Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study

Abstract

BackgroundTranslating 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.MethodsA 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).ResultsSix 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).ConclusionsFindings 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.

What influences the implementation of the New Zealand stroke guidelines for physiotherapists and occupational therapists?

“…Although the NZ context of this study is unique, the key findings that guideline characteristics, hospital policies, resources, patient and family characteristics and therapist characteristics are all influential factors in guideline implementation are consistent with international studies with a variety of health professional participants [3,[12][13][14][15][16].…”

“…This has not been previously identified specifically in literature but can be inferred when considering the impact of the barriers to guideline implementation [13].…”

“…These resources could include inadequate staffing, physical resources (e.g. equipment and hospital beds), and time [3,13,15,16]. Lack of time was frequently mentioned as a barrier and has consistently been reported as a major influencing factor throughout relevant literature.…”

“…McClusky et al found that a range of health professionals recognised that their knowledge, skills, role identities, and beliefs about guidelines affected their ability and motivation to implement guideline recommendations [13]. Guideline characteristics have also been recognised as a barrier to therapists' knowledge [14].…”

Cardiorespiratory Stress is not Achieved During Routine Physiotherapy in Chronic Stroke

“…Clinicians are often aware of the content of clinical practice guidelines, but specific strategies to help facilitate implementation of research findings into clinical practice need to be tailored to the individuals' contexts and settings [29].…”