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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


Example of potential Item

CPG Characteristics


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


Type B personality (i.e. relaxed and easygoing)









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.


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])


My lack of skills on how to achieve goal calories.

Complex procedure

Limited circle of influence


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


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].