The systematic review of evidence and development of clinical guidelines pose significant challenges for health professionals in the practical setting. Evidence-based practice necessitates guideline development, education and review in order to achieve improved clinical outcomes. However, initiatives that endeavor to disseminate and implement clinical practice guidelines have often faced significant barriers and opposition, such as restricted access to
information, environmental factors, professional inertia and perceived degrees of usefulness or uselessness! (Hutchinson & Baker, 1999).

We would argue that the ultimate success of the evidence-based movement is dependent upon the degree to which it has an impact on health service outcomes. The uptake of evidence into practice is often slow at best and the process can be intractably difficult for a range of complex reasons. Thus, a coordinated strategy requiring appropriate skill, determination, time, money and planning is prudent for the success of any program of implementation. In Australia, the National Health & Medical Research Council (NHMRC, 2000) suggest that there are four elements that are desirable in order for the successful translation of research evidence into action to occur. These include good information based on research that is capable of standing up to rigorous critical appraisal and that will assist in solving practical problems; effective mechanisms and strategies for dissemination that enable health professionals and consumers to access information; physical and intellectual environments in which research is valued and uptake of research based knowledge is supported and encouraged; and interventions that demonstrably promote the uptake of knowledge and lead to behavior change.

There is sometimes the assumption that in order to improve care, clinicians primarily need more concise information and user-friendly formats and systems to help them apply research findings and evidence-based guidelines. However, there is a need to address not only the information needs of health professionals and organizations but also the social and organizational factors that interfere with the application of research findings.

Regardless of profession or discipline, any plan for change requires the ability to overcome barriers to its successful implementation. These barriers may occur at different levels, regardless of whether it is organizational, staff or consumer driven, and the barriers will vary considerably for the stakeholders involved. A variety of strategies are available to overcome such barriers, and that is why it is imperative that they are identified prior to initiating any approach to facilitating change. This may be achieved through the utilization of surveys, interviews or focus groups involving all key stakeholders. The aim is to elicit their perspectives on the proposed change and to provide the stakeholders with an opportunity to feel ownership for that change.

It is important to identify potential barriers to change in the local context and there may be characteristics of the proposed change that have the potential to influence its adoption. For example, it may be necessary to pilot the change in order to assess whether or not it is compatible with current beliefs and practices of the context, as well as whether health professionals in the target group are open to the possibility of change. Small, brief tests of change can serve a valuable role in adapting change implementation strategies before widespread introduction.

Other potential external barriers to implementation of evidence-based practice might include inadequate access to information, insufficient time and money to acquire new skills, low levels of baseline skills in critical appraisal, problems with the medical and nursing hierarchy, perceived threats to medical autonomy, or lack of evidence.

If it is possible, identify those issues or problems that may make it difficult to develop evidence-based practice, and then try to identify an equal number of points that assist the process.
When a number of barriers and enablers have been identified, a useful strategy might be to discuss them with the clinical team to see if there are ways of using the enabling factors and if there are any ways around the blocking factors. In the event that those blocking factors prove to be insurmountable, the most constructive approach may be to abandon that particular project and move on to another. For example, a clinical audit might be conducted where the staff identify seven areas of concern in the prevention of falls by residents. They may be successful in changing five of those areas of concern, but it may be that management is unable to afford the costs associated with the last two. The staff will have improved the things that lay within their power and might comfortably move on to audit a new topic. Some of the most common barriers to change include:

Changing healthcare practice is essentially bringing about an alteration in behavior or substituting one way of behavior for another. Some changes occur because of things around us, but most changes cannot occur effectively without being planned. Planned change is inevitably easier to manage than change which is imposed, haphazard or misunderstood. Healthcare
professionals are agents of change. They frequently endeavor to bring about changes in the behavior of clients, such as changing dependence into independence, fear into feelings of security and so forth.

Although now something of a cliché, it is true that change is a part of our everyday lives. Is it then, a quirk of human nature that causes us to resist that which is known to be inevitable? In order to understand and work around resistance to change, it is helpful for leaders to consider resistance as a fundamental component of the change process. An understanding of why people resist and ways in which resistance is manifested can go some way towards helping healthcare professionals to lead and to smooth the path of change. It is therefore an important prerequisite to planning. Resistance is commonly viewed in two ways:

Resistance can thus be considered to be both good and bad; bad in terms of preventing or blocking something which may be advantageous or even essential; good in terms of tempering and balancing, thus constituting a brake on unplanned change.

One of the most effective ways of minimizing resistance is to actively involve people at all stages of the process. Giving people the opportunity to contribute and become part of the change personally engages them and offers them the chance to help rather than hinder. It can create a feeling of worth and recognition. As in all negotiations, the achievement of those things that we consider essential will often involve trading off those things that we consider to be less important.

Response to change is also concerned with emotional reactions. The emotional cycle of the change process, described by Kelley and Conner (1979), relates to the feelings experienced by people participating in change. As they point out, ‘emotions of the participants fluctuate from highs to lows, and it would appear that these ‘highs’ and ‘lows’ can be identified with particular stages in the change process’. Although now somewhat dated, this work still rings true to the experience of the majority of change agents. They go on to describe this cycle in the following way:

The hostility of medicine toward change, it has been suggested, has been a product of concerns regarding the potential threat to professional autonomy of individual practitioners, rationing of healthcare and the idea that evidence-based medicine presents a distorted or partial view of science and rejects much that is central to the scientific method. Although evidence-based medicine has made an enormous impact on healthcare education and policy, its translation into practice has not been universally accepted and the integration of the principles of evidence-based practice has been equally inconsistent as for other health disciplines.

There is evidence to suggest that nurses tend to see current evidence generated through nursing research as impractical and therefore irrelevant to everyday practice. Nagy, Lumby, McKinley and Macfarlane (2001) suggest that nurses do not see themselves as possessing sufficient skills, time or organizational support to locate, appraise and implement the best available evidence. Thompson, McCaughan, Cullum, Sheldon, Mulhall and Thompson (2001) report that nurses in the UK generally do not find current guidelines, whether in printed or electronic formats, as convenient as oral information. It is likely that this is also true in Australia. Johnson and Griffiths (2001) show, however, that practice change can be promoted if practitioners are involved in processes that raise their awareness and encourage them to evaluate their own practice.