To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).
Four randomly selected community nursing homes.
NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).
Interviews (n = 35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers’ Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.
None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were ‘‘checklists’’ to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.
Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.
clinical practice guidelines; nursing facilities; qualitative research
Careful hand hygiene (HH) is the single most important factor in preventing the transmission of infections to patients, but compliance is difficult to achieve and maintain. A lack of understanding of the processes involved in changing staff behaviour may contribute to the failure to achieve success. The purpose of this study was to identify nurses’ and administrators’ perceived barriers and facilitators to current HH practices and the implementation of a new electronic monitoring technology for HH.
Ten key informant interviews (three administrators and seven nurses) were conducted to explore barriers and facilitators related to HH and the impact of the new technology on outcomes. The semi structured interviews were based on the Theoretical Domains Framework by Michie et al. and conducted prior to intervention implementation. Data were explored using an inductive qualitative analysis approach. Data between administrators and nurses were compared.
In 9 of the 12 domains, nurses and administrators differed in their responses. Administrators believed that nurses have insufficient knowledge and skills to perform HH, whereas the nurses were confident they had the required knowledge and skills. Nurses focused on immediate consequences, whereas administrators highlighted long-term outcomes of the system. Nurses concentrated foremost on their personal safety and their families’ safety as a source of motivation to perform HH, whereas administrators identified professional commitment, incentives, and goal setting. Administrators stated that the staff do not have the decision processes in place to judge whether HH is necessary or not. They also highlighted the positive aspects of teams as a social influence, whereas nurses were not interested in group conformity or being compared to others. Nurses described the importance of individual feedback and self-monitoring in order to increase their performance, whereas administrators reported different views.
This study highlights the benefits of using a structured approach based on psychological theory to inform an implementation plan for a behavior change intervention. This work is an essential step towards systematically identifying factors affecting nurses’ behaviour associated with HH.
Hand hygiene; Knowledge translation; Compliance; Behaviour change; Electronic monitoring
Translating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care.
This qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data.
The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction.
Identifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify efficient strategies to overcome barriers on an organizational and individual level. Getting evidence into practice and implementing clinical guidelines are dependent upon more than practitioners' motivation. There are factors in the local context, e.g. culture and leadership, evaluation, feedback on performance and facilitation, -that are likely to be equally influential.
Despite the drive towards evidence-based practice, the extent to which research evidence is being implemented
in nursing practice is unclear, particularly in developing countries. This study was to assess the levels of perceived
barriers to and facilitators of research utilization in practice among Chinese nurses and inter-relationships between these
barriers and facilitators and their socio-demographic characteristics. A cross-sectional, descriptive survey was conducted
in 2011 with 743 registered nurses randomly selected from four general hospitals in China. They completed the Barriers to
Research Utilization and Facilitators of Research Utilization scales. Correlation tests were used to test the relationships
between the nurses’ perceived barriers and facilitators, their demographic characteristics and research training and
involvement. The Chinese nurses’ level of perceived barriers was moderate on average and lower than that in previous
research. Among the 10 top-ranked items, six were from the subscale ‘Organizational Characteristics’. Their perceived
barriers were correlated positively with age and post-registration experience and negatively with research training
undertaken. Junior diplomatic nurses reported a significantly higher degree of barriers than those senior ones with postgraduate
education. Higher and more diverse barriers to research utilization in practice are perceived by Chinese nurses
than those in Western countries and they are associated with a few socio-demographic factors. Future research on these
barriers/facilitators and their relationships with occupational and socio-cultural factors in Chinese and other Asian nurses
Cross-sectional survey; perceived barriers; perceived facilitators; research utilization; registered nurses; Chinese.
Objective: This multisite study compared the perceptions of three stakeholder groups regarding information technologies as barriers to and facilitators of clinical practice guidelines (CPGs).
Design: The study settings were 18 U.S. Veterans Affairs Medical Centers. A purposive sample of 322 individuals participated in 50 focus groups segmented by profession and included administrators, physicians, and nurses. Focus group participants were selected based on their knowledge of practice guidelines and involvement in facility-wide guideline implementation.
Measurements: Descriptive content analysis of 1,500 pages of focus group transcripts.
Results: Eighteen themes clustered into four domains. Stakeholders were similar in discussing themes in the computer function domain most frequently but divergent in other domains, with workplace factors more often discussed by administrators, system design issues discussed most by nurses, and personal concerns discussed by physicians and nurses. Physicians and nurses most often discussed barriers, whereas administrators focused most often on facilitation. Facilitators included guideline maintenance and charting formats. Barriers included resources, attitudes, time and workload, computer glitches, computer complaints, data retrieval, and order entry. Themes with dual designations included documentation, patient records, decision support, performance evaluation, CPG implementation, computer literacy, essential data, and computer accessibility.
Conclusion: Stakeholders share many concerns regarding the relationships between information technologies and clinical guideline use. However, administrators, physicians, and nurses hold different opinions about specific facilitators and barriers. Health professionals' disparate perceptions could undermine guideline initiatives. Implementation plans should specifically incorporate actions to address these barriers and enhance the facilitative aspects of information technologies in clinical practice guideline use.
Although considerable efforts are directed at developing international guidelines to improve clinical management in low-income settings they appear to influence practice rarely. This study aimed to explore barriers to guideline implementation in the early phase of an intervention study in four district hospitals in Kenya.
We developed a simple interview guide based on a simple characterisation of the intervention informed by review of major theories on barriers to uptake of guidelines. In-depth interviews, non-participatory observation, and informal discussions were then used to explore perceived barriers to guideline introduction and general improvements in paediatric and newborn care. Data were collected four to five months after in-service training in the hospitals. Data were transcribed, themes explored, and revised in two rounds of coding and analysis using NVivo 7 software, subjected to a layered analysis, reviewed, and revised after discussion with four hospital staff who acted as within-hospital facilitators.
A total of 29 health workers were interviewed. Ten major themes preventing guideline uptake were identified: incomplete training coverage; inadequacies in local standard setting and leadership; lack of recognition and appreciation of good work; poor communication and teamwork; organizational constraints and limited resources; counterproductive health worker norms; absence of perceived benefits linked to adoption of new practices; difficulties accepting change; lack of motivation; and conflicting attitudes and beliefs.
While the barriers identified are broadly similar in theme to those reported from high-income settings, their specific nature often differs. For example, at an institutional level there is an almost complete lack of systems to introduce or reinforce guidelines, poor teamwork across different cadres of health worker, and failure to confront poor practice. At an individual level, lack of interest in the evidence supporting guidelines, feelings that they erode professionalism, and expectations that people should be paid to change practice threaten successful implementation.
The potential barriers and facilitators to change should guide the choice of implementation strategy. Implementation researchers believe that existing methods for the evaluation of potential barriers and facilitators are not satisfactory. Discrete choice experiments (DCE) are relatively new in the health care sector to investigate preferences, and may be of value in the field of implementation research. The objective of our study was to investigate the complementary value of DCE for the evaluation of barriers and facilitators in implementation research.
Clinical subject was the implementation of the guideline for breast cancer surgery in day care. We identified 17 potential barriers and facilitators to the implementation of this guideline. We used a traditional questionnaire that was made up of statements about the potential barriers and facilitators. Respondents answered 17 statements on a five-point scale ranging from one (fully disagree) to five (fully agree). The potential barriers and facilitators were included in the DCE as decision attributes. Data were gathered among anaesthesiologists, surgical oncologists, and breast care nurses by means of a paper-and-pencil questionnaire.
The overall response was 10%. The most striking finding was that the responses to the traditional questionnaire hardly differentiated between barriers. Forty-seven percent of the respondents thought that DCE is an inappropriate method. These respondents considered DCE too difficult and too time-consuming. Unlike the traditional questionnaire, the results of a DCE provide implementation researchers and clinicians with a relative attribute importance ranking that can be used to prioritize potential barriers and facilitators to change, and hence to better fine-tune the implementation strategies to the specific problems and challenges of a particular implementation process.
The results of our DCE and traditional questionnaire would probably lead to different implementation strategies. Although there is no 'gold standard' for prioritising potential barriers and facilitators to the implementation of change, theoretically, DCE would be the method of choice. However, the feasibility of using DCE was less favourable. Further empirical applications should investigate whether DCE can really make a valuable contribution to the implementation science.
Patients in hospitals and nursing homes are at risk of the development of, often preventable, adverse events (AEs), which threaten patient safety. Guidelines for prevention of many types of AEs are available, however, compliance with these guidelines appears to be lacking. Besides general barriers that inhibit implementation, this non-compliance is associated with the large number of guidelines competing for attention. As implementation of a guideline is time-consuming, it is difficult for organisations to implement all available guidelines. Another problem is lack of feedback about performance using quality indicators of guideline based care and lack of a recognisable, unambiguous system for implementation. A program that allows organisations to implement multiple guidelines simultaneously may facilitate guideline use and thus improve patient safety.
The aim of this study is to develop and test such an integral patient safety program that addresses several AEs simultaneously in hospitals and nursing homes. This paper reports the design of this study.
Methods and design
The patient safety program addresses three AEs: pressure ulcers, falls and urinary tract infections. It consists of bundles and outcome and process indicators based on the existing evidence based guidelines. In addition it includes a multifaceted tailored implementation strategy: education, patient involvement, and a computerized registration and feedback system. The patient safety program was tested in a cluster randomised trial on ten hospital wards and ten nursing home wards. The baseline period was three months followed by the implementation of the patient safety program for fourteen months. Subsequently the follow-up period was nine months. Primary outcome measure was the incidence of AEs on every ward. Secondary outcome measures were the utilization of preventive interventions and the knowledge of nurses regarding the three topics. Randomisation took place on ward level. The results will be analysed separately for hospitals and nursing homes.
Major challenges were the development of the patient safety program including a digital registration and feedback system and the implementation of the patient safety program.
Trial registration: ClinicalTrials.gov ID [NCT00365430]
Barriers exist that prevent nurse practitioners from using their primary health care knowledge and skills. We present the incidence of and specific barriers experienced by nurse practitioner respondents in California, the state with the largest number of nurse practitioners in the nation. A January 1995 survey was sent to all nurse practitioners certified in California to elicit their experiences regarding legal or social barriers in their practice, with space for an open-ended response. Of an estimated 3,895 nurse practitioners in California, 2,741 (70%) returned surveys. Most nurse practitioner (65%) respondents in California are providing primary care. Perceived barriers to practice are lack of prescriptive authority, lack of support from physicians, reimbursement difficulties, and lack of public awareness. Current barriers to nurse practitioner practice in California are similar to national barriers discovered in 1992 data. The development of interprofessional dialogue and the recognition of the contributions of all primary care professionals are some of the steps that can be taken to reduce these barriers and increase the use and effectiveness of nurse practitioners in primary care.
The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain.
Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation.
Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices.
Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain.
The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P = .04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior.
Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care setttings.
clinical guidelines; feedback; low back pain; patient education; randomized trial
This study was a pre-program evaluation of hospital-based nurses' tobacco intervention beliefs, confidence, training, practice, and perceived intervention barriers and facilitators. It was designed to identify relevant information prior to implementing tobacco cessation guidelines across a large northern rural region, home to 1 urban and 12 rural hospitals.
This cross-sectional survey was distributed by nurse managers to nurses in the 13 hospitals and returned by nurses (N = 269) via mail to the researchers.
Nurses were somewhat confident providing cessation interventions, agreed they should educate patients about tobacco, and 94% perceived tobacco counselling as part of their role. Although only 11% had received cessation training, the majority reported intervening, even if seldom--91% asked about tobacco-use, 96% advised quitting, 89% assessed readiness to quit, 88% assisted with quitting, and 61% arranged post-discharge follow-up. Few performed any of these steps frequently, and among those who intervened, the majority spent < 10 minutes. The most frequently performed activities tended to take the least amount of time, while the more complex activities (e.g., teaching coping skills and pharmacotherapy education) were seldom performed. Patient-related factors (quitting benefits and motivation) encouraged nurses to intervene and work-related factors discouraged them (time and workloads). There were significant rural-urban differences--more rural nurses perceived intervening as part of their role, reported having more systems in place to support cessation, reported higher confidence for intervening, and more frequently assisted patients with quitting and arranged follow-up.
The findings showed nurses' willingness to engage in tobacco interventions. What the majority were doing maps onto the recommended minimum of 1-3 minutes but intervention frequency and follow-up were suboptimal. The rural-urban differences suggest a need for more research to explore the strengths of rural practice which could potentially inform approaches to smoking cessation in urban hospitals.
Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit.
A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005).
Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler).
Findings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.
Translational research; Implementation; Quality improvement
A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.
A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.
Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%–90% of respondents, but less than 50% stated that these strategies were in place at their institutions.
Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.
Optimizing the dietary intake of older people can prevent nutritional deficiencies and diet-related diseases, thereby improving quality of life. However, there is evidence that the nutritional intake of older people living in care homes is suboptimal, with high levels of saturated fat, salt, and added sugars. The UK Food Standards Agency therefore developed nutrient- and food-based guidance for residential care homes. The acceptability of these guidelines and their feasibility in practice is unknown. This study used the Normalization Process Theory (NPT) to understand the barriers and facilitators to implementing the guidelines and inform future implementation.
We conducted a process evaluation in five care homes in the north of England using qualitative methods (observation and interviews) to explore the views of managers, care staff, catering staff, and domestic staff. Data were analyzed thematically and discussed in data workshops; emerging themes were then mapped to the constructs of NPT.
Many staff perceived the guidelines as unnecessarily restrictive and irrelevant to older people. In terms of NPT, the guidelines simply did not make sense (coherence), and as a result, relatively few staff invested in the guidelines (cognitive participation). Even where staff supported the guidelines, implementation was hampered by a lack of nutritional knowledge and institutional support (collective action). Finally, the absence of observable benefits to clients confirmed the negative preconceptions of many staff, with limited evidence of reappraisal following implementation (reflexive monitoring).
The successful implementation of the nutrition guidelines requires that the fundamental issues relating to their perceived value and fit with other priorities and goals be addressed. Specialist support is needed to equip staff with the technical knowledge and skills required for menu analysis and development and to devise ways of evaluating the outcomes of modified menus. NPT proved useful in conceptualizing barriers to implementation; robust links with behavior-change theories would further increase the practical utility of NPT.
Normalization process theory; Nutrition policy; Guideline; Long-term care; Older people; Qualitative research
A number of recent reports published in the UK have put the quality of care of adults with Rheumatoid Arthritis (RA) centre stage. These documents set high standards for health care professionals and commissioning bodies that need to be implemented into routine clinical practice. We therefore have obtained the views of recipients and providers of care in inner city settings as to what they perceive are the barriers to providing integrated care.
We conducted focus groups and face to face interviews between 2005-8 with 79 participants (patients, carers, specialist medical and nursing outpatient staff and general practitioners (GPs)) working in or attending three hospitals and three primary care trusts (PCT).
Three barriers were identified that stood in the way of seamless integrated care in RA from the perspective of patients, carers, specialists and GPs: (i) early referral (e.g. 'gate keeper's role of GPs); (ii) limitations of ongoing care for established RA (e.g. lack of consultation time in secondary care) and (iii) management of acute flares (e.g. pressure on overbooked clinics).
This timely study of the multi-perspective views of recipients and providers of care was conducted during the time of publications of many important reports in the United Kingdom (UK) that highlighted key components in the provision of high quality care for adults with RA. To achieve seamless care across primary and secondary care requires organisational changes, greater personal and professional collaboration and GP education about RA.
One strategy to enhance research use and change current practice is to identify barriers and then implement tailored interventions to reduce these barriers. In nursing, the BARRIERS scale has been frequently used to identify nurses' perceptions of barriers to research utilization. However, this scale has not been applied to care of older people, and only one study has investigated how identified barriers link to research utilization. Therefore, the purpose of this study was twofold: to describe RNs' perceptions of barriers to and facilitators of research utilization and to examine the validity of the BARRIERS scale in relation to research use.
A cross-sectional survey design was used and registered nurses (RNs) working in the care of older people participated (response rate 67%, n = 140/210). Two questionnaires, the BARRIERS scale and the Research Utilization Questionnaire (RUQ), were used. Data were analyzed using descriptive and bivariate inferential statistics.
Characteristics of the organization and the presentation of research findings were rated as the most prominent barriers. The three items most frequently reported as barriers were: the nurse is isolated from knowledgeable colleagues with whom to discuss the research (89%); the facilities are inadequate for implementation (88%); and, the relevant literature is not compiled in one place (81%). Surveyed RNs suggested more support from unit managers and better availability of user-friendly reports in Swedish to enhance research use.
The RNs reported a modest use of research. A weak but significant correlation was found between the Research Use index in RUQ and the Presentation subscale in the BARRIERS scale (r = -0.289, p < 0.01), suggesting that the RNs reporting more research use were less likely to perceive presentation of research as a barrier. Dividing the sample into research users (n = 29) and non-research users (n = 105), the research users rated significantly lower on the subscales Presentation, Nurse and Research in the BARRIERS scale.
The BARRIERS scale revealed differences in the perception of barriers between research users and non-research users. Thus, methodologically the scale appears useful in identifying some types of barriers to research utilization but not organizational barriers. The identified barriers, however, are general and wide-ranging, making it difficult to design useful specific interventions.
Patient decision aids are increasingly regarded as important components of clinical practice that enable shared decision making (SDM) and evidence based patient choice. Despite broad acceptance of their value, there remains little evidence of their successful implementation in primary care settings.
Health care practitioners from five general practice surgeries in northern England participated in focus group sessions around the themes of patient decision aids, patient and practitioner preferences and SDM. Participants included general practitioners (n = 19), practice nurses (n = 5) and auxiliary staff (n = 3). Transcripts were analysed using a framework approach.
We report a) practitioners' discussion of the current impetus towards sharing decisions and their perspectives on barriers to SDM, and b) the implementation of patient decision aids in practice and impediments such as lack of an evidence base and time available in consultations.
We demonstrate two orientations to sharing decisions: practitioner-centred and patient-centred with the former predominating. We argue that it is necessary to rethink the changes required in practice for the implementation of SDM.
Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators.
This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators.
The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources.
Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.
Decubitus ulcer; Skin ulcer; Pressure ulcer; Practice guidelines; Evidence-based medicine; Prevention; Spinal cord injuries
To assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital based primary health care setting.
A survey of all clinicians and nursing staff of the outpatient, casualty and antenatal clinics in University Malaya Medical Centre using a self-administered questionnaire.
Hundred and eight out of 188 available staff participated. Sixty-two percent of the clinicians and 66.9% of the nursing staff perceived the prevalence of domestic violence within their patients to be very rare or rare. Majority of the clinicians (68.9%) reported asking their patients regarding domestic violence 'at times' but 26.2% had never asked at all. Time factor, concern about offending the patient and unsure of how to ask were reported as barriers in asking for domestic violence by 66%, 52.5% and 32.8% of the clinicians respectively. Clinicians have different practices and levels of confidence within the management of domestic violence. Victim-blaming attitude exists in 28% of the clinicians and 51.1% of the nursing staff. Less than a third of the participants reported knowing of any written protocol for domestic violence management. Only 20% of the clinicians and 6.8% of the nursing staff had ever attended any educational program related to domestic violence.
Lack of positive attitude and positive practices among the staff towards domestic violence identification and management might be related to inadequate knowledge and inappropriate personal values regarding domestic violence.
Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.
Functional decline is a common adverse outcome of hospitalization in older people. Often, this decline is not related to the illness that precipitated admission, but to the process of care delivered in hospital. The association between immobility and adverse consequences is well established, yet older inpatients spend significant amounts of time supine in bed. We aim to implement and evaluate the impact of an evidence-based strategy to promote early mobilization and prevent functional decline in older patients admitted to university-affiliated acute care hospitals in Ontario, Canada. We will implement a multi-component educational intervention to support a change in practice to enhance mobilization of older patients.
Implementation of our early mobilization strategy is guided by the Knowledge to Action Cycle. Through focus groups with frontline staff, we will identify barriers and facilitators to early mobilization. We will tailor the intervention at each site to the identified barriers and facilitators, focusing on the following key messages: to complete a mobility assessment and care plan within 24 hours of the decision to admit patients aged 65 years and older; to achieve mobilization at least 3 times per day; and, to ensure that mobilization is scaled and progressive. The primary outcome, number of patients observed out of bed, will be documented three times per day (in the morning, at lunch and in the afternoon), two days each week. This data collection will occur over 3 phases: pre-implementation (10 weeks), implementation (8 weeks), and post-implementation (20 weeks).
This is the first large, multisite study to evaluate the impact of a multi-component knowledge translation strategy on rates of mobilization of older patients in hospital. Our implementation is framed by the Knowledge to Action Cycle, and the intervention is being adapted to the local context. These unique features render our intervention approach more generalizable to multiple practice settings. Contextualization of the intervention has also facilitated engagement of participants from multiple hospitals. Upon completion of this study, we will better understand the barriers and facilitators to implementing an early mobilization strategy across a spectrum of hospitals, as well as the impact of a mobilization strategy.
Mobilization; Frail; Older adult; Hospital; Quality improvement
Computerized decision support systems (CDSSs) have the potential to significantly improve the quality of nursing care of older people by enhancing the decision making of nursing personnel. Despite this potential, health care organizations have been slow to incorporate CDSSs into nursing home practices.
This study describes facilitators and barriers that impact the ability of nursing personnel to effectively use a clinical CDSS for planning and treating pressure ulcers (PUs) and malnutrition and for following the suggested risk assessment guidelines for the care of nursing home residents.
We employed a qualitative descriptive design using varied methods, including structured group interviews, cognitive walkthrough observations and a graphical user interface (GUI) usability evaluation. Group interviews were conducted with 25 nursing personnel from four nursing homes in southern Norway. Five nursing personnel participated in cognitive walkthrough observations and the GUI usability evaluation. Text transcripts were analyzed using qualitative content analysis.
Group interview participants reported that ease of use, usefulness and a supportive work environment were key facilitators of CDSS use. The barriers identified were lack of training, resistance to using computers and limited integration of the CDSS with the facility’s electronic health record (EHR) system. Key findings from the usability evaluation also identified the difficulty of using the CDSS within the EHR and the poorly designed GUI integration as barriers.
Overall, we found disconnect between two types of nursing personnel. Those who were comfortable with computer technology reported positive feedback about the CDSS, while others expressed resistance to using the CDSS for various reasons. This study revealed that organizations must invest more resources in educating nursing personnel on the seriousness of PUs and poor nutrition in the elderly, providing specialized CDSS training and ensuring that nursing personnel have time in the workday to use the CDSS.
Computerized; decision support system; graphical user interface evaluation; nursing homes; qualitative; content analysis
Health authorities in several countries have decided that the health care services should be evidence-based. Recent research indicates that evidence-based practice may be more successfully implemented if the interventions overcome identified barriers.
The present study aimed to examine factors influencing the implementation of evidence-based practice among nurses in a large Norwegian university hospital.
Cross-sectional data was collected from 407 nurses during the period November 8 to December 3, 2010, using the Norwegian version of Developing Evidence-based Practice questionnaire (DEBP). The DEBP included data on various sources of information used for support in practice, on potential barriers for evidence-based practice, and on self-reported skills on managing research-based evidence. The DEBP was translated into Norwegian in accordance with standardized guidelines for translation and cultural adaptation.
Nurses largely used experienced-based knowledge collected from their own observations, colleagues and other collaborators for support in practice. Evidence from research was seldom used. The greatest barriers were lack of time and lack of skills to find and manage research evidence. The nurse’s age, the number of years of nursing practice, and the number of years since obtaining the last health professional degree influenced the use of sources of knowledge and self-reported barriers. Self-reported skills in finding, reviewing and using different sources of evidence were positively associated with the use of research evidence and inversely related to barriers in use of research evidence.
Skills in evidence-based practice seem to reduce barriers to using research evidence and to increase use of research evidence in clinical practice.
Evidence-based practice; Nurses; Sources of knowledge; Barriers
Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.
Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.
Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.
Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.
BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 .
Clinical guidelines can improve health-care delivery, but there are a number of challenges in adopting and implementing the current practice guidelines for depression. The aim of this study was to determine clinical experiences and perceived barriers to the implementation of these guidelines in psychiatric care.
A web-based survey was conducted with 386 psychiatric specialists to inquire about experiences and attitudes related to the depression guidelines and barriers influencing the use of the guidelines. Quantitative data were analyzed, and qualitative data were transcribed and coded manually.
Almost three quarters of the psychiatrists (74.6%) were aware of the clinical guidelines for depression, and over half of participants (55.7%) had had clinical experiences with the guidelines in practice. The main reported advantages of the guidelines were that they helped in clinical decision making and provided informative resources for the patients and their caregivers. Despite this, some psychiatrists were making treatment decisions that were not in accordance with the depression guidelines. Lack of knowledge was the main obstacle to the implementation of guidelines assessed by the psychiatrists. Other complaints addressed difficulties in accessing the guidelines, lack of support for mental health services, and general attitudes toward guideline necessity. Overall, the responses suggested that adding a summary booklet, providing teaching sessions, and improving guidance delivery systems could be effective tools for increasing depression guideline usage.
Individual barriers, such as lack of awareness and lack of familiarity, and external barriers, such as the supplying system, can affect whether physicians’ implement the guidelines for the treatment of depression in Korea. These findings suggest that further medical education to disseminate guidelines contents could improve public health for depression.
Depressive disorder; Practice guidelines; Health care surveys; Questionnaires