Barriers and Facilitators—Lessons Learned From a Randomised Trial to Implement Clinical Practice Guidelines for the Prevention of Coercion in Psychiatry

Abstract

The PreVCo study (‘Prevention of Violence and Coercion’) investigated the effects of a structured programme for the implementation of guideline recommendations for the management of aggression and the prevention of violence and coercion in psychiatric hospitals in a multicentre randomised controlled trial with 55 participating wards. The intervention was a 1-year individually tailored implementation programme supported by external consultants. An independent evaluation of the individual wards' process aimed at identifying barriers and facilitators in implementation. We conducted guideline-based group interviews with 53 of 55 participating teams during the implementation process. The Consolidated Framework for Implementation Research (CFIR) was used for the qualitative analysis. Two coders independently coded the transcripts and conducted a summary content analysis. The focus was on facilitators and barriers in the implementation process. The design of the intervention, in particular the framework of a controlled study, external guidance and the opportunity to choose and adapt the implementation programme according to the wards' possibilities and needs, was generally perceived as useful and supportive. The context of pandemic management at the time of the study interfered with the implementation process, mostly because of organisational transformations, challenges for information exchange and increased workload of the staff. With regard to the wards participating in the study, the main facilitators were a receptive, collaborative ward culture, team spirit and previous experiences in successful transformation processes. Barriers included the demanding working situation, frequent fluctuation of staff and low team cohesion, obstacles in communication, a deficit-oriented perception of patients and low priority of the implementation process. Provision of necessary resources by the organisation was not self-evident. Stakeholders devoted to the ideas of transformation of psychiatry and reduction of coercion were important facilitators of the implementation; however, some employees kept a resigned attitude and could not be engaged. The analysis of barriers and facilitators shows that an implementation process of innovative routines on psychiatric wards can benefit from external, individually tailored guidance. However, the working conditions on psychiatric wards remain to be challenging.

Trial Registration: Clinical Trial Registration at www.isrctn.com with the identifier ISRCTN 71467851