The relative effectiveness of practice change interventions in overcoming common barriers to change: a survey of 14 hospitals with experience implementing evidence-based guidelines

AIMS AND OBJECTIVES: Changing practice to reflect current best evidence can be costly and time-consuming. The purpose of this survey was to determine the optimal combination of practice change interventions needed to overcome barriers to practice change commonly encountered in the intensive care unit (ICU). DESIGN: A survey instrument delivered by mail with email follow-up reminders. SETTING: Fourteen hospitals throughout Australia and New Zealand. SUBJECTS: Individuals responsible for implementing an evidence-based guideline for nutritional support in the ICU. SURVEY: Practice change interventions were ranked in order of effectiveness and barriers to change were ranked in order of how frequently they were encountered. RESULTS: A response rate of 100% was achieved. Interventions traditionally regarded as strong (academic detailing, active reminders) were ranked higher than those traditionally regarded as moderate (audit and feedback), or weak (posters, mouse mats). The high ranks of the site initiation visit (educational outreach, modest) and in-servicing (didactic lectures, weak) were unexpected, as was the relatively low rank of educationally influential, peer-nominated opinion leaders. Four hospitals reported the same doctor-related barrier as 'most common' and the remaining 10 hospitals reported three different doctor-related barriers, two nursing-related barriers and three organizational barriers as most common. CONCLUSIONS: When designing a multifaceted, multi-centre change strategy, the selection of individual practice change interventions should be based on: (1) an assessment of available resources; (2) recognition of the importance of different types of barriers to different sites; (3) the potential for combinations of interventions to have a synergistic effect on practice change, and (4) the potential for combinations of interventions to actually reduce workload.