What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

Abstract

Objective:

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

Background:

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

Methods:

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

Results:

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

Conclusions:

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon’s individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

Recent innovations in surgery have outpaced the study of their efficacy in everyday practice, including the introduction of robotic surgery, advances in image-guidance, the use of new devices, and perioperative protocols. Randomized controlled trials of surgical procedures are scarce and are frequently the target of criticism about generalizability owed to differences in surgeon skill and patient heterogeneity.^1,2 Moreover, the well-established volume-outcome relationship in surgery and related learning curve are unique barriers to both trial design and implementation of new procedures.^3,4 In an era of accelerated innovations, the tension between consistency and change is constant; that is, surgeons face the difficult decision to either acknowledge and implement or forgo new advances throughout their careers. Understanding the facilitators and barriers influencing a surgeon’s decision regarding a practice change is critical to implementing best practices and de-implementing less effective or harmful surgical practices.

Although changing surgical practice to align with evidence is an imperative of health systems, new evidence and practice guidelines have not consistently translated into change. Studies examining the impact of guidelines on clinical practice patterns attribute this discrepancy to individual, environmental, and social factors, such as unawareness of guidelines, variable strength of evidence underlying guideline recommendations, local or financial barriers to implementation, anecdotal preferences, and perceived lack of contextual and patient relevance.^5–12 This research suggests that the implementation of clinical practice guidelines alone may be insufficient and a comprehensive, systematic approach is needed to facilitate sustainable practice change. Moreover, the literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. The reviews and editorials in this area have focused on (1) ethical considerations surrounding the adoption of innovations,¹³ (2) promoting learning organizational models and paradigms for innovation development,^14,15 and (3) surgeon-level barriers to the uptake of innovations (eg, technical and interpersonal skills).^15,16 No reviews to date have grounded their analysis within an implementation science framework.

Implementation science, the study of “strategies to adopt and integrate evidence-based interventions and change practice patterns within specific settings,” has particular relevance to surgical practice.^17–19 As surgical outcomes research increasingly involves the dissemination and implementation of evidence-based practice, understanding the extant literature through the lens of implementation science has the potential to inform the adoption of innovations and effectiveness studies moving forward. In this review, we employ the Theoretical Domains Framework (TDF), an implementation science conceptual framework, to identify and understand facilitators and barriers to change.^20–22 The TDF includes 14 domains that derive from 3 determinants of behavior (summarized in Table 1): Capability, Opportunity, and Motivation (COM-B model).^21,23 These concepts are highly applicable within the context of surgical practice change. Capability refers to the individual’s psychological and physical capacity to engage in an activity (eg, TDF domains: knowledge and skills); Opportunity includes extrinsic factors outside the individual that make the behavior possible or prompt it (eg, TDF domains: environmental context and resources and social influences); Motivation involves brain processes that energize and direct behavior, including habitual processes, emotional responses, and analytical decision-making (eg, TDF domains: reinforcement and beliefs about consequences).^24,25

TABLE 1.

Overlap of Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation, Behavior (COM-B) Model^*

TDF Domain	Definition in Context of Surgical Practice Change	Capability	Opportunity	Motivation
Knowledge	Awareness that procedure exists and/or having sufficient knowledge about it to make change	x
Skills	Physically possessing skills and expertise to make change	x
Behavioral regulation	Actions taken to directly change behavior	x
Memory, attention, and decision processes	Recalling the processes to make change and the decision making surrounding it	x
Social/professional role and identity	Individual behaviors and qualities that impact change	x
Beliefs about capabilities	Believing they have the skills and capacity to make change	x
Environmental context and resources	Possessing appropriate resources and/or being in environment or situation conducive to change		x
Social influences	Interactions between colleagues, mentors, thought leaders, and patients that impact their thoughts and actions surrounding the change		x
Optimism	Confidence that the change will improve outcomes			x
Beliefs about consequences	What they think will happen if they make the change			x
Reinforcement	Being more likely to repeat/carry out change if they experience a positive result			x
Intentions	Why they made the change			x
Goals	What they want the change to happen			x
Emotion	Reactions or feelings surrounding change			x

^*TDF Framework domains derive from COM-B behavioral factors.^22,24

Using the TDF framework, this scoping review summarizes the literature on surgical practice change. We identify facilitators and barriers that influence practice change to inform further research focused on implementing and evaluating new surgical practices. Improved understanding of this topic has the potential to promote evidence-based practice and to help de-implement less effective or harmful surgical practices.

METHODS

Systematic Review and Study Selection

We searched the MEDLINE database via Pubmed, Scopus, Web of Science, ERIC, CINAHL, PsycINFO (ProQuest), and Education Research Complete. The literature search was completed in May 2018 to reflect practices over the previous 5 years, using a combination of controlled vocabulary and key terms related to innovation adoption, behavior change, surgery, and surgeons (see Document, Supplemental Digital Content 1, Search Strategy, http://links.lww.com/SLA/C502). Reference lists of articles were hand-searched and recent reviews addressing surgeon practice change to identify additional relevant articles.

Inclusion criteria were developed in consultation with an expert panel of surgeons, health services researchers, and a reference librarian. Included were original studies of all designs involving surgical practice change published in English. Excluded were studies related to medical education or residency training. Three independent investigators (NAA, TG, and MT) reviewed abstracts to determine candidacy for full-text review. Similarly, 3 independent investigators (NAA, TG, and MT) reviewed the full text of candidate studies to determine whether they met inclusion criteria for data extraction. Senior investigators (DOF and SFT) resolved discrepancies. The review was completed using DistillerSR software (Evidence Partners, Ottawa, Canada).

Data Extraction and Analysis

One investigator (TG) extracted data regarding study design, descriptions of study population and intervention and comparison groups (if applicable), and baseline and outcome data using a standardized form. A second investigator independently (NAA) verified the accuracy of the extraction and revised as needed. Principal measures of interest were the facilitators of, barriers to, and neutral factors for change. Barriers, facilitators, and neutral factors were abstracted from study results and were defined as: (a) barrier: factor that impedes the implementation outcomes; (b) facilitator: factor that enables the implementation outcomes; and (c) neutral factor: factor that does not impact the implementation outcomes.²⁶ Any disputes about coding and classification as a facilitator, barrier, or neutral factor involved 2 senior investigators (DOF and SFT) rereviewing data, discussing the dispute, and making a consensus determination. Study setting refers to the scope and environment in which the data for the study was collected (academic or community hospitals, regional/national, or global). We also identified whether a targeted intervention was studied (eg, introduction of clinical practice guidelines) and examined which barriers and facilitators within the TDF framework impacted its effectiveness at changing practice.

Qualitative Synthesis

Significant heterogeneity in outcomes reported and study design precluded meta-analysis; thus, we synthesized the data qualitatively using the TDF. Two independent reviewers (NAA and TG) mapped results from included studies to categorize facilitators and barriers within TDF domains and their derivative COM-B components based on the published conceptual framework.^21,23 Senior investigators (DOF and SFT) were consulted to reconcile disagreements. Recurring concepts within the dominant TDF domains and COM-B components further characterized the literature.

RESULTS

Characteristics of the Studies

Our search identified 2427 citations of which 104 met inclusion criteria (Fig. 1). All studies included and data extracted are listed in a supplementary table (see Table, Supplemental Digital Content 1, Characteristics of Selected Surgical Practice Change Articles, http://links.lww.com/SLA/C502). Included studies were predominantly from the United States (n = 47, 45.2%) and Europe (n = 28, 26.9%) and conducted in regional/national (n = 50, 48.1%) or hospital settings (academic only: n = 14; 13.5%; community only: n = 2, 1.9%; both: n = 14; 13.5%; hospital type not specified: n = 18, 26.9%; Table 2). Subspecialties with the most publications on surgical practice change were urology (n = 12, 11.5%), obstetrics and gynecology (n = 11, 10.6%), and orthopedics (n = 11, 10.6%).

FIGURE 1.

PRISMA diagram.

TABLE 2.

Descriptive Statistics of Full-text Articles Included

Geographic Region	n	%
USA	47	45.2
Europe	28	26.9
Canada	10	9.6
Asia	9	8.7
Australia	4	3.9
Africa	1	1.0
2 or more regions	5	4.8
Setting of study*
Regional/national	50	48.1
Hospital(s), nonspecific†	18	17.3
Mix of academic and community hospitals	14	13.5
Academic center(s) only	14	13.5
Global	6	5.8
Community hospital(s) only	2	1.9
Included a targeted intervention
No	79	76.0
Yes	25	24.0
Field of surgery
Urology	12	11.5
Obstetrics and Gynecology	11	10.6
Orthopedics	11	10.6
Surgery, nonspecific‡	11	10.6
Cardiac	8	7.7
Breast	5	4.8
General surgery	5	4.8
Pediatric	5	4.8
Bariatric	4	3.9
Colorectal	4	3.9
2 or more fields	7	6.7
Other	21	20.2

^*Settings are mutually exclusive; mixed settings indicate that the study took place in a combination of these settings.

^†Hospital(s), nonspecific indicates that the study did not state hospital type.

^‡Surgery, nonspecific indicates that the study did not state field of surgery.

Facilitators and Barriers to Surgeon Practice Change

Capability, Opportunity, and Motivation were represented across TDF domains and, depending on circumstances, acted as facilitators and barriers. The most frequently cited behavioral determinants (TDF domains), in order, were: Opportunity (environmental context and resources and social influences), Capability (knowledge and skills), and Motivation (beliefs about consequences and reinforcement). Overlap of COM-Bcomponents and TDF domains are shown in Figure 2 and described below in order of prevalence. How specific TDF domains affected practice change is best described by a spectrum; that is, depending on the circumstances, they could act as facilitators, barriers, or as neutral factors (ie, no effect on outcome; Fig. 3).

FIGURE 2.

Frequencies of TDF domains as barriers and facilitators.

FIGURE 3.

Recurring factors affecting surgical practice change derived from the literature are shown on a spectrum. The spectrum illustrates the bidirectionality of TDF domains (denoted in blue) and examples within these domains (denoted in black). Position on the spectrum derives from the frequency that domains/examples were documented in this literature.

Opportunity

Opportunity is an extrinsic determinant of behavior change that linked to the most frequently cited TDF domains affecting surgeon change: environmental context and resources and social influences. Both domains acted as both as facilitators or barriers to change depending on circumstances.

Environmental context and resources represented the greatest facilitator of and barrier to practice change (n = 51; 49% and n = 46; 44.2%; respectively). Within environment and resources, 5 categories affecting change recurred: (1) physical (eg, facility type/capacity/geographic location); (2) infrastructure (eg, available resources); (3) cultural (eg, culture and climate), (4) extrinsic factors (eg, local competition), and (5) patient population (eg, insurance, demographics).

Facilitators:

Practice change was fostered in well-resourced regional referral centers^27–59 that embraced innovation and were amenable to changes in surgical guidelines.^{36,50,51,60–65} In 1 study, robot-assisted radical prostatectomy was more likely to be adopted by high-volume surgeons and was more common at teaching, larger-sized (200 or more beds), or urban hospitals.³⁴ Change was also accelerated in settings with high patient demand and when competing facilities offered the innovation.^{36,43,54,56,65–70} For example, Horwitz et al found that hospitals were 79% more likely to adopt percutaneous coronary intervention if neighboring hospitals offered the service.⁶⁷ In addition, specific patient factors and conditions facilitated practice change.^{35,38,42,47,49,56,58,68,71–76} For instance, areas with patient populations of higher socioeconomic status were associated with earlier uptake of bariatric surgery in the United Kingdom.

Barriers:

Surgical practice change was less likely to occur in poorly resourced centers^{30–33,36–39,42,44,46,47,50,57,58,60,61,67,68,70,72,75–98} with rigid, nonconforming organizational structures or practice patterns.^{29,32,44,50,67,68,76,79,81,84–86} For example, Schootman et al found a more rapid uptake of robot-assisted colectomy in teaching versus nonteaching hospitals between 2010 and 2012 (35.7% vs 9.1%).³¹ Certain patient factors also acted as barriers to practice change, including sex, age, race, and socioeconomic status, and affected their candidacy for a new practice.^{32,38,39,42,47,58,65,72,80,82,88,91} One study found that diffusion of bariatric surgery was slower in older (50–59 year old) obese populations due to the higher risk of complications and in geographic areas with fewer morbidly obese patients.³³

Social influences were another common facilitator (n = 29; 27.9%) and barrier (n = 15; 14.5%) to practice change. This domain captures professional interactions between colleagues, mentors, and thought leaders, educational interactions with instructors, students, and residents, and clinical interactions with patients.

Facilitators:

Positive interpersonal interactions, such as support and encouragement among colleagues,^{50,63,70,96,99} strong senior leadership and mentorship,^{27,29,36,43,44,46,53,55,60,61,70,99–104} and effective communication^{36,46,51,54,62,87,94,99,104} led to faster and more widespread uptake of a new practice. Encouraged collaboration (eg, opportunities for interdisciplinary partnership)^{29,43,44,50,61,62,64,94, 104–106} and constructive pressure to promote growth (eg, competition among colleagues or potential disruption of referral base)⁹⁸ were also observed to influence the likelihood of change. In a qualitative study examining attitudes toward adopting accelerated partial breast radiotherapy, encouragement from peers and positive social pressure from patients influenced breast surgeons’ and radiation oncologists’ adoption of thetechnology.⁷⁰ Similarly, feeling a strong sense of community in local obstetrics and gynecology groups, effective exposure and dissemination, and strong thought-leader support facilitated surgeons’ adoption of salpingectomies in Canada.⁹⁹

Barriers:

Prominent social influence barriers to adoption of a new practice were negative interpersonal interactions, such as adherence to group norms,^{29,44,50,85,105} social pressure to conform,^61,77,101 lack of social support or collaboration,^{50,60,70,101,105} power dynamics between senior and junior surgeons,^70,79,90 and poor communication.^{44,49,60,85,90,97} For example, Brindle, et al found that the successful implementation of a new surgical debriefing program was hindered by loss of leadership support, poor communication, and lack of meaningful and early feedback.⁶⁰ In addition, the implementation of the innovative Da Vinci minimally invasive surgical system was less likely in diverse professional social networks (eg, age, specialty) and under conditions of less collaboration with other providers.¹⁰⁵

Capability

A surgeon’s or organization’s capability to engage in behavior change was also an essential feature across dominant domains. Knowledge was a frequently observed facilitator (n = 28; 26.9%) or barrier (n = 17; 16.3%). Surgeon awareness of the procedure or guidelines was directly related to their capability to carry out the change.

Facilitators:

Surgeons, practice groups, and organizations were more likely to change if they were aware of a procedure, had sufficient knowledge to implement the practice (eg, published literature or evidence-based guidelines),^{44,57,61,70,82,85,87,88,93,107–111} had knowledge of data showing positive outcomes,^46,81,93 and had opportunities for procedural education and awareness.^{29,43,44,51, 81,90,93,94,99,103,104,106,112} For example, Gramlich et al observed a 25% increase in adherence to Enhanced Recovery after Surgery (ERAS) protocol guidelines after implementing a system-wide campaign of educational interventions.²⁹ Giusti et al, found that guidelines on surgical antibiotic prophylaxis in children were well-received and implemented if they had a strong evidence base, were developed by respected clinical leaders, and were disseminated appropriately.⁸⁷

Barriers:

Change was less likely to occur if individual or group of surgeons were unaware of the procedure or did not have enough supporting information to make the change, such as insufficient or unreliable evidence or poor-quality guidelines.^{61,64,75,81,87,90,94,113,114} For example, gaps in knowledge about the timing of umbilical cord clamping, including unclear criteria for patient selection (35%), unfamiliarity (31.6%), and poor understanding of the benefits (29.9%), impeded provider compliance with the evidence-based protocol.⁸² Furthermore, insufficient knowledge about potential patient burden (eg, risks, complications, negative long-term outcomes) deterred surgeons from changing.^{36,41,77,81,92,94,96,101,106,115} For instance, barriers to implementing guidelines for adjuvant radiotherapy after prostatectomy included urologists’ perceived lack of evidence and underrepresentation of patient burden, such as side effects and unnecessary treatment.¹⁰⁶

Skills also appeared as a facilitator (n = 15; 14.4%) but more prominently as a barrier (n = 17; 15.4%) to practice change. Lacking the skills (eg, inexperience, lack of training) to adopt the new procedure negatively affected the surgeon’s likelihood of making the change.^{36,37,59,61,74,75,79,84,89,90,92,95,96,100,101,109,113} For instance, some cardiac surgeons were deterred from adopting transcatheter aortic valve implantation (TAVI) because of the complex and intensive training, and multidisciplinary expertise required.¹⁰² Although frequently cited, possessing the appropriate skillset (eg, proficiency, training) was represented as a promotor of change in a smaller proportion of studies.

Motivation

Individual’s motivation to pursue or reject behavior change categorized the remaining dominant domains. Surgeons’ beliefs about consequences acted as a facilitator of (n = 15; 14.4%) and a barrier to change (n = 23; 22.1%). These beliefs, in many cases, are experiential and affected the surgeons’ motivation to change.

Facilitators:

Surgeons were more likely to adopt new practices if they believed that patient outcomes would be improved,^{47,57,70,77,96,101,111,113} personal and organizational benefits outweigh the risks,^{78,93,116–118} the change would improve safety and efficiency,^63,74,77 and there would be consequences if they did not change practice.⁷² For example, orthopedic surgeons would be more likely to incorporate robotic technology into knee arthroscopy if they believed it had the potential to improve efficiency and decrease iatrogenic cartilage damage in patients.¹¹⁷ In addition, the perception of usefulness was an integral facilitator in the orthopedic surgeons’ decision to continue using computer-assisted surgical approaches.⁶³

Barriers:

Surgeons resisted change if they believed patient outcomes would be negative,^74,86,91,113 the financial, logistical, or staff burden outweighed the benefits,^{36,49,60,70,74,77,84,90,95,96,106,114–116,118} or the practice was not useful.^{47,64,82,114,119} For example, orthopedic surgeons would not change their total knee replacement technique if they believed that risks outweigh the benefits or the learning curve would negatively affect patient outcomes.⁸⁴ Another study found that surgeons would not implement the use of hysterectomy clinical pathways if they believed it was a waste of time or inappropriate for their patient population.⁸²

Reinforcement (ie, surgeon’s likelihood to repeat or carry out a change increased if they experienced a positive result) appeared as one of the most frequent facilitators (n = 35; 33.7%) and was rarely a cited barrier in the studies reviewed. Studies with a targeted intervention were also largely affected by positive reinforcement. Practice change was more likely to be repeated and fully implemented if the procedure was successful and there was positive feedback (eg, no unexpected events, positive patient outcomes, or reimbursement).^{28–30,36,44,46,51,56,60,64,67,69,70,77,80–82,85,87,90,91,97,100,101,103,104,108,111–114,117,120–122} For instance, a telementoring program for sleeve gastrectomy was implemented without intraoperative complications and was well-received by the participating surgeons. After successful completion, surgical mentees were more likely to implement new techniques learned into their practice and be more confident in their technical skill.¹⁰²

DISCUSSION

Identifying the facilitators and barriers that affect a surgeon’s decision to change clinical behavior helps to inform implementation of best practices. In the present scoping review, we used the TDF implementation science framework to characterize what is known about changing surgical practice. Many aspects of the framework are reflected in our analysis of the literature on how surgeons change practice. However, our results emphasize the importance of environmental context and resources in both facilitating and inhibiting surgical practice change. In other words, successful implementation of new surgical practices is driven by a conducive environmental context with adequate resources. Furthermore, evidence suggests that co-occurring facilitators of change (eg, knowledge, social influences, and beliefs about consequences) are most effective within a conducive environment.

Theoretical Domains Framework and Behavior Change

The environmental context and resources domain falls within the COM-B model component of opportunity.^21,23 Environment and resources are foundational to change and often intransigent. In contrast, TDF domains related to individual capability and motivation (knowledge, skills, beliefs about consequences, and reinforcement) are popular targets of behavior change interventions. Specifically, our review found that most barriers to change were deficiencies in opportunity (environmental context and resources, social influences) and capability (knowledge, skills). Similarly, opportunity was the most cited facilitator of change (environmental context and resources, social influences) followed by motivation (beliefs about consequences, reinforcement). Together, the findings suggest environment, circumstances, and resources largely determine the adoption of new surgical practices. In the context of supportive infrastructure, it is individual knowledge, technical skill, and personal beliefs that encourage the initiation and sustainment of practice change.

In contrast, personal responses or reflection (eg, emotion, optimism or pessimism, and beliefs about capabilities) were infrequently observed as facilitators or barriers to change across all studies (range: 2.9%–7.7%). Such reflective responses are integral to a deeper understanding of how surgeons individually process practice change; however, they are difficult to measure. It is likely that these domains play a major role in surgeon behavior change, but they are not measured in hospital-level, population-level, or interventional studies. Qualitative research focused on the implementation of new techniques, devices, or behaviors is needed to better understand how surgeons process and reflect on clinical experiences to initiate and sustain practice change.

Practice Change Interventions: What’s Been Tried and What Works?

Although environmental context and resources were paramount to practice change, these factors were rarely targeted by interventions to promote the adoption of new practices. It is possible that these implementations are not published. However, it is more likely that developing interventions to alter infrastructure is difficult and expensive. Instead, most effective change interventions focused on individual factors related to surgeons’ knowledge, feedback loops with positive reinforcement, and perceived advantage of the new practice.

Despite great enthusiasm for evidence-based guidelines, studies show that their existence alone has limited effect on surgical practice.^123–125 However, the adoption of evidence-based practice is greatly increased when implemented in conjunction with educational, interactive, systematic, and regulatory components. For example, multifaceted implementation of an evidence-based protocol for prevention of orthopedic fractures achieved 90% compliance among US surgeons. This intervention included guideline dissemination that was integrated with surgeon- and patient-level education, mentorship, collaboration, and reinforcing feedback.¹⁰⁴ Furthermore, implementation and dissemination of guidelines and provision of best practice has been directly related to the strength of the evidence based underpinning the guideline recommendations.^9–11 Our study highlights that guideline implementation requires targeted provider-level and patient-level education reinforced by reliable evidence and adapted for the unique practice environment.

Contextual Factors in Adoption of Innovations

Similar to other types of practice change, surgeons’ likelihood of adopting new technologies or innovations is influenced by clinical environment (eg, financial capacity and need to change). The significance of such contextual factors in adopting innovation is recognized in existing frameworks.^126–131 These frameworks, Rogers’diffusion of innovation theory being the most prominent, characterize context by modeling the complex interactions between leadership, infrastructure, culture, the meaningful use of evidence, and individual characteristics in implementing innovation and fostering sustainable change.¹³² The dominant TDF domains discussed herein (eg, environmental context and resources, knowledge, social influences) mirror these concepts, emphasizing the role of influential thought leaders within well-resourced and well-informed institutions as contextual facilitators of change.

Limitations

This was a scoping review which differs from a systematic review or meta-analysis in its purpose. Specifically, a scoping review provides an overview of the available research evidence without producing a summary answer to discrete a priori research questions. The multiple exclusion criteria and the heterogeneity of reporting limit the ability to produce definitive conclusions. Publication bias is inherent to any systematic review of the literature (eg, nonsignificant findings are often not published) and null findings may be under-reported. However, most studies evaluated multiple implementation outcomes simultaneously and therefore, allowed for the identification of null change factors. Furthermore, our study was not designed for quantitative summative assessment of change interventions and consequently, any quantitative findings reported could be subject to selection and/or misclassification bias. It does, however, provide a broad overview of the concepts and general roadmap for what affects behavior/practice change among surgeons. At the same time, its breadth underscores the heterogeneity that prevents direct recommendations about approaches to surgeon behavior change in specific situations and in particular surgical subspecialties.

CONCLUSIONS

To ensure best practice in a rapidly changing healthcare environment, it is critical to promote understanding of facilitators and barriers influencing surgeons’ likelihood of changing behavior. Our review shows that practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeons’ individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Enriching our understanding the factors that impact surgical practice change has major implications. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.