Question

• Review the Resources and reflect on the various strategies presented throughout the course that may be helpful in disseminating effective and widely cited EBP.
  • This may include: unit-level or organizational-level presentations, poster presentations, and podium presentations at organizational, local, regional, state, and national levels, as well as publication in peer-reviewed journals.
• Reflect on which type of dissemination strategy you might use to communicate EBP.

Answer 1

Developing a dissemination strategy
 The dissemination process must be part of the implementation of
research project cycle. Involving stakeholders in the
dissemination process early will enhance greater ownership of the
research process and the ultimate uptake of the research
findings. Specific steps are recommended for research teams as they
discuss and identify their dissemination strategies and related needs.
 This is intended as generic guidance that can be modified and customized for specific projects.
The end result should be a context-sensitive strategy designed to
disseminate particular research findings to specific audiences.

Strategies to facilitate dissemination

A variety of strategies enhance the dissemination and regular implementation of evidence-based practices. Three are reviewed here: manual- and guideline-based strategies that make evidence-based practices more user-friendly to line-level staff; education-based approaches that increase staff members' knowledge and skills; and organization-based strategies that enhance the team's ability to work collaboratively.

Making manuals and guidelines user-friendly

Some evidence-based practices have components that interfere with their transfer from the academic settings in which they were developed to real-world settings. For example, the resources and policies that foster development of an innovative practice in a research environment may not parallel the demands of consumers, providers, and administrators in the public mental health system. Moreover, evidence-based practices that have survived clinical trials are often steeped in jargon and principles that are unintelligible to those who do not work in academic settings.The development of treatment manuals and practice guidelines is a key strategy for making evidence-based practices more accessible to line-level staff.

Treatment manuals originally were designed to ensure that clinicians participating in efficacy studies were implementing interventions according to the protocol. These manuals spell out the specific steps through which therapists must guide consumers to accomplish the goals of the service. As the manuals were being developed, dissemination investigators realized that they provide a technology for overcoming some of the translation barriers posed by evidence-based treatments. Treatment manuals and practice guidelines have been successfully developed and disseminated for social skills training programs , family treatment , supported employment , and assertive community treatment.

Manuals for evidence-based treatments serve several purposes. The microskills contained in many treatment manuals can be quickly learned by line-level generalists, so there is no need to hire specially trained and costly professionals to implement the programs. Treatment manuals often have high face validity, which improves the likelihood that provider staff will understand the treatment's rationale and implement the technology. The manuals typically have built-in fidelity systems that practitioners can use to ensure that they are implementing the program correctly. These systems may also include outcome assessments that assist staff in determining whether consumer goals are being accomplished.

Despite these benefits, manuals have some limitations that need to be addressed in future work. Practice guidelines and treatment manuals vary in level of detail and specific guidance. Most were not developed with the high school-educated worker as the intended provider audience and therefore require additional translation and elaboration. Manuals were not meant to be stand-alone dissemination strategies. Rarely do innovators believe that the information in these manuals can be implemented without some basic training. Education strategies are often combined with manuals to enhance dissemination and implementation.

Educating staff on skills and principles

Education programs target two different groups of people: those in preservice training—for example, students preparing for a career in mental health services—and those in in-service training—for example, paraprofessionals and professionals who must learn recently developed evidence-based approaches to update their practices. In terms of preservice training, university-based curriculum programs have identified a variety of competencies needed for contemporary positions.Innovators in this area who are training future behavior technicians prefer to target discrete skills rather than overwhelming students with the breadth of facts and principles that constitute the body of knowledge related to mental health. Follow-up research has shown that students who complete these curricula actually pursue careers in their discipline and report that they were adequately prepared for their jobs.

A larger body of research has examined the impact of in-service training on the day-to-day practices of mental health treatment providers. Like preservice education, in-service programs for line-level staff have focused on teaching discrete skills that make up the evidence-based practice.Trainers use such learning activities as modeling, role play, feedback, and homework to help staff learn new skills and apply them in their treatment settings. Frequently these programs are paired with education for staff on how to use manual-based practices.

Research has shown that service providers who complete these kinds of training programs have improved attitudes about innovative practices,learn more skills, and show some use of the skills at their practice setting, Skills learned in in-service training are likely to be maintained over time when training is paired with ongoing, regular consultation.

Although education-based approaches are a necessary first step in disseminating evidence-based practices, they have two significant limitations. First, many professionals and paraprofessionals decide not to participate in staff education programs or drop out before training is completed. As a result, a significant portion of the provider population never receives training. Second, treatment providers who learn new skills during in-service training fail to develop enduring treatment services based on these skills.

In an attempt to identify factors that promote technology transfer, researchers have compared programs that seem to embrace innovative ideas with those that remain stuck in old ways and hence fail to benefit from education approaches. They found that in the first case, "innovators" within the program had sufficient organizational commitment and administrative support to introduce and maintain innovations within their teams. Industrial and organizational psychologists have developed a variety of strategies to foster this kind of commitment and support. Some of these strategies are reviewed below.

Education programs are more successful when the use of new skills by staff members is reinforced. Organizational behavior management is the application of behavior modification principles to reinforce individual and group behaviors within organizations. For example, organizational consultants may teach supervisors and staff how to use work-related rewards, such as extra days off, monetary bonuses, and prime parking spaces, to increase the use of newly learned skills. Organizational behavior management, which is based on B. F. Skinner's form of applied behavior analysis, yields several benefits as a dissemination strategy.

First, it provides the staff developer with a broad and empirically well-supported theoretical perspective for understanding staff behaviors. Professionals who are familiar with behavior modification can quickly master the fundamentals of the strategy. Second, this theoretical perspective provides a useful method for tracking the effects of organizational behavior management as well as a useful "bag of tricks" from which training consultants might select such interventions as goal setting and performance feedback to effect desired staff behavior.

Improving organizational dynamics

A team of treatment providers may not be interacting cohesively for several reasons, as outlined above. Each of these reasons suggests necessary foci for organization-based strategies. Research conducted by organizational psychologists and management experts from the business sector points to some of these strategies.

Improving team leadership. Research has identified two types of leadership skills that are especially effective for the services team: transformational and transactional.Leaders who use transformational skills encourage team members to view their work from more elevated perspectives and to develop innovative ways to deal with work-related problems. Specific skills related to transformational leadership promote inspiration, intellectual stimulation, and individual consideration. Transactional leadership skills include goal setting, feedback, self-monitoring, and reinforcement strategies that help team members maintain effective programs.

Two studies have examined whether leadership models that were primarily developed in business and military settings are relevant for mental health and rehabilitation teams. Because the goals and tasks that define mental health settings are different from those in industrial and military systems, one might expect that the leadership needs of mental health teams would not be explained by investigations conducted in those systems. However, the research does not support this concern. Findings from studies of more than 1,000 staff members working in human service settings showed that independent groups of mental health providers and rehabilitation providers identified leadership factors that paralleled transformational and transactional leadership. Findings from these studies were then discussed with eight focus groups comprising team members and leaders to develop a curriculum for mental health team leaders. Subsequent research found that team leaders who participated in training in this curriculum showed significant improvement in individualized consideration and supervisory feedback . Improved leadership has also been associated with consumer satisfaction and quality of life.

Total quality management. Targeting leadership skills may often be insufficient to improve teamwork and collaboration. Organizational psychologists have developed total quality management strategies that are useful for facilitating a team's ability to work together and implement effective intervention programs. Three principles are central to total quality management. First, total quality management is a set of organizational development strategies that attempts to improve the quality and productivity of the work environment from the bottom up—for example, from the level of the case manager, the job coach, and the rehabilitation counselor charged with the day-to-day implementation of the program. Supervisors and administrators are frequently removed from day-to-day affairs and therefore are not aware of immediate programmatic needs.

Second, development efforts need to be driven by data rather than by opinion. Hence employees need to collect objective information to identify program needs and client progress. Employees must also collect data to assess the impact of any program development. Finally, total quality management values continuous quality improvement. Staff members are therefore required to make explicit decisions about the program that will improve the quality and productivity of the work environment over time.

Organizational decision-making efforts, such as those supported by total quality management, often fall short when they are general and not specific to the needs of the staff or when they are not conducted for a significant length of time.Therefore, total quality management efforts that seek to increase evidence-based approaches need to focus specifically on composite skills for an extended period. Few studies of this management style have addressed evidence-based mental health practices, although there has been some study of efforts that affected charting and data-gathering activity in service settings.

Interactive staff training. Interactive staff training represents an integration of the education approach and the total quality management approach to dissemination. As such, it varies from more traditional training efforts in two important ways. First, training focuses on the team in its practice setting; in this way, team members can work together to learn new practices and form them into a viable plan for their agency. Second, it encourages the development of user-friendly programs. Interactive staff training accomplishes these goals by walking the team through four stages.

Stage 1 provides an introduction to the system. Consultants who provide interactive staff training usually come from outside the team. Hence they need to gain the trust of team members before significant training and program development occurs .This trust can often be obtained by beginning the training effort with a needs assessment; the message here is that the team best knows its own training needs. Individuals from within the existing team are then assembled as a program committee charged with making preliminary decisions about how to implement the selected intervention. One person from the committee is chosen to champion the training and development effort.

In stage 2 a program is developed. Interactive staff training consultants work with the program champion and committee to make specific decisions about which evidence-based practice best meets their needs. The training consultant uses this opportunity to educate committee members and other key staff about the principles and services of the selected intervention. The consultant then engages the program committee in making decisions about how the ideal program will be adapted to meet the needs of participants and staff. Consultants use their expertise to help the committee evaluate initial decisions. Socratic questioning is a useful means for accomplishing this goal.Rather than trying to ascertain a weakness or a limitation of a program, the purpose of Socratic questioning is to help the champion and the program committee evaluate for themselves the costs and benefits of specific program choices.

Stage 3 focuses on program implementation. Before a full-fledged trial of the program occurs, the committee pilots a draft program to uncover potential weaknesses. Pilot programs are conducted with a subgroup of team members and a subset of program participants. The program committee then uses a problem-solving approach to resolve difficulties discovered in the pilot program. Through this process, program committees and treatment teams are taught that limitations in an evidenced-based program are problems that can be fixed, rather than overwhelming difficulties that indicate that the program should be abandoned.

Stage 4 covers program maintenance. In the final stage, the team sets up structures that help maintain the newly developed package over the long term. Staff members are encouraged to brainstorm to produce questions about the efficacy of the program that lead to suggestions for correcting problems. The program committee then collects data to determine program efficacy in terms of the specific questions (96,97). The committee uses the data to adjust the program where needed.

Three studies have examined the impact of interactive staff training on participating staff and their clients. The first study evaluated the impact of nine months of interactive staff training on attitudes and burnout levels of 35 participating staff members. The results showed significant reductions in burnout and improvements in collegial support and in attitudes about program development.

The second study used a team level of analysis to examine whether interactive staff training led to actual change in the behavior of staff who were conducting a rehabilitation program in a residential setting. The results showed increases in staff participation in evidence-based services from zero to more than 75 percent of team members. Moreover, the proportion of consumers who participated in targeted strategies rose from less than 10 percent to more than 85 percent of program participants.

The third study obtained similar results with a time series design that measured changes in staff behavior related to the evidence-based program and consumers' response to that program. In that study, burnout diminished among all team members. The staff's attitudes about innovations and the actual implementation of the innovations improved significantly. Consumer satisfaction with the program improved, and overall consumer outcome, as measured with the Global Assessment of Functioning, showed significant improvement.

Known as the three Ps, posters, presentations, and papers, have historically been the three primary ways of dissemination and remain as the most popular methods in the nursing field.