Table 3 Barriers for guideline adherence (75 unique barriers) ranked in Barriers Top-3 (N = 158 in total)
| Â | Category | Barrier | 1st place N (%) | 2nd place N (%) | 3rd place N (%) |
|---|---|---|---|---|---|
| Â | Intervention characteristics | Â | 6 (8.7) | 3 (5.6) | 1 (2.9) |
1 | Â | Lack of scientific evidence | 2 | 0 | 0 |
2 |  | Complexity—unclear/ambiguous guidelines | 2 | 0 | 0 |
3 |  | Complexity—the guidelines are too extensive | 1 | 0 | 0 |
4 | Â | Risk for the patient | 1 | 0 | 0 |
5 |  | Complexity—the guidelines are too detailed | 0 | 1 | 0 |
6 |  | Complexity—the guidelines contain many actions to carry out | 0 | 1 | 0 |
7 | Â | Patient unfriendly guidelines | 0 | 1 | 0 |
8 |  | Complexity—the guidelines contain many stop moments | 0 | 0 | 1 |
| Â | Societal context | Â | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Â | Implementation characteristics | Â | 0 (0.0) | 2 (3.7) | 0 (0.0) |
9 | Â | Being exposed too late to implementation efforts | 0 | 2 | 0 |
| Â | Organizational characteristics | Â | 27 (39.1) | 23 (42.6) | 14 (40.0) |
10 | Â | Lack of time/time pressure | 13 | 8 | 5 |
11 | Â | Workload | 4 | 1 | 0 |
12 | Â | IT | 1 | 3 | 2 |
13 | Â | Relevant information is missing, incomplete, or wrong | 1 | 2 | 1 |
14 |  | Organizational preconditions—preparations not adequately executed | 0 | 2 | 0 |
15 |  | Staff—capacity/lack of personnel | 1 | 0 | 1 |
16 |  | Organizational preconditions—a large group has to do the same thing at the same time | 1 | 0 | 0 |
17 |  | Staff—turnover of personnel | 1 | 0 | 0 |
18 | Â | Logistics | 1 | 0 | 0 |
19 | Â | Availability of resources and materials | 1 | 0 | 0 |
20 | Â | Impossibility to meet all requirements within the current organization | 1 | 0 | 0 |
21 | Â | Capacities | 1 | 0 | 0 |
22 | Â | Organization of care processes | 1 | 0 | 0 |
23 | Â | Unclear who is responsible for what; in case of shared responsibility, no one feels responsible | 0 | 1 | 0 |
24 | Â | Organizational complexity | 0 | 1 | 0 |
25 | Â | Prioritizing | 0 | 1 | 0 |
26 | Â | Pressure to run production/finish surgeries on time | 0 | 1 | 0 |
27 | Â | Lack of decisional power | 0 | 1 | 0 |
28 |  | Guests not aware of hospital—specific implementation of the guidelines | 0 | 1 | 0 |
29 |  | Organizational preconditions—nursing preparations not carried out | 0 | 0 | 1 |
30 | Â | Too many communication lines | 0 | 0 | 1 |
31 | Â | Low standard of working procedures | 0 | 0 | 1 |
32 | Â | Too bureaucratic | 0 | 0 | 1 |
| Â | Social context | Â | 11 (15.9) | 6 (11.1) | 3 (8.6) |
33 | Â | Culture | 3 | 1 | 0 |
34 | Â | Collaboration (by nurses) | 2 | 0 | 0 |
35 | Â | It is not accepted that the perioperative process is stopped or slowed down because some earlier stop moments are not (correctly) performed | 1 | 0 | 0 |
36 | Â | Being overruled by doctors | 1 | 0 | 0 |
37 | Â | Absence of anesthesiologist during sign-out | 1 | 0 | 0 |
38 | Â | The surgeon as initiator for performance of the time-out and sign-out | 1 | 0 | 0 |
39 | Â | Not taken seriously or involved in the TOP by the rest of the team | 1 | 0 | 0 |
40 | Â | Lack of initiative of the team | 1 | 0 | 0 |
41 | Â | Lack of support | 0 | 1 | 1 |
42 | Â | Collaboration by some surgeons | 0 | 1 | 0 |
43 | Â | Having to appeal people | 0 | 1 | 0 |
44 | Â | Inefficient teamwork/people have different interests when working in shifts | 0 | 1 | 0 |
45 | Â | Pressure by surgeons to start the surgery, while the time-out is not listed yet | 0 | 1 | 0 |
46 | Â | Opposition by colleagues | 0 | 0 | 1 |
47 | Â | Social pressure | 0 | 0 | 1 |
48 | Â | Communication problems | 0 | 0 | 1 |
| Â | Professional characteristics | Â | 9 (13.0) | 13 (24.1) | 3 (37.1) |
49 | Â | Attitude (of especially doctors) | 2 | 0 | 1 |
50 |  | Opinions—too excessive | 2 | 1 | 0 |
51 | Â | Behavioral routines | 0 | 2 | 0 |
52 |  | Opinions—adherence to the guidelines may create a wrong sense of safety (i.e. hidden unsafety) by weakening independent thinking and responsibility taking | 0 | 2 | 0 |
53 | Â | Awareness and knowledge about the importance and purpose | 0 | 1 | 2 |
54 | Â | Behavior | 1 | 1 | 0 |
55 |  | Opinions—customization is preferred over standardization | 1 | 0 | 0 |
56 |  | Opinions—in some situations it makes totally no sense to apply the guidelines | 1 | 0 | 0 |
57 | Â | Unclear handwriting | 1 | 0 | 0 |
58 |  | Opinions—finding it not useful to repeat things too often | 0 | 1 | 0 |
59 | Â | Forgetting | 0 | 1 | 1 |
60 | Â | Consideration for the wishes of the patient/perceiving patient discomfort | 0 | 1 | 1 |
61 | Â | Concerns about whether the use of checklists promotes a mentality of just ticking boxes | 0 | 1 | 0 |
62 | Â | Embarrassment toward the patients by asking several times the same question | 0 | 1 | 0 |
63 | Â | Common sense | 0 | 0 | 1 |
64 | Â | Motivation | 0 | 0 | 1 |
65 | Â | Indifferent following of procedures | 0 | 0 | 1 |
66 | Â | Self-overestimation | 0 | 0 | 1 |
67 | Â | Personality | 0 | 0 | 1 |
68 | Â | Lack of interest | 0 | 0 | 1 |
69 | Â | Rationalities to allow deviant behavior (e.g. not following guidelines will not harm patients) | 0 | 0 | 1 |
70 | Â | Own interpretation | 0 | 0 | 1 |
| Â | Patient characteristics | Â | 11 (15.9) | 4 (7.4) | 3 (8.6) |
71 | Â | Emergency patient | 9 | 2 | 2 |
72 | Â | Patient ability/cognitive abilities | 1 | 1 | 0 |
73 | Â | The patient in general | 1 | 0 | 0 |
74 | Â | Language problems | 0 | 1 | 0 |
75 | Â | Preferences | 0 | 0 | 1 |
| Â | No barriers perceived | Â | 5 (7.2) | 3 (5.6) | 1 (2.9) |
| Â | Total | Â | 69 (100) | 54 (100) | 35 (100) |