Attitudes Toward Practice Guidelines Among ICU Personnel: A Cross-Sectional Anonymous Survey

doi:10.1016/j.hrtlng.2006.08.005

Heart Lung. Author manuscript; available in PMC 2008 July 1.

Published in final edited form as:

Heart Lung. 2007; 36(4): 287–297.

doi: 10.1016/j.hrtlng.2006.08.005

PMCID: PMC2034210

NIHMSID: NIHMS27728

Attitudes Toward Practice Guidelines Among ICU Personnel: A Cross-Sectional Anonymous Survey

Dave Quiros, MS, Susan Lin, DrPH, and Elaine L Larson, PhD, FAAN

School of Nursing, Columbia University New York, NY

Corresponding Author: Elaine Larson Associate Dean, Columbia University School of Nursing 630 W. 168^th St. New York, NY 10032 212-305-0723 Fax: 212-305-0722 ; Email: ELL23/at/columbia.edu

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Abstract

Objectives

To assess attitudes of ICU staff members toward practice guidelines in general and toward a specific guideline, CDC's Guideline for Hand Hygiene in Healthcare Settings; to correlate these attitudes with staff and hospital characteristics; and to examine the impact of staff attitudes toward the Hand Hygiene Guideline on self reported implementation of the Guideline.

Methods

A cross-sectional survey of staff in 70 ICUs in 39 U.S. hospitals, members of The National Nosocomial Infection Surveillance (NNIS) System. A survey, “Attitudes Regarding Practice Guidelines”, was administered anonymously to all willing staff during a site visit at each hospital; 1,359 ICU personnel: 1,003 nurses (74%), 228 physicians (17%), and 128 others (10%) responded.

Results

Significantly more positive attitudes toward practice guidelines were found among staff in pediatric as compared with adult ICUs (p<0.001). Nurses and other staff when compared with physicians had more positive attitudes toward guidelines in general but not toward the specific Hand Hygiene Guideline. Those with more positive attitudes were significantly more likely to report that they had implemented recommendations of the Guideline (p<0.001) and used an alcohol product for hand hygiene (p=0.002).

Conclusions

The majority of staff members were familiar with the CDC Hand Hygiene Guideline. Staff attitudes toward practice guidelines varied by type of ICU and by profession, and more positive attitudes were associated with significantly better self-reported guideline implementation. Because differences in staff attitudes might hinder or facilitate their acceptance and adoption of evidence-based practice guidelines, these results may have important implications for the education and/or socialization of ICU staff.

Keywords: practice guidelines, attitudes, adherence, hand hygiene

Variations in patient care are common, but only appropriate if they are related to variations in the patient's needs for care. Unfortunately, factors in the clinical environment such as type of intensive care unit (ICU), characteristics of care providers (e.g. experience, staffing levels), and hospital size have been shown to result in differences in the quality of care provided and, subsequently, higher rates of adverse events. [1-6] Over the past two decades, clinical practice guidelines have been promulgated as one way to assure that patient care for specific conditions is standardized and reflective of ‘best practices’.[7] In light of the proliferation of practice guidelines as a mechanism to improve the quality, equity, and efficiency of patient care, the purposes of this study were to assess the attitudes of staff members working in critical care units toward practice guidelines in general and toward a specific guideline, the Centers for Disease Control and Prevention's Guideline for Hand Hygiene in Healthcare Settings[8], to correlate these attitudes with staff and hospital characteristics, and to examine the impact of staff attitudes toward the Hand Hygiene Guideline on self reported implementation of the Guideline.

Methods

Sample and setting

This cross-sectional, anonymous survey was a component of a larger study, “Effect of Hand Hygiene Guideline on Infections and Costs” (1 R01 NR008242, National Institute of Nursing Research). Hospitals were recruited from The National Nosocomial Infection Surveillance (NNIS) System, a voluntary CDC reporting network of acute care hospitals. Electronic messages were sent from CDC to NNIS hospitals explaining the study and inviting them to contact the principal investigator if they were interested in participating. The following were inclusion criteria for study participation: being a NNIS hospital or using NNIS methods and definitions since at least 1999 and having reported data using the Intensive Care Unit (ICU) surveillance component since at least 2000 (to assure that sufficient, standardized data were available), and not using alcohol-based products for hand hygiene prior to June, 2002. All hospitals that contacted us and met the inclusion criteria were included.

Survey instrument

The instrument, “Attitudes Regarding Practice Guidelines”, modeled after tools originally developed by Cabana, et al.[9-11], was used to collect the data. In a systematic literature review, Cabana and colleagues identified six categories of barriers to physician adherence to practice guidelines: lack of familiarity or awareness, lack of agreement with guidelines in general or with specific guideline recommendations, lack of outcome expectancy, lack of self-efficacy, lack of motivation, or external barriers such as patient or environmental factors.[11] Our tool was based on this empirical evidence and designed to measure staff attitudes toward these barriers. Initial psychometric evaluation of the Attitude Instrument has been reported in [12].

The original survey form had two sections: The first section included 18 attitudinal statements about practice guidelines in general and the second section included 18 parallel statements specifically regarding the Hand Hygiene Guideline. Items in the tool were rated using a 6-point Likert scale with selections from ‘strongly disagree’ to ‘strongly agree’. Negative items were reverse scored so that the higher the score, the more positive the attitudes. A total score for the form was obtained by adding the points from each of the individual items (from 0 for the most negative attitude to 5 for the most positive). In addition, questions about the extent to which the respondent implemented the Hand Hygiene Guideline and used alcohol products for hand hygiene (never to almost always) were included. Demographic data collected included gender, race/ethnicity, age, and discipline of respondent; type of ICU; and characteristics of the hospital (geographic location, bed size, and affiliation with an academic health center) in which the staff member worked.

Exploratory factor analyses using principal component analysis and Varimax rotation with Kaiser normalization were performed to examine underlying constructs of the survey instrument. Analyses were performed separately for Section 1 (attitudes toward practice guidelines in general) and Section 2 (attitudes specifically regarding the Hand Hygiene Guideline). For Section 1, six items with lower correlation coefficients with the components (r<.3) were omitted from the tool. The final instrument consisted of three factors (12 items) with a possible range of scores from 0-60, and had a Cronbach's alpha coefficient of .83. These three final factors were labeled relevance, motivation, and outcome expectancy. For the section of the instrument measuring attitudes toward the Hand Hygiene Guideline (Section 2), the final scale consisted of two factors (labeled relevance and motivation) with 10 items explaining 50.3% of the variance, a Cronbach's alpha of .77, and the scores ranging from 0-50, Tables Tables1a,1a, ,b.b. Results from this revised instrument are presented in this paper.

Table 1a

Subscales comprising items measuring attitudes regarding clinical practice guidelines in general (Section 1)

Table 1b

Subscales comprising items measuring attitudes regarding attitudes specifically regarding the Hand Hygiene Guideline (Section 2)

Procedures

The study Project Director (DQ) made a two-day site visit to each participating hospital. The Attitude Surveys were distributed in person to patient care personnel who were working in the study hospital ICUs during the site visit. Staff members were asked to complete the surveys during the site visit and return them directly to the Project Director. Those who expressed willingness to participate, but who said they were too busy at the time, were provided with a stamped return envelope and asked to mail the survey form. This study was approved by the institutional review boards of Columbia University Medical Center and of each participating hospital.

Data analysis

Descriptive statistics were used to examine the characteristics of the study population. Analysis of variance (ANOVA) was used to determine whether there were significant differences in mean attitude scores for practice guidelines in general and for the Hand Hygiene Guideline among staff with different demographic characteristics and from different ICUs and hospitals. Variables examined in these analyses included ICU staff characteristics (professional discipline, age, gender, race) and hospital characteristics (type of ICU, affiliation with an academic health center, geographic region, number of active beds). Those variables were then entered into two separate linear regression models to examine the independent effects of each variable on attitude scores for the general practice guideline and for the Hand Hygiene Guideline scales. To test the hypothesis that staff attitudes toward the Hand Hygiene Guideline were associated with the self reported implementation of the Guideline (yes/no) and use of alcohol based hand hygiene product always or almost always, logistic regression was used. Odds ratios comparing the odds of implementing the Guideline or using an alcohol product were calculated for various potential predictors such as discipline, age, geographic region, etc.

Results

Personnel from 70 ICUs in 39 U.S. hospitals were included. A total of 1,995 surveys were distributed and 1,359 were returned (68.2%). Respondents included 1,003 nurses (74%), 228 physicians (17%), and 128 others (e.g. phlebotomist, radiologist, respiratory therapist, dieticians, 10%). Staff participants were predominantly female and white with a mean age of 37 years. The mean number of active beds of the 39 hospitals visited was 417. Almost three-fourths (70.9%) of the respondents were in the eastern region of the United States, and 60.6% were affiliated with an academic health center, Table 2.

Table 2

Characteristics of ICU staff

Attitudes regarding clinical practice guidelines in general

While most respondents reported that they were familiar with the practice guidelines in their field, 10.2% stated that they were not. The mean score for the scale measuring general attitudes regarding clinical practice guidelines was 44.1 out of a possible 60 (95% confidence intervals: 43.7-45.1). While attitude scores of nurses and other staff members (phlebotomist, radiologist, respiratory therapist, dietician) did not differ significantly from each other, both groups scored significantly higher than physicians (p<0.001). In the univariate analyses, female staff scored higher than male staff members (p<0.001) and older respondents had significantly more positive attitudes than did younger staff (p=0.004). Among the hospital characteristics examined, number of active beds and type of ICU were significantly correlated with attitudes toward guidelines. Attitude scores were significantly lower in larger hospitals (p=0.007), and staff in the pediatric units scored significantly higher than staff in other ICUs (p<0.001). Scores of staff in the medical, surgical, and medical-surgical ICUs did not significantly differ. Neither affiliation with an academic health center nor geographic region was correlated with attitudes. In the regression analyses, each of those variables significant in univariate analyses was also found to be significant when the effects of other variables were controlled, Tables 3a, b.

Table 3a

Attitude scores by staff and hospital characteristics (Univariate analysis)

Attitudes specifically regarding the Hand Hygiene Guideline

The majority of respondents (90.4%) noted that they were familiar with the Hand Hygiene Guideline. The mean score for the scale measuring attitudes regarding the Hand Hygiene Guideline was 38.3 (95% CI: 38.0- 38.6) out of a possible 50. There were two characteristics correlated with attitudes toward the Hand Hygiene Guideline: type of ICU and age. Staff in the pediatric units scored significantly higher than staff in other units (p=.05), and older staff members had higher scores than younger (p<0.001). In the regression analysis, older age and working on a pediatric unit continued to be significantly associated with more positive attitudes, Tables 3a, b.

Relationship between attitudes and reported Guideline implementation

About half of respondents (52%) stated that following the Hand Hygiene Guideline would result in worsened skin condition. These individuals reported using alcohol products significantly less frequently than individuals who did not feel that the risk of skin damage would increase (63.7% versus 72.3%, p=0.002). The majority of respondents (96.9%) stated that following the Hand Hygiene Guideline would reduce the risk of healthcare-associated infections. There was no significant difference in the reported frequency of alcohol use for hand hygiene among those who reported that following the Guideline would reduce risk of infection or not (p=0.85). Almost all (92.7%) staff members reported that they personally implemented the recommendations of the Hand Hygiene Guideline and 67.2 % reported using an alcohol based product for hand hygiene. In the logistic regression models, staff members who scored higher on the attitude survey were more likely to report that they implemented the Guideline recommendations (OR: 1.11; CI: 1.06-1.16; p<0.001) and used alcohol for hand hygiene (OR: 1.05; CI: 1.02-1.08 p=0.002), Table 4.

Table 4

Relationship between attitudes toward Hand Hygiene Guideline and self-reported implementation of the Guideline and use of alcohol for hand hygiene (Logistic regression)

Discussion

Correlates of attitudes toward practice guidelines

This attitude survey included the largest sample of critical care staff of any published to date, which allowed us to identify possible differences in attitudes by certain staff and hospital characteristics. Most of the research related to attitudes and beliefs about practice guidelines has been conducted among physicians in general[11, 13-16] and in various specialties including psychiatry,[17] pediatrics,[10] family medicine,[18, 19] and intensivists.[20, 21] Several studies have also examined attitudes among nurses and other staff.[21-24] Consistent with previous data,[21-23] nurses and other healthcare professionals in this survey reported more positive attitudes toward practice guidelines than did physicians. Nurses have also been found to be more adherent to guidelines than physicians.[21] However, it is not clear whether the differences in attitudes toward guidelines among the two disciplines reflect variations in the content or modality of educating professionals in keeping up-to-date with clinical practice guidelines.

Several differences in attitudes based on staff characteristics deserve mention. First, both gender and profession were significantly related to attitude scores in our study, but after controlling for gender in the multivariate analysis, differences in attitudes toward guidelines between nurses and physicians still existed. Apparently these differences in attitudes between the disciplines cannot be explained by gender differences, pointing to possible variations in the education and/or socialization of these two professional groups. Second, a surprising finding in our survey was that increasing age was associated with significantly more positive attitudes toward guidelines. Others have reported either no association with age[25] or, for physicians, more acceptance of guidelines and practice standards among younger physicians such as house officers.[26-29] Since attitudes toward the Hand Hygiene Guideline were significantly more positive with increased age for both the physicians and nurses in our study, our findings differed from those previously reported. Reasons for this warrant further examination.

Despite the fact that others have reported that staff from non-teaching hospitals have less positive attitudes toward guidelines,[13] the only hospital characteristic significant in our survey was that staff in pediatric units had consistently more positive attitudes than staff in other ICU types. Similarly, in a survey of >1,000 members of the American Academy of Pediatrics, Flores, et al.[30] reported that 89% of pediatricians agreed that practice guidelines are likely to improve patient outcomes and 94% were motivated to use guidelines to improve the quality of care.

The level of diffusion and adoption of the Hand Hygiene Guideline

Most respondents in our study were familiar with the CDC Guideline; this rapid rate of guideline diffusion (<2 years) has not been the case for most guidelines. Further, dissemination was considerably faster for this Guideline when compared with previous CDC guidelines published several decades ago, consistent with the fact that diffusion of innovation may be faster and easier with electronic communication such as the Internet and email and the increasing availability of rapid publication.[31, 32].

The fact that personnel had more positive attitudes toward the Hand Hygiene Guideline than toward practice guidelines in general may be related to several factors. First, reasons for adhering to practice guidelines have been shown to differ for physicians and nurses. Physicians have reported that their non-adherence relates to disagreement with trial results, lack of consensus, or the belief that practice guidelines will not improve patient outcomes. They are more likely to respond positively to guidelines from professional groups in their specialty or sources they consider to be influential and knowledgeable.[10, 11, 16, 21, 22, 33] For nurses, barriers to guideline adherence have been reported to be primarily environmental (e.g. lack of supplies or staff).[21] In the case of the Hand Hygiene Guideline, barriers to non-adherence reported by both physicians and nurses were minimized; i.e. the Guideline was from a highly respected source (CDC) likely to enhance consensus (important to physicians) and the supplies needed to adhere to the Guideline (alcohol products, sinks, gloves) were generally available (facilitators important to nurses).

Secondly, the Hand Hygiene Guideline recommendations have been included as one assessment parameter during accreditation visits by The Joint Commission for Accreditation of Healthcare Organizations. Others have reported that external motivators and administrative mandate are effective strategies for improving/changing practice.[34-37] Organizational factors such as high levels of staff turnover and the extent to which guidelines are integrated into the quality programs and policies of hospitals are associated with improved adherence and sustainability.[37, 38] Elovainio and colleagues[39] examined the effects of certain job characteristics on attitudes toward practice guidelines, and found that the perceived usefulness, availability, and practicality of guidelines were important factors. This is consistent with our finding that relevance and outcome expectancy were important components of our attitude scale. They also reported that those with high job motivation were more ready to use guidelines, even when they had similar attitudes toward guidelines. Finally, it may be that the Hand Hygiene Guideline was more readily accepted simply because it was less controversial than some guidelines.

Relationship between attitudes and reported guideline implementation

In this study there was a strong correlation between self-reported positive attitudes toward guidelines and increased adherence to the Hand Hygiene Guideline. The theory of planned behavior has been postulated to explain the link between attitudes and behavior. This theory hypothesizes that the intention to perform a behavior such as using alcohol for hand hygiene can be predicted by three intermediate factors—attitudes, subjective norms, and perceived behavioral control.[40, 41] This is consistent with evidence that nurses have both a more positive attitude regarding guidelines and are also more adherent. On the other hand, O'Boyle and colleagues[42] tested the extent to which this theory predicted hand hygiene behavior and found, as we did, that attitudes were significantly correlated with self-reported hand hygiene adherence. However, there was no significant relationship between attitudes and observed adherence. They postulated that actual hand hygiene behavior may be more sensitive to work intensity, and this would be particularly relevant in a critical care setting, i.e. work activities may override one's intentions and attitudes.

The Attitude Survey instrument

One of the challenges of measuring attitudes is the availability of valid and reliable tools. Unfortunately, studies have not often reported the psychometric properties of instruments used in sufficient detail to allow study replication.[26, 37, 43, 44] Further, even when a tool is reported to have acceptable reliability and validity, revalidation of the instrument with each use is important. For example, a tool developed by experts to measure attitudes toward clinical practice guidelines[45] was subsequently found to have poor internal construct validity when translated into French and used in another group of practitioners.[46] The survey tool we used was initially derived empirically from research to identify barriers perceived by physicians to use of practice guidelines and underwent preliminary psychometric testing.[12] In this study, we further modified the instrument based on a factor analysis. Since it is now shorter, easy to administer, and had sound psychometric properties when used in a large sample of ICU staff, we recommend this tool to others interested in studying attitudes toward guidelines who could then adapt it for their own use (tool available from authors upon request).

Are guidelines the answer?

Clearly, staff attitudes toward practice guidelines should depend upon the extent to which such guidelines are useful in improving patient care. While there is some evidence that guidelines improve outcomes when they are appropriately implemented,[7] there are a number of problems which mitigate their acceptability, relevance, and applicability. Several of the most important problems include their external validity, currency, and feasibility. In many cases, guideline recommendations are based on expert opinion or on clinical trials from only a few sites. Because guidelines become outdated quickly,[47-49] The National Guideline Clearinghouse requires that guidelines published there must be updated at least every 5 years (http://www.guideline.gov/about/inclusion.aspx). Even when guidelines are based on rigorous scientific evidence, efforts to disseminate them and educate users can be expensive and daunting. Hence, questions have been raised about how best to balance the experience and professional autonomy of the individual clinician with the positive benefits of guideline use (reduced costs and practice variations and use of evidence to guide decisions).[50-53] These issues are likely to explain, at least in part, skepticism among staff about the appropriate role of guidelines. As noted by Hanneman,[50] “blind adherence to clinical guidelines is undesirable because it removes patient context from decision making”.

Clearly, personal motivation plays a major role in guideline adherence, and in our study motivation was also a significant factor in the scale for measuring attitudes toward guidelines. Hysong, et.al.[54] found that there was wide variability in the mental concept and models regarding clinical practice guidelines among employees of 15 different Veterans Health Administration facilities. Since they found that a clear, focused model of guidelines was a characteristic of high performing facilities, it seems important that an institution strive to clarify for employees their model for clinical guidelines.

Study limitations

This study suffers from the same limitations as does any study using self-report data. Although self-report is one of the few ways to assess attitudes, there is concern about desirability bias (i.e. participants provide responses they think the researcher wants or expects). We attempted to minimize this potential bias by assuring respondent anonymity. Despite the fact that survey forms were collected in person, it is unlikely that this would have had a major impact on responses since the data collector was unknown to any of the staff members. The sample of NNIS hospitals cannot be generalized to all U.S. hospitals because they represent a group of hospitals that voluntarily report their infection rates into a national database. While it was not the purpose of this study to assess the correlation between attitudes and actual use of guidelines, we did find significant correlations between more positive attitudes toward guidelines and higher self-reported frequency of implementation of the Hand Hygiene Guideline, possible evidence of internal consistency. Finally, the large sample size in this survey has resulted in statistically significant differences, even when the actual differences in scores were small. Because of the large sample sizes in each category of independent variables and the fact that participants were instructed carefully and then generally completed the survey immediately while the data collector was available to respond to questions, it is unlikely that differences in scores are related to different numbers of respondents in the various categories or to measurement error. Nevertheless, the clinical significance of some of these findings needs to be considered.

Summary and Implications

In this large survey of ICU personnel, significantly more positive attitudes toward practice guidelines were found among staff in pediatric as compared with adult ICUs. Nurses and other staff when compared with physicians had more positive attitudes toward guidelines in general but not toward the specific Hand Hygiene Guideline. Older respondents had more positive attitudes, and respondents scored significantly higher on the specific Hand Hygiene Guideline compared with attitudes toward guidelines in general. While some of our results were confirmatory of what has been previously described, this study contributes to an understanding of practice guidelines in several ways. First, we conducted further testing on a psychometrically sound, simple to administer tool to measure staff attitudes toward guidelines that can be adapted to other settings. Second, because these differences in staff attitudes might hinder or facilitate their acceptance and adoption of evidence-based practice guidelines, these results may have important implications for the education and/or socialization of ICU staff.

Acknowledgments

Funded by The National Institute of Nursing Research, National Institutes of Health, 1 RO1 NR008242, “Impact of Hand Hygiene Guideline on Infections and Costs”.

Footnotes

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References

1. O'Connor GT, Quinton HB, Traven ND, et al. Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project. JAMA. 1999;281:627–33. [PubMed]

2. Giugliano RP, Camargo CA, Jr., Lloyd-Jones DM, et al. Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines. Arch Intern Med. 1998;158:1113–20. [PubMed]

3. Mitchell PH, Shortell SM. Adverse outcomes and variations in organization of care delivery. Med Care. 1997;35:NS19–32. [PubMed]

4. Archibald LK, Manning ML, Bell LM, Banerjee S, Jarvis WR. Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J. 1997;16:1045–8. [PubMed]

5. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 1996;17:150–8. [PubMed]

6. Larson E. Status of practice guidelines in the United States: CDC guidelines as an example. Prev Med. 2003;36:519–24. [PubMed]

7. Bahtsevani C, Uden G, Willman A. Outcomes of evidence-based clinical practice guidelines: a systematic review. Int J Technol Assess Health Care. 2004;20:427–33. [PubMed]

8. Boyce JM, Pittet D., Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force Guideline for Hand Hygiene in Health-Care Settings. Am J Infect Control. 2002;30:S1–46. [PubMed]

9. Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000;154:685–93. [PubMed]

10. Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence to asthma guidelines. Arch Pediatr Adolesc Med. 2001;155:1057–62. [PubMed]

11. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–65. [PubMed]

12. Larson E. A tool to assess barriers to adherence to hand hygiene guideline. Am J Infect Control. 2004;32:48–51. [PubMed]

13. Greving JP, Denig P, de Zeeuw D, Haaijer-Ruskamp FM. Physicians' attitudes towards treatment guidelines: differences between teaching and nonteaching hospitals. Eur J Clin Pharmacol. 2006;62:129–33. [PubMed]

14. Hayward RS, Guyatt GH, Moore KA, McKibbon KA, Carter AO. Canadian physicians' attitudes about and preferences regarding clinical practice guidelines. CMAJ. 1997;156:1715–23. [PMC free article] [PubMed]

15. Hayward RS, Wilson MC, Tunis SR, Guyatt GH, Moore KA, Bass EB. Practice guidelines. What are internists looking for? J Gen Intern Med. 1996;11:176–8. [PubMed]

16. Powell-Cope GM, Luther S, Neugaard B, Vara J, Nelson A. Provider-perceived barriers and facilitators for ischaemic heart disease (IHD) guideline adherence. J Eval Clin Pract. 2004;10:227–39. [PubMed]

17. Healy DJ, Goldman M, Florence T, Milner KK. A survey of psychiatrists' attitudes toward treatment guidelines. Community Ment Health J. 2004;40:177–84. [PubMed]

18. Wolfe RM, Sharp LK, Wang RM. Family physicians' opinions and attitudes to three clinical practice guidelines. J Am Board Fam Pract. 2004;17:150–7. [PubMed]

19. James PA, Cowan TM, Graham RP, Majeroni BA. Family physicians' attitudes about and use of clinical practice guidelines. J Fam Pract. 1997;45:341–7. [PubMed]

20. Rello J, Lorente C, Bodi M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?: a survey based on the opinions of an international panel of intensivists. Chest. 2002;122:656–61. [PubMed]

21. Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2003;31:2693–6. [PubMed]

22. Stein AD, Makarawo TP, Ahmad MF. A survey of doctors' and nurses' knowledge, attitudes and compliance with infection control guidelines in Birmingham teaching hospitals. J Hosp Infect. 2003;54:68–73. [PubMed]

23. Luther SL, Nelson A, Powell-Cope G. Provider attitudes and beliefs about clinical practice guidelines. SCI Nurs. 2004;21:206–12. [PubMed]

24. Neugaard B, Luther S, Powell-Cope G, Escabi J, Nelson A. Measuring provider compliance with ischemic heart disease guidelines. South Med J. 2004;97:942–7. [PubMed]

25. Angtuaco TL, Oprescu FG, Lal SK, et al. Universal precautions guideline: self-reported compliance by gastroenterologists and gastrointestinal endoscopy nurses--a decade's lack of progress. Am J Gastroenterol. 2003;98:2420–3. [PubMed]

26. Haagen EC, Nelen WL, Hermens RP, Braat DD, Grol RP, Kremer JA. Barriers to physician adherence to a subfertility guideline. Hum Reprod. 2005;20:3301–6. [PubMed]

27. Halm EA, Atlas SJ, Borowsky LH, et al. Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. Arch Intern Med. 2000;160:98–104. [PubMed]

28. Halm EA, Atlas SJ, Borowsky LH, Benzer TI, Singer DE. Change in physician knowledge and attitudes after implementation of a pneumonia practice guideline. J Gen Intern Med. 1999;14:688–94. [PMC free article] [PubMed]

29. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260–73. [PubMed]

30. Flores G, Lee M, Bauchner H, Kastner B. Pediatricians' attitudes, beliefs, and practices regarding clinical practice guidelines: a national survey. Pediatrics. 2000;105:496–501. [PubMed]

31. Celentano DD, Morlock LL, Malitz FE. Diffusion and adoption of CDC guidelines for the prevention and control of nosocomial infections in US hospitals. Infect Control. 1987;8:415–23. [PubMed]

32. Neuzil KM, Dupont WD, Wright PF, Edwards KM. Efficacy of inactivated and cold-adapted vaccines against influenza A infection, 1985 to 1990: the pediatric experience. Pediatr Infect Dis J. 2001;20:733–40. [PubMed]

33. Mansfield CD. Attitudes and behaviors towards clinical guidelines: the clinicians' perspective. Qual Health Care. 1995;4:250–5. [PMC free article] [PubMed]

34. Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices. Am J Infect Control. 1998;26:245–53. [PubMed]

35. Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. 2000;26:14–22. [PubMed]

36. Ward MM, Doebbeling BN, Vaughn TE, et al. Effectiveness of a nationally implemented smoking cessation guideline on provider and patient practices. Prev Med. 2003;36:265–71. [PubMed]

37. Vaughn TE, Ward MM, Doebbeling BN, Uden-Holman T, Clarke WT, Woolson RF. Organizational and provider characteristics fostering smoking cessation practice guideline adherence: an empirical look. J Ambul Care Manage. 2002;25:17–31. [PubMed]

38. Brand C, Landgren F, Hutchinson A, Jones C, Macgregor L, Campbell D. Clinical practice guidelines: barriers to durability after effective early implementation. Intern Med J. 2005;35:162–9. [PubMed]

39. Elovainio M, Makela M, Sinervo T, Kivimaki M, Eccles M, Kahan J. Effects of job characteristics, team climate, and attitudes towards clinical guidelines. Scand J Public Health. 2000;28:117–22. [PubMed]

40. Ajzen I. Attitudes, personality and behavior. Dorsey; Chicago, IL: 1988.

41. Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Prentice Hall; Englewood Cliffs, NJ: 1980.

42. O'Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001;29:352–60. [PubMed]

43. Maue SK, Segal R, Kimberlin CL, Lipowski EE. Predicting physician guideline compliance: an assessment of motivators and perceived barriers. Am J Manag Care. 2004;10:383–91. [PubMed]

44. Ward MM, Vaughn TE, Uden-Holman T, Doebbeling BN, Clarke WR, Woolson RF. Physician knowledge, attitudes and practices regarding a widely implemented guideline. J Eval Clin Pract. 2002;8:155–62. [PubMed]

45. Elovainio M, Eccles M, Makela M. Changing professional practice. Theory and practice of clinical guidelines implementation. Danish Institute for Health Services Research and Development; Copenhagen: 1999. Attitudes towards guidelines and a scale for measuring them; pp. 153–167.

46. Touze E, Glenisson FS, Durieux P, et al. Lack of validity of a French adaptation of a scale measuring attitudes towards clinical practice guidelines. Int J Qual Health Care. 2006

47. Shekelle P, Eccles MP, Grimshaw JM, Woolf SH. When should clinical guidelines be updated? BMJ. 2001;323:155–7. [PMC free article] [PubMed]

48. Shekelle PG, Ortiz E, Rhodes S, et al. Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA. 2001;286:1461–7. [PubMed]

49. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318:593–6. [PMC free article] [PubMed]

50. Hanneman SK. Is adherence to clinical guidelines a good thing? Crit Care Med. 2003;31:2711–2. [PubMed]

51. Graf J. Guidelines for critical care services and personnel-Innovations and improvements in patient care? Crit Care Med. 2003;31:2709–10. [PubMed]

52. DeMonaco HJ. Guidelines, pathways, and the end result. Crit Care Med. 2000;28:889–90. [PubMed]

53. Cowie RL, Underwood MF, Mack S. The impact of asthma management guideline dissemination on the control of asthma in the community. Can Respir J. 2001;8(Suppl A):41A–5A.

54. Hysong SJ, Best RG, Pugh JA, Moore FI. Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration. Health Serv Res. 2005;40:829–47. [PMC free article] [PubMed]