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Table 4 Survey results mapped onto the action cycle component of the knowledge-to-action framework

From: Speech pathologists’ experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study

Action cycle component  
Identifying a problem Speech pathologists identified evidence to practice gaps and that audits provided assistance to identify and address those gaps.
However, not all services were auditing their practice and respondents acknowledged some gaps went unaddressed.
Identifying, review, select knowledge The majority of respondents were aware of stroke CPGs and had used the guidelines, with most utilising the 2010 National Stroke Foundation guideline. Most respondents reported that the stroke CPG were “somewhat useful” or “very useful”. 46 participants did not use the guidelines and the reasons for their non-use remains unknown.
Some speech pathologists still acknowledged the need to continue to select, examine, and synthesise the broader and more recent literature. Participants also identified fields of evidence not sufficiently addressed in the guidelines e.g. right hemisphere stroke, severe aphasia, long-term stroke management.
Adapt the knowledge to local context Over half of the participants had adapted the stroke CPG to their clinical setting in pathways, policies, or procedures. Others had not had the opportunity to implement the CPG in their local context.
Access barriers to knowledge use Barriers and facilitators to the continued use of stroke CPGs were:
(a) The guideline itself: e.g. facilitator: clarity of information; barrier: recommendations are not practical.
(b) Work environment (context/setting): e.g. facilitator: influence or interest from others; barrier: lack of time, staff, resources.
(c) Factors relating to the speech pathologist (adopters): e.g. facilitator: a desire to implement evidence-based practice; barrier: insufficient skills to implement the guideline. A greater proportion of clinicians who did not use stroke CPGs worked in private practice, did not work in a multidisciplinary team, or had 1-5 years experience working with neurogenic communication disorders.
(d) Patient characteristics: e.g. patients with severe aphasia could be both a barrier and facilitator to the use of stroke CPGs depending on the context.
(e) Type of implementation strategy: (See Selecting, tailoring ,and implement interventions below)
Action cycle component  
Selecting, tailoring, and implement interventions Eighty (32.3%) of the 248 speech pathologists reported that they were provided with strategies or support to help implement the stroke CPG. Speech pathologists indicated that the most useful strategies are educational meetings, support from colleagues, auditing, and educational resources. All but one participant received multifaceted intervention.
Monitor knowledge use 250 respondents (84.6%) had used the stroke CPG in some way. The main reasons to use the guideline were to implement the best available research evidence, improve clinical practice outcomes, and to guide decision-making. The guidelines had also been used to inform clinical practice, develop pathways, and develop policies.
The most common method to evaluate adherence to stroke CPGs were the National Stroke Foundation audit (45.3%), other workplace audits (34.9%), and use of quality indicators (32.8%). Seventy of 232 respondents reported that no evaluation took place of the implementation of stroke CPGs.
Evaluate outcomes 190 participants (80.5%) reported that the stroke CPG had helped improve the care they provided, and 46 (19.5%) indicated that it had not. The perceived reasons for how the guidelines have helped improve healthcare were:
Changed speech pathologist’s behaviour or knowledge: e.g. something they could refer to, made them feel more confident in the services they provided, and encouraged them to read more literature.
Improved patient care: e.g. more dysphagia screening within 24 hours, patients not being given inappropriate PEG tubes, less patients inappropriately being kept nil by mouth, less aspiration pneumonia.
Changed, developed, or improved workplace services: e.g. advocate for services, encouraged client centred or multidisciplinary care, supported the development of policies and practices.
Sustain knowledge use Speech pathologists identified strategies that helped them to continue to use the stroke CPG. For example, National Stroke Foundation audits and use of quality indicators. Obtaining detail data on the sustained use of stroke CPGs over a period of time was beyond the scope of this study.