Table 1 Characteristics of included studies

Meurer (2011) [60]

USA

To describe barriers to thrombolytic use in acute stroke care

t-PA

Qualitative study

- 65 emergency physicians

- 62 nurses

- 15 neurologists

- 12 radiologists

- 12 hospital administrators

- 3 others (hospitalists and pharmacist)

Focus groups/interviews

topic guide

Patient factors:

delayed presentation, family issues, age of patient, demand for t-pa, language, adverse to taking ambulance, early symptom recognition

Guideline factors:

characteristics of the guideline, outcome expectancy, presence of contradictory guidelines or “position statements on guidelines, lack of clarity on guidelines

Individual health professionals:

lack of awareness of acute stroke guidelines, lack of guideline familiarity, interpretation confidence, lack of guideline agreement, lack of self-efficacy, lack of motivation, inadequate communication of the time sensitive nature of CT ordering and interpretation, inaccurate patient weight, staff recognition of stroke symptoms

Resources and incentives:

availability of scanner, financial issues, lack of motivation and ICU bed availability

Organisation context/health system:

lack of system process to alert radiologists of the emergency nature of stroke-related scans, laboratory-based barriers, limited neurosurgery, lack of follow up/feedback, ED overcrowding, lack of a protocol, limited neurology, hospital notification, lack of speed, pharmacy and drug delivery delay or shortage barriers, fear of liability for use or non-use of t-PA, triage barriers, difficulty arranging for transfer from clinics

Hargis

(2015) [65]

USA

To identify barriers to the administration of intravenous tissue plasminogen activator (t-PA)

t-PA

Cross-sectional study

Stroke coordinators (36)

Survey

questionnaire

Individual health professionals:

physician reluctance to use t-PA and lack of urgency in emergency department

Professional interactions:

poor communication between care providers

Organisation context/health system:

lack of a dedicated and trained stroke nurse, role definition not clear

Patient factors:

patients’ late arrival

Chan (2005) [63]

USA

To assess the experience, knowledge and attitudes of emergency department directors on their use of t-PA

t-PA

Cross-sectional study

52 emergency physicians (directors)

Survey questionnaire

Guideline factors:

ED directors’ attitudes regarding its safety

Individual health professionals:

suboptimal nursing staff support, lack of neurological support, lack of neurosurgical support, lack of radiological support, willingness to use t-PA to treat acute ischemic stroke

Resources and incentives:

lack of CT access and lack of CT interpretation availability

Organisation context/health system:

lack of institutional attitudes, availability of ED protocols for use t-PA use, general lack of institutional support, limited radiological back up for CT interpretation and lack of protocols to support t-PA use

O’Rourke (2013) [66]

Australia

To determine stroke clinicians’ preferences for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit model

Stroke unit

Cross-sectional study

228 participants

−99 allied health

−72 nurses

−57 doctors

Survey questionnaire

Organisation context/health system:

Stroke unit care not seen as priority by hospital, lack of management support and lack of staffing

Professional Interactions:

lack of allied health support, lack of nursing support and lack of physician support

Resources and incentives: lack of time, lack of money and lack of physical space

Guideline factors:

lack of evidence

William (2013) [69]

Australia

To identify barriers which prevent rural health care providers from utilising t-PA in acute ischaemic stroke and proposes possible support mechanisms to increase its utilisation

t-PA

Cross-sectional study

11 physicians

13 nurses

Survey questionnaire

Organisation context/health system:

lack of stroke protocols and pathways support, lack of administrative support, emergency department delays, lack of support

Resources and incentives:

unsuitable hospital setting

Individual health professionals:

lack of knowledge and education on the use of t-PA, uncertainty with patient selection criteria, experience with t-PA inclusion and exclusions, personal stroke neurological experience, clinical diagnostic uncertainty

Patient factors:

pre-hospital delays

Guideline factors:

risk of intracerebral haemorrhage, uncertainty about benefits of t-PA

Purvis (2014) [62]

Australia

To determine the local enablers and barriers to providing evidence-based stroke care

Stroke unit and t-PA

Qualitative study

84 clinicians (nurses, allied health staff, department or unit managers and physicians)

Semi-structured interviews and focus group

topic guide

Organisation context/health system:

shortage of neurologists, lack of formalized guidelines or protocols, inconsistent use of pathways, lack of staff to constantly update pathways/guidelines, lack of formalised process to support consistent education, heavy workloads, lack of dedicated physician or nurse for stroke care, limited funding for staff professional development, lack of dedicated allied health positions, frequent rotation of staff, lack of executive support and employment of part time staff

Resources and incentives:

limited number of stroke unit beds, lack of dedicated stroke unit, lack of resources, lack of time to provide education

Professional interactions:

lack of strong medical leadership–delays in clinical decisions

Individual health professionals:

resistance from ED doctors to use thrombolysis, lack of awareness on time constraints to t-PA, inability to administer t-PA and inconsistency administering of t-PA

Grady (2014) [64]

Australia

To assess emergency physicians’ perceptions of individual and system enablers to the use of tissue Plasminogen activator in acute stroke

t-PA

Cross-sectional study

429 participants

Australasian College for Emergency Medicine Members

Survey

questionnaire

Organisation context/health system:

performance monitoring, providing feedback on stroke care performance, checklist/decision aids (maintenance)

Individual health professionals:

knowledge on the use of t-PA treatment, skill and competency to use t-PA, modelling use of t-PA by senior staff

Van Der Weijden (2004) [68]

The Netherlands

To investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies

Aspirin

t-PA

Cross-sectional study

201 neurologists

Survey

questionnaire

Organisation context/health system:

lack of manpower, poor patient flow to the rehabilitation care centre and time to treatment delays (defiant referral behaviour of general practitioners)

Resources and incentives :

insufficient hospital logistics or beds

Individual health professionals:

negative attitude towards guideline use, lack of experience or competence, lack of knowledge

Patient factors:

patients are too late in hospital, hesitation by the patient or carer to use guideline

Guideline factors:

lack of confidence in the evidence, fear of complications, disagreement with stroke care guidelines and doubt of cost effectiveness/high cost of guideline implementation

Slot (2009) [67]

Scandinavian countries (Norway, Denmark and Sweden)

To describe the use of t-PA in the hospitals, assess stroke doctors’ opinions on the use of t-PA, identify existing barriers against treatment and to ways to overcome the barriers

t-PA

Cross-sectional study

453 doctors

Survey

questionnaire

Organisation context/health system:

lack of urgent triaging of stroke patients by ED due to high workload, hospitals lack of good protocols⁄routines for t-PA, and ambulance service staff inadequate triaging of acute stroke patients

Individual health professionals:

ambulance staff lack of knowledge about t-PA, ED lack of knowledge about thrombolytic treatment and disapproval of the use of t-PA by physicians

Patient factors:

patients ⁄lack of early recognition of symptoms, patients delay in contacting ambulance service and patients disinterest in t-PA due to side effects

Guideline factors:

risk of intracranial haemorrhage

Stecksen (2013) [61]

Sweden

Identify facilitators of and barriers to the implementation of national guidelines on thrombolytic therapy for acute ischemic stroke

t-PA

Qualitative study

9 physicians

7 nurses

Semi-structured interviews

Interview guide

Organisation context/health system:

stressful and overburdened working conditions, formal power structures, failure to react to guideline deviations, limited human resource capacity/few staff for stroke care, lack of continuity, duty schedule inhibiting training and lack of institutional support

Resources and incentives:

limited financial resources and insufficient time

Professional interactions:

poor professional identity, insufficient recognition by peers, inter-intra professional power structures, lack of support from more advanced hospitals and prestige and power relations

Individual health professionals

old-fashioned views, lack of experience with thrombolytic therapy, limited time, patients’ recruitment difficulties, lack of knowledge, lack of awareness of stroke as an emergency by ambulance services and other hospital staff and anxiety in using t-PA

Patient factors:

low awareness/knowledge of stroke symptoms causes delays

Guideline factors:

low expectations of therapeutic options, undue respect for the treatment (t-PA) and strict criteria for t-PA