This study used some methods from the implementation science to identify barriers to implementing guidelines for postpartum care and matching implementation strategies. Our analysis resulted in ten barriers and matched several related implementation strategies.
Participants in our interviews identified “patient needs and resources” as one of the major barriers to the implementation of the guidelines. Due to the limitations of the postpartum physiological conditions and economic factors for advanced maternal age, their compliance with postnatal care guidelines has decreased. Advanced maternal age is more likely to choose a caesarean section with poor physiological condition such as postpartum incision pain and indwelling catheter, it may cause women to ignore the health education given by some nurses. In addition, the economic factor has been also considered by patients and their families and one of the major barriers to the implementation of guidelines in the clinical practice(27, 28). For example, a guideline recommends that women with gestational diabetes conduct the fasting plasma glucose at postpartum 6 to 13 weeks(13), but some of them do not do it after discharge because this cost may not include in the medical insurance. Women are unwilling to pay extra costs. ERIC gave strong recommendations: “Involve patients/consumers and family members”, “Conduct local needs assessment”, “Obtain and use patients/consumers and family feedback”, “Prepare patients/consumers to be active participants”, and “Intervene with patients/consumers to enhance uptake & adherence”. Therefore, in response to these barriers, the concrete strategies developed by our team were: (a) in the process of implementation, strengthen communication with women and their families to increase maternal trust in nurses; (b) meet the physical and psychological needs of women, and develop individualized care plans based on guidelines with women and their families; (c) carry out various forms of health educations (health education meeting, health education materials, video technology, etc.) at appropriate times to encourage women and their families to actively participate in implementation; (d) obtain and use maternal and family feedback for continuous improvement of the care plan.
In CFIR, the most barriers were in the fields of inner setting (obstetrics department), including Compatibility, Structural Characteristics, Access to knowledge and information, and Learning Climate. Most participants agreed that in the inner setting, insufficient staffing and implementation time were the main barriers. In China, since the endorsement of the two-child policy in 2016, the number of advanced maternal age has increased(29, 30). There is no doubt that the workload of nurses continues to increase, resulting in a lack of time to learn and implement the guidelines. The insufficient allocation of nurse staffing has existed in the hospital, and it is not advisable to increase sufficient human resources just for the implementation of the guidelines. However, we can reduce the time required to implement the guidelines and the nurses' workload by increasing familiarity and improving the compatibility for the guidelines to facilitate their integration into the daily workflow. Pellecchia et al. mentioned that sometimes researchers’ questions of interest and those of partners were different, so at the local consensus discussions, listening to partners’ priorities and incorporating their views into the research questions and design are likely to improve implementation outcomes(31). To improve the compatibility of the guidelines, our team plans to conduct a local consensus meeting once a month to discuss implementation progress and adjust clinical practices. It is recommended that all aspects of postnatal care in the guidelines are categorized with each topic forming a nursing record. Nurses implement nursing interventions within the set time and finally make a record in the corresponding form.
The lack of knowledge is an important barrier to the clinical implementation of the guidelines. From the results of the interviews, most nurses stated that they lacked both theoretical knowledge and skills related to evidence-based practice and direct access to new evidence of postnatal care, which led to a lack of their confidence in implementing the guidelines. In addition, they pointed out a lack of multi-faceted training in their hospital. This reflected the three barriers to CFIR: “Access to knowledge and information”, “Knowledge & Beliefs about the Intervention”, “Self-efficacy”, and “Key Stakeholders”. ERIC recommended strong strategies focusing on education and training. Maastrup et al. found that exclusive breastfeeding rates in preterm infants at discharge improved after training neonatal nurses in breastfeeding-supportive evidence-based practical training(32); with planning, systems review, and trained staff, postpartum depression (PPD) screening can be integrated into obstetric and paediatric practices and high screening and referral rates can be achieved(33). Others have also demonstrated that effective evidence-based knowledge training is of great significance for improving nurses' evidence-based practical ability and facilitating the translation of evidence into the clinical practice(34–36). Our team planned to continuously provide nurses with various evidence-based medicine websites and with dedicated team members guiding them through the electronic library to access materials, conducting a variety of training regularly. It was identified that in addition to distributing some paper versions of educational materials, nurses also expected to have access to electronic materials and educational videos on their mobile phones, and to study the guidelines through online educational courses. Online training has proven to be more scalable, providing convenient and flexible learning(37, 38). While online learning has potential benefits, it must engage and empower learners for the learnings to be applied in the real world(39). To be precise, training should be relevant to practice and implemented when learners are exposed to clinical cases to practice the skills learnt(39, 40). Furthermore, based on evidence-based nursing training, we should strengthen cooperation between hospitals and nursing schools, and organically combine the relevant resources to effectively promote evidence-based nursing in clinical practice.
Two of the eight structures in the area of Intervention Characteristics appeared, with “Evidence Strength & Quality” and “Complexity” highlighted as barriers. The complexity of the guidelines is critical to influencing the implementation of the interventions. Several aspects of postnatal care are listed in the guidelines(12, 13): postpartum haemorrhage, breastfeeding, perineal health, psychological care, and postpartum visit. According to participants, in addition to spending a lot of time on study guidelines prior to implementation, the evaluation of implementation effectiveness has been needed to collect and collate relevant maternal medical data. The data variables are very cumbersome, placing a relatively heavy burden on medical staff when reporting this data and taking a lot of time(41). For example, in postpartum perineal care, the guideline(13) recommended using a validated pain scale to monitor perineal pain. Nurses only take maternal complaints to assess the degree of perineal pain, and adding a new scale into the daily workflow will undoubtedly increase the nurses' workload. But some nurses are still skeptical about scales or other interventions that have not been validated in the local clinical context. ERIC recommends primarily educational meetings and ongoing consultation to address these barriers. For the complexity as a barrier, it is recommended to conduct cyclical small tests of change to implement changes and to study the results of change tests before taking changes system-wide, and this process continues serially over time, with refinement added to each cycle(22).
This study has potential limitations. On the one hand, because the guidelines were implemented in only a single hospital, the sample included only nurses who had participated in the implementation of the guidelines, which may make the results of this study impossible to generalize. On the other hand, the CFIR interview guide suggests that they have not been validated in postnatal clinical care practice and that not all CFIR-ERIC strategies apply. Thus, these strategies need to be further applied in clinical practice to test their effectiveness.