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QHR24310.1177/1049732313514137Qualitative Health ResearchStecksén et al.

Article

Implementing Thrombolytic Guidelines in Stroke Care: Perceived Facilitators and Barriers

Qualitative Health Research 2014, Vol. 24(3) 412­–419 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732313514137 qhr.sagepub.com

Anna Stecksén1, Berit Lundman1, Marie Eriksson1, Eva-Lotta Glader1, and Kjell Asplund1

Abstract We performed a qualitative study to identify facilitators of and barriers to the implementation of national guidelines on thrombolytic therapy for acute ischemic stroke. We interviewed physicians and nurses at nine Swedish hospitals using 16 explorative, semistructured interviews, and selected hospitals based on their implementation rate of new stroke care methods according to data from the Swedish Stroke Register, Riks-Stroke. Through content analysis, we identified facilitators and barriers to implementation, which we classified into three categories: (a) individuals, (b) social interactions and context, and (c) organizational and resource issues. Insights obtained from this study can be used to identify target areas for improving the implementation of thrombolytic therapy and other new methods in stroke care. Keywords health care professionals; interviews, semistructured; knowledge utilization; stroke Clinical guidelines based on the best available scientific evidence are routinely used as standard approaches for ensuring uniform, high-quality clinical practices. However, the development of clinical guidelines is unlikely to improve practice and benefit patients unless active steps are taken to ensure their appropriate use (Oxman & Flottorp, 2001). To achieve this goal, we must understand the factors that impede or enable the implementation of clinical guidelines (Oxman & Flottorp). The use of thrombolytic agents, so-called thrombolytics, to treat acute ischemic stroke (AIS) can serve as an example of the discrepancy between the existence and application of clinical guidelines. Previous randomized clinical trials have consistently provided solid evidence that, despite their association with a risk of bleeding, thrombolytics improve functional outcomes after stroke. Consequently, many national and international guidelines strongly recommend the use of thrombolytics for AIS. However, the implementation of thrombolytic agents in routine clinical practice has been slow in many countries, including the United States (Adeoye, Hornung, Khatri, & Kleindorfer, 2011) and the United Kingdom (Lees et al., 2008). The situation in Sweden is similar (Eriksson et al., 2010), in spite of the fact that the National Board of Health and Welfare has developed national stroke guidelines with an emphasis on scientific evidence (Norrving et al., 2007), and all acute care hospitals in Sweden have established stroke units (Asplund et al., 2011).

Previous studies have explored how the characteristics of the stroke care organization, such as its type, size, specialty, and access to dedicated stroke units, influence the dissemination of thrombolytics for AIS (Asplund, Glader, Norrving, & Eriksson, 2011; Eriksson, et al., 2010). We sought to identify the factors that impact the implementation of national thrombolytic guidelines in Sweden. Through the present study, we analyzed the facilitators of and barriers to implementation as perceived by stroke care professionals (nurses and physicians) at selected hospitals that implemented national thrombolytic guidelines at various rates. We focused on the overall determinants of the implementation process and only briefly considered technical or logistical factors involved in thrombolytic therapies, such as ambulance services or time delays within hospitals. In addition, we examined factors related to health care rather than factors related to patients or the general public.

Methods Informants This study was performed as part of a broader project to explore the implementation of guidelines in routine 1

Umeå University, Umeå, Sweden

Corresponding Author: Anna Stecksén, Department of Public Health and Clinical Medicine, Umeå University, SE-901 85 Umeå, Sweden. Email: [email protected]

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Stecksén et al. stroke practice. The Swedish Stroke register, Riks-Stroke, provides extensive systematic feedback regarding the quality of stroke care (Asplund, Hulter Asberg, et al., 2011). Using data from this register, we strategically sampled hospitals with respect to their specialization, geographic location, and maximum variation in the successful implementation of stroke care guidelines. In this article, we consider only the thrombolytic therapies guideline implementation rate (upper quartile = high implementation rate; lowest quartile = low implementation rate), which we used to categorize hospitals as rapid (RIHs), intermediate (IIHs), or slow implementers (SIH). We invited one nurse and one physician involved in stroke care at each of 11 hospitals to participate in the study. One physician at an SIH and one nurse at an IIH declined participation because of lack of time or interest; one physician at an IIH did not respond to our request. No stroke physician was available at one SIH because of a lack of continuous staffing. At one RIH, the invited nurse was on sick leave and was replaced by a physician. One hospital visit with an SIH was canceled because of time constraints. The final informant pool contained 9 physicians and 7 registered nurses, including 7 men and 9 women (all nurses were women). Most informants were first-line leaders or coordinators at their stroke unit. Informants were employed at two university hospitals, four large nonuniversity hospitals, and three community hospitals. There were three SIHs, three IIHs, and three RIHs. When invited to participate in the study and at the start of each interview session, all informants were instructed that their participation was voluntary and their responses would be kept confidential. The Ethical Review Board of Umeå University, Sweden, reviewed this study. The board had no ethical concerns and determined that the Swedish law on ethical approval was not applicable to this study.

The first author performed research interviews from March to June 2010. Interviews were recorded with a digital voice recorder. The informants chose the time, date, and location for the interviews, which occurred during weekday office hours at the stroke unit or in adjacent facilities and lasted from 24 to 72 minutes (median, 60 minutes). The first author asked about the informant’s experiences regarding the implementation of national stroke guidelines and a few new specific methods, including the use of thrombolytics for AIS. The first author and a medical secretary transcribed each interview verbatim within 2 weeks of the interview. The interviews resulted in 159 pages of single-spaced text.

Data Collection

Facilitators.  The major themes that emerged in this category were knowledge, work pride, and participation. Informants underlined the importance of awareness and knowledge of stroke guidelines at many levels of care, not only in the stroke unit, but also in the emergency department (ED), radiology, and other wards where stroke patients might be placed; in primary health care; and among telephone counselors. Informants emphasized that the rapid expansion of stroke treatment options in recent decades has contributed to work pride and improved motivation to implement guidelines. They mentioned active participation in quality improvement processes, including advisory committees, development groups, and research programs, and having a teaching role. They identified access to continuous medical education as important, such as the ability to attend scientific

Because we wanted to be open to the various experiences and perceptions of the informants, and because knowledge about factors affecting the implementation of thrombolytic guidelines is scarce, we chose to use semistructured interviews rather than a questionnaire for our study. Applying information from relevant literature (Dahlgren, Emmelin, & Winkvist, 2004), the Swedish National Guidelines for Stroke Care (Socialstyrelsen, 2009), and their own clinical experiences, the first and third authors prepared a semistructured interview guide. Then, the first author performed two test interviews with the fourth and fifth authors, both experienced physicians in clinical stroke care. Through consensus discussions, we decided on a final interview guide format.

Data Analysis The first, second, third, and fifth authors analyzed the full-text transcripts using qualitative thematic content analysis (Graneheim & Lundman, 2004; Krippendorff, 2004). Disagreements were resolved through consensus discussions. We identified and characterized the barriers to and facilitators of implementation with an inductive approach (Elo & Kyngas, 2008).

Results Grol, Wensing, and Eccles (2005) previously identified factors that might directly impact changes in how health care professionals treat patients. We designated the informants’ responses as facilitators of or barriers to implementation. Because our identified factors were related to the areas identified by Grol et al. (2005), we applied their structure and classified the factors into three main categories: (a) individuals, (b) social interactions and context, and (c) organizations and resources (see Table 1).

Relating to Individuals

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Table 1.  Facilitators of and Barriers to the Implementation of Thrombolytic Guidelines in Stroke Care. Categories

Facilitators

Barriers

Individuals

Guideline awareness and knowledge among all staff

 

Work pride and motivation

 

Taking active part in quality improvement and research programs Continuing professional education Good leadership

  Social interactions and context             Organization and resources    

Positive staff attitudes, within and outside the stroke unit Involvement of all professionals in implementation work Close collaboration with staff outside the stroke unit (emergency department in particular) Formal and informal meetings Feedback on success or failure Between-hospital benchmarking and sharing experiences with staff at other hospitals Quality assurance with continuous feedback on implementation progress Implementation work included in routines Short intrahospital distances for thrombolytic processes

   

conferences and professional stroke meetings. Many proposed a decision support system that could make colleagues feel more comfortable with the treatment, thereby reducing feelings of inexperience and ambiguity. Barriers.  The major themes that emerged in this category were lack of recognition, lack of knowledge, lack of experience, and stressful working conditions. Many informants claimed that, despite stroke care now having a higher degree of specialization with many new therapeutic options, physicians and nurses outside stroke care did not always recognize the treatment possibilities that were available. For example, one nurse stated, “Some have a view . . . a hundred years old. There is ignorance on the disease, old delusions.” She claimed that young physicians were often more humble and attentive compared to the often hierarchical nature of the older physicians. Many professionals outside stroke care were still affected by the opinion that stroke was a “sad” disease that only tired and run-down professionals worked with. Other hospital staff and ambulance services often had little awareness and inadequate appreciation of the critical importance of time in the management of AIS. Several physicians mentioned that a common barrier to implementing

Old-fashioned views on stroke, with low expectations of therapeutic options Lack of knowledge about and experience with thrombolytic therapy Undue respect for treatment Stressful working conditions Insufficient recognition by peers and decision makers Formal power structures and prestige Failure to react to guideline deviations Lack of support from more advanced hospitals       Lack of continuity (with various dimensions) Recruitment difficulties Duty schedule inhibiting training Limited time, human, and financial resources Poor professional identity

thrombolytics was anxiety and an undue respect for the treatment. One informant stated that physicians “could dare a bit more” and “consider differential diagnostics a bit too much.” One frequently cited problem was a lack of experience with thrombolytics among physicians on duty. For example, one physician stated, “You can always find a reason to refrain from [using] thrombolysis, and you will never be accused [reprimanded] for it.” Some considered the exclusion criteria for thrombolytic therapy to be far too strict, causing unnecessary concern. They alluded to the much more frequent off-label use of thrombolytics in Finland without major negative consequences. The staff’s general interest in guideline implementation was affected by stressful and overburdened working conditions. For instance, one nurse stated that she felt weak just thinking about all of the new things, reorganizations, cuts, or new methods to be implemented. She was afraid new reorganizations could limit the implementation of new guidelines. Many informants indicated that a stressful working situation made it “easy to go back to the way things were before.” Finally, many informants considered that public awareness and knowledge of stroke symptoms and how to react to them were alarmingly low, claiming that this lack of knowledge resulted

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Stecksén et al. in inappropriate delays that impeded the use of thrombolytic therapy.

Relating to Social Interactions and Context Facilitators.  The major themes that emerged in this category were leadership, attitudes, involvement, meetings, and feedback. Informants uniformly suggested that good leadership and performance were prerequisites for successful guideline implementation. Among the leadership tasks mentioned were close adherence to guidelines, being a good role model, encouraging staff members to participate in the development of future implementation strategies, providing feedback, and showing enthusiasm, support, and interest. Informants stated that the stroke unit leader’s awareness of the daily work at the unit was important because it created confidence among the staff when stroke guidelines were to be implemented. Informants expressed the need for leadership and explained that the stroke leader should “take command and avoid time-consuming opinion-based debates.” One physician made a comparison with the Finnish leadership style, which was said to be much more authoritarian: Here [in Sweden] there is always someone questioning, “Why should I do this?” In the Swedish mentality, everyone should be able to discuss, there should be a consensus for everything. You cannot please everybody all the time. You have to be authoritarian.

Informants emphasized that the implementation of guidelines was a task for all professional groups, and many seemed to work tightly and cross-professionally together toward this end. Many informants perceived that professionals in other units had improved their awareness and knowledge of stroke and stroke care guidelines over the previous few years. Many informants regarded medical students practicing on the ward as assets in the implementation process because they had up-to-date knowledge from medical school and were accustomed to evidence-based thinking. The informants emphasized the importance of collaboration and stroke professionals’ active participation in interspecialty meetings. An essential goal was to educate nonstroke staff (e.g., ED staff) regarding tight adherence to stroke guidelines. Informants considered support from stroke-interested colleagues outside the stroke unit to be crucial for the implementation of stroke guidelines. Many informants expressed a need for more formal and informal forums to discuss guideline implementation and/or feedback on stroke patient management. For example, informants stated that awareness of the guidelines was facilitated if they routinely asked ED staff why a seemingly eligible patient was not considered to be a

candidate for thrombolytic therapy. Informants viewed between-hospital cooperation and benchmarking as significant facilitators. Recognition and motivation to deal with problems increased when challenges were shared. Barriers.  The major themes that emerged in this category were power structures and lack of institutional support. Inter- and intraprofessional power structures acted as barriers to implementation. A sensitive issue was how to react when members of the stroke team deviated from agreed-upon routines. One informant said that it was “getting one’s own preconceptions on others’ competence or attitude verified.” Others said that it was important to promote a continuous dialogue, but difficulties sometimes emerged. According to one physician, it was important that “someone in their own rank” point to necessary changes, so as not to create conflicts between physicians and nurses. Informants perceived staff at some university hospitals as being insufficiently supportive or understanding in the implementation process, considering the differences in resources available at university vs. community hospitals. Prestige and power relationships were barriers in these interhospital relationships. One physician reported from a meeting with staff at another hospital: We try to write common memos, but it is a slow process with prestige involved. They do not have any explanation for performing so few thrombolytic therapies. They say, “We act according to [the guidelines].” But they obviously do not. It was difficult to discuss, as if they were objecting to a “Big Brother” reprimanding them.

Relating to Organization and Resources Facilitators.  The major themes that emerged in this category were quality assurance, routines, and logistics. Informants viewed continuous and stable professional teams at the stroke unit and the ED as essential for guideline implementation. Systems for continuous feedback on stroke care performance (e.g., the national quality register and benchmarking) provided incentives and motivation to adhere to the guidelines. Facilitators included quality improvement and the systematic incorporation of implementation work in the routines of the stroke unit. Informants suggested several technical facilitators related to the organization of the thrombolytic process. At some stroke units, one nurse was continuously assigned responsibility for all activities associated with thrombolytic treatments. Some informants regarded telemedicine as a means by which stroke patients in remote areas could receive proper acute care, including thrombolytic therapy. Informants identified short distances between the ED, imaging facilities, and the thrombolytic treatment

416 site (usually the intensive care unit or the stroke unit) as facilitating factors (and somewhat of a dream scenario). Barriers.  The major themes that emerged in this category were lack of continuity, inadequate recruitment/ staffing, and lack of professional identity. A lack of continuity (i.e., because of frequent reorganizations, leadership changes, and large staff turnover) broke up work teams and routines and took time and energy that would otherwise have been spent on guideline implementation and quality improvements. One nurse stated, “Reorganizations break well-functioning work teams, where you have worked together, assuring competence, been working together on routines. Workmates disappear and routines are easily demolished. Even though you have proper, fixed routines, it can be hard to stick to them.” Informants considered a lack of continuity to be stressful and associated with tense feelings about the future. Almost all informants who had leadership roles explained that insufficient time and human resources were dedicated to the difficult task of implementing stroke care guidelines. Informants claimed that stroke physicians were too few, causing vulnerability. The problem of recruiting competent stroke professionals seemed to contribute to a feeling of loneliness and a high burden of responsibility among stroke physicians with leadership roles. The lack of qualified stroke professionals resulted in the short-term employment of external physicians. According to informants, these physicians did not contribute as much to clinical care development as permanently employed physicians would have done. Informants often attributed the recruitment problems to the low status of stroke and stroke care. One nurse believed that stroke care involved more nursing care than medicine, which might be why many physicians did not find it very interesting. Informants emphasized a need for a more distinct professional identity, such as the establishment of stroke care as a formal medical specialty or subspecialty. Informants mentioned cardiology as an example of a specialty with good human and financial resources and public awareness, stating that the hospital burdens for cardiology and stroke care were similar. Some suggested that cardiology could serve as a role model for stroke care, and hoped that stroke care one day would be viewed as equally important: “I believe this hospital has many physicians at the cardiology clinic, and me alone working permanently on this [stroke care]. There are as many myocardial infarctions as ischemic strokes here, but the resources are very unequally balanced.”

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Discussion The facilitators of and barriers to the implementation of national stroke guidelines on thrombolytic therapies could broadly be categorized into those related to individuals, to social interactions and context, and to organizational and resource issues. The key facilitating factors were work pride and motivation, good leadership, involvement of all staff members in the implementation process, and quality assurance. Major barriers concerned lack of competence and experience, outdated attitudes regarding stroke management, counterproductive power structures, lack of continuity, and insufficient human resources. Because this study was a part of a broader project to explore the implementation of guidelines in routine stroke practice, a possible limitation is that the interviews also concerned the implementation of methods other than thrombolytics. Previous studies on stroke guideline implementation have mainly been focused on practical and operational barriers (e.g., Kwan, Hand, & Sandercock, 2004; Slot, Murray, Boysen, & Berge, 2009). In contrast, we identified barriers to and facilitators of implementation, focusing on basic preconditions for the implementation of guidelines, such as leadership, attitudes, power structures, quality assurance, organization, and resources. In accordance with Grol and colleagues (Grol, Bosch, Hulscher, Eccles, & Wensing, 2007; Grol et al., 2005) and other authors (Carter-Jones, 2011; Davies, Walker, & Grimshaw, 2010; Eccles, Grimshaw, Walker, Johnston, & Pitts, 2005; Kwan et al.; Van Der Weijden, Hooi, Grol, & Limburg, 2004), we think it is important to consider the theoretical perspectives of potential barriers and facilitators to understand guideline implementation. We next consider the findings from our study in light of different theories on why implementation is or is not successful (see Table 2). Social-influence and organizational theories are particularly relevant to understanding the implementation of guidelines on stroke therapies. Strong leadership was a key facilitator for implementation, consistent with socialinfluence theories and studies in other areas of medical care highlighting the pivotal role of leaders (Parmelli et al., 2011; Ploeg, Davies, Edwards, Gifford, & Miller, 2007). The informants in our study identified the leader’s drive, enthusiasm, and credibility, rather than formal superiority, as essential when new methods were to be implemented. Nevertheless, because many of the informants in our study had leadership roles themselves, they could have overestimated the importance of leadership. The involvement of all categories of staff in the implementation process was another important facilitator. This finding is similar to that of other studies of implementation processes (Rycroft-Malone et al., 2004). Work pride,

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Stecksén et al. Table 2.  Theoretical Perspectives on the Facilitators of and Barriers to the Implementation of Thrombolytics. Theory Cognitive theories Adult learning approaches

Description Knowledge about guidelines by staff and other key stakeholders is essential. People must experience a problem before they are motivated to change.

Behavioral theories

Performance is stimulated by external stimuli and can be influenced by feedback, incentives, modeling, and external reinforcement.

Social-influence theories

Social norms and leadership affect implementation.

Organizational theories

System failures affect individuals.

motivation, and peer recognition emerged as important facilitators. These individual-related facilitators were linked to social context, with good leadership and close interprofessional collaboration being key determinants of successful implementation work (Medves et al., 2010; Ploeg et al., 2007). Strong impediments to successful implementation were lack of support from superiors, insufficient staff, and insufficient time (cf. Francke, Smit, de Veer, & Mistiaen, 2008)). The availability of new modalities to treat AIS helped to improve work pride and the general esteem of stroke care. Many informants regarded formal recognition of stroke care as critical. Organizational theories also identify close links between social interactions and organizational issues in the implementation of change. For example, these theories identify the inadequate organization of care processes, a noncollaborative environment, and a culture that is not oriented toward care improvement as pivotal barriers to the implementation of new methods (Grol et al., 2005; Kwan et al., 2004). Several organizational theories also emphasize the human/social dimension in the workplace and state that group performance is a result of interactions between leaders, staff, and the work environment (Anonymous, 2010). Van Der Weijden et al. (2004) reported that adherence to recommendations for AIS were most hindered by

Authors’ Comments The informants often identified improved knowledge and skills as being facilitators. Between-hospital benchmarking in Riks-Stroke (Asplund, Hulter Asberg, et al., 2011) has put pressure on many hospitals to improve their performance. Increased attention to thrombolytic therapies by patient organizations, opinion leaders, health care decision makers, and the mass media has increased the motivation for change. Quality assurance, with regular feedback on hospitals’ performances provided by Riks-Stroke, serves this purpose (an expression of the Hawthorne effect [Moser & Kalton, 1971]). Participation in research programs might have a similar effect. Our findings emphasize the critical role of social interactions for successful implementation. Facilitators include strong leadership, involvement of all staff, and feedback. Important barriers are counterproductive power structures and lack of recognition and peer support. Our findings show quality assurance, well-established routines, and logistics to be major facilitators. Barriers include lack of continuity, recruitment problems, insufficient clinical experience, lack of professional identity, and limited resources.

organizational-level barriers, such as insufficient hospital logistics, manpower, or hospital beds. These barriers were present in the Swedish stroke care setting, but we also identified lack of continuity in organization, leadership, and staff as critical barriers to implementation. It might be that in many hospitals inferior performance has primarily been addressed by repeated reorganizations and leadership changes. Thus, the organizational-level barriers might have adversely affected continuity, a key facilitating factor for implementation. Some informants questioned the scientific evidence for the national stroke guidelines. Guidelines that are easy to understand and apply and do not require specific resources have a greater chance for implementation (Francke et al., 2008). The quality of the evidence presented with the guidelines might affect adherence to them (Francke et al.; Grol & Grimshaw, 2003). Additionally, well-designed educational materials, meetings, outreach visits, patient-mediated interventions, audits, feedback, reminders, marketing, local consensus processes, and support from opinion leaders improve the implementation of new methods in clinical practice (Mowatt, Grimshaw, Davis, & Mazmanian, 2001). However, simply focusing on a single approach to promote guideline implementation is only modestly successful, if at all (Francke et al.; Medves et al., 2010), and multifaceted

418 interventions are more likely to improve practice than single interventions (Francke et al.; Mowatt et al., 2001).

Conclusions We identified major facilitators of and barriers to the implementation of thrombolytic therapies for AIS, which largely concerned the spheres of social interaction and organization. Facilitators of implementation included strong leadership, interprofessional involvement, and quality assurance. Barriers included counterproductive power struggles, a lack of continuity, and limited resources. These insights point to target areas for improving the implementation of thrombolytics and other new methods in stroke care. The quality of first-line leadership is a major determinant of the working conditions, multidisciplinary involvement, power structures, quality assurance, continuity, and professional competence. Acknowledgment The authors are grateful to Bo Norrving for helpful comments on earlier drafts of this article.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was funded by the Vinnvård Research Program.

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Author Biographies Anna Stecksén, MScPH, PT, is a doctoral student at the Department of Public Health and Clinical Medicine at Umeå University, Umeå, Sweden. Berit Lundman, PhD, RN, is a professor emerita at the Department of Nursing at Umeå University, Umeå, Sweden. Marie Eriksson, PhD, is an associate professor at the Department of Statistics, Umeå School of Business Education at Umeå University, Umeå, Sweden. Eva-Lotta Glader, PhD, MD, is a stroke physician at the Department of Public Health and Clinical Medicine at Umeå University, Umeå, Sweden. Kjell Asplund, PhD, MD, is a professor emeritus at the Department of Public Health and Clinical Medicine at Umeå University, Umeå, Sweden, register manager of Riks-Stroke, and chair of the Riks-Stroke steering committee.