Table 2.
Overview of themes, categories and sub-categories of implementation barriers in the DIP project according to the Grol and Wensing (2004) framework
| Theme | Sub-category level 1 | Sub-category level 2 | |
|---|---|---|---|
| The innovation | Project purpose | Difficulties in realizing the purposes | RCT-study, patient enrolment, data collection failed |
| of the DIP project | Development of treatment of depression in PHC units partially failed | ||
| Work environment improvements failed | |||
| Design | RCTs are extensive and complex | Extensive methodology | |
| Difficult to fulfil in a clinical context | |||
| Strains among DIP components (eg, screening, pharmacological treatment and psychological treatment) | |||
| Questionnaires were time consuming and impractical | |||
| Content | Tensions between DIP Project components | Different components of the project were valued differently (eg, screening, pharmacological treatment and psychological treatment) | |
| Screening procedure challenging patients’ rights | Waiting room screening exposed patients, endangering patient confidentiality | ||
| Unethical to approach patients about their psychiatric status when they were at the PHC for other reasons | |||
| Treatment procedures that challenged | Challenging professional roles and behaviours | ||
| the professional roles and PHC routines | Challenging PHC routines concerning length/frequency of patient visits | ||
| Challenging terminology and principles of patient interviews/counselling | |||
| Implementation | Stress associated with implementation | Meetings for education, supervision and/or training time-consuming | |
| activities | activities | Visits from DIP research group were time-consuming | |
| Conflicts emerged during out-reach visits | |||
| Reminders and feedback system contributed to stress | |||
| The professionals | Attitudes/Motivation | Underestimation of project resources | More resources needed in terms of own work than predicted/initially described |
| DIP deteriorating work environment | DIP increased work load and/or stress | ||
| Lack of agreement with the CPG-D | CPG-D viewed as unrealistic | ||
| New CPG-Ds unnecessary, previous agreements about treatment are valid | |||
| SSRI exclusive use is effective and a better treatment for the patient group | |||
| Lack of agreement with the DIP project | Negative attitudes towards PHC medical staff performing psychotherapy | ||
| Experiences of not performing according to contract | |||
| Behaviour | Not participating actively in project | Not including patients in the study | |
| Not attending DIP meetings | |||
| Deficient communications between participants | |||
| The patients | Negative attitudes | Towards depression | Patients not wanting to accept their own depression/mental illness |
| Towards screening procedure | Negative experiences of being faced with unexpected questions about mental health at PHC visit | ||
| Negative experiences of being overtly approached in waiting room | |||
| Patient | CPG-D/DIP did not suit the | PHC patients having multiple complex disorders, CPG-D too rigid | |
| characteristics | patient group | Most patients with mild or moderate depression were known | |
| Few patients | New cases of depression did not occur at the expected pace | ||
| The social network | Collaboration DIP | Participants’ needs not considered in | Meetings not responding to PHC needs (location, topics, language) |
| network and PHC | meetings | Experiences of declining interest in participating in meetings | |
| Cultures in the network | Clash between research and clinical praxis | PHC staff experienced DIP language and procedures/methods as foreign and separated from PHC practices | |
| Experienced difficulties and limited option to perform research in PHC | |||
| The organizational context | Leadership | Ambivalent leadership in PHC | Ambivalence about participating in and realizing the aims of the DIP Leaders unclear in communications and unavailable in meetings PHC management charged with complex, multifaceted tasks |
| Ineffective decision making process in PHC participating in DIP | Insufficient anchoring of DIP project with PHC management Insufficient anchoring of DIP with PHC GPs and nurses by PHC management Incomplete analysis of the resource implications for PHC units in the DIP | ||
| Capacities/resources | Staff turnovers in PHC and in DIP research group | High degree of staff turnovers in PHC during the research period | |
| Terms in PHC | Strenuous work environment in PHC | Work stress in clinical work, at the PHC units | |
| Stress and insecurity in PHC units due to fundamental organizational changes | |||
| Low control in PHC work situation and unpredictable workloads | |||
| Organizational | Shortage of staff – low priority for | Development projects not prioritized when staff shortage occurred | |
| structures | Research and Development (R&D) | Temporary GPs not suited/allowed to participate in DIP | |
| activities | Strict prioritizations of available GPs work tasks | ||
| Coinciding organizational changes in PHC – low priority for R&D | ‘Freedom of Choice in Health Act’ reform demanded time and resources | ||
| ‘Freedom of Choice in Health Act’ reform redefining PHC’s core task | |||
| Temporary emergency organization for large-scale swine-flu vaccinations | |||
| The economic and political context | Financial arrangements | R&D not one of PHC core tasks | Changed conditions for finical reimbursement, gratifying accessibility |
| Regulations Policies | PHC changed ownership from public to private |
DIP=depression in primary care; RCT=randomized clinical trial; PHC=primary health care; CPG-D=clinical practice guideline depression; SSRI=selective serotonin reuptake inhibitor.