http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(8): 674–685 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.932444

RESEARCH PAPER

Factors affecting speech pathologists’ implementation of stroke management guidelines: a thematic analysis Melissa Miao1,2, Emma Power1,2, and Robyn O’Halloran2,3 1

Discipline of Speech Pathology, Faculty of Health Sciences, University of Sydney, Cumberland Campus C43S, Lidcombe New South Wales, Australia, Centre for Clinical Research Excellence in Aphasia Rehabilitation, Brisbane, Queensland, Australia, and 3Department of Human Communication Sciences, Faculty of Health Sciences, La Trobe University, Melbourne Campus HS1, Bundoora, Victoria, Australia

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Abstract

Keywords

Purpose: Although clinical practice guidelines can facilitate evidence-based practice and improve the health outcomes of stroke patients, they continue to be underutilised. There is limited research into the reasons for this, especially in speech pathology. This study provides the first in-depth, qualitative examination of the barriers and facilitators that speech pathologists perceive and experience when implementing guidelines. Methods: A maximum variation sample of eight speech pathologists participated in a semi-structured interview concerning the implementation of the National Stroke Foundation’s Clinical Guidelines for Stroke Management 2010. Interviews were transcribed, thematically analysed and member checked before overall themes were identified. Results: Three main themes and ten subthemes were identified. The first main theme, making implementation explicit, reflected the necessity of accessing and understanding guideline recommendations, and focussing specifically on implementation in context. In the second theme, demand versus ability to change, the size of changes required was compared with available resources and collaboration. The final theme, Speech pathologist motivation to implement guidelines, demonstrated the influence of individual perception of the guidelines and personal commitment to improved practice. Conclusions: Factors affecting implementation are complex, and are not exclusively barriers or facilitators. Some potential implementation strategies are suggested. Further research is recommended.

Clinical practice guidelines, evidence-base practice, implementation science, knowledge translation, qualitative research, speech pathologists, stroke rehabilitation History Received 28 August 2013 Revised 11 May 2014 Accepted 04 June 2014 Published online 8 July 2014

ä Implications for Rehabilitation    

In most Western nations, stroke remains the single greatest cause of disability, including communication and swallowing disabilities. Although adherence to stroke clinical practice guidelines improves stroke patient outcomes, guidelines continue to be underutilised, and the reasons for this are not well understood. This is the first in-depth qualitative study identifying the complex barriers and facilitators to guideline implementation as experienced by speech pathologists in stroke care. Suggested implementation strategies include local monitoring of guideline implementation (e.g. team meetings, audits), increasing collaboration on implementation projects (e.g. managerial involvement, networking), and seeking speech pathologist input into guideline development.

Introduction Stroke remains the single greatest cause of disability in most Western nations [1] and presents a significant global healthcare burden [2]. Communication and swallowing difficulties are common post-stroke. In recent incidence estimates following first ever acute ischaemic stroke, it is suggested that around 44%

Address for correspondence: Emma Power, Discipline of Speech Pathology, Faculty of Health Sciences, University of Sydney, PO Box 170 C43S, Lidcombe New South Wales, Australia. Tel: + 612 93519748. E-mail: [email protected]

of patients experience dysphagia, or swallowing disorders, 42% experience dysarthria, or speech impairment, and 30% experience aphasia, or language impairment, with 28% experiencing both dysphagia and dysarthria, and 10% experiencing all three disorders [3]. Effective speech pathology care is therefore essential for the optimal recovery of stroke patients with these difficulties. Evidence-based practice (EBP) is defined as ‘‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’’ [4, p. 71]. EBP is integrated into standards of practice by speech pathology associations internationally [5,6]. To facilitate EBP in healthcare, clinical practice guidelines (CPGs) have been developed to

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summarise clinically relevant evidence [7]. For example, the Clinical Guidelines for Stroke Management 2010 [8] is the current CPG available to Australian speech pathologists involved in stroke care, with adherence to previous versions of this CPG [9,10] shown to improve health outcomes for stroke patients [11]. Despite their value and availability, CPGs are frequently underutilised in clinical contexts across many health professions [12,13]. A national audit of the Clinical Guidelines for Stroke Management 2010 [14,15] indicated that many guideline recommendations are not implemented in clinical practice, including in speech pathology. For example, in a recent clinical audit of acute services [14], only 62% of eligible stroke patients (n ¼ 3320) received speech pathology assessment within 48 hours of admission as recommended, and nearly one quarter (23%) of all patients presenting with stroke (n ¼ 3548) did not receive a swallow screen. This disparity between available evidence and clinical practice has been described as the ‘‘evidence-practice’’ gap [16]. To understand and address the evidence-practice gap, researchers have attempted to draw on the experiential knowledge of research users through ‘‘knowledge transfer and exchange’’ (KTE) [17]. The premise of KTE is that ‘‘researchers and decision makers are normally separate groups with distinct cultures and perspectives on research and knowledge, with neither fully appreciating the other’s world’’ [18, p. 17]. KTE literature therefore advocates a reciprocal exchange of knowledge between research producers and users [17]. Preliminary KTE research indicates that guideline implementation in healthcare can be affected by (i) environmental factors, such as organisational support [19], (ii) factors associated with the guideline itself, such as guideline complexity [7], (iii) characteristics of the health professional, such as attitudes towards EBP [20], as well as (iv) factors associated with the client, such as co-morbidities [21]. Common recommendations in the KTE literature include a need to specify how implementation will occur locally [22], adapt guidelines to local contexts [23,24] and address local barriers [25]. However, systematic reviews in medicine [26–29], nursing Figure 1. The Knowledge-to-Action-Process Framework. Copyright (2006) Wiley. Used and adapted with permission from Graham et al., Lost in Knowledge Translation: Time for a Map?, The Journal of Continuing Education in the Health Professions, Wiley. (Graham et al. [18]).

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[30] and allied health [31] have found low methodological quality, mixed to modest effects and equivocal results in the existing studies, concluding that more rigorous further research is needed. A relative strength of the KTE literature is in its numerous conceptual models and frameworks [32] which can be used in research to theoretically guide and evaluate implementation strategies [33,34]. The Knowledge-to-Action (KTA) model [18] is notable in that it summarises commonalities in over 60 existing theories and conceptualisations of implementation. It also specifically identifies the importance of ‘‘knowledge tools and products’’ like CPGs (Figure 1), and contains a ‘‘barriers assessment’’ phase for identifying potential barriers and facilitators to implementation. It thus offers a valuable theoretical foundation for the development of tailored CPG implementation strategies. Within the current paucity of evidence, there is a particular lack of research involving speech pathologists. The majority of KTE research is in the medical and nursing literature [31] and research into the allied health professions has focussed on physiotherapists and occupational therapists [35,36]. This is particularly problematic given that the factors affecting CPG implementation have been found to vary with profession [37], and because speech pathologists have distinctive responsibilities for the swallowing and communication function of stroke patients. To date only a small number of studies have investigated the effectiveness of implementation strategies in speech pathology practice with neurological populations. Pennington and colleagues conducted a cluster randomised trial [38] contrasting (i) the outcomes for departments receiving education on evaluating evidence and (ii) departments receiving education on both evaluating evidence and theoretical models of diffusion. The education was provided to eight and nine departments respectively, via two representatives from each department who were responsible for passing on their learning. CPG adherence was measured prior to and six months after intervention through case note audits and semi-structured interviews. Results varied widely across individual departments, and overall there were no consistent, observable practice changes for either strategy.

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Simmons-Mackie and colleagues [39] conducted a qualitative study on the effects of a two-day tailored training program for different multidisciplinary healthcare teams from acute care (n ¼ 11), rehabilitation (n ¼ 15) and long-term care facilities (n ¼ 11). One speech pathologist was included in the acute care team and four were present in the rehabilitation team. The authors found that all teams increased in knowledge, but actual implementation changes were more successful in the rehabilitation and community teams compared with the acute care team, due to the effects of different barriers and facilitators in these settings. Also using a tailored training strategy, Molfenter and colleagues [40] completed a case study in which four speech pathologists were given practical training, support and mentoring from academics to implement a novel therapy technique for dysphagia. Based on semi-structured interview data and sustained connections between the researchers and clinicians, they concluded that the implementation of the therapy technique was successful. Both Simmons-Mackie et al. [39] and Pennington et al. [38] concluded that the success of implementation varied with local settings and teams. However, Pennington et al. [38] did not specifically tailor intervention to established barriers in their KTE intervention, reflecting the wider trend in the KTE literature to trial implementation strategies without a prior investigation of barriers and facilitators. Preliminary data focussing on implementation factors has only been obtained supplementary to other research, such as more general surveys exploring current practice in aphasia [41] or EBP in speech pathology [42]. Some factors were also identified through a single structured interview question by Molfenter and colleagues [40], and the qualitative data evaluating the implementation trial by Simmons-Mackie and colleagues [39]. The most consistently reported barrier across these studies has been lack of time [39–42]. Speech pathologists also identified competing priorities as a barrier to accessing evidence [40], and the prioritisation of dysphagia as a barrier to appropriate aphasia management [41]. The provision of quality speech pathology services was also reportedly limited by funding, staffing levels, early patient discharge [39,41] and infrequent access to sources of evidence such as CPGs [42]. Simmons-Mackie and colleagues [39] found implementation could be bolstered by experiences of success, concrete goals, organizational support and a sense of ownership of facilityspecific training. However, acute care staffs were particularly hindered by their lack of success in implementation, lack of time to meet about implementation, and their attitudes towards the knowledge being implemented. Molfenter and colleagues also suggested speech pathologists’ lack of confidence in using a new technique as potentially hindering implementation [40]. These additional findings in the two qualitative studies demonstrate the potential for qualitative methods to identify less obvious factors. In summary, there is a particular lack of original research into the factors that influence speech pathologists’ implementation of evidence in clinical practice. Without this research, researchers and clinicians remain ill-equipped to reduce the evidence-practice gap for the benefit of stroke patients. Therefore, this study aims to identify speech pathologists’ perceptions and experiences of barriers and facilitators to implementing the Clinical Guidelines for Stroke Management 2010, as outlined in the KTA model’s barriers assessment phase.

Methods Approach To explore speech pathologists’ experiences and perceptions of CPG implementation, we adopted a qualitative research strategy

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within a phenomenological theoretical framework [43]. This included in-depth interviewing to capture any complex and less obvious factors that may not be represented in surveys [36], and thematic analysis to gain a rich understanding of the underresearched views of the speech pathology profession [44]. A semistructured interview format enabled some standardisation of inquiry as well as flexible questioning with participant-driven data [45], including open-ended questions and statements that allowed unanticipated factors to be raised [12]. Sampling procedure To obtain rich qualitative data on user experiences of guideline implementation, we adopted a purposive sampling approach in which participants were required to be qualified speech pathologists who had worked in primary stroke care in the past twelve months and had used the National Stroke Foundation’s Clinical Guidelines for Stroke Management 2010. This purposive sampling approach was used to seek the experiences of users who had attempted to use the guidelines. This enabled us to explore both the superficial and more in-depth barriers and facilitators encountered throughout the implementation process, as outlined in the action cycle of the KTA model [18]. As an exploratory study, the exact nature of participants’ guideline use was explored during data collection, rather than predetermined in eligibility criteria. Given the lack of previous research into the factors that affect speech pathologists’ guideline implementation, we also sought a maximum variation sample of clinical settings and experiences in our purposive sampling approach. We recorded factors related to clinician and practice context on the premise that these affect evidence-based practice more generally [46], and selected the greatest diversity possible out of the expressions of interest received. In this way a maximum variation sample was considered preferable to convenience sampling as it enabled a greater diversity of these factors to be represented. Dimensions included different levels of experience with stroke, caseload types, stroke unit involvement, geographical settings and gender, across the continuum of stroke care. Given this wide range of variables, the study scope was limited to the New South Wales (NSW) public health system in Australia. Participants were recruited through the NSW State-wide Stroke Services mailing list, Speech Pathology Email Chats (SPECS: an online interest group for speech pathologists working in adult care), the Adult Neurogenic Communication Interest Group (ANCIG) and the Centre for Clinical Research Excellence in Aphasia Rehabilitation (CCRE) newsletter. Twelve speech pathologists agreed to participate. Eight were invited to participate on the basis of maximum variation sampling criteria, outlined in Table 1 below. Participant characteristics have been listed as aggregations to preserve their anonymity, as some of the dimensions when listed in combination are potentially identifying within the closely connected local profession of speech pathology. Data collection procedure Interview design We developed a semi-structured interview protocol with reference to current literature exploring barriers, facilitators, and use of CPGs, and theoretically correlated with the barriers assessment phase of the KTA model [18]. Based on qualitative theory, especially phenomenology, we included questions specifically tapping participant perceptions and experiences. The sequence and open-ended phrasing of the questions was informed by researcher experience. The semi-structured format also allowed participants to refer to any broader experiences of guideline

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Table 1. Characteristics of participants.

Variable Continuum of Care (Note: most participants have caseloads in more than one area) Geographical Setting Experience in stroke care Caseload responsibilities Stroke Unit Gender

Participant characteristic Acute Inpatient Outpatient Community Metropolitan Regional Rural Less than 5 years 6–10 years Over 10 years Primarily clinical Managerial and clinical Yes No Male Female

Representation in sample (8 participants in total) 5 7 5 3 4 2 2 3 2 3 5 3 6 2 1 7

Figure 2. Note-taking spaces are indicated by the question number in interview protocol.

implementation, such as previous editions of the guidelines, as they considered relevant. This protocol was piloted with a participant who did not work in NSW, but met all other eligibility criteria. We made minor modifications to the protocol based on feedback from the pilot participant and the reflections of the interviewer. The final questions were established through the consensus of the research team. The full final protocol is provided in Table A1. The interview questions were also transferred to an A1-sized notetaking map (Figure 2) for each interview, to facilitate fluid exploration of topics as they were raised by the participants, and also to ensure that all areas were covered during the interview. Interview procedure Interviews were conducted from March 2012 to July 2012 by the first author. Telephone interviewing was selected for its ability to yield rich textual data for qualitative analysis [47], to facilitate the participation of rural and regional participants, and to minimise the effect of note taking on rapport. Telephone-based communications can also be considered naturally suited to the semistructured interview format in that callers are expected to have an agenda for the call while remaining flexible based on the interaction with the respondent [47]. Interviews were audio recorded via speakerphone using a digital voice recorder and ranged from 41 to 89 minutes duration. Recordings were transcribed verbatim by an independent listener without a speech pathology background. During this process only the first

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and second authors were aware of the identities of the participants. This study received ethical approval from the University of Queensland and the University of Sydney. Analysis The first author (MM) conducted a thematic analysis of the interview data in accordance with the six phases outlined by Braun and Clarke [44]. MM is hereafter referred to in the first person to maintain awareness of the active role of the researcher in the study outcomes [48]. Individual analysis occurred in phases one and two. I verified the data transcriptions against the recordings, divided each transcript into discrete meaning units, condensed each unit, and then summarised these into an initial code, as detailed in Table 2. I also annotated some early reflections. During these phases I systematically colour-coded every initial code across the data set according to the five areas explored by the interview protocol; (i) perceived barriers, (ii) experienced barriers, (iii) perceived facilitators, (iv) experienced facilitators and (v) use or perception of the guidelines. Colours were assigned based on the meaning of individual codes, rather than the concept tapped by any preceding questions. This enabled me to group each participant’s initial codes into an individual written summary under the five generic subheadings. Each participant was emailed their individual summary of the phase one and two analysis for member checking. Six out of eight participants returned these forms. If participants clarified their intended meanings, the coding was updated accordingly. If participants provided additional information, this finalised data was included and coded as if it were part of the original interview. In phase three, analysis began at a collective level. All codes across the full data set were grouped into subthemes labelled with provisional headings. The groupings were mutually exclusive and based on the semantic similarity of codes irrespective of colourcoding. However, I kept a record of the original colour-codes to enable me to identify any relevant patterns within each subtheme in later stages of analysis. During phase four, I refined the subtheme groupings to ensure internal homogeneity and external heterogeneity of codes. I then grouped these subthemes into provisionally labelled themes, with no subthemes discarded. The hierarchy of themes, subthemes and codes was maintained using a spreadsheet table. During phase five, all authors discussed and agreed upon the names and definitions of themes, and confirmed the grouping of subthemes under each theme. In phase six, the authors agreed on the overall analysis of the findings, including the selection of appropriate quotations to convey each theme. Rigour We undertook numerous strategies to enhance the rigour of this qualitative study. To facilitate ethical and credible data collection [49], we used semi-structured interviews to follow participantdriven data rather than wholly direct participant responses. Interviews were also conducted by a researcher with undergraduate experience in stroke (MM). As noted in a reflective journal, this potentially reduced the interviewer’s preconceptions of implementation barriers in comparison to an experienced stroke clinician and researcher. To enhance credibility during analysis, MM referred to the original voice recording when parsing transcripts into meaning units, and considered meaning unit length to avoid fragmentation or overlooked meanings. A research team member also peer checked phase two analysis of five interviews, and any differences in coding were discussed among the research team to achieve consensus. Each participant also received a written member checking summary of the

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Table 2. Example of condensation of meaning units and initial coding. No.

Speaker

Highlighted meaning unit

Condensed meaning unit

Initial code

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P3

I use the guidelines as a first point and then go to the literature

Guidelines as first reference before literature

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P3

So, I really do use it as sort of a first point and then go to the literature. And I guess, um, you know there’s a sort of, there’s uh, there’s quite an absence of um, consideration of the qualitative research? In the guidelines. Um, that is always in my mind. That um, most of the qualitative research is not there.

The absence of qualitative research in the guidelines is always in my mind

Guidelines lack qualitative literature

preliminary analysis as an opportunity to withdraw, clarify or add to findings. Wherever possible, participant’s own words were also used in the naming of subthemes and themes, and in the final phase six report. The maximum variation sample, as opposed to a convenience sample, also enhanced the transferability of our results [50] by increasing the factors by which readers and users of our research might infer similarities to their own experiences. While preserving the anonymity of our participants, these dimensions were recorded, analysed and described in as much detail as possible for the consumers of our research to determine the extent to which our ultimate results relate to and reflect their own experiences [50]. To enhance the confirmability of our results [49], MM used a journal to maintain reflexivity about any preconceived expectations, the effectiveness of interview techniques used, initial thoughts about the data, and any questions to discuss with the research team and explore in future. We also acknowledged our active role in the research process by reporting our methodology in the first person. Finally, we increased the dependability [49] by transparently reporting our sampling and data collection processes, acknowledging our qualitative phenomenological approach and theoretical basis in the KTA model and identifying our strategies to maintain rigour. We also detailed each phase of our thematic analysis as outlined by Braun and Clark [44] with examples.

Results The thematic analysis described above led us to identify 10 subthemes. These were grouped into three key themes: Making implementation explicit, Demand versus ability to change and Speech pathologist motivation to implement guidelines. Each of these themes and subthemes are outlined in Table 3. We have detailed the results below with quotations, using pseudonyms to preserve participant anonymity. Quotations have been selected based on their effectiveness in conveying the ideas contained in each theme and subtheme. They do not represent which participants contributed most to a theme, as all eight participants contributed data to each of the three themes. Making implementation explicit In three subthemes concerning ‘‘Guideline awareness and access’’, ‘‘Focus on implementation’’ and ‘‘Transferability to own context’’, all eight participants described the value of understanding how their current practice compared with the guidelines, and how guideline implementation could occur in their specific context. At the most basic level of ‘‘Guideline awareness and access’’, participants described learning about the guidelines through professional development, undergraduate education or

Table 3. Subthemes informing each theme. Theme Making implementation explicit Demand versus ability to change

Subthemes      

Speech pathologist motivation to implement guidelines

  

Guideline awareness and access Focus on implementation Transferability to own context Coordinated collaboration (internally and externally) Stroke specialty and experience Size of change required in relation to funding and resources Authority of guidelines Personal commitment to best practice Perceived instructiveness of guidelines

exposure to similar guidelines. Participants perceived a lack of guideline awareness as a barrier: . . .if I didn’t do those courses [about stroke care and guidelines] I would still – I mean I would probably try and seek research out, but I don’t know that I would have gone straight to the stroke guidelines to find that? – Charlie Following this awareness, it was fundamentally necessary to have access to the guidelines, with lack of access being a potential implementation barrier: . . .they [the guidelines] weren’t sort of readily accessible to me, I didn’t really know where to look for them and I hadn’t really received a copy or been made aware of where a copy was until I asked. – Sam Participants also described the subsequent challenge of locating contextually relevant information from the sizeable document. While some found this viable, participants who felt guidelines could be easier to navigate expressed a common desire to access sections specifically relevant to their setting: . . .what I would like to see is it [the guidelines] a bit separated out into the phases of stroke management a bit more. – Jamie In the second subtheme ‘‘Focus on implementation’’, all participants identified the importance of explicitly focusing on implementation itself, particularly through formalised team or department meetings to review performance and plan solutions. Without this clear focus: . . .it’s very easy to get sucked into just going to work, trying to see as many people as you can and then that’s about it, without

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really a focus on how can I improve on what I’m doing, and how can I use these guidelines to help me do that? – Shannon Many participants considered the necessity of monitoring implementation: . . .how do you know if you’re doing it, unless you do an audit of the files, and see if people are actually receiving them [the recommended aphasia-friendly handouts]? – Kim However, some of the local challenges of achieving this focus were raised in the final subtheme concerning ‘‘Transferability to own context’’, in which all eight participants suggested a need to clearly understand how the guidelines applied in their context. Given the previously described challenge of considering implementation beyond daily tasks, it follows that participants identified the advantage of integrating guideline recommendations into existing routine. They explored the benefit of having practical local facilitators that aligned with guidelines, such as screening tools, stroke referral pathway documents, guideline user guides and case conference checklists: . . .different templates or sort of cheat sheets for teams or particular professions, might be something that’s sort of helpful to sort of pick up and run with. – Sam The specificity of guideline recommendations was perceived as either an advantage or disadvantage for implementation in one’s own setting. On one hand, the breadth of the guidelines enabled the use of clinical judgement: I think it [the guidelines] takes into account the sort of variable nature of the acute setting. Like it always says ‘as possible’ or ‘as tolerated by the patient’ and it does consider all the other factors. – Taylor However, this flexibility could also be problematic as it allowed significant variation in practice and made gauging a service’s implementation progress more difficult: For speech pathology they just say ‘as much as the patient can tolerate’. But when you’re auditing, how do you measure that? – Jamie This participant also pointed out that the auditing criteria were not always adequately specific and objective to accurately measure whether recommendations had been met, especially if auditing was performed by someone without background knowledge in speech pathology. In particular, some participants noted that guidelines would be more useful if they contained more specific information about optimum therapy intensity: . . .at least have just a rough guideline of how to be spending your time. – Alex Participants also expressed desire for contextual sensitivity in the guideline implementation and auditing process. For some participants their receptiveness to audits, identified above, was tempered by wariness of arbitrary judgement by external parties: I wonder if it seems a bit too ‘Big Brother’ at that broader level. You know, if it would be really resented, and whether it would have, I mean I guess there’s got to be some level of flexibility needed, but whether it would have the sort of

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built-in flexibility that it would have if you conducted it sort of further down the track. You know, by an individual department head with good knowledge around how that department works. – Leslie Equally, there was a preference for internal coordination of implementation: It’s got to be someone who has a vested interest in the team and somebody that would be accepted by the rest of the team to make such comments. – Jamie

Demand versus ability to change Even across the maximum variation sample, all eight participants explored potential disparities in Demand versus ability to change, which concerned services’ actual capacities to implement the changes needed to meet guideline recommendations. In a subtheme about the ‘‘Coordinated collaboration (internally and externally)’’ descriptions from all eight participants highlighted how a service’s capacity to achieve change was affected by teamwork, management and leadership. Participants considered quality internal collaboration as a facilitator of implementation: Having a really good team that you work within can be really, really helpful, because it means that you can brainstorm amongst yourselves and come up with a coordinated plan, trial it, review it, and then, you know, provide information back to management about how it went’’ – Shannon However, lack of collaboration could be a primary barrier: I think the main thing [participant’s emphasis] is that we haven’t been able – we haven’t sat down as a team and looked at the guidelines and said that we’re not using them in the way that we should. – Jamie In many ways, leadership and management appeared to be important for such collaboration to occur. Participants explored the idea of having a supervisory person responsible for their service’s implementation initiatives: It really needs senior people to take responsibility. – Leslie Participants had experienced or suggested the advantage of having speech pathology department managers, stroke clinical nurse consultants, stroke care coordinators or case managers in this role. Conversely, the absence of a key authority was reported to be a barrier to initiating coordinated implementation efforts: I’ve not been given the role of leading the stroke unit. And I think, you know, other allied health professionals would go ‘Well, why is she doing that?’ – Jamie Participants also discussed the degree of collaboration with management as being a potential barrier or facilitator to implementation. One participant summarised these views: . . .if your management structure is very pro-making sure that you’re implementing evidence-based practice, i.e. the guidelines, then you’ve got more support behind doing certain practices, whereas if someone’s not as positive in terms of making sure you implement those things, then you don’t have as much support behind you. – Shannon

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Internal collaboration did not only have to be with staff in the service. One participant suggested that families of stroke patients could also be educated about the guidelines and be empowered to hold services accountable for the recommended care: You know, some of that relinquishing control if you’re saying ‘This is what you can expect us to do’. You know, ‘and tell us if we’re not doing, if you don’t feel like we’ve done it’. So it’s another way of creating more of a partnership role with the client and family. – Leslie A service’s ability to change also varied at the clinician level due to their allocated responsibilities. Six participants explored this in a second subtheme concerning ‘‘Stroke specialty and experience’’. Having a stroke-specific caseload was described as a facilitator, while a generalist caseload presented challenges: . . .they’ve [generalist clinicians] got, I guess, limited awareness of the guidelines. And I think that’s about, I guess, competing demands for their attention? – Leslie In stroke-specific roles, experience was also a factor. The basic learning needs and tasks of a novice clinician needed to be managed before considering guideline implementation: When I have had staff who’ve stayed a couple of years, like up to three or four years, then they generally start to initiate like; ‘This kind of therapy’s not working, and when I was reading the stroke guidelines. . .’ [laughs]! But, you know, that takes a few years, usually. For people to get to that stage. – Kim However, experience was also reported as potentially disadvantageous: It’s hard to change the way you’ve been doing things for 23 years if you know how to do it and you’re quick at it, efficient at it. – Kim In the final subtheme concerning ‘‘Size of change required in relation to funding and resources’’, all participants described funding and resources as a factor that could subsequently increase or decrease this current capacity to implement recommendations: If they honestly and really want minimum [sic] of five hours a week of inpatient aphasia therapy, we’re going to have to have lots more speech pathologists! So yeah, it’s a funding issue. – Kim Some participants touched on the benefit of having existing services and processes that supported guideline implementation: . . .having an early supported discharge team meant that a lot of guidelines about safe discharge and all of those things were easy to be implemented. – Jamie

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bit unrealistic in terms of what we have to work within’’. – Shannon Two participants with dual clinical and managerial roles described ways they had tried to manage feasibility issues, such as considering a service’s priorities when planning implementation: ‘‘We’re a very small department, so obviously you can’t do it all, you have to pick from – say there’s 20 guidelines, well this year we’re going to do these two, so you have to prioritise what’s important for your patients for this year, and use our 2.5 staff effectively. – Kim This view is also congruent with the theme of ‘‘Making implementation explicit’’, where participants explored the need to relate implementation to one’s specific context. The three participants with more than ten years’ experience in stroke also particularly noted that guideline implementation and the negotiation of that process was in itself demanding on time and human resources. The breadth of the issues raised by these participants is summarised in this response: You then have to potentially put a lot of time into addressing gaps within services, and that takes time to prepare, plan, document, talk to, negotiate, and then redo all of that at a higher level, potentially, so, you know. It’s not necessarily just the basic resources that we’re dealing with, but it’s actually trying to implement change within public health can be quite time-consuming in itself. – Shannon This insight from the more experienced participants into the need for collaboration at different levels may go some way in explaining why all participants found support from colleagues and management were particularly significant factors. Their recognition of the challenging nature of making changes also seems to support the overall participant consensus that implementation required specific focussed effort in its own right, as outlined in the theme ‘‘Making implementation explicit’’. However, these issues of internal and individual capacities appeared to be supplemented by external networking. Drawing on these external networks seemed to expand a service’s capacity to change. Two of the participants with both clinical and managerial responsibilities identified networking as a facilitator. They found discussion and collaboration on concrete implementation projects in peer supervision groups, special interest groups, EBP groups, working parties and area health service networks assisted guideline implementation. A summary of these responses: . . .some sort of way of interacting between clinicians and brainstorming about how we can implement the clinical guidelines, is certainly something that’s going to be of more benefit to a lot of people as well as what they’ve got in place. – Shannon

Six participants mentioned gaps in adherence to the guideline recommendations, with varying levels of acceptance or frustration at this current achievement. A distinct subgroup of more experienced clinicians tended to comment on the limited feasibility of implementing every recommendation in the guidelines, and more explicitly conveyed a sense of resignation and frustration:

The final theme exploring Speech pathologist motivation to implement guidelines consisted primarily of facilitators. All participants explored the subtheme of the ‘‘Authority of the guidelines’’, with many identifying the guidelines’ role in ratifying their practice as its primary benefit:

Ideal world? We’d all be able to use the recommendations, so that we could say we were adhering to them 100%, but that’s a

It [the guidelines] backs me up, in terms of wanting to give the best for my patients. – Jamie

Speech pathologist motivation to implement guidelines

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The guidelines were described as supporting participants in advocating for best practice, justifying new initiatives and making funding applications. Participants credited the prestige and credibility of the National Stroke Foundation and the relevant professional bodies who endorsed the guidelines as enabling this type of use. The authority of the guidelines was also derived from its evidence-based nature: There’s research that’s behind it so, that’s why we should use them; because there’s research that supports the implementation of them. – Charlie However, participants also seemed to be wary of the limitations of the guidelines and the more general research limitations in speech pathology. They valued the grading of evidence for their own judgment and tended to perceive the guidelines as an initial reference to other articles or further searches for more specific or recent literature. This approach was consistent with a second subtheme in which all participants explored ‘‘Personal commitment to best practice’’. Participants described being motivated to use the guidelines due to a sense of their professional integrity: I think it’s also about a commitment to evidence based practice at a personal level, a commitment to working in the best possible way with the best possible evidence base. – Leslie Guidelines implementation was also affected by whether speech pathologists adopted guideline implementation as a task of value in addition to their basic responsibilities. In one participant’s words: I think as long as we’ve got clinicians who are proactive, in terms of trying to address shortfalls in service provision, and trying to address how we can best provide services for our patients, so they get the best outcomes, then we’re going to be starting out better than people who don’t care. – Shannon In the final subtheme outlining ‘‘Perceived instructiveness of guidelines’’, participants generally agreed that the guidelines were more likely to affirm existing knowledge than be highly instructive: It kind of more validated what we were doing. Yeah. It wasn’t like we were going, [sarcastic] ‘Wow!’ [laughs]. – Taylor Despite this, participants reported that the guidelines could be useful for educational purposes. A typical response: I think it’d be good for even new clinicians to read them and I think it helps you have an understanding of the other allied health as well. – Taylor

Discussion This study is the first qualitative investigation of the factors affecting speech pathologists’ implementation of stroke guidelines. Across the entire set, some factors were variously perceived as barriers or facilitators, rather than inherently hindering or enabling implementation. These results therefore offer a complex, in-depth understanding of factors experienced by a variety of speech pathologists implementing CPGs in stroke care. Results are generally consistent with the KTA model [18] as well as previous KTE research findings.

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Through three different subthemes, participants explored the theme of ‘‘Making implementation explicit’’. These subthemes were consistent with the KTA model [18] in a number of respects. Firstly, the KTA model (Figure 1) suggests tailoring each and every stage of the knowledge creation process to the needs of potential users, including the method of dissemination, the design of the research product and the information provided [18]. Participants highlighted the need to address these issues in discussing guideline awareness and access, the ability to navigate guidelines, and recommendation specificity, respectively. The National Stroke Foundation did receive stakeholder input on the guidelines through Speech Pathology Australia representatives [8]. However, our discovery that different participants perceived or experienced the same factors, such as broad recommendations, as either a barrier or facilitator, suggests a possible need to discuss guidelines at a more specific level. Participants suggested that CPGs might be more readily related to practice with interactive, expert-facilitated sessions for clinicians to review guidelines and brainstorm implementation. This preference for in-person sessions has also been identified in qualitative studies with occupational therapists and physiotherapists [51,52], and personal contact between researchers and decision makers is one of the most frequently advocated facilitators in the KTE literature [53,54]. Therefore a potential challenge for KTE is finding a balance between the distancing that occurs when research users are represented by associations, and the feasibility of consulting with individual clinicians. At another level, the KTA model suggests ‘‘adapting knowledge to the local context’’ as a key component of the action cycle [18] and the theme of ‘‘Making implementation explicit’’ reflects this step. These findings also echo the conclusions of previous studies involving speech pathologists, in which the individual characteristics of implementation settings were highly significant for the outcome [38,39]. This theme is also supported by broader literature describing the need to adapt guidelines to local contexts [23,24], address implementation barriers [25] and specify how implementation will occur locally [22]. Participants’ identification of practical tools and local pathway or summary documents as facilitators to implementation offers some experiential validation of the idea of local adaption. Participants’ expressed need to reflect on and audit implementation progress also corresponds to the ‘‘monitor knowledge use’’ component of the KTA model [18]. Potential implementation strategies could therefore involve teams and management meeting regularly to specifically plan and measure guideline implementation in their service. The provision of tools to specifically aid reflection, auditing and implementation may be a practical way to support this. These results therefore support the National Stroke Foundation’s production of clinical tools [55] and an implementation guide [56]. However, as only one participant explicitly mentioned the implementation guide, and none mentioned the online tools, awareness of these resources may not be high. Therefore the dissemination challenges that occur for guidelines may also apply to any supporting resources. The second theme exploring ‘‘Demand versus ability to change’’ also captured many of the factors identified in existing literature. These included issues of funding, staffing levels and competing priorities previously identified in the few existing studies specific to speech pathology [39–42]. Participants’ positive experiences of increased funding and services, and converse experiences when these were lacking, suggest that these issues may be potential targets to improve implementation. However, the three subthemes informing this theme in our study offered a more diverse perspective on factors affecting a service’s capacity to meet recommendations. Participants identified effective internal collaboration on implementation as a

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significant facilitator, and suggested that this collaboration needs to be coordinated under appropriate leadership or management in order to be effective. This is similar to previous findings from other allied health professions [57] and the organisational support and teamwork highlighted in an implementation trial in speech pathology [39]. Therefore implementation strategies should be targeted at the management and leadership level to ensure coordinated support and collaboration on implementation. A novel finding in this study was the way services might naturally draw on external networks to potentially expand human resources for implementation projects. This is consistent with results from a very recent qualitative investigation into the role of clinical networks in NSW health [58], in which various stakeholders reported the value of networks in providing mechanisms to meet important goals, especially on challenging issues such as implementation. Therefore, future implementation interventions might focus on promoting the quality and quantity of connections and networks within and between services implementing guidelines. For example, the establishment of an area-wide network for guideline implementation with brainstorming sessions for clinicians at different services and working parties devising local tools. One participant’s suggestion that families also be informed and involved in CPG use is similar to Gagliardi and colleagues’ [22] recommendation that alternate versions of guidelines be developed for different decision-making purposes. Another potential implementation strategy might therefore involve the development of guidelines that stroke patients and their families can use to collaborate in decision-making with their speech pathologist, or request the services recommended. Such strategies could potentially apply to the ‘‘evaluating outcomes’’ stage of the KTA action cycle [18], with the experience of service users as a possible outcome measure or key accountability. Promoting collaboration on implementation may serve as a more immediately feasible intervention target than increasing staffing levels, funding or resources in the public health system. In this study, the concept of an individual’s capacity to change was related to the factor of individual stroke experience. Participants reported that significant stroke experience could be a barrier, as familiarity with established practices could make practice change difficult. However, stroke-specific experience was also considered to be beneficial because it allowed clinicians to consider and focus on stroke care in relation to the guidelines. Participants seemed to consider this issue in terms of a need to personally make change and focus on implementation, rather than a lack of skill as identified by Molfenter and colleagues [40]. The dichotomy of this factor again demonstrates the complexity of some of the issues that may be affecting implementation, and that mutually exclusive categories of barriers and facilitators in research may be too simplistic. Overall, the issues identified in this theme are consistent with aspects of the barriers assessment and intervention tailoring stages of the KTA model [18]. The diversity and prevalence of factors identified reinforces the necessity of considering this stage in any implementation process if it is to succeed. In our investigations within the KTA barriers assessment phase [18], participants offered diverse perspectives on each factor, but ‘‘Speech pathologist motivation to use guidelines’’ was the only theme predominantly identified as a facilitator. Although motivation to use guidelines was specifically probed by one of the questions in the semi-structured interview protocol, this theme was discussed by all eight participants and was developed from three diverse subthemes; ‘‘Authority of guidelines’’, ‘‘Personal commitment to best practice’’ and ‘‘Perceived instructiveness of guidelines’’.

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Speech pathologists’ motivations to use the guidelines reflected the different purposes outlined in the ‘‘Monitoring knowledge use’’ phase of the KTA cycle, namely conceptual, instrumental and strategic use [18]. Participants’ perceived benefit of guidelines as an educational resource reflects the notion of conceptual use, and the guidelines’ reported role in ratifying practice and supporting funding reflects the strategic advocacy that they provide. However, subthemes concerning the perceived significance and instructiveness of CPGs seemed to convey that instrumental use was limited by how informative and valuable the guidelines were for speech pathologists, resulting in the guidelines being used more for advocacy and support than specific clinical guidance. A potential way to promote instrumental use, which is what most directly improves health outcomes through practice change, might be to involve speech pathologists in CPG development in accordance with the KTA model. Incorporating speech pathologists’ needs and expectations in their guidelines may potentially enhance motivation, especially given an increased sense of ownership has been found to be a facilitator to implementation [39]. However, this strategy also faces the aforementioned challenges concerning the feasibility of consulting individual clinicians versus potentially decreased ownership when individuals are represented through broader associations like Speech Pathology Australia. In a recent systematic review of nursing literature by Squires and colleagues [20], clinician attitude towards research was identified as the only characteristic consistently found in a sufficient number of studies to have a positive association with the use of research or tools like CPGs. Likewise in our initial study of speech pathologists, the supporting evidence was one of many facilitators in this theme. The results differ from those in studies of medical practitioners, who indicated resistance toward guidelines due to doubts about supporting evidence [59] and applicability [21]. This contrast was also noted by Kortteisto and colleagues [37], who concluded that implementation factors vary with profession, and especially between medicine and other allied health. In this study, the participant’s positive attitudes towards EBP, in tandem with the profession’s broader commitment to EBP [5,6], would support the idea that strengthening the evidence base of the guidelines through new knowledge creation may be particularly influential for the speech pathology profession. The broad nature and limited evidence for speech pathology recommendations could be considered a major point of difference from medical guidelines. This study targets the need for more intentional and tailored implementation by adhering to the KTA model. Although the KTA model has not yet been empirically tested, it is based on planned action theories and specifies a barriers assessment phase for targeted interventions [18]. It has thus provided a theoretical underpinning that has been advocated in but largely absent from KTE research. This study also contains a number of methodological strengths in the rigour of data collection and analysis. Purposive sampling of relevant individuals, strategies to verify transcription, reflective journaling, member checking, peer checking and use of a clear audit trail strengthened the credibility of results. However, credibility could have been further enhanced if an external researcher uninvolved with the study had checked the analysis, and if all participants had returned their member checking forms. The selection of semi-structured interview and thematic analysis methods allowed complex and unanticipated factors to be identified in this previously underexplored profession [44]. The rigour of our thematic analysis process also enabled us to inductively derive three diverse and internally coherent themes. These described implementation factors more deeply than previous nominal categorisations at clinician, organisational,

Implementation factors in speech pathology

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client and guideline levels. They also allowed us to capture the complexity of factors that could be both a barrier and facilitator. Our phenomenological approach was also particularly consistent with KTE principles by giving voice to the perspectives of speech pathologists as research users [60]. As previously described, the transferability of results was enhanced by maximum variation sampling across multiple parameters of clinical setting and experience. There was a relatively an even distribution across all considered variables, with the exception of gender. However, we felt that the larger proportion of female participants was reflective of the broader dominance of females in the profession of speech pathology [61]. A limitation of our analysis was that it could only offer a general appraisal of some common factors among the interviewed individuals. Our maximum variation sample allowed preliminary identification of varying perspectives of some factors from distinct subgroups, such as speech pathologists with both clinical and managerial experience, and those with more than ten years’ experience. This suggests that these diverse opinions may also be worth more detailed qualitative investigation in future. Additionally, a larger quantitative study could use statistical methods to investigate any relationships between settings and demographic variables and particular implementation practices, experiences and perceptions. Furthermore, the scope of this study was restricted to the NSW public health system of Australia. Future research needs to be conducted in the private health sector and other Australian states to determine similar or different factors in these settings. A limitation of the study was that the samples consisted of voluntary participants from the NSW State-wide Stroke Services mailing list, as well as special interest groups, and are therefore likely to have had increased commitment to or interest in EBP and guidelines. There may also be a degree of social desirability in demonstrating these attitudes in a profession overtly committed to EBP [5,6]. The interview protocol also did not probe participants’ attitudes towards any specific recommendations. Therefore, although these findings demonstrated how a positive attitude to EBP might facilitate guideline implementation, it offers limited information on the impact of attitudes like indifference or disagreement with specific recommendations, or guidelines generally. Finally, there are a number of apparent limitations for an exploratory study of research users’ experiences and perceptions. Interviews with participants do not allow researchers to directly document or observe implementation factors in the field. Therefore these results might be appropriately accompanied by ethnographic observational studies of speech pathologists as they implement CPGs in their settings. And, as our results do not offer an explanatory theory or conceptualisation of the implementation process, further qualitative research using grounded theory may be an appropriate way to achieve this understanding. Moreover, given the purpose of the study was to identify influencing factors to inform future implementation interventions, it would be appropriate to trial such interventions once a theoretical understanding of the implementation process is obtained. This could be achieved by conducting participatory action research with speech pathologists, thus upholding principles of KTE. Speech pathologists’ implementation of CPGs is influenced by their motivation to use guidelines, the clarity with which guidelines are related to practice, and the tension between the demanding task of implementation and a service’s capacity to make such changes. These implementation factors are complex and not exclusively barriers or facilitators. The identification of these factors informs current understanding of the guideline implementation process in speech pathology and may assist stroke services to more effectively target implementation strategies in

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future. If such strategies are successful in creating practice change, this has the potential to improve health outcomes for patients with communication and swallowing difficulties poststroke. This research therefore has implications for stroke patients with communication and swallowing difficulties as well as multidisciplinary stroke services which include speech pathologists. Furthermore, as the first rigorous qualitative study to specifically examine guideline implementation factors in speech pathology, this study contributes to the KTE evidence base and provides support for the KTA model of implementation.

Acknowledgements We would like to thank Dr Angela Dew and Dr Belinda Kenny from the University of Sydney for their advice on earlier versions of this paper, and Professor Leanne Togher from the University of Sydney for her advice in the early stages of research design and writing.

Declaration of interest The third author was an employee of the CCRE in Aphasia Rehabilitation at the time of this study. The authors report no other conflicts of interest.

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Appendix

Table A1. Semi-structured interview protocol. Introduction/Warm-up Hi, [participant’s name], thank you for participating in this interview. As you know, we’re interested in exploring speech pathologist’s opinions of the Clinical Guidelines for Stroke Management 2010 that were recently released by the National Stroke Foundation. I really look forward to hearing your thoughts. First of all, I just need to check some basic details before we get started.  Review demographic information  Ask whether participant is part of a stroke unit Interview questions Area Tapped CPG Use/Perceptions

Experienced Facilitators Experienced Barriers Experienced Facilitator or CPG Use/Perceptions CPG Use/Perceptions CPG Use/Perceptions CPG Use/Perceptions Perceived Barriers Perceived Facilitators Experienced Facilitators

Unanticipated barriers/facilitators

Primary Question

Potential Follow-up Probes

1. Can you tell me how you and your service currently use the Clinical Guidelines for Stroke Management 2010? 2. Is there anything that helps you use them in this way? 3. Is there anything that made implementing the guidelines difficult? Despite these challenges, what motivates you to use the guidelines? 4. Is there anything that deters you from using guidelines, or that you do not find useful? 5. So in an ideal world, how would you like to be able to use the guidelines? 6. What are the ways you’d like to be able to use the guidelines but currently don’t? 7. Why do you think you are unable to do that? 8. What do you think it would take to overcome these issues? 9. Have you experienced any of these strategies?

   

10. Do you have any other final thoughts or comments that you haven’t mentioned?

How often does that happen? Who does [participant’s words]? Where does this happen? Is there anything in particular that comes to mind that illustrates that?  Could you perhaps give me an example?  So, [paraphrase using participant’s words]?  So, [paraphrase using participant’s words]?             

So, [paraphrase using participant’s words]? Tell me about [participant’s words]. So, [paraphrase using participant’s words]? Tell me about [participant’s words]. Tell me about [participant’s words]. Could you perhaps give me an example? Tell me about [participant’s words]. Could you perhaps give me an example? Tell me about [participant’s words]. How often did that happen? Who did [participant’s words]? Where did this happen? So, [paraphrase using participant’s words]

Wrap-up Thanks. If you do think of anything else, I will be in touch again shortly via email with a summary of what I understood from your interview, to make sure we correctly interpret what you’ve said. So that will also be another opportunity if you feel like you would like to add or clarify anything. What would be the best way to contact you again to do this? Thank you so much for your time and input [participant’s name], it’s been a pleasure and I will be in touch again soon.

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Factors affecting speech pathologists' implementation of stroke management guidelines: a thematic analysis.

Although clinical practice guidelines can facilitate evidence-based practice and improve the health outcomes of stroke patients, they continue to be u...
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