42 Chapter 2 Barrier assessment A barrier assessment was performed in twenty-three (43%) studies. 'Nineteen studies explicitly used the outcomes of the barrier assessment to select tailored implementation strategies. Lack of knowledge was the most common found barrier, described by eleven studies (48%). Other barriers were accessibility of products (n=6 %), time limitations (n=4%), and lack of leadership/motivation (n=4%). There was no difference in studies who described a positive significant effect on patient-related nursing outcomes or guideline adherence between studies that did or did not perform a barrier assessment. From the studies which measured patient-related nursing outcomes, eleven studies performed a barrier assessment, of which seven reported a positive significant effect on patient-related nursing outcomes, and four did not report a change (Pearson ChiSquare 0.335, df 1, p= 0.56). From the studies which measured adherence, nineteen studies performed a barrier assessment, of which twelve showed a positive significant effect on adherence (Pearson Chi-Square 0.229, df 1, p=0.63). Use of Implementation theory, models or frameworks Seventeen (31%) studies used a theory, model or framework. The Johanna Briggs Institute Getting Research in to Practice model was used in six studies, the Implementation Model of Change by Grol and Wensing in four, and the Promoting Action on Research Implementation in Health Services in two. The Normalisation Process Theory, Knowledge to action model, Theory of Change, RE-AIM model, and Awareness Desire Knowledge Ability Reinforcement (ADKAR) Change management model were used once. Nine of the studies which measured patient-related nursing outcomes used a theory, model or framework, of which six reported a positive significant effect on patient-related nursing outcomes (Pearson Chi-Square 0.68, p= 0.79). Sixteen of the studies which measured adherence used a theory, model or framework, of which eight reported a positive significant effect on adherence (Pearson Chi-Square 0. 860, p= 0.35). Study duration The duration of the implementation studies varied widely, from a few weeks up to several years. Some studies used point prevalence measures, others used continuous data. Several studies did not describe the duration and/or interval of the measurements performed. Seventeen studies did not mention the duration of the baseline measurements, twentyfour the implementation phase, and eleven the post-implementation phase. Overall, among the studies providing the respective information, baseline measurements were collected over a median period of three months (IQR 1-6), and the implementation phase lasted a median of three months (IQR 2-9.5). The post-implementation phase had a median duration of 3.5 months (IQR 1.75-6.0). Fourteen studies performed a second
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