Table 4.
GRADE-CERQual summary of qualitative review findings table: barriers and facilitators of implementing evidence-based guidelines in long-term care
| 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, 39–44, 47, 49, 53, 55–57, 60, 61, 63–65] | 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 | [36–41, 43, 48, 51, 53, 55–57, 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 | [36–42, 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, 55–59, 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, 58–60, 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, 58–60, 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, 43–46, 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, 52–54, 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, 57–59, 61, 63–65, 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, 52–54, 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 |