Table 2

Themes, thematic statements and descriptions of barriers to implementing (inter)nationally endorsed health and social care standards with level of confidence in the evidence* reporting the barriers

Barriers to implementing (inter)nationally endorsed health and social care standards
Themes (†N)Thematic statementsDescriptions
1. Standards have limited adaptability (n=10).Standards have limited applicability due to inherent differences between services including geographical locations.30 41 49 54 59 61 62 Differences in service type, service delivery and geographical location, results in difficulty applying standards to all service areas. Examples include differences between urban and rural services, healthcare and community settings, emergency and outpatient services.
Standards overlap and use compliance or medical oriented language making them difficult to embed in practice.49 65 66 Standards use language that is compliance or medical oriented. There is a high number of standards resulting in different overlapping standards and information overload which make it difficult to embed the standards in practice.
Standards do not align well with legislation, accreditation or regulatory frameworks.49 53 62 Standards do not fit neatly with legislation, accreditation or regulatory frameworks. Aspects of these frameworks do not support effective implementation of standards.
2. Services work in silos, have limitations with staffing and knowledge of standards (n=31).Services have a lack of knowledge, awareness and understanding of what standards are.28 30 38 39 41 44 47 49–53 55 59 60 62–65 67–70 There is a gap in knowledge, awareness and understanding of standards among staff relating to the rationale for standards, content of standards, expectations of service delivery and available support tools.
Services are experiencing staffing constraints that act as a barrier to complying with standards.28 30 38–40 44–50 56 59 63 66 70 71 Services are experiencing a lack of and a shortage of staffing resources such as unfilled specialist positions. This can lead to other issues such as loss of skills at local level, poaching of staff and an increase in transient staff.
Services have managers who do not support staff to comply with the standards.37–39 44 47 48 50 56 65 69 A lack of support from management includes a lack of; consistent processes, enforcement, leadership, understanding and onsite presence to support compliance with standards.
Services take a monodisciplinary approach with poor communication practices resulting in a lack of shared understanding and knowledge and poor implementation of standards.30 37–39 49 59 60 63 70 Services have poor integration and communication practices resulting in a lack of shared knowledge and joined up working, thus limiting the broader effectiveness of service delivery resulting in poor implementation of standards.
Services do not involve staff members including managers and professionals in decision-making and implementation of standards.38 39 44 65 69 Service managers and healthcare professionals are not consistently involved in implementation of standards.
3. Services and service-users have misconceptions about healthcare and support (n=15).Service-users lack awareness and knowledge leading to misconceptions about healthcare and demotivates standards implementation.41 46 49 59 60 63 68 70 Patients, carers and family members have a lack of awareness, knowledge and understanding of healthcare needs and service delivery which demotivates standards implementation.
Services do not have appropriate supports available to service-users including families and carers to comply with standards.30 45 48 49 51 55 60 62 Care and support can be patient focused and hence, families and carers can experience challenges accessing appropriate support services. Ethnic minority groups can be difficult to reach posing challenges to providing supports.
Standards may harm relationships between healthcare professionals and service-users. As such, healthcare professionals are reluctant to implement the standards.49 52 60 63 Healthcare professionals are threatened by a shift in power dynamics and fear that they will harm relationships with patients and family when raising sensitive health issues as recommended in a standard. This results in reluctance to implement the standards.
4. Services have poor access to resources and funding (n=25).Services have insufficient funds causing resource issues and competing tenders for safety and quality projects impacting on implementing the standards.28 38 39 46–50 56 57 61 63 65 66 70 71 A lack of funding can result in: shortages in medical equipment and supplies; poor maintenance of equipment and infrastructure; poor morale in services. Insufficient funding hinders implementation and is problematic for services. For example, standards have cost demands that result in competing tenders for safety and quality projects.
Services have a limited supply of resources such as equipment and medical supplies and hence are unable to provide all the activities set out in the standards.30 38 39 44 46 50 56 59 62 64 66 67 69–71 Services have poor access to resources including equipment, medical supplies and materials. Reasons are described as shortages in supply, lack of availability or distribution and allocation issues.
Services do not have specialist programmes to implement the standards effectively.30 40 48–50 56 59 63 64 68 There is poor access to specialised services or programmes to support individuals at all times and to implement the standards effectively.
Services have infrastructural issues such as limited space and service size affecting compliance with standards.38–40 44 48 49 57 64 65 69 A lack of physical space, old structures and service size can affect the quality of a service and pose challenges to compliance with standards.
5. Services experience resistance to change due to cultural practices (n=31).Services have insufficient time to implement standards due to increased service capacity and work overload.30 37 38 42 48 49 52 59 61 63 65 66 69–71 Services experiencing increased capacity coupled with implementing standards creates additional work and limits the provision of care and support due to time constraints.
Services have entrenched cultures that resist change acting as a barrier to implementing standards.41 43 45 49 50 56 58 59 63–65 67 70 71 Services may have cultural sensitivities with a reluctance to change. Compliance with aspects of standards may be perceived as a burden such as documentation practices.
Services have competing priorities and hence variations can exist with implementation of standards.28 44 49–51 59 71 Time spent on standards means time away from other competing projects. This can result in variations in implementation where more urgent activities are prioritised, for example, mandatory standards are prioritised over aspirational standards.
Services have unclear accountability systems resulting in a misunderstanding of roles and responsibilities with implementing standards.46 49 55 60 63 69 Staff do not feel implementation of various aspects of standards fall within their scope of practice and hence roles and responsibilities are unclear.
Services perceive the standards as not being the norm for high quality care and in doing so, hinders implementation.53 59 62 Healthcare professionals do not perceive the standard as the norm for quality. Standards can miss important elements of care and lack focus on promoting improvements.
6. Services have a lack of training, support tools and consistent monitoring processes (n=21).Services have an absence of clear policies, guidelines, protocols and pathways at local and national level to support local implementation of standards.30 41 48 51 57 60 62–64 70 Services have a lack of clear and effective policies, guidelines, protocols, pathways and interventions. This can result in contradictory advice from professionals and uncertainty in care provision and thus standards implementation.
Services experience challenges with education and training such as cost, replacing staff, time and this acts as a barrier to establishing the standards.28 30 40 44 47 49 50 56 62 64 69 Generic training does not always adapt to local settings. There is a lack of formal, on-site and refresher training programmes due to no backup capacity to replace staff while training occurs. There is a lack of trainers, funding and time, hence staff can become unreceptive to training.
Services do not have internal monitoring and evaluation processes to assess the effectiveness of standards implementation.41 47 49 50 53 64 68 [ Services do not monitor, assess or evaluate their performances or programmes to establish effectiveness of standards implementation. Reasons for this include a lack of time, lack of requirement to do so and lack of reliable assessments.
Services are at risk of inconsistent external assessments and judgements about standards implementation due to different monitoring agencies.53 66 Implementation of standards is at risk of inconsistencies in assessments and judgements about performances, thus resulting in low reliability and undermining the standards credibility. This can occur if there are different monitoring agencies.

  • Embedded Image High confidence in the evidence reporting the barrier; Embedded Image Moderate confidence in the evidence reporting the barrier; Embedded Image Low confidence in the evidence reporting the barrier.

  • *Level of confidence in the evidence was assessed using the four CERQual (Confidence in Evidence from Reviews of Qualitative research) components: methodological limitations; relevance of data; coherence; adequacy of the data. High, moderate or low confidence was based on the judgement that the finding was highly likely, likely, or possibly a reasonable representation of a barrier to implementing (inter)nationally endorsed standards. Please refer to section ‘Assessment of confidence in evidence’ in the main manuscript for further details.

  • †n: Number of studies that contributed to this theme.