Moore Gregory, Reszel Jessica, Daboval Thierry, Lemyre Brigitte, Barker Conor, Dunn Sandra
Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.
Faculty of Medicine, University of Ottawa, Ottawa, Canada.
J Matern Fetal Neonatal Med. 2020 Mar;33(6):973-981. doi: 10.1080/14767058.2018.1512575. Epub 2018 Nov 26.
The decision to attempt resuscitation or provide palliative care at birth for extremely preterm infants between 22 and 25 weeks remains complex. The purpose of this study was to identify facilitators and barriers to implementation of a clinical practice guideline developed to support shared decision-making for these cases. A purposeful sample of healthcare providers, involved in the care of one of five cases of anticipated extremely preterm birth, was recruited for interviews. Participants shared their views on the guideline content, implementation process, and facilitators and barriers encountered. Interviews were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code, categorize, and thematically describe the data. The Knowledge-Attitudes-Behaviours framework was used to organize the findings. Twenty-five key informants (16 physicians, nine nurses) were interviewed. Participants described varying levels of knowledge of the guideline. Facilitators to implementation included: (1) an awareness of, familiarity with and belief in the content; (2) hard copy and electronic guideline accessibility; and, (3) institutional expertise to provide necessary care. Barriers included: (1) minimal awareness or familiarity with the content; (2) lack of agreement with the recommendations; (3) inadequate evidence and applicability to support changes in practice; and, (4) lack of resources to care for the most immature infants. Identified facilitators and barriers will inform the development of tailored strategies for improved local and future broader implementation. Other institutions can use the results to facilitate implementation of their guidelines on this ethically charged area.
对于孕周在22至25周之间的极早产儿，决定在出生时尝试复苏还是提供姑息治疗仍然很复杂。本研究的目的是确定为支持这些病例的共同决策而制定的临床实践指南实施过程中的促进因素和障碍。我们招募了参与五例预期极早产病例之一护理的医疗保健提供者作为有目的的样本进行访谈。参与者分享了他们对指南内容、实施过程以及所遇到的促进因素和障碍的看法。访谈进行了录音并逐字转录。采用定性内容分析法对数据进行编码、分类和主题描述。使用知识-态度-行为框架来组织研究结果。我们采访了25名关键信息提供者（16名医生、9名护士）。参与者对指南的了解程度各不相同。实施的促进因素包括：（1）对内容的认识、熟悉程度和信念；（2）纸质版和电子版指南易于获取；以及（3）提供必要护理的机构专业知识。障碍包括：（1）对内容的了解或熟悉程度极低；（2）对建议缺乏共识；（3）缺乏支持实践变革的充分证据和适用性；以及（4）缺乏护理最不成熟婴儿的资源。确定的促进因素和障碍将为制定针对性策略提供参考，以改善当地及未来更广泛的实施情况。其他机构可以利用这些结果来促进其在这个充满伦理争议领域的指南实施。
