The resistance to changing guidelines – what are the challenges and how to meet them

doi:10.1016/j.bpa.2006.02.005

Best Practice & Research Clinical Anaesthesiology

Volume 20, Issue 3, September 2006, Pages 379-395

https://doi.org/10.1016/j.bpa.2006.02.005 Get rights and content

Bridging the gap between scientific evidence and its practical application is of the utmost importance in improving the quality of care and increasing patient safety. Guidelines based on evidenced-based medicine (EBM) have led to improved performances and better outcomes. However, even though scientific data are available, resistance to adopting evidence-based guidelines is still enormous. Significant barriers hinder the introduction of best medical practice into the daily clinical routine. The barriers to implementing change are complex, multifunctional, and influenced on many levels by various interests both inside and outside the health-care system. Political, organizational, financial, cultural and scientific interests are regarded as being as important as the perception of patients and health workers. Strategies need to be planned which take account of the multidimensional character of quality of care and incorporate it at the various levels. The conclusion, therefore, is that we need to combine methods and tools to tailor our interventions to the patient's needs.

Section snippets

Definition of clinical guidelines

According to Field and Lohr:¹³ ‘clinical guidelines are systematically developed statements to assist practitioner or patient decisions about appropriate health care for specific clinical circumstances’. They are based on the best available scientific evidence to provide clinicians with guidance to ensure that best practice is offered to patients.³ Guidelines are supposed to evaluate the wealth of scientific data, clarify different points of view, and finally define state-of-the-art procedures.

The process of change: the case of preoperative fasting

Unlike the field of industry, where people are forced to bring new ideas into practice because of fierce economic competition, it seems that within health systems the issue of ‘how to make guidelines work’ has always played a minor role.12, 17 As a consequence, data concerning the implementation process of liberalized guidelines for preoperative fasting are rare. Nevertheless, since several anaesthesiology societies from different countries have officially changed their recommendations for

Summary

As we have seen, clinical guidelines are meant to facilitate best medical practice. One might therefore expect them to be widely used. However, research has shown that the existence of an excellent guideline guarantees neither its wide nor its consistent use. Besides the efforts being made in developing guidelines, a lot more has to be done to encourage their implementation. Identifying the vast number of obstacles to any change in clinical practice is a decisive part of an implementation

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Cited by (68)

APPRAISE-RS: Automated, updated, participatory, and personalized treatment recommender systems based on GRADE methodology
2023, Heliyon
Clinical practice guidelines (CPGs) have become fundamental tools for evidence-based medicine (EBM). However, CPG suffer from several limitations, including obsolescence, lack of applicability to many patients, and limited patient participation. This paper presents APPRAISE-RS, which is a methodology that we developed to overcome these limitations by automating, extending, and iterating the methodology that is most commonly used for building CPGs: the GRADE methodology.
APPRAISE-RS relies on updated information from clinical studies and adapts and automates the GRADE methodology to generate treatment recommendations. APPRAISE-RS provides personalized recommendations because they are based on the patient's individual characteristics. Moreover, both patients and clinicians express their personal preferences for treatment outcomes which are considered when making the recommendation (participatory). Rule-based system approaches are used to manage heuristic knowledge.
APPRAISE-RS has been implemented for attention deficit hyperactivity disorder (ADHD) and tested experimentally on 28 simulated patients. The resulting recommender system (APPRAISE-RS/TDApp) shows a higher degree of treatment personalization and patient participation than CPGs, while recommending the most frequent interventions in the largest body of evidence in the literature (EBM). Moreover, a comparison of the results with four blinded psychiatrist prescriptions supports the validation of the proposal.
APPRAISE-RS is a valid methodology to build recommender systems that manage updated, personalized and participatory recommendations, which, in the case of ADHD includes at least one intervention that is identical or very similar to other drugs prescribed by psychiatrists.
Resistance of health personnel to changes in healthcare
2018, Kontakt
This study is based on scientific literature in the fields of health, management, sociology and psychology. It notes that the implementation of changes in healthcare (from major conceptual changes to changes at the level of a particular workplace) usually results in objections on the part of health personnel. The study is structured into six parts. The first part describes the difficulties associated with defining the term “resistance to change”. It also provides an overview of different types of resistance to change. The second part illustrates the general concept of resistance to change by means of examples from the area of health care. It also introduces conceptual changes to the healthcare system, changes in IT use, changes in nursing, and organizational changes within an institution. The third part is devoted to three theoretical models: the three-dimensional model of change (Pettigrew), the cyclical concept of the four phases of change (Lawrence), and the psychological model of experiencing change by an individual (a modification of the Kübler-Ross five stage model). The fourth part gives an overview of factors that (according to the results of previous research) contribute to the resistance of health personnel to change. The fifth part focuses on methods used to assessment the resistance to change, and presents basic information about ten questionnaires used for this purpose. The sixth (and final part) points out that the critical attitudes of health personnel to change do not fully reject it. The workers’ attitudes and behaviour are rather ambivalent with a tendency to change over time, but they may also have a positive function: they maintain the stability of the system; preventing superficial, ill-conceived changes and uncritically accepted innovations. If management listens to workers’ opinions, they can initiate a thorough debate and can provide stimuli to improve the original form of change. Seriously conceived resistance to change can alter the change for the better.
Starvation before surgery: is our practice based on evidence?
2017, BJA Education
Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review
2016, American Journal of Emergency Medicine
This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome.
An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes.
The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients.
The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.
Preoperative fasting guidelines: An update
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Desde 1990 las sociedades de Anestesiología han realizado distintas guías de ayuno preoperatorio ya no solo para disminuir la incidencia de aspiración pulmonar y morbilidad anestésica, sino para aumentar el bienestar del paciente previo a la anestesia. Algunas de estas sociedades han ido actualizando sus guías, de manera que desde 2010 ya disponemos de 2 dedicadas al ayuno preoperatorio basadas en la evidencia.
Con este trabajo se ha pretendido revisar las actualizaciones de las guías, así como las pautas actuales para pacientes más controvertidos, como lactantes, obesos y programados para cierto tipo de cirugía oftálmica.
Anesthesiology societies have issued various guidelines on preoperative fasting since 1990, not only to decrease the incidence of lung aspiration and anesthetic morbidity, but also to increase patient comfort prior to anesthesia. Some of these societies have been updating their guidelines, as such that, since 2010, we now have 2 evidence-based preoperative fasting guidelines available.
In this article, an attempt is made to review these updated guidelines, as well as the current instructions for more controversial patients such as infants, the obese, and a particular type of ophthalmic surgery.
Perioperative Surgical Home. Perspective II.
2015, Anesthesiology Clinics

View all citing articles on Scopus

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2The resistance to changing guidelines – what are the challenges and how to meet them

Section snippets

Definition of clinical guidelines

The process of change: the case of preoperative fasting

Summary

Intensive & Critical Care Nursing

Lancet

Lancet

Chest

Health Policy

Clinical Nutrition

Assessing health quality – the case for tracers

The New England Journal of Medicine

Der Internist

To Err is Human

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality

Journal of the American Medical Association

How good is the quality of health care in the United States?

The Milbank Quarterly

Barriers to translating evidence into practice

Current Opinion in Critical Care

What drives change? Barriers to and incentives for achieving evidence-based practice

The Medical Journal of Australia

Acting on the Evidence

Beliefs and evidence in changing clinical practice

British Medical Journal

Guidelines for Clinical Practice: From Development to Use

Kritische Bewertung von Leitlilnien

Evidence based medicine: what it is and what it isn't

British Medical Journal

The Development and Implementation of Quality and Improvement System (QIS) in Health Care – Recommendation

Clinical guidelines to improve patient care

The Netherlands Journal of Medicine

Healthcare rationing-are additional criteria needed for assessing evidence based clinical practice guidelines?

British Medical Journal

Barriers and bridges to evidence based clinical practice

British Medical Journal

Why don't medical textbooks teach? The lack of logic in the differential diagnosis

The Netherlands Journal of Medicine

Wie ließe sich die ärztliche Behandlung der Kranken angesichts der jetzigen wirtschaftlichen Notlage der Bevölkerung sparsam und doch sachgemäß gestalten?

Deutsche Medizinische Wochenschrift

Introduction: the philosophy of evidence based medicine

Closing the gap between research and clinical practice

Topics in Stroke Rehabilitation

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice

CMAJ: Canadian Medical Association Journal

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study

British Medical Journal

Consensus methods: characteristics and guidelines for use

American Journal of Public Health

Evidence-based disease management

Journal of the American Medical Association

Effects of feedback of information on clinical practice: a review

British Medical Journal

Framework for guidelines implementation studies

Why don't physicians follow clinical practice guidelines? A framework for improvement

Journal of the American Medical Association

An overview of strategies to promote implementation of evidence-based health care

2
The resistance to changing guidelines – what are the challenges and how to meet them