Barriers and facilitators to implementing pulmonary rehabilitation guidelines in China: a qualitative study using implementation science frameworks

Abstract

Objective

To understand barriers and facilitators to the implementation of pulmonary rehabilitation guidelines in pulmonary and critical care medicine (PCCM) from an interdisciplinary perspective and to determine potential contextual implementation strategies.

Design

A qualitative study guided by the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF).

Setting

Four departments of pulmonary and critical care medicine in China.

Participants

Forty-two healthcare professionals (12 physicians, 22 nurses, 4 rehabilitation therapists, 2 respiratory therapists, and 2 physiotherapists).

Interventions

None.

Main outcome measures

We conducted semi-structured interviews with healthcare professionals. Transcripts of the semi-structured interviews were analysed using content analysis. Data were coded using a deductive approach. Identified factors influencing non-adherence and utilization of guidelines were then mapped to corresponding intervention strategies from the CFIR-Expert Recommendations for Implementing Change compilation (ERIC) database.

Results

Our analysis revealed barriers and facilitators across three themes: opportunity and support, staff characteristics and motivating factors. Key barriers to guideline implementation encompassed environmental hindrances, guideline complexity and time restriction, poor interdisciplinary communication, lack of awareness, knowledge or skills, capability concerns, and vague professional roles. Potential facilitators included social support and peer influence, MOH policies, robust evidence base and contextual adaptability, planning, monitoring, feedback, autonomous motivation, sense of optimism, and positive outcome expectations of guideline adoption. Environmental restructuring, educational meeting and ongoing training, clinician implementation team meetings and electronic order sets/digital proforma may be needed to facilitate guideline implementation.

Conclusions

CFIR and TDF provided valuable frameworks for evaluating both contextual-level and individual-level facilitators and barriers to implementing pulmonary rehabilitation guidelines and understanding what adaptations may be needed to improve compliance. These would be essential to inform future interventions in the PCCM and contribute to optimize pulmonary rehabilitation management.

Introduction

Chronic respiratory diseases (CRDs) are among the leading causes of morbidity and mortality globally, posing an escalating burden on patients and health systems [1, 2]. In 2017, CRDs affected approximately 545 million people globally (7.1% prevalence), resulting in 4 million annual deaths [3]. Pulmonary rehabilitation (PR) is recognized as the core component of the management of individuals with CRDs, complementing the benefits of pharmacotherapies and improving patient outcomes [4,5,6]. Pulmonary rehabilitation has been demonstrated to reduce symptoms, healthcare visits and hospitalizations, and to improve exercise capacity and health-related quality of life (HRQoL) [7, 8].

To increase delivery and implementation of pulmonary rehabilitation, Chinese national guidelines for respiratory rehabilitation management of chronic respiratory diseases were published in 2021 [9]. The national guidelines, tailored to the Chinese healthcare system, update previous respiratory rehabilitation recommendations and examine new areas of research [10, 11]. These guidelines provide a comprehensive, evidence-based framework for PR, encompassing exercise training, education, patient assessment, nutritional intervention, occupational therapy, psychosocial support and telerehabilitation [9].

Despite efforts to disseminate PR guidelines, a gap persists between evidence-based recommendations and clinical practice, with PR remaining underutilized in pulmonary and critical care medicine (PCCM) [12]. Less than 5% of eligible candidates benefit from PR across the global healthcare landscape [13, 14]. The success of rehabilitation programmes is attributed to the multiprofessional team, including physicians, physiotherapists, nurses, rehabilitation therapists, respiratory therapists, psychologists and social workers [4]. In China, physicians play an integral role in PR implementation and administration, as they are primarily responsible for referring patients with CRD to PR programmes [12, 15]. Recent multi-regional cross-sectional surveys reported that only about half of Chinese respiratory physicians had provided PR referrals [15], and fewer than 17% of physicians routinely offered evidence-based PR services [12].

Implementation science is the scientific study of methods to promote the systematic uptake of evidence-based practices (EBP), which in this case are the PR guidelines, into routine clinical practice [16]. Existing studies have identified several factors influencing the uptake of PR, such as insufficient knowledge, time constraints, complex clinical behavioural changes and difficult referral processes [17,18,19,20]. However, few studies have examined barriers and facilitators to guideline recommended PR. In addition, to date, no study has used principles of implementation science to systematically explore the reasons for the implementation gap in PCCM from an interdisciplinary perspective, and theory-informed behaviour change implementation interventions are understudied.

Consolidated Framework for Implementation Research (CFIR) is a well-operationalized, multi-level implementation determinant framework [21]. CFIR identifies five major domains focusing more on the contextual factors: (1) innovation characteristics (e.g. adaptability), (2) outer setting (e.g. partnerships and connections), (3) inner setting (e.g. culture), (4) individual characteristics (e.g. capability), and (5) process (e.g. planning) [21]. Theoretical Domains Framework (TDF) integrates 33 preceding behaviour change theories and includes 14 domains (e.g. knowledge, skills, social/professional role and identity, and beliefs about capabilities) [22]. The TDF, an overarching framework providing an additional focus on individual-level behaviour change factors, has been extensively applied in implementation research [23].

Therefore, we used principles of implementation science, combining the CFIR with the TDF, to systematically explore determinants underlying interdisciplinary staff’s non-adherence to and utilization of PR guidelines in PCCM from a multilevel perspective [21, 24]. Furthermore, potential contextual implementation strategies were also explored. To our knowledge, this study might be the first to investigate this topic using robust implementation science frameworks and this would be essential to optimize management and outcomes of patients with CRDs.

Methods

Study design

This qualitative study was underpinned by a constructivist epistemology [25] and used a critical realist ontological perspective [26]. Data collection and analysis were guided by the CFIR and the TDF. The research team comprised clinicians and implementation scientists with expertise in PR. The principal investigators (Y.J. and H.W.) are experienced qualitative researchers, both pursuing doctoral degrees, who acknowledged that their subjectivity and context may influence the research processes. Regular team discussions, peer debriefing, member checking and reflexive journaling were employed to ensure trustworthiness. The Ethics Committee of Nursing and Rehabilitation College of Shandong University approved this study (Project ID: 2023-R-210).

Study participants

We recruited a purposive sample of healthcare professionals (HCPs) between December 2023 and May 2024. HCPs with at least 3 years of clinical experience from multiple health disciplines, involved in pulmonary disease management, and practising in PCCM were eligible to participate in the study. In total, 42 participants from four tertiary hospitals in China were recruited, including 12 physicians, 22 nurses, 4 rehabilitation therapists, 2 respiratory therapists and 2 physiotherapists. Written informed consent was obtained from all participants before starting the interviews.

Data collection

The interview topic guide addressed the CFIR constructs and TDF domains to identify determinants of national guideline implementation [24], and flexible and open discussions on topics were also allowed [27] (Supplementary Material). The principal investigator (Y.J.) and co-investigator (H.W.), both trained in qualitative methods and ethics, conducted face-to-face semi-structured interviews (duration: 19–53 min) in public and private settings. The decision to conclude participant recruitment was based on situated subjective judgments, aiming to strike a balance between practical feasibility and informational richness [28, 29]. Both investigators had an in-depth understanding of the theoretical context of each CFIR construct and TDF domain. All interviews were audio-recorded and transcribed verbatim, and any identifying information was deleted.

Data analysis

Two members of the research team (Y.J. and H.W.) conducted the content analysis of transcribed interviews [27], guided by the Framework Approach [30]. Data were coded using deductive approach (coding of theoretical constructs) by two analysts (Y.J. and H.W.) [27, 31]. Data pertaining to contextual and/or individual barriers and facilitators to guideline implementation were deductively mapped onto the domains and constructs of the CFIR and TDF. Discrepancies or conflicts were resolved through a consensus meeting among the larger research team members (Y.J., H.W., B.M., Y.C. and X.R.) [27]. The transcripts were organized using QSR International NVivo V.11 software.

Mapping to interventions

We used the CFIR-Expert Recommendations for Implementing Change (ERIC) mapping tool to prioritize and develop appropriate contextual implementation strategies [32]. Specifically, identified domains influencing guideline implementation were matched to corresponding intervention strategies from the ERIC database. The use of frameworks across the study design and steps for theory-based development of implementation intervention are outlined in Fig. 1.

Fig. 1

A schematic outlining the use of frameworks during the study and steps for theory-based development of implementation intervention. CFIR Consolidated Framework for Implementation Research, TDF Theoretical Domains Framework

Results

Participant characteristics

Of the 42 participating HCPs, 13 were male and 29 were female. The mean age was 35 years (range: 25–48) and mean time in practice was 10 years (range: 3–24). Thirty-five participants (83%) had 5–24 years of work experience, and seventeen (40%) held advanced degrees. Table 1 presents a summary of participant characteristics.

Table 1 Characteristics of the participating healthcare professionals (N = 42)

Key themes

Barriers and facilitators to guideline implementation were grouped into three overarching themes: opportunity and support, staff characteristics, and motivating factors (Fig. 2). A summary of barriers and facilitators and example quotes are presented in Table 2.

Fig. 2

Summary of themes including Theoretical Domains Framework and Consolidated Framework for Implementation Research domains associated with the barriers (purple) and facilitators (green) within each theme. Markers in orange indicate barriers or facilitators within each theme

Table 2 A summary of the barriers and facilitators of guideline implementation grouped by CFIR/TDF subdomain (N = 42)

Opportunity and support

Environmental hindrances

The limited funding, staffing, practice facilities and pulmonary rehabilitation systems were considered major practical barriers for conducting the complete pulmonary rehabilitation process in PCCM departments (CFIR: inner setting – available resources, innovation – innovation cost; TDF: environmental context and resources). Some participants expressed that the financial resources were somewhat limited in the setting, and they were also concerned about potential cost and burden on patients or their families, which deterred them from recommending intervention:

You have to acknowledge that money is often an issue as well… I don’t want to burden the patients or their families… it is a problem, and of course, it is a barrier. (P38.Physician.11)

Some participants highlighted that integrating multidisciplinary specialists (e.g. psychologists, nutritionists, respiratory rehabilitation nurses) into PCCM teams could optimize PR for patients with CRD:

It would compete with other priorities to upskill our physicians and nurses on pulmonary rehabilitation in our setting… Support from interdisciplinary teams will help… (P10.Physician.2)

Some participants reported facing additional obstacles and challenges. They indicated that essential clinical resources for patient assessment, education and telerehabilitation (e.g. standardized exercise testing equipment and therapeutic exercise tools) were not readily available in their clinical settings (CFIR inner setting – structural characteristics):

I mean, with regard to equipment or examinations, we do not have enough space or infrastructure to provide exercise rehabilitation services, such as a cycle ergometer… (P9.Nurse.8)

In addition, several participants noted that it was difficult to expand their knowledge of the guidelines due to poor electronic availability of knowledge resources or limited system access (CFIR inner setting – structural characteristics).

Guideline complexity and time restriction

Given the tight working schedule, the majority of participants stated that using the PR guidelines posed challenges to keeping up with their current workloads, which might result in increased demands on resources and staff time (CFIR: innovation – innovation complexity, inner setting – tension for change). Several clinicians stated their ability to recall all recommendations from guidelines was compromised (TDF: memory, attention and decision processes):

For the guidelines… an additional part-time position would probably be needed for me. (P8.Nurse.7)

It might be difficult to recall and follow all recommendations from the guidelines as there are multiple disciplines and specialty cases that need to be dealt with… (P10.Physician.2)

Poor interdisciplinary communication

Many participants noted that a lack of interdisciplinary communication and limited information exchange with patients remained barriers to subsequent utilization of the guidelines (CFIR: inner setting – relational connections, communications; TDF: social influences). They stated that formal communications amongst interdisciplinary staff were quite poor in their clinical areas. Furthermore, only a small number of HCPs consistently maintained ongoing communication with patients with CRD via telephone calls or purpose-designed web platforms to deliver telerehabilitation services (CFIR: inner setting – information technology infrastructure). Some patients and their families were not involved or did not even know about the guidelines (CFIR: individuals – innovation recipients):

Formal communications among interdisciplinary staff in specialty departments are limited in the setting… (P12.Respiratory therapist.1)

I particularly hope they [CRD patients] could adhere to aerobic exercise [after discharge]… It’s an effective approach for pulmonary rehabilitation… However, [now] I suddenly realized I haven’t discussed this with them… (P41.Rehabilitation therapist.3)

Social support and peer influence

Some social-support facilitators, such as external team learning, academic conferences, practice team support and colleague exchanges, were identified as facilitators to guideline implementation (CFIR: inner setting – incentive systems, available resources, individuals – opportunity; TDF: reinforcement, social influences). Furthermore, participants stated that these contributed to a positive learning climate and increased potential for successful guideline implementation in their settings (CFIR: inner setting – relational connections; TDF: culture):

Our department has always attached great importance to pulmonary rehabilitation and has provided opportunities for team external learning and academic conferences… (P19.Physician.5)

MOH policies

A few participants also noted that the Ministry of Health (MOH) policies, including specific resource allocations to support a role for PCCM in providing pulmonary rehabilitation services, inevitably contributed to the implementation of the guidelines (CFIR: outer setting – policies and laws; TDF: social influences).

Robust evidence base and contextual adaptability

Furthermore, many participants recognized the evidence-based guidelines as a relative advantage, as they provide systematic and detailed recommendations for PR, including specific parameters for exercise training (e.g. frequency, intensity, duration, volume and modality). This offers a solid foundation for clinical practise and promotes the sustained implementation of the guidelines (CFIR: innovation – innovation evidence-base, innovation relative advantage):

It’s quite useful because you can access systematic and specific pulmonary rehabilitation techniques… it’s kind of nice to have some hands-on guidance. (P14.Nurse.9)

In addition, some participants expressed that the implementation of the guidelines fit well with existing workflows in practice, and the flexibility of the guidelines made it possible to use them across different situations (CFIR: innovation – adaptability, innovation relative advantage):

I think it [the guideline] is simple and flexible enough to incorporate into our existing workflows… (P32.Nurse.18)

Staff characteristics

Lack of awareness, knowledge or skills

A number of nurses stated that although they had access to the national guidelines, awareness and utilization of specific components (e.g. exercise assessment and prescription, education, and energy conservation techniques) remained sources of confusion for them. Some physiotherapists outlined that their skills or roles were primarily in musculoskeletal therapy, and there was virtually no respiratory focus in their competencies, which had affected their capacity to implement the guidelines (CFIR: individuals – capability; TDF: knowledge, skills):

Frankly, there is no staff in our department whose skills or roles are respiratory management-oriented. (P31.physiotherapist.1)

Many participants stated that ongoing education and training with respiratory focus, through in-service and awareness programmes would be helpful to augment staff awareness, utilization and adherence (TDF: reinforcement).

Planning, monitoring and feedback

In terms of facilitators, some participants stated that personalized rehabilitation plans, regular monitoring and feedback facilitated the early identification of implementation issues and assisted in better utilization of the guidelines (CFIR: implementation process – planning; TDF: behavioural regulation):

Our interdisciplinary team would assess CRD patients’ abilities, needs, and disposition to develop feasible and realistic rehabilitation goals and interventions. (P32.Nurse.18)

In addition, potential areas of quality improvement were expressed by experienced HPCs, including rehabilitation assessment, exercise training, nutritional management and education. Participants stated that each of these areas could be improved (CFIR: implementation process – reflecting and evaluating).

Motivating factors

Capability concerns

Around half of the participants disclosed concerns about their capability of providing pulmonary rehabilitation to patients with CRDs, which might be a barrier to implementation (CFIR: individuals – capability; TDF: beliefs about capabilities). They noted that the nature, busy pace and time pressure in PCCM departments diminished their capability to provide pulmonary rehabilitation as per guideline recommendations (CFIR: innovation – innovation adaptability; TDF: beliefs about capabilities):

Frankly, I’m not very confident… but at least I know them [the guidelines], and I know their benefits. I wouldn’t say that I’m 100% confident now, but better than before… about 60%… (P22.Nurse.15)

Vague professional roles

Some participants stated that they were confused regarding their role and scope of practice in the PCCM (CFIR: innovation – innovation complexity; TDF: social/professional role and identity). For example, nurses expressed that the nurse-led psychological intervention was a challenge emotionally, as they felt uncertainty about taking on the role of a psychologist (CFIR: implementation process – doing):

To be honest, we don’t have a good grasp of cognitive behavioural therapy, mindfulness-based stress reduction, etc.… we are worried that we cannot provide professional psychological assessment and intervention for patients like psychologists, right? (P35.Nurse.21)

Autonomous motivation

A number of facilitators were also identified within this overarching theme. Interviews suggested that HCPs’ autonomous motivation to apply the guidelines was high and maintained over the course of pulmonary rehabilitation (CFIR: individuals – motivation). Most participants expressed they intended to follow the national guidelines and felt positive when involving in pulmonary rehabilitation services for patients with CRDs (TDF: intentions, optimism, emotion):

If possible, I would like to use my spare time to do this [health education]…(P35.Nurse.21)

Sense of optimism

A sense of optimism was also present among HCPs. Some participants reported that they would remain positive and persevere although their patients’ compliance was low, particularly at first (CFIR: individuals – innovation recipients; TDF: optimism). Furthermore, over half the participants interviewed expressed willingness to participate in continuous education so as to easily work with the guidelines:

… So, I think everyone should learn [the guidelines]… and I’m happy and so grateful to provide pulmonary rehabilitation to CRD patients… as it’s beneficial… (P8.Nurse.7)

Positive outcome expectations of guideline adoption

HCPs’ substantially positive emotion was often accompanied by beliefs in the effectiveness of the guidelines (TDF: beliefs about consequences, optimism). The majority of participants described positive outcome expectations of guideline adoption. Pulmonary rehabilitation was deemed a useful approach to improve patients’ health-related quality of life (HRQoL). Success in PR pulmonary rehabilitation motivated staff (TDF: reinforcement):

Of course, I feel more confident about what I am doing. When I look back after the implementation [the guideline], I feel it’s effective… then I’m happy… that motivates me… That is enough for me. (P15.Nurse.22)

Implementation strategies

The 15 highest-ranked implementation strategies identified using the CFIR-ERIC mapping tool are detailed in Supplementary Table S1. We identified the following implementation strategies as target areas for further exploration after considering priority barriers and clinical practice context:

• Conduct educational meetings.

• Access new funding.

• Develop a formal implementation blueprint.

• Develop educational materials.

• Conduct ongoing training.

• Involve patients and family members.

• Organize clinician implementation team meetings.

Definitions of these seven strategies, along with examples of the barriers they may address, are outlined in Supplementary Table S2.

Discussion

Healthcare professionals face considerable barriers when implementing clinical practice guidelines (CPGs) [33, 34]. In the present study, we used robust implementation science frameworks to examine why PR guidelines are underused in PCCM departments from an interdisciplinary perspective and to map targeted, evidence-based implementation strategies. These strategies would be essential to promote guideline adoption, optimize the management of pulmonary rehabilitation and improve health outcomes for patients with CRDs.

We identified three overarching themes of barriers and facilitators. Within the theme of opportunity and support, limited funding, staffing, equipment and pulmonary rehabilitation systems were frequently reported. These constraints resulted in a perceived effort–reward imbalance, echoing HCPs’ views in previous studies [35, 36]. These could be due to the nature, busy pace and time pressure in PCCM departments, which restricted their opportunities and capability to follow the guidelines, especially during peak hours and in the winter timeframe [37]. Recommended strategies from the ERIC database include accessing new funding, involving patients/consumers and family members, and organizing clinician implementation team meetings. These have been used successfully to implement evidence-based interventions [38, 39].

In addition, environmental restructuring, involving the creation of a dedicated team and space for delivering PR and the provision of clinical reminders with easier access to concise guidelines, may be a pragmatic intervention to adapt to the bustling nature of the departments. Electronic order sets/digital proformas can provide role clarity, improve time efficiency and facilitate adherence to clinical guidelines [40, 41]. Currently, research on electronic order sets for PR management in CRDs remains limited. Therefore, developing guideline-based electronic order sets/digital proformas appears to be another solution. We also found a number of potential facilitators, including the high value that healthcare professionals placed on the capacity-building opportunities in PCCM departments. This is consistent with recent studies indicating the importance of having opportunities and support to use the guidelines [42].

Guideline implementation is a complex process and requires providers to undergo extensive training and develop expertise to achieve fidelity; however, this remains a challenge for many staff [43]. The theme of staff characteristics noted that a lack of awareness, knowledge and skills were most often mentioned as impediments to guideline adherence, which has also been reported by providers in previous studies [44, 45]. Major gaps in physicians’ knowledge and skills were described as barriers hampering guideline-compliant care implementation and communication [44]. At the same time, these have highlighted gaps in education and training among HCPs [46, 47]. To resolve this issue, educational meetings and ongoing training, targeting management, could be conducted [48]. Specifically, lengthening the initial training session and adding a booster session might be effective implementation strategies to provide opportunities for reflection on experiences and continued capacity-building [49].

Furthermore, printed educational materials tailored to the department and the role of each target group are also recommended [50]. Educational materials should explain the benefits of pulmonary rehabilitation for patients with CRD, its role in the clinical pathway and staff responsibilities. Our findings also indicated that action planning, monitoring and feedback might be the drivers of improvement in guideline adherence. Audit and feedback, a quality improvement tool, would assist in the improvement of professional practice [51].

Motivation is the direct cause of promoting individual emotion and behaviour change, which is considered crucial to succeeding in guideline implementation [52]. Similar to previous studies [53, 54], the theme of motivating factors demonstrated that most HCPs continued to feel very positive about guideline embeddedness. The ongoing and sustained motivation may be largely driven by the following: (i) beliefs in the effectiveness of pulmonary rehabilitation; (ii) the perceived relative advantage of national guidelines; and (iii) observed success in pulmonary rehabilitation in clinical practice.

HCPs also expressed positive outcome expectations of guideline adoption, and this was deemed a facilitator for guideline implementation. They noted significant further improvements in their patients, which they attributed, at least in part, to pulmonary rehabilitation. Such improvements acted as reinforcement and sustained motivation to continue using the guidelines. Furthermore, positive outcome expectations among staff partly reflected a sense of collective efficacy – defined as a shared belief in the group’s capability to accomplish goals [55] – which was reported to have the potential to impact implementation effectiveness [56, 57]. Therefore, it is worth further exploring how to cultivate collective efficacy specifically for PR implementation.

Despite motivation for the guidelines, some HCPs raised concerns about their capability of providing PR to patients with CRDs, in line with previous findings [58]. HCPs may not feel equipped with the requisite skills and knowledge, and may be unsure whether they will acquire them. This, again, may reflect the importance of education and training in guideline implementation. In discussing social/professional role and identity, it became clear that vague professional roles may require rethinking roles and responsibilities, and restructuring the healthcare delivery team. A formal implementation blueprint would facilitate the effective implementation of guideline recommendations in practice [59].

While previous studies have investigated barriers and facilitators to the referral and participation of PR, with findings partially consistent with ours (e.g. financial constraints, role confusion, lack of support, intentions and optimism) [60, 61], this study systematically examined determinants of guideline-recommended PR using implementation science principles. We identified novel facilitators and barriers pertaining to guideline characteristics, implementation processes and contextual factors. These included guideline complexity, robust evidence base and contextual adaptability, peer influence, planning, monitoring and feedback. Implementation strategies targeting these factors would enhance evidence-informed PR practices in PCCM.

Strengths and limitations

Our study provides first-hand, in-depth insights into the perceived challenges of implementing PR guidelines using a multidisciplinary approach, which assisted in capturing the perspectives of HCPs from a range of health-related disciplines. Another strength of this study lies in its robust theoretical basis, which was applied in the design and analysis. Guided by the CFIR and TDF frameworks, we systematically identified both contextual-level and individual-level facilitators and barriers to the implementation of PR guidelines, and corresponding contextual intervention strategies were determined using the CFIR-ERIC mapping tool.

There are also limitations that should be considered: our sample consists of a small number of healthcare professionals from one geographic area, and hence generalizability may be limited. In addition, the department did not employ psychologists, thus no inclusion of this area of allied health engagement could be captured. Furthermore, there was a possible social desirability bias in responses to guideline implementation. However, HCPs were generally frank in their criticisms and shared their honest opinions; thus, we consider the risk of bias to be rather low.

Conclusions

The results demonstrate that perceptions of their own capabilities, opportunities, and autonomous motivation highly influenced HCPs’ engagement in PR management. Environmental restructuring, educational meetings and ongoing training, clinician implementation team meetings, and electronic order sets/digital proformas could be prominent and preferred implementation strategies to improve guideline compliance. In addition, these theory-informed, multi-component implementation strategies merit further investigation. Our findings are essential to optimize PR management and ultimately increase patient wellbeing.