title: Multi-level barriers analysis to promote guideline based nursing care: a leadership strategy from home health care.
abstract: BACKGROUND
  Understanding the types of barriers that exist when implementing change can assist healthcare managers to tailor implementation strategies for optimal patient outcomes.
  
  
  OBJECTIVE
  The aim of this paper is to present an organising framework, the Barriers Assessment Taxonomy, for understanding barriers to nurses' use of clinical practice guideline recommendations. Barriers to recommendations are illustrated using the Barriers Assessment Taxonomy and insights discussed.
  
  
  METHODS
  As part of a pilot implementation study, semi-structured interviews (n = 26) were conducted to understand barriers to nurses' use of nine guideline recommendations for diabetic foot ulcers. Content analysis of verbatim transcripts included thematic coding and categorising barriers using the Barriers Assessment Taxonomy.
  
  
  RESULTS
  Nineteen barriers were associated with nine recommendations, crossing five levels of the health care delivery system. The Barriers Assessment Taxonomy revealed that all recommendations had individual and organisational level barriers, with one recommendation having barriers at all levels. Individual level barriers were most frequent and lack of knowledge and skills was the only barrier that crossed all recommendations.
  
  
  CONCLUSIONS
  The Barriers Assessment Taxonomy provides a framework for nursing managers to understand the complexity of barriers that exist, and can assist in choosing intervention strategies to support improved quality care and patient outcomes.
authors.affiliation: School of Nursing, University of Ottawa, Ottawa, Ontario, Canada. wgifford@uottawa.ca
authors.forename: Wendy A
authors.initials: WA
authors.lastname: Gifford
authors.forename: Ian D
authors.initials: ID
authors.lastname: Graham
authors.forename: Barbara L
authors.initials: BL
authors.lastname: Davies
mesh_terms: D055317:Evidence-Based Practice / Q000458:organization & administration; D019983:Guideline Adherence / Q000458:organization & administration*; D064650:Home Health Nursing / Q000592:standards*; D006801:Humans; D007857:Leadership; D017146:Models, Organizational; D009732:Nursing Care / Q000592:standards*; D015404:Nursing Methodology Research; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care
keywords: barriers assessment; clinical practice guidelines; implementing change; leadership; management; taxonomy