Table 4 GRADE-CERQual summary of qualitative review findings table: barriers and facilitators of implementing evidence-based guidelines in long-term care

Time constraints and inadequate staffing: lack of time or personnel to carry out tasks as indicated by the guideline

[36, 37, 39,40,41,42,43,44, 47, 49, 53, 55,56,57, 60, 61, 63,64,65]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Knowledge gaps: inadequate training, expertise, or awareness of the targeted condition or guideline recommendations

[36,37,38,39,40,41, 43, 48, 51, 53, 55,56,57, 61, 62, 65, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Cost and lack of resources: inadequate financial and other resources (e.g., equipment) to carry out tasks as indicated by the guideline

[36,37,38,39,40,41,42, 44, 45, 48, 51, 56, 57, 62, 63, 65]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Lack of teamwork: lack of cooperation and role coordination among the resident’s circle of care, including the LTC staff, family members, clinicians, and specialized health professionals

[36, 41, 42, 49, 51, 53, 55,56,57,58,59, 61, 63, 66, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Lack of organizational support: lack of impetus for guideline implementation from LTC home management.

[37, 38, 43, 44, 51, 53, 54, 56, 57, 60, 64, 65, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Resident complexity: complex comorbidities of LTC residents

[36, 37, 44, 50, 52, 53, 56, 57, 63, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Compromised communication and information flow: inadequate communication of relevant information between the resident, their family, staff, and/or allied health professions

[45, 48, 49, 51, 52, 54, 56, 58, 61, 66]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Staff turnover: frequent change in staff

[37, 41, 43, 47, 52, 53, 56, 63, 65, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Belief against the guideline: distrust of the guideline’s recommendations and/or of its evidence base

[36, 37, 39, 44, 51, 52, 58,59,60, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Conflict with clinical autonomy: guideline recommendations conflict with health professional’s independence for clinical judgement

[36, 40, 46, 47, 49, 51, 53, 56, 58,59,60, 62]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Emotional responses to work and confidence in skills: staff having lack of interest, negative attitude towards work, or low confidence in their ability to carry out guideline recommendation

[37, 40, 51, 56, 57, 59, 61, 62, 65]

Moderate confidence

Moderate concerns regarding methodological limitations, minor concerns regarding adequacy, and no or very minor concerns regarding coherence and relevance

Competing priorities: staff burdened with too many tasks to place guideline adherence at high priority

[36, 38, 44, 46, 50, 52, 56, 57, 60, 63, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Reluctance to change: comfort with existing behaviour and resistance to developing new ones.

[37, 38, 40, 41, 43,44,45,46, 51, 52, 54, 65]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Inconsistent practices: variations in practice between different health professionals in the LTC homes.

[45, 46, 49, 56, 57]

Moderate confidence

Moderate concerns regarding methodological limitations, minor concerns regarding adequacy, and no or very minor concerns regarding coherence and relevance

Moral distress: guideline conflicts with resident/staff values or generate perception that the guideline will cause negative outcomes.

[36, 41, 48, 53, 56]

Moderate confidence

Moderate concerns regarding methodological limitations, minor concerns regarding adequacy, and no or very minor concerns regarding coherence and relevance

Guideline complexity and associated workload: guideline creates additional workload to the staff due to the nature of its recommendations or complexity to process and understand the tasks

[36, 39, 41, 46, 56, 65]

Moderate confidence

Moderate concerns regarding methodological limitations, minor concerns regarding adequacy, and no or very minor concerns regarding coherence and relevance

Healthcare system structure: inability to follow the guidelines due to the organizational structure of the healthcare system

[36, 51, 54, 56]

Moderate confidence

Moderate concerns regarding methodological limitations, minor concerns regarding adequacy, and no or very minor concerns regarding coherence and relevance

Simultaneous changes or change fatigue: guideline introduces too many changes at once or staff are burdened with too many changes

[37, 53, 54]

Moderate confidence

Moderate concerns regarding adequacy, minor concerns regarding methodological limitations, and no or very minor concerns regarding coherence and relevance

Limited physical environment: lack of appropriate physical infrastructure to carry out guideline recommendations

[39, 47, 56, 61]

Moderate confidence

Moderate concerns regarding methodological limitations and adequacy, no or very minor concerns regarding coherence and relevance

Conflicting guidelines: guideline conflicts with another guideline on the same topic or current practice in the LTC homes

[36, 47, 56]

Moderate confidence

Moderate concerns regarding adequacy, minor concerns regarding methodological limitations, and no or very minor concerns regarding coherence and relevance

Impractical guideline: guideline is not practical to the LTC setting

[44, 60]

High confidence, moderate confidence

Minor concerns regarding methodological limitations and adequacy, no or very minor concerns regarding coherence and relevance

Reactive approach: responding to problems once they occur rather than focusing on prevention

[36, 48]

Moderate confidence, high confidence

Moderate concerns regarding adequacy, minor concerns regarding methodological limitations, and no or very minor concerns regarding coherence and relevance

Lack of noticeable improvement from guideline implementation

[65, 67]

Moderate confidence

Moderate concerns regarding adequacy, minor concerns regarding methodological limitations, and no or very minor concerns regarding coherence and relevance

Leadership and champions: LTC managers and leaders support the guideline implementation. Experienced champions are present to actively promote change and provide support to organizational members

[28, 37, 40, 44, 46, 49, 52,53,54, 57, 64, 65]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Well-designed strategies, protocols, and resources: designing strategies, protocols, and tools that promote guideline uptake and minimize burden on the LTC system

[28, 38, 40, 44, 53, 55, 57, 64, 65, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Facilitators

Support and coordination among staff: collaborative decision-making, clear role coordination, and encouragement among LTC staff

[28, 37, 42, 44, 49, 50, 57, 61, 64, 65, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Adequate knowledge and education: continuous education and training specific to the LTC context to ensure that the care team have the knowledge and skills to carry out guideline interventions

[37, 38, 46, 50, 52, 55, 57,58,59, 61, 63,64,65, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Involving residents and families: engaging residents and families in decision-making and education

[38, 42, 44, 50, 53, 57, 63, 65]

High confidence, high confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Positive emotional responses to work and the intervention: the resident’s care team value the intervention and demonstrate interest in developing care

[40, 52,53,54, 64, 65]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Adequate services, resources, and time: staff have enough resources and time to carry out guideline interventions

[28, 44, 46, 49, 50, 54, 57, 64]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Noticeable outcomes from guideline implementation: positive outcomes following guideline usage

[28, 37, 44, 47, 53, 64]

Moderate confidence

Moderate concerns regarding methodological limitations, minor concerns regarding adequacy, and no or very minor concerns regarding coherence and relevance

Good communication and information flow: information regarding new protocols or resident assessment is communicated promptly and regularly to and among the resident’s care team

[42, 44, 50, 54, 55]

Moderate confidence

Moderate concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance

Conviction that the guideline is evidence-based and will demonstrate improvement: the resident’s care team believe that the guideline is evidence-based and that guideline interventions will lead to positive outcomes

[44, 50]

Low confidence

Serious concerns regarding adequacy, minor concerns regarding methodological limitations, no or very minor concerns regarding coherence and relevance

Innovative environmental modifications: innovative physical modification in the physical environment that promotes guideline usage

[38, 63, 67]

High confidence

Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance