title: Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, New South Wales, Australia. annie.mccluskey@sydney.edu.au
authors: Annie
authors: A
authors: McCluskey
authors: Angela
authors: A
authors: Vratsistas-Curto
authors: Karl
authors: K
authors: Schurr
mesh_terms: D002983:Clinical Competence; D005260:Female; D017144:Focus Groups; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D009517:New South Wales; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D058996:Quality Improvement; D020521:Stroke / Q000628:therapy*; D057170:Translational Research, Biomedical
references: Phys Ther. 2007 Oct;87(10):1284-303
references: 17684088
references: Clin Rehabil. 2000 Dec;14(6):611-7
references: 11128736
references: Disabil Rehabil. 2010;32(8):646-9
references: 20205577
references: BMC Health Serv Res. 2010 Jan 19;10:18
references: 20082725
references: JAMA. 2008 Jan 9;299(2):211-3
references: 18182604
references: Int J Rehabil Res. 1981;4(4):483-92
references: 7333761
references: BMJ. 2003 Jul 5;327(7405):33-5
references: 12842955
references: Qual Saf Health Care. 2005 Feb;14(1):26-33
references: 15692000
references: Implement Sci. 2012 Apr 24;7:37
references: 22530986
references: Cochrane Database Syst Rev. 2012 Jun 13;(6):CD000259
references: 22696318
references: Implement Sci. 2006 Feb 22;1:3
references: 16722572
references: Qual Health Res. 2000 May;10(3):293-308
references: 10947477
references: Top Stroke Rehabil. 2012 Mar-Apr;19(2):132-40
references: 22436361
references: Stroke. 2009 Jun;40(6):2123-8
references: 19359633