Table 7 Participants' perceptions of most important barriers to implementation

Lack of time to work with patients in emergency department

Staff resistance

Workload and competing demands

Time and workload pressure for nurses

Client resistance to smoking cessation

Time and workload pressures

Too few asthma patients on in-patient units (not peak asthma season)

Public Health Nurses' limited access to CRN and lactation consultant

Limited time spent with patient, patient stay too short

Difficulty getting support and buy- in from all levels of organization (managers, nurses, physicians)

Time and workload pressures, and competing demands

SARS outbreak created delay in education and implementation

Timing of project, timing of launch, lost momentum

Workload and limited availability of CRN‡in hospital

Complexity of skills required for RPNs§

Patient issues: cost of taking action, patient motivation, communication, follow-up

Challenges of administration and coordination across four sites

Lack of physicians willingness to order high compression bandaging

Change in management in two key units

Lack of communication between hospital and public health

Lack of buy-in from nurse managers at unit level and some nurses

Lack of CRN‡ for a period of time, delay in appointing new CRN

Attitudes re clients, past experience led to belief clients can't quit smoking

Format of education manual

Lack of physician and administrative support in emergency; physicians in a hurry to send patients home

Lack of management support

Changes in senior personnel and lack of consistent champion

Organizational change, reorganization

Documentation not changed for staff to record assessment of smoking cessation

Lack of educational material for clients