Background
Clinical practice guidelines (CPGs) are designed to support decision-making processes in patient care and are classically defined as "systematically developed statements to assist practitioners' and patients' decisions about appropriate healthcare for specific circumstances" [
1]. While there is some evidence that CPGs improve outcomes when they are appropriately implemented, [
2,
3] there are numerous factors which influence their acceptability and use by healthcare providers [
4].
Some of the major barriers to guideline adherence can be related to practitioner, patient, organisational or guideline factors, [
5‐
7] although practitioners appear to be a key factor. Aspects such as knowledge, perceptions of and attitudes toward CPGs in general, are professional-related. Other factors that affect the success of guideline implementation are content or format related, like clarity and presentation of the recommendations or the existence of a quick reference guide or algorithm [
8]. The grading system used to classify the quality of the evidence and the strength of recommendations is an important characteristic of guideline format. However, the growing number of different grading systems employed across different institutions [
9] could possibly be a source of confusion, impeding the correct comprehension of recommendations and their application in clinical practice.
The evidence on clinicians' knowledge, perceptions and attitudes toward CPGs is growing. The majority of published studies on this topic used quantitative design (surveys or record audits), investigating the association between barriers or facilitators and CPG use. Alternative approaches used by some investigators were qualitative designs, where concepts are collected in focus groups, interviews or through open-ended questions in questionnaires. Finally, some studies considered a mixed-method design including both qualitative and quantitative techniques.
Survey results were systematically reviewed in two publications, [
4,
10] concluding that most clinicians were supportive of CPGs, finding them to be useful, educational and likely to improve quality of care. Less frequent findings were that CPGs were impractical, unable to be used for individual patients, limited clinician autonomy, increased the likelihood of litigation or disciplinary action, and were used to cut costs [
10].
A recent systematic review and meta-synthesis of qualitative studies of general practitioners' (GPs') attitudes to and experience with the use of CPGs [
11] offers a conceptual framework for their interpretation. Six broad themes were identified in the analysis: questioning the guidelines; GPs' experience; preserving the doctor-patient relationship; professional responsibility; practical issues and guideline format. No systematic pattern in the distribution of these themes was found. However, comparative analysis and synthesis suggested that GPs' reasons for not following the CPGs differed according to whether the guidelines encouraged (prescriptive type) or discouraged (proscriptive type) particular interventions or behaviours [
11].
Some authors suggest that clinicians find guideline contents too complex and confusing, and perceive difficulties in understanding the CPG development process. More specifically, there is very little research on clinicians' perceptions and understanding of the grading systems used to rate the evidence, quality, and strength of recommendations [
12,
13]. In our context, a qualitative study about the GRADE system showed important difficulties in understanding it and an important level of disagreement among the participating clinicians, with and without previous experience in CPG development [
14]. However, the participants had hardly any experience with the use of this grading system, which requires substantial methodological expertise and practice.
Given this context there is a need for systematically reviewing the evidence on this topic and an assessment of the situation in our context. Additionally, the scarce information about the perceptions and understanding of the grading systems by healthcare professionals in the international literature provide the impetus for an investigation, both qualitative and quantitative, about this important aspect of clinical practice guidelines.
Discussion
Clinicians' knowledge, perceptions and attitudes toward CPGs are important aspects towards the necessary implementation of these tools and subsequent change in clinical practice. To date, these aspects have been systematically reviewed in three main papers [
4,
10,
11]. A number of later studies surveyed clinicians' knowledge about and attitudes towards CPG in general in different clinical settings: among general practitioners (GPs), [
27‐
30] specialists, [
28,
31‐
34] and healthcare providers in Intensive Care Units [
35‐
37]. Generally, most findings reported in these studies confirm that higher familiarity with the guidelines is related to more positive attitudes towards them and to more frequent reported use of CPGs.
Guidelines concerning both diagnosis and treatment of common diseases, developed on a national level and adapted locally, presented in summarized format and transmitted directly by the practitioners of the department, have the best chance of being used, as Riou et al. observed in a described setting [
32]. On the other hand, the predictive role of characteristics, such as age, personality traits and professional qualifications, in professionals' attitudes towards CPGs is still controversial [
31,
36‐
38]. Additionally, several studies have focused on the factors which influence the use and acceptance of a specific guideline in a local context, [
39‐
44] making the generalization of their results difficult.
Carlsen et al. [
45] carried out focus groups amongst Norwegian GPs and add two important findings. First, the participants were concerned that guideline recommendations may be more heavily influenced by economic considerations than by clinical aspects. Second, in contrast to earlier findings, changes in recommendations due to evidence-based updates were mostly viewed positively. This latter point should be viewed in light of the Norwegian context, which has a relatively small number of published guidelines. In addition to these findings Boivin et al., using semi-structured focus group interviews, observed that in circumstances where clinicians judge patient participation in decision-making to be important, they perceive tension between the need to respect patients' preferences and the pressure to apply guidelines [
46]. The authors conclude that CPGs should include information that supports shared decision-making in addition to their current focus on influencing prescription patterns, costs and health outcomes.
In Spain, to the best of our knowledge, this study will be the first to explore the perceptions, beliefs and attitudes of clinicians (GPs and other specialists, with or without previous experience in guideline development) towards CPGs. In relation to grading systems used to rate the evidence, quality and strength of recommendations, it will be one of the first to explore this issue qualitatively in more detail. Limitations and difficulties which we expect to face during the study originate from the natural complexity of qualitative designs and more specifically, group discussions. The researcher, or moderator, in these types of studies has less control over the data produced [
47] than in either quantitative studies or in-depth interviews. The moderator has to allow participants to talk to each other, ask questions and express doubts and opinions, while having very little control over the interaction other than generally keeping participants focused on the topic. By its nature, the group discussion method is open-ended and cannot be entirely predetermined. Additionally, it should not be assumed that the individuals in a group discussion are expressing their own definitive individual view. They are speaking in a specific context, within a specific culture, and thus sometimes it may be difficult for the researcher to clearly identify an individual message. It is to be anticipated that dominant group members influence the statements and opinions of others, as they do in "real" group meetings and other social settings [
45]. Nevertheless, there are also important advantages to carrying out group discussions. They allow for gathering a lot of relevant information in a short period of time, offering insight on the existing contradictions and differences in the individual opinions of the participants. This social interaction is produced in a real context and helps getting a broader conceptual perspective of the issues discussed. Another potential disadvantage of corpus analysis is that the findings are not necessarily valid in other settings and cannot be extended to wider populations. However, we will undertake our study in a wide and diverse population of clinicians, assuring wide applicability of our results in Spain and probably elsewhere.
The limitations would be potentially neutralized by completing initial results from group discussions with survey findings. On the other hand, the most apparent limitation of the survey could be a possible low response rate. However, in survey research, no single response rate is considered a standard [
48,
49]. For some surveys, a response rate of 80 percent is desired; in others, 60 percent is deemed adequate. Mail surveys typically have lower response rates than other types of surveys, and because non-response may introduce error, researchers should take steps designed to promote responses. Some of these steps include personally contacting potential respondents and asking them to participate, sending a reminder to non-respondents, assuring respondents of confidentiality, and making the survey short and easy to complete. In our study, all these measures will be adopted. Finally, caution will be taken when interpreting information about the connection between attitudes and actions. Research indicates that positive attitudes to guidelines do not necessarily mean that doctors follow their recommendations [
10,
50].
Based on the results from both phases of our study, we expect to deepen our understanding about the perceived difficulties and barriers to the comprehension and application of CPGs and to answer whether different grading systems, recommendation phrasing and guideline format presentation influence these processes. We expect to identify and describe the CPGs' adoption factors specific to each professional group participating and thus inform health professionals and decision makers about the needs and challenges in this field.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
PAC and IS conceptualized the study. AK and PAC drafted a first version of the protocol. All authors participated in revising it critically for important intellectual content and have given final approval of the version to be published.