Barriers to and Facilitators of Clinical Practice Guideline Use in Nursing Homes

Abstract

OBJECTIVES-To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs). DESIGN-Qualitative analysis. SETTING-Four randomly selected community nursing homes.PARTICIPANTS-NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs). MEASUREMENTS-Interviews(n = 35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.RESULTS-None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were ''checklists'' to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.CONCLUSION-Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.Address corresponding to Cathleen Colon-Emeric, MD,

Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators

“…Innovation attractiveness, credibility, and feasibility of the innovation (i.e., guideline or intervention that is perceived as new) 1) Too difficult (2/8 studies a ) (Chapman and Newenhouse, 2013;Colon-Emeric et al, 2007) Quote Licensed practical nurse : "Now, if [protocols] were technical and difficult for a layperson to read, then they weren't useful to me." (Colon-Emeric et al, 2007) 2) Not developed in view of context (2/8 studies) (ColonEmeric et al, 2007;Etheridge et al, 2014) 3) Too long (1/8 studies) (Resnick et al, 2004) 4) Not user-friendly (1/8 studies) (Resnick et al, 2004) 5) Absence of measurable outcomes (1/8 studies) (Etheridge et al, 2014) 1) Good credibility, way to promote evidence based practice, keep up-to-date with progress in a field (3/8 studies) (Capezuti et al, 2007;Colon-Emeric et al, 2007;Resnick et al, 2004) Quote Nurse practitioner: "I think it is better to do stuff that has been proven to be effective .…”

“…(Colon-Emeric et al, 2007) 2) Provide tools for implementation (2/8 studies) (Chapman and Newenhouse, 2013;Resnick et al, 2004) Quote Director of nursing: "Getting prepared to implement them (i.e., the guidelines); 'tooling them' by developing tools for each guideline as each one is different and unique." (Resnick et al, 2004) Individual professional awareness, knowledge, attitude, motivation of the individual professional toward the intervention 1) Staff feeling helpless, frustrated, and concerned about ability to control fall management; overwhelmed by excess protocols and required training (6/8 studies) (Capezuti et al, 2007;Colon-Emeric et al, 2007Etheridge et al, 2014;Wagner et al, 2010;Williams et al, 2011) Quote Staff development nurse: "Sometimes they get a little too much overload. You got guidelines for care plans, tube feedings, [tracheostomy] care, HIPAA, OSHA, dysphagia protocol 1) Raising awareness and interest (3/8 studies) (Capezuti et al, 2007;Chapman and Newenhouse, 2013;Colon-Emeric et al, 2014) Quote Licensed practical nurse: "A lot of the falls policies that we were learning we already had in place, but it's still that reeducating and reminding everybody of these things."…”

“…(ColonEmeric et al, 2014) 2) Sense-making to understand underlying fall causes (1/8 Resnick et al, 2004) knowledge deficit of quality improvement processes, (Wagner et al, 2010) poor falls management (Chapman and Newenhouse, 2013) and computer skills (Capezuti et al, 2007;Chapman and Newenhouse, 2013 (Wagner et al, 2010) 4) Low awareness (1/8 studies) (Colon-Emeric et al, 2007) studies) (Colon-Emeric et al, 2014) 3) Staff being motivated to learn and use skills regularly (1/8 studies) (Resnick et al, 2004) Resident residents' motivation and compliance 1) Resident/family noncompliance (2/8 studies) (Chapman and Newenhouse, 2013;Wagner et al, 2010) Quote Nurse supervisor: "It's not that we don't know [hip protectors] are effective, we just don't have many [residents] that will wear them." (Wagner et al, 2010) 2) Conflict with resident/family goals or expectations (1/8 studies) (Colon-Emeric et al, 2007) 3) Resident boredom (1/8 studies) (Wagner et al, 2010) Not available…”

“…Social context teamwork, leadership, and support from colleagues 1) Poor communication (5/8 studies): poor information transfer between care providers/shifts (Colon-Emeric et al, 2007Wagner et al, 2010) and between staff/family (Wagner et al, 2010), lack of care plan communication, (Chapman and Newenhouse, 2013;Wagner et al, 2010) failure to communicate falls (Wagner et al, 2010) or training information, (Resnick et al, 2004) and communication tension/hostility between licensed staff and unlicensed staff (Wagner et al, 2010) Quote Licensed practical nurse: "It doesn't do a whole lot of good if one shift is really working hard on trying to put things in place to keep a patient from falling or reduce the number of times that they fall if nobody else is following through. I think that one thing that we need is shift to shift; if we come up with an idea to make sure that it is followed through by other people and that the whole crew is involved."…”

Osteoporosis Prescribing in Long-Term Care: Impact of a Provincial Knowledge Translation Strategy

“…These include (a) not including osteoporosis and fracture risk assessment as part of standardized processes (e.g., admission, quarterly reviews); (b) not capturing risk variables electronically; and (c) failure to incorporate preventative osteoporosis and fracture strategies into formal care-plans (Colon-Emeric et al, 2004;Colon-Emeric et al, 2007a;Kennedy et al, 2011b;Kennedy et al, 2012a;Kennedy et al, 2013). Given the interdisciplinary, team-based approach to care in LTC facilities, it is imperative that knowledge translation efforts target both practice-level and organizational changes.…”