Using a Pre-Implementation Intervention to Impact School Clinicians’ Beliefs and Attitudes about CBITS Implementation

Introduction: The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is a well-researched evidence-based practice (EBP) for reducing symptoms of trauma, anxiety, and depression in students. CBITS was designed to include implementation support through ongoing consultation and online resources. Despite explicit attention to implementation, studies suggest that many implementation barriers remain.

Several strategies exist to address problems with EBP implementation, and strategies targeting the individual provider level are crucial. The present study aimed to (1) test a theory-driven implementation strategy targeting individual factors (e.g., intentions to implement EBP) among clinicians delivering CBITS and (2) identify the most common and relevant determinants of EBP implementation for clinicians delivering CBITS.

Methods: Twenty-four school-based clinicians were randomly assigned to one of two conditions. The Beliefs and Attitudes for Successful Implementation in Schools (BASIS) condition received a 3-hour group-based intervention prior to being trained in CBITS. BASIS was designed to increase positive attitudes toward EBP, strengthen social norms about implementing EBP, and enhance efficacy to implement EBP. The control condition received a 3-hour educational session prior to being trained in CBITS. All clinicians completed measures before and after training and participated in exit interviews after CBITS implementation. During implementation, all clinicians participated in biweekly group consultation.

Results: Relative to control clinicians, BASIS clinicians reported increased appeal of EBP (Cohen’s d = 0.91), EBP fit with current work and clients (Cohen’s d = 1.16), divergence between current practices and EBP (Cohen’s d = 1.06), EBP implementation descriptive norms (Cohen’s d = 0.93), and intentions to implement EBP (Cohen’s d = 0.96). Survival analysis indicated that BASIS clinicians remained in CBITS consultation longer than control clinicians (i.e., 120 vs. 30 days to attrition). However, there was no difference between conditions in CBITS adoption—only 5 clinicians in the study began a CBITS group. Exit interviews revealed 10 vital determinants that influenced CBITS implementation. For example, the burden required to initiate CBITS (e.g., screening, consent) inhibited adoption, and clinicians’ action planning was essential to CBITS implementation.

Conclusions: BASIS shows promise for impacting theoretically-informed mechanisms of implementation (i.e., attitudes, subjective norms, intentions to implement). However, in this small sample, BASIS did not change implementation behavior. Additional supports are likely needed (beyond ongoing consultation and online resources) to overcome implementation barriers.