Barriers and facilitators to implementation of proper limb positioning in hemiplegic stroke patients: a qualitative study

Zhang, Xin-Yue; Leng, Min-Min; Yang, Jia-Wei; Li, Shuo-Tao; Li, Min; Ji, Xiao-Xu; Cui, Quan-Qin; Liang, Fang; Chen, Xia; Yang, Li-Juan

doi:10.1590/1980-220X-REEUSP-2025-0110en

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ORIGINAL ARTICLE • Rev. esc. enferm. USP 59 • 2025 • https://doi.org/10.1590/1980-220X-REEUSP-2025-0110en linkcopy

Barriers and facilitators to implementation of proper limb positioning in hemiplegic stroke patients: a qualitative study

Barreiras e facilitadores para a implementação do posicionamento adequado dos membros em pacientes com hemiplegia por AVC: um estudo qualitativo

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: To identify factors that can be targeted to promote the standardized management of proper limb positioning and improve the rehabilitation outcomes of patient.

Method: A qualitative descriptive study was conducted using semi-structured face-to-face in-depth interviews with 24 clinical nurses working in stroke-related departments between April and May 2024. Based on the COM-B model, the data were analyzed by employing the deductive content analysis method using the NVivo12 software and manual coding.

Results: Analysis revealed 11 themes and 22 sub-themes associated with the four domains of the COM-B model, including 15 barriers and 7 facilitators.

Conclusion: Clinical nurses' adherence to proper limb positioning is dynamic and positioning should address barriers related to capability, opportunity, and motivation, such as prioritize knowledge and skills training for clinical nurses, improved compliance among patients and caregivers, establish robust systems and supervisory mechanisms, and support scientific research and innovation to explore intelligent management solutions.

DESCRIPTORS
Stroke; Nurse Clinicians; Patient Positioning; Qualitative Research; Implementation Science

Feature	Overall (n = 24)
Gender
Man	1 (4.2%)
Woman	23 (95.8%)
Age (x ± s)	34.38 ± 6.96
Hospital level
Secondary hospital	7 (29.2%)
Tertiary hospital	17 (70.8%)
Department
Neurology	17 (70.8%)
Department of Neurohealth	3 (12.5%)
Military sursery	2 (8.3%)
Department of rehabilitation medicine	2 (8.3%)
Education background
Undergraduate course	23 (95.8%)
Postgraduate	1 (4.2%)
Years of working (x ± s)	12.02 ± 7.77
Professional ranks and titles
Nurse	2 (8.3%)
Primary nurse	8 (33.3%)
Nurse-in-charge	11 (45.8%)
Co-chief superintendent nurse	3 (12.5%)
Position
Nurse	21 (87.5%)
Head nurse	3 (12.5%)

COM-B	Themes	Sub-themes	Barriers/Facilitators
Capabilities	The patients’ physical condition	Disease condition	Barriers
	The patients’ physical condition	Special patients	Barriers
	Knowledge, skills and accessibility of information	Lack of knowledge and skills	Barriers
	Knowledge, skills and accessibility of information	The training effect is not good	Barriers
	Compliance of patient and family	Cognitive levels are limited	Barriers
		Changes in the way of education	Facilitators
		Demographic characteristics	Barriers
Opportunity	Availability of time	Time-consuming operation	Barriers
	Availability of time	High intensity work	Barriers
	Auxiliary means	The scarcity of quantity	Barriers
	Auxiliary means	Differences in quality	Barriers
	Allocation and utilization of medical and health resources	Unreasonable allocation of human resources	Barriers
		Multidisciplinary collaboration and communication	Facilitators
		The distribution of medical resources is uneven	Barriers
	Social influence	Good working atmosphere	Facilitators
Motivation	The relevant system and supervision strategy	Lack of evaluation criteria	Barriers
	The relevant system and supervision strategy	Lack of regulatory strategy	Barriers
	Belief about consequences	The positive effect of proper limb positioning	Facilitators
	Belief about consequences	Positive feedback	Facilitators
	Guidelines and policies related to proper limb positioning	Guidelines and policies to guide the practice of proper limb are lacking	Barriers
	A sense of professional worth	Work sense of achievement	Facilitators
	A sense of professional worth	Work Ethic	Facilitators

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Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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