“I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
Abstract Background Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive be...
| Главные авторы: | , , , , , , , , |
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| Формат: | Статья |
| Язык: | English |
| Опубликовано: |
BMC
2018-06-01
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| Серии: | Implementation Science |
| Предметы: | |
| Online-ссылка: | http://link.springer.com/article/10.1186/s13012-018-0768-z |
| _version_ | 1831533684753170432 |
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| author | Joseph Mignogna Lindsey Ann Martin Juliette Harik Natalie E. Hundt Michael Kauth Aanand D. Naik Kristen Sorocco Justin Benzer Jeffrey Cully |
| author_facet | Joseph Mignogna Lindsey Ann Martin Juliette Harik Natalie E. Hundt Michael Kauth Aanand D. Naik Kristen Sorocco Justin Benzer Jeffrey Cully |
| author_sort | Joseph Mignogna |
| collection | DOAJ |
| description | Abstract Background Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice. Methods A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. Results Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). Conclusions The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. Trial registration ClinicalTrials.gov, NCT01149772 |
| first_indexed | 2024-12-16T22:05:36Z |
| format | Article |
| id | doaj.art-e5c84aaf06c94d6b97bc8b8c5872d2b9 |
| institution | Directory Open Access Journal |
| issn | 1748-5908 |
| language | English |
| last_indexed | 2024-12-16T22:05:36Z |
| publishDate | 2018-06-01 |
| publisher | BMC |
| record_format | Article |
| series | Implementation Science |
| spelling | doaj.art-e5c84aaf06c94d6b97bc8b8c5872d2b92022-12-21T22:14:30ZengBMCImplementation Science1748-59082018-06-0113111110.1186/s13012-018-0768-z“I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary careJoseph Mignogna0Lindsey Ann Martin1Juliette Harik2Natalie E. Hundt3Michael Kauth4Aanand D. Naik5Kristen Sorocco6Justin Benzer7Jeffrey Cully8VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA Health Care SystemHouston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical CenterNational Center for Posttraumatic Stress Disorder, Executive DivisionHouston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical CenterSection of Health Services Research, Department of Medicine, Baylor College of MedicineHouston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical CenterOklahoma City VA Health Care SystemVISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA Health Care SystemHouston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical CenterAbstract Background Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice. Methods A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. Results Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). Conclusions The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. Trial registration ClinicalTrials.gov, NCT01149772http://link.springer.com/article/10.1186/s13012-018-0768-zCognitive behavioral therapyFidelityAdaptationImplementationIntegrated primary careDepression |
| spellingShingle | Joseph Mignogna Lindsey Ann Martin Juliette Harik Natalie E. Hundt Michael Kauth Aanand D. Naik Kristen Sorocco Justin Benzer Jeffrey Cully “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care Implementation Science Cognitive behavioral therapy Fidelity Adaptation Implementation Integrated primary care Depression |
| title | “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care |
| title_full | “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care |
| title_fullStr | “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care |
| title_full_unstemmed | “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care |
| title_short | “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care |
| title_sort | i had to somehow still be flexible exploring adaptations during implementation of brief cognitive behavioral therapy in primary care |
| topic | Cognitive behavioral therapy Fidelity Adaptation Implementation Integrated primary care Depression |
| url | http://link.springer.com/article/10.1186/s13012-018-0768-z |
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