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Vervilleetal. BMC Health Services Research (2022) 22:702
https://doi.org/10.1186/s12913-022-07999-z
RESEARCH
Exploring clinician perceptions ofacare
pathway forthemanagement ofshoulder pain:
aqualitative study
Leslie Verville1*, Carol Cancelliere1, Gaelan Connell1, Joyce Lee2, Silvano Mior2, Sarah Munce3, Robin Kay1 and
Pierre Côté1
Abstract
Background: Clinical care pathways may be useful tools to improve the quality of healthcare by facilitating the trans-
lation of evidence into practice. Our study is situated within a larger project, whereby end-users co-developed a care
pathway for the management of shoulder pain. In this study, we explored end-user perceptions of the usefulness and
practicality of implementing a care pathway to manage shoulder pain. We also solicited feedback for the pathway’s
improvement.
Methods: We conducted a qualitative study using a transcendental phenomenological approach seen through a
constructivist lens. Clinicians recorded themselves interacting with the care pathway while working through a clinical
case. Clinicians described their thoughts and movements aloud as they completed the activity. Second, we con-
ducted individual semi-structured interviews to discuss the usefulness and practicality of pathway implementation.
Interview transcripts were coded independently by reviewers. Transcript codes and associated quotes were grouped
into themes. Themes were sequenced and linked creating a ‘web’ of thematic connections. Summary statements were
developed to synthesize the overall essence of the phenomena.
Results: Nine clinicians participated. Participants included eight chiropractors and one medical physician. We found
that clinicians believed the care pathway could be useful at various levels, including education (students, interns), for
early career clinicians, for engaging patients, facilitating interprofessional communication, and as a reminder of infor-
mation for certain, less familiar conditions. When discussing the practicality of implementing the care pathway into
practice settings, clinicians expressed that agreement with the care pathway and its recommendations may influence
its acceptability among clinicians. Additionally, integrating recommendations into practice may be a skill requirement
included into clinical training. Clinicians described the importance of opinion leaders in the acceptability of new
evidence. Various difficulties with the replicability of interventions into clinical care was also discussed. In general,
clinicians suggested the layout of the care pathway was manageable, and there was sufficient information for clinical
decision-making. Clinicians also made several recommendations for improvement.
Conclusions: End-user involvement and collaboration provides tangible instruction to improve care pathways
themselves, their implementation strategies and helps to support and strengthen future research for overcoming
individual, systemic and contextual barriers.
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Open Access
*Correspondence: leslie.verville@ontariotechu.ca
1 University of Ontario Institute of Technology (Ontario Tech University),
Oshawa, Ontario, Canada
Full list of author information is available at the end of the article
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Vervilleetal. BMC Health Services Research (2022) 22:702
Background
e translation of research into practice is often slow,
incomplete, and inconsistent [1]. e lag time between
research development and its uptake into practice results
in the possibility that patients may not be receiving the
most beneficial, up-to-date care possible. Clinical care
pathways may be useful tools to help fill this gap and
facilitate the translation of research into practice.
Clinical care pathways are structured healthcare man-
agement tools designed to provide consistent, up-to-date
evidence-based care [2]. In addition, care pathways sup-
port the mutual decision-making between patients and
clinicians [2]. Conceptually, the growing body of litera-
ture supports the use of care pathways; however, their
development and dissemination alone are not enough to
meaningfully impact practice behaviour [3, 4]. Significant
individual, systems, and contextual barriers along with
awareness and lack of familiarity may hinder the uptake
of care pathways and associated clinical recommenda-
tions in practice settings [5–7]. For instance, hesitancy to
implement new evidence may be due to limited organi-
zational support, conflicting information between sets
of guidelines, and reluctance to change currently offered
interventions to patients, especially when there appears
to be anecdotal evidence of effectiveness [8]. Further-
more, clinicians may be hesitant to implement clinical
care pathways because of perceived loss of autonomy
over their clinical decision-making [4, 9, 10].
In an effort to appeal to end-users, clinical care path-
ways are developed in collaboration and/or consultation
with end-users, with consideration of evidence-based
recommendations and context-specific elements [5].
Engaging with end-users throughout the development
of the care pathway may provide helpful insights about
these specific barriers, as well as strategies to overcome
them [6, 11–13]. is engagement and collaboration may
be facilitated by employing integrated Knowledge Trans-
lation (iKT) strategies. iKT is a well-supported approach
to conducting research that involves integrating knowl-
edge users throughout the entire research process along-
side the researchers, thereby maximizing the accessibility,
relevance, and endurance of research outcomes [14–20].
Our study is situated within a larger project, whereby
end-users (i.e., clinicians) co-developed an evidence-
based practice tool with our team of researchers [21]. e
practice tool is an online care pathway that aims to facili-
tate the clinical management of soft-tissue shoulder pain
in adults. e practice tool was developed based upon
the recommendations and clinical pathway described
in the clinical guideline for the management of soft tis-
sue shoulder injuries by Yu etal. [22]. While we used this
guideline for the content of the care pathway tool, it was
not the primary focus of our study. Our primary inter-
est was the tool itself; we envision the content could be
substituted with other guideline information in future
iterations. For the purposes of this study, we engaged
end-users to gain an understanding of their needs and
preferences (e.g., current practice patterns, knowledge
gaps, information trends, preferred tool formatting),
as well as barriers to its implementation (e.g., patient,
professional, organizational, system, economic, politi-
cal, or social/cultural factors). In this current study, our
objectives were to 1) explore end-user perceptions of the
usefulness of the care pathway; 2) explore end-user per-
ceptions about the practicality of implementing the care
pathway into practice settings; and 3) describe end-user
feedback and recommendations for improving the care
pathway.
Methods
Study design
We conducted a qualitative study using a transcenden-
tal phenomenological approach seen through a con-
structivist lens (Fig. 1) [23–26]. is approach aims to
understand the essence of a phenomenon whereby the
researcher seeks to achieve a bias-free state of mind and
relies on the objective interpretation of participants’ lived
experiences [23].
We obtained ethics approval through the Research Eth-
ics Board of Ontario Tech University (REB #15436). We
used the Consolidated Criteria for Reporting Qualita-
tive Research (COREQ) to guide this study’s conduct and
reporting. e methods of this study have been previ-
ously reported in a related study [21].
Participants andrecruitment
We invited clinicians, from our professional networks,
with disciplines that commonly manage patients with
shoulder pain (i.e., chiropractors, medical physicians,
physiotherapists) to co-develop a care pathway with our
team of researchers, and then participate in a semi-struc-
tured interview to address our current research objec-
tives. We used purposeful maximum variation sampling
to increase generalizability to achieve diversity in years
of practice, discipline, practice characteristics (multi-
disciplinary vs. solo), and geographical representation
(Canada, United States). Clinicians were contacted via
email and sent an invitation letter. Recruitment occurred
Keywords: Integrated knowledge translation, Clinical care pathway, Qualitative inquiry
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Vervilleetal. BMC Health Services Research (2022) 22:702
between May 2020 and October 2020 until data satura-
tion was reached, defined as the point at which no new
helpful information relative to our study objectives was
obtained for two consecutive interviews [27].
Care pathway
Before the interviews, we developed an online care
pathway for managing shoulder pain based on the clini-
cal practice guideline on the non-invasive management
of soft tissue disorders of the shoulder (Fig.2) [22]. e
care pathway tool included information about the shoul-
der guideline [22], its scope and purpose, and links to
outcome measurement tools. e care pathway also
included essential aspects of the clinician-patient inter-
action, including components of the clinical evaluation
and treatment recommendations. Each decision or state-
ment in the care pathway flowchart was hyperlinked that
when selected provided more detailed information or
definition.
Think aloud activity
Clinicians were asked to use a software called ‘Loom’ to
create audio and video recordings of their interaction
with the care pathway and the clinical case [28]. A clini-
cal case study on the management of shoulder pain was
randomly assigned to each clinician and sent to them
prior to the recording. Each case provided details about a
patient from the beginning of an interaction to the treat-
ment and follow-up period. Clinicians were instructed
to describe their thoughts and movements aloud as they
complete the activity.
Once they completed the activity, they were asked to
answer the following questions: (1) what did you like
about the care pathway? (2) what didn’t you like about
the care pathway? (3) was there enough information in
the care pathway to inform your clinical decision-mak-
ing? (4) how would you improve the care pathway? and
(5) how would you use the care pathway in your practice?
eir answers were also captured in the audio and video
recordings using ‘Loom’. e recorded responses from
the ink Aloud activity were analyzed to inform the rec-
ommendations to improve the care pathway.
Semi‑structured interviews
After developing the care pathway and completing the
ink Aloud activity, we conducted individual semi-
structured interviews using Zoom v.5.0. Interviews were
used to explore participants’ perceptions about the use-
fulness of the care pathway (research objective 1) and
their perceptions about the practicality of its imple-
mentation in clinical practice (research objective 2). We
also collected feedback on participants’ likes, dislikes,
and suggestions for improving the care pathway tool
(research objective 3). We used a semi-structured inter-
view methodology because of its versatility and flexibility,
enabling reciprocity between the interviewer and inter-
viewee, enabling a more natural flow of conversation
while ensuring key points were explored [28, 29].
A trained interviewer led all interviews (GC) [cre-
dentials: BHK, DC; occupation: research associate; sex:
male]. An additional female researcher was present dur-
ing each interview (LV, JL). eir role was to support the
primary interviewer to ensure conversation remained in-
line with the interview guide, when necessary, and write
field notes. e interviewers and participants knew each
other within a professional capacity. Participants were
unaware of the interview questions before the inter-
view (Additionalfile1). Interviews lasted approximately
Fig. 1 Transcendental phenomenological approach
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Vervilleetal. BMC Health Services Research (2022) 22:702
45 minutes and were audio-recorded. Recordings were
saved as audio files and transcribed verbatim by an exter-
nal transcriptionist. Following each interview, clinicians
were offered an opportunity to review and correct/clar-
ify their transcripts before analysis (i.e., member check-
ing). is was done to ensure clinicians felt that their
responses to the interview questions were accurately por-
trayed [30]. We conducted only one round of interviews
per participant. Personal identifying information was
removed from the transcripts prior to analysis.
Analysis
We used a transcendental phenomenological approach
to conduct our identifying analysis from the interviews.
In addition, we adopted the six-phase conceptual frame-
work by Braun and Clark [30] to support our approach: 1)
familiarizing yourself with the data; 2) generating initial
codes; 3) searching for themes; 4) reviewing themes; 5)
defining and naming themes, and 6) producing the report
[31]. While this framework is presented in phases, this
process was not conducted linearly. We revisited phases
throughout the analysis process to facilitate a thorough
interpretation of the data [31].
An initial open coding manual with definitions was
developed a priori based on our research objectives
and the interview guide to identifying major categories
(themes) of information (Table1) [32]. roughout the
analysis process, new codes were added, and existing
codes were modified and refined to develop a complete
and representative coding scheme.
Transcripts were analyzed throughout the data col-
lection period. Ongoing transcript analysis allowed us
to update our interview guide iteratively, ensure we met
our research objectives’ needs, and determine when we
had reached saturation of themes. Following each inter-
view, three reviewers (LV, GC, JL) independently coded
the transcript. Independent coding of transcripts was
used to ensure reliability of interpretation. Field notes
Fig. 2 Care pathway for the management of shoulder pain
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Vervilleetal. BMC Health Services Research (2022) 22:702
were used to provide contextualization of the transcript
quotes when necessary. Reviewers then met as a group to
compare coding and reach consensus through discussion.
roughout the analysis, the coding scheme and defini-
tions were revised as reviewers attempted to construct
meaning about the phenomenon [32]. Subsequent tran-
scripts were coded using the continually revised coding
scheme. Once the coding scheme was revised, previous
transcripts were re-coded (LV) according to the updated
scheme. is process was continued until all transcripts
were coded. Saturation was assessed following the con-
sensus of each transcript and was determined when no
new themes emerged for two consecutive interviews.
We used NVIVO v.11 to organize the codes and
quotes from the interview transcripts (conducted by LV;
checked by GC, JL). We created mind maps [33, 34] with
headings representing our three research objectives: cli-
nician perception of usefulness (1) clinician perceptions
of the practicality of implementation (2) and feedback to
improve the care pathway (3). Transcript codes and asso-
ciated quotes were grouped into themes. Broad themes
were linked to sub-themes to describe overall phenom-
ena related to our objectives. emes were sequenced
and linked to one another, creating a ‘web’ of thematic
connections. We implemented member checking to
improve the trustworthiness of our analysis by asking cli-
nicians to review and provide feedback about the mind
maps, themes, and definitions to ensure that our inter-
pretation of the comments was appropriate [35]. Sum-
mary statements were developed to synthesize the overall
essence of the phenomena for each research objectives
supported by themes and clinician quotes. We selected
representative quotes that most articulately described
each theme.
Results
Eighteen clinicians were invited to participate (9 chiro-
practors, 3 physiotherapists, and 6 medical physicians); of
those, 12 consented, and nine participated. We were una-
ble to obtain reasons for non-participation. Saturation of
themes was achieved within the participant sample.
Of the clinicians who participated, eight were chi-
ropractors (89%) and one was a medical physician. No
physiotherapists participated. Most clinicians were male
(89%). Age ranged from (27–77 years); with a mean age
of 46 years (SD 15.2). Most clinicians practiced in Canada
(8/9). Years in practice ranged from (2–45 years) with a
mean of 16 years in practice (SD 13). Most professional
degrees were attained in Canada (78%); 67% of clini-
cians reported attaining at least one additional advanced
degree (e.g., Master’s degree, Ph.D.).
We invited all participants to review their transcripts
and resultant findings. One participant edited their tran-
script, and five provided edits to the mind maps, themes,
and definitions.
Research objective 1: end‑user perceptions ofusefulness
oftheonline care pathway
We aimed to understand whether clinicians thought the
care pathway was useful in practice and who they per-
ceived would use it. ree themes emerged from explor-
ing clinicians’ perceptions of usefulness of the online care
pathway.
Theme: clinical applicability ofthecare pathway
Clinicians indicated that the care pathway could be a
useful educational tool for students, interns, and nov-
ice practitioners. Specifically, the clinician participants
perceived the care pathway as more appropriate and of
greater benefit to novice clinicians than experienced cli-
nicians. For example:
“Certainly, having access to tools to help me in my
practice better assess and treat shoulders would be
beneficial because it is not something that I see every
day and so as someone who is a new grad I am still
trying to gain experience and that experience might
come over a good length of time. If I were to have
tools and evidence-based pathways to help me, I
think it would be more beneficial, and help me gain
that experience and gain my confidence in treat-
ing those conditions.” –Clinician 8 (male; 2 years in
practice)
Conversely, more experienced clinicians, with previ-
ous experience managing shoulder conditions, suggested
they would not likely refer to the care pathway for assis-
tance. Clinicians also expressed that because the care
Table 1 Organizational coding tree and definitions
Theme Denition
Perceived usefulness to clinicians Pertaining to the use or perceived use of the care pathway in practice
Practicality Pertaining to barriers or enablers (real or perceived) of implementing
the care pathway into practice
Feedback Pertaining to any design or content feedback that could be used to
improve the care pathway
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Vervilleetal. BMC Health Services Research (2022) 22:702
pathway did not highlight any new or changing evidence
from what they already knew, they would be less likely to
use the care pathway.
“…the reality of it is, our colleagues would already
believe that they have this sorted out. So no need to
take a look at this, I’ve got this one covered; which is
why I think you were again right to point out that if
there was some change or some new research or some
new way or approach or new way of thinking about
this that was different than the way that you would
typically practice then you would for sure have an
upswing in people wanting to engage this material.
In the absence of that, people would be like yeah,
yeah, I got no problems on shoulders.” – Clinician 3
(male; 20 years in practice)
In addition, it was expressed that the care pathway
may be useful as a refresher or reminder for certain top-
ics they may be less familiar or use it as a tool to con-
firm their understanding and knowledge of the current
evidence.
“I am not so sure these are created for people to use
with every single person but I think they are meant
to just be a brush up sometimes for people to refer
back to.” –Clinician 2 (male; 16 years in practice)
Theme: facilitating communication
Some clinicians expressed that they envision the care
pathway as a useful tool for improving or facilitating
collaborative- and interprofessional communication.
Clinicians explained the tool would be useful to guide
meaningful discussions between colleagues or when
asked by a colleague about a particular condition.
“I am very grateful in the environment that I work in
where I feel that would lead to a conversation. I hope
that that is the purpose of this tool is that it leads to
conversations about the clinical application of it…I
think through conversations about why things are
the way they are; there is a certain curiosity amongst
my peers that there would be a discussion and we
would have a discussion about how we would imple-
ment it. So I like it as a, let’s call it, a conversation
starter… So that is how I would use it.” – Clinician 8
(male; 2 years in practice)
Similarly, clinicians discussed that the tool could be
used to guide interprofessional communication about
the care provided to patients. e tool could be shared
among healthcare providers to discuss the care being
provided to the patient.
“I think it is great…it is a good little pathway. Even
to share with some other colleagues like a per-
sonal trainer to be able to, if I’m seeing one of their
patients, to be able to say, ‘Hey, this is why I am
doing this.’ So even to give it to, like I said, allied
health professionals is a good idea.” – Clinician 6
(female; 12 years in practice)
Conversely, one clinician expressed the perception
that the use of the care pathway as a communication
tool may be unlikely.
“So to try and get it so that one clinician will talk
to another clinician about it and say ‘hey this is
great, I use this tool, you should start using it too’, I
just don’t see chiropractors as using it very much.”
– Clinician 1 (male; 23 years in practice)
Theme: patient education
Clinicians reported that the care pathway might be a
useful resource for their patients. ey described using
it as a visual tool to demonstrate where a patient is cat-
egorized within the care pathway, the available care
options, and as a supportive resource to authenticate
their treatment plan. Clinicians discussed that hav-
ing such a visual tool may assist healthcare providers
to engage patients and promote meaningful discussion
about their care.
“One of the main kind of things that I saw myself
using this for was not really for myself but more so
for patient education … if this was a bit more of a
piece of art, I would be happy to show oh here we go
patients, take a look at this, this is what we are doing
and this is why you can feel confident.” – Clinician 9
(male; 1 year in practice)
During the review of themes, one clinician contested
the use of the care pathway for the purpose of an educa-
tional tool for patients. ey discussed that the purpose
of developing the care pathway is for clinicians, and con-
sidered use for patient education inappropriate.
“I don’t love the patient education theme. I under-
stand that other participants said they would use it
to show patients where they fit in the algorithm but I
don’t think this guideline is meant for that purpose.
I think this is a tool that should strictly be used for
clinician use. Sure clinicians can pull the informa-
tion and inform patients. I think that is very impor-
tant and a key facet of knowledge transfer but I do
not think one of the main purposes of this pathway
is that it should be used as an infographic to educate
patients.” -Clinician 8 (male; 2 years in practice)
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Vervilleetal. BMC Health Services Research (2022) 22:702
Research objective 2: end‑user perceptions
aboutthepracticality ofimplementing theonline care
pathway intopractice settings
Clinicians were asked to describe their thoughts regard-
ing the practicality of trying to implement the care
pathway into practice settings. Specifically, clinicians
described enablers and barriers that may influence its
implementation. Four themes arose through discussion.
Theme: agreement withthecare pathway
Clinicians alluded that they would be more apt to adopt
the information into their practice if they agreed with the
information presented in the care pathway. Similarly, cli-
nicians would consider adopting the clinical pathway if
the information presented closely resembled how they
currently practiced.
ey [clinicians] are going to focus on what they
know and what they are comfortable with and what
they have been taught. So regardless of whether or
not they actually follow the recommendations, tough
to say, I feel like some people would be kind of maybe
stuck in their ways.” –Clinician 8 (male; 2 years in
practice)
Conversely, if the clinician disagrees with the presented
recommendations or if it differs from their current prac-
tice behaviours, they may be less motivated to adopt
the information. One clinician described the dilemma
of disagreeing with recommendations presented in the
care pathway but held value in conceptually representing
themselves as an evidence-based clinician.
“Now whether they agree or disagree with the data
and the evidence; I mean, I was surprised by certain
recommendations made and I made a comment
and said, okay well I agree with this, I don’t agree
with this but at the end of the day I know even if I
don’t agree with it that is evidence right. So, I am
at a crossroads. Am I going to be an evidence-based
practitioner and follow the data or am I going to go
off and be a cowboy.” – Clinician 8 (male; 2 years in
practice)
Theme: inuence ofclinician training
Clinicians expressed that the basic understanding of how
to implement new evidence into practice should be a skill
taught during the training to become a clinician and that
trying to teach clinicians to do this after years in practice
may not be successful.
“I think with these guidelines and these pathways
you’re trying to facilitate a thought process so that
people can optimize their skill set and their knowl-
edge base. But you have to go backwards in their
undergrad to do that because if you don’t, you’re
spending a lot more time trying to teach them how
to implement the guideline and it almost comes to a
point where it’s a skill unto itself and then you have
to execute on the guideline. at is just too much
work, it is arduous.” – Clinician 4 (male; 13 years in
practice)
When there is a discrepancy between what was learned
and what is presented as new information (i.e., the care
pathway); the acceptance of the new information/evi-
dence may be limited.
“e reality is, people are going to insert their own
personal opinions and styles but if you show them a
more simplistic path or simplistic set of choices they
will say ‘oh I do that already’ or ‘oh I should add
that’”- Clinician 2 (male; 16 years in practice)
Further, a clinician’s experience and comfort level with
sourcing and appraising research may influence the use
of the care pathway in practice. While some clinicians
may have experience with appraising research and how
to integrate it into practice, other clinicians may lack this
knowledge.
“In my particular clinical situation, I won’t have an
older chiropractor who I go and ask for help from.
is [the care pathway] is where I am going to get
my information from other than messaging some of
my colleagues and gathering information that way.”
– clinician 9 (male; 1 year in practice)
Theme: role ofopinion leaders
Many professions, such as chiropractic, have opinion
leaders who are regarded as trustworthy sources of infor-
mation. ese individuals are often seen as influential
persons who can facilitate the uptake of evidence into
clinical practice. Participants discussed the concept of
having opinion leaders and their influential role in facili-
tating the implementation of the care pathway.
“…what we do know is that when people feel that
some of their colleagues are part of this, people they
know and respect and are champions and leaders,
they are more likely to think that this is for them.” –
Clinician 5 (male; 14 years in practice)
Theme: diculties withreplicability ofrecommended
interventions
Some clinicians discussed the challenges with imple-
menting new evidence into their practices. ey reported
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Vervilleetal. BMC Health Services Research (2022) 22:702
that published research studies often lack clear reporting
or description of specific interventions, making it dif-
ficult for clinicians to replicate the intervention in their
practices.
“…in a rehab context for any condition, the literature
is a disaster. ere is not enough description of inter-
ventions in most studies to come to any reasonable
answer to average out what intervention might be
best for anything so we are kind of left up in the air
that way.” – Clinician 2 (male; 16 years in practice)
One clinician addressed the issue of replicability
because of limitations in available resources/equipment.
For example, if the care pathway recommends a particu-
lar intervention requiring specialized equipment, only
clinicians with access to this equipment will be capable of
implementing the intervention. is is an important con-
sideration with regard to developing care pathways as not
all recommendations will be suitable for implementation
in all care settings.
…if they don’t have a piece of equipment. So, if one
of the things is ultrasound, if they don’t have it they
can’t use it so that might be a barrier, right? – Clini-
cian 6 (female; 12 years in practice)
Research objective 3: end‑user feedback
andrecommendations forimproving thecare pathway
Clinicians were asked to provide their feedback about
the care pathway while participating in the ink Aloud
activity. Comments and suggestions were summarized.
Generally, clinicians appeared to find the layout of the
care pathway manageable. Other design items such as
colour, font size, and easy-to-find hyperlinks to addi-
tional information were also noted as positive aspects
of the pathway. Several clinicians also indicated that
the care pathway had sufficient information for clinical
decision-making.
“I personally like the pathway and the way they are
laid out because they are simple to use. It is not an
algorithm that is all over the place…to make it nice
and tight and compact and in a nice package to
hand to people, it makes it a lot easier to digest.” –
Clinician 6 (female; 12 years in practice)
Regarding design features, some clinicians did not like
the colour scheme; they felt the colours were too muted
and suggested additional colours and design elements
to make it more appealing to users. ey also suggested
there was too much information on each page, some
hyperlinks appeared to be broken (non-functional), and
that the instructions for clicking on the decisions or
statements of the care pathway to obtain more informa-
tion were not intuitive and required further clarity.
Clinicians made several recommendations for improv-
ing clinical components of the care pathway. Clinicians
suggested including additional information in the clinical
evaluation, such as listing specific orthopaedic tests and
their predictive likelihood ratios, and providing hyper-
links to other care pathways and resources for patients
who may present with other pathologies or conditions.
“e other key to this is it can’t not just be for shoul-
der, this has to be something structured that has
continuity with other joints.” – Clinician 4 (male; 13
years in practice)
Clinicians suggested that prioritizing the list of rec-
ommendations/interventions from the guideline may be
helpful. ey provided several suggestions to improve
clarity to the recommended interventions, such as
including additional details of the recommended exer-
cises with links to illustrative pictures and related arti-
cles. One clinician recommended using patient lifestyle
education, such as smoking cessation. Finally, the care
pathway indicates that clinicians should refer to a physi-
cian if the patient had an incomplete recovery following
the management of chronic symptoms (Fig.1). Several
clinicians reported that this wording may be inappro-
priate given presumed limitations to access or expertise.
Instead, a referral to an ‘appropriate healthcare provider,’
such as an orthopaedic surgeon, nurse practitioner, phys-
ical therapist, or sports chiropractor, may be preferable.
Discussion
Our study explored end-user (clinician) perceptions of
the usefulness and practicality of implementing a care
pathway to manage shoulder pain. Additionally, we
solicited feedback and recommendations for improving
the care pathway. Our study included nine clinicians.
We found that clinicians believed the care pathway
could be useful at various levels, including education
(students and interns), for early career clinicians, and
as a reminder of information for certain, less familiar
conditions. Clinicians also considered the care path-
way to be useful for engaging patients and for facilitat-
ing interprofessional communication. Conversely, some
clinicians did not perceive that the care pathway would
be a useful tool to experienced clinicians because, from
their perspective, the care pathway did not highlight
any new or changing evidence. Our findings suggest
the care pathway may be best suited as an educational
resource for early career clinicians or as a part of cur-
riculum in educational settings. e relationship
between a clinicians’ level of experience and the per-
ceived use of the care pathway is unclear. However, it
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Page 9 of 11
Vervilleetal. BMC Health Services Research (2022) 22:702
is possible that clinicians who have been in practice
longer may perceive clinical experience as outweighing
of scientific evidence [36, 37]. Future research should
explore how the pathway could be modified to also ben-
efit experienced clinicians.
With regard to the practicality of implementing the
care pathway into clinical practice settings, clinicians
described factors associated with implementation;
described as barriers and facilitators. Our analysis of cli-
nicians’ perceptions of usefulness demonstrates that the
care pathway may address some personal barriers (i.e.,
clinicians thought the care pathway was a useful tool
and saw themselves using it in a variety of ways). On the
other hand, clinicians’ perceptions about the practical-
ity of implementing the care pathway highlights systemic
and contextual barriers as also demonstrated in previous
studies (i.e., the need for opinion leaders, lack of time,
lack of resources) [5, 6]. Addressing such barriers may
have been due to our iKT approach; by including input
from the clinicians throughout the development of the
clinical tool we may have been able to directly address
potential personal barriers to implementation. ough
many of the clinicians who participated play other roles
outside of their clinical responsibilities (e.g., education,
research, administrative), it is possible that the inclusion
of other key stakeholders (i.e., patients,) would have pro-
vided additional recommendations to address other con-
textual and systemic barriers implementing the clinical
tool.
Our findings support the results of previous qualita-
tive studies that identified barriers and facilitators for
using and implementing clinical pathways in healthcare
settings [4, 38–40]. For example, a qualitative study by
Reyneke, etal. [4] aimed to identify barriers and facilita-
tors of general practitioners using clinical pathways in a
primarily urban health region in New Zealand. e care
pathways were web-based flow diagrams directing prac-
titioners to treatment modalities available in the commu-
nity. In general, practitioners agreed that there is merit
in using the care pathways to improve patient care and
outcomes; however, they also identified significant bar-
riers to its implementation. For example, practitioners
described feelings of information overload, challenges
with learning and using new technology, as well as los-
ing their autonomy over clinical decision-making, among
others [4]. Additional studies of varying healthcare dis-
ciplines (surgeons, nurses, and anesthesiologists [38],
physicians, hospital administration, and nurses [39],
nurses, ICU physicians, transplant coordinator, social
workers, senior physicians, senior surgeons [40]) report
similar findings as well. Our study comprised primar-
ily of chiropractors, however, our findings related to the
barriers of care pathway acceptability and practicality
of implementation are similar to those involving other
healthcare professions.
Strategies to promote implementation need to be mul-
tifaceted and context-specific, considering individual,
systemic, and contextual factors [3, 5–7, 41]. While cli-
nicians appear to play a significant role in implementing
evidence-based care, other stakeholders also play signifi-
cant roles. Future research should consider including all
individuals who play a role in implementing evidence
into practice. ese stakeholders may include, but are not
limited to, clinic support staff, educators, opinion lead-
ers, governing associations, electronic charting software
developers, and policymakers. A study by De Allegri,
et al. [38] explored the experiences of interdisciplinary
staff members (surgeons, anaesthesiologists, nurses) at
all hierarchy and seniority levels of a surgery department
in a German hospital aiming to develop and implement
care pathways for the management of kidney transplan-
tation, thoracic surgery and colorectal surgery. Interest-
ingly, this study highlights an important phenomenon
whereby the hierarchical structure of the hospital setting
may have marginalized the participation of some indi-
viduals, in this case nurses. ough this study does not
provide suggestion to overcome this barrier, it is of par-
ticular importance when considering the implementation
of care pathways into interdisciplinary settings. Future
research should consider aiming to identify strategies
to overcome barriers of hierarchical structure in health-
care settings as we know that the implementation of care
pathways in healthcare settings is best facilitated by all
those involved in its application. Finally, patients may
also play an important role in the implementation of evi-
dence-based practice guidelines. With information read-
ily at their fingertips, patients may be better informed
and state their preferences for specific treatments that
may or may not be recommended [42–44]. Some clini-
cians considered that the care pathway could also be used
as an educational tool for patients. ough this senti-
ment was not agreed upon by all participating clinicians,
future research should engage patients as stakeholders
to explore their perspective on the perceived usefulness
and potential implementation strategies of the tool as a
patient-specific educational resource.
Our study is situated within a larger project, whereby
end-users co-developed an evidence-based care pathway
to facilitate the clinical management of shoulder pain in
adults. In a previous publication, we describe clinicians’
experiences of co-producing the care pathway and their
perceptions of participating in knowledge tool develop-
ment [21]. Collectively, our findings provide a guide for
engaging clinicians in integrated knowledge translation
(iKT) endeavors and co-producing clinical resources
[45–51].
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 11
Vervilleetal. BMC Health Services Research (2022) 22:702
Strengths andlimitations
Our study has several strengths. We followed a sound
qualitative methodology to guide the conduct of our
study. Using this framework, themes were sequenced
and linked to create a web of thematic connections
insightfully describing the overall phenomena for each
of our research objectives. To improve trustworthi-
ness of our data and externally audit our analysis, we
implemented member checking at two time points: 1)
following each individual interview and 2) review of the
overall analysis (mind maps, themes, and definitions).
We also acknowledge some limitations. e transfer-
ability of our findings may be impacted by our inabil-
ity to recruit a balanced sample across professions. It is
unknown whether our findings may have differed with
a more professionally-diverse (i.e., profession, years in
practice, healthcare setting) group of clinicians. How-
ever, within our study population, it appears that we
were able to reach saturation. Additionally, our sam-
pling method (recruitment from professional networks)
may have influenced our findings by yielding more
homogeneous perspectives. Finally, the research team’s
assumptions and biases were not formally assessed
which may have, inadvertently, perpetuated bias within
our findings. For example, we did not specifically dis-
cuss how the research teams’ personal beliefs and
biases may have influenced the process of data collec-
tion and analysis (reflexivity). However, in the analysis
stage, we aimed to limit these biases through bracket-
ing and by having the same experienced interviewer
lead all interviews using an interview guide, and a sec-
ond researcher was present for all interviews. Further-
more, three researchers independently coded themes
and we used member checking to confirm overall the-
matic analyses.
Conclusion
Exploring the perceptions of end-users about the
perceived use and practicality of implementing care
pathways in healthcare settings provides tangible
instruction to improve the care pathways themselves as
well as their implementation strategies. While research
continues to explore the individual, systemic and con-
textual barriers present in our healthcare settings, our
methods of end-user involvement and collaboration
may help to support and strengthen future strategies
for implementation.
Abbreviations
iKT: Integrated knowledge translation; COREQ: Consolidated Criteria for
Reporting Qualitative Research Checklist; CCGI: Canadian Chiropractic Guide-
line Initiative.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12913- 022- 07999-z.
Additional le1. Interview Guide
Acknowledgements
Not applicable.
Authors’ contributions
LV contributed to the design, data collection, analysis, and writing of the
manuscript. CC contributed to the manuscript’s design, analysis, and writing.
GC and JL contributed to the data collection, analysis, and writing of the
manuscript. SiM, SaM, RK, and PC contributed to the design and writing of the
manuscript. All authors read and approved the final manuscript.
Funding
This study was funded by the Canadian Chiropractic Research Foundation
(CCRF). The funding body did not participate in the design, analysis, interpreta-
tion of data, or manuscript writing.
Availability of data and materials
The datasets generated and/or analyzed during the current study are not pub-
licly available due to ethical standards protecting study participation; however,
can be made available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
We obtained ethics approval through the Research Ethics Board of Ontario
Tech University (REB #15436). All participants signed an informed consent
form prior to participation. All methods were conducted in accordance to the
Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 University of Ontario Institute of Technology (Ontario Tech University),
Oshawa, Ontario, Canada. 2 Canadian Memorial Chiropractic College, Toronto,
Ontario, Canada. 3 KITE-Toronto Rehabilitation Institute, University Health
Network, Toronto, Ontario, Canada.
Received: 19 January 2022 Accepted: 25 April 2022
References
1. Hanney SR, Castle-Clarke S, Grant J, Guthrie S, Henshall C, Mestre-Fer-
randiz J, et al. How long does biomedical research take? Studying the
time taken between biomedical and health research and its translation
into products, policy, and practice. Health Res Policy Syst. 2015;13:1.
2. Schrijvers G, van Hoorn A, Huiskes N. The care pathway: concepts and
theories: an introduction. Int J Integr Care. 2012;12(Spec Ed Integrated
Care Pathways):e192.
3. Stokes T, Tumilty E, Doolan-Noble F, Gauld R. HealthPathways imple-
mentation in a New Zealand health region: a qualitative study using
the consolidated framework for implementation research. BMJ Open.
2018;8(12):e025094.
4. Reyneke A, Jaye C, Stokes T. Local clinical pathways: from ’good ideas’ to
’practicality’ for general practitioners. J Prim Health Care. 2018;10(3):215–23.
5. Evans-Lacko S, Jarrett M, McCrone P, Thornicroft G. Facilitators and barriers to
implementing clinical care pathways. BMC Health Serv Res. 2010;10(1):1–6.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 11
Vervilleetal. BMC Health Services Research (2022) 22:702
6. Correa VC, Lugo-Agudelo LH, Aguirre-Acevedo DC, Contreras JAP, Borrero
AMP, Patiño-Lugo DF, et al. Individual, health system, and contextual barriers
and facilitators for the implementation of clinical practice guidelines: a
systematic metareview. Health Res Policy Syst. 2020;18(1):74.
7. Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko
M, et al. A checklist for identifying determinants of practice: a systematic
review and synthesis of frameworks and taxonomies of factors that prevent
or enable improvements in healthcare professional practice. Implement Sci.
2013;8(1):35.
8. Li S-A, Jeffs L, Barwick M, Stevens B. Organizational contextual features that
influence the implementation of evidence-based practices across health-
care settings: a systematic integrative review. Syst Rev. 2018;7(1):72.
9. Martin GP, Kocman D, Stephens T, Peden CJ, Pearse RM. This study was
carried out as part of a wider randomised controlled trial E. pathways to
professionalism? Quality improvement, care pathways, and the interplay of
standardisation and clinical autonomy. Sociol Health Ill. 2017;39(8):1314–29.
10. Martin GP, Armstrong N, Aveling E-L, Herbert G, Dixon-Woods M. Profes-
sionalism redundant, reshaped, or reinvigorated? Realizing the “third logic”
in contemporary health care. J Health Soc Behav. 2015;56(3):378–97.
11. Grol R, Grimshaw J. From best evidence to best practice: effective imple-
mentation of change in patients’ care. Lancet. 2003;362(9391):1225–30.
12. Grol R, Wensing M. What drives change? Barriers to and incentives for
achieving evidence-based practice. Med J Aust. 2004;180(S6):S57–60.
13. Camden C, Shikako-Thomas K, Nguyen T, Graham E, Thomas A, Sprung J,
et al. Engaging stakeholders in rehabilitation research: a scoping review of
strategies used in partnerships and evaluation of impacts. Disabil Rehabil.
2015;37(15):1390–400.
14. Gagliardi AR, Berta W, Kothari A, Boyko J, Urquhart R. Integrated knowledge
translation (IKT ) in health care: a scoping review. Implement Sci. 2016;11:38.
15. Lomas J. Essay: using ‘linkage and Exchange’To move research into policy
at a Canadian Foundation: encouraging partnerships between researchers
and policymakers is the goal of a promising new Canadian initiative. Health
Aff. 2000;19(3):236–40.
16. King G, Currie M, Smith L, Servais M, McDougall J. A framework of operating
models for interdisciplinary research programs in clinical service organiza-
tions. Eval Prog Plan. 2008;31(2):160–73.
17. Ettelt S, Mays N. Health services research in Europe and its use for informing
policy. J Health Serv Res Policy. 2011;16(2_suppl):48–60.
18. Newton MS, Estabrooks CA, Norton P, Birdsell JM, Adewale AJ, Thornley R.
Health researchers in Alberta: an exploratory comparison of defining char-
acteristics and knowledge translation activities. Implement Sci. 2007;2(1):1.
19. Ray KN, Miller E. Strengthening stakeholder-engaged research and research
on stakeholder engagement. J Comp Eff Res. 2017;6(4):375–89.
20. (CIHR) CIoHR. Guide to Knowledge Translation Planning at CIHR: Integrated
and End-of-Grant Approaches 2012. Available from: https:// cihr- irsc. gc. ca/e/
docum ents/ kt_ lm_ ktplan- en. pdf.
21. Verville L, Cancelliere C, Connell G, Lee J, Munce S, Mior S, et al. Exploring
clinicians’ experiences and perceptions of end-user roles in knowledge
development: a qualitative study. BMC Health Serv Res. 2021;21(1):926.
22. Yu H, Côté P, Wong JJ, Shearer HM, Mior S, Cancelliere C, et al. Noninvasive
management of soft tissue disorders of the shoulder: a clinical practice
guideline from the Ontario protocol for traffic injury management (OPTIMa)
collaboration. Eur J Pain. 2021;25(8):1644–67.
23. Neubauer BE, Witkop CT, Varpio L. How phenomenology can help us learn
from the experiences of others. Perspect Med Educ. 2019;8(2):90–7.
24. Lopez KA, Willis DG. Descriptive versus interpretive phenomenology: their
contributions to nursing knowledge. Qual Health Res. 2004;14(5):726–35.
25. Adom D, Yeboah A, Ankrah AK. Constructivism philosophical paradigm:
implication for research, teaching and learning. Global J Arts Human Soc Sci.
2016;4(10):1–9.
26. Fischer CT. Bracketing in qualitative research: conceptual and practical mat-
ters. Psychother Res. 2009;19(4–5):583–90.
27. Guest GNE, Chen M. A simple method to assess and report thematic satura-
tion in qualitative research. PLoS One. 2020;15(5):e0232076.
28. Loom. 4.0.28 ed. [Computer software]. San Francisco: Loom Inc; 2015.
29. Kallio HPA, Johnson M, Kangasniemi M. Systematic methodological review:
developing a framework for a qualitative semi-structured interview guide. J
Adv Nurs. 2016;72(12):2954–65.
30. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.
2006;3(2):77–101.
31. Galletta A. Mastering the semi-structured interview and beyond: from
research design to analysis and publication. New York: NYU press; 2013.
32. McGrath C, Palmgren PJ, Liljedahl M. Twelve tips for conducting qualitative
research interviews. Med Teach. 2019;41(9):1002–6.
33. Wheeldon J, Faubert J. Framing experience: concept maps, mind maps, and
data collection in qualitative research. Int J Qual Methods. 2009;8(3):68–83.
34. Wheeldon J. Is a picture worth a thousand words? Using mind maps to facil-
itate participant recall in qualitative research. Qual Rep. 2011;16(2):509–22.
35. Cresswell JW, Poth CN. Five qualitative approaches to inquiry. Qual Inq Res
Design. 2007;2:53–80.
36. Thompson C. Clinical experience as evidence in evidence-based practice. J
Adv Nurs. 2003;43(3):230–7.
37. Dawson GC. Years of clinical experience and therapist professional develop-
ment: a literature review. J Contemp Psychother. 2018;48(2):89–97.
38. De Allegri M, Schwarzbach M, Loerbroks A, Ronellenfitsch U. Which factors
are important for the successful development and implementation of clini-
cal pathways? A qualitative study. BMJ Qual Saf. 2011;20(3):203–8.
39. Delilovic S, Hasson H, Åhström M, von Knorring M. Implementing standard-
ized cancer patient pathways (CPPs) - a qualitative study exploring the per-
spectives of health care professionals. BMC Health Serv Res. 2019;19(1):577.
40. Sleeman KE, Koffman J, Bristowe K, Rumble C, Burman R, Leonard S, et al. ’It
doesn’t do the care for you’: a qualitative study of health care professionals’
perceptions of the benefits and harms of integrated care pathways for end
of life care. BMJ Open. 2015;5(9):e008242.
41. Akehurst J, Sattar Z, Gordon I, Ling J. Implementing online evidence-based
care pathways: a mixed-methods study across primary and secondary care.
BMJ Open. 2018;8(12):e022991.
42. Sjöström AE, Hörnsten Å, Hajdarevic S, Emmoth A, Isaksson U. Primary
health care nurses’ experiences of consultations with internet-informed
patients: qualitative study. JMIR Nurs. 2019;2(1):e14194.
43. Clarke MA, Moore JL, Steege LM, Koopman RJ, Belden JL, Canfield SM, et al.
Health information needs, sources, and barriers of primary care patients
to achieve patient-centered care: a literature review. Health Inform J.
2015;22(4):992–1016.
44. Ramsey I, Corsini N, Peters MDJ, Eckert M. A rapid review of consumer
health information needs and preferences. Patient Educ Couns.
2017;100(9):1634–42.
45. Redman S, Greenhalgh T, Adedokun L, Staniszewska S, Denegri S. Co-
production of knowledge: the future. BMJ. 2021;372:n434.
46. Nguyen T, Graham ID, Mrklas KJ, Bowen S, Cargo M, Estabrooks CA, et al.
How does integrated knowledge translation (IKT) compare to other col-
laborative research approaches to generating and translating knowledge?
Learning from experts in the field. Health Res Policy Syst. 2020;18(1):35.
47. Bowen SJ, Graham ID. From knowledge translation to engaged scholar-
ship: promoting research relevance and utilization. Arch Phys Med Rehabil.
2013;94(1 Suppl):S3–8.
48. Denis J-L, Lomas J. Convergent evolution: the academic and policy roots of
collaborative research. J Health Serv Res Policy. 2003;8:1–6.
49. Jagosh J, Macaulay AC, Pluye P, Salsberg JON, Bush PL, Henderson JIM, et al.
Uncovering the benefits of participatory research: implications of a realist
review for health research and practice. Milbank Q. 2012;90(2):311–46.
50. Macaulay AC, Ing A, Salsberg J, McGregor A, Saad-Haddad C, Rice J, et al.
Community-based participatory research: lessons from sharing results with
the community: Kahnawake schools diabetes prevention project. Prog
Community Health Partnersh. 2007;1(2):143–52.
51. Graham ID, Tetroe J, Pearson A. Turning knowledge into action: practical
guidance on how to do integrated knowledge translation research. Phila-
delphia: Lippincott Williams & Wilkins; 2014.
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