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Perspectives of health care professionals on the facilitators and barriers to the implementation of a… Munce, Sarah E P; Graham, Ian D; Salbach, Nancy M; Jaglal, Susan B; Richards, Carol L; Eng, Janice J; Desrosiers, Johanne; MacKay-Lyons, Marilyn; Wood-Dauphinee, Sharon; Korner-Bitensky, Nicol; Mayo, Nancy E; Teasell, Robert W; Zwarenstein, Merrick; Mokry, Jennifer; Black, Sandra; Bayley, Mark T Jun 26, 2017

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RESEARCH ARTICLE Open AccessPerspectives of health care professionals onthe facilitators and barriers to theimplementation of a stroke rehabilitationguidelines cluster randomized controlledtrialSarah E. P. Munce1*, Ian D. Graham2, Nancy M. Salbach3, Susan B. Jaglal3, Carol L. Richards4,5, Janice J. Eng6,Johanne Desrosiers7, Marilyn MacKay-Lyons8, Sharon Wood-Dauphinee9, Nicol Korner-Bitensky9, Nancy E. Mayo10,Robert W. Teasell11, Merrick Zwarenstein12, Jennifer Mokry1, Sandra Black13 and Mark T. Bayley14AbstractBackground: The Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was acluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotionof the uptake of best practice recommendations for interventions targeting upper and lower extremity function,postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either thefacilitated or passive KT intervention. The objective of the current study was to understand the factors influencingthe implementation of the recommended treatments and KT interventions from the perspective of nurses, occupationaltherapists and physical therapists, and clinical managers following completion of the trial.Methods: A qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understandthe factors influencing the implementation of the recommended treatments and KT interventions. The Clinical PracticeGuidelines Framework for Improvement guided the analysis.Results: Thirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5sites from the passive KT arm). The following factors influencing the implementation of the recommended treatmentsand KT interventions emerged: facilitation, agreement with the intervention – practical, familiarity with the recommendedtreatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes offacilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as anunintended outcome of the trial across both arms in addition to a facilitator to the implementation of thetreatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in thepassive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial.(Continued on next page)* Correspondence: sarah.munce@uhn.ca1Toronto Rehabilitation Institute-University Health Network, 550 UniversityAvenue, Toronto, Ontario M5G 2A2, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Munce et al. BMC Health Services Research  (2017) 17:440 DOI 10.1186/s12913-017-2389-7(Continued from previous page)Conclusions: This is one of the first studies to examine the factors influencing the implementation of strokerecommendations and associated KT interventions within the context of a trial. Findings highlight the important role ofself-selected facilitators to implementation efforts. Future research should seek to better understand the specificcharacteristics of facilitators that are associated with successful implementation and clinical outcomes, especiallywithin the context of stroke rehabilitation.Keywords: Facilitators, Barriers, Implementation, Evidence-based recommendations, Clinical practice guidelines,Rehabilitation, Stroke, QualitativeBackgroundImplementation of best evidence is paramount to optimizepost-stroke recovery outcomes [1, 2]. Clinical practiceguidelines containing evidence-based recommendationshave been proposed as a method to facilitate clinicians’uptake of evidence [3–5]. A meta-review of 12 systematicreviews [6] categorized factors influencing guidelineimplementation into five main areas: 1) the guideline itself(e.g., guidelines that did not require specific resourceswere easier to implement); 2) the target health care profes-sional user (e.g., less experienced health care professionalswere more likely to implement guidelines than moreexperienced health care professionals); 3) patient charac-teristics (e.g., having patients with co-morbidities wasassociated with less guideline adherence by their healthcare professionals); 4) the work environment (e.g., limitedresources and negative attitudes from colleagues lead toless clinical practice guideline adherence); and, 5) the typeof implementation strategy used (e.g., a multifaceted inter-vention was shown to be more effective in implementingclinical practice guidelines than using one strategy only).A variety of studies have demonstrated that strokeclinical practice guidelines are not routinely implemented[7–9]. For example, a 2005 Canadian study of 1800 strokerehabilitation clinicians identified a significant gap be-tween best and actual practices in stroke rehabilitationmanagement. Specifically, there was a low prevalence ofscreening for high-risk, post-stroke sequelae and incon-sistent use of assessment of important aspects of strokerecovery such as community reintegration and participa-tion [7]. Complicating this scenario is the fact that strokerehabilitation is characterized by an interdisciplinary teamapproach to care and the availability of multiple treatmentrecommendations. To date, there are no reports in theliterature describing how to facilitate guideline implemen-tation in this context.The Canadian Stroke Network funded the Stroke CanadaOptimization of Rehabilitation by Evidence (SCORE)Project team (Phase I). A consensus conference was heldto address areas of stroke rehabilitation that require add-itional research. The priorities from this conference havebeen previously described [10]. In addition, our researchteam previously explored the facilitators and barriers tothe implementation of the Evidence Informed PracticeRecommendations in stroke to inform the KT interven-tions used in the intervention trial comparing the effect-iveness of two KT interventions [11]. This approach isconsistent with the finding that implementation strategiesare more likely to be effective if they address local facilita-tors and barriers to change [12–14].Phase II of the SCORE project was a cluster randomizedimplementation trial (SCORE-IT) that evaluated two KTinterventions for the promotion of the uptake of bestpractice recommendations for interventions targetingupper extremity (UE) and lower extremity (LE) function,postural control, and mobility. Twenty rehabilitation cen-ters across Canada were randomly assigned to either thefacilitated or passive KT intervention (unpublished work).Facilitation is defined as “…enabling individuals, teams,and organizations to change”. There are many interpreta-tions of the facilitator role in practice and they can involvea practical role of assisting change to a more complex,multi-dimensional role [15]. The specific details of thefacilitated and passive KT intervention are presentedin Table 1.Consistent with the Medical Research Council (MRC)Framework [16] for evaluating complex interventions,qualitative research is essential to understanding guide-line implementation interventions (e.g., in this case,whether the KT interventions adequately addressed allof the barriers previously identified) and guide futureefforts. There is a paucity of qualitative studies on theviews of stakeholders and health care professionalsregarding the implementation of stroke clinical guide-lines and/or tools or interventions aimed to increasetheir uptake. However, a few qualitative studies exist onhealth care professionals’ perspectives on facilitators andbarriers to stroke clinical guideline implementation. Forexample, Donnellan and colleagues [17], in qualitativestudy of perceived facilitators and barriers to implement-ing clinical guidelines in stroke (by stakeholders andhealth care professionals), determined that having dedi-cated resources, user-friendly guidelines relevant at thelocal level, and having supportive advocates acted asfacilitators to implementation. Inadequate resources, poorguidelines characteristics, and insufficient training andMunce et al. BMC Health Services Research  (2017) 17:440 Page 2 of 13education acted as barriers. Similarly, Miao and colleagues[18] examined factors affecting speech pathologists’ imple-mentation of stroke management guidelines and deter-mined that factors affecting implementation were complexand not exclusively facilitators or barriers. They identifiedthe following three themes: making implementation expli-cit, demand versus ability to change, and motivation ofspeech pathologists to implement guidelines. To the bestof our knowledge, no previous studies have examined thebarriers and facilitators to the implementation of both theimplementation of stroke clinical guidelines and the toolsor interventions aimed to increase their uptake. Thus, theobjective of the current study was to understand the facili-tators and barriers influencing the implementation of therecommended treatments and KT interventions from theperspective of nurses, occupational therapists (OTs) andphysical therapists (PTs), and clinical managers followingcompletion of the SCORE-IT. We compared the identifiedfacilitators and barriers influencing recommendation andKT intervention uptake by arm of the trial.MethodsGuiding conceptual frameworkThe Clinical Practice Guidelines Framework for Improve-ment [19] and its updates [20–22] were used to guide thecoding framework in the current study. Legaré andcolleagues [21] formulated a definition for each type ofbarrier to promote the standardization in the reporting ofbarriers and facilitators across different studies. Examplesof barriers and facilitators include knowledge (awareness,familiarity), attitudes (e.g., agreement with intervention),and behavior, including environmental factors [20–22].The use of the Clinical Practice Guidelines Framework forImprovement [19] was not decided a priori. We decidedto use the Clinical Practice Guidelines Framework forImprovement [19] and its updates [20–22] as it is one ofthe most recognized frameworks for assessing barriersand facilitators and after analyzing several focus groupsand determining that the emerging categories clearlyaligned with the barriers outlined in the framework.Design/ApproachThis study took a qualitative descriptive approach thatconsisted of telephone focus groups. A qualitative descrip-tive approach is well-accepted for researching topics aboutwhich little is known and yielding practical answers ofrelevance to policy makers and health care practitioners[23, 24]. Telephone focus groups were selected because ofthe geographic dispersion (i.e., national scale) of the studyparticipants.RecruitmentParticipants included staff members from the three differ-ent professional groups, nurses, therapists (OTs and PTs),and health care/clinical managers, who had participated inthe SCORE-IT and agreed to be contacted at the conclu-sion of the trial. Participants were contacted by telephoneand email about their willingness to participate in thefocus groups. Purposive sampling [25] was used to recruitequal numbers of participants across professional groups(nurse, therapist, clinical manager), randomization arms(facilitated KT intervention or passive KT intervention),and geographic locations (Western, Central, Quebec,Eastern). Uniprofessional focus groups were conductedfor nurses, therapists, and clinical managers at each of theparticipating sites. This approach was adopted to mitigateTable 1 Descriptions of the facilitated and passive knowledge translation interventionsFacilitated knowledge translation intervention Passive knowledge translation interventionPersonnel There was funding for two facilitators (one nurse and one therapist). NoneFrequency and duration 4 h/week/facilitator in each intervention site to promote guidelineimplementation over a 16-month periodNot applicableComponents At a two-day workshop: facilitators received change managementeducation, a practice-change toolkit, information on successfulguideline implementation strategies from the pilot study, slidepresentations, and clinician-targeted media releases for marketingSCORE. They also completed training to apply treatments,compared current practice with recommended practice, identifiedbarriers to practice change, developed a guideline implementationplan addressing barriers and incorporating behaviour changestrategies, and learned how to conduct small group education/training sessions.In addition, stroke teams received SCORE guideline booklets withtreatment recommendations and evidence-based treatmentprotocols, pocket reminder cards, and posters describing protocolsdesigned for therapists or nurses. Teleconferences and a web-basedplatform were provided for facilitators to communicate and sharesuccessful strategies.Sites in the passive KT intervention received aversion of the SCORE guideline without treatmentprotocols, and a handbook and educational DVDon the use of standardized assessment toolspost-stroke.In addition, clinicians were invited by email toparticipate in a list serve to obtain additionalinformation or share experiences about the trialoutcome measures.Research team involvement The research team provided external facilitation to the facilitators;specifically, advice and support via teleconferences.NoneMunce et al. BMC Health Services Research  (2017) 17:440 Page 3 of 13potential power imbalances that may have influenced whatparticipants might be willing to share. Participants wererecruited between January 2009 and March 2010.Recruitment ceased when a discussion and review of theresponses revealed that saturation had been achieved (i.e.,no new responses or themes were emerging) [26].Data collectionEach participant took part in a semi-structured telephonefocus group lasting approximately 45–60 min. The princi-pal investigators (MB, SWD) and the research coordina-tors involved in the trial conducted the focus groups. Thefocus group guide consisted of semi-structured open-ended questions and was informed by the results of ourpilot project [11]. The interview guide was pilot testedwith a researcher experienced in qualitative methods.Probes or recursive questioning were used during thefocus groups to explore issues in greater depth and toverify understanding of the information being collected[25]. The probes were revised and refined as data collec-tion progressed to establish saturation [26]. The completelist of questions is included in Additional file 1. No repeatinterviews were conducted. All focus groups were audiorecorded. Field notes were made during and/or after thefocus groups. The recordings were transcribed verbatimfor data analysis. These transcripts were not returned toparticipants for comment and/or correction.Data analysisTo facilitate the organization and analysis of the qualita-tive data, the transcripts were entered into NVivo 10[27]. Thematic analysis as described by Braun and Clark[28] was used to understand the factors influencing theimplementation of the recommended treatments andKT interventions by study arms. The lead author (SM)reviewed the transcripts to develop an initial codebookbased on the Clinical Practice Guidelines Framework forImprovement. Following this, two researchers (SM, MB)independently coded a sample of the transcripts (20%),revised the codebook as themes emerged, and met todiscuss and reconcile discrepancies until agreement ofthe coded transcripts was reached. SM is a female post-doctoral fellow and has a PhD in Health ServicesResearch as well as expertise in knowledge translation.She has approximately 10 years of experience conductingqualitative research. MB is a physiatrist (i.e., MD) withexpertise in stroke, brain injury, rehabilitation, clinicalpractice guidelines, prognostic factors, and health servicesresearch. He has approximately 10 years of experienceconducting qualitative research. Our background in know-ledge translation science has influenced the conceptualframeworks that we have been exposed to including ourknowledge and selection of the Clinical Practice Guide-lines Framework for Improvement [19] for this study.Disagreements/discrepancies around codes, themes, andsubthemes were resolved by discussion and reference tothe original transcripts. The lead author (SM) analyzedthe remaining transcripts. Relevant quotations were iden-tified and selected from the transcripts to illustrate thethemes and include the participant’s professional group(nurse, therapist, or clinical manager), and randomizationarm (facilitated KT intervention or passive KT interven-tion). Participants were not provided feedback on thefindings.Ethics and trial registrationResearch ethics approval was obtained from each site andaffiliated university. All participants provided written con-sent prior to the interview. The trial was registered atClinicalTrials.gov (NCT00359593).ResultsDescription of the rehabilitation centersFocus groups were conducted with 33 individuals includ-ing 11 nurses, 11 therapists, and 11 clinical managers.There were between two and six participants in attend-ance at each focus group. Participants were from 11 of 20sites in Western, Central and Eastern Canada as well asQuebec. This sample represented 6 sites from the facili-tated KT arm and 5 sites from the passive KT arm.Overview of themes - facilitators and barriers influencingimplementation of the SCORE-ITOverall, five themes were identified. The following themesinfluencing the implementation of the recommendedtreatments and KT interventions emerged: facilitation,agreement with the intervention – practical, familiaritywith the recommended treatments, and environmentalfactors (including time pressure, insufficient staff, lack ofspace and equipment, and organizational constraints).These themes, for the most part, emerged as facilita-tors and barriers influencing the implementation ofthe SCORE-IT. Furthermore, the theme of improvedteam communication and interdisciplinary collaborationemerged as an unintended outcome of the trial acrossboth arms in addition to facilitating the implementation ofthe treatment recommendations. Representative quotesare given in Tables 2 and 3.FacilitationFacilitatorFacilitation often involved individuals who championedthe trial and its recommendations and/or interventions.The majority of participants representing all professionalgroups and randomization arms noted that facilitationenhanced recommendation and KT intervention uptake.In the facilitated KT intervention sites, the theme offacilitation often referred to the designated facilitators inMunce et al. BMC Health Services Research  (2017) 17:440 Page 4 of 13this arm of the trial (i.e., having two facilitators 4 h/week/facilitator). In the passive KT sites, facilitation was usuallyself-initiated by a local staff member (frequently amanager) who appeared to be highly motivated. Forexample, informal workshops or team activities were initi-ated by such individuals at some passive KT interventionsites. Participants in both arms of the trial indicatedthat staff acting as facilitators provided support andmotivation to their colleagues. Furthermore, the pres-ence of the facilitator often provided continuity forthe trial (procedures/tasks) in the face of high staffturnover.Table 2 Facilitators to ImplementationTheme Quote SourceFacilitation Without the facilitator and the model, I don’t think we would have gotten as far as wedid with the implementation of best practice.Manager, Facilitated Site 4One of the physiotherapists initially oriented the staff as to what it was about, and I’vealways thought of her as the go-to person for information.Nurse, Passive Site 3And what I tried to sort of make clear early on was that this, we were all in this project.Participation wasn’t an option so if either of the two sort of leaders of the projectencountered any difficulties, be it with staff or lack of equipment, resources, anything likethat, they were to let me know. Because if need be either [name] or I would have beenthe bad guy and stepped in. That never happened but they, I think they certainly felt thatthey weren’t out there on their own and we stressed at the beginning, it wasn’t theirproject, it was a [site name] project so they … We didn’t need to be the heavy but I thinkeveryone understood that, you know, if need be we were there.Manager, Facilitated Site 2I think [name] took a leadership role in regards to the project itself. Therapist, Passive Site 5Agreement with theIntervention – PracticalYes, we had our pocket cards, little laminated pocket cards, and those were quite useful.And also the posters in the rooms, for positioning, if you weren’t sure it was right there,so that was wonderful.Nurse, Facilitated Site 2The posters in the rooms were very helpful. The transfer and positioning posters weregreat to have above the beds, just to help make sure everything was done properly.The digital frame was also very helpfulNurse, Facilitated Site 6Familiarity with theRecommended TreatmentsWe were doing the CMSA (Chedoke-McMaster Stroke Assessment) before so thatwasn’t new...We were already doing some of the upper extremity tasks…Therapist, Passive Site 4From the recommendations, a lot of the stuff we were already doing. Things like aerobicconditioning, I found like the implementations reinforced that that was a good thing wewere doing.Manager, Passive Site 3Team Communication andInterdisciplinary CollaborationWe have good relationships. Certainly it is a good relationship but I think it only gotbetter when we did this particular education piece of it or how we particularly did it.Because I think we gave each of the groups a little more respect for the other group interms of what they do. Because, you know, a lot of nurses really don’t know what OTsactually do because O therapy is a little more objective in terms of working with musclegroups and joints and things like this. But with OT, you know, they sort of take thepatients off to the bathroom or up to their work area or whatever and they just don’tknow a heck of a lot of what they do. But with this little educational piece that we did,they learned.Nurse, Passive Site 1I think generally, among the physios, we tend to talk to each other a fair bit. And evenamong the OTs and the other team, if there’s issues, we’re talking. If not on a daily basis,then at least every 2 or 3 days. Definitely in rounds. Sort of even informally consulting inthe corridors with stuff like that about various patients.Therapist, Passive Site 1…we established early, early on was a committee, sort of a joint therapist, nursing staff,healthcare aid committee. So as we were moving forward communication happenedwithin that committee.Manager, Passive Site 2Team Communication andInterdisciplinary CollaborationThe workshop was very good at explaining the “why” behind the treatment modalities,and I think that was helpful. That was more helpful than just a list of recommendations,because having a rationale and a justification for why a treatment is the best choicewas useful.Therapist, Passive Site 3Yes. From an interdisciplinary standpoint, PT and OT have a mixed office now. The strokeunit has an office now as well. There has been more collaboration and team work. Thestaff that has signed up to work on the dedicated stroke unit are working on thededicated stroke unit. They interact more, and there is more collaborationManager, Facilitated Site 4And I think you’re also encouraging each other with it because now that you’ve gonethrough the education and been part of this project…Nurse, Passive Site 1Munce et al. BMC Health Services Research  (2017) 17:440 Page 5 of 13Table 3 Barriers to implementationTheme Quote SourceLack of facilitation It was good in theory, but we needed a person to continue with the program andreinforce it. After the booklets were handed out, we never went back to them, and Ithink the education needed to continue right away. If there had been someonewhose main goal was to facilitate the implementation, without being pulled indifferent directions by other responsibilities, I think things would have gone muchbetter.Nurse, Facilitated Site 4We didn’t have somebody who I thought could be an actual overseer of this. If wewere trying to do this again, it might be better to either have a senior being theperson overseeing the project, or even get the nurse educator we have on boarddoing that kind of thing.Manager, Passive Site 3We did have some new staff that came in and watched the DVD but had a bit oftrouble with it because it was a very busy time for us so there was very littlementorship I think.Therapist, Passive Site 3So I think one of the things I would suggest too is that we get a champion on thenursing unit to really, somebody who works on the unit. I mean I don’t work on theunit. I’m all over the building as an educator but somebody like [name] who wouldget specific education and be the champion, be the one that could be, you know,the supporter on the units, be encouraging the other staff that she’s working with tobe involved and to be doing it. I think that would help…Nurse, Passive Site 1We had one nurse who was more involved in SCORE, but because she didn’t workfull time she wasn’t there every day so we missed a bit of the information and theteaching we could have gotten because she wasn’t a full time worker. I think weneeded a full-time worker to be involved to have a more significant influence inpushing SCORE. She tried to get everyone aware of the project and the recommendations, and she transferred the information along to the staff. She made sure everyone was involved, and that everyone was up to date on the information about theproject.Nurse, Facilitated Site 6Lack of agreement with theintervention – not practicalThe DVD was a little dry. It was hard to stay awake during the presentation, so I reallydon’t remember much of it. At the time we were watching it we were short-staffedand trying to cram it into a lunch hour so it was hard to pay attention. I didn’t findthe DVD all that useful.Manager, Passive Site 3I know, for example that one of the recommendations for the frequency of the FESfor the upper extremity was feasible for clients that were completely independent forthe setup of the FES, but I think the two 30 min sessions per day recommendationwas difficult to complete. Some of the recommendations were not so realistic tofollow due to time constraints.Therapist, Facilitated Site 6Lack of familiarity with therecommended treatmentsThere were some knowledge barriers about the process of functional electricalstimulation. The specifics of being comfortable with doing it, and the intricacies,those were a barrier.Manager, Passive Site 3I think the one thing I really struggled with before I left on Mat leave was starting themuscle stim just because I didn’t have the background as to why it was being used.Therapist, Facilitated Site 2It could have been nice to see how that worked but we didn’t have the equipmentor the education, and we wouldn’t have been comfortable doing FES without theproper training and knowledge.Therapist, Facilitated Site 4I think we struggled the most with the [spell out acronym] CAHAI because that wasnew for a lot of us, and that we needed to review the most.Therapist, Facilitated Site 7Environmental factors[Lack of Space and Equipment]Space was a bit of a barrier for the 6 min walk test, in terms of finding enough openspace without obstacles.Manager, Passive Site 5Equipment was also a barrier. Some of the slings seemed to go missing, and wedidn’t have FES equipment so those are just a few examples.Therapist, Facilitated Site 4Environmental factors[Organizational Constraints]It was a good experience, and I would do it again, but it was definitely a lot of work,and maybe it could have been more heightened with our leadership team.Manager, Facilitated Site 4I would say no. They were aware of the project, and were given updates at thequarterly meetings, but they did not have a direct involvement.Manager, Passive Site 5Munce et al. BMC Health Services Research  (2017) 17:440 Page 6 of 13BarrierA lack of facilitation (i.e., not enabling individuals, teams,and organizations to change) was a barrier identified by allthe professional groups and by those in the passive KT arm,in particular, as hindering the uptake of the KT interven-tions. This theme involved the lack of an individual(s) tochampion the trial. A lack of facilitation had implicationsfor mentorship of other staff members, the continuity of theproject overall (especially in the face of staff turnover), andthe sustainability of the KT interventions during the trialperiod and beyond (e.g., to champion the use of the DVD).Agreement with the intervention – practicalFacilitatorAccording to Legaré and colleagues [21, 22], the definitionof agreement with the intervention – practical is theTable 3 Barriers to implementation (Continued)Environmental factors[Time Pressure]Another thing is I guess the implementation took more time than I thought it would,it was a bit harder to set things up than I expected.Manager, Facilitated Site 4The CMSA was very time consuming, so I think people struggled with the time aspect,spending so much time on all of the implementations. The value of theactivities was appreciated, but going through all of the tools and processes was timeconsuming and people resented how much time it took to implement everything.Manager, Passive Site 3…we just haven’t got time. We’ve got new people coming in, we’ve got measures torecord that we didn’t do before and I think an underlying problem is that the unitnow is so busy that it isn’t adequately staffed for both physio and OT. And that’s apre-existing problem. I think the study maybe just highlighted it a little bit but I thinkthe therapists were, did feel a certain pressure because they knew they hadn’t gottheir assessments done. They knew they hadn’t got their discharge paperwork donebut the patients just kept coming and coming and coming. And I’m sure that’s notunique to us and I’m sure, you know, if we gave them ten more therapists in a year’stime they’d say, they were short of staff. But I think the time was the big thing.Manager, Facilitated Site 2Environmental factors[Insufficient Staff]We’ve been through a lot of change in the hospital, because our therapists rotate, sowe were moved around a bit. That’s really part of the whole problem, because thestaff that was up here got moved around, and the unit was closed for a bit aroundChristmas. It became difficult to incorporate best practices when we were dealingwith all of these issues. I think we had to deal with therapists moving around and alsobeing a bit understaffed.Therapist, Passive Site 5We had staffing issues, especially OT staffing issues. We still have those issues. We’vebeen at about 60% of OT staffing for a while now. The staffing for RN as well, wecouldn’t get those ratios to the level we wanted.Manager, Passive Site 4It was quite difficult since we were short staffed for probably two thirds of theduration of the project; it was difficult to do new things. When we hired a seniortherapist she came on board for the last 3 months and she was able to startimplementing things we would have liked to have done, some of therecommendations. I think if you have the right people, it is much easier but when wewere short staffed that limited us and we just tried to do our best.Manager, Passive Site 3Environmental factors[Lack of Space and Equipment]Space was a bit of a barrier for the 6 min walk test, in terms of finding enough openspace without obstacles.Manager, Passive Site 5Equipment was also a barrier. Some of the slings seemed to go missing, and wedidn’t have FES equipment so those are just a few examples.Therapist, Facilitated Site 4Environmental factors[Organizational Constraints]It was a good experience, and I would do it again, but it was definitely a lot of work,and maybe it could have been more heightened with our leadership team.Manager, Facilitated Site 4I would say no. They were aware of the project, and were given updates at thequarterly meetings, but they did not have a direct involvement.Manager, Passive Site 5Lack of team communication andinterdisciplinary collaborationWell I haven’t even seen these recommendations, so I think getting together as agroup and discussing it would have been useful. We should have had a meetingtogether to go over it, because I think we only really knew about the sheets wherewe ticked off the patients’ progress.Nurse, Passive Site 5Some of the feedback I heard was that it would have been great if we had a blog orif we had a bulletin board of some sort that people would go in, post their question,had their questions answered and that kind of thing. So it would have been a littlemore timely in terms of getting things off the ground and that kind of stuff. It wouldhave provided more timely clarification I think.Manager, Passive Site 1I would, like I was saying, just maybe more communication between the disciplines asto what’s going on. That nurse facilitators may be having a meeting every fewmonths or whatever it is, just to make sure that everybody is on the same page.Nurse, Passive Site 2Munce et al. BMC Health Services Research  (2017) 17:440 Page 7 of 13following: “…agreement with [an intervention] because itis clear or practical to follow”. Nurses and therapists, inthe facilitated KT arm stated that elements of the KTintervention, including the posters in patient rooms forpositioning for shoulder pain prevention, were clear andpractical to follow, and supported implementation of therecommendations. Specifically, nurses and therapistsnoted that the posters were specific and could be used atthe point of care. As such, they were regarded favorably(i.e., judged to increase the quality of care) and werefrequently used.BarrierAccording to Legaré and colleagues [21, 22], the defin-ition of lack of agreement with the intervention – i.e.,not practical is the following: “lack of agreement with[an intervention] because it is unclear or impractical tofollow”. In contrast, across both arms of the trial, partici-pants indicated that components of the trial that werereportedly unclear and/or not practical served as a bar-rier to implementation. The KT interventions that werediscussed most frequently as not practical were watchingthe DVD (passive KT arm) and the pocket cards (facili-tated KT arm). For example, staff in the facilitated KTarm indicated that they have too many pocket cards andthat the information was too general. Across both arms ofthe trial, participants also mentioned that certain recom-mendations/tests were not practical to implement becausethey were time-consuming (e.g., functional electricalstimulation (FES unit)).Familiarity with the recommended treatmentsFacilitatorPTs and OTs, in both trial arms indicated that havingsome recommendations already in use at the site servedto encourage their wider uptake. Aerobic conditioningand some of the positioning practices were the mostcommonly cited recommendations already being used inpractice. Many of the participants indicated that theinclusion of the evidence-based recommendations in thetrial underscored their importance.BarrierParticipants across the professionals groups and acrossboth arms of the trial indicated that a lack of familiaritywith the recommended treatments, including equipment(e.g., FES unit) and assessment tools (e.g., Chedoke Armand Hand Inventory (CAHAI)), discouraged implementa-tion efforts. Participants also noted that a lower volume ofpatients, which was associated with fewer opportunities tobecome familiar with the tools/measures and/or equip-ment, limited their ability to implement certain com-ponents of the trial.Environmental factorsBarrierAlmost all of the participants in both arms of the trialindicated that time pressure was a key obstacle to imple-mentation of the KT interventions. This barrier oftencoincided with a lack of staff or staff turnover (i.e., insuf-ficient staff ) and was related to a lack of funding foradditional positions. Time pressure was also associatedwith competing initiatives and/or roles/responsibilitiesof staff members. In addition, participants in both armsindicated that some of the recommended treatments/mea-sures themselves were time-consuming to implement.Barriers associated with the environment also included alack of space and equipment needed to perform therecommendations (e.g., the 6 min walk test, the lack of aFES unit). Finally, some of the participants noted a lack ofactive support from senior management for the imple-mentation of the trial despite their senior managementsanctioning the project.Team communication and interdisciplinary collaborationFacilitatorAcross both arms of the trial, managers in particularnoted that increased team communication and interdis-ciplinary collaboration were facilitators to the implemen-tation of the recommended treatments (fostered via theeducational interventions in both arms of the trial).Unintended outcomeAt other sites, it was noted that the KT interventionshad the unintended benefit of increasing team commu-nication and interdisciplinary collaboration (via the edu-cational sessions or in discussing the DVD). This wasalso noted across both arms of the trial. In particular,some participants noted that the collaboration betweenPTs and OTs improved as a result of the trial. A greaterunderstanding of the roles and responsibilities of eachprofessional group was also noted, particularly for theroles and responsibilities of OTs.DiscussionSummary of main findingsThe objective of the current study was to understand thefacilitators and barriers influencing the implementation ofthe recommended treatments and KT interventions fromthe perspective of nurses, OTs and PTs, and clinical man-agers following completion of the SCORE-IT. This is oneof the first studies to examine the factors influencing theimplementation of evidence-informed stroke recommen-dations and associated KT interventions among alliedhealth care professionals within the context of a trial.All of the factors influencing the implementation ofthe recommended treatments and KT interventions in-cluding facilitation, agreement with the intervention –Munce et al. BMC Health Services Research  (2017) 17:440 Page 8 of 13practical, familiarity with the recommended treatments,environmental factors, and team communication andinterdisciplinary collaboration were identified in botharms of the trial. Team communication and interdiscip-linary collaboration also emerged as an unintended out-come of the trial in both arms of the trial. It isparticularly noteworthy that facilitation was identified asa facilitator to implementation in the passive KT interven-tion arm despite the lack of formally instituted facilitatorsin this arm of the trial. The order of the remainder of thisDiscussion section is the same as the Results section. Asin the Results section, where applicable, we have used thesame terms from the Clinical Practice Guidelines Frame-work for Improvement [19] as headings to organize ourDiscussion section.Role of facilitationThe presence or absence of facilitation in this trialemerged as both a facilitator and barrier to imple-mentation of the recommendations and KT interven-tions. Indeed, the results of a systematic review onlocal opinion leaders and their effects on professionalpractices revealed that opinion leaders alone or incombination with other interventions may successfullypromote evidence-based practice [29]. In fact, research onbarriers to research use in health care have consistentlyidentified the behaviors of managers and their lack ofleadership as major limiting factors to research use byclinicians [30–34].One of the main findings of this study was that thetheme of facilitation was noted in both arms of the trial,despite the fact that only the facilitated KT arm had for-mal facilitators. Previous research has raised the ques-tion of whether the process by which opinion leaders areselected affects the success of educational initiatives[29]. If self-selected facilitators (i.e., in this case, staff atthe passive KT sites) are more beneficial (to implementa-tion outcomes) than facilitators who are selected byexternal influences, it is possible that other componentsof the facilitated KT arm of the trial may not have beenoptimized. Alternatively, the self-initiated facilitationroles taken by staff members at the rehabilitation centersin the passive KT arm may explain why the outcomes atthese centers were better than anticipated. Indeed, theresults of the trial revealed that while the facilitated KTintervention was associated with a significantly greaterimprovement in the rate of implementing sit-to-standtraining and walking practice, the passive KT interven-tion was associated with significantly greater improve-ment in the rate of implementing standing balancetraining (after adjusting for clustering at patient and pro-vider levels and covariates) (i.e., between group differ-ences) (unpublished work). It should be noted that theoriginal trial was dealt with as a pragmatic trial, whichtries to mimic the usual care situation and not imposetoo many fidelity standards on the basis that they pro-duce a trial result which is not applicable/externally validfor the use of the same intervention under usual careconditions. Furthermore, as Horne [35] noted, staff canbe trained to be good managers, but leadership is lesssusceptible to training and is better obtained by selectiverecruitment. This phenomenon may explain why facilita-tion (including a lack of facilitation) was noted acrossboth arms of the trial. At the same time, we are not link-ing facilitation behaviour to the actual use of the recom-mendations, rather, we are presenting perceptions ofwhat may or may not have occurred (i.e., in the controlarm, it appears that individuals in some sites stepped upto try to mobilize and encourage the uptake of recom-mendations and the KT interventions themselves).Future research should seek to better understand thespecific characteristics/behaviours of facilitators thatare associated with successful implementation andclinical outcomes, especially within the context of strokerehabilitation.Role of practicality/familiarityPracticality of and familiarity with the recommended treat-ments and KT interventions also emerged as significantfacilitators and barriers. For example, participants indi-cated that certain recommendations/tests were not prac-tical to implement because they were time-consuming(e.g., FES unit). Indeed, it is likely that a variety of facilita-tors and barriers acted together and in combination toinfluence the implementation of the interventions in thetrial (e.g., interaction of time and practicality). Similarly, alack of familiarity with certain components of the recom-mended treatments, including equipment such as the FESapparatus and measures such as the CAHAI, limited theimplementation efforts. Indeed, results from the SCORE-IT indicated that complex treatments that either involvedmultiple steps or technology, including the FES, wererarely implemented at baseline and demonstrated eitherno change or reduced application post-intervention (un-published work). This finding suggests that the KT inter-ventions did not adequately overcome these barriers. It ispossible that these barriers cannot be overcome with KTinterventions, especially within the context of a trial (i.e.,lack of familiarity with a recommendation(s) and itsimplementation can only be overcome with a significantamount of time); however, it is possible that facilitation(i.e., mentorship) could be leveraged to overcome barriersassociated with practicality and/or familiarity. Further-more, previous research has reported that insufficientskills and a lack of experience with guideline recommen-dations are key barriers to implementation of bestpractices [6, 11, 36–38]. It could be that a mid-point checkMunce et al. BMC Health Services Research  (2017) 17:440 Page 9 of 13of progress and renewed goal setting might be helpful toaddress these barriers.Role of environmental factorsEnvironmental factors, including time pressure, insuffi-cient staff (lack of staff, staff turnover), lack of space andequipment, and organizational constraints (insufficientsupport from the organizational/senior management)emerged as the most frequently cited barriers to imple-mentation of the KT interventions during the trial aswell as the recommendations. In a recent study describ-ing the factors influencing the implementation of strokeclinical practice guidelines among speech pathologists,Hadely and colleagues [36] also reported that factorswithin the work environment were barriers to imple-mentation. Specifically, the main barriers included lackof time, education, treatment resources, and standardizedassessments to carry out guideline implementation [36].Environmental/work factors as barriers (and facilitators)to guideline implementation have been reported consist-ently in literature – in the treatment of persons post-strokeas well as other chronic conditions [6, 11, 37, 39, 40]. Inthe current study, one of the main findings was that envir-onmental factors were seldom noted as facilitators to theimplementation of the recommended treatments and/orKT interventions. It should also be highlighted that someof these environmental factors were mitigated by team fac-tors/facilitation. Thus, a main message from our researchis that in the absence of more organizational resources(time, money), team factors can be leveraged to overcomesuch deficits. For example, a high level of staff turnoverwas noted across the rehabilitation centers; however, ifstrong leadership/management support was present at therehabilitation center, this person often ensured that newstaff knew the procedures/responsibilities associated withthe trial. Horne [35] similarly noted that leaders andeven the larger hospital administrative culture couldact as key mediators between the environmental fac-tors (time, money, equipment) and the implementa-tion of recommendations.Role of team communication and interdisciplinarycollaborationThe presence of team factors, including communicationand interdisciplinary collaboration, served as a facilitatorto the implementation of the recommended treatments.Donnellan and colleagues [17] also determined that bar-riers to adherence to generic stroke guidelines related toorganization and multidisciplinary team factors [41–43].Similarly, team factors played a significant role in influ-encing the implementation of stroke clinical practiceguidelines in the study by Hadely and colleagues [36]. Forexample, they determined that working in a multi-disciplinary team emerged as a main factor for facilitatingthe use of guidelines among speech pathologists. Thesefactors have also been reported among physicians, nurses,and OTs [11, 40, 44–47]. Hadely and colleagues [36] con-cluded that fostering teamwork can have a significantinfluence not only in improving guideline implementationbut also patient functional gains [48] and length ofhospital stay [49].Use of the clinical practice guidelines framework forimprovementFindings from the current study also suggest that the Clin-ical Practice Guidelines Framework for Improvement [19]is relevant in the context of implementing recommendedtreatments and KT interventions in stroke rehabilitationas agreement with the intervention – practical, familiarity(with the recommended treatments), and three aspects ofenvironmental factors were identified as factors influen-cing implementation. The other identified factors of facili-tation and team communication and interdisciplinarycollaboration are not included in the Clinical PracticeGuidelines Framework for Improvement [19] and itsupdates [20–22] but are included in other implementationframeworks, namely the Consolidated Framework forImplementation Research (i.e., formally appointed internalimplementation leaders versus champions, networks andcommunications) [50] and the Promoting Action onResearch Implementation in Health Services (PARIHS)(i.e., facilitation) [51]. Future iterations of the ClinicalPractice Guidelines Framework for Improvement [19]could consider these factors, which may improve its abilityto address common facilitators and barriers in thiscontext. Lastly, another area of future research would bedetermining the perceived relative importance of theseidentified facilitators and barriers (e.g., using a modifiedDelphi process).Comparison of identified facilitators and barriers to pilotprojectIt is noteworthy that many of the identified factors influ-encing the implementation of the recommended treat-ments and KT interventions were also identified in ourprevious multi-site pilot project on the barriers to theimplementation of evidence-based recommendation forstroke rehabilitation (i.e., lack of time, inadequate staff-ing, and equipment). As previously identified, many ofthese environmental barriers are difficult to overcomeand beyond the control of the trial implementationeffort. We also previously noted that leaders at theorganizational level may be required to overcome theseissues; however, in the current study, organizational con-straint (insufficient support from the organizational/se-nior management) was a noted barrier across both armsof the trial. Thus, we may not have adequately addressedthese barriers (and the interrelated nature of theseMunce et al. BMC Health Services Research  (2017) 17:440 Page 10 of 13barriers) in the current trial. At the same, team function-ing and communication was previously noted in thepilot study but was identified as both a facilitator andunintended benefit in the current study.LimitationsWe acknowledge some limitations. Only one personcoded the majority of the data, which may have resultedin bias. The persons conducting the original study alsoconducted the focus groups, which presents a significantconcern about the social desirability of participantresponses. At the same time, however, the focus groupleaders were careful to avoid biasing the participants to-wards or away from the intervention and were themselvesneutral on its effectiveness (i.e., clinical equipoise). Fur-thermore, only 11 of the 20 sites participated (but almostequal representation from the facilitated KT and passiveKT arms), and thus it is possible that a selection bias oper-ated in that those participants who agreed to take part inthis study may have had a greater interest and successwith implementing evidence-based recommendations forstroke than those individuals who chose not to participate(i.e., limiting the applicability of the study findings). In dis-cussing factors influencing the implementation of the KTinterventions following completion of the trial, partici-pants may have had recall bias; in a focus group setting,participants may also have felt limited in their ability toshare their experiences due to social desirability issues.Organizing the focus groups by professional group was anattempt to mitigate this potential barrier. Furthermore,the focus group questions did not specifically ask about allof the factors influencing the 18 recommended treatmentsof interest (e.g., training for sitting balance, training forstanding balance) or did not consistently ask about eachof the KT interventions. As such, we are only able toobtain a global sense of the factors influencing implemen-tation of the recommended treatments and their associ-ated KT interventions. This may mask specific issues forspecific interventions. The focus group questions were notanchored on the actual performance of the rehabilitationcentres; more specific knowledge about the facilitatorsand barriers to implementation would have been obtainedif this approach has been adopted (as discussed above inthe Role of Facilitation section). Lastly, the trial and thesubsequent focus groups were conducted a number ofyears ago; it is unknown how a more recent implementa-tion of stroke recommendations and interventions toincrease their uptake would affect the current results(e.g., with health system advances such as electronicmedical records with reminders).ConclusionsFactors influencing the implementation of the recom-mended treatments and KT interventions includingfacilitation, agreement with the intervention – practical,familiarity with the recommended treatments, environ-mental factors, and team communication and interdiscip-linary collaboration were identified in both arms of thetrial. Despite the absence of formally instituted facilitatorsin the passive KT arm, facilitation was identified as an im-portant facilitator influencing implementation of the KTinterventions in this arm of the trial. This may suggest theimportant role of self-selected facilitators to implementa-tion efforts. Future research should seek to better under-stand the specific characteristics/behaviours of facilitatorsthat are associated with successful implementation andclinical outcomes, especially within the context of strokerehabilitation. Lastly, the current study highlights thechallenges of overcoming environmental factors includingtime pressures and insufficient staff in implementationefforts and the need for organizational support to mitigatethese challenges.Additional fileAdditional file 1: SCORE-IT Interview Guide for Facilitated and ActiveSites’ Focus Groups. Description of data: Interview guides for facilitatedand active sites’ focus groups including guides for the clinical managers,therapists, and nurses. (DOCX 40 kb)AbbreviationsCAHAI: Chedoke Arm and Hand Inventory; EIPR: Evidence Informed PracticeRecommendation; FES: Functional electrical stimulation; OT: Occupationaltherapist; PT: Physical therapists; SCORE-IT: Stroke Canada Optimization ofRehabilitation by Evidence Implementation TrialAcknowledgementsWe thank Ms. Saeha Shin for her assistance with completing the references.FundingSEPM has received support from a Heart and Stroke Foundation of CanadaFocus on Stroke Fellowship, the Toronto Rehabilitation Institute-UniversityHealth Network, and a Canadian Institutes of Health Research Fellowship.NMS is supported by the Canadian Institutes of Health Research and theGovernment of Ontario.The SCORE-IT trial was funded by the Canadian Stroke Network of the Networksof Centers of Excellence program.Availability of data and materialsThe data generated during and/or analyzed during the current study areavailable from the corresponding author on reasonable request.Authors’ contributionsMTB and SWD designed the original trial in consultation with SB, JD, JJE, IDG,SBJ, N K-B, M M-L, NEM, JM, CLR, NMR, RWT and MZ. MTB, SWD, and JMcollected the data. SEPM analyzed the data in consultation with MTB. SEPMdrafted the manuscript. All authors reviewed and revised the manuscriptcritically for important intellectual content. All authors read and approvedthe final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Munce et al. BMC Health Services Research  (2017) 17:440 Page 11 of 13Ethics approval and consent to participateResearch ethics approval was obtained from each site and affiliated university,including Toronto Rehabilitation Institute-University Health Network. Allparticipants provided written consent prior to the interview.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Toronto Rehabilitation Institute-University Health Network, 550 UniversityAvenue, Toronto, Ontario M5G 2A2, Canada. 2Centre for Practice-ChangingResearch, The Ottawa Hospital Research Institute, 501 Smyth Road, Box 711,Ottawa, Ontario K1H 8L6, Canada. 3Department of Physical Therapy,University of Toronto, 160-500 University Ave, Toronto, Ontario M5G 1V7,Canada. 4Department of Rehabilitation, Faculty of Medicine, Université Lavaland Centre de Recherche en Réadaptation et Intégration Sociale (CIRRIS),Québec City, Quebec, Canada. 5Institut de Réadaptation en DéficiencePhysique de Québec (IRDPQ) Site Hamel, 525 Boul. Wilfrid-Hamel Est, QuébecCity, Quebec G1M 2S8, Canada. 6University of British Columbia, 212 - 2177Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. 7Université de Sherbrooke,Faculty of Medicine and Health Sciences, 3001, 12e avenue nord, BureauFM-2208, Sherbrooke, Québec J1H 5N4, Canada. 8Office 405 Forrest Building,School of Physiotherapy, Dalhousie University, 5869 University Avenue, POBox 15000, Halifax, Nova Scotia B3H 4R2, Canada. 9McGill University, Schoolof Physical and Occupational Therapy, 3630 Promenade Sir William Osler,Montreal, Quebec H3G 1Y5, Canada. 10Division of Clinical Epidemiology,Division of Geriatrics, McGill University Health Center, Royal Victoria HospitalSite, Ross Pavilion R4.29, 687 Pine Ave West, Montreal, Quebec H3A 1A1,Canada. 11Parkwood Institute, 550 Wellington Road, London, Ontario N6C0A7, Canada. 12Schulich School of Medicine & Dentistry, Western University,Western Centre for Public Health and Family Medicine, 1151 Richmond St,London, Ontario N6A 3K7, Canada. 13Sunnybrook Health Sciences Centre,2075 Bayview Avenue, Room A4 21, Toronto, Ontario M4N 3M5, Canada.14Neuro Rehabilitation Program, Toronto Rehabilitation Institute-UniversityHealth Network, 550 University Avenue, room 3-131 (3-East) 3rd FloorUniversity Wing, Toronto, ON M5G 2A2, Canada.Received: 14 December 2016 Accepted: 14 June 2017References1. 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Nurs Care Qual. 2004;19(4):297–304.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Munce et al. BMC Health Services Research  (2017) 17:440 Page 13 of 13

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