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Table 1 Framework for adherence to critical care nutrition clinical practice guidelines

From: Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients

Thematic domain and sub-domain Barrier Example of potential Item
CPG Characteristics Outdated Current scientific evidence supporting some nutrition interventions is inadequate to inform practice.
Vague or complex statements
Lack of evidence
Implementation Process Lack of availability of all ICU Team to attend meetings, educational sessions etc. Not enough time dedicated to education and training on how to optimally feed patients.
No dedicated individual willing to ‘champion’ the guidelines
Time commitment to develop and implement educational strategies
Restricted access to computers
Displacement of posters and pamphlets over time
Institutional Characteristics   
Hospital and ICU Structure Community hospital N/A (i.e., non actionable barriers)
  Open structure  
  Rural location  
  Small hospital and/or ICU  
  Lack of geographical consolidation  
Hospital Processes Long, slow administrative process Our ICU Managers/Directors are [not] supportive of implementing nutrition guidelines.
Disconnect between priorities of management and clinical personnel
Organizational constraints on practice
Resources for Implementation Shortage of staff Not enough nursing staff to deliver adequate nutrition.
Limited budget
Lack of appropriate equipment/materials
Lack of access to specialist services
Prevailing Culture of ICU No cohesive, multi-disciplinary team structure Our ICU team [does not] engage in joint decision-making in planning, coordinating and implementing nutrition therapy for our patients.
  No multi-disciplinary daily rounds  
  Unresolved conflict or disagreements between ICU team members  
  Reliance on written communication (e.g., Cardex, paper notes)  
  Leadership not physically present on unit  
  Poor communication  
Provider Intent to Adhere   
Provider Characteristics   
Professional Roles Circle of influence of nursing staff and allied healthcare professionals (e.g., dietitian) dependent on support of physician and leadership team I [do not] feel responsible for ensuring that my patients receive adequate nutrition while in the ICU.
Critical Care Expertise Junior, novice staff  
Locum or casual staff
Educational Background Clinical training >10 years  
Reliance on expert opinion
Personality Type B personality (i.e. relaxed and easygoing)  
Familiarity CPGs infrequently used due to rare clinical condition or narrow case-mix I am not familiar with our current guidelines for nutrition in the ICU.
Awareness Conflicting and numerous CPGs on same topic There is not enough time dedicated to education and training on how to optimally feed patients.
  Information overload  
  Time required to remain updated  
  Poor dissemination  
Outcome Expectancy Experience of adverse event from following guideline Fear of adverse events due to aggressively feeding patients.
General belief among ICU team that provision of adequate nutrition does not impact on patient outcome.
Self-efficacy (i.e., belief that one does not have the capability to perform the actions required to implement the recommendation [36]) Labour-intensive My lack of skills on how to achieve goal calories.
Complex procedure
Limited circle of influence
Motivation Inertia of previous practice, especially among experienced, older staff I am [not] willing to change my routines and habits in order to implement the recommendations of nutrition guidelines.
Resistance to change, especially locums, surgeons and non-ICU physicians.
High cost/work burden associated with following the guideline
Agreement Paucity of evidence supporting recommendation Current scientific evidence
Lack of generalizability to critical care and/or specific patient groups supporting some nutrition interventions is inadequate to inform practice.
Patient Characteristics Poor prognosis In resuscitated, hemodynamically stable patients, other aspects of patient care still take priority over nutrition.
Other priorities of care
Unstable clinical condition or contraindication
Surgical patients
Reconciliation with family preferences
  1. Italics = new themes/sub-categories not included in Cabana et al.s knowledge-attitudes-behavior framework [26].