Reducing low-value practices: a functional-contextual consideration to aid in de-implementation efforts

Farmer, R.L., Zaheer, I., Duhon, G.J., & Ghazal, S. (2020). Reducing low-value practices: a functional-contextual consideration to aid in de-implementation efforts. Canadian Journal of School Psychology. https://doi.org/10.1177/0829573520974915

Low-value practices are practices that are either unproven or discredited by evidence. Low-value practices sometimes persist in practice, and may interfere with implementation efforts for competing strategies. The de-implementation of low-values practices may be a necessary step in an implementation science approach to the adoption of evidence-based practices. Steps in de-implementation include identifying a low-value practice to be reduced, evaluating variables that may affect the de-implementation process, determining and using strategies that should reduce or eliminate the practice, and evaluation of the effects of de-implementation. Strategies for de-implementation could include policy change at the system level or ‘unlearning’ at the individual.

The authors of this paper consider how applied behaviour analysis could inform de-implementation due to the focus on functional relationships between context and future behaviour (i.e., functional-contextual lens). Briefly, the authors explain that the likelihood of a behaviour can be altered by changing the reinforcement, salience of contextual cues, or effort to engage in the behaviour. Through this lens, the authors suggest that low-value practices viewed as behaviours have little consequences and are rather rule governed behaviours. Behaviour reduction strategies are described including extinction through removal of reinforcement, differential reinforcement where extinction is paired with targeting of alternate behaviour, increasing response effort by requiring approvals or extra paperwork to use a behaviour, and punishment involving the addition or removal of stimulus when engaged in behaviour. The authors argue that these behavioural reduction strategies have the potential to assist in de-implementation of low-value practices but stress the importance of pairing this goal with efforts to implement evidence-based practices. 

The focus on the persistent use of low-value practices as a barrier to implementation of evidence-based practice is interesting. When implementing a new evidence-based practice, clinicians would do well to consider how it fits in with existing practice and any need for change.

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