There is a growing consensus in the literature regarding the role of innovation implementation in improving public healthcare provision [2–7]. These implementation processes are particularly challenging within the human services, where technological innovations are delivered by individuals and organisations operating within complex and multi-level systems of influence [4, 8]. The drug and alcohol treatment setting exemplifies this complexity . While there are many factors that may mediate the process of implementing evidence-based practices (EBPs) in drug and alcohol treatment settings, it is important to consider that the decision to adopt and implement a new EBP lies with the individual clinician . Research into the effects of provider-level characteristics on implementation outcomes within substance use disorder settings is limited . One approach has been to examine the extent to which these factors influence treatment delivery fidelity of evidence-based interventions following implementation efforts.
From a theoretical perspective, social cognitive theories have been widely used to explain health-related behaviours of individuals . Although very little research has applied social cognitive theories to the study of health practitioner behaviour , research evaluating EBP implementation in drug and alcohol settings has often been guided by the assumption that clinician factors have an important relationship to implementation fidelity . Clinician factors most frequently measured in such studies include demographics (e.g. gender, age, experience, education, [15–30]), knowledge [22, 28, 30] and attitudes [15, 18, 19, 23, 24, 26]). Organisational change theories such as Rogers’  diffusion of innovations theory have also highlighted the importance of clinician perceptions of the capacity of their organisation to support and implement new innovations, and drug and alcohol clinician perceptions of factors related to their organisational context have been evaluated as a possible mediator of implementation fidelity .
While clinician demographics have frequently been included in studies investigating factors related to implementation fidelity in drug and alcohol contexts, significant relationships are not often found . Some studies have indicated that higher levels of education are associated with higher fidelity , that this distinction is sometimes no longer present following training , and that clinicians with lower levels of education can demonstrate greater increases in implementation fidelity following training . Years of experience  and gender  have also been found to influence implementation fidelity.
Outcomes of studies investigating the relationship between drug and alcohol clinician knowledge and attitudes and implementation fidelity have also been mixed. Findings demonstrating a relationship between clinician knowledge and implementation outcomes have emphasised the importance of increased knowledge and optimism about treatment outcomes , and increased knowledge acquisition and retention skills . Findings related to salient attitudes have found that low endorsement of disease belief models , higher self-efficacy [19, 35] and an increased belief in the efficacy of the intervention  have implications for implementation outcomes. Furthermore, studies have shown that clinicians who are prepared for change and who have positive attitudes to EBP [15, 36–38], and treatment manuals  are more likely to implement such practices. On the other hand, evidence suggests that attitudes such as interest, confidence, and commitment to EBPs do not have a strong relationship with treatment fidelity [18, 39, 40]. Clinician perceptions of the organisational climate comprise a distinct set of beliefs found to influence implementation outcomes in drug and alcohol settings [40, 41].
The Pathways to Comorbidity Care (PCC) project evaluated the implementation of a multi-modal training package designed to improve Clinician Practice (identification and treatment), confidence (self-efficacy), knowledge and attitudes to comorbid substance use and mental disorders . We have previously reported that the training package improved the percentage of clinical files demonstrating identification and management of comorbidity, self-efficacy, and attitudes toward screening and monitoring of comorbidity . Barriers and facilitators of the PCC program have also been reported previously . Specific facilitators of the implementation included characteristics of the intervention (credible source, uncomplicated approach, convincing evidence and quality design), a good consideration of patient needs, factors within the organisation (positive learning environment, leadership engagement), and the use of clinical champions. Mixed results were found with regards to clinician characteristics whereby self-efficacy was a strong facilitator, while specific personal beliefs and attitudes were implementation barriers .
Given inconsistencies in the existing literature regarding the role of clinician demographics and attitudes in facilitating implementation, in this study we aimed to examine the relationship between clinician characteristics on EBP implementation in the PCC program. We hypothesised that high implementation would be associated with characteristics across three domains: (i) demographics (gender, education, experience), (ii) attitudes (attitudes to evidence-based practice, attitudes to therapist manuals, counselling self-efficacy), and (iii) perceptions of organisational readiness to change.