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NATIONAL INSTITUTE

OF CLINICAL STUDIES
Identifying
to evidence uptake
Foreword
Thi s gui de i s f or heal t h prof essi onal s who want t o i ncrease evi dence upt ake i n speci c cl i ni cal
areas. To do t hi s t hey wi l l need t o change current pract i ce. An i mport ant rst st ep i n pl anni ng f or
change i s t o i dent i f y t he barri ers t hat prevent best use of evi dence, as choosi ng i nt ervent i ons
t hat are most l i kel y t o overcome t he i dent i ed barri ers can i mprove t he ef f ect i veness and
ef ci ency of i mpl ement at i on ef f ort s. The gui de ai ms t o provi de heal t h care prof essi onal s wi t h
basi c i nf ormat i on about t he t echni ques t hat can be used t o i dent i f y barri ers t o change and t o
provi de some i deas and t ool s t o hel p i dent i f y barri ers t o change at a l ocal l evel .
Part I out l i nes reasons f or i dent i f yi ng barri ers and t he t ypes of barri ers t hat may exi st . It
descri bes t he vari ous t echni ques t hat may be used t o i nvest i gat e barri ers and t he f act ors t o
consi der when sel ect i ng whi ch t echni que t o use. Part II provi des a more det ai l ed descri pt i on
of each of t he i nvest i gat i on t echni ques. Users of t he gui de shoul d ref er t o rel evant sect i ons
as needed. Det ai l s of where t o nd f urt her i nf ormat i on about speci c t echni ques and when t o
seek expert i nput are provi ded t hroughout .
The Nat i onal Inst i t ut e of Cl i ni cal St udi es (NICS) i s Aust ral i as nat i onal agency f or hel pi ng cl ose
i mport ant gaps bet ween t he best avai l abl e evi dence and current cl i ni cal pract i ce i n heal t h
care. Thi s gui de i s t he rst of a seri es ai med at provi di ng pract i cal hel p t o heal t h prof essi onal s
who want t o i mprove evi dence upt ake. We woul d wel come f eedback and suggest i ons f or
i mprovement on t hi s gui de or i deas f or f urt her gui des.
Dr Heather Buchan
Chi ef Execut i ve Of cer
Nat i onal Inst i t ut e of Cl i ni cal St udi es
www.ni csl .com.au
II IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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Identifying
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Acknowledgements
Thi s gui de was commi ssi oned by NICS. It was prepared by Kat hy Rai nbi rd i n consul t at i on
wi t h Rob Sanson-Fi sher and Heat her Buchan. Judi t h St oel wi nder prepared t he suggest ed
l i t erat ure search st rat egy f or i dent i f yi ng rel evant research papers cont ai ned i n Appendi x A.
We woul d l i ke t o t hank Nat han Hawki ns who prepared an earl i er paper on whi ch t hi s gui de i s
based. We woul d al so l i ke t o t hank t he f ol l owi ng peopl e f or t hei r revi ew and hel pf ul comment s
on draf t s of t hi s gui de: Robyn Consi di ne, Dave Davi s, Davi d Henderson-Smart , Bri an M cAvoy,
Jane M unro, Penel ope Schoel d.
Copyright
Thi s work i s copyri ght . It may be reproduced i n whol e or i n part f or educat i onal use subj ect t o t he i ncl usi on of an
acknowl edgement of t he source. It may not be reproduced f or commerci al use or sal e.
ISBN: 0-9756964-6-7
NATIONAL INSTITUTE OF CLINICAL STUDIES
Fawkner Cent re
Level 5 499 St Ki l da Road M el bourne VIC 3004
Phone: 03 8866 0400 Fax: 8866 0499
Emai l : admi n@ni csl .com.au
Websi t e: www.ni csl .com.au
ABN 60 095 459 804
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE III
The National Institute of Clinical Studies (NICS) is Australias
national agency for improving health care by helping close
important gaps between best available evidence and current
clinical practice. NICS is funded by the Australian Government.
Table of Contents
PART I Page
Why i s i t i mport ant t o i dent i f y barri ers when at t empt i ng t o change cl i ni cal pract i ce? 1
Whose rol e i s i t t o i dent i f y barri ers? 1
What t ypes of barri ers mi ght be encount ered? 1
What are t he di f f erent t echni ques t hat can be used t o i nvest i gat e barri ers? 5
How t o sel ect t he most sui t abl e t echni que? 6
PART II
Techni ques t o i nvest i gat e barri ers 9
Where t o st art ? 9
How t o nd rel evant expert s? 9
Brai nst ormi ng 11
Case St udi es 17
Key Inf ormant s 21
Int ervi ews 25
Focus Groups 31
Di rect Observat i on 39
Surveys 43
Nomi nal Group Techni que 49
Del phi Techni que 53
MORE INFORMATION 57
REFERENCES 61
APPENDIX A
A suggest ed l i t erat ure search st rat egy f or i dent i f yi ng rel evant research papers 63
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 1
Why is it important to identify barriers when
attempting to change clinical practice?
Evi dence-pract i ce gaps = t he di f f erence bet ween what we know f rom t he best
avai l abl e research evi dence and what act ual l y happens i n current pract i ce.
Wi t hi n t he Aust ral i an heal t h care set t i ng, and t hroughout t he worl d, t here are many
gaps bet ween best avai l abl e evi dence and current cl i ni cal pract i ce.
Changi ng pract i ce can be di f cul t some st rat egi es t o change t he pract i ce of heal t h
care prof essi onal s are successf ul i n i mprovi ng heal t h care whi l e ot hers are not .
There are of t en a number of barri ers t o change, wi t h di f f erent barri ers i n di f f erent
set t i ngs and at di f f erent t i mes.
Ident i f yi ng t he barri ers t o change i s an i mport ant st ep i n pl anni ng ways t o cl ose
evi dence-pract i ce gaps as change may be more l i kel y i f st rat egi es are speci cal l y
chosen t o address t he i dent i ed barri ers (Shaw et al ., 2005).
Whose role is it to identify barriers?
Any heal t h care prof essi onal or group want i ng t o i mprove evi dence upt ake, f or
exampl e, by cl osi ng a gap bet ween evi dence-based gui del i ne recommendat i ons and
exi st i ng cl i ni cal care.
p Government expert groups, medi cal col l eges or non-government organi sat i ons
t hat want t o i mpl ement nat i onal gui del i nes
p M anagers who want t o i mprove heal t h care qual i t y
p Heal t h care prof essi onal s want i ng t o change an aspect of care del i vered i n t hei r
speci al i st area
What types of barriers might be encountered?
Vari ous barri ers mi ght be encount ered when at t empt i ng t o i mprove cl i ni cal pract i ce.
Barri ers t o change can occur across di f f erent l evel s of heal t h care (Grol & Wensi ng,
2004). The t abl e on t he f ol l owi ng page descri bes t he t ypes of barri ers t hat may
i mpede best pract i ce across t he di f f erent l evel s of heal t h care and provi des some
exampl es of pot ent i al barri ers.
PART I
Identifying
to evidence uptake
The types of barriers that may impede best practice across
different levels of health care.
Level at which the
Barrier operates
Type of Barriers Example/s
The i nnovat i on i t sel f Feasi bi l i t y
Credi bi l i t y
Accessi bi l i t y
At t ract i veness
Cl i ni cal pract i ce gui del i nes may be
percei ved as i nconveni ent or di f cul t t o
use (Cabana et al ., 1999).
Gui del i nes recommendi ng t he el i mi nat i on
of an est abl i shed cl i ni cal pract i ce, such
as screeni ng f or l ung cancer wi t h chest x-
rays, may be more di f cul t t o f ol l ow t han
gui del i nes t hat recommend addi ng a new
behavi our (Cabana et al ., 1999).
Indi vi dual prof essi onal Awareness
Knowl edge
At t i t ude
M ot i vat i on t o
change
Behavi oural
rout i nes
Cl i ni ci ans may not agree wi t h a speci c
gui del i ne or t he concept of gui del i nes i n
general (Cabana et al ., 1999).
Cl i ni ci ans may not have t he mot i vat i on t o
change (Cabana et al ., 1999) or may not
f eel compet ent t o provi de speci c servi ces,
such as counsel l i ng about exerci se or di et
(Oxman and Fl ot t orp,1998).
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Level at which the
Barrier operates
Type of Barriers Example/s
Pat i ent Knowl edge
Ski l l s
At t i t ude
Compl i ance
Pat i ent s may expect cert ai n servi ces,
such as t he prescri pt i on of ant i bi ot i cs f or
upper respi rat ory i nf ect i ons (Oxman and
Fl ot t orp,1998).
Soci al cont ext Opi ni on of
col l eagues
Cul t ure of t he
net work
Col l aborat i on
Leadershi p
Local opi ni on l eaders may encourage t he
use of f orms of care t hat have not been
shown t o be ef f ect i ve, such as screeni ng
f or ovari an or prost at e cancer (Oxman and
Fl ot t orp,1998).
Organi sat i onal cont ext Care processes
St af f
Capaci t i es
Resources
St ruct ures
Burdensome paperwork or poor commun-
i cat i on may i nhi bi t provi si on of ef f ect i ve
care (Oxman and Fl ot t orp,1998).
Economi c and pol i t i cal
cont ext
Fi nanci al
arrangement s
Regul at i ons
Pol i ci es
Rei mbursement syst ems may promot e
unnecessary servi ces or di scourage best
pract i ce (Oxman and Fl ot t orp,1998).
Whi l e change st rat egi es may need t o be mul t i di mensi onal or mul t i sect ori al , a
comprehensi ve approach t hat at t empt s t o address al l barri ers i n al l sect ors and
i n al l set t i ngs i s usual l y not f easi bl e or af f ordabl e. A barri ers anal ysi s shoul d hel p
peopl e pl anni ng i mpl ement at i on programs t o deci de where t o f ocus t hei r ef f ort s wi t h
i nt ervent i ons t ai l ored t o address speci c barri ers (Hul scher M EJL, Wensi ng M , van
der Wei j den T, Grol R, 2005).
PART I [CONTINUED]
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An Example fromthe Literature
(Tooher et al ., 2005)
The Problem: Venous thromboembolism (VTE) is a signicant problem for surgical
and medical hospitalised patients, with the possibility of causing serious illness
or death.
The Evidence: A number of clear evidence-based guidelines are available which
outline the appropriate use of prophylaxis for VTE.
The Barriers: A study of the introduction of guidelines for VTE prophylaxis in
Scotland (Walker et al., 1999) identied a number of barriers across a variety of
levels in relation to the guidelines themselves there was a lack of acceptance;
at the individual health professional level there was a perceived lack of need in
particular clinical areas and problems with staff responsible for implementation;
while at the organisational level there was a lack of supportive systems, such as
systems for data collection and audit.
The Possible Solution: Interventions designed to improve prophylaxis for VTE
should include a process for demonstrating the importance and relevance of
VTE prophylaxis to clinicians in their own clinical setting; a process for improving
clinician knowledge about VTE risk assessment and prophylaxis practice; a
method for reminding clinicians to assess patients for VTE risk; a process for
assisting clinicians to prescribe the appropriate prophylaxis; and a method for
assessing the effectiveness of any changes.
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 5
What are the different techniques that can be
used to investigate barriers?
There are a vari et y of t echni ques avai l abl e f or exami ni ng barri ers t o best cl i ni cal
pract i ce (ref er t o Part II f or f urt her det ai l s about a speci c t echni que).
p Brainstorming a group of peopl e brought t oget her t o generat e i deas about a
speci c t opi c.
p Case Studies a comprehensi ve descri pt i on and anal ysi s of a speci c past
si t uat i on, event or case usual l y i nvol vi ng a vari et y of dat a col l ect i on t echni ques.
p Key Informants i ndi vi dual s who underst and and have si gni cant i nsi ght i nt o
a part i cul ar probl em or si t uat i on usual l y t hei r vi ews are sought t hrough i nf ormal
conversat i ons.
p Interviews a f ace-t o-f ace or t el ephone di scussi on where i ndi vi dual part i ci pant s
are asked speci c quest i ons by an i nt ervi ewer.
p Focus Groups a f aci l i t at ed di scussi on among a group of peopl e i n whi ch a
moderat or uses open-ended quest i ons t o encourage di scussi on of a part i cul ar
t opi c or i ssue.
p Direct Observation wat chi ng and l i st eni ng t o i nt erpersonal i nt eract i ons,
event s or act i vi t i es i n a gi ven set t i ng.
p Surveys a st andardi sed set of quest i ons assessi ng part i ci pant s knowl edge,
at t i t udes and/ or sel f -report ed behavi our usual l y admi ni st ered vi a mai l .
p Nominal Group Technique a hi ghl y st ruct ured di scussi on among of a group
of peopl e where i deas are pool ed and pri ori t i sed.
p Delphi Technique an i t erat i ve process i n whi ch i nf ormat i on i s col l ect ed f rom
t he same group of part i ci pant s t hrough a seri es of surveys.

PART I [CONTINUED]
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How to select the most suitable technique?
M ost of t he t echni ques l i st ed above are sui t abl e f or appl i cat i on across a range of
cl i ni cal pract i ce set t i ngs or behavi ours.
A combination of techniques is often useful when examining barriers to adoption of
best clinical practice. For instance, brainstorming or focus group sessions with relatively
small groups of clinicians could be used to initially identify potential barriers to a specic
evidence-based guideline. The outcomes from this process could then be tested in a large
scale survey allowing the views of a greater number of clinicians to be canvassed.
Deci si ons about whi ch i s t he most sui t abl e t echni que wi l l depend upon t he area
of cl i ni cal pract i ce under consi derat i on, t he amount of avai l abl e f undi ng, t he t i me
avai l abl e f or t he i nvest i gat i on, how ri gorous t he process of i dent i cat i on of barri ers
i s i nt ended t o be, and whet her you have access t o someone wi t h rel evant expert i se.
For exampl e, a hospi t al manager who wi shes t o exami ne t he barri ers t o i nt roduci ng
a new prot ocol i n a ward may opt f or a t echni que t hat i s rel at i vel y qui ck and easy t o
use wi t h mi ni mal cost s (eg key i nf ormant s). In cont rast , an organi sat i on t hat want s t o
i nvest i gat e barri ers t o t he upt ake of nat i onal evi dence-based gui del i nes may choose
a t echni que t hat i s more ri gorous (eg semi -st ruct ured i nt ervi ews wi t h a represent at i ve
sampl e of surgeons).
Regardl ess of t he t echni que t hat i s sel ect ed, some pri nci pl es t hat shoul d be t aken
i nt o consi derat i on i ncl ude:
p Acceptability t he degree t o whi ch t he t echni que i s accept abl e t o respondent s.
Indi vi dual s percept i on about t he accept abi l i t y of t he met hod used t o i dent i f y
barri ers may part l y det ermi ne whet her or not t hey are prepared t o engage i n t he
change process whi ch f ol l ows.
Accept abi l i t y can be i ncreased by usi ng a t echni que whi ch al l ows part i ci pant s
t o express t hei r i deas, encourages a posi t i ve rapport and may ef f ect i vel y
engage t hose who at t end t he sessi ons.
Quest i onnai res can al so engage respondent s but onl y i f t he i t ems cont ai ned
wi t hi n t he quest i onnai re cl earl y and sensi t i vel y reect i ssues of concern t o
t he part i ci pant s.
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p Accuracy t he ext ent t o whi ch cl i ni cal behavi our changes i f t he i dent i ed
barri ers are modi ed. The ul t i mat e t est of whet her or not barri er i dent i cat i on
i s wel l done i s i f t hese barri ers are modi ed and t hen t he rel evant behavi our or
cl i ni cal pract i ce i s al so changed. The rel at i onshi p bet ween i dent i ed barri ers and
change i n act ual cl i ni cal perf ormance i s not al ways st rong.
Fact ors t hat may i nuence accuracy i ncl ude t he qual i t y of quest i ons or surveys,
whet her part i ci pant s are abl e t o make i ndependent j udgement s wi t hout
undue i nuence by ot hers, whet her part i ci pant s responses are bi ased by
soci al desi rabi l i t y or l ack of anonymi t y, t he ski l l of t he i nt ervi ewer/ moderat or/
observer at recordi ng dat a, and t he ski l l of t he i nvest i gat or i n i nt erpret i ng t he
resul t s.
p Generalisability t he degree t o whi ch t he i dent i ed barri ers can be general i sed
t o ot her cont ext s or cl i ni cal groups.
Fact ors t hat may i nuence general i sabi l i t y i ncl ude t he represent at i veness of
part i ci pant s. For exampl e, i f t he sel ect i on of respondent s t o t ake part i n t he
barri ers i dent i cat i on i s bi ased i n some way, t hen t he ndi ngs may not be
rel evant t o t he wi der cl i ni cal group.
p Reliability t he ext ent t o whi ch t he same or si mi l ar barri ers t o change are
el i ci t ed f rom t he same group of part i ci pant s on t wo or more separat e occasi ons.
Fact ors t hat may i nuence t he rel i abi l i t y of t he t echni que i ncl ude t he wordi ng
of quest i ons or surveys and/ or t he ski l l of t he i nt ervi ewer/ moderat or at posi ng
quest i ons i n a consi st ent and unbi ased manner.
PART I [CONTINUED]
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p Cost-effectiveness t he cost of undert aki ng t he i nvest i gat i on wei ghed agai nst
t he pot ent i al benet s of obt ai ni ng accurat e i nf ormat i on regardi ng barri ers t o t he
adopt i on of best -evi dence pract i ce.
Fact ors t hat may i nuence t he cost of t he t echni que wi l l depend upon t he scal e
of t he i nvest i gat i on and may i ncl ude t he i nvest i gat ors t i me, part i ci pant s t i me,
i nput f rom rel evant expert s, admi ni st rat i ve resources, equi pment , venue and
provi di ng f eedback t o part i ci pant s. However, t he scal e of t he i nvest i gat i on
may al so i mpact upon t he st rengt h of t he ndi ngs. For i nst ance, conduct i ng
ext ra i nt ervi ews wi t h a range of cl i ni ci ans may i ncur great er cost s but enabl e
t he ndi ngs t o be more readi l y general i sed across si mi l ar pract i ce set t i ngs.
The cost -ef f ect i veness of undert aki ng work exami ni ng barri ers shoul d be
caref ul l y consi dered. Barri ers anal ysi s i s onl y wort hwhi l e i f t he i nf ormat i on
obt ai ned i s used t o bot h i dent i f y and t hen shape subsequent i nt ervent i ons
ai med at i mprovi ng evi dence upt ake.
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PART II
Techniques to investigate barriers
Thi s sect i on provi des a more det ai l ed descri pt i on of t he t echni ques ref erred t o i n
t he rst part of t he gui de, desi gned f or t hose who wi sh t o undert ake or commi ssi on
t hei r own i nvest i gat i on i nt o barri ers t hat may be occurri ng wi t hi n t hei r area of care
del i very.
Thi s sect i on i s not a t ext book, rat her an overvi ew of t he essent i al component s of
each t echni que, what i s i nvol ved, i mport ant consi derat i ons and key st eps.
For more det ai l ed i nf ormat i on about a speci c t echni que ref er t o t he art i cl es, t ext s
and websi t es l i st ed at t he end of each descri pt i on.
Where to start?
A useful starting point for any barriers investigation is to undertake a quick review of the
existing literature to determine whether or not the area of clinical interest has previously
been examined and any potential barriers identied. A suggested search strategy that can
be adapted to help identify relevant papers is provided in Appendix A.
How to nd relevant experts?
Whi chever t echni que i s sel ect ed f or exami ni ng barri ers t o best cl i ni cal pract i ce, i t i s
wort h seeki ng i nput f rom rel evant expert s.
Rel evant expert s may i ncl ude:
p soci al sci ent i st s
p behavi oural sci ent i st s
p heal t h researchers
p psychol ogi st s
p st at i st i ci ans
p ot her prof essi onal groups who have devel oped an i nt erest i n t hi s el d
A good st art i ng poi nt f or ndi ng a rel evant expert i s t o cont act and seek advi ce f rom
your l ocal Uni versi t y, t hrough t he rel evant depart ment (eg Soci ol ogy, Soci al Sci ences,
Psychol ogy, M edi cal Sci ences or Heal t h Research).
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How to nd relevant experts? [CONTINUED]
Commerci al rms undert aki ng t hi s t ype of act i vi t y i ncl ude t hose speci al i si ng i n soci al
market i ng.
Indi vi dual s wi t h t he above ment i oned qual i cat i ons may not necessari l y have
expert i se i n t he speci c t echni que you wi sh t o use i t i s wort h aski ng about t hei r
experi ence wi t h t he t echni que (eg how many f ocus groups have you conduct ed?) and
f or exampl es of t hei r work (eg do you have a paper or report of t he ndi ngs f rom your
observat i onal st udy?).
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 11
PART II
Brainstorming
What is brainstorming?
A group of peopl e brought t oget her t o generat e i deas about a speci c t opi c.
When might you use this technique?
Brai nst ormi ng can be a usef ul t echni que f or st i mul at i ng consi derat i on of a part i cul ar i ssue
among part i ci pant s. It can be used t o generat e new i deas and novel sol ut i ons t o probl ems.
Who is involved?
Ideal l y, part i ci pant s shoul d come f rom a range of areas and backgrounds rel evant t o t he t opi c
bei ng di scussed. For i nst ance, i f you were i nt erest ed i n expl ori ng t he barri ers t o promot i ng
excl usi ve breast f eedi ng f or t he rst si x mont hs of l i f e, your brai nst ormi ng sessi on mi ght
i ncl ude women expect i ng t hei r rst baby, new mot hers, new f at hers, chi l d-heal t h nurses,
general pract i t i oners, breast f eedi ng counsel l ors and mat erni t y hospi t al st af f .
How are brainstorming sessions conducted?
The group i s asked t o generat e as many di f f erent i deas as possi bl e about a speci c t opi c or
quest i on. The most i mport ant rul e i s t hat ext reme or unpract i cal i deas be al l owed and t hat no
cri t i ci sm i s permi t t ed duri ng t he sessi on.
What types of questions can be used?
Part i ci pant s may be gi ven wri t t en background i nf ormat i on and prompt s (eg spend 15 mi nut es
l i st i ng al l t he ways mat erni t y hospi t al st af f coul d promot e excl usi ve breast f eedi ng f or t he rst
si x mont hs of l i f e).
How to collect the information?
The i deas generat ed by t he group can be l i st ed on paper or a whi t eboard as t he sessi on
progresses.
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How to analyse the data?
General l y brai nst ormi ng sessi ons are used t o st i mul at e consi derat i on of an i ssue and not t o
generat e dat a or concl usi ve evi dence. However, t he l i st s of i deas generat ed duri ng mul t i pl e
brai nst ormi ng sessi ons may be exami ned f or common t hemes.
Other considerations
Art i cul at e or powerf ul members of t he group may domi nat e di scussi on or af f ect i nput
of ot her part i ci pant s
Organi si ng a group di scussi on among busy heal t h prof essi onal s can be di f cul t and/
or l eave resources wi t hi n a gi ven set t i ng depl et ed
What are the key steps involved in conducting a
brainstorming session?
Consi der who shoul d be i nvol ved
Sel ect a moderat or
Devel op background i nf ormat i on and prompt s
Recrui t part i ci pant s
Arrange sui t abl e venue and t i me f or sessi ons
Undert ake and record sessi ons
Anal yse and i nt erpret dat a
What special expertise do you need?
A ski l l ed moderat or
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What are the advantages & disadvantages of this technique?
The advant ages of brai nst ormi ng sessi ons are t hat t hey are rel at i vel y f ast and easy t o execut e;
a wi de range of i deas can be generat ed i n a short amount of t i me; t hey al l ow part i ci pant s t o
express t hei r own vi ews and t o be part of t he change process.
The di sadvant ages of t hi s t echni que are t hat a ski l l ed moderat or i s requi red; part i ci pant s
l ack anonymi t y and some may be i nhi bi t ed; i ncent i ves may be needed t o encourage peopl e t o
at t end; and t he i nf ormat i on gai ned does not provi de concl usi ve dat a.
What are the costs of this technique?
The cost of undert aki ng a brai nst ormi ng i nvest i gat i on wi l l vary dependi ng upon t he number
of sessi ons conduct ed. Key cost s may i ncl ude: moderat ors f ees, room or venue hi re,
ref reshment s, i ncent i ves, payment s t o rel evant expert s f or i nput i n pl anni ng and/ or anal ysi s.
Are there times when you would not use brainstorming?
As wi t h ot her group-based t echni ques, brai nst ormi ng i s not sui t abl e when organi si ng a group
sessi on i s i mpossi bl e; or when powerf ul group members may i nhi bi t ot hers responses.
Where to get more information about conducting a brain-
storming session?
Websites
http://www.brainstorming.co.uk
websi t e of a UK based company dedi cat ed t o creat i ve t hi nki ng and brai nst ormi ng,
provi des f ree onl i ne t rai ni ng i n brai nst ormi ng i ncl udi ng t he rul es of brai nst ormi ng and
runni ng a brai nst ormi ng sessi on.
http://www.directedcreativity.com
websi t e of a US based company t hat f ocuses on t he use of creat i vi t y i n busi ness.
Sample tools
t he NICS barri ers t ool (versi on 2) a t ool desi gned f or use i n workshops t o encourage
t he concept ual i sat i on of barri ers; copi es are avai l abl e f rom t he NICS websi t e:
www.nicsl.com.au
PART II
Brainstorming [CONTINUED]
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Examples fromthe literature where brainstorming has been used to identify barriers
to change in health care
Fl ot t orp S & Oxman AD. (2003) Ident i f yi ng barri ers and t ai l ori ng i nt ervent i ons t o
i mprove t he management of uri nary t ract i nf ect i ons and sore t hroat : a pragmat i c
st udy usi ng qual i t at i ve met hods. BM C Heal t h Servi ces Research. 3(1): 3.
Khunt i K. (1999) Use of mul t i pl e met hods t o det ermi ne f act ors af f ect i ng qual i t y of
care of pat i ent s wi t h di abet es. Fami l y Pract i ce. 16(5): 48994.

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Notes
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 17
Case Studies
What is a case study?
A comprehensi ve descri pt i on and anal ysi s of a speci c past si t uat i on, event or case usual l y
i nvol vi ng a vari et y of dat a col l ect i on t echni ques.
When might you use this technique?
Case st udi es are usef ul when very det ai l ed i nf ormat i on about a past event may t hrow l i ght on
exi st i ng barri ers. For exampl e, you mi ght wi sh t o i nvest i gat e why a woman wi t h breast cancer
was t reat ed wi t h breast conservi ng surgery al one when best avai l abl e evi dence recommends
radi ot herapy af t er l umpect omy (Nat i onal Breast Cancer Cent re, 2002).
Who is involved?
Al l key i ndi vi dual s i nvol ved i n t he event shoul d be i ncl uded i n t he case st udy. In addi t i on,
anyone who manages or mai nt ai ns rel evant document at i on or records shoul d al so be
i nvol ved.
How to collect the information?
A vari et y of t echni ques are usual l y used i n case st udi es. These may i ncl ude i n-dept h
i nt ervi ews wi t h key i ndi vi dual s, revi ew of i nt ernal document s and records and/ or observat i on
of i nt erpersonal i nt eract i ons.
How to analyse the data?
Dat a anal ysi s depends on t he t echni ques used t o col l ect t he i nf ormat i on. Usual l y mul t i pl e
t ypes of dat a are combi ned t o gi ve a det ai l ed descri pt i on of t he event .
Other considerations
A wi de vari et y of research ski l l s are requi red
Consent f rom rel evant i ndi vi dual s and/ or organi sat i ons may be requi red bef ore
records can be accessed
The ndi ngs f rom one speci c event may not be readi l y general i sed t o ot her cases
Inf ormat i on gai ned may be open t o subj ect i ve i nt erpret at i on
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What are the key steps involved in conducting a case study?
Ident i f y t he speci c si t uat i on, event or case t o be i nvest i gat ed
Ident i f y al l key i ndi vi dual s and record keepers
Conduct i n-dept h i nt ervi ews, revi ew document at i on et c
Anal yse and i nt erpret dat a
What special expertise do you need?
A ski l l ed and i ndependent i nt ervi ewer
Input f rom expert s wi t h ski l l s i n t he sel ect ed t echni ques and rel at ed dat a anal ysi s
What are the advantages & disadvantages of this technique?
The advant ages of case st udi es are t hat t hey can provi de very det ai l ed i nf ormat i on about an
i ssue or event ; and t he i nvest i gat or may gai n i nsi ght s f rom t he i nt erpret at i on of combi ned
dat a t hat were previ ousl y unnot i ced.
The di sadvant ages of t hi s t echni que are t hat mul t i pl e f orms of dat a col l ect i on and anal ysi s
are t ypi cal l y requi red; i nput f rom a vari et y of expert s may be needed; t he i nvest i gat i on can be
t i me consumi ng and expensi ve; t he ndi ngs are open t o t he subj ect i ve i nt erpret at i on of t he
i nvest i gat or; and ndi ngs f rom one case st udy may not be readi l y general i sed t o t he wi der
popul at i on or t arget group.
What are the costs of this technique?
The cost of undert aki ng a case st udy i nvest i gat i on depends upon t he combi nat i on of
t echni ques empl oyed t he cost s associ at ed wi t h each t echni que need t o be consi dered.
For i nst ance i f usi ng i n-dept h i nt ervi ews and a revi ew of i nt ernal document s t he key cost s
may i ncl ude: i nt ervi ewers f ees, phot ocopyi ng and researchers f ees, as wel l as payment s t o
rel evant expert s f or i nput i n pl anni ng and/ or anal ysi s.
Are there times when you would not use a case study?
A case st udy may not be sui t abl e when havi ng an i nvest i gat or aski ng quest i ons may i nuence
event s, when si gni cant vari abi l i t y exi st s among t he group t hat i s of i nt erest or i n a si t uat i on
where l egal act i on f or negl i gence i s i nvol ved.
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Where to get more information about conducting a case study?
Articles
Keen J & Packwood T. (1995) Qual i t at i ve research: case st udy eval uat i on, BM J 311:
444446.
Yi n, R. K. (1999) Enhanci ng t he Qual i t y of Case St udi es i n Heal t h Servi ces Research,
Heal t h Servi ces Research 34: 12091224.
Textbooks
Hamel , J., Duf our, S., & Fort i n, D. (1993). Case st udy met hods. Newbury Park, CA:
Sage Publ i cat i ons.
Yi n, R. K. Case St udy Research, Desi gn and M et hods, 3rd ed. Newbury Park, Sage
Publ i cat i ons, 2002.
Websites
http://bmj.bmjjournals.com/cgi/content/full/311/7002/444
a di rect l i nk t o t he art i cl e by Keen & Packwood (1995) l i st ed above. Thi s paper descri bes
t he f eat ures of case st udy eval uat i ons and how t hey can be used t o eval uat e heal t h
servi ces and pol i cy.
PART II
Case Studies [CONTINUED]
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 21
Key Informants
What is a key informant?
An i ndi vi dual who underst ands and has si gni cant i nsi ght i nt o a part i cul ar probl em or
si t uat i on usual l y t hei r vi ews are sought t hrough i nf ormal conversat i ons.
When might you use this technique?
Key i nf ormant s can be part i cul arl y usef ul when i ni t i al l y f ormul at i ng an i dea and cl ari f yi ng
concept s.
Who is involved?
The i nf ormant shoul d be someone who not onl y underst ands a si t uat i on but al so t hi nks about
i t . A good i nf ormant wi l l be abl e t o express t hei r t hought s, f eel i ngs, opi ni ons and perspect i ve
on a t opi c.
What types of questions can be used?
Di scussi ons wi t h key i nf ormant s are usual l y i nf ormal , f ree-owi ng conversat i ons. You may wi sh
t o t hi nk of some open-ended quest i ons t o i ncl ude i n t he conversat i on. Key i nf ormant s can al so
be consul t ed regul arl y t o provi de f eedback and al l ow moni t ori ng of a part i cul ar i ssue.
How to collect the information?
You may wi sh t o record t he key i nf ormant s vi ews and i deas as not es ei t her duri ng or f ol l owi ng
t he conversat i on.
How to analyse the data?
General l y di scussi ons wi t h key i nf ormant s are used t o devel op i deas and not t o generat e dat a
or concl usi ve ndi ngs.
Other considerations
Your rel at i onshi p wi t h t he i nf ormant may i nuence t he i nf ormat i on you get
It t akes t i me t o sel ect good i nf ormant s and bui l d t rust
Inf ormant s vi ews may be bi ased
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What are the key steps involved in using key informants?
Ident i f y area of i nvest i gat i on
Approach rel evant peopl e wi t hi n t he area and ask who i s i n t he know
Sel ect key i nf ormant and arrange t o meet i nf ormal l y
Take t i me t o bui l d rapport / t rust
Seek f urt her f eedback f rom your i nf ormant
What special expertise do you need?
None apart f rom bei ng abl e t o engage your i nf ormant i n t he conversat i on
What are the advantages & disadvantages of this technique?
The advant ages of usi ng key i nf ormant s are t hat det ai l ed, i n-dept h i nf ormat i on can be
obt ai ned; t he i nvest i gat or i s abl e t o cl ari f y i deas as t he i nvest i gat i on progresses; and i t i s
rel at i vel y f ast and i nexpensi ve t o execut e.
The di sadvant ages of t hi s t echni que are t hat t he rel at i onshi p bet ween t he i nvest i gat or and
i nf ormant may i nuence t he i nf ormat i on obt ai ned; i t t akes t i me t o sel ect good i nf ormant s and
bui l d t rust ; i nf ormant s vi ews may not be represent at i ve; t he i nf ormat i on gai ned does not
provi de concl usi ve dat a and may need t o be corroborat ed usi ng ot her t echni ques.
What are the costs of this technique?
Due t o t he i nf ormal nat ure of most i nt eract i ons wi t h key i nf ormant s, t hi s t echni que general l y
requi res l i t t l e t i me and i s l ow i n cost .
Are there times when you would not use a key informant?
Whi l e usef ul f or gai ni ng i nsi ght i nt o a part i cul ar area or cl ari f yi ng concept s, usi ng key
i nf ormant s as t he sol e t echni que t o i dent i f y barri ers t o change woul d not be sui t abl e when
st rong, ri gorous evi dence i s needed.
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Where to get more information about the key informants
technique?
Articles
M arshal l M (1996) The key i nf ormant t echni que. Fami l y Pract i ce. 13: 9297.
Examples fromthe literature where key informants have been used to identify
barriers to change in health care
Dawson W. Brown S. Gunn J. M cNai r R. Luml ey J. (2000) Shari ng obst et ri c care:
barri ers t o i nt egrat ed syst ems of care. Aust ral i an & New Zeal and Journal of Publ i c
Heal t h. 24(4): 4016.
Larme AC. Pugh JA. (2001) Evi dence-based gui del i nes meet t he real worl d: t he case
of di abet es care. Di abet es Care. 24(10): 172833.
PART II
Key Informants [CONTINUED]
24 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 25
Interviews
What is an interview?
A f ace-t o-f ace or t el ephone di scussi on where i ndi vi dual part i ci pant s are asked speci c
quest i ons by an i nt ervi ewer.
When might you use this technique?
Int ervi ews are usef ul when you want t o gai n i n-dept h i nf ormat i on about an i ssue f rom a
speci c t arget group.
Who is involved?
Part i ci pant s may be heal t h care provi ders or pat i ent s. The number of part i ci pant s may vary
accordi ng t o t i me and nanci al const rai nt s, however you shoul d t ry t o sel ect part i ci pant s t hat
adequat el y represent t he wi der popul at i on bei ng st udi ed (eg a randoml y sel ect ed group of
general pract i t i oners f rom Queensl and).
What types of questions can be used?
Int ervi ews can be unst ruct ured where one or t wo prepared quest i ons are used and
part i ci pant s are encouraged t o respond wi t h as l i t t l e gui dance as possi bl e (eg Can you t el l
me about your experi ences usi ng cl i ni cal pract i ce gui del i nes? ). Furt her quest i ons or prompt s
can be used t o expl ore or cl ari f y i deas.
Int ervi ews can be semi -st ruct ured where a seri es of open-ended quest i ons are used. The
i nt ervi ewer may use an i nt ervi ew gui de t hat l i st s a pre-det ermi ned set of quest i ons or i ssues
t hat are t o be expl ored duri ng t he i nt ervi ew. The order and act ual worki ng of t he quest i ons i s
not det ermi ned i n advance and t he i nt ervi ewer i s f ree t o pursue quest i ons i n great er dept h.
Or i nt ervi ews can be st ruct ured where a set of predet ermi ned quest i ons are admi ni st ered i n
a st andardi sed manner (eg How much woul d you agree wi t h t he st at ement t hat my current
work envi ronment does not provi de t he resources I requi re t o support changes t o cl i ni cal
pract i ce? answered on a ve-poi nt scal e f rom st rongl y agree t o st rongl y di sagree ). The
same quest i ons are used across al l part i ci pant s.
PART II
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How to collect the information?
The i nt ervi ewer usual l y records responses duri ng t he i nt ervi ew process. Int ervi ews may al so
be vi deo and/ or audi o t aped.
How to analyse the data?
Dat a anal ysi s depends upon t he t ype of quest i ons used i n t he i nt ervi ews. Open-ended
quest i ons may be summari sed and syst emat i cal l y coded, whi l e cl osed-response quest i ons
may be col l at ed vi a comput er dat abase. Descri pt i ve anal yses may t hen be undert aken.
Other considerations
Qual i t y of t he dat a i s dependent upon t he qual i t y of t he quest i ons used and t he ski l l s
of t he i nt ervi ewer
A set of predet ermi ned quest i ons ensures t opi cs are not negl ect ed or f orgot t en
Int ervi ew quest i ons need t o be caref ul l y devel oped
What are the key steps involved in conducting interviews?
Ident i f y area of i nvest i gat i on and associ at ed t arget group
Devel op i nt ervi ew quest i ons
Seek i nput about t he quest i ons f rom rel evant expert s
Sel ect a represent at i ve sampl e of t he t arget group
Pi l ot and revi se t he i nt ervi ew quest i ons
Conduct i nt ervi ews
Summari se and ent er dat a
Anal yse dat a
What special expertise do you need?
An experi enced i nt ervi ewer
Input f rom rel evant expert s when devel opi ng t he quest i ons
Input f rom st at i st i ci an or ot her heal t h researchers when anal ysi ng dat a
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What are the advantages & disadvantages of this technique?
The advant ages of i nt ervi ews are t hat det ai l ed, i n-dept h i nf ormat i on can be obt ai ned; part i ci pant s
can express t hei r own vi ews; and compl ex or unant i ci pat ed i ssues can be expl ored.
The di sadvant ages of t hi s t echni que are t hat conduct i ng t he i nt ervi ews can be t i me consumi ng
and expensi ve; t he i nt ervi ewer may i nt roduce bi as i n t he way quest i ons are asked or recorded;
some part i ci pant s responses may be i nhi bi t ed; summari si ng and compari ng responses t o
open-ended quest i ons can be di f cul t .
What are the costs of this technique?
The cost of t hi s t echni que wi l l vary dependi ng upon t he number of i nt ervi ews conduct ed. Key
cost s may i ncl ude: i nt ervi ewers f ees, room or venue hi re, or t el ephone cal l cost s, part i ci pant
i ncent i ves, and payment s t o rel evant expert s f or i nput i n quest i on devel opment , pl anni ng
and/ or anal ysi s.
Are there times when you would not use interviews?
Int ervi ews may not be a sui t abl e t echni que when anonymi t y i s pref erred f or i nst ance when
aski ng about a speci c cl i ni cal pract i ce t hat may not be consi dered l egi t i mat e.

PART II
Interviews [CONTINUED]
28 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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An Example fromthe Literature where Interviews
were used to identify Barriers to Change
(McKinlay et al ., 2004)
The Problem: General practitioners in New Zealand did not regularly use guidelines
to support decision-making regarding patient care.
The Evidence: A number of evidence-based guidelines were available to general
practitioners in New Zealand.
The Study: In-depth, semi-structured interviews were conducted with a sample
of currently practicing general practitioners. Interview schedules, developed in
collaboration with stakeholders, included open-ended questions about knowledge
and use of existing guidelines; the role and importance of guidelines; use of
guidelines; perceived barriers and facilitators to the use of guidelines. Interviews
were generally undertaken face-to-face and recorded by audio tape.
The Barriers: A variety of barriers to guideline use were reported by the general
practitioners, these included: guideline formats not being recognisable or
user-friendly; lack of involvement in development of guidelines; inuence of
stakeholders; information overload and recommendations not being accessible
or relevant.
The Possible Solution: Several strategies have been initiated to address the
barriers to guideline use among general practitioners, these include: developing
a uniform and recognisable appearance for evidence-based guidelines; seeking
endorsement from professional colleges or other GP networks; involving GP
organisations in the planning of guideline strategies; incorporating practical
guidance to readers where treatment or care options are not accessible.
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Where to get more information about conducting interviews?
Articles
Bri t t en N (1995) Qual i t at i ve Research: Qual i t at i ve i nt ervi ews i n medi cal research.
BM J 311:251253.
Textbooks
Font ana A, Frey JH. Int ervi ewi ng: t he art of sci ence. In: Denzi n NK, Li ncol n YS, eds.
Handbook of qual i t at i ve research. London: Sage, 1994:36176.
Kval e S. (1996) Int ervi ews: An Int roduct i on t o Qual i t at i ve Research Int ervi ewi ng.
London: Sage.
Examples fromthe literature where interviews have been used to identify barriers
to change in health care
M cKi nl ay E, M cLeod D, Dowel l A & M arshal l C. (2004) Cl i ni cal pract i ce gui del i nes
devel opment and use i n New Zeal and: an evol vi ng process. NZM J 117: 9991009.
PART II
Interviews [CONTINUED]
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 31
Focus Groups
What is a focus group?
A f aci l i t at ed di scussi on among a group of peopl e i n whi ch a moderat or uses open-ended
quest i ons t o encourage di scussi on of a part i cul ar t opi c or i ssue.
When might you use this technique?
Focus groups are a usef ul t echni que f or gat heri ng a wi de range of i nf ormat i on i n a short
amount of t i me. The group di scussi on can reveal areas of agreement and di sagreement as
wel l as di f f erent perspect i ves and unexpect ed i deas.
Who to involve?
Try t o ensure t hat t he i ndi vi dual s i nvol ved i n your f ocus group have a common i nt erest or
charact eri st i c rel evant t o t he area i n whi ch you are t ryi ng t o achi eve pract i ce change t hey
coul d be general pract i t i oners, nurses, heal t h care managers or a mi xed group of heal t h care
prof essi onal s.
How many people per group and how many groups?
Groups of si x t o t en peopl e are t ypi cal l y used t hi s al l ows al l t o have i nput i nt o t he di scussi on.
Three t o ve groups are usual l y convened t o ensure al l possi bl e i ssues are reveal ed.
What does the moderator do?
The moderat or asks quest i ons and st i mul at es di scussi on about t he speci c t opi c wi t hout
rest ri ct i ng t he spont anei t y or ri chness of t he di scussi on. It i s i mport ant t hat t he moderat or
creat es a permi ssi ve and nurt uri ng envi ronment t hat encourages di f f erent percept i ons and
poi nt s of vi ew f rom al l members of t he group.
How are focus group sessions conducted?
Usual l y t he moderat or wi l l st art by expl ai ni ng t he purpose of t he di scussi on, t he probabl e
l engt h of t he sessi on and how t he sessi on i s bei ng recorded. Part i ci pant s wi l l t hen be asked
t o i nt roduce t hemsel ves t o t he group. Then t he di scussi on i s commenced, usual l y wi t h some
open-ended quest i ons used t o encourage di scussi on.
PART II
32 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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What types of questions should be used?
The quest i ons shoul d be open-ended t o st i mul at e di scussi on. Of course, t he speci c quest i ons
used wi l l be det ermi ned by t he area i n whi ch you are t ryi ng t o i mprove cl i ni cal pract i ce.
Sampl e quest i ons: Can you t el l t he group about your experi ences wi t h usi ng cl i ni cal pract i ce
gui del i nes? ; In your experi ence, what are t he mai n reasons f or not vacci nat i ng chi l dren and
adul t s wi t h chroni c condi t i ons agai nst i nuenza? ; What do you t hi nk hospi t al management
coul d do t o support changes t o your cl i ni cal pract i ce?
How to record the information?
Usual l y recorded by vi deo or audi o t ape. In some cases audi o t api ng i s pref erred as vi deo
cameras and l i ght s may i nt i mi dat e part i ci pant s.
How to analyse the data?
Summari es of t he cont ent s of t he di scussi ons are usual . Syst emat i c codi ng or cont ent anal ysi s
may al so be undert aken.
Other considerations
Qual i t y of t he dat a i s dependent upon t he qual i t y of t he quest i ons used
The moderat or may need t o probe f or underl yi ng reasons rat her t han si mpl e
rat i onal i sat i ons
Art i cul at e or powerf ul members of t he group may domi nat e di scussi on or af f ect i nput
of ot her part i ci pant s
Organi si ng a group di scussi on among busy heal t h prof essi onal s can be di f cul t and/
or l eave resources wi t hi n a gi ven set t i ng depl et ed
Incent i ves may be used t o recrui t part i ci pant s, but may al so bi as t he sampl e
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What are the key steps involved in conducting a focus group?
Consi der who shoul d be i nvol ved
Sel ect a moderat or
Devel op quest i ons
Recrui t part i ci pant s
Arrange sui t abl e venue and t i me f or sessi ons
Undert ake and record sessi ons
Anal yse and i nt erpret dat a
What special expertise do you need?
A ski l l ed and experi enced moderat or
Input f rom rel evant expert s when devel opi ng t he quest i ons
Input f rom rel evant expert s when anal ysi ng and i nt erpret i ng t he dat a
What are the advantages & disadvantages of this technique?
The advant ages of f ocus groups are t hat t hey are rel at i vel y f ast and easy t o execut e; a wi de
range of i nf ormat i on can be gat hered i n a short amount of t i me; det ai l ed, i n-dept h i nf ormat i on
can be obt ai ned; t hey al l ow part i ci pant s t o express t hei r own vi ews and t o be part of t he
change process.
The di sadvant ages of t hi s t echni que are t hat respondent s l ack anonymi t y and may be
i nt i mi dat ed; a hi ghl y ski l l ed moderat or i s requi red; i ncent i ves may be needed t o encourage
peopl e t o at t end; and consi derabl e t i me may be needed f or pl anni ng and anal ysi s.
What are the costs of this technique?
The cost of undert aki ng a f ocus group i nvest i gat i on wi l l vary dependi ng upon t he number of
sessi ons conduct ed. Key cost s may i ncl ude: moderat ors f ees, room or venue hi re, ref reshment s,
i ncent i ves, payment s t o rel evant expert s f or i nput i n pl anni ng and/ or anal ysi s.
PART II
Focus Groups [CONTINUED]
34 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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Are there times when you would not use a focus group?
Focus groups may not be a sui t abl e t echni que when t he group of i nt erest i s wi del y di spersed
(eg general pract i t i oners worki ng i n rural or remot e areas); when organi si ng a group sessi on
i s not f easi bl e (eg among Emergency Room st af f at a busy hospi t al ); or when powerf ul group
members may i nhi bi t ot hers responses (eg Head of Surgery and ot her cl i ni c st af f ).
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An Example fromthe Literature where Focus Groups
were used to identify Barriers to Change
(Phillips, Marton & Toer, 2004)
The Problem: Heart failure is a chronic and complex syndrome with high morbidity
and mortality.
The Evidence: Clinical practice guidelines recommend the use of angiotensin-
converting enzyme (ACE) inhibitor and beta-blocker therapies. There is evidence
that ACE inhibitors improve symptoms of heart failure, improve heart function,
decrease admissions to hospital and enable patients to live longer. Evidence also
shows that beta-blocker therapy can improve survival, decrease hospitalisation
and improve left ventricular function. However, in practice there is substantial
undersue of each of these therapies.
The Study: Semi-structured focus groups or telephone interviews with 35 general
practitioners were used to explore potential barriers to the optimal diagnosis and
management of heart failure in primary care.
The Barriers: The most common barrier noted for why GPs might not prescribe ACE
inhibitors in newly diagnosed cases was a concern about possible side effects.
Another reason was that many GPs were unaware or unconvinced of the benets
of ACE inhibitors, or were more familiar with the use of other drugs. When asked
to consider what might inhibit GPs from using beta-blockers, the most common
barriers were concerns about the possible side effects of the drug, difculties
associated with comorbidities and polypharmacy, and contraindications.
Other reasons for not prescribing beta-blockers were lack of awareness of the
recommendation that they should be used; lack of familiarity with the ndings of
trials; lack of condence in applying these ndings; and no experience in beta-
blocker use, particularly in a community setting.
The Possible Solution: Tailored strategies to meet the information needs and
practical concerns of GPs, and to facilitate better links between GPs and specialists
were recommended. Specic strategies could include: reinforcing the effectiveness
of ACE inhibitors and beta-blockers in retarding disease progression, improving
the patients quality of life, and reducing the risk of rehospitalisation and death;
providing GPs with clear schedules describing when and how to initiate and titrate
medication; and encouraging closer collaboration between GPs and cardiologists.
PART II
Focus Groups [CONTINUED]
36 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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Identifying
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Where to get more information about conducting a
focus group?
Articles
Barbour RS. (2005) Maki ng sense of f ocus groups. Medi cal Educat i on. 39(7): 74250.
Ki t zi nger J. (1995) Int roduci ng f ocus groups Bri t i sh Medi cal Journal 311: 299302.
Textbooks
Krueger RA (1988) Focus groups: A pract i cal gui de f or appl i ed research. Newbury
Park CA; Sage Publ i cat i ons.
M organ DL (1997) Focus groups as qual i t at i ve research (2nd Ed). Newbury Park, CA;
Sage Publ i cat i ons.
Websites
http://bmj.bmjjournals.com/cgi/content/full/311/7000/299
a di rect l i nk t o t he paper by Ki t zi nger J. (1995). The paper i nt roduces f ocus group
met hodol ogy, gi ves advi ce on group composi t i on, runni ng t he groups, and anal ysi ng
t he resul t s.
http://www.soc.surrey.ac.uk/sru/SRU19.html
an art i cl e by Gi bbs A. cal l ed Focus Groups as publ i shed i n Soci al Research Updat e.
The art i cl e descri bes f ocus group met hodol ogy, t he rol e of f ocus groups, t hei r
pot ent i al and l i mi t at i ons, t he pract i cal organi sat i on of f ocus groups i ncl udi ng et hi cal
consi derat i ons.
http://www.tc.umn.edu/~rkrueger/focus.html
a websi t e about f ocus group i nt ervi ewi ng by Krueger RA. Thi s si t e provi des a vari et y
of pract i cal handout s t hat of f er advi ce about f ocus group i nt ervi ewi ng, such as t i ps
on ndi ng part i ci pant s and get t i ng t hem t o at t end; t he t ask of gui di ng t he f ocus group
i nt ervi ew; and devel opi ng, sequenci ng and phrasi ng f ocus group quest i ons.
http://www.scu.edu.au/schools/gcm/ar/arr/arow/rlewis.html
an overvi ew of t he l i t erat ure on f ocus group i nt ervi ews. Topi cs i ncl ude t he ori gi n of
f ocus groups, deni t i ons, use of f ocus groups, part i ci pant s, t he i nt ervi ew gui de, t he
moderat or, col l ect i ng and anal ysi ng dat a. Incl udes a l i st of case st udi es where f ocus
group i nt ervi ews or di scussi on have been used i n al l i ed heal t h research.
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Notes
38 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 39
PART II
Direct Observation
What is direct observation?
Wat chi ng and l i st eni ng t o i nt erpersonal i nt eract i ons, event s or act i vi t i es i n a gi ven set t i ng.
When might you use this technique?
Di rect observat i on i s most usef ul when ot her t echni ques are not possi bl e, i n part i cul ar when
part i ci pant s are not aware of t hei r behavi our.
Who is involved?
The number and t ype of peopl e i nvol ved depends on t he si t uat i on or pract i ce under
i nvest i gat i on. For exampl e, you may wi sh t o observe a general pract i t i oners consul t at i on
wi t h pat i ent s or t he i nt eract i on t hat occurs at a mul t i di sci pl i nary meet i ng.
The observer may part i ci pat e i n t he act i vi t y (part i ci pant observat i on) or remai n out si de t he
act i vi t y (non-part i ci pant observat i on).
How to collect the information?
Det ai l ed descri pt i ons of observed behavi ours and i nt eract i ons are t ypi cal l y recorded i n el d
not es or usi ng a dened codi ng syst em. The not es may al so i ncl ude t he observers f eel i ngs,
i deas, hunches and i nt erpret at i on.
How to analyse the data?
Summari es of t he observat i ons are usual l y col l at ed. Syst emat i c codi ng or cont ent anal ysi s
may t hen be appl i ed.
Other considerations
The presence of t he observer may i nuence t he act i vi t y or behavi our bei ng observed
It may be di f cul t t o get cl i ni ci ans t o agree t o be observed
40 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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What are the key steps involved in undertaking direct
observations?
Sel ect act i vi t y t o be observed
Recrui t a ski l l ed, t rai ned observer
Obt ai n consent f rom rel evant part i es
Devel op codi ng syst em
Undert ake observat i ons
Col l at e and anal yse dat a
What special expertise do you need?
A wel l -qual i ed, ski l l ed observer
Input f rom rel evant expert s when devel opi ng t he codi ng syst em and i nt erpret i ng
t he dat a
What are the advantages & disadvantages of this technique?
The advant ages of observat i ons are t hat t hey can provi de di rect i nf ormat i on about an
i ndi vi dual s behavi our or pract i ces; t he observer i s abl e t o ent er and underst and t he si t uat i onal
cont ext ; unant i ci pat ed out comes may be reveal ed; and t he pract i ce or act i vi t y occurs i n i t s
nat ural set t i ng.
The di sadvant ages of t hi s t echni que are t hat i t can be di f cul t t o get cl i ni ci ans t o agree
t o be observed; undert aki ng t he observat i ons can be very t i me consumi ng; t he presence of
an observer may i nuence t he act i vi t y or behavi our; and a wel l -t rai ned, ski l l ed observer i s
requi red.
What are the costs of this technique?
The cost of undert aki ng a di rect observat i on i s pri mari l y associ at ed wi t h t he t i me consumi ng
nat ure of t hi s t ype of i nvest i gat i on. The mai n cost t o be consi dered i s t hat of t he observers
f ees as wel l as payment s t o rel evant expert s f or i nput i n pl anni ng and/ or anal ysi s.
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Are there times when you would not use a direct
observation?
Di rect observat i on may not appropri at e when i ssues of pat i ent pri vacy or condent i al i t y are
concerned or when havi ng an observer present may i nuence behavi our. Di rect observat i on
i s onl y sui t abl e (or at l east pract i cal ) f or event s t hat occur f requent l y. For exampl e, i t mi ght
be appropri at e wi t h regard t o t he i nvest i gat i on of suspect ed ski n cancer but not suspect ed
t hyroi d cancer because you mi ght have t o wai t mont hs or years f or one i nst ance t o ari se.
Where to get more information about undertaking direct
observations?
Articles
M ays N & Pope C. (1995) Qual i t at i ve research: observat i onal met hods i n heal t h care
set t i ngs. BM J 311: 182184.
Websites
http://bmj.bmjjournals.com/cgi/content/full/311/6998/182
a di rect l i nk t o t he paper by M ays & Pope (1995) l i st ed above. Thi s paper descri bes
t he observat i onal met hod as a research t ool , t he rol e of t he researcher i n undert aki ng
observat i ons and ot her i ssues of sampl i ng, recordi ng and anal ysi s.
PART II
Direct Observation [CONTINUED]
42 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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Notes
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 43
Surveys
What is a survey?
A st andardi sed set of quest i ons assessi ng part i ci pant s knowl edge, at t i t udes and/ or sel f -
report ed behavi our usual l y admi ni st ered vi a mai l .
When might you use this technique?
Surveys (or quest i onnai res) are usef ul when i nf ormat i on i s needed f rom a l arge number of
part i ci pant s.
Who is involved?
Surveys are usual l y t arget ed at a speci c group of heal t h prof essi onal s (eg general
pract i t i oners, surgeons, nurses) or pat i ent s.
What types of questions can be used?
Quest i ons can be open ended al l owi ng part i ci pant s t o report t hei r responses verbat i m;
cl osed response where part i ci pant s have t o sel ect an answer f rom a predet ermi ned l i st ; or
a combi nat i on of open and cl ose response st yl e quest i ons may be used.
How to collect the information?
The compl et ed surveys are ret urned t o t he i nvest i gat or. The i nf ormat i on i s t hen coded and
usual l y ent ered i nt o a comput er dat abase.
How to analyse the data?
Basi c descri pt i ve dat a anal yses may i nvol ve det ermi ni ng t he proport i on of responses i n a
gi ven cat egory (eg t he proport i on of GPs who i ndi cat ed t hey had never heard of gui del i ne X).
Furt her st at i st i cal dat a anal yses may be used t o exami ne t he rel at i onshi ps bet ween di f f erent
responses and ot her demographi c i nf ormat i on.
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Other considerations
Quest i ons must be caref ul l y const ruct ed so t hat t hey are cl ear and one-di mensi onal
Qual i t y of t he dat a i s dependent upon t he qual i t y of t he quest i ons used
St eps may need t o be t aken t o encourage part i ci pant s t o respond i ncl ude a repl y-
pai d envel ope wi t h t he survey, ensure t he survey i s easy t o compl et e, f ol l ow-up non-
respondent s by t el ephone
Be aware of t he l i mi t at i ons of sel f -report ed behavi our
Opi ni ons or at t i t udes may not di rect l y reect behavi our
What are the key steps involved in conducting a survey?
Ident i f y area of i nvest i gat i on and associ at ed t arget group
Devel op a set of quest i ons
Seek i nput about t he quest i ons f rom rel evant expert s
Consi der how cont act det ai l s of t he t arget group mi ght be obt ai ned (eg col l ege l i st s)
Pi l ot t he survey wi t h a smal l group
Revi se t he quest i ons
M ai l out survey
Log ret urns and f ol l ow-up non-respondent s
Ent er dat a
Anal yse dat a
What special expertise do you need?
Input f rom rel evant expert s when devel opi ng t he quest i ons
Input f rom st at i st i ci an or ot her expert s when anal ysi ng dat a
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What are the advantages & disadvantages of this technique?
The advant ages of surveys are t hat t hey can be sent t o heal t h care prof essi onal s or pat i ent s
anywhere i n t he count ry; dat a can be gat hered f rom a l arge number of peopl e i n a rel at i vel y
short amount of t i me; respondent s can compl et e surveys at t hei r conveni ence and can remai n
anonymous; and t hey are rel at i vel y i nexpensi ve t o execut e.
The di sadvant ages of surveys are t hat consi derabl e t i me may be needed f or devel opment
of t he quest i ons and pi l ot -t est i ng; i t i s not possi bl e t o ask f ol l ow-up quest i ons; i ndi vi dual s
may not accurat el y report t hei r behavi our or t he f act ors t hat i nuence t hei r pract i ces; and
response rat es may be l ow.
What are the costs of this technique?
The mai n cost s i nvol ved i n undert aki ng a survey are payment s t o rel evant expert s f or i nput
duri ng t he devel opment of t he quest i ons and/ or subsequent anal ysi s and i nt erpret at i on of t he
dat a. Ot her cost s associ at ed wi t h surveys i ncl ude: phot ocopyi ng or pri nt i ng of t he surveys;
post age; f ol l ow-up of non-respondent s and dat a ent ry.
Are there times when you would not use a survey?
Surveys may not be a sui t abl e t echni que when responses may be prone t o soci al desi rabi l i t y.
For exampl e, what pat i ent s or doct ors say t hey do i s of t en not t he same as what t hey act ual l y
do, especi al l y when t hey t hi nk t hei r l i f est yl e or cl i ni cal pract i ce i s bei ng j udged by ot hers.
PART II
Surveys [CONTINUED]
46 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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Identifying
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Where to get more information about conducting a survey?
Articles
Boynt on PM . & Greenhal gh T. (2004) Sel ect i ng, desi gni ng, and devel opi ng your
quest i onnai re. BM J. 328(7451): 13125.
Boynt on PM (2004) Admi ni st eri ng, anal ysi ng, and report i ng your quest i onnai re.
BM J. 328(7452): 13725.
Textbooks
Bowl i ng A. Const ruct i ng and eval uat i ng quest i onnai res f or heal t h servi ces research.
In: Research met hods i n heal t h: i nvest i gat i ng heal t h and heal t h servi ces. Bucki ngham:
Open Uni versi t y Press, 1997.
Frazer L & Lawl ey M (2000) Quest i onnai re desi gn and admi ni st rat i on: a pract i cal
gui de. Bri sbane, Wi l ey.
Websites
http://bmj.com/cgi/content/full/328/7451/1312
a di rect l i nk t o t he paper by Boynt on & Greenhal gh (2004) l i st ed above. Thi s paper
descri bes key aspect s of quest i onnai re desi gn i ncl udi ng whet her a quest i onnai re i s
appropri at e, usi ng exi st i ng measures, how t o present your quest i ons and ot her i ssues
t o consi der when conduct i ng research vi a quest i onnai res.
http://bmj.com/cgi/content/full/328/7452/1372
a di rect l i nk t o t he paper by Boynt on (2004) l i st ed above. Thi s paper det ai l s how t o
pi l ot your quest i onnai re, di st ri but e and admi ni st er i t ; and get i t ret urned, anal ysed,
and wri t t en up f or publ i cat i on.
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Sample tools
Quest i onnai re of percei ved barri ers t o change (Pet ers et al ., 2003) a val i dat ed
quest i onnai re desi gned t o i dent i f y percei ved barri ers t o change, i ncl udes quest i ons
about t he charact eri st i cs of t he i nnovat i on, t he care provi der, t he pat i ent and t he
cont ext ; t he quest i onnai re has been used i n a number of i mpl ement at i on st udi es i n
t he Net herl ands; copi es are avai l abl e f rom
http://www.wokresearch.nl/default.asp?product=39
Evi dence-Based Pract i ce i n Pri mary Care quest i onnai re (M cKenna et al .,2004) a
quest i onnai re desi gned t o exami ne barri ers t o t he use of evi dence-based pract i ce,
as wel l as t he research and i nf ormat i on resources avai l abl e i n pri mary care; t he
quest i onnai re i s i ncl uded i n t he paper by M cKenna and col l eagues.
Examples fromthe literature where surveys have been used to identify barriers to
change in health care
Dorn RA, Swart z M S, El bogen EB, Swanson JW, Ki m M , Ferron J, M cDani el LA,
Scheyet t AM . (2005) Cl i ni ci ans at t i t udes regardi ng barri ers t o t he i mpl ement at i on of
psychi at ri c advance di rect i ves. Adm Pol i cy M ent Heal t h 112.
PART II
Surveys [CONTINUED]
48 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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Notes
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 49
Nominal Group Technique
What is the nominal group technique?
A hi ghl y st ruct ured di scussi on among of a group of peopl e where i deas are pool ed and
pri ori t i sed.
When might you use this technique?
The nomi nal group t echni que can be used t o i dent i f y a probl em, generat e sol ut i ons and
devel op a pl an of act i on, usual l y i n rel at i on t o a si ngl e i ssue or t opi c. Whi l e si mi l ar t o f ocus
groups, t he nomi nal group t echni que i s more st ruct ured.
Who is involved?
Try t o ensure t hat t he i ndi vi dual s i nvol ved i n your nomi nal group have a common i nt erest or
charact eri st i c rel evant t o t he area i n whi ch you are t ryi ng t o achi eve pract i ce change.
What does the moderator do?
The moderat or present s t he t opi c f or consi derat i on and gui des t he process, ensuri ng al l
part i ci pant s cont ri but e. The moderat or al so ranks, t abul at es and present s t he i deas back t o
t he group.
How are nominal group sessions conducted?
Part i ci pant s are usual l y gi ven several mi nut es t o wri t e down t hei r i deas about a gi ven t opi c.
Each part i ci pant , i n t urn, present s one i dea t o t he group. Responses are t hen di scussed and
pool ed. Each part i ci pant t hen pri vat el y ranks each i dea. Ranki ngs are col l ect ed f rom al l
part i ci pant s, aggregat ed and t hen present ed t o t he group. The overal l ranki ng i s di scussed
and re-ranked i f necessary. Fi nal ranki ngs are t abul at ed and present ed t o t he part i ci pant s.
What types of questions can be used?
The nomi nal group t echni que i s usual l y best appl i ed t o a si ngl e i ssue or t opi c. It coul d be used
t o i dent i f y and pri ori t i se pot ent i al barri ers t o a speci c evi dence-pract i ce gap, f or i nst ance
barri ers t o t he assessment and t reat ment of pai n i n oncol ogy pat i ent s.
PART II
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How to collect the information and analyse the data?
Answers are not ed as t he sessi on progresses. Anal ysi s occurs t hroughout t he sessi on as t he
part i ci pant s t hemsel ves i dent i f y and rank t he i mport ant i ssues.
Other considerations
The ski l l of t he moderat or i s i mport ant i t can be di f cul t t o ensure t hat al l members
of a sessi on have equal i nput and t hat t he f ocus remai ns upon onl y one i ssue or t opi c
of i nt erest .
Whi l e nomi nal groups have t he pot ent i al t o generat e sol ut i ons t o si mpl e probl ems,
more compl ex i ssues can be di f cul t t o address.
What are the key steps involved in organising a nominal
group session?
Consi der who shoul d be i nvol ved
Sel ect a moderat or
Devel op quest i ons
Recrui t part i ci pant s
Arrange sui t abl e venue and t i me f or sessi ons
Undert ake sessi ons and record out come
What special expertise do you need?
A ski l l ed and experi enced moderat or
Input f rom rel evant expert s when devel opi ng t he quest i ons
What are the advantages & disadvantages of this technique?
The advant ages of t he nomi nal group t echni que are t hat many i deas can be generat ed i n a short
amount of t i me; al l part i ci pant s have i nput ; t hey are rel at i vel y f ast and easy t o execut e; and t hey
can be used t o seek group consensus regardi ng pri ori t i sat i on of i ssues or proj ect pl anni ng.
The di sadvant ages of t hi s t echni que are t hat a hi ghl y ski l l ed moderat or i s requi red; i ncent i ves
may be needed t o encourage peopl e t o at t end; and general l y onl y a si ngl e i ssue or t opi c can
be expl ored.
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What are the costs of this technique?
The cost of undert aki ng an i nvest i gat i on usi ng t he nomi nal group t echni que wi l l vary
dependi ng upon t he number of sessi ons conduct ed. Key cost s may i ncl ude: moderat ors f ees,
room or venue hi re, ref reshment s, i ncent i ves.
Are there times when you would not use the nominal group
technique?
The nomi nal group t echni que i s not sui t abl e when organi si ng a group sessi on i s i mpract i cal ;
or when more t han one t opi c or i ssue i s bei ng exami ned.
Where to get more information about the nominal group
technique?
Articles
Al l en J Dyas, J Jones M. (2004) Bui l di ng consensus i n heal t h care: a gui de t o usi ng t he
nomi nal group t echni que. Bri t i sh Journal of Communi t y Nursi ng. 9(3): 1104.
Jones J & Hunt er D (1995) Qual i t at i ve Research: Consensus met hods f or medi cal and
heal t h servi ces research. BM J: 311: 376380.
Websites
http://bmj.bmjjournals.com/cgi/content/full/311/7001/376
a di rect l i nk t o t he paper by Jones & Hunt er (1995) whi ch descri bes bot h t he nomi nal
group and Del phi t echni ques, i t det ai l s key met hodol ogi cal i ssues and provi des
exampl es of appl i cat i ons of t he t echni ques i n heal t h research
Examples fromthe literature where the nominal group technique has been used to
identify barriers to change in health care
Goeman DP, Hogan CD, Aroni RA, Abramson M J, Sawyer SM , St ewart K, Sanci LA &
Dougl ass JA (2005) Barri ers t o del i veri ng ast hma care: a qual i t at i ve st udy of general
pract i t i oners. M ed J Aust 183(9): 45760.
Hi ckl i ng J, Rogers S & Nazaret h I (2005) Barri ers t o det ect i ng and t reat i ng
hyperchol est erol aemi a i n pat i ent s wi t h i schaemi c heart di sease: pri mary care
percept i ons. Bri t i sh Journal of General Pract i ce. 55(516): 5348.
PART II
Nominal Group Technique [CONTINUED]
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Delphi Technique
What is the Delphi technique?
An i t erat i ve process i n whi ch i nf ormat i on i s col l ect ed f rom t he same group of part i ci pant s
t hrough a seri es of surveys.
When might you use this technique?
The Del phi t echni que i s usef ul when i t i s di f cul t t o bri ng part i ci pant s t oget her f or a f ace-
t o-f ace sessi on (eg general pract i t i oners worki ng i n remot e areas). Somet i mes ref erred t o as
a consensus met hod, t he Del phi t echni que i nvol ves harnessi ng t he i nsi ght s of appropri at e
expert s t o enabl e deci si ons t o be made.
Who is involved?
Thi s t echni que can be used t o exami ne t he vi ews of a speci c t arget group (eg nurses) or
across a mi xed group of heal t h care prof essi onal s (eg al l t hose i nvol ved i n cari ng f or peopl e
wi t h ast hma).
What types of questions can be used?
General l y, cl osed-response st yl e quest i ons are used t o assess part i ci pant s l evel of agreement
wi t h a number of i deas (eg Improved access t o t he i nt ernet woul d hel p me t o provi de best
evi dence-based care answered on a 10-poi nt scal e f rom di sagree t o agree ).
How to collect the information?
The i nf ormat i on i s usual l y col l ect ed vi a a seri es of mai l ed surveys; however t hi s t echni que
can be adapt ed f or el ect roni c groups. Inf ormat i on col l ect ed f rom t he rst survey i s used t o
generat e f eedback i n subsequent rounds. Part i ci pant s are gi ven t he opport uni t y t o revi se t hei r
j udgement s on t he basi s of t hi s f eedback. The number of rounds may range f rom t wo t o f our.
How to analyse the data?
Each round of surveys requi res summari es t o be col l at ed and f eedback generat ed. The
respondent s t hemsel ves hel p t o devel op and rene i deas as t he rounds of surveys are
compl et ed.
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Other considerations
Part i ci pant cooperat i on and cont i nued i nvol vement over t he course of t he Del phi i s
cri t i cal
Feedback based upon responses shoul d be provi ded i n a way t hat ensures anonymi t y
f or i ndi vi dual part i ci pant s
The revi si on of surveys accordi ng t o t he part i ci pant s responses can be di f cul t and
t i me-consumi ng
What are the key steps involved in the Delphi technique?
Ident i f y area of i nvest i gat i on and associ at ed t arget group
Devel op i ni t i al set of quest i ons
Seek i nput about t he quest i ons f rom rel evant expert s
Consi der how cont act det ai l s of t he t arget group mi ght be obt ai ned (eg col l ege l i st s)
Cont act pot ent i al part i ci pant s and sol i ci t t hei r part i ci pat i on (be sure t o expl ai n t he
purpose and process of t he t echni que)
M ai l out surveys and col l ect ret urns
Fol l ow-up non-respondent s
Summari se responses, prepare f eedback and revi se quest i ons
Repeat t he l ast t hree st eps unt i l no f urt her i nf ormat i on i s gai ned or consensus
i s reached
What special expertise do you need?
Input f rom rel evant expert s when devel opi ng t he i ni t i al quest i ons and revi si ng l at er
quest i ons/ f eedback
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What are the advantages & disadvantages of this technique?
The advant ages of t he Del phi t echni que are t hat part i ci pant s remai n anonymous and surveys
can be sent t o heal t h prof essi onal s or pat i ent s across t he count ry.
The di sadvant ages of t hi s t echni que are t hat consi derabl e t i me may be needed f or quest i on
devel opment , revi si on and anal ysi s; part i ci pant s may not be wi l l i ng t o compl et e mul t i pl e
surveys and response rat es may be l ow.
What are the costs of this technique?
The cost s associ at ed wi t h t he Del phi t echni que i ncl ude: phot ocopyi ng or pri nt i ng of t he
surveys; post age; f ol l ow-up of non-respondent s; possi bl e i ncent i ves f or part i ci pant s; and
payment s t o rel evant expert s f or i nput duri ng t he devel opment of t he quest i ons, subsequent
revi si ons and anal ysi s.
Are there times when you would not use the Delphi
technique?
The Del phi t echni que mi ght not be sui t abl e when t he respondent s vi ews mi ght not be st abl e
over t i me. For i nst ance, pat i ent s mi ght change t hei r vi ews as t hei r i ndi vi dual ci rcumst ances
change t hey may be get t i ng bet t er or worse and wi t h t he passage of t i me t he sal i ence of a
pai nf ul experi ence mi ght di mi ni sh.
PART II
Delphi Technique [CONTINUED]
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Where to get more information about the Delphi technique?
Articles
Jones J & Hunt er D (1995) Qual i t at i ve Research: Consensus met hods f or medi cal and
heal t h servi ces research. BM J: 311: 376380.
Textbooks
Li nst one HA & Turof f M (eds). The Del phi met hod: t echni ques and appl i cat i ons.
Readi ng, M ass: Addi son-Wesl ey Publ i shi ng Company, 1975.
Websites
http://bmj.bmjjournals.com/cgi/content/full/311/7001/376
a di rect l i nk t o t he paper by Jones & Hunt er (1995) whi ch descri bes bot h t he nomi nal
group and Del phi t echni ques, i t det ai l s key met hodol ogi cal i ssues and provi des
exampl es of appl i cat i ons of t he t echni ques i n heal t h research
http://www.is.njit.edu/pubs/delphibook
a l i nk t o t he el ect roni c versi on of t he t ext by Li nst one & Turof f (1975) as l i st ed above
http://www.uwex.edu/ces/pdande/resources/pdf/Tipsheet4.pdf
provi des a bri ef overvi ew of t he Del phi t echni que, wi t h sampl e document s t o recrui t
part i ci pant s and accompany surveys

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PART II
MORE INFORMATION
Ref erences about speci c t echni ques f or i dent i f yi ng barri ers t o pract i ce change are
l i st ed i n t he rel evant sect i ons above
Some general ref erences t hat may be usef ul f or t hose want i ng t o know more are
provi ded bel ow:
For more information about research methods and
data analysis
Articles
Pope C, Zi ebl and S & M ays N (2000) Qual i t at i ve research i n heal t h care: anal ysi ng
qual i t at i ve dat a. BM J 320: 114116
Textbooks
Berg, BL (2003) Qual i t at i ve Research M et hods f or t he Soci al Sci ences
(5t h edi t i on). Al l yn & Bacon
Cassel l , C & Symon G (2004) Essent i al Gui de t o Qual i t at i ve M et hods i n Organi zat i onal
Research. Sage Publ i cat i ons
M ays N & Pope C (1999) Qual i t at i ve Research i n Heal t h Care (2nd edi t i on). London,
BM J Books
M orse JM & Ri chards L (2002) Readme Fi rst f or a Users Gui de t o Qual i t at i ve M et hods.
Sage Publ i cat i ons
Websites
http://bmj.bmjjournals.com/cgi/content/full/320/7227/114
a di rect l i nk t o t he art i cl e by Pope, Zi ebl and & M ays (2000) l i st ed above
58 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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For more information about improving evidence uptake
across the health care system
Articles
Grol R, Gri mshaw J. (2003) From best evi dence t o best pract i ce: ef f ect i ve
i mpl ement at i on of change i n pat i ent s care. Lancet 362: 122530.
Textbooks
Grol R, Baker R & M oss F (2002) Qual i t y i mprovement research: underst andi ng t he
sci ence of change i n heal t h care. London, BM J Books.
Grol R, Wensi ng M , Eccl es M (2005) Improvi ng Pat i ent Care. The Impl ement at i on of
Change i n Cl i ni cal Pract i ce. El sevi er But t erwort h Hei nemann.
Websites
http://www.nhmrc.gov.au/publications/synopses/cp71syn.htm
a l i nk t o t he Nat i onal Heal t h and M edi cal Research Counci l , downl oad publ i cat i on,
How t o put t he evi dence i nt o pract i ce: i mpl ement at i on and di ssemi nat i on st rat egi es.
Canberra: NHM RC, 2000, wi t h l i nks t o rel at ed publ i cat i ons.
http://www.mja.com.au/public/issues/180_06_150304/suppl_contents_
150304.html
a l i nk t o t he M edi cal Journal of Aust ral i a suppl ement : 15 M arch 2004, Adopt i ng Best
Evi dence i n Pract i ce.
http://www.epoc.uottawa.ca/index.htm
a l i nk t o t he Cochrane Ef f ect i ve Pract i ce & Organi sat i on of Care (EPOC) Group,
whi ch undert akes syst emat i c revi ews of i nt ervent i ons desi gned t o i mprove heal t h
prof essi onal pract i ce and t he organi sat i on of heal t h care servi ces.

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For more information about organisations involved in working
to improve evidence uptake across the health care system
Websites
http://www.nicsl.com.au
websi t e of t he Nat i onal Inst i t ut e of Cl i ni cal St udi es, Aust ral i as nat i onal agency
f or i mprovi ng heal t h care by hel pi ng cl ose i mport ant gaps bet ween best avai l abl e
evi dence and current cl i ni cal pract i ce. NICS i s f unded by t he Aust ral i an Government .
http://www.wokresearch.nl
websi t e of t he Cent re f or Qual i t y of Care Research (WOK), a col l aborat i on of t he
uni versi t i es of Ni j megen and M aast ri cht i n t he Net herl ands.
http://www.ktp.utoronto.ca
websi t e of t he Knowl edge Transi t i on Program at t he Uni versi t y of Toront o i n Canada.
http://www.g-i-n.net
websi t e of t he Gui del i nes Int ernat i onal Net work.

PART II
MORE INFORMATION [CONTINUED]
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Cabana M D, Rand CS, Powe NR, Wu AW, Wi l son M H, Abbound PC and Rubi n HR. (1999) Why
dont physi ci ans f ol l ow cl i ni cal pract i ce gui del i nes? A f ramework f or i mprovement . JAM A
282: 14581465
Grol R & Wensi ng M . (2004) What dri ves change? Barri ers t o and i ncent i ves f or achi evi ng
evi dence-based pract i ce. M JA 180: S57S60
Hul scher M EJL, Wensi ng M , van der Wei j den T, Grol R, Int ervent i ons t o i mpl ement prevent i on
i n pri mary care. The Cochrane Dat abase of Syst emat i c Revi ews 2005, Issue 3
M cKenna HP, Asht on S & Keeney S. (2004) Barri ers t o evi dence-based pract i ce i n pri mary
care. Journal of Advanced Nursi ng 45: 178189
M cKi nl ay E, M cLeod D, Dowel l A & M arshal l C. (2004) Cl i ni cal pract i ce gui del i nes devel opment
and use i n New Zeal and: an evol vi ng process. NZM J 117: 9991009
Nat i onal Breast Cancer Cent re. Cl i ni cal pract i ce gui del i nes f or t he management of earl y
breast cancer: 2nd edi t i on. Nat i onal Breast Cancer Cent re, Wool l oomool oo, 2002
Oxman AD & Fl ot t orp S. An overvi ew of st rat egi es t o promot e i mpl ement at i on of evi dence
based heal t h care. In Si l agy C & Hai nes A (eds), Evi dence Based Pract i ce i n Pri mary Care.
(p. 91109). BM J Books, 1998
Phi l l i ps SM , M art on RL & Toer GH. (2004) Barri ers t o di agnosi ng and managi ng heart f ai l ure
i n pri mary care. M JA 181: 7881
Shaw B, Cheat er F, Baker R, Gi l l i es C, Hearnshaw H, Fl ot t orp S, Robert son N. Tai l ored
i nt ervent i ons t o overcome i dent i ed barri ers t o change: ef f ect s on prof essi onal pract i ce and
heal t h care out comes. The Cochrane Dat abase of Syst emat i c Revi ews 2005, Issue 3. Art . No.:
CD005470
Tooher R, M i ddl et on P, Pham C, Fi t ri dge R, Rowe S, Babi dge W & M addern G. (2005) A
syst emat i c revi ew of st rat egi es t o i mprove prophyl axi s f or venous t hromboembol i sm i n
hospi t al s. Ann Surg 241: 397415
Wal ker A, Campbel l S, Gri mshaw J, et al ., (1999) Impl ement at i on of a nat i onal gui del i ne on
prophyl axi s of venous t hromboembol i sm: a survey of acut e servi ces i n Scot l and. Heal t h Bul l
57: 141147
Wensi ng M & Grol R. M et hods t o i dent i f y i mpl ement at i on probl ems. In R Grol , M Wensi ng
& M Eccl es (eds), Improvi ng Pat i ent Care: The i mpl ement at i on of change i n cl i ni cal pract i ce.
(p. 109120). Edi nburgh, El sevi er But t erwort h Hei nemann, 2005
REFERENCES
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APPENDIX
APPENDIX A A suggested literature search
strategy for identifying relevant research papers
Thi s sect i on i s not i nt ended as a comprehensi ve gui de t o searchi ng t he l i t erat ure, but t o gi ve
i deas about how t o get st art ed when l ooki ng f or rel evant j ournal art i cl es and t o provi de a f ew
hi nt s on how t o prepare a search st rat egy.
How to nd studies about barriers to the implementation of
guidelines for specic health topics?
To i dent i f y st udi es exami ni ng t he barri ers t o gui del i ne i mpl ement at i on wi t hi n a speci c heal t h
area, you wi l l need t o conduct a search of t he medi cal l i t erat ure.
The st rat egy f or searchi ng i ncl udes t he sel ect i on of dat abases t o be searched, and t he
devel opment of a l i st of subj ect t erms and f ree t ext words t o be appl i ed when searchi ng each
of t he possi bl e dat abases.
Which databases to search?
Wi l l be dependent on t he resources avai l abl e t o you f or access t o t he vari ous bi bl i ographi c
dat abases, and whet her t he search i s f or a f ew key ref erences or an ext ensi ve search of t he
medi cal l i t erat ure.
St art wi t h M edl i ne and EM BASE as t hey cont ai n bi bl i ographi c ref erences f rom a wi de range
of medi cal , nursi ng and al l i ed heal t h j ournal s publ i shed worl dwi de.
Medl i ne covers bi omedi ci ne and heal t h, and encompasses t he sci ences rel evant t o basi c
research and cl i ni cal care, publ i c heal t h, and t he heal t h care syst em. May be avai l abl e vi a your
i nst i t ut i on as Ovi d Medl i ne or ot her dat abase vendor, or may be accessed at t he Nat i onal Li brary
of Medi ci ne PubMed si t e f or f ree at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
EM BASE covers pharmacol ogy, bi omedi ci ne, and psychi at ry, wi t h part i cul ar coverage of
European j ournal s. M ay be avai l abl e vi a your i nst i t ut i on f rom a dat abase vendor such as Ovi d
or Embase.com.
It may al so be usef ul t o search t he more speci al i sed cont ent of dat abases such as CINAHL f or
nursi ng and al l i ed heal t h t opi cs or PsycINFO f or psychol ogy and psychi at ry t opi cs.
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What search terms to use?
Two groups of search t erms are needed:
1. Terms coveri ng t he barri ers t o i mpl ement at i on of gui del i nes and,
2. Terms coveri ng t he speci c heal t h area or heal t h condi t i on of i nt erest t o you.
The resul t s of searchi ng t he t wo groups of t erms are t hen combi ned wi t h t he Bool ean operat or,
AND.
Search t erms are usual l y a combi nat i on of subj ect headi ngs speci c f or each dat abase, and
f ree t ext words.
Subject Headings:
Bi bl i ographi c dat abases use a l i st of subj ect headi ngs f or i ndexi ng t he cont ent of each j ournal
art i cl e, and t o i ndi cat e t he mai n concept s di scussed i n t he art i cl e.
Use of subj ect headi ngs has t he advant age of bri ngi ng t oget her several expressi ons of t he
same concept under t he one headi ng.
For exampl e,
The M edl i ne subj ect headi ng (M eSH) f or Gui del i ne Adherence i s descri bed as Conf ormi t y
i n f ul l l i ng or f ol l owi ng of ci al , recogni zed, or i nst i t ut i onal requi rement s, gui del i nes,
recommendat i ons, prot ocol s, pat hways, or ot her st andards. (M eSH Scope Not e 2005)
Gui del i ne Adherence i s used i n pref erence t o t he expressi ons i nst i t ut i onal adherence ,
pol i cy compl i ance or prot ocol compl i ance .
When searchi ng i n Ovi d M edl i ne, i f you ent er ei t her of t hose phrases, your search wi l l be
di rect ed or mapped t o t he appropri at e M eSH headi ng, Gui del i ne Adherence. For dat abases
whi ch have t hi s mappi ng f aci l i t y, af t er you ent er a word or phrase i n t he search box, t he most
rel evant subj ect headi ng wi l l be ret ri eved.
Searchi ng t he l i st of subj ect headi ngs f or each dat abase i s usual l y of f ered as an opt i on on t he
search screen. In Ovi d M edl i ne i t i s f ound at t he Search Tool s i con where a word or phrase can
be ent ered. EM BASE of f ers an Emt ree keyword i con f or searchi ng t he t hesaurus of pref erred
t erms. A l i st of subj ect headi ngs cont ai ni ng t he word or phrase i s present ed so t hat t he most
rel evant headi ngs can be sel ect ed.
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Be aware t hat a subj ect headi ng used i n one dat abase may not be avai l abl e i n anot her
dat abase. The t erm Gui del i ne Adherence i s avai l abl e i n M edl i ne onl y. A si mi l ar headi ng may
be used i n di f f erent dat abases. M edl i ne and CINAHL have t he same t erm Pract i ce Gui del i nes,
whi l st EM BASE has Pract i ce Gui del i ne, and PsycINFO uses t he t erm Treat ment Gui del i nes.
When a sui t abl e subj ect headi ng i s not avai l abl e, t hen a search usi ng f ree t ext words i s t he
next opt i on.
Free text terms:
Free t ext searchi ng i s used t o ret ri eve art i cl es cont ai ni ng t he word or phrase as part of t he
t i t l e of t he art i cl e, or as part of a sent ence wi t hi n t he abst ract of t he art i cl e. It i s recommended
t hat t he Hel p or Search Hi nt s provi ded f or each dat abase be checked f or speci c det ai l s on
how t o ent er f ree t ext words or phrases. Words can be combi ned usi ng t he Bool ean operat ors,
AND, OR or NOT. Thi nk of al l t he synonyms f or t he concept bei ng searched, and combi ne t hem
wi t h OR. For exampl e, compl i ance OR adherence.
Phrases may be si mpl y ent ered or may need t o be encl osed wi t hi n quot at i on marks t o obt ai n
an exact mat ch.
Words can be t runcat ed usi ng t he t runcat i on symbol appropri at e f or t he dat abase.In Ovi d
dat abases, use t he symbol $ t o ret ri eve al l suf x vari at i ons of t he word i n t he i ndi cat ed
el d of t he record. For exampl e, adher$.t i . ret ri eves ref erences wi t h t he word adher, adheres,
adhered, or adherence i n t he t i t l e.
Wi l dcards are used where t here are vari at i ons i n spel l i ng of a word. The symbol f or t he
wi l dcard opt i on i s speci c f or each dat abase. In Ovi d dat abases, use t he symbol # t o repl ace
exact l y one charact er. For exampl e, wom#n.t i . ret ri eves woman or women i n t he t i t l e.
Posi t i onal or proxi mi t y operat ors are used t o ret ri eve phrases wi t h t he search t erms wi t hi n
an i ndi cat ed number of words of each ot her. In Ovi d dat abases, use ADJx t o ret ri eve such
phrases. For exampl e, (gui del i nes adj 3 adherence).t w. ret ri eves phrases i n whi ch gui del i nes
and adherence are wi t hi n 3 words of each ot her.
APPENDIX [CONTINUED]
66 IDENTIFYING BARRIERS TO EVIDENCE UPTAKE
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NATIONAL INSTITUTE OF CLINICAL STUDIES
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FEB 2006
Identifying
to evidence uptake
Suggested strategy for searching for studies about barriers
to the implementation of guidelines?
The f ol l owi ng i s a st rat egy f or Ovi d M edl i ne usi ng a combi nat i on of M eSH and f ree t ext t erms.
Thi s i s a suggest ed st rat egy onl y i t i s not a f ul l y t est ed gol d st andard search l t er. It may
need t o be adapt ed f or conduct i ng a search on ot her dat abases.
1. Gui del i nes/ OR Pract i ce Gui del i nes/
2. Heal t h Pl anni ng Gui del i nes/
3. 1 OR 2
4. (barri er$ OR obst acl e$ OR di f cul t $).t w.
5. 3 AND 4
6. Gui del i ne Adherence/
7. (adher$ OR i mpl ement $ OR f aci l i t at $ OR compl i an$ ).t w.
8. 3 AND 7
9. 5 OR 6 OR 8
[St rat egy l i nes #1 t o #9 are t erms coveri ng t he barri ers t o i mpl ement at i on of gui del i nes. You
woul d cont i nue by searchi ng on t he t erms coveri ng t he speci c heal t h area or heal t h condi t i on
of i nt erest t o you. The resul t s of searchi ng t he t wo groups of t erms are t hen combi ned wi t h
AND.
The t opi c of back pai n i s used here as an exampl e.]
10. Back Pai n/ OR Low Back Pai n/
11. 9 AND 10
NATIONAL INSTITUTE OF CLINICAL STUDIES
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FEB 2006
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IDENTIFYING BARRIERS TO EVIDENCE UPTAKE 67
Where to get more information about conducting a search
of the literature?
Read the Help or Search Hints section provided by each database.These gi ve essent i al
i nf ormat i on speci c t o each dat abase on how t o search, pri nt , downl oad or save ref erences
or search st rat egi es. Take not e of t he i nst ruct i ons on t he use of Bool ean operat ors, wi l dcards,
t runcat i on, and proxi mi t y searchi ng.
Ask a medical librarian for assistancewi t h det ermi ni ng t he most appropri at e subj ect
headi ngs f or your search, how t o broaden your search i f t he i ni t i al search ret ri eval i s t oo
l ow, or how t o narrow t he search i f your i ni t i al search ret ri eval cont ai ns t oo many i rrel evant
ref erences.
Websites
The New Zeal and Gui del i nes Group websi t e sect i on on Devel opi ng Gui del i nes: St eps
i n Gui del i ne Devel opment : Current dat a acqui si t i on and l i t erat ure searchi ng can be
f ound at
http://www.nzgg.org.nz/index.cfm?fuseaction=evidence&fusesubaction=
article&documentID=10&articleID=99
The chapt er on Fi ndi ng t he Evi dence Li t erat ure Searchi ng f or Gui del i ne Devel opment
provi des i nf ormat i on about rel evant dat abases, how t o rene t he search st rat egy,
hi nt s on searchi ng ei t her Ovi d M edl i ne or PubM ed, and l i nks t o websi t es of gui del i ne
cl eari nghouses.
The NICS websi t e: Wheres t he Evi dence? provi des st ep by st ep i nf ormat i on on
how t o search f or t he best avai l abl e evi dence on-l i ne.
http://wherestheevidence.nicsl.com.au
APPENDIX [CONTINUED]