPAS) assesses mental health service provider attitudes toward adopting evidence-based practices. The original scale development was done in one large California County using paper/pencil surveys. The present study examined the factor structure and internal consistency of the EBPAS in a sample of service providers from 17 states. Participants were mental health workers from agencies affiliated with communities funded under the federal Comprehensive Community Mental Health Services for Children and Their Families Program. A confirmatory factor analysis supported the originally derived a priori factor structure of the EBPAS in this new more geographically diverse sample and with a different data collection method. Analyses also demonstrated better internal consistency than in the original psychometric analyses. This study supports the factor structure and reliability of the EBPAS. This work has not been presented at any conferences or professional meetings.     

The Role of State Mental Health Authorities in Promoting Improved Client Outcomes through Evidence-Based Practice

The role of state mental health authorities (SMHA) is critical to implementing and sustaining evidence-based practices. This paper describes the seven major tasks of SMHA’s that comprise that role and provides examples from states which have been actively pursuing evidence-based practices.     

Mental Health Quality and Accountability: The Role of Evidence-Based Practices and Performance Measurement

Both evidence-based practices and performance measurment in mental health systems have been implemented as largely independent initiatives, each facing issues related to systemwide, sustained implementation. A major thrust of this article is that a broader quality and accountability framework is crirical for obtaining better outcomes and for incorporating these initiatives into business as usual. This article provides an overview of national initiatives in these areas, lessons learned from implementation efforts, and problems encountered. Building on these experiences, a model for a quality and acountability framework is proposed in which evidence-based practices and performance measurement systems can together provide productive and ongoing synergy.     

The Relationship Between Maternal and Child Symptom Change in Community Mental Health

The mental health of mothers and children are closely linked. This study examined the relationship between child and maternal symptom change during a period in which children participated in community mental health treatment. Symptom change was measured using the Child Behavior Checklist for children and the Beck Depression Inventory for Mothers. Results indicate that mothers whose children improve in community mental health treatment are significantly more likely to report a reduction in maternal depressive symptoms than mothers whose children do not improve. Implications of these findings for mental health service settings are discussed.     

Academic/State/Federal Collaborations and the Improvement of Practices in Disaster Mental Health Services and Evaluation

Academic, state, and federal agencies collaborated over the last 9 years to improve disaster mental health services and evaluation. This process, which included literature reviews, a number of expert panels, and case studies, is described. The products resulting from this process have included the development of a systematic cross-site evaluation of the federally funded crisis counseling program and field guides for interventions aimed at providing services to distressed individuals in the immediate aftermath of disasters and to individuals needing resilience skills training weeks or months after the event. Future improvement of disaster mental health services calls for continued research, evaluation, training, and intervention development.     

Implementation of Evidence-Based Practice in Community Behavioral Health: Agency Director Perspectives

Despite a growing supply of evidence-based mental health treatments, we have little evidence about how to implement them in real-world care. This qualitative pilot study captured the perspectives of agency directors on the challenge of implementing evidence-based practices in community mental health agencies. Directors identified challenges as limited access to research, provider resistance, and training costs. Director leadership, support to providers, and partnerships with universities were leverage points to implement evidenced-based treatments. Directors' mental models of EBP invoked such concepts as agency reputation, financial solvency, and market niche. Findings have potential to shape implementation interventions.     

Effects of School-Based Mental Health Programs on Mental Health Service Use by Adolescents at School and in the Community

Many schools provide counseling to adolescents with behavioral and emotional problems on-site, but little is known about the use of school-based counseling services in the United States, and it is unclear whether these services complement or substitute for counseling services available outside of school. In this study data on mental health services offered in schools are used to estimate the probability of receiving emotional counseling at school and elsewhere. Where mental health services were available on-site, students were substantially more likely to see a counselor in the previous year, controlling for mental health status, health insurance coverage, and other factors. The effects of availability were greater for students enrolled in special education programs than for other students. However, these data also suggest that, relative to other schools, schools offering on-site mental health counseling do not increase or reduce use of counseling services outside of school on average.     

Service Priority and Standard Performance of Community Mental Health Centers in South Korea: A Delphi Approach

Objective

The role of community mental health centers (CMHCs) in Korea is quite different than that of these centers in Western countries due to nation-specific health care system characteristics. For example, CMHCs of Korea are expected to provide services for serious mental illness in addition to other services in response to community needs, such as internet addiction of adolescents. Consequently, it is important to determine service priorities of CMHCs and to define standard service performances in order to maximize their effectiveness with limited resources. The present study aimed to generate expert consensus on service priorities and to identify standard service performances of CMHCs in South Korea.

Methods

Forty-five mental health professionals participated as experts in a Delphi survey. We made a survey questionnaire based on Korean and international data and guidelines of some countries such as the UK and Australia. Experts answered the first and second round questionnaires and their answers were analyzed using frequency analysis.

Results

For the question about future directions of CMHCs, twenty-two experts (49%) answered that the growth of services for serious mental illness should be preferred to other areas. The service for chronic mental illness was thought to be the most important service area (27.1%) and, early psychosis (10.5%) is included, the services for serious mental illness should be regarded as the most important service area of Korean CMHCs. It is followed by child and adolescent services (13.2%) and mental health promotion services (10.8%). The relative importance of service performances on each service domain were given by answers of experts.

Conclusion

CMHCs in Korea should focus their priority on the management of serious mental illness. Service standardization by the relative importance of service performances on each service domain is needed.     

Management of Mental Disorders in VA Primary Care Practices

The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.     

What Gets Noticed: How Barrier and Facilitator Perceptions Relate to the Adoption and Implementation of Innovative Mental Health Practices

This mixed-method study examined the facilitators and barriers discussed by 166 informants interviewed from 78 innovative mental health projects. Facilitator and barrier coding reflected two dimensions: the topic of the comment (e.g., funding); and the time phase of the issue’s influence (e.g., pre-decision). Proportions of facilitators to the sum of facilitator and barrier comments made by project informants were calculated. Overall, facilitator proportions were higher for projects that proceeded with implementation than those that did not adopt the practice. In addition, facilitator proportions were generally highest at pre-decision and lowest at full implementation for implementing projects.     

What Gets Noticed: How Barrier and Facilitator Perceptions Relate to the Adoption and Implementation of Innovative Mental Health Practices

This mixed-method study examined the facilitators and barriers discussed by 166 informants interviewed from 78 innovative mental health projects. Facilitator and barrier coding reflected two dimensions: the topic of the comment (e.g., funding); and the time phase of the issue’s influence (e.g., pre-decision). Proportions of facilitators to the sum of facilitator and barrier comments made by project informants were calculated. Overall, facilitator proportions were higher for projects that proceeded with implementation than those that did not adopt the practice. In addition, facilitator proportions were generally highest at pre-decision and lowest at full implementation for implementing projects.     

Long-Term Sustainability of Evidence-Based Practices in Community Mental Health Agencies

This study examined rates of sustainability, defined as program continuation, and factors associated with sustainability 6 years after full implementation of five evidence-based practices in 49 sites in the National Implementing Evidence-Based Practices Project. Based on interviews with agency leaders and state leaders, 47 % of sites sustained the practice for 6 years, 16 % restarted the practice after a period of discontinuation, and 37 % discontinued the practice permanently. Agency leaders from discontinuing sites identified inadequate financial support, lack of prioritization, and workforce issues as barriers to continuation. Adequate financing, ongoing supervision, and monitoring of fidelity and outcome may promote long-term sustainability.