Keisuke Iwase, Hironori Tsuzuki, Masushi Kohta, Koji Harima, Junko Sugama
8 min
This qualitative pilot study investigated the potential barriers and facilitators to implementing a pressure injury (PI) prevention program within the Japanese home care system. The researchers utilized the Consolidated Framework for Implementation Research (CFIR) to conduct semi-structured interviews with five care managers (CMs). Because the participants had no previous experience with the program, the study provides insight into their anticipated challenges and requirements for successful adoption rather than observations of established practice.
The study identified 32 facilitators and 32 barriers categorized across the five CFIR domains. Key barriers included excessive caseloads and staff shortages, which contribute to low perceived urgency for PI prevention. Furthermore, the diverse professional backgrounds of CMs—ranging from social welfare to medical fields—resulted in uneven levels of clinical knowledge and confidence. Many CMs expressed uncertainty regarding the evidence for the program's effectiveness, which hindered their motivation to prioritize it amidst their existing, demanding daily routines.
Despite these challenges, participants identified several factors that could support implementation, including the program's inherent simplicity, potential for improved multidisciplinary communication, and the utility of structured tools like the Pressure Injury Primary Risk Assessment Scale for Home Care (PPRA-Home). The authors suggest that future implementation efforts should focus on tailoring training to accommodate varying professional backgrounds, securing support from chief care managers to manage workloads, and developing digital tools to streamline information sharing between home care providers and medical professionals.
Objectives: This study aimed to explore care managers' (CMs) perceptions of potential barriers and facilitators to implementing a pressure injury (PI) prevention program within Japan's home care system. Methods: A pilot qualitative study was conducted using the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. Semi-structured interviews were conducted with five CMs employed at a home-based long-term care support facility (October 2022-March 2023). Two researchers independently coded the transcripts, reached consensus through discussion, and conducted member checking to enhance rigor. Results: A total of 32 facilitators and 32 barriers were identified across five CFIR domains. Key facilitators included the program's perceived ease of use and its potential to enhance multidisciplinary communication. Frequently perceived barriers included uncertainty regarding the program's effectiveness, insufficient knowledge and low perceived urgency regarding PI prevention among CMs and chief CMs, excessive workload, and limited resources. As participants had no prior experience implementing the program, these findings reflect anticipated perceptions rather than actual implementation experiences. Conclusions: This study provides preliminary observations regarding potential facilitators and barriers to implementing a PI prevention program in home care settings. Future research is required to further examine these perceptions and explore whether similar barriers and facilitators are observed in other settings and populations.
Alex: Previous studies had supported the assessment scale’s reliability and validity. But the authors distinguish that from evidence that the full prevention program improves outcomes in practice. Few studies had evaluated the complete program’s clinical effectiveness. A credible risk measure is not the same thing as a proven prevention service.
Sam: How did the researchers make unfamiliar participants’ expectations concrete enough to study?
Alex: They gave participants a one-hour online orientation before interviewing them. Then they used the Consolidated Framework for Implementation Research, a framework for organizing influences on putting interventions into practice. Its domains directed attention beyond the tool itself, toward the workplace, individuals, outside relationships, and implementation planning.
Sam: Can you give an example where looking beyond the tool changed the question?
Alex: A participant said, “I don’t know how to share the PI assessment results with other professionals and the patient’s family members.” Here, PI means pressure injury. The obstacle wasn’t necessarily completing the assessment. It was turning the result into information that other people could use.
Sam: That also exposes a tension in the program. A collaboration checklist might help communication, but using it still depends on relationships and workable ways to exchange information.
Alex: Participants expressed both sides. They saw potential for better multidisciplinary communication, meaning communication across different professions. They also anticipated difficulty contacting medical professionals, especially among managers with social welfare backgrounds. Some reported limited experience seeking advice from other professions.
Sam: With interviews this small, interpretation matters a lot. How did the researchers check their reading of what participants said?
Alex: Researchers independently coded the transcripts, then discussed disagreements to reach consensus. A researcher outside the initial coding checked participant summaries. Those summaries also went back to participants for comment. The team discussed how their own nursing and community-health backgrounds might influence interpretation.
Sam: Those checks support the interpretation, but they don’t expand the sample. How narrow was the setting?
Alex: All participants worked at a single home-care support center. Recruitment depended on availability and willingness, so the authors acknowledge possible sampling bias. This gives us detailed perspectives from that workplace, not a representative picture of Japanese care managers.
Sam: Within that boundary, what were the main findings? Which concerns kept returning?
Alex: The analysis identified 32 facilitators and an equal number of barriers. Those are categorized factors, not counts of people endorsing each concern. Recurring themes were uncertain effectiveness, heavy workloads and staff shortages, limited knowledge and low urgency, and communication difficulties across professions.
Sam: An equal tally doesn’t tell us whether implementation is likely to succeed. What did participants actually think would make it easier?
Alex: They perceived the program as simple and potentially adaptable to existing assessment practices. Supportive workplace relationships, opportunities to consult colleagues, regular training, and clear leadership were also seen as helpful. Preparing before home visits and incorporating assessment into routine work were anticipated facilitators.
Sam: That makes ease of use sound conditional. A short assessment might still be difficult if it duplicates existing work or creates follow-up nobody has time for.
Alex: Participants did identify incompatibility with existing assessment tools and workload-related limits on collaboration. They also described lower perceived need where few clients seemed at high risk. So perceived usefulness depended partly on the workplace and the clients it served, not simply on the program’s design.
Sam: The authors propose ways forward. Which suggestion best shows the trade-offs rather than just saying “provide more training”?
Alex: Case selection does. They suggest exploring whether prioritizing some clients could make implementation manageable under heavy workloads. But they explicitly recognize the cost: limiting coverage reduces opportunities to assess people at risk. They therefore pair that possibility with improving managers’ knowledge so high-risk clients are not overlooked.
Sam: Were selective assessment or any of the other proposed solutions tested here?
Alex: No. The authors call them exploratory considerations, not evidence-based recommendations. They also discuss tailored training, engaging chief care managers, improving information-sharing tools, and generating clinical evidence. A proposed digital tool could combine assessment records, team communication, and educational resources, but this study did not evaluate one.
Sam: What most limits how far we should trust the conclusions: the small workplace sample, or the absence of actual implementation?
Alex: Both matter, but for me the decisive boundary is that these are expectations. The study cannot show which anticipated barriers actually arise, or which facilitators change practice. Pandemic-related restrictions also reduced face-to-face communication during the study, potentially shaping how participants described collaboration.
Sam: Given those limits, who should read the full document, and where should they begin?
Alex: Researchers planning home-care implementation studies, and leaders considering a prevention program, should read it. Start with the Results organized by implementation domain, particularly the workplace and individual-level concerns. Then read the Discussion’s Evidence Generation section, which separates an established assessment scale from an incompletely evaluated prevention program.
Sam: And for someone outside home care who only carries away one idea?
Alex: A tool can be simple while the work around it is not. Here, the contribution is a grounded set of questions to test during implementation—not proof that the program works, or that these barriers apply everywhere.
Sam: Thanks for listening.