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Implement Sci. 2018 Nov 12;13(1):139. doi: 10.1186/s13012-018-0832-8.

Defining barriers and enablers for clinical pathway implementation in complex clinical settings.

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Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Road, Room W1415, Ottawa, ON, K1H 8L1, Canada.
University of Ottawa, Ottawa, ON, Canada.
Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
Department of Pediatrics, Division of General Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada.
Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
Alberta Health Services, Calgary, AB, Canada.
School of Nursing, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada.
Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada.



While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings.


This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel.


Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model.


Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change.



Barriers and enablers; Clinical pathways; Emergency medicine; Implementation; Theoretical domains framework

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