Editorial
The Journal of School Nursing
Attention to Fidelity: Why Is It Important
Clinical trials are epitomized by control of extraneous
contextual and demographic variables. Participants in
intervention and control or comparison groups are assessed
for similarities and differences. The content, dose, and dura-
tion of interventions are prescribed explicitly. Intervention-
ists are trained, supervised, evaluated, and in some cases
retrained during the intervention to ensure adherence to the
protocol. Outcome variables are assessed before and after
the intervention, and those variables that could influence the
results are controlled statistically. Implementing interven-
tions found to be effective in research provides an empirical
base for practice, yet control in practice is elusive.
Fidelity is paramount in translating research to practice.
Fidelity (sometimes called integrity; or delivery, treatment,
intervention, or implementation fidelity) is defined as the
degree to which an intervention or procedure is delivered
as intended. One of the most important factors when imple-
menting empirically supported interventions is that they are
delivered with fidelity. In fact, lack of fidelity to an interven-
tion model may underlie why interventions that work well in
highly controlled research trials fail to produce the same out-
comes in real-world settings. Therefore, monitoring and
assuring fidelity is critical in replicating the beneficial
results of an intervention in a variety of settings and popula-
tions. Therefore, developing a comprehensive fidelity plan
is critical for dissemination and translation into practice.
Fidelity is an important component of implementation
science (Eccles & Mittman, 2006). Implementation science
is ‘‘the scientific study of methods to promote the systematic
uptake of research findings (and other EBPs) into routine
practice, and, hence, to improve the quality and effective-
ness of health services and care’’ (Eccles & Mittman,
2006, {2). In other words, implementation science is the
study of how research and evidence-based practices (EBPs)
are adopted and used in day-to-day practice with fidelity
being key to achieving the positive effects in the adoption
and implementation process.
Measuring Fidelity
Attention to fidelity measurement has become an important
methodological consideration in both research and the
implementation of EBPs. Monitoring fidelity can help
improve and inform intervention science and delivery. The
following two main components of fidelity are frequently
measured: adherence and competence. Adherence refers to
the extent to which interventionists’ behaviors conform to the
intervention protocol (Hogue et al., 2008). Measurements of
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adherence focus on the quantity or presence of prescribed
behaviors defined in an intervention manual or protocol.
Competence is the skill of the interventionists in delivering
the intervention, or how well the intervention is delivered
(Breitenstein, Gross, et al., 2010). The most commonly
reported methods to collect fidelity data are self-report and
observations (live, video, and/or audio).
In complex behavioral interventions, fidelity assessment
plays an important role as a feedback mechanism for key
implementation processes. For example, fidelity assessment
can provide information to (a) improve interventionists’ per-
formance through ongoing coaching and supervision, (b)
inform interventionist selection requirements, and (c) guide
improvements in training. Using fidelity assessment as a for-
mative evaluation tool can ultimately effect targeted
improvements of the intervention. In addition, fidelity
assessment can provide critical information regarding
implementation successes and failures in regard to the con-
text of diverse settings and populations.
Robbins, Pfeiffer, Maier, LaDrig, and Berg-Smith (2012)
used a standardized measure of fidelity for individual-based
motivational interviewing (MI) sessions involving middle
school girls and a school nurse to help the girls increase
physical activity (Moyers, Martin, Manuel, Miller, & Ernst,
2010). Using audio recordings of the interview sessions, the
school nurse was rated on her adherence to the MI interven-
tion. Robbins et al. used the findings of the fidelity assess-
ment to inform the adequacy of training for school nurses
to implement the intervention and identify ways to promote
widespread adoption of the intervention.
Likewise, Breitenstein, Fogg, et al. (2010) developed and
tested an observational method of fidelity (adherence and com-
petence) assessment specific to a 12-session group-based par-
enting intervention. Similar to Robbins et al., the authors found
that fidelity assessment was important in guiding ongoing
training and supervision of the group leaders. Specifically,
Breitenstein, Fogg, and colleagues found that adherence to the
intervention fell below the mean around Session 7 of the inter-
vention indicating a need to include some additional training
and support to group leaders mid-way through the intervention.
These two examples highlight the importance of using the data
from fidelity assessment to inform interventionists’ behavior
and implementation processes.
Fidelity and Adaptation
As the importance of using EBPs in various clinical settings
increases, tension may arise between the local interest to
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adapt and the need to maintain fidelity to the intervention.
Proponents of adaptation argue that adaptations are impor-
tant to meet the specific needs of a certain population or
setting—often, adaptations make an intervention culturally
and contextually relevant for a given audience. Opponents
to adaptation argue that any adaptation runs the risk of
moving off the evidence base of the intervention potentially
rendering it ineffective. We would argue that the conflict
between adaptation and fidelity is not whether adaptations
or modifications of an intervention occur, but what changes
can be made to allow for flexibility in meeting the needs of
the setting and/or population without compromising the core
components of the evidence-based intervention. O’Connor,
Small, and Cooney (2007) provide an excellent summary
of components for adaptation for meeting local needs but not
compromising the effectiveness of an intervention. Exam-
ples of acceptable adaptations include translation or modifi-
cation of vocabulary, using images similar to the target
audience, and replacing or changing cultural references.
Examples of risky or unacceptable adaptations are changing
the dose of the intervention sessions, removing content, and
changing the theoretical approach. The potential for adapta-
tions and changes to an intervention model is another good
argument for constructing a comprehensive fidelity plan as
part of the implementation and dissemination process in
order to assess, identify, and modify potential adaptations
that might negatively or positively influence the effective-
ness of the intervention.
School Nursing Implications
School nurses face many challenges in implementing tested
interventions with a high degree of fidelity because of fiscal
constraints, multiple demands on nursing time, school nurse
staffing issues, and competing priorities. Effective commu-
nication between school nurses and administrative decision
makers is critical and their relationship needs to be fostered
continually to maintain fidelity of interventions. School
nurses need to be part of the decision-making team so that
decisions are informed by empirical evidence showing the
importance of fidelity.
The Journal of School Nursing 28(6)
Susan Breitenstein, PhD, RN, PMHCNS-BC
Journal of School Nursing Editorial Advisory Board
Assistant Professor, Rush University College of Nursing
Lorraine Robbins PhD, RN, FNP-BC
Journal of School Nursing Editorial Advisory Board
Associate Professor, Michigan State
University, College of Nursing
Julia Muennich Cowell, PhD, RN, APHN-BC, FAAN
Executive Editor
References
Breitenstein, S., Fogg, L., Garvey, C., Hill, C., Resnick, B., & Gross,
D. (2010). Measuring implementation fidelity in a community
based parenting intervention. Nursing Research, 59, 158–165.
Breitenstein, S., Gross, D., Garvey, C., Hill, C., Fogg, L., &
Resnick, B. (2010). Implementation fidelity in community-
based interventions. Research in Nursing and Health, 33,
164–173.
Eccles, M., & Mittman, B. (2006). Welcome to implementation sci-
ence [Electronic version]. Implementation Science, 1, 1. doi:10.
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Hogue, A., Henderson, C. E., Dauber, S., Barajas, P. C., Fried, A.,
& Liddle, H. A. (2008). Treatment adherence, competence, and
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Moyers, T. B., Martin, T., Manuel, J. K., Miller, W. R., & Ernst, D.
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ment integrity (MITI): Retrieved January 12, 2012, from http://
casaa.unm.edu/download/MITI3_1.pdf
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Robbins, L. B., Pfeiffer, K. A., Maier, K. S., LaDrig, S. M., &
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