|Home | About | Journals | Submit | Contact Us | Français|
Evidence-based practice is recognized as an important element of health care. Over the past decade it has become an expected component of physiotherapy practice. It is widely recognized that as clinicians, physiotherapists are expected to identify evidence, access it, and incorporate it into their clinical practice. However, it is becoming increasingly clear that there are major difficulties in implementing new innovations in traditional health care practices.1 While there is widespread acknowledgement across all stakeholders (patients, physiotherapists, referrers, and funders) of the need to bridge the evidence–practice gap, achieving practice change and implementing evidence is difficult. There is an increasing number of systematic reviews on the effectiveness of various interventions to address barriers and promote behaviour change.2–4 However, these secondary evidence sources indicate that there is no one-size-fits-all approach for promoting change. As Barack Obama's presidential campaign was all about change, it can inform evidence implementation and provide lessons to those who need to address barriers to change in clinical practice.
Obama's campaign was built around the message of “change” from the “usual.” Throughout the campaign, this was the central theme and slogan.5 This effective but simple message ultimately became synonymous with Obama. When implementing evidence, it is essential to convey a clear and simple message that resounds with the target population. In order to achieve this, it is important to identify the stakeholders who are most likely to be affected by the change. “Buy-in” is then needed from these stakeholders in order to successfully achieve behaviour change. Lack of “buy-in” from stakeholders, coupled with complex and unclear messages, can lead to confusion, loss of direction, and, ultimately, loss of opportunities for change to occur.
Making change the central theme of Obama's campaign also shone the spotlight on the readiness for change. Implementing evidence in clinical practice should also take into account the target population's readiness to change.6 The target population must recognize that current practices require change, that the time is right for change, and that change will be supported. Without such recognition, any initiatives aimed at implementing evidence into clinical practice will not result in widespread behaviour change.
Obama's campaign used innovative and radical tools to engage the wider population.7 This multi-modal engagement strategy ensured regular and timely engagement to optimize numbers of potential voters. Efforts to implement evidence in clinical practice and promote behaviour change can also benefit from such multifaceted interventions.6
During the presidential campaign, unanticipated developments, including the global financial crisis, threatened to overshadow the election generally and Obama's campaign specifically. While his opponent, Republican nominee John McCain, chose to suspend his campaign, Obama chose to proceed, providing visible, concerned, and credible leadership. This decision ensured that Obama's campaign remained focused, maintained momentum, and continued to promulgate the message of change. Evidence implementation and sustainable behaviour change also require credible leadership at appropriate levels to steer, focus, and maintain momentum.8 Without credible leadership, especially during times of crisis or hardship, evidence implementation is likely to falter and not achieve the desired change.
As the campaign progressed, many of Obama's opponents, worried by his successes, kept altering or modifying their messages.5 Obama's campaign, on the other hand, was steadfast in its message of change.9 Implementing evidence in clinical practice with the aim of achieving practice and behaviour change also requires consistency and persistence. Cockburn has emphasized that sustaining change is the biggest challenge, requiring dedicated resources, structured planning, a vision for the future, and built-in monitoring.6 Without consistency and persistence, key messages will become diluted and influenced by competing agendas.
Obama's campaign was able to convey a message that was highly relevant to local contexts across America. This unified approach ensured that his message of change resonated across different groups and was seen as highly relevant to all Americans in their local environments.10 Local contexts with particular focus on local enablers and barriers to change need to be identified. Oxman and Flottrop have emphasized that social, organizational, economic, and political context influence the uptake of evidence into clinical practice.11 Recognition of local contexts, and their associated barriers, will promote the development of targeted enabling strategies for the uptake of evidence into clinical practice and for sustained behaviour change.
One of the strengths of Obama's campaign was its ability to communicate and build effective relationships across the electorate. In a change from traditional campaigning, it set out to mix and match different cultures, viewpoints, and relationships.9 It was these diverse relationships that contributed to Obama's producing significant outcomes in terms of finance, advertising, and engagement.10 Successful evidence implementation also relies on effective relationships across conventional boundaries, leading disparate groups to work toward a common goal. For example, Oxman and Flottrop found that multi-professional collaboration strategies were effective in implementing evidence across a range of different chronic conditions.12 Peer influence and opinion leaders have also been shown to be effective in countering barriers related to beliefs and attitudes, and to aid in promoting change.13 Effective relationships can build on these enabling initiatives to effect and sustain change.
The management of whiplash-associated disorders (WAD) is a prime example of a systematic failure, in spite of evidence, to change practice and practitioner behaviour. Since the late 1980s, research has consistently shown that early mobilization of the neck is more effective than immobilization with a soft cervical collar in the treatment of WAD. Mealy et al., in 1986, compared early mobilization and exercise to immobilization with a soft cervical collar in two groups of patients who had sustained a whiplash injury. Findings from this research indicated that immobilizing the neck with a soft cervical collar for two weeks after whiplash injury gave rise to prolonged symptoms, whereas a more rapid improvement was achieved in the group who received early active management.14 Two randomized studies published in 1989 further strengthened findings supporting early mobilization and the avoidance of soft cervical collars.15,16 Since this time, consistent high-level, high-quality research evidence has been published strongly recommending against the use of soft collars, and advocating early active management for WAD.17–19 Despite such strong research evidence, an investigation into the routine management of whiplash injuries reported that 50% of consultants and more than half of middle grade and junior staff in Emergency Departments in Wales used a soft collar for treatment of whiplash.20 Why have these health care practices failed to change to reflect the evidence base?
If one was to use the same principles used by Obama to achieve change and apply it to achieve practice and behaviour change in the management of WAD (avoid soft cervical collars and promote early mobilization and active management), how would one proceed? Table 1 outlines, from a practical perspective, how Obama's campaign principles could potentially be implemented to achieve change in the management of WAD.
Change came to America for complex and multilayered reasons. What Obama's campaign was able to do was to achieve this change, as well as the success of its candidate, by using radical, innovative, and far-sighted methods. Similarly, evidence-based practice requires such innovative approaches. First, it must be recognized that implementing evidence in clinical practice and achieving sustained behaviour change is a complex, yet achievable, goal. Second, practice and behaviour change require clarity on processes and outcomes, inclusiveness, and targeted approaches that recognize local issues. Third, multiple approaches need to be aimed at different levels, in order to achieve initial and sustained change. Finally, there must be a uniform recognition that implementing evidence and achieving change as part of evidence-based practice can lead to safe and quality health care practices. In the case of WAD, lessons learned from Obama's campaign offer a template for effecting change in physiotherapy clinical practice and bridge current evidence practice gaps.