Given the importance of schools in improving access to evidence-based practices (EBPs) for children, this study sheds new light on important variables that may facilitate or hinder implementation of EBPs within the school setting. We found a number of important implementation barriers (i.e., competing responsibilities, logistics, parental consent, and administrator/teacher support) as well as facilitating factors (i.e., professional networks, financial resources). These insights from the direct experiences of providers echo themes that have been highlighted in systematic reviews and conceptual models of implementation in a variety of service settings such as support from administrators and other staff, implementation support and consultation, availability of resources (e.g., time, money, tangible supports), and perceptions about the intervention itself (e.g., ease of use, relevance, compatibility with the setting) (e.g., Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005
; Greenhalgh, Robert, McFarlane, Bate, & Kyriakidou, 2004
; Klein and Sora, 1996
; Schoenwald & Hoagwood, 2001
). Similar barriers and facilitators were found in a study of school-based treatment developers’ perceptions of implementation barriers and facilitators (Forman, Olin, Hoagwood, Crowe, & Saka, 2009
). The current study also provides important information about the types of support and consultation models desired by school-based providers that have experience using an EBP.
Given that both implementers and non-implementers perceived that implementing the CBITS group protocol would be relatively easy, it does not seem like perceptions of the intervention was an implementation barrier in the case of CBITS. In addition, it makes sense that clinicians who have implemented an intervention and have more practice with the components of an intervention would report being more likely to use such components in the future, versus those who have not yet been able to implement, since they have established experience and comfort level with the materials. Rather, the major barriers to successful implementation appeared to at the systems and organizational levels.
Competing responsibilities emerged as the strongest barrier to program implementation, with all non-implementers endorsing it. It was endorsed as the second most frequent implementation barrier by successful implementers, and is consistent with prior research (Forman et al., 2009
). Its prominence in this study highlights the importance of this barrier to the experience of frontline clinicians in school settings. For non-implementing clinicians, competing responsibilities appear to ultimately be the reason that they were unable to successfully implement. Subsequently, they may not have identified some of the other barriers (i.e., parent engagement, logistics, administrator, and teacher buy-in) as frequently because they had not gotten far enough along in the implementation process to experience them.
Interestingly, community clinicians who co-located onto a school campus (a partnership between mental health/community agency and schools) reported fewer competing responsibilities while on the school grounds than their school-employed counterparts. This may reflect the fact that they could focus on implementation with less likelihood of being pulled away for another school responsibility or crisis. These successful implementers from a mental health agency who co-located onto campus to run groups with a school-employed clinician reported being able to support implementation by bringing the snacks or materials for the groups and providing copies of worksheets, handouts, and screeners to decrease time and financial burden to school-employed clinicians and support staff. On the other hand, the school-employed clinician appeared to be more able to successfully support the logistical aspects of working and scheduling within the school building and calendar. In addition to capitalizing on opportunities for partnership to aid implementation success, the importance of competing responsibilities also highlights a need for school-based clinicians’ roles to be redefined in such a way to allow time for the CBITS groups and their formation. This was a critical step for those who were able to successfully implement, and caused difficulties in the cases where it did not happen. This type of realignment of staff has been identified by Fixsen et al. (2005
) as one of the elements of program installation as an organization seeks to implement a new practice.
Insufficient teacher buy-in was ranked as the fourth highest barrier among successful implementers of CBITS. Clinician’s perceived teacher buy-in as affecting implementation of CBITS groups since teachers who were not supportive of CBITS or who did not perceive benefits of the program were more reluctant to let their students leave class for the group. This perception is in line with research and models of school-based implementation, which highlight the importance of the support of teachers and administrators to successful implementation (Domitrovich et al., 2008
; Forman et al., 2009
). Pre-implementation activities designed to increase buy-in among administrators, school staff, and parents are an important part of a program’s implementation. To this end, a multimodal strategy to increase the awareness of the problem being targeted and its impact on students may be called for, and can include teacher in-services, parent meetings, and community and stakeholder focus groups. As part of this process, there may be additional value in using community partnerships between clinicians, school staff, community organizations, and parents to engage communities and address ongoing implementation issues (Ngo et al., 2008). It may be that within the process of establishing a school mental health partner relationship, some of this groundwork is taking place in a way that it may not be in a system using internal school-employed clinicians where relationships are already established.
Teacher concerns about issues like pulling students out of class also contributed to the logistical concerns barrier, endorsed by a majority of both implementers and non-implementers with regard to difficulty with some teachers letting kids leave class, while it also speaks to difficulty finding space, making copies, and other pragmatic issues. Logistical concerns are important to implementation across a variety of settings (Fixen et al., 2005
; Greenhalgh et al., 2004
). Their presence in the current study as one of the four major barriers highlights the unique and complex challenges inherent to implementing in a non-specialty mental health setting such as schools.
The final major barrier to implementation was obtaining parent permission. In the sites that successfully implemented CBITS, groups were run with the subset of students whose parents had provided permission, despite clinicians’ sense that they were missing a number of other students that could benefit. They reported, however, that they may have identified and included more youth if they had gotten better consent rates and had an easier time getting in contact with parents during groups. Parent engagement in school-based services has been a consistent challenge in the implementation of school mental health programs more broadly (Weist, Evans, & Lieber, 2003
), and it is not surprising that parental involvement was a challenge here. The development of strategies for engaging parents in school-based mental health services like CBITS may be a key element in increasing access to quality mental health services for youth in schools.
Among the sites interviewed in this study, schools partnering with mental health agencies appeared to be more likely to experience successful implementation of an EBP. All four of the sites who had this arrangement were able to successfully implement CBITS. Establishing partnerships between schools and mental health agencies appear to lead to a greater ability to surmount the inherent challenges in school-based mental health provision, thereby distinguishing sites that were able to implement the program from those that were not. Joint resources and expertise may enhance the capacity of providers across both settings to manage the competing demands and logistic challenges.
Successful implementers were all from sites with some degree of grant funding that enabled them to have devoted time to implement CBITS. Although the frontline clinicians interviewed in this study did not explicitly mention funding as a barrier, this pattern is a reflection of Forman et al.’s (Forman et al. 2009
) findings in which treatment developers cited funding as the most frequently cited obstacle to successful implementation. Likewise, Aarons, Wells, Zagursky, Fettes, & Palinkas (2009
) found among multiple stakeholders implementing EBPs in community mental health agencies that funding was endorsed as both the most important and least changeable factor in implementation success. With grant funding, often comes dedicated time and resources that would reduce the barrier of competing responsibilities described above. It may be that such funding is necessary, yet not sufficient factor, to successful implementation.
Beyond the surmounting of barriers, familiarity with others implementing the same program clearly distinguished implementers from non-implementers. This may be a facilitator in terms of perceived buy-in from peers and the organization. Moreover, providers may experience a greater sense of support if they know that they can confer with another implementer if needed. Finally, although the model for clinical support or consultation varied from site to site, all successful implementers had some form of clinical support or consultation in place that a majority found to be quite helpful. The forethought of understanding the importance of and creating a plan for clinical support and consultation may reflect an organizational characteristic that facilitates implementation success. The fact that most successful implementers preferred group consultation meetings highlights the importance of both the availability of consultation support itself as well as the aforementioned ability to connect, learn from, and share ideas with others who are also engaged in the implementation process. Interestingly, some noted this venue to be best in-person, especially with larger groups, so group size is an important factor to consider when planning for consultation. Likewise, the notions of having consultation available on an as-needed basis and session-specific support for program content that clinicians may find challenging were notable ingredients that could be integrated into an informed plan for clinical support. Each of these findings makes the case for setting up consultation and supervision plans before and during training in EBP.
There are some limitations to the study that are important to consider. The clinicians interviewed for this study are not representative of all providers who have implemented an EBP in schools, and there may be some bias introduced by selecting them via nominations from their director. There are certainly school-community mental health agency partnerships and/or grant-funded programs that do not successfully implement EBPs in schools. Similarly, there may be additional cases of school-only and clinic-only programs that have been able to implement EBPs successfully. More focused study of these types of sites might illuminate additional strategies for allocating resources and addressing other challenges specific to these organizational structures. However, our findings provide useful insight into models of service delivery and conditions that may increase the likelihood of surmounting common implementation challenges. Finally, it is important to note that the current study examines provider experiences of a single EBP. There may be some results that are unique to CBITS. However, because the themes in our study are similar to those found in the broader implementation literature, the insights gleaned from this study may generalize to the implementation of other school EBPs.
Although common challenges exist among all sites attempting to adopt and implement an evidence program in the school setting, there are a few things that tend to distinguish those who are able to overcome barriers to implementation from those who are not. The service model for school-based implementation seems to be related to implementation, with more success when a school partners with a community or mental health agency. Instead of focusing on what specific barriers are, it may be relevant to shift the focus onto what sets of conditions make it more or less likely that barriers can be surmounted.