Qualitative evaluation of a guideline supporting shared decision making for extreme preterm birth

<b>Background and objectives:</b> The decision to attempt resuscitation or provide palliative care at birth for extremely preterm infants between 22 and 25 weeks remains complex. The purpose of this study was to identify facilitators and barriers to implementation of a clinical practice guideline developed to support shared decision-making for these cases. <b>Methods:</b> A purposeful sample of healthcare providers, involved in the care of one of five cases of anticipated extremely preterm birth, was recruited for interviews. Participants shared their views on the guideline content, implementation process, and facilitators and barriers encountered. Interviews were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code, categorize, and thematically describe the data. The Knowledge-Attitudes-Behaviours framework was used to organize the findings. <b>Results:</b> Twenty-five key informants (16 physicians, nine nurses) were interviewed. Participants described varying levels of knowledge of the guideline. Facilitators to implementation included: (1) an awareness of, familiarity with and belief in the content; (2) hard copy and electronic guideline accessibility; and, (3) institutional expertise to provide necessary care. Barriers included: (1) minimal awareness or familiarity with the content; (2) lack of agreement with the recommendations; (3) inadequate evidence and applicability to support changes in practice; and, (4) lack of resources to care for the most immature infants. <b>Conclusions:</b> Identified facilitators and barriers will inform the development of tailored strategies for improved local and future broader implementation. Other institutions can use the results to facilitate implementation of their guidelines on this ethically charged area.

**研究背景与研究目的：** 针对孕22至25周的极早产儿，在出生时选择尝试复苏或给予姑息治疗的决策始终极具复杂性。本研究旨在明确针对此类病例制定的、用于支持共同决策的临床实践指南（clinical practice guideline）的实施促进因素与阻碍因素。
**研究方法：** 本研究采用目的性抽样方法，招募曾参与5例预期极早产病例中至少一例照护的医疗服务提供者进行访谈。参与者分享了其对指南内容、实施流程以及实际遭遇的促进与阻碍因素的看法。访谈全程录音并逐字转录，采用定性内容分析（qualitative content analysis）对采集到的数据进行编码、分类与主题化描述，并运用知识-态度-行为（Knowledge-Attitudes-Behaviours）框架对研究结果进行梳理整合。
**研究结果：** 本研究共访谈25名关键知情人，其中医师16名、护士9名。参与者对该指南的认知程度参差不齐。实施促进因素包括：（1）对指南内容的知晓、熟悉与认可；（2）指南的纸质版与电子版可及性；（3）具备提供此类必要照护的机构专业能力。实施阻碍因素则包括：（1）对指南内容知晓度极低或完全不熟悉；（2）不认同指南的推荐建议；（3）缺乏足够证据支撑实践变革，且指南适用性不足；（4）照护极不成熟早产儿的相关资源匮乏。
**研究结论：** 本研究明确的促进与阻碍因素，将为制定定制化策略以优化本地区及未来更广泛的指南实施工作提供依据。其他医疗机构可参考本研究结果，推动其在这一涉及伦理争议的领域中开展指南实施工作。