Table 1 Framework for adherence to critical care nutrition clinical practice guidelines
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CPG Characteristics | ● Outdated | Current scientific evidence supporting some nutrition interventions is inadequate to inform practice.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) | |
● Uncooperative | ||
● Laggard/skeptic | ||
Knowledge | ||
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 | ||
Attitudes | ||
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 |