Spinal cord injury (SCI) patients are at high risk for pressure ulcers. Prevalence estimates of pressure ulcers in the spinal cord injury patient range from 8-33%, presenting a challenge for patients and their caregivers in the prevention and management of this costly and sometimes deadly condition. Guidelines based on evidence at varying levels can assist in reducing the burden of pressure ulcers on patients and health care systems. The authors discuss the need to identify barriers to the implementation of guidelines in order to address them. Five categories of barriers were listed as:

1. Organizational factors, such as lack of ownership of the process and lack of willingness to do the work necessary at all levels.

2. Inadequate education and training on the guidelines and implementation throughout an organization.

3. Inadequate resources that may require partnerships and collaboration between stakeholders.

4. Lack of evidence to guide care practices, including risk factors and prevention, assessment, management, and follow-up.

5. Unclear design and communication of recommendations.

In each of these areas, the authors give example quotes from the focus groups to demonstrate the meaning. For instance, in the category of “organizational factors” quotes ranged from noting that the guidelines contradict their current facility or regional guideline to what is generally done in their facility that seems out of sync with the guideline. For lack of training and education quotes offered examples of the variation in knowledge about assessment and treatment strategies. Resources listed staffing and equipment limitations. The category of limited research/evidence suggested the need for more specific research to be done on procedures and equipment. The communication of the guidelines suggested that wording is important to both the understanding and implementation of the guideline. In this case, suggesting prioritization of the list, changing wording to be more acceptable to clinicians and patients, and defining terms were recommended.

The authors suggested that the development and publication of guidelines is not sufficient to adopting them as a practice standard. It is important to understand what practitioners perceive as barriers to the implementation of guidelines in order to assure that guidelines are successfully implemented. The authors suggested that because there were only eight recommendations that had the highest level of evidence it may have lowered agreement with many of the recommendations with lower levels of evidence support. There were some differences in responses between nurses and physicians, but the authors attributed this to differing types of responsibilities for wound care management.

Limitations suggested the overlap of clinicians from the same sites, potential lack of time to fully explore the lengthy list of recommendations, and that other disciplines were not included.

Summary:

This research was conducted to determine the barriers to implementation of guidelines published for the prevention and treatment of pressure ulcers in spinal cord injury patients. A mix of survey and focus group investigation was completed for this study. The authors determined barriers to agreement with 32 recommendations by the participating nurses and physicians. Physician participants agreed unanimously with half of the guidelines and nurses agreed unanimously with six of the 32 guidelines. Physicians disagreed most with guidelines on the use of electrical stimulation, repositioning of the patient every two hours, and the performance of daily inspections. Nurses disagreed most with the use of electrical stimulation, assessing nutritional status, repositioning the patient every two hours, identifying psychosocial impacts, evaluation of posture/weight distribution/and sitting schedules, daily inspections, evaluation of support environment, and assessing risk factors. More physicians stated that their facility had successfully implemented the guidelines than nurses. The barriers were categorized as lack of evidence, complexity of wording/design, organizational factors, lack of knowledge, and lack of resources. The subtleties of the reasons for disagreement were uncovered during the focus group sessions. In some cases it was a matter of wording rather than the general recommendation concept that was disagreed upon. Other disagreements were based on available resources and training. It was apparent that there is a need for guidelines that are realistic and appropriately worded to encompass the meaning that is important to clinicians who implement these guidelines. There is also a need for specific and compelling evidence to support the adoption of such guidelines.