Three main categories were formed to describe barriers or facilitators for successful implementation of psychiatric clinical guidelines. Our analysis showed individual, organizational, and attitudinal factors related to perception of guidelines and strategies. These categories were: (1) organizational resources, (2) health care professionals' individual characteristics and (3) their perception of guidelines and implementation strategies. Table uses these categories in presenting a summary of the barriers and facilitators influencing implementation of clinical guidelines as reported in the interviews.
summarizes reported barriers and facilitators influencing implementation of clinical guidelines.
Resources were raised as an essential issue that enables the progress of implementation work. There was general consensus among practitioners at the control clinic concerning lack of trust in the guidelines' recommendations and an environment not supportive to clinical guidelines was described. It was suspected that financial motives often lay behind clinical guidelines, and there were concerns that cost control and standardization of care might threaten the doctor or therapeutic-patient relationship. Loss of autonomy, and beliefs about standardized care were also described by the non-implementers. One clinician explained: "I'm afraid that the clinical guidelines lead to a standardized care, we cannot meet the patients' needs...my long clinical experience is no longer valuable..." (C).
The health practitioners at the control clinic reflected on this perceived concern about losing control. One of the participants said:
"...standardizing the content of the meeting with the patient and care, I see as very difficult" (C).
At the control clinic lack of time was highlighted as a barrier. However, this was not addressed by the interviewees at the implementation site. Time factors were characterized by the experience that there was inadequate time for training based on the guidelines, implementation into clinical practice, or updating the evidence from research literature.
"We do not have time to read and take note of all the scientific treatment guidelines and relevant literature for our profession or field" (C).
One factor reported to be successful was an active leadership with senior administration supporting clinical guidelines. This served to increase awareness and willingness to change clinical practice Support from the local leader and at department level was deemed important. Academic detailing was also identified as a promoter. The expert-facilitated dialogue encouraged others to measure change, and promoted guideline acceptance within the implementation team.
"...our implementation leader influenced the process by calling meetings, facilitating discussions, creating a positive atmosphere and encouraging the team to increase our knowledge" (I).
During the implementation and adaptation phase, good leadership and consistent communication was described as being fundamental to the successful implementation of guidelines. Participants described leadership support and an organizational vision emphasizing guideline implementation as facilitators. Concerns about lack of investment from the organization and lack of organizational strategies were identified as barriers. Participants at the control clinic felt that they did not have support from senior administration in implementing the guidelines or working according to their requirements. Practitioners felt they lacked authority to effect changes and were not certain how to implement the clinical guidelines in their practice in an effective and organized way. Thus practitioners from the control clinic were more pessimistic and felt constrained by resources and the organization.
The issues of creating a supporting environment and providing support for changing clinical patterns were addressed. Most of the participants described the difficult task of deviating from established practice patterns. Practitioners reported that a major barrier to using guidelines in practice was that they did not always have access to recommended diagnostic assessment tools and standardized rating scales. One practitioner said: "I mean, how can you change your clinical practice when we don't have access to, or adequate skills to use, recommended tools?" (C).
To observe changes in clinician behaviour requires knowledge of the baseline care. Regular audits of patient care delivered by the clinicians were reported to be of help in identifying ongoing important gaps between current care and guideline recommendations. One of the practitioners said: "At first, I thought it was very difficult... Then we started to get the hang of things, and really saw that we all were improving..." (I).
At the implementation clinic, audit data were used to inform the implementation teams about practice change. Quality indicators were collected as part of implementation intervention and used for learning and adjusting practice and services. After implementation, the participants in the focus groups expressed the importance of information gathering or auditing in order to access the gap between knowledge and clinical practice.
"Indicators helped us to support the change and identified what needed to be improved... It was so obvious that we were not using some of the effective methods to any great extent; they also showed us that we were not putting some of the recommended methods into practice" (I).
"Indicators from the guidelines gave us a clear picture of the gap between guidelines and practice. Gave me a clear overview of my own and colleagues' work... without audit and feedback we were not sure what we needed to change, and would not know if we're improving" (I).
A strong theme emerging from focus groups and interviews from the implementation site was the positive benefits of having a multidisciplinary implementation team. Participation in the team resulted in a sense of local ownership of the implementation and practice changes. It also gave team members an opportunity to consider the evidence involved.
"Most probably its strength was that it was a multi-disciplinary team...We could see the results when other professions got involved in the care... It certainly changed my view of others' knowledge and capacity..." (I).
The emphasis on working across disciplines, identifying areas for a collaborative and team-oriented approach was seen as essential for successful local implementation. One example was that assessment using the standardized rating scale could be performed by other professionals than physicians.
Practitioners reported that the focus group sessions acted as a strong facilitating factor, and that they promoted knowledge and the implementation of guidelines.
Providers gave many example of ways in which guidelines helped them in their clinical practice; in clinical decision making, in setting treatment goals and in evaluating outcomes. Apart from direct patient encounters, the guidelines and the quality indicators stimulated quality improvement initiatives. In the implementation group, providers believed that using the guidelines would result in an improved quality of care.
Health care professionals' individual characteristics
Participants who believed that implementation of clinical guidelines would result in improved outcomes for patients and a more effective care had a positive attitude towards implementation and the guidelines.
"When we examined the psychiatric care that we gave the patients and considered outcome from the patient's point of view, this gave us an insight regarding our ability to describe the treatment, assess it and not least the opportunity to see if the patient recovered after our intervention" (I).
Lack of knowledge, skills and motivation were described as major barriers to implementation and the use of research findings in clinical practice. A failure to internalize guidelines into clinical routines was also identified as a barrier to guideline implementation. Participant perspectives on the barriers to using clinical guidelines in clinical work were identified. The need to bridge the gap between knowledge and skills was a perspective described by participants.
"I know it's quite silly. I mean I know it's only a matter of starting to do it, but still we don't change our behaviour. ... I'm not sure that we have the skills... it's so hard to reflect upon our own and colleagues' behaviour" (I).
"...The clinical guidelines really help us to understand that there is a gap between what we do and the evidence... It's clear what we are supposed to do... It's also fascinating to suddenly understand that there is a large gap between what we think we are doing and what we really do..." (I).
Guidelines were seen as necessary, but sometimes not an adequate aid to decision-making.
"...We need to work more systematically and structured in our clinical work... It is a tradition in psychiatry to choose treatment and methods based on one's own clinical experience... There is a lack of support for people with psychiatric co-morbidity..." (I).
Barriers related specifically to psychiatry as a medical discipline were described and differences between psychiatric and other medical specialties were highlighted. Most participants thought that there was a definite difference in attitudes to, and knowledge about, the guidelines and how to practice evidence-based medicine in the psychiatric discipline compared to somatic specialties.
"We have no tradition in psychiatry of following clinical guidelines. It is a new approach and requires great adaptation.... "(I).
The guidelines led to discussions between representatives of different schools of thought and theories in psychiatry. Traditional treatment approaches were questioned in the light of presented evidence and this was addressed as a barrier.
"...difficult for me as a psychotherapist to possess knowledge and skills that do not comply with modern requirements. There are great demands to change my clinical work..." (C).
Several practitioners addressed the complexity of using evidence-based medicine in practice.
"During my residency training at an internal medical department, no one contested the guidelines. It was a part of one's work to be guided by clinical guidelines, based on evidence. Quite differently, today, I feel resistance and that I am questioning a colleague if I bring up the issue of whether our treatments are based on evidence and guidelines" (C).
All practitioners had been exposed to research-based teaching. In the focus group there was a consensus that being taught about research enabled them to learn how to question, look for evidence and evaluate its relevance for practice. Learning new skills was initially experienced as increased workload and stress, but it led to a new conceptualization of the discipline and generated new practice-based knowledge.
"...you seek the evidence and evaluate the evidence for practice, ... you don't rely on what others do..." (I).
The relationship between higher levels of qualification and research utilisation were addressed in the interviews. Further training led the providers to become more knowledgeable, confident and aware of the importance of research.
"Further training has made me critically appraise the evidence for treatment and its validity and try to improve the quality and outcome of care. It makes you aware of the need to evaluate your methods and aware of the importance of research" (I).
Several providers felt that the guidelines were not presented in a user-friendly format, were too long, disorganized and difficult to access on-line.
Perception of guidelines and implementation strategies
At the control clinic the participants said that they were unfamiliar with the published guidelines. The lack of familiarity was often attributed to the overwhelming amount of medical research, and difficulties in keeping up to date with recent recommendations.
A belief that the guidelines originated from unreliable sources as well as doubts about their authors' credibility were noted as barriers. 'Missing' recommendations or a lack of addressing issues believed to be important for clinical practice and for patients, influenced the providers' willingness to accept guidelines.
Participants expressed concern about the applicability of guidelines in their own clinical practice. Providers noted difficulties in applying guidelines to specific patients, in particular, patients with psychiatric comorbidities and the elderly. The difficulty of applying guideline recommendations, e.g. a standardized rating scale, to specific populations, in particular, non-Swedish and non-English speaking persons, was also noticed.
Providers typically overestimated the quality of current psychiatric care. Audit and feedback gave providers at the intervention clinics a meaningful insight into their own practice.