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Table 3 Barriers to implementation

From: Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial

Theme Quote Source
Lack of facilitation It was good in theory, but we needed a person to continue with the program and reinforce it. After the booklets were handed out, we never went back to them, and I think the education needed to continue right away. If there had been someone whose main goal was to facilitate the implementation, without being pulled in different directions by other responsibilities, I think things would have gone much better. Nurse, Facilitated Site 4
We didn’t have somebody who I thought could be an actual overseer of this. If we were trying to do this again, it might be better to either have a senior being the person overseeing the project, or even get the nurse educator we have on board doing that kind of thing. Manager, Passive Site 3
We did have some new staff that came in and watched the DVD but had a bit of trouble with it because it was a very busy time for us so there was very little mentorship I think. Therapist, Passive Site 3
So I think one of the things I would suggest too is that we get a champion on the nursing unit to really, somebody who works on the unit. I mean I don’t work on the unit. I’m all over the building as an educator but somebody like [name] who would get specific education and be the champion, be the one that could be, you know, the supporter on the units, be encouraging the other staff that she’s working with to be involved and to be doing it. I think that would help… Nurse, Passive Site 1
We had one nurse who was more involved in SCORE, but because she didn’t work full time she wasn’t there every day so we missed a bit of the information and the teaching we could have gotten because she wasn’t a full time worker. I think we needed a full-time worker to be involved to have a more significant influence in pushing SCORE. She tried to get everyone aware of the project and the recommendations, and she transferred the information along to the staff. She made sure everyone was involved, and that everyone was up to date on the information about the project. Nurse, Facilitated Site 6
Lack of agreement with the intervention – not practical The DVD was a little dry. It was hard to stay awake during the presentation, so I really don’t remember much of it. At the time we were watching it we were short-staffed and trying to cram it into a lunch hour so it was hard to pay attention. I didn’t find the DVD all that useful. Manager, Passive Site 3
I know, for example that one of the recommendations for the frequency of the FES for the upper extremity was feasible for clients that were completely independent for the setup of the FES, but I think the two 30 min sessions per day recommendation was difficult to complete. Some of the recommendations were not so realistic to follow due to time constraints. Therapist, Facilitated Site 6
Lack of familiarity with the recommended treatments There were some knowledge barriers about the process of functional electrical stimulation. The specifics of being comfortable with doing it, and the intricacies, those were a barrier. Manager, Passive Site 3
I think the one thing I really struggled with before I left on Mat leave was starting the muscle stim just because I didn’t have the background as to why it was being used. Therapist, Facilitated Site 2
It could have been nice to see how that worked but we didn’t have the equipment or the education, and we wouldn’t have been comfortable doing FES without the proper training and knowledge. Therapist, Facilitated Site 4
I think we struggled the most with the [spell out acronym] CAHAI because that was new for a lot of us, and that we needed to review the most. Therapist, Facilitated Site 7
Environmental factors [Lack of Space and Equipment] Space was a bit of a barrier for the 6 min walk test, in terms of finding enough open space without obstacles. Manager, Passive Site 5
Equipment was also a barrier. Some of the slings seemed to go missing, and we didn’t have FES equipment so those are just a few examples. Therapist, Facilitated Site 4
Environmental factors [Organizational Constraints] It was a good experience, and I would do it again, but it was definitely a lot of work, and maybe it could have been more heightened with our leadership team. Manager, Facilitated Site 4
I would say no. They were aware of the project, and were given updates at the quarterly meetings, but they did not have a direct involvement. Manager, Passive Site 5
Environmental factors [Time Pressure] Another thing is I guess the implementation took more time than I thought it would, it was a bit harder to set things up than I expected. Manager, Facilitated Site 4
The CMSA was very time consuming, so I think people struggled with the time aspect, spending so much time on all of the implementations. The value of the activities was appreciated, but going through all of the tools and processes was time consuming and people resented how much time it took to implement everything. Manager, Passive Site 3
…we just haven’t got time. We’ve got new people coming in, we’ve got measures to record that we didn’t do before and I think an underlying problem is that the unit now is so busy that it isn’t adequately staffed for both physio and OT. And that’s a pre-existing problem. I think the study maybe just highlighted it a little bit but I think the therapists were, did feel a certain pressure because they knew they hadn’t got their assessments done. They knew they hadn’t got their discharge paperwork done but the patients just kept coming and coming and coming. And I’m sure that’s not unique to us and I’m sure, you know, if we gave them ten more therapists in a year’s time they’d say, they were short of staff. But I think the time was the big thing. Manager, Facilitated Site 2
Environmental factors [Insufficient Staff] We’ve been through a lot of change in the hospital, because our therapists rotate, so we were moved around a bit. That’s really part of the whole problem, because the staff that was up here got moved around, and the unit was closed for a bit around Christmas. It became difficult to incorporate best practices when we were dealing with all of these issues. I think we had to deal with therapists moving around and also being a bit understaffed. Therapist, Passive Site 5
We had staffing issues, especially OT staffing issues. We still have those issues. We’ve been at about 60% of OT staffing for a while now. The staffing for RN as well, we couldn’t get those ratios to the level we wanted. Manager, Passive Site 4
It was quite difficult since we were short staffed for probably two thirds of the duration of the project; it was difficult to do new things. When we hired a senior therapist she came on board for the last 3 months and she was able to start implementing things we would have liked to have done, some of the recommendations. I think if you have the right people, it is much easier but when we were short staffed that limited us and we just tried to do our best. Manager, Passive Site 3
Environmental factors [Lack of Space and Equipment] Space was a bit of a barrier for the 6 min walk test, in terms of finding enough open space without obstacles. Manager, Passive Site 5
Equipment was also a barrier. Some of the slings seemed to go missing, and we didn’t have FES equipment so those are just a few examples. Therapist, Facilitated Site 4
Environmental factors [Organizational Constraints] It was a good experience, and I would do it again, but it was definitely a lot of work, and maybe it could have been more heightened with our leadership team. Manager, Facilitated Site 4
I would say no. They were aware of the project, and were given updates at the quarterly meetings, but they did not have a direct involvement. Manager, Passive Site 5
Lack of team communication and interdisciplinary collaboration Well I haven’t even seen these recommendations, so I think getting together as a group and discussing it would have been useful. We should have had a meeting together to go over it, because I think we only really knew about the sheets where we ticked off the patients’ progress. Nurse, Passive Site 5
Some of the feedback I heard was that it would have been great if we had a blog or if we had a bulletin board of some sort that people would go in, post their question, had their questions answered and that kind of thing. So it would have been a little more timely in terms of getting things off the ground and that kind of stuff. It would have provided more timely clarification I think. Manager, Passive Site 1
I would, like I was saying, just maybe more communication between the disciplines as to what’s going on. That nurse facilitators may be having a meeting every few months or whatever it is, just to make sure that everybody is on the same page. Nurse, Passive Site 2