Barriers and supports to implementation of MDI/spacer use in nine Canadian pediatric emergency departments: a qualitative study

Scott, Shannon D; Osmond, Martin H; O'Leary, Kathy A; Graham, Ian D; Grimshaw, Jeremy; Klassen, Terry

The dissemination of research evidence rarely is sufficient by itself to improve healthcare and specific interventions are needed to address local barriers and facilitators [20] . This is true with MDI/spacer adoption because, despite strong research evidence that MDI/spacer can produce results equivalent to nebulisers, adoption of MDI/spacers for the treatment of mild and moderate asthma has been slow. Building upon the findings of key articles in the field [16, 17] , we studied the natural evolution of diffusion patterns of MDI/spacers for the treatment of mild to moderate asthma in children in nine PEDs. Through this research, we developed new knowledge about the social and political nature (i.e., in terms of resource allocation and presence of champions) of the adoption process as well as complexity in terms of the number of factors and levels that innovation adoption demands. Clinical treatment and management of children's asthma exacerbations are engrained decisions and behaviours that are shaped by factors at the individual practitioner, department, and institutional levels. Adding to this complexity, parental perceptions and expectations weighed heavily into healthcare professionals' decision making processes and the overall adoption process. Generally speaking, the findings make important contributions to the complexity of innovation adoption processes on two fronts. First, awareness or knowledge of the innovation is not enough to change practitioner behaviour. Rather, of note, most practitioners knew of the merit of MDI/spacer use, however, this knowledge was not enough to independently propel successful adoption because of the magnitude of other unit level barriers. Second, there were no 'magic bullets' or patterns of barriers and/or facilitators that consistently led to adoption success at each of the adopter/ adopting sites. Rather, the unit/departmental barriers and facilitators interacted and interplayed with historical, contextual, and cultural values at each site. Our findings represent important knowledge for EDs preparing to implement MDI/spacers for asthma treatment, and potentially other innovation adoption decisions that are based upon strong research evidence. This study demonstrates the value of assessing the unit-specific barriers and facilitators prior to planned implementation change initiatives in order to tailor implementation strategies.