Implementation of the Canadian clinical practice guidelines for nutrition support: A multiple case study of barriers and enablers

Background: The Canadian Nutrition Support Clinical Practice Guidelines (CPGs), published in 2003, were designed to improve nutrition support practices in intensive care units (ICUs). However, their impact to date has been modest. This study aimed to identify important barriers and enablers to implementation of these guidelines. Methods: Case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each site. During the interviews, the key informants were asked about their perceptions of the barriers and enablers to implementation of the Canadian Nutrition Support CPGs. Interview transcripts were analyzed qualitatively, using a framework approach. Results: Resistance to change, lack of awareness, lack of critical care experience, clinical condition of the patient, resource constraints, a slow administrative process, workload, numerous guidelines, complex recommendations, paucity of evidence, and outdated guidelines were cited as the main barriers to guideline implementation. Agreement of the ICU team, easy access to the guidelines, ease of application, incorporation into daily routine, education and training, the dietitian as an opinion leader, and open discussion were identified as the primary enabling factors. Although consistent across all sites, the influence of these factors seemed to differ by site and profession. Conclusions: Our findings suggest that implementation of the Canadian Nutrition Support CPGs is profoundly complex and is determined by practitioner, patient, institutional, and guideline factors. Further research is required to quantify the impact of each barrier and enabler and the mechanism by which they influence guideline adherence.