Barriers, Enablers, and Impacts of Implementing National Comprehensive Care Standards in Acute Care Hospitals: An Interview Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

• Sampling nuance. You acknowledge potential volunteer bias via organizational communications/social media and a high proportion of leaders; consider adding a sentence on how this may shape the salience of resource/structural themes and how future work could purposively sample more frontline non-leaders.

• Saturation description. You state that no new themes emerged after three consecutive interviews; a brief note on how “codes and meaning” saturation was operationalized would improve transparency.

• Summary of the Manuscript

  This manuscript presents a timely and important qualitative descriptive study exploring the perspectives of 28 Australian healthcare professionals on the implementation of the national Comprehensive Care Standard (CCS). Using the Consolidated Framework for Implementation Research (CFIR), the authors skillfully identify key barriers, enablers, and perceived impacts of the CCS. The findings highlight a crucial tension: while the standard is perceived to improve multidisciplinary care, its implementation has also led to significant increases in staff workload and fatigue, particularly for nursing staff.

  Major Strengths

  1. Methodological Rigor: The study's design is a significant strength. The use of the CFIR to develop the interview guide and structure the thematic analysis provides a robust theoretical grounding. Furthermore, mapping the identified barriers and enablers to the Expert Recommendations for Implementing Change (ERIC) framework offers tangible, evidence-based strategies for improvement. This elevates the paper from a simple descriptive study to a practical guide for policy and practice.

  2. Rich Qualitative Data: The authors have collected and effectively presented rich qualitative data. The inclusion of illustrative quotes (e.g., in Table 2) gives a powerful voice to the participants and provides deep context to the identified themes, such as the "disconnect from above and staff on the floor."

  3. Important and Nuanced Findings: The paper does an excellent job of exploring the impacts of the CCS (Section 3.3). The finding that the CCS has increased staff workload, burnout, and fatigue is a critical counterpoint to its intended benefits. This aligns with the "Quadruple Aim" of healthcare (which the authors rightly cite in the discussion) and underscores the risk of implementing new standards without sufficient resources or workflow redesign.

  4. Clarity and Structure: The manuscript is well-written, logically organized, and easy to follow. Figure 1 provides an excellent visual summary of the findings within the CFIR domains, and the tables are clear and informative.

  Areas for Minor Revision

  My recommendation for minor revision is based on the following points, which I believe the authors can address without new data collection.

  1. Imbalance in Participant Sample: The most significant limitation is the composition of the professional sample. Of the 28 participants, 20 are nurses, 6 are allied health professionals, and only 2 are doctors. The authors acknowledge this in the limitations, but it could be more strongly emphasized in the discussion. The findings are overwhelmingly reflective of the nursing perspective. This is valuable, but the authors can explicitly state that the identified barriers (e.g., "A culture of nursing dependency," "Implementation work is nursing focused") may be perceived differently by medical or managerial staff, whose perspectives are underrepresented.

  2. Synthesis of "Nursing Dependency" Theme: The study finds that the implementation is "nursing focused" and that a "culture of nursing dependency" is a barrier as displayed in Figure 1. The findings also show the impact is increased workload and fatigue, primarily for nurses (Section 3.3.4). I suggest the authors strengthen their discussion (Section 4.2 or 4.3) to synthesize these points more explicitly. The data suggests the CCS implementation may not only be encountering a barrier of nurse dependency but may also be actively reinforcing it by placing the documentation and coordination burden squarely on nurses. This is a powerful insight that could be sharpened.

  3. Clarity on Survey vs. Interview Contributions: The authors frequently reference a previous survey study. In the discussion (Section 4.2), they note that this interview study identified "additional barriers" not found in the survey. To strengthen the paper's "value added," I suggest the authors dedicate a brief paragraph to explaining why these qualitative interviews were essential. The interviews provide the rich 'why' and 'how' (the context, the frustrations, the processes) that the survey's 'what' (the statistics) could only allude to. This reframing would make the justification for this paper even stronger.

  4. Clarity on "Perceived" Patient Impacts: The section on "Impacts on patients" (3.3.3) is, by design, based on staff perceptions rather than direct patient-reported outcomes. The authors are clear about this in the limitations. However, to ensure this is clear to all readers, I suggest they make this distinction more explicit in the section heading itself (e.g., "Perceived Impacts on Patients") and reinforce this caveat at the beginning of that results section and in the discussion.

  To conclude, this is an excellent and highly relevant piece of implementation science research. The authors have done a commendable job. My suggestions are intended to help them further refine their discussion and strengthen the framing of their findings. I trust these detailed comments will be useful to the authors. I stand by my recommendation of Accept after minor revision and would be happy to review the revised manuscript.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

It was a pleasure to review this manuscript, which explores an important and timely topic, the implementation of the Comprehensive Care Standard in Australian acute care hospitals. The study addresses an area of growing interest in implementation science and provides meaningful insights into barriers, enablers, and impacts associated with a national standard of comprehensive care. The manuscript demonstrates considerable empirical work, theoretical grounding in the CFIR and ERIC frameworks, and strong practical relevance. However, certain aspects would benefit from clarification and refinement to enhance transparency, methodological rigor, and overall readability. Abstract The abstract presents the study clearly, but it would benefit from specifying the qualitative design, sample size (n=28), and the use of CFIR and ERIC frameworks in the Methods. Clarify how the 12 barriers, 13 enablers, and 16 strategies were derived and briefly mention the most prominent categories. Ensure the conclusion explicitly links the recommendations to the study findings. Introduction The introduction provides a good overview of comprehensive care and the Australian context. However, the rationale could be strengthened by clearly articulating the gap that this study fills compared with prior survey research. Explicitly connect how the qualitative design complements the previous findings and allows a more in-depth understanding. Consider ending the section with the study’s aims or research questions in bullet form for clarity. Methods The methodological framework is appropriate, and the combination of CFIR and ERIC is commendable. Please expand the description of the analytical process, clarifying how data were coded, how the semi-quantitative approach (n≥5) was justified, and how coder disagreements were resolved. More details are also needed on data saturation—how it was monitored and when it was considered achieved. Mention confidentiality procedures with the transcription services. Strengthen the reflexivity section by discussing how previous relationships with two participants and prior survey knowledge were managed to minimize bias. Results The results are comprehensive and well organized under CFIR domains. The clear differentiation between barriers and enablers is appreciated. Still, more analytical depth would strengthen the section, for instance, distinguishing between barriers intrinsic to the CCS design (e.g., complexity, adaptability) and contextual challenges (resources, infrastructure). The presentation of quotes is effective; however, a summary table linking CFIR constructs with the corresponding ERIC strategies and agreement percentages should be included in the main text. The section on perceived impacts is valuable, consider structuring it into positive, negative, and mixed impacts for clarity and linking them to illustrative quotes. Discussion The discussion is thoughtful and aligns well with the findings, though it could further emphasize how this study builds upon prior ACSQHC reports and literature on national care standards. Revisit claims of improved patient care to ensure they reflect participants’ perceptions rather than measured outcomes. Expand on the practical implications of the 16 strategies, noting which can be implemented at the local hospital level versus those requiring system-level support. Discuss limitations more explicitly, such as over-representation of Queensland, public sector dominance, and potential selection bias. Finally, ensure the discussion closes with a concise synthesis of how this study advances knowledge in implementation science. Conclusion The conclusion appropriately highlights the study’s relevance but could better connect the findings to broader international contexts. Suggest articulating key recommendations for policymakers and healthcare leaders—such as simplifying standards, ensuring adequate resources and training, and enhancing stakeholder engagement. A short, action-oriented statement would strengthen the final impression. Overall presentation and clarity The manuscript reads clearly and logically, yet some sections would benefit from minor language editing for conciseness and uniformity (e.g., capitalization of CFIR domains, consistent use of 'patients' vs. 'consumers'). Ensure all acronyms are defined at first mention (CCS, NSQHS, CFIR, ERIC, MDT, CNC, IEMR, PREMs). Figures and tables are informative; adding brief explanatory notes or legends would improve readability. Cross-reference supplementary files (S1–S3) in the main text to enhance transparency.

Comments on the Quality of English Language

The English is generally clear and professional, allowing readers to follow the study’s rationale and findings. However, minor revisions are needed to enhance fluency and consistency. Some sentences are lengthy and could be shortened for clarity. Attention should also be paid to uniform capitalization of CFIR domains and consistent terminology (e.g., use either patients or consumers throughout). A light linguistic edit by a native or professional scientific editor is recommended before publication.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript presents a proposal that transcends time in relation to the importance and concern for comprehensive care, which continues to be a challenge. It offers a relevant perspective on the barriers and facilitators that influence strategies and their effectiveness. It is methodologically structured and systematized with its corresponding reference frameworks. It has contributed significant categories to the sustainability of comprehensive care implementation.

For my part, the only suggestion for improvement relates to:

1. Introduction

The content “Twelve barriers, ten enablers, and sixteen enhancement strategies were identified” – Are these results from this study or from the previously conducted reference study? Because they coincide with the results presented in the abstract. If they are from this study, I recommend moving them to the results section. I don't see them as an introduction.

On the other hand, the content “…the brevity of survey responses may have limited the depth of information obtained, potentially underexploring important barriers or facilitators. A more detailed exploration could be achieved through in-depth interviews” – I recommend moving this to the discussion. I see it as a possible limitation of the study and not as an introduction.

Author Response

Comment 1: The content “Twelve barriers, ten enablers, and sixteen enhancement strategies were identified” – Are these results from this study or from the previously conducted reference study? Because they coincide with the results presented in the abstract. If they are from this study, I recommend moving them to the results section. I don't see them as an introduction.

Response 1: Thank you for noting this point. The figures “twelve barriers, ten enablers, and sixteen enhancement strategies” refer to the findings from the previous national survey study, not the results of the current qualitative study. This survey identified 12 barriers, 10 enablers, and 16 potential strategies based on free-text survey responses.

In contrast, the current interview study identified 12 barriers, 13 enablers, and 16 strategies, with partially overlapping but not identical content. The distinctions between the survey findings and the interview findings are discussed in the Discussion section. To avoid confusion, we have clarified in the Introduction that these numbers refer to the prior survey study and not the present qualitative analysis.

Comment 2: On the other hand, the content “…the brevity of survey responses may have limited the depth of information obtained, potentially underexploring important barriers or facilitators. A more detailed exploration could be achieved through in-depth interviews” – I recommend moving this to the discussion. I see it as a possible limitation of the study and not as an introduction.

Response 2: Thank you for this helpful comment. The sentences highlighted refer to a limitation of the previous national survey study, not a limitation of the current interview study. We included this point in the Introduction to articulate the gap in the existing literature and to explain why a qualitative study was needed. This directly aligns with another reviewer’s suggestion to strengthen the rationale for conducting in-depth interviews. In line with other reviewers’ feedback, we also expanded the Discussion to more clearly highlight the value added by the qualitative findings.