STRATEGIES, FACILITATORS AND BARRIERS TO CHANGE: A SYSTEMATIC REVIEW OF IMPLEMENTATION RESEARCH WITHIN DEMENTIA CARE

Abstract

Evidence-based guidelines and good practice in dementia care are inconsistently implemented, leading to fragmented and poor quality care. There is a recognised need for a better understanding of how best to implement evidence-informed dementia care but no synthesized evidence is available on this topic. We conducted a systematic review to: (i) examine the effectiveness of dissemination and implementation strategies within dementia care and (ii) identify facilitators and barriers to implementation, across dementia stages and care settings. We searched twelve databases (including MEDLINE, Embase, and the Cochrane Library) from inception to October 2015, supplemented by forward citation searches. Two reviewers independently screened titles and abstracts, reviewed full texts, and performed quality appraisal. Data extraction was performed by one reviewer and checked by a second. We used the ERIC compilation to classify strategies from quantitative studies. Emerging themes from qualitative analysis were clustered to describe barriers and facilitators at the innovation, family and patient, individual-staff, and organisational level. We used a mixed-methods synthesis. Thirty-six studies were included (8 cluster RCTs, 28 qualitative). The identified trials were of modest methodological quality and used multifaceted implementation strategies that all included educational components. However, strategies were not easily comparable across trials and demonstrated variable effectiveness on knowledge, compliance to guidelines and protocols, and prescribing behaviour. Most of the qualitative studies were of good quality. Positive beliefs about the innovation, staff receptivity and engagement, family involvement, and supportive leadership act as facilitators to implementation of change but are often at odds with the reality of working at long-term care settings which urges staff to revert to familiar routines. Staff shortages, time pressure, high workload, lack of funding to support change, and logistics issues impede implementation and jeopardise the quality of dementia care. Although there is an urgent need for evidence of the effectiveness of specific implementation strategies within dementia care, this evidence is lacking. Qualitative findings highlight factors across multiple levels that may affect implementation and indicate that future efforts are more likely to be successful when they invest in staff support and engagement and address chronic organisational issues within long-term care settings.