Translating evidence into practice
Translating evidence into practice, also known as implementation, is an active process involving individuals, teams and organisations
. Knowledge translation is an essential phase of evidence-based practice which is challenging, as this phase often involves changes in knowledge, attitude and behaviour. It cannot be assumed that an intervention which has demonstrated a positive effect, been described in a journal and recommended in a clinical guideline will be translated into practice
. Nor can it be assumed that the majority of people with a health condition will routinely receive that intervention
Barrier identification is an important step in the process of knowledge translation
. As with quality improvement, clinical audits of practice may be conducted and audit feedback presented to staff
, with opportunities provided for discussion of practice gaps. Evidence-practice gaps may arise because of systemic, team or individual barriers to change. Barriers may include lack of knowledge and skills, negative or out-dated attitudes, or inefficient systems
. Some of these barriers may also be enablers. For example, a senior clinician may reject a recommended practice or conversely act as an opinion leader
. While it is possible to anticipate some barriers, assumptions should not be made about which barriers affect a team or health service
. In addition, assumptions should not be made that barriers will be the same across disciplines.
Translating stroke guideline recommendations into practice
Australian clinical guidelines for stroke management
 aim to assist clinical decision-making and promote evidence-based care. Yet guidelines contain multiple recommendations which compete for a clinicians’ attention. For example, recommendation 6.3.4 (page 18) states that patients with difficulty walking should be given the opportunity to undertake as much repetitive practice as possible, which may involve using a mechanically-assisted device such as a treadmill. To implement this recommendation, physiotherapists may need to purchase a treadmill, learn how to operate the device confidently and persuade patients to trial the equipment. Assuming that clinicians agree with, and accept these recommendations, major changes in practice are often required.
Implementation of guideline recommendations may start by conducting a baseline medical record audit, to monitor practice. Clinical audits are commonly used for quality improvement, and the process is familiar to many clinicians. Feedback can then be provided to clinicians about audit findings. Audit feedback has been shown to influence practice
. A national audit of stroke services is conducted every two years in Australia. Subsequent audit reports provide valuable feedback about practice and allow benchmarking and comparison of like-services
Audits of medical records are often conducted by individual stroke services between national sentinel audits. Staff on our stroke unit conducted three medical record audits between 2009 and 2011 to determine how much screening, assessment and intervention were being provided. An audit checklist was developed which included recommendations from the most recent stroke guidelines. A retrospective consecutive sample of 15 files of patients admitted to the stroke unit was audited in November 2009. The audits were conducted by the authors and additional staff on the unit. The audit revealed a number of practice areas where compliance with guideline recommendations was low (less than 60% compliance). Practice areas which became the focus for change included: upper limb sensory impairments, mobility including sitting balance and treadmill training; vision; anxiety and depression; neglect; swallowing; communication; education of stroke survivors and carers; return to work; and return to driving. After completing the first audit and providing feedback to stroke unit staff, the next step was to discuss potential barriers and enablers to implementation
[6, 13]. The process of using audit and feedback to drive behaviour change, and the outcomes will be described in a companion publication.
Common barriers to implementation of stroke guideline recommendations
Barriers have been identified and reported for several areas of stroke care. These barriers include lack of resources, knowledge and skills, lack of motivation to change, professional’s beliefs about their capabilities, unhelpful attitudes about a guideline recommendation and role identity issues
Professional’s beliefs about their capabilities have been reported as one key barrier to implementing recommendations
[14, 16, 20]. For example, Canadian physical therapists lacked confidence in their ability to appraise and apply stroke research
 recommended in guidelines. Occupational therapists in two Australian stroke services lacked confidence to take patients into the community for escorted outings and travel training
, as recommended in national guidelines.
Attitudes to, and beliefs about, providing an intervention were a barrier in other studies, as well as beliefs about the original research. For example, Australian medical, nursing and allied health professionals reported concerns about patient safety and the impact on their workload when asked to implement protocols for fever, hyperglycaemia and swallowing management
. In that same study, there was a reluctance to accept evidence-based protocols for early management of swallowing problems using nasogastric feeding; that reluctance reduced compliance with the protocols
Limited knowledge and skills represent a third barrier to implementing guideline recommendations in stroke rehabilitation
[14–18, 20]. In one Australian study, occupational therapists and physiotherapists reported a lack of knowledge about the evidence for providing escorted outings to people with stroke, to promote community participation
. Some stroke professionals in Canada reported difficulty appraising research and implementing some guideline recommendations
, while others felt they possessed the necessary skills (and tools) to screen for depression
. Thus there can be differences across sites and disciplines. British occupational therapists wanted training to improve their confidence when conducting depression screening, particularly when screening patients with suicidal ideation
Reduced motivation to change and implement a recommended practice is another known barrier
[15, 18]. For example Canadian occupational therapists reported low motivation to implement recommended neglect management
. In Australia, health professionals were resistant to implementing guideline recommendations for managing fever, hyperglycaemia and swallowing in acute stroke
Limited resources is one of the most commonly reported barriers to implementing stroke guideline recommendations including lack of equipment, time and staff
[14, 15, 17–20]. For example, equipment and time are necessary for implementation of neglect training
. The importance of allocating dedicated work time cannot be overstated; clinicians need to read and interpret original research
 to understand what they must ‘do’ when implementing a recommendation.
Finally, difficulty accepting that a treatment is part of a discipline’s role is a sixth barrier to implementation of guideline recommendations. For example some professionals may not identify that a particular intervention is part of their role. Stroke professionals in Australia were concerned about blurring of professional boundaries related to management of fever, hyperglycaemia and swallowing after stroke
. Some occupational therapists and physiotherapists in Australia did not identify outdoor journey training as part of their role, reducing their compliance with guideline recommendations and the evidence
. On the contrary, Canadian allied health professionals generally perceived depression screening to be part of their role when a small sample of 19 staff were surveyed
. Similarly, in England, occupational therapists were keen to assume a role screening patients for depression in the absence of an on-site clinical psychologist, since therapists already screened stroke patients for cognitive impairments
In summary, the process of identifying then targetting barriers is known to be important for successful knowledge translation. Failure to anticipate problems and barriers may results in little or no practice change. Barriers (and some enablers) have been reported to implementing stroke guideline recommendations in acute care and some areas of inpatient rehabilitation. While it is important to build on this existing knowledge, attitudes, skills and resources are likely to be different across settings, disciplines and countries. Limited research has been published about barriers facing Australian inpatient rehabilitation staff. Furthermore, much of the published data were generated from surveys, rather than in-depth interviews which can provide rich data and examples.
To help local professionals implement multiple stroke guideline recommendations, we engaged in a process to identify local barriers and enablers, informed by this prior research. We needed to determine what health professionals knew about the published research in the guidelines (knowledge), if they felt the research was strong enough to justify practice change (attitudes and intentions) and how able they felt to implement the specific recommendations and interventions with patients (skills and capabilities). The methods which we describe for obtaining the in-depth data, and the findings, should be informative for other stroke services.