Skip to main content

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

From: Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis

  Summary of review finding Contributing articles Frequency CERQual Assessment of confidence in the evidence Explanation of CERQual assessment
Barriers 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] 32 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] 26 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] 25 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] 22 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] 20 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] 19 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] 15 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] 15 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] 15 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] 13 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] 12 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] 12 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] 11 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] 8 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] 8 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] 8 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] 5 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] 4 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] 4 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] 2 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] 2 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] 2 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] 20 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] 19 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] 18 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] 16 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] 13 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] 13 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] 12 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] 12 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] 7 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] 5 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] 5 High confidence Minor concerns regarding methodological limitations, no or very minor concerns regarding coherence, adequacy, and relevance