Table 1.

Characteristics of included studies

Lead author, year and country	Study aim	Stroke intervention	Study design	Participants/sample size	Data collection methods tools	Barriers or enablers
Meurer (2011) [60] USA	To describe barriers to thrombolytic use in acute stroke care	t-PA	Qualitative study	- 65 emergency physicians - 62 nurses - 15 neurologists - 12 radiologists - 12 hospital administrators - 3 others (hospitalists and pharmacist)	Focus groups/interviews topic guide	Patient factors: delayed presentation, family issues, age of patient, demand for t-pa, language, adverse to taking ambulance, early symptom recognition Guideline factors: characteristics of the guideline, outcome expectancy, presence of contradictory guidelines or “position statements on guidelines, lack of clarity on guidelines Individual health professionals: lack of awareness of acute stroke guidelines, lack of guideline familiarity, interpretation confidence, lack of guideline agreement, lack of self-efficacy, lack of motivation, inadequate communication of the time sensitive nature of CT ordering and interpretation, inaccurate patient weight, staff recognition of stroke symptoms Resources and incentives: availability of scanner, financial issues, lack of motivation and ICU bed availability Organisation context/health system: lack of system process to alert radiologists of the emergency nature of stroke-related scans, laboratory-based barriers, limited neurosurgery, lack of follow up/feedback, ED overcrowding, lack of a protocol, limited neurology, hospital notification, lack of speed, pharmacy and drug delivery delay or shortage barriers, fear of liability for use or non-use of t-PA, triage barriers, difficulty arranging for transfer from clinics
Hargis (2015) [65] USA	To identify barriers to the administration of intravenous tissue plasminogen activator (t-PA)	t-PA	Cross-sectional study	Stroke coordinators (36)	Survey questionnaire	Individual health professionals: physician reluctance to use t-PA and lack of urgency in emergency department Professional interactions: poor communication between care providers Organisation context/health system: lack of a dedicated and trained stroke nurse, role definition not clear Patient factors: patients’ late arrival
Chan (2005) [63] USA	To assess the experience, knowledge and attitudes of emergency department directors on their use of t-PA	t-PA	Cross-sectional study	52 emergency physicians (directors)	Survey questionnaire	Guideline factors: ED directors’ attitudes regarding its safety Individual health professionals: suboptimal nursing staff support, lack of neurological support, lack of neurosurgical support, lack of radiological support, willingness to use t-PA to treat acute ischemic stroke Resources and incentives: lack of CT access and lack of CT interpretation availability Organisation context/health system: lack of institutional attitudes, availability of ED protocols for use t-PA use, general lack of institutional support, limited radiological back up for CT interpretation and lack of protocols to support t-PA use
O’Rourke (2013) [66] Australia	To determine stroke clinicians’ preferences for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit model	Stroke unit	Cross-sectional study	228 participants −99 allied health −72 nurses −57 doctors	Survey questionnaire	Organisation context/health system: Stroke unit care not seen as priority by hospital, lack of management support and lack of staffing Professional Interactions: lack of allied health support, lack of nursing support and lack of physician support Resources and incentives: lack of time, lack of money and lack of physical space Guideline factors: lack of evidence
William (2013) [69] Australia	To identify barriers which prevent rural health care providers from utilising t-PA in acute ischaemic stroke and proposes possible support mechanisms to increase its utilisation	t-PA	Cross-sectional study	11 physicians 13 nurses	Survey questionnaire	Organisation context/health system: lack of stroke protocols and pathways support, lack of administrative support, emergency department delays, lack of support Resources and incentives: unsuitable hospital setting Individual health professionals: lack of knowledge and education on the use of t-PA, uncertainty with patient selection criteria, experience with t-PA inclusion and exclusions, personal stroke neurological experience, clinical diagnostic uncertainty Patient factors: pre-hospital delays Guideline factors: risk of intracerebral haemorrhage, uncertainty about benefits of t-PA
Purvis (2014) [62] Australia	To determine the local enablers and barriers to providing evidence-based stroke care	Stroke unit and t-PA	Qualitative study	84 clinicians (nurses, allied health staff, department or unit managers and physicians)	Semi-structured interviews and focus group topic guide	Organisation context/health system: shortage of neurologists, lack of formalized guidelines or protocols, inconsistent use of pathways, lack of staff to constantly update pathways/guidelines, lack of formalised process to support consistent education, heavy workloads, lack of dedicated physician or nurse for stroke care, limited funding for staff professional development, lack of dedicated allied health positions, frequent rotation of staff, lack of executive support and employment of part time staff Resources and incentives: limited number of stroke unit beds, lack of dedicated stroke unit, lack of resources, lack of time to provide education Professional interactions: lack of strong medical leadership–delays in clinical decisions Individual health professionals: resistance from ED doctors to use thrombolysis, lack of awareness on time constraints to t-PA, inability to administer t-PA and inconsistency administering of t-PA
Grady (2014) [64] Australia	To assess emergency physicians’ perceptions of individual and system enablers to the use of tissue Plasminogen activator in acute stroke	t-PA	Cross-sectional study	429 participants Australasian College for Emergency Medicine Members	Survey questionnaire	Organisation context/health system: performance monitoring, providing feedback on stroke care performance, checklist/decision aids (maintenance) Individual health professionals: knowledge on the use of t-PA treatment, skill and competency to use t-PA, modelling use of t-PA by senior staff
Van Der Weijden (2004) [68] The Netherlands	To investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies	Aspirin t-PA	Cross-sectional study	201 neurologists	Survey questionnaire	Organisation context/health system: lack of manpower, poor patient flow to the rehabilitation care centre and time to treatment delays (defiant referral behaviour of general practitioners) Resources and incentives : insufficient hospital logistics or beds Individual health professionals: negative attitude towards guideline use, lack of experience or competence, lack of knowledge Patient factors: patients are too late in hospital, hesitation by the patient or carer to use guideline Guideline factors: lack of confidence in the evidence, fear of complications, disagreement with stroke care guidelines and doubt of cost effectiveness/high cost of guideline implementation
Slot (2009) [67] Scandinavian countries (Norway, Denmark and Sweden)	To describe the use of t-PA in the hospitals, assess stroke doctors’ opinions on the use of t-PA, identify existing barriers against treatment and to ways to overcome the barriers	t-PA	Cross-sectional study	453 doctors	Survey questionnaire	Organisation context/health system: lack of urgent triaging of stroke patients by ED due to high workload, hospitals lack of good protocols⁄routines for t-PA, and ambulance service staff inadequate triaging of acute stroke patients Individual health professionals: ambulance staff lack of knowledge about t-PA, ED lack of knowledge about thrombolytic treatment and disapproval of the use of t-PA by physicians Patient factors: patients ⁄lack of early recognition of symptoms, patients delay in contacting ambulance service and patients disinterest in t-PA due to side effects Guideline factors: risk of intracranial haemorrhage
Stecksen (2013) [61] Sweden	Identify facilitators of and barriers to the implementation of national guidelines on thrombolytic therapy for acute ischemic stroke	t-PA	Qualitative study	9 physicians 7 nurses	Semi-structured interviews Interview guide	Organisation context/health system: stressful and overburdened working conditions, formal power structures, failure to react to guideline deviations, limited human resource capacity/few staff for stroke care, lack of continuity, duty schedule inhibiting training and lack of institutional support Resources and incentives: limited financial resources and insufficient time Professional interactions: poor professional identity, insufficient recognition by peers, inter-intra professional power structures, lack of support from more advanced hospitals and prestige and power relations Individual health professionals old-fashioned views, lack of experience with thrombolytic therapy, limited time, patients’ recruitment difficulties, lack of knowledge, lack of awareness of stroke as an emergency by ambulance services and other hospital staff and anxiety in using t-PA Patient factors: low awareness/knowledge of stroke symptoms causes delays Guideline factors: low expectations of therapeutic options, undue respect for the treatment (t-PA) and strict criteria for t-PA