Healthcare providers’ experience of delivering a heart rate variability feedback intervention to individuals living with spinal cord injury to inform implementation into usual care

Abstract

Background

This study aimed to explore healthcare providers’ experiences of delivering heart rate variability feedback (HRV-F) therapy to individuals living with spinal cord injury (SCI) and identify potential facilitators and barriers to implementing HRV-F into usual rehabilitation care.

Methods

Six healthcare providers involved in delivering HRV-F therapy participated in an interview. The interviews were dual coded to the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) version 2.0 to identify potential barriers and facilitators for implementation.

Results

From the interviews, 166 facilitators and 187 barriers were identified and mapped into 29 interview statements for facilitators and 30 interview statements for barriers under CFIR domains, constructs and sub-constructs. The key facilitators included: (i) evidence-based implementation of HRV-F therapy, (ii) availability of champions and mentors among healthcare providers to promote delivery of HRV-F, and (iii) adaptability of HRV-F therapy to implement in different contexts and for different needs. Common barriers included: (i) workplace culture (ii) negative attitudes of healthcare providers towards HRV-F therapy, (iii) inadequate funding, (iv) information technology issues with HRV-F equipment, and (v) effectiveness of HRV-F for a wide range of individuals living with SCI.

Conclusions

The findings highlight potential facilitators and implementation strategies to overcome identified barriers to ensure effective adoption of HRV-F therapy into usual rehabilitation practices for individuals living with SCI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14800-y.

Background

Spinal cord injury (SCI) is a profoundly debilitating condition that often requires ongoing medical care and may increase the risk of secondary health issues, including cardiovascular, respiratory, and metabolic disorders [1], [2]. Globally, it is estimated that between 250,000 and 500,000 new cases of SCI occur annually, contributing to a worldwide prevalence of over 15 million individuals living with SCI [1, 3, 4]. In Australia, the healthcare system faces increasing pressure to manage both the acute and long-term complexities of providing care to individuals with SCI, with individuals with SCI accounting for approximately 1.95 million emergency department presentations and 537,000 hospitalisations in 2020–21 [5]. Over time in Australia, the SCI hospitalisation rates have increased by an annual average of 4% from 2017 to 18 to 2020–21 [5, 6]. The increase in the average hospitalisation rate of SCI highlights the need for patient-centered, innovative care models for individuals living with SCI that can improve long-term outcomes and quality of life and that can also reduce the burden on healthcare system [5, 7].

Current care approaches for individuals living with SCI are multifaceted, focusing on both acute management and long-term rehabilitation. Common current physical rehabilitation approaches include physical therapy, the use of assistive devices or mobility aids such as power assisted wheelchairs, hand bikes, adapted footwear or adapted vehicles [8]. However, apart from the mobility focused strategies, SCI rehabilitation often includes pain management and autonomic regulation through pharmacological treatments, cognitive-behavioral therapy, and invasive interventions such as spinal cord stimulators, intrathecal drug delivery systems, and surgical procedures [7, 9, 10]. While these approaches can be effective, they also have limitations, such as surgical risks, dependence on medication, or accessibility challenges [11, 12]. Existing rehabilitation approaches do not always fully address the complex and long-term needs of people living with SCI, leaving a gap in addressing chronic pain, psychological distress, and autonomic dysfunction [7, 13]. To address the long-term management of the care of individuals living with SCI, research has begun to explore non-invasive treatment options that can address the diverse physical and mental challenges, such as pain management, faced by individuals living with SCI [9, 14, 15].

Heart rate variability feedback (HRV-F) has emerged as a promising non-invasive treatment option where individuals can monitor and then influence their autonomic nervous system by regulating their heart rate and breathing [10, 11, 15]. One of the life-threatening issues for individuals living with SCI is autonomic dysreflexia (AD), caused by dysregulation in the autonomic nervous system, leading to dangerous spikes in blood pressure [12, 16]. HRV-F intervention aims to improve autonomic functions through biofeedback which promotes better autonomic control [17, 18]. This may help to reduce the frequency and severity of AD episodes [12, 18, 19]. Evidence from randomized controlled trials (RCTs) and observational studies has demonstrated HRV’s potential to improve pain perception, emotional regulation, and cardiovascular stability in individuals with neurological conditions [9, 15, 20]. Systematic reviews have suggested that HRV can help modulate the autonomic nervous system, with reported benefits including reductions in pain intensity, improvements in heart rate variability metrics as an indicative of better autonomic regulation, and reductions in anxiety and depressive symptoms [10, 11, 21, 22]. HRV-F has also been used successfully with other cohorts to improve the experience of chronic pain [21], asthma [20], depression [23], chronic obstructive pulmonary disease [24], and hypertension [25].

A clinical randomised controlled trial (RCT) to assess the feasibility of introducing HRV-F into rehabilitative care for individuals living with SCI is being conducted [17]. If the HRV-F therapy is demonstrated to be effective in improving the physical and mental health of individuals living with SCI, to ensure effective implementation of the HRV-F therapy into usual rehabilitation care, information is needed on the best approaches to deliver HRV-F. The successful adoption of HRV-F in SCI rehabilitation depends not only on its clinical effectiveness but also on the perspectives and engagement of healthcare providers, who are key stakeholders in rehabilitation service delivery. Healthcare providers play a crucial role in introducing, delivering, and advocating for new interventions, influencing patient adherence and long-term integration into care models [26, 27]. HRV-F’s feasibility, effectiveness, and alignment with current rehabilitation approaches depend on the perception of healthcare provider which directly impacts HRV-F’s implementation. Understanding their insights, including perceived barriers and facilitators, is essential for informing strategies to optimise HRV-F’s uptake into routine care for individuals living with SCI. Evaluating the experiences of healthcare professionals [26] involved in delivering the HRV-F intervention as part of the RCT, could provide valuable insights for the implement of HRV-F into usual rehabilitation care for individuals living with SCI. There is a current knowledge gap regarding potential barriers (such as resistance to change, lack of skill and facilitators (such as strong leadership, interprofessional collaboration) of implementing a new care model into usual rehabilitation care for individuals living with SCI [10]. Using the Consolidated Framework for Implementation Research (CFIR) version 2.0 [28], this study aims to explore healthcare providers’ experiences of delivering the HRV-F therapy to individuals living with SCI and identify potential facilitators and barriers to implementing HRV-F into usual rehabilitation care.

Method

Design

This was a qualitative study of healthcare providers embedded within a RCT trial that investigated HRV-F as a non-invasive self-regulatory treatment option for individuals living with SCI. The trial protocol is published elsewhere [17], but the primary goal of the HRV-F intervention was to improve autonomic and neural function by training participants to self-regulate their HRV-F through biofeedback and customised breathing strategies. Participants were randomly assigned to either a treatment group to receive HRV-F or a control group to receive usual care. The HRV-F involved weekly sessions using computer-based feedback to regulate heart rate variability through approaches to customised breathing strategies in a clinical lab setting. The study assessed the impact of HRV-F on autonomic nervous system function and cerebral blood circulation for individuals living with SCI, along with cognitive capacity, psychological status, and their quality of life. While the primary focus of HRV-F was on improving autonomic nervous system function and cerebral blood circulation, secondary outcomes included psychological measures such as stress reduction, enhanced cognitive function, and quality of sleep [17]. Preliminary results of the trial for two individuals living with SCI using HRV-F found HRV-F lowered stress, enhanced emotional control, and altered heart rate [29].

Settings and recruitment

Key informant interviews were conducted with healthcare providers involved in delivering HRV-F as part of the RCT for individuals living with SCI. Healthcare providers were providers who were involved in the design or delivery of the HRV-F intervention in the trial. Although HRV-F was self-regulated, the healthcare providers offered guidance and initial training after assessing the customised breathing patterns of individuals living with SCI and monitored participants’ progress during the trial. Ten healthcare providers were invited to participate, and six participated (60% response rate) in the interviews. Three interviewees refused to participate because they were too busy or travelling overseas and were unable to be interviewed within the study timeframe. All interviewees were given the option to be interviewed face-to-face or virtually, and all interviews were conducted virtually. Two participants were solely responsible for delivering the intervention. Additionally, one participant assisted with session scheduling and follow-ups, another contributed to delivering the initial assessment sessions, and three participants were involved in designing, guiding, and monitoring the project activities. Two participants were asked questions about the delivery of HRV-F. Questions about delivery were omitted for the participants not involved in HRV-F delivery during the interviews.

Materials

The interview guide was developed by two authors (RM, NBH) in consultation with the other team members. As the HRV-F intervention was being trialed, the interviews sought to capture information that would potentially assist in informing the implementation of HRV-F or could be viewed as a potential barrier to implementation. The interview topic covered five broad areas: (i) their current role and responsibilities within the trial; (ii) perspectives on implementation of new care initiatives or protocols in a healthcare setting; (iii) facilitators or barriers they may have experienced in the design and/or delivery of the HRV-F intervention; (iv) requirements to support the implementation of the HRV-F intervention into usual care; and (v) any recommendations regarding the potential to implement the HRV-F intervention into usual care in rehabilitation (Additional file 1. Key informant interview questions-Healthcare providers).

Data collection

All participants were provided with a participant information sheet that outlined the purpose of the study and were given an opportunity to ask any questions before the start of the interview. All interviews were conducted using Microsoft Teams and were audio-recorded. One author (NBH) conducted the interviews, with the average length of each interview of around 25–30 minutes. The interview recording was labeled with a unique identifier and stored anonymously (e.g., HCP/01). Consent for recording and participation were provided in writing prior to the interview’s commencement and verbally at the beginning of each interview. Participants were able to withdraw from the interview at any point.

Data analysis

Initially all interview recordings were auto transcribed using MS Word. Then all transcripts were read and/or listened to by one investigator (NBH). and any errors were manually corrected for accuracy. Interviews were transcribed verbatim from audio recordings. Three authors checked and read the auto-transcribed transcripts for accuracy and de-identified them (NBH, FK, RM). All the transcripts were entered into NVivo (QSR International Pty Ltd., Version 21], and a codebook based on the CFIR domains and constructs was developed from the transcripts by two authors (NBH, FK). Qualitative data obtained from the interviews were analysed by two authors (NBH, FK). Analysis was conducted to identify common CFIR domains, constructs, and sub-constructs in participants responses [28].

The CFIR is a widely used framework to identify and categorise potential barriers and facilitators for the implementation of a new initiative in healthcare [28, 30]. The CFIR has five domains: (i) innovation, (ii) outer setting, (iii) inner setting, (iv) individuals, and (v) implementation process; and 48 constructs aimed at creating an understanding of what factors can influence implementation outcomes [28]. To ensure the validity, two authors (NBH, FK) dual coded each transcript using the CFIR and met regularly to review coding consistency. Allocation of the CFIR domains and constructs was discussed among investigators. Any disagreements around allocation of CFIR domains and constructs were resolved by discussion among team members and through revisiting the original transcripts and audio recordings. The most common CFIR domains, constructs and subconstructs were illustrated by quotes from the interview participants.

Results

Six healthcare providers (four males and two females) completed the interviews. Two participants were involved in the delivery of the intervention and four participants were involved in both the design and delivery of the intervention. Each participant had different clinical roles and responsibilities within the trial, such as project principal investigator, clinical trial coordinator, or research assistant (Additional file 2). The participants were from different health backgrounds, including clinical physiotherapists, clinical psychologists, and rehabilitation physicians.

From the interviews, 166 facilitators and 187 barriers to the implementation of HRV-F into usual rehabilitation care for individuals living with SCI were able to be mapped to 29 interview statements for facilitators and 30 interview statements for barriers under CFIR constructs and sub-constructs, respectively (Fig. 1. Facilitators and barriers mapped into CFIR; and Additional file 3 and 4).

Fig. 1.

Facilitators and barriers mapped into CFIR. Frequency = the number of times a construct was mentioned across all interviews

Innovation domain

Seven constructs from the innovation domain were identified as facilitators or barriers to the implementation of HRV-F into usual rehabilitation care for individuals living with SCI: (i) innovation evidence-base, (ii) innovation relative advantage, (iii) innovation adaptability, (iv) innovation trialability, (v) innovation complexity, (vi) innovation design, and (vii) innovation cost.

The importance of implementing innovative practices in healthcare that were evidence-based was identified as a facilitator by all interview participants (6 out of 6 participants). Interview participants believed that demonstrating the effectiveness of HRV-F as a tool to improve the physical and/or mental health of individuals living with SCI could increase the uptake of HRV-F into usual practice, stating:

“A healthcare provider, usually in general, likes evidence-based proof … that’s what drives implementation of new treatment. (Participant 2).”

However, barriers to implementing new forms of treatment into usual rehabilitative care were also identified. A key barrier was the preference for familiar treatments, as noted by one interview participant. Common challenges included lack of clarity around existing evidence for HRV-F, with one interview participant stating:

“We don’t really know if it’s going to work for everyone. (Participant 2).”

Half (3 out of 6) of the interview participants mentioned the potential effectiveness of HRV-F to provide health benefits for individuals living with SCI as a facilitator (i.e. innovation relative advantage). The potential adaptability of delivering the HRV-F therapy virtually was discussed by all interview participants (6 out of 6 participants) and was recognised as a facilitator, with participants appreciating flexibility in delivery methods that can increase accessibility stating:

“Obviously, you don’t get the exact same feedback via telehealth, but it does promote accessibility. (Participant 1).”

The low cost and affordability of the HRV-F therapy for individuals living with SCI was cited as a facilitator (2 out of 6 participants) (e.g:“It is a self-regulation tool, non-invasive [and] very low cost and very accessible.“(Participant 2). However, cost was also identified as a barrier in terms of facilities purchasing the equipment required to deliver the HRV-F therapy as part of usual care (e.g.“The barriers would be things like buying new equipment.” (Participant 5). Most interview participants highlighted technical difficulties with an app used by individuals living with SCI to practice HRV-F at home as a common barrier (5 out of 6 participants).

Outer setting domain

Three constructs from the outer setting domain were identified as either facilitators or barriers to the implementation of HRV-F into usual rehabilitation care for individuals living with SCI: (i) local attitudes, (ii) local conditions, and (iii) policies and laws. Interview participants mentioned the negative perspective of some clinicians (3 out of 6 participants) as well as patients which could create implementation barriers, stating:

“Some clinicians don’t have any respect for this sort of treatment … like more stereotype. (Participant 3).”

Interview participants (3 out of 6 participants) identified potential issues with delivery of HRV-F to individuals living with SCI in rural and remote communities, due to the need for information technology capabilities, and delivering HRV-F outside of a rehabilitation setting (1 out of 6 participants).

Inner setting domain

Nine constructs from the inner setting domain were identified as facilitators or barriers to the implementation of HRV-F into usual rehabilitation care for individuals living with SCI: (i) structural characteristics (information technology infrastructure and work infrastructure subconstructs), (ii) relational connections, (iii) communications, (iv) culture, (v) tension for change, (vi) compatibility, (vii) relative priority, (viii) incentive systems, and (ix) available resources (funding, space, materials and equipment, and access to knowledge and information subconstructs).

Interview participants (3 out of 5) highlighted both facilitators and barriers related to the use of technology for HRV-F therapy. Facilitators included the potential empowerment of individuals living with SCI through the use of wearable devices, which allowed them to practice HRV-F at home and take control of their health stating:

“The idea of using a wearable device at home, such as the polar H10 strap, I think by allowing participants to practise at home daily. It definitely kind of gives empowers the individual to have control over their own health (Participant 1).”

Another facilitator noted by one of the interview participants was the explanation of HRV-F intervention using power point presentations before the commencement of the HRV-F trial, stating:

“Material such as the power point presentation … that helps with the delivery … not everyone learns verbally. So, by having visuals as well, I think that really helps …. this treatment. (Participant 1).”

However, there were several barriers identified which included issues with Bluetooth connectivity between devices and smart phones, leading to periods where individuals living with SCI could not practice HRV-F at home due to technical difficulties. Interview participants (3 out of 6 participants) felt that there was potential for a lack of clear roles and responsibilities within an organisation to act as barriers to the successful implementation of HRV-F into usual rehabilitation care (i.e. work infrastructure). However, interview participants (Participants 4 and 5) also mentioned that building relationships among healthcare providers through collaborative partnerships could have a positive impact on a healthcare providers confidence to deliver the HRV-F therapy into usual care (2 out of 2 participants).

Cultural resistance to accept any change was identified as a barrier, with one interview participant stating,

“If changes are a bit deviating from how individuals perceive things … individuals might … push back” (Participant 2).

Resistance to change within an organisation (3 out of 6 participants) and the potential compatibility of HRV-F in different settings were noted as barriers by interview participants (5 out of 6 participants). All interview participants agreed that the availability of resources, in terms of adequate funding for implementation, including the cost of training staff to deliver HRV-F, identification of a designated space to provide HRV-F to individuals living with SCI, and the development and provision of HRV-F therapy materials to healthcare providers, such as reading materials, presentations and other information to aid understanding of the mechanics behind, and how to deliver, the HRV-F therapy were potential implementation barriers. The interview participants particularly mentioned the importance of ensuring healthcare providers received training to deliver the HRV-F therapy. One interview participant mentioned the potential for reimbursement of time as a potential incentive to motivate healthcare providers to undertake training and implement HRV-F therapy into usual care.

Individuals domain

Eight constructs from the individual domain were identified as facilitators or barriers to the implementation of HRV-F into usual rehabilitation care for individuals living with SCI: (i) high-level leaders; (ii) opinion leaders; (iii) implementation facilitators; (iv) innovation deliverers; (iv) innovation recipients; (v) capability; (vi) opportunity; and (vii) motivation. The majority of participants emphasised the importance of gaining support from high-level leaders (3 out of 6 participants) or opinion leaders (2 out of 6 participants) within an organisation to make the implementation process for HRV-F into usual care in facilities easier. Mentors (2 out of 6 participants) and champions (4 out of 6 participants) within the healthcare team were identified as facilitators, stating:

“A champion on within the health team … can drive the change (Participant 2).”

“Having [a] mentor does help (Participant 1).”

Overall, all interview participants identified a range of healthcare providers who could potentially deliver the HRV-F therapy if it were included within usual care, including psychologists, physiotherapists, nurses, physicians, and specialist consultants. However, barriers to the delivery of HRV-F as part of usual care included the potential to overload healthcare providers with an additional responsibility (6 out of 6 participants). Interview participants were of the view that there may be potential reluctance of physicians and specialist consultants to recommend HRV-F as part of rehabilitation due to the overloaded responsibilities in hospitals and lack of time (3 out of 5 participants). Additionally, the appropriateness of the HRV-F therapy for a wide range of individuals living with SCI was questioned before the RCT results were finalised (6 out of 6 participants), stating:

“To what extent the intervention is appropriate to a wide range of individuals with spinal cord injury …. who’ll benefit is less clear (Participant 4).”

Implementation process domain

Five constructs from the implementation process domain were identified as facilitators or barriers to the implementation of HRV-F into usual rehabilitation care for individuals living with SCI: (i) assessing needs; (ii) assessing context; (iii) planning; (iv) tailoring strategies; and (v) engaging. All participants noted the importance of assessing both the need for HRV-F therapy and the context in which it is implemented. Facilitators included the ability to tailor the HRV-F therapy based on individual needs (4 out of 6 participants) and the ability to tailor the therapy to different settings and contexts (e.g. after discharge from acute care) (6 out of 6 participants). However, interview participants expressed concerns about personal and logistical challenges faced by some individuals living with SCI to receiving HRV-F, such as family issues, health problems, and financial issues, stating:

“There have been many participants actually face family challenge health challenges and financial challenges … create a kind of barrier maybe to the participation and engagement. (Participant 2).”

Interview participants had different opinions about encouraging individuals living with SCI to engage with the HRV-F therapy, if it was implemented as part of usual care. While some interview participants thought that the HRV-F therapy had good strategies to engage the individuals living with SCI (3 out of 6 participants), some participants (2 out of 6 participants) mentioned the need to shorten the time required for participation in the therapy to potentially increase engagement.

Discussion

This study explored the experience of healthcare providers in delivering an HRV-F therapy to individuals living with SCI as part of an RCT and identified the potential facilitators and barriers to implementing HRV-F into usual rehabilitation care. The main facilitators included implementation of a technique that was evidence-based, the use of champions and mentors among healthcare providers to promote delivery of HRV-F, and the ability to tailor the HRV-F therapy to different contexts and needs. The main barriers included workplace culture and potential negative attitudes of healthcare providers towards a new technique, inadequate funding to effectively implement the HRV-F therapy into usual care, the ability to deliver the HRV-F therapy in all settings (e.g. for individuals living in remote areas), information technology infrastructure-related issues with technology used for delivering the HRV-F therapy, and potential effectiveness of HRV-F for a wide range of individuals living with SCI.

Interview participants highlighted as a facilitator the importance of establishing the evidence-based for HRV-F before it could gain acceptance for widespread implementation in usual rehabilitative care. If the RCT produced demonstrable health benefits for individuals living with SCI, both individuals living with SCI and healthcare providers would be more likely to utilise the HRV-F therapy as part of usual care. Within healthcare, the need for robust evidence to implement innovative care models has been well documented [31, 32]. As reported previously, the implementation of new care models within a rehabilitation setting often yield more consistent positive outcomes when the care model is firmly supported by scientific evidence and has demonstrated benefits through lived experience of the target population [33, 34].

Interview participants highlighted the importance of leadership support and the presence of a ‘champion’ or ‘mentor’ as implementation support within the healthcare team to drive the implementation process and to overcome potential resistance to change. Existing research supports the use of champions as an aid to implementing new techniques or care models in healthcare, including in a rehabilitation setting [35–37]. Interview participants thought that support from champions would aid staff to adopt the HRV-F technique and also help keep individuals living with SCI motivated to use the technique. The involvement of champions and use of direct mentoring can act as to boost healthcare providers’ confidence when delivering new models of care [27, 38]. However, while having champions or mentors was identified as a facilitator for implementation, the lack of support from a high-level champion can act as a barrier, particularly when healthcare providers have competing responsibilities [35, 36].

Over half of the interview participants found the adaptability of delivery of HRV-F to be a facilitator to the HRV-F’s viability for individuals living with SCI, especially considering the unique needs of some individuals living with SCI. Adaptability of the delivery of HRV-F was viewed in terms of potential flexibility of session scheduling, which was found to be an enabler to accommodate different patient needs, such as delivery of HRV-F for individuals with varying levels of SCI impairment. Similarly, reflections of the application of a national policy to improve inclusion of individuals with disabilities also reported the need for adaptability in the transition process [39]. It is recognised in many studies that a lack of adaptability could hamper the adoption of a new model of care, due to the complex needs of some patients [40, 41]. However, while adaptability of a new model of care is widely cited as beneficial, adaptability has the potential to create a barrier if there is limited adherence to a care protocol (i.e. fidelity), which could diminish the effectiveness of a care model [32, 42].

Work infrastructure, such as staff workload, workplace culture that maybe resistant to change, and communication issues, particularly in rural and remote areas, were cited as barriers. Participants noted that healthcare providers are overburdened and may not have the time or willingness to take on additional tasks related to delivering the HRV-F therapy into usual care. Interview participants expressed the importance of collaborative partnerships between different healthcare providers and effective communication to build up a supportive workplace culture. Similarly, ongoing staff communication has been found to be an effective strategy to promote the readiness to change among the organisation employees in other studies [43, 44]. However, a clinician’s lack of awareness or disengagement exacerbated by non-supportive leadership can hinder the adoption of new care models [45, 46]. Some interview participants also felt that a few healthcare providers may express a negative attitude towards a new treatment for individuals living with SCI and may view HRV-F as an unconventional technique. Clinician attitudes and beliefs have been found to influence staff and patients views on the implementation of other programs, such as management of lifestyle risk factors in primary care or implementation of new surgical technologies in hospital settings [27, 41].

A lack of resources and funding for necessary equipment to deliver the HRV-F therapy within community and clinical environments was identified as a barrier by interview participants. The interview participants suggested it may be possible to use lower-cost alternatives such as using virtual trial sessions instead of face-to-face delivery in a clinical setting to make HRV-F therapy more widely accessible. However, it is possible that a low-cost alternative might not yield the desired outcomes for individuals living with SCI and may potentially compromise the quality of care [47].

The ability to train the workforce in the delivery of HRV-F was viewed by participants as essential, both to aid engagement around delivery of HRV-F and confidence among healthcare providers in adopting and delivering the HRV-F therapy in usual care. The interview participants praised the availability of clear protocol which helped them to train and deliver the HRV-F therapy during the RCT for individuals living with SCI. Investing in comprehensive and adaptive training programs enables organisations to strengthen the knowledge and skills of healthcare providers, supporting the successful adoption of new care models [48, 49].

Technology was cited as a barrier by participants in relation to the HRV-F app’s Bluetooth connectivity, which hampered the continuity of HRV-F practice sessions at home by individuals living with SCI. Interview participants thought it could be possible that equipment simplification and use of dependable technology would be able to ensure ease of use of HRV-F by individuals living with SCI. Complex information technology has previously been reported as a barrier by Dias and colleagues where the design of the electronic health record system for colorectal cancer screening led the staff not wanting to use the technology in several federally qualified health centres [50]. However, another study demonstrated that user friendly innovative information technologies can drive positive health behavior change through patient engagement in various contexts [51].

For some individuals living with SCI, there could be personal challenges, such as changes in their health status, family issues, or financial difficulties, that need to be overcome in order to engage fully with adopting HRV-F. Tailored strategies according to a patients’ need can enhance engagement and reduce drop-out, especially in settings where patients face unique barriers due complex conditions, other health-related barriers or due to their socioeconomic status [52]. The current study highlights the need for adaptation of the delivery of HRV-F therapy to allow for adjustments based on individuals living with SCI’ and their health status and other personal needs.

This study’s strength is the detailed qualitative data obtained from participants on the delivery of a new model of care, HRV-F therapy, for individuals living with SCI. Using the CFIR as a framework provided a comprehensive structure to identify factors likely to influence the implementation of HRF-F into usual rehabilitative care. The use of the CFIR strengthens the study’s rigor and allows for comparability to other implementation studies using the CFIR. However, the study has several limitations. The small sample size of the interviews may affect the generalisability of the results. Although the diversity of healthcare providers provides valuable insights, a larger sample size, including a broader representation of healthcare providers would strengthen the validity of the results. All the participants were working on the delivery of the RCT at the time of the interview, which might have caused attention biases in their views towards HRV-F. Lastly, the CFIR framework was used without any modifications, which may have caused some overlapping in the selection of constructs according to the framework. The study used predefined domains and constructs of CFIR, there might be some data that were overlooked as it did not fit within the framework.

Successfully implementing new models of care in rehabilitation is reliant on addressing potential barriers and encouraging facilitators. For example, simple, adaptable care models are often viewed as a facilitator [53–58] while complex models can be seen as a barrier [56, 59–66] to implementation. Previous studies have examined the effects of HRV, but HRV through biofeedback, which is comparatively new, and the trial outcomes are still being investigated [17, 18]. Future research should explore the long-term effects of HRV-F therapy, its applicability to other neurological conditions, and its integration with other rehabilitation interventions. Conducting larger-scale studies will be essential to validate these findings and continue to refine therapy protocols.

Conclusion

The research provided detailed insights into the facilitators and barriers of delivering a new model of care for individuals living with SCI. The findings underscore the importance of addressing barriers and facilitators and refining a model of care based on real-world feedback. Integrating HRV-F into usual rehabilitation practices and developing supportive policies could help to make this innovative therapy widely accessible for individuals living with SCI. The findings may inform future implementation strategies for similarly non-invasive interventions, particularly within a rehabilitation setting.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

AD

Autonomic dysreflexia

CFIR

Consolidated Framework for Implementation Research

HRV-F

Heart rate variability feedback

IT

Information technology

RCT

Randomised controlled trial

SCI

Spinal cord injury

Author contributions

Nabila Binte Haque: Methodology, Investigation, Visualization, Writing - Original Draft, Writing - Reviewing and Editing; Reidar P. Lystad: Conceptualization, Methodology, Investigation, Writing - Reviewing and Editing, Visualization, Supervision; Jeffrey Braithwaite: Writing - Reviewing and Editing, Supervision; Rebecca J. Mitchell: Conceptualization, Methodology, Investigation, Writing - Reviewing and Editing, Supervision, Felicia Kreps: Data analysis.

Funding

This work was funded by a grant from the NSW Ministry of Health and a Macquarie University international research excellence scholarship (iMQRES).

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval

The study involves human participants, and ethical approval was granted by the Human Research Ethics Committee (HREC) of Northern Sydney Local Health District (2020/ETH02554 and 2021/STE05161) and Macquarie University (HREC 15,907). Participants gave informed consent to participate in the study before taking part.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.