What Keeps Clinicians from Changing Practice? Lessons from the SUGAR Project
Written by Enyo Ablordeppey MD MPH, Blake Forte MD, Nick Leonard MD, Tiffany Rosenzweig PhD
Every emergency physician has seen it: a practice-changing study is published, guidelines follow, and yet months or even years later, little has changed at the bedside. Why? Evidence alone rarely changes practice. Clinicians often know what to do, but behavioral and organizational factors determine whether new evidence becomes routine care. That evidence-to-practice gap inspired the SUGAR (Subclavian Vein Cannulation under Ultrasound Guidance with Advanced Retention) project, supported by a Missouri College of Emergency Physicians (MOCEP) research grant. Although SUGAR focused on ultrasound-guided subclavian vein cannulation (UGSCV), its broader goal was based in implementation science: to understand how clinicians adopt new practices and why even the strongest evidence sometimes fails to change behavior.
UGSCV represents one of emergency medicine’s clearest evidence-to-practice gaps. Compared with internal jugular and femoral access, it is associated with fewer catheter-related infections, less thrombosis, greater patient comfort, and when performed with ultrasound a lower risk of pneumothorax. Yet despite these advantages, UGSCV accounts for fewer than 10% of central venous catheter placements nationally. The obvious explanation is insufficient training, but what if training is not the primary barrier? Rather than asking, “Can clinicians learn this procedure?” the SUGAR project asked, “What prevents clinicians from using an evidence-based procedure after they have learned it?”
Diagnosing the Problem Before Prescribing the Solution
While educational research often asks whether training improves performance, implementation science asks, “What prevents clinicians from using what they’ve learned in practice?” Rather than assuming education alone changes behavior, it identifies barriers before selecting interventions. We used the Capability, Opportunity, Motivation–Behavior (COM-B) framework, which recognizes that sustained behavior change requires three conditions:
- Capability: clinicians have the knowledge, skills, and confidence to perform the behavior.
- Opportunity: the environment supports the behavior through supervision, workflow, and organizational resources.
- Motivation: clinicians believe the behavior is worthwhile and choose it over familiar alternatives.
Behavior change is unlikely if only one domain is addressed. Lasting adoption requires identifying and intervening across all three domains so that solutions target the factors truly limiting implementation.
Looking at the Problem from Multiple Angles
Because behavior change is complex, we used a sequential mixed-methods design. We first reviewed more than a decade of central venous catheter placements within our emergency department to determine whether subclavian utilization had changed over time. Next, we surveyed faculty and residents regarding procedural experience, preferred catheter site, training history, and perceived barriers. Survey findings then informed semi-structured interviews and focus groups, which were designed using the Consolidated Framework for Implementation Research (CFIR) to allow us to explore how individual experience, departmental culture, supervision, and workflow influenced procedural decisions. Finally, we used Best-Worst Scaling, a preference-based research method commonly used in health services research, to identify which of the identified factors clinicians considered most influential when deciding whether to perform UGSCV. Quantitative findings identified patterns; qualitative interviews explained why those patterns existed; and preference testing helped identify which barriers and facilitators were most important.
What We Learned
The chart review revealed a striking finding. Despite advances in ultrasound education and growing evidence supporting UGSCV, subclavian utilization remained largely unchanged over more than a decade. The surveys helped explain why. More than half of respondents had never received formal UGSCV training, and only 6% identified the subclavian vein as their preferred site for central venous access. The interviews uncovered the study’s most important insight. The greatest barrier was not simply technical skill; it was shared confidence between the proceduralist and the supervisor. Residents avoided UGSCV because they perceived faculty were uncomfortable supervising it, while faculty deferred because they believed residents lacked sufficient experience. Each group was waiting for the other to become comfortable first. This created a self-reinforcing cycle: fewer procedures meant fewer opportunities to build confidence for both learners and supervisors, leading to even fewer attempts. Underuse was influenced by training, but it was a behavioral and organizational challenge reinforced by departmental culture and supervisory dynamics.
What Actually Changes Behavior?
The final phase of SUGAR asked a practical question: What would make clinicians choose the subclavian vein? Using a Best-Worst Scaling experiment, we found that three factors drove adoption: confidence performing the procedure, previous successful experience, and understanding that ultrasound guidance reduces pneumothorax risk. These findings highlight a fundamental challenge of implementing low-frequency procedures. Clinicians need repeated successful experiences to build confidence, but they need enough confidence to attempt the procedure in the first place. Breaking this cycle requires supporting clinicians through the period of discomfort that accompanies adopting a new practice. These are factors that educational programs can intentionally address.
One of the most important lessons from SUGAR is that a single workshop is unlikely to produce lasting practice change for a low-occurrence procedure. Sustained adoption requires a longitudinal approach. Initial mastery learning builds the confidence and may provide psychological capability to make the first attempt. Deliberate, supervised clinical practice provides the repetition needed to strengthen confidence and establish new habits. Longitudinal refresher training mitigates skill decay, while faculty development, audit and feedback, and peer modeling reinforce the supervisory and organizational support needed to sustain behavior. Together, these strategies address capability, opportunity, and motivation, the conditions required for lasting practice change. Building on these findings, our team is now piloting a longitudinal simulation-based mastery learning curriculum designed to support both the initial adoption and sustained use of ultrasound-guided subclavian vein cannulation.
Beyond the Subclavian Vein
SUGAR began as a study of ultrasound-guided subclavian vein cannulation but became a study of how clinical practice changes. Whether implementing a new procedure, technology, or clinical pathway, sustained practice change requires a comprehensive understanding of the behavioral, educational, supervisory, and organizational factors that influence clinician behavior. By diagnosing these barriers before selecting interventions, implementation science helps align solutions with the problems they are intended to solve.