This study is the first to report an examination of the Singaporean context in which guideline implementation may be influenced by an understanding of the local barriers to change in acute care hospitals so as to assist in the process of selecting and more appropriately targeting implementation strategies locally. Advocates for an evidence-based approach to guideline implementation have advised that prior to choosing one or more interventions, decision-makers need an understanding of the target group and setting and potential facilitators of, and barriers to change [38
]. The results of our study will inform the development of implementation strategies targeting the barriers to change, to facilitate the role of MOH in ensuring the effective implementation of CPGs and adoption of evidence-based practice.
The barriers most frequently mentioned by nurses in this study were related to care providers and the context in which practice occurred. Specifically, care provider characteristics, such as knowledge and motivation, were nominated as important barriers to implementation of guidelines by 82.4% of nurses, which is similar to the findings of other international studies [51
]. The expanding body of research and the increasing emphasis on evidence-based practice make it difficult for any practitioner to be aware of, familiar with, and able to critically apply, every applicable guideline to practice [53
]. This is especially so in the Singapore context where 19% of nurses hold a Bachelors or Masters university qualifications (Singapore Nursing Board, 2005). This concern is also highlighted in this study in which the majority of nurses (65%) are either certificate-trained in the technical institute or possess only a diploma in nursing from the polytechnic. These nurses were neither exposed to research nor evidence-based practice within their curriculum. Moreover, our results indicate that 66% of respondents had no research experience and even fewer (24%) had a degree qualification. These results are not surprising in the Singapore context, where nurses are starting to work towards attainment of degree qualifications.
A systematic review of the literature to identify barriers to guideline adherence yielded similar results to those found in the present study, identifying care provider characteristics, particularly knowledge, as a highly reported barrier in 38% of surveys [52
]. Our findings are also similar to those of Peters et al. [51
], in three different implementation studies in the Netherlands involving 190 general practitioners (GPs); 40 GPs; and 160 midwives respectively. Eighty percent reported knowledge and motivation as a perceived barrier to change.
Appropriate knowledge and attitudes are necessary, but not sufficient, for guideline adherence [55
]. Practitioners may still encounter barriers to adoption of guideline recommendations due to the guideline itself, patient, or social/environmental factors [52
]. Furthermore, adherence to guidelines may require changes that are beyond the control of the practitioner, such as acquisition of resources or facilities [56
]. This is clearly a challenging area that hospitals need to explore given their tight budgets and restrictions to additional resources. Context factors, such as lack of equipment or facilities; insufficient staff; and lack of opinion leaders, described by respondents as barriers in the study by Cabana et al [52
], were congruent with those context characteristics identified in our study. This study found a high percentage of respondents (73.3%) perceived a lack of facilities and equipment such as bed alarms to be a barrier to the implementation of guidelines.
Currently, in the Singapore context, the MOH guidelines are simply disseminated to nurses through distribution the hospital wards in conjunction with a single 'road-show' to inform them of the publication. Seventy-seven per cent of respondents reported 'availability of supporting staff' as a barrier to implementation of guidelines. These findings were consistent with international studies where perceptions of general practitioners similarly identified lack of supporting staff as a barrier to change [51
] This finding clearly highlighted the critical need for appropriate facilitation which has been echoed by PARIHS [36
]. The nurses also perceived that a change champion or a facilitator leading and supporting the change to implement the guidelines in their respective hospitals would result in change in their practice.
Leadership is vital in effective guideline implementation [28
]. It is encouraging that few nurses in the present study (4.4%) perceived leadership as a barrier to implementation. It could be argued that this illustrates that the nurses believe that their current leadership provides strong support and direction when guidelines are implemented.
The inability to reconcile patient characteristics (health status and ethnicity) with guideline recommendations was also identified as a barrier to change and these results are similar to those of other studies. This particularly could be explained by the multi-racial context in Singapore where nurses find such cultural differences difficult when implementing certain recommendations in the guideline, such as lack of interpreters to inform patients about risk of falling.
It is encouraging to note that most respondents in our study did not rate any 'innovation' characteristics as barriers to the implementation of guidelines which suggests that the nurses believe in the innovation and evidence, and find the recommendations of the guideline to be compatible with their daily practice. These results were similar to the reported perceptions of midwives in the study by Peters et al[51
] It is possible the reason nurses believed the characteristics of the innovation did not present barriers to implementation is that the Fall Prevention CPG was locally adapted by the MOH workgroup, making it relevant to, and compatible with, the Singapore context [51
Change management theories are instructive when implementing strategies to facilitate change in practice. There is no single change theory that dominates behavioral change and many concepts in different theories overlap [38
]. However, change theories are helpful in explaining behavior and nurses' propensity to change practice following the implementation of the CPG at acute care hospitals in Singapore.
The environmental context within which the nurses practice is a key determinant of guideline adoption to facilitate a change in practice. Behavioral theory based on conditioning and controlling behavior, emphasizes the importance of the environmental context of behavior, suggesting that environmental cues and reinforcements are central in encouraging and maintaining behaviour [59
]. The main strategies used in the present study, consistent with the stimuli that Skinner described were: reviewing performance and providing feedback to care providers, giving reminders, providing incentives and instituting sanctions such as policies related to specific actions. Environmental and organizational supports, which enabled and reinforced the use of the CPG, operated at two levels in the acute care settings in Singapore. At the clinical level, strategies such as reminders, which integrated the CPG into the process of care, were found to provide important environmental support for change. Organizational supports for guideline implementation such as policy revision to comply with the Fall Prevention CPG and accreditation standards, were important stimuli for change in practice. It has been suggested that the provision of such environmental and organizational support can help to build positive attitudes among care providers, which strengthens the drive for change [60
Social influence theory emphasizes the role of others in decision making about behavior, postulating that factors such as customs, habits, beliefs of peers and prevailing practices and social norms shape the change of practice [61
]. Social influence theory can help to expand our understanding of the social processes which influence success of guideline implementation. Strategies to promote behavior change through social influence, including the use of change champions [62
] and educational sessions [63
] have been shown to be effective and were used in the present study. The opinions of peers and change champions play a major part in influencing the attitudes of care providers and, most importantly, their decisions to change practice [64
]. The value of this approach lies in its emphasis on professional communication, whereby care providers constantly look to each other for support, approval, role models, information, and feedback. Collectively, these theories were useful in guiding development of the multifaceted intervention to target barriers to change, promote clinical behavior change, and ultimately improve patient care and outcomes.
Guided by theories of practice change [25
], the implementation strategy (Table ) targeted perceived barriers to implementation of guidelines identified in the present study. Interventions included conduct of educational sessions; facilitation and support by change champions including a fall nurse specialist; allocation of resources and equipment; revision of the hospital fall prevention policy; reminders and identification systems; and audit and feedback.
Interventions in implementation strategy
Reporting bias associated with the self-report method raises questions about the extent to which the responses accurately represent nurses' actual experiences of barriers to change. That is, nurses may have reported 'socially acceptable' responses when completing the questionnaire. The written survey could have excluded other responses or items that were perceived by nurses as barriers to change. Additionally, there was limited psychometric testing of the revised tool, given that six questions were removed and six questions were reworded to address the practice guideline. The re-worded questions were pilot tested for understandability and relevance in the Singapore context, but have not undergone extensive psychometric testing.