Barriers and Facilitators to the Implementation of Discharge Preparation Services for Elderly Patients with Multimorbidity—A Qualitative Study Using the Consolidated Framework for Implementation Research (CFIR)

Barriers and Facilitators to the Implementation of Discharge Preparation Services for Elderly Patients with Multimorbidity—A Qualitative Study Using the Consolidated Framework for Implementation Research (CFIR) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to the Implementation of Discharge Preparation Services for Elderly Patients with Multimorbidity—A Qualitative Study Using the Consolidated Framework for Implementation Research (CFIR) Xing W, Xu Yao, Shanshan Dou, Jiahui Lv, Yajuan Feng, Ru Zhang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8688559/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Purpose To explore barriers and facilitators to implementing a discharge preparation program for elderly patients with multimorbidity, and to inform improvements in this service. Methods We developed semi-structured interview guides based on the Consolidated Framework for Implementation Research (CFIR). Using purposive sampling, we recruited 18 medical staff from a tertiary hospital in Urumqi and conducted interviews with 6 patients and 6 caregivers from the same hospital's service population between November and December 2025. Data were analyzed deductively using CFIR as the coding framework. NVivo 15.0 was used for data management and analysis. Results The findings encompassed 20 constructs across the four CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals), identifying 11 facilitators, 14 barriers, and 2 neutral factors. Key implementation facilitators included a reliable evidence base, favorable environmental conditions and resources, multidisciplinary team establishment, and leadership support. Primary barriers comprised intervention complexity, increased labor costs, incomplete policies and models, lack of financial incentives, and poor compliance. Conclusion The implementation of discharge preparation services for elderly patients with multimorbidity is influenced by multiple factors. Developing targeted strategies to address identified barriers is essential for facilitating successful implementation. Elderly multimorbidity discharge preparation services Comprehensive framework for implementation research Qualitative research Introduction The co-occurrence of two or more chronic conditions, termed multimorbidity (also referred to as multiple chronic conditions or chronic disease multimorbidity)( 1 , 2 ), is associated with increased risks of premature mortality, hospitalization, and prolonged length of stay compared with single chronic disease( 1 ). As population aging extends life expectancy, the prevalence of multimorbidity rises sharply with advancing age( 3 , 4 ). Among Chinese older adults, the prevalence of multimorbidity reaches 65.14%( 5 ), with 20%–22% of these patients experiencing unplanned readmission within 30 days post-discharge( 6 ). This substantially impedes patients' activities of daily living and disease self-management while escalating healthcare costs( 7 ). Discharge Preparation Service (DPS), a continuum-of-care model originating in the United States, enhances patients' readiness for discharge and self-care capabilities, ensuring continuous and comprehensive post-discharge care, reducing readmission and recurrence rates, shortening hospital stays, and improving patient satisfaction( 8 , 9 ). Implementing comprehensive and standardized DPS is particularly imperative for optimizing health outcomes and disease management in older adults with multimorbidity( 10 ). To improve health outcomes for this population, our research team previously conducted a systematic evidence review and developed a DPS protocol encompassing admission screening and assessment, inpatient planning and intervention, pre-discharge preparation and referral, and post-discharge follow-up and support. However, a substantial gap persists between evidence-based recommendations and clinical practice. How to systematically identify implementation barriers and optimize the intervention using evidence-based approaches represents a critical challenge that must be urgently addressed( 11 ). The Consolidated Framework for Implementation Research (CFIR) represents one of the most widely employed determinant frameworks in implementation science( 12 , 13 ). CFIR comprises five domains—Innovation, Outer Setting, Inner Setting, Individuals, and Implementation Process—encompassing 48 constructs and 19 sub-constructs[13]. Collecting target populations' expectations regarding the clinical intervention and their perceptions of implementation determinants prior to execution facilitates the selection and tailoring of implementation strategies, thereby enhancing the likelihood of successful adoption( 14 ). Utilizing theoretical frameworks in empirical research contributes to building a comprehensive knowledge base for effective implementation( 15 ). Therefore, CFIR was selected as the theoretical framework for this study. Using qualitative research, we explored key barriers and facilitators to protocol implementation from the perspectives of healthcare professionals, patients, and caregivers, providing a foundation for developing implementation strategies and informing evidence-based DPS for older adults with multimorbidity. Method Study design This study is part of a larger project aimed at exploring the barriers and facilitators to implementing a discharge readiness service protocol for elderly patients with multimorbidity, thereby providing an evidence-based reference for improving discharge preparation services for this population. As this study was conducted prior to protocol implementation, we excluded the Implementation Process domain and utilized the remaining four CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals) as the theoretical framework for developing the interview guides ( 16 ). Following a comprehensive literature review and team discussions, we formulated two initial interview guides—one for healthcare professionals and another for patients and caregivers—adhering strictly to the CFIR Interview Guide ( 17 , 18 ). Pilot interviews were conducted with one healthcare professional, one patient, and two caregivers using the initial guides. Based on the pilot findings and input from content experts and research team members through in-depth discussions, the guides were revised to produce the final interview guides (Table 1 ). Table 1 interview guide interviewee Interview content Nurse 1.Have you ever encountered a patient who came back to the hospital a few days after being discharged? Why do you think it is? 2.What do you know about discharge readiness services for older patients with comorbidities? (Evaluate with 0 ~ 10 points)? What do you think of it? 3.Compared with the department's current 'discharge education', what aspects of this discharge preparation service plan make you feel 'more worth doing'? What are the advantages and disadvantages? 4.How confident are you in the successful implementation and application of the intervention? (Evaluated on a scale of 0 ~ 10)? What knowledge and skills do you currently need to supplement to successfully implement the intervention? 5.What aspects of the intervention plan do you think are prone to execution deviations, and what changes need to be made to successfully implement them? 6.What do you think about the quality of the evidence and effectiveness of the intervention program? 7.Are interventions complex to implement and in what ways? 8.What are the costs associated with the implementation of the intervention? It can be started from three perspectives: people, money and materials 9.Do you think the department currently has sufficient resources to implement and manage interventions (e.g., number of beds, nurse manpower, level of informatization)? What is missing? 10.How much do you think the department needs to implement the intervention? Is it urgent and why? 11.Do you know if other hospitals or other departments have implemented similar interventions, and will they give the department a competitive advantage compared to them? 12.Can relevant medical and nursing institutions and home care platforms effectively undertake referrals? What are the docking pain points? 13.How are your relationships with your colleagues, leaders, patients? Do you collaborate and communicate with them when they encounter difficulties in implementing the intervention program? 14.What do you think of the organizational culture of the department? (e.g., what values and nursing concepts are there), and will it affect the implementation of the intervention? 15.Is the intervention consistent with your current work pattern? Does the meaning and value of the intervention program align with your values, needs, and direction of your efforts? If not, please give the corresponding suggestions or reasons. 16.Does the scheduling, authorization, and collaboration process give you enough time and authority to implement the intervention? Please give an example. 17.How much has the intervention helped you with your personal career growth or bonus? What drives you the most? 18.How will you mobilize active participation in discharge readiness service interventions? 19.Overall, what factors do you think might facilitate/hinder the implementation of this intervention? Patient / Caregiver 1.Have you ever had a patient come back to the hospital shortly after being discharged? Why do you think it is? 2.Are you confident that you can take care of yourself or your family after you leave the hospital? (Evaluated with 0 ~ 10 points). Need more help? 3.Do you have the time, energy, transportation and other conditions to complete the discharge preparation service? What is missing? 4.Who would like to be in charge of this service? (such as responsible nurses, bed doctors, social workers)? 5.How do you feel that the discharge preparation services are provided to you according to the content of the intervention compared to when you were discharged from the hospital before? Does it match the actual needs of you and your family? 6.In your opinion, what should be included in an ideal discharge preparation service? 7.Do you think society and medical staff pay attention to the care and discharge experience of patients after discharge? 8.Do you know about medical resources in your community or region? Do you think these resources will meet your or your patient's recovery and care needs? 9.Do you feel like healthcare professionals have time to prepare you for discharge? 10.How do you think the medical team within the hospital (e.g., doctors, nurses, rehabilitators, etc.) should collaborate in the discharge preparation service? Have you ever experienced poor collaboration among your healthcare team? 11.If the ward provides you with a missionary video, QR code, or paper list, which form is the most acceptable to you? 12.How often do you expect to receive a return call from the hospital after discharge? What feedback do you want to know the most (blood pressure/medication/exercise)? 13.What else do you think needs to be explored further? Setting and sample To maximize sample variation, we employed purposeful sampling to recruit healthcare professionals with diverse professional ranks, educational levels, and years of experience; patients with varying numbers and types of chronic conditions; and caregivers of different ages and care durations. This strategy ensured a rich and complementary information base. Participants—healthcare professionals, older patients with multimorbidity, and their caregivers—were recruited from a tertiary geriatric hospital in Xinjiang between November and December 2025. Sample size was determined following Hennink( 19 ) et al .'s recommendations for qualitative research and guided by the principle of data saturation; specifically, data collection ceased when no new information emerged during analysis, thereby establishing the final sample size. Three participant groups were recruited: 1. medical staff Inclusion criteria: (i) Regular staff with licensed physician or nurse practitioner qualifications; (ii) Minimum of 1 year clinical experience with no intention to resign within the next 3 months; (iii) Voluntary participation with informed consent. Exclusion criteria: On leave due to health or other reasons within the past month. 2. Older Adults with Multimorbidity Inclusion criteria: (i) Aged ≥ 60 years; (ii) Diagnosed with ≥ 2 chronic conditions; (iii) ADL score ( 20 ) (Activities of Daily Living) < 100, indicating need for long-term caregiver support; (iv) Capable of expressing intentions clearly and willing to participate. Exclusion criteria: Currently participating in other research studies. 3. Primary Caregivers Inclusion criteria: (i) Aged ≥ 18 years; (ii) Primary caregiver for the patient, providing care ≥ 4 hours daily for ≥ 2 months; (iii) Normal cognitive function with capacity for comprehension and communication; (iv) Voluntary participation with informed consent. Exclusion criteria: Currently participating in other research involving themselves or their family. Data collection Data were collected through face-to-face semi-structured interviews conducted in quiet office or ward settings to minimize environmental distractions and facilitate focused communication. Prior to each interview, we explained the study's purpose, significance, and procedures, and obtained written informed consent. Researchers maintained a neutral stance, employing techniques such as repetition, probing, and clarification as appropriate while emphasizing the necessity of audio recording. Interviews were scheduled 1–2 days before discharge, lasting 25–30 minutes each. During interviews, researchers simultaneously observed participants' facial expressions and body language to enhance interpretation of their responses. Data analysis All research team members completed comprehensive training in qualitative research methodology covering foundational theory, interview techniques, data coding, and analytical processes. This training ensured proficiency in interview techniques and provided a solid theoretical foundation for the study. Within 24 hours after each interview, two research team members (X.Y. and S.S.D.) transcribed the audio recordings verbatim into Microsoft Word documents and supplemented them with field notes. Data were organized and managed using NVivo 15.0 software. The transcripts, originally prepared in Chinese, were subsequently translated into English; a bilingual researcher (X.W.) carefully reviewed the translations to ensure accuracy and completeness. Two team members (X.Y. and S.S.D.) independently coded, categorized, and analyzed the data according to the CFIR codebook ( 21 ). Throughout the coding process, the research team held regular meetings to review coded segments line-by-line, discuss discrepancies, and achieve consensus to ensure coding consistency. The manuscript was prepared in accordance with the Standards for Reporting Qualitative Research (SRQR) ( 22 ). Additionally, coded constructs were classified as facilitators, barriers, and neutral factors based on the CFIR evaluation criteria ( 23 ). Results There were no participant withdrawals. Based on the principle of data saturation, this study enrolled a total of 30 participants, comprising 18 medical staff, 6 patients, and 6 caregivers. The general characteristics of the study participants are presented in Tables 2 , 3 , and 4 . The analysis yielded four primary themes (consistent with the initial primary themes) and 20 secondary themes (derived from the constructs of CFIR 2.0). A total of 27 influencing factors were ultimately identified, including 11 facilitators, 14 barriers, and 2 neutral factors, as detailed in Table 5 . Table 2 General information on medical staff Number Gender Age Educational Level professional title duty level Working years N1 Female 25 Undergraduate Nurse Nurse N1 2 N2 Female 35 Junior high school Supervisor nurse Nurse N3 14 N3 Female 21 Junior high school Nurse Nurse N1 1 N4 Male 26 Undergraduate Nurse Nurse N1 2 N5 Male 22 Junior high school Nurse Nurse N1 1 N6 Female 37 Undergraduate Supervisor nurse Head nurse N3 17 N7 Female 32 Undergraduate Supervisor nurse No N2 13 N8 Female 25 Undergraduate Nurse No N1 1 N9 Female 40 Undergraduate Supervisor nurse Head nurse N3 19 N10 Female 39 Undergraduate Supervisor nurse Head nurse N3 18 N11 Female 22 Junior high school Nurse Nurse N1 2 N12 Female 25 Undergraduate Nurse Nurse N1 2 N13 Female 29 Undergraduate Nurse practitioner Nurse N2 5 N14 Female 30 Undergraduate Nurse practitioner Nurse N2 7 D1 Female 49 Master Chief Physician Department Head / 26 D2 Male 46 Undergraduate Associate Chief Physician Physician / 24 D3 Female 31 Master physician Physician / 2 D4 Female 30 Master physician Physician / 2 Table 3 General information about patients Number Gender Age Educational Level Multimorbidity ( species ) The course of disease ( years ) Medical Expense Payment Method Long- Term Residence primary caregivers P1 Male 63 Hing school Hypertension + coronary atherosclerosis + osteoporosis + rheumatism + prostatic hyperplasia 15 Resident medical care Rural spouse P2 Male 73 primary school Diabetes + coronary atherosclerosis + angina pectoris + hypertension + cerebral infarction + lumbar disc herniation + prostatic hyperplasia 15 Employee medical insurance Towns child P3 Male 64 primary school Hypertension + atherosclerosis + angina pectoris + chronic obstructive pulmonary disease + respiratory failure + cervical spondylosis 6 Employee medical insurance Towns nursing worker P4 Male 65 Junior high school Diabetes + chronic renal insufficiency + cataracts 15 Employee medical insurance Towns spouse P5 Female 74 Undergraduate Hypertension + varicose veins in the lower extremities + sleep disorders 13 Employee medical insurance Towns spouse P6 Female 63 Hing school Hypertension + atherosclerosis + angina pectoris + chronic gastritis + osteoporosis + hyperlipidemia + fatty liver + chronic cholecystitis + hypothyroidism 20 Resident medical care Towns child Table 4 General information about caregivers Number Gender Age Educational Level Relationship with patients Daily patient care hours ( hours) C1 Female 62 Undergraduate child 10 C2 Female 52 primary school nephew 20 C3 Female 29 master child 6 C4 Female 34 High school child 10 C5 Male 51 junior high school child 12 C6 Male 66 Undergraduate spouse 8 Table 5 Analysis of influencing factors for the implementation of discharge preparation service plan for elderly patients with multimorbidity territory component influencing factors innovation Evidence-Base Facilitator The program is supported by robust evidence Adaptability neutral factor The program can be adjusted according to the actual situation Trialability Facilitator The program be piloted in the wards. Complexity Barrier The process of developing the program is more complicated Cost Barrier Increase in labor costs outer setting Local Attitudes Barrier Limited follow-up opportunities Local Conditions Barrier The patient lives in a remote area and has no access to transportation Barrier Low institutional trust in community healthcare facilities Policies & Laws Barrier Imperfect policies and models External Pressure Facilitator will give the department or hospital a competitive advantage. Inner setting Structural Characteristics Facilitator The department has the environment and conditions to realize the plan Barrier Nurses have a vague concept of discharge readiness services Relational Connections and communications Facilitator The hospital has built a multidisciplinary team Barrier Multidisciplinary teams lack cooperation. Culture Facilitator Medical staff have patient-centered values and concepts Tension for Change neutral factor Respondents have different views on the urgency of change Compatibility Facilitator There are some similarities between the program and the usual workflow Barrier The plan does not correspond to the actual circumstances. Incentive Systems Facilitator It can promote personal growth. Barrier Lack of material incentives Access to Knowledge & Information Barrier Some nurses are reluctant to participate in the training individuals Innovation Recipients Barrier Poor compliance Need Facilitator There is a need for discharge preparation services and related knowledge Capability Barrier Caregivers lack relevant care knowledge Barrier Some nurses lack solid theoretical knowledge and practical experience Motivation Facilitator Leadership support Facilitator Potential material or moral encouragement Theme one: Innovation Subtopic 1 Evidence-Base (Facilitator) generally believed that the program derived from the evidence summary was reliable. D1 and N5 noted: “The plan is based on the previous evidence summary, including high-quality guidelines and expert consensus at home and abroad, which makes me feel that the plan is trustworthy.” Subtopic 2 Adaptability (Neutral factor) Some respondents believe that the program can be adjusted according to the actual situation N4 explained: “About referral services, regular comprehensive evaluation after discharge seems not easy to achieve, appropriate adjustments can be made to facilitate the implementation.” Subtopic 3 Trialability (Facilitator) Respondents generally believe that discharge preparation services can be piloted in the ward. N2 and N14 noted: “It can be tried in advance, and it can be very mature to do this content for more patients in the later period.” N5 started: “feels that it can be gradual, and suddenly it may increase a lot of work.” Subtopic 4 Complexity (Barrier) Some respondents thought that the process of carrying out discharge preparation service was more complicated. N11 and N14 explained: “fixed on patients discharged from hospital after seven days, one month, three months of follow-up, if the patient is more, there may be no way to accurately follow-up time.” D2, N1 and N9 explained: “We are now in a group system, and there are limitations in the level of nurses. Nurses are responsible for the entire process of patients from admission assessment to discharge follow-up, which is not easy to complete.” N6 noted: “The patient is older and has a variety of chronic diseases. It is somewhat complicated to provide personalized discharge preparation services according to the patient 's condition. ” Subtopic 5 Cost (Barrier) Respondents generally believe that the implementation of discharge preparation services will increase labor costs. N2 and N4 explained: “The ratio of personnel is insufficient, and in this case, if more people are selected to prepare for the discharge preparation service, the difficulty may be greater.” N10 and N12 started: “Every day everyone is busy with trivial work, which is not enough to support more work to complete related discharge preparation services.” C1 noted: “I see they are sometimes busy running, sometimes delayed off work, I think it is not enough manpower, give me the feeling if you add some tasks to him is very difficult.” Theme two: Outer Setting domain Subtopic 6 Local Attitudes (Barrier) Limited follow-up opportunities. N11: “To prevent being deceived, patients and their carers may sometimes refuse to answer follow-up calls.” Subtopic 7 Local Conditions ( 1 ) Geographic barriers due to remote residence locations (Barrier). N8 explained: “Some patients come from southern Xinjiang, so they're in a hurry to catch the train after discharge.” ( 2 ) Low institutional trust in community healthcare facilities (Barrier). Participants expressed low confidence in the professional competence of community healthcare providers, which discouraged patients from seeking care at these institutions. P4 stated: “Facilities like health centers, service stations, and some county-level hospitals—not to mention those that don't meet tertiary standards—nearly cost me my life on several occasions.” C3 noted: “Community institutions don't really focus on daily chronic disease management or fall prevention for older adults; at least I've never seen such services in our community.” N1 observed: “Among nursing homes, some have comprehensive medical facilities, while others simply hire staff to feed the elderly—just to keep them from starving.” D2, D4: “Community hospitals may have difficulties in effective referral and lack certain medical and rehabilitation equipment.” Subtopic 8 Policies & Laws (Barrier) Some participants identified inadequacies in referral policies and models (barrier factor). N10 stated: “We are not in a position to recommend specific hospitals due to conflict-of-interest concerns. Currently, the policy remains incomplete in various aspects, creating certain difficulties in the referral process.” C4: “My father has multiple chronic conditions. When he needs to go to a specialized ward such as endocrinology, the doctors there only focus on endocrine issues and tend to ignore or superficially manage other problems. This elderly man had a severe urinary tract infection—why was he discharged without proper treatment, resulting in ICU admission just five days after returning home? Moreover, every hospital visit requires numerous tests, and when transferring between departments, the next department refuses to accept our patient even though the previous one had already completed all the examinations.” D2: “Since the DRG (Diagnosis-Related Groups) payment system is currently implemented, there are various policy restrictions on treatment.” D1: “The current three-tier referral system is poorly implemented.” Subtopic 9 External Pressure (Facilitator) Participants widely acknowledged that implementing discharge preparation services would confer competitive advantages on departments or hospitals. N6 stated: “This will improve patient satisfaction and make them perceive us as more professional, resulting in greater recognition.” N10 noted: “Discharge preparation services are well-established in developed countries and regions; implementing them would certainly give our department a competitive edge and generate positive social impact.” D2 and N9 added: “Higher satisfaction also increases patient loyalty, meaning patients become more willing to seek treatment from the same provider, department, or hospital.” Theme three: Inner Setting domain Subtopic 10 Structural Characteristics ( 1 ) Physical Infrastructure (facilitator). Dedicated infrastructure and conditions for implementing discharge preparation services and comprehensive geriatric assessment were available. N8 stated: “Currently, our ward has a dedicated comprehensive geriatric assessment room equipped with instruments such as a body composition analyzer.” P5, P6: “The hospital ward has a good environment and can meet my various activity requirements.” ( 2 ) Work Infrastructure (barrier). Some clinical nurses had a vague understanding of the discharge preparation services concept. N2 noted: “Many nurses in our hospital and other hospitals have never heard of the term 'discharge preparation services'.” N12 added: “I recently joined the geriatrics department; on a scale of 0–10, my understanding of discharge preparation services for elderly patients with multimorbidity would be only one point.” N6, N14: “There is currently a lack of a clear flow chart for discharge readiness services.” N13: “At present, the department does not have discharge manuals, videos and other materials related to elderly comorbid patients, and may need to be produced.” Subtopic 11 Relational Connections and communications ( 1 ) Multidisciplinary collaboration infrastructure (facilitator). The hospital had established systems for multidisciplinary consultations, and some departments had formed dedicated multidisciplinary teams. N1 noted: “The department director has established a multidisciplinary team, and pharmacists and rehabilitation specialists participate in joint ward rounds during morning handovers.” N5, N7, and N8 highlighted supportive team dynamics: “If I encounter difficulties with a task, I can request the head nurse to reassign staff or help mediate the situation.” ( 2 ) Fragmented multidisciplinary collaboration (barrier). Some participants reported challenges in coordinated teamwork. N4 explained: “Due to factors such as different work locations, it is rare for multidisciplinary team members to convene and discuss a single patient.” N7 added: “Communication with pharmacists and rehabilitation therapists is limited.” Subtopic 12 Culture (Facilitator) Medical staff have patient-centered values and concepts. P5, C6: “My attending doctor is very kind, and I really enjoy communicating with her.” C4: “Besides excellent medical skills, medical ethics and professionalism are also essential. I think the healthcare staff at this hospital excel in this area—I'd travel here from anywhere for treatment.” Subtopic 13 Tension for Change (Neutral factor) Participants held divergent views regarding the urgency of implementing the change. Proponents emphasized its necessity: N6 stated, “If we aim to enhance our service quality and patient satisfaction, I believe it is very much needed,” while N10 asserted, “I consider discharge preparation services necessary for every patient.” In contrast, N9 expressed reservations: “It is not particularly urgent. First, we have no prior exposure to these initiatives; second, we are currently engaged in another project.” N1 and N7 noted: “ongoing incremental efforts: "We are also attempting to develop educational videos to provide patient guidance.” Subtopic 14 Compatibility ( 1 ) Congruence with existing clinical workflows (facilitator). D4,N7 and N13 noted: “Mostly consistent, because we are doing these things too, but not exactly following this pattern.” ( 2 ) Perceived misalignment between the protocol and clinical reality (barrier). N7 and N14 explained: “Typically, patients are notified of discharge on the same morning. Many simply want to leave immediately after receiving their discharge documentation and are unwilling to listen to explanations, let alone undergo pre-discharge assessments.” N1 noted: “Comprehensive geriatric assessment requires considerable time to complete. Even when offered free of charge, patients are reluctant because they perceive it as wasting their time.” D4 and N11 explained: “Patients are unwilling to return to the hospital specifically for post-discharge comprehensive assessment, nor do we conduct home-based evaluations.” C3 noted: “Regular comprehensive assessments after discharge—essentially, patients only return when they themselves feel unwell, correct?” Subtopic 15 Incentive Systems ( 1 ) Professional development opportunities (facilitator). Participants identified potential for knowledge acquisition and skill enhancement. N3 and N11 stated: “In the process of promoting this initiative, I would naturally gain more knowledge in this area.” D3 and N1 noted: “Systematically reviewing a patient's condition from start to finish reinforces my own memory and builds clinical experience.” ( 2 ) Absence of material incentives (barrier). D2 and N6 explained: “Since this generally does not involve chargeable services, it may increase workload without corresponding enhancement in performance-based compensation.” Subtopic 16 Access to Knowledge & Information (barrier) Some participants expressed unwillingness to engage in training activities. N2 identified procedural uncertainties: “How to train nurses in discharge preparation services and how to assess training competency remain unclear.” N1 highlighted practical constraints: “Training will inevitably encroach upon our off-duty time.” Theme four: Individual domain Subtopic 17 Innovation Recipients (barrier) Participants widely perceived poor adherence among patients and caregivers. D3, N1, N2, and N5 noted: "Patients have their own established behaviors and mindset; even when instructed, they fail to comply or cooperate.” P2 and C3 reported: “Elderly patients, particularly those over 80, are stubborn and confused; they simply disregard our advice and do as they please.” N3 and D4 observed: “Some patients are more inclined to listen to physicians while ignoring nurses.” D1 and C4reported: “Some patients have family conflicts, and caregivers do not want to take care of patients, so no matter how much medical staff trains caregivers, it is useless.” Subtopic 18 Need (facilitator) Expressed need for discharge preparation services and related knowledge. P1, P3, and C2 stated: “We hope to receive follow-up calls after discharge asking about our condition, recovery progress, medications, and so on.” P2 AND P5 noted: “I hope to receive a call from my attending physician after discharge, as he best understands my condition.” N11reported: “My own understanding in this area is insufficient, so I believe I should learn more about these aspects.” Subtopic 19 Capability ( 1 ) Deficient caregiver knowledge (barrier). Participants identified gaps in family caregivers' professional knowledge and technical skills. N10 explained: “Family caregivers lack professional knowledge and caregiving skills; improper patient repositioning results in pressure ulcers.” N1 and N2 noted: “Patient readmissions sometimes result from family caregivers' negligence.” D3, N6 and N8 stated: “In China, it is common for adult children to care for elderly parents. When several children take turns caring for a patient, some caregivers are aware of the health education content while others are not.” C5 and N14 noted: “Different caregivers have varying levels of caregiving ability, and the information obtained during follow-up is not necessarily accurate.” ( 2 ) Insufficient nurse theoretical knowledge and clinical experience (barrier). Participants acknowledged limitations in their own competencies. N2 stated: “When providing health education to patients, I can offer some information, but there remain areas where my teaching is inadequate.” N4 and N3 observed: “Most nurses in the ward are relatively junior and lack understanding of disease progression and subsequent changes in patient conditions.” N1 added: “Typically, the department chief or head nurse provides suggestions, as my own knowledge is limited in its ability to help patients.” Subtopic 20 Motivation ( 1 ) Leadership support (facilitator). Participants highlighted institutional backing for discharge preparation services. N10 stated: “We really want to make hospital preparation services to benefit the patient and reduce his re-hospitalization, rather than doing it for scientific research.” N8 and N14 stated: “Our department director is quite supportive, and our department is already implementing similar initiatives.” ( 2 ) Potential for professional recognition and economic benefits (facilitator). Participants anticipated both symbolic and tangible rewards. N4 noted: “If patients are highly satisfied, they might present me with a banner of appreciation.” N9 and N14 noted: “Although readmission rates may decrease, when patients require hospitalization again, they will still choose our hospital. Moreover, other patients may seek care here after hearing about our quality services. With increased patient volume and workload, there may be enhanced economic benefits.” Discussion To ensure the rigor of intervention design and implementation, this study employed qualitative research prior to protocol implementation to explore barriers and facilitators across the four CFIR domains: Intervention Characteristics, Outer Setting, Inner Setting, and Individual Characteristics. In the Intervention Characteristics domain, our findings identified reliable evidence sources and applicability as key facilitators. Clinical nurses' willingness to adopt new interventions is contingent upon these factors, demonstrating that a robust evidence base is a critical driver of practice change. When translating research into clinical practice, investigators must prioritize the core concept of "evidence-based practice," as credible, valid, and generalizable evidence forms the foundation for clinical decision-making ( 24 ). Conversely, intervention complexity and increased costs emerged as significant barriers. Since the protocol was derived from evidence in high-quality domestic and international studies, some components may not align with local contexts. Indeed, participants noted that the protocol requires adaptation to real-world circumstances, underscoring the need for localized, individualized translation to ensure applicability across diverse clinical settings ( 25 ). Increased complexity renders implementation processes cumbersome ( 26 , 27 ). Focusing on core intervention components deemed essential for achieving better outcomes represents a potential strategy for simplification; designing well-supported clinical pathways or deconstructing complex interventions into more manageable components for stepwise adoption can also mitigate complexity ( 26 ). Discharge preparation service implementation involves multiple steps and necessitates substantial human resource investment; insufficient staffing may compromise service accessibility and continuity. Optimizing workflows and rationalizing human resource allocation are therefore critical for successful implementation ( 28 ). Beyond maximizing human resource utilization through competency-based training and rational scheduling, future research and practice should explore how technological tools or collaborative models can reduce complexity and costs. For example, utilizing mobile applications or virtual reality technologies to support discharge preparation could effectively address current human resource shortages ( 29 ). In the Outer Setting domain, external pressure emerged as a powerful facilitator. Within the CFIR framework, external pressure refers to driving forces originating from the external environment ( 13 ). The competitive advantage that discharge preparation services would confer upon departments or hospitals demonstrates their strategic importance, offering potential for positive social impact and economic benefits over the long term. Local conditions, community attitudes, and absence of referral policies constituted important barriers. Insufficient caregiver understanding of patient conditions compromised follow-up data reliability, likely reflecting inadequate communication and education mechanisms. Additionally, transportation difficulties in remote areas and low public trust in community healthcare institutions limited service implementation ( 30 ). We therefore recommend strengthening capacity building within community healthcare facilities to enhance their role in managing elderly patients with multimorbidity, and improving caregiver health literacy through multiple channels (e.g., community outreach, online education). Comprehensive policy support can safeguard service implementation by reducing operational barriers ( 31 ); thus, we urge relevant authorities to refine referral policies and clarify responsibilities and collaborative mechanisms across healthcare levels to facilitate effective discharge preparation for this population. In the Inner Setting domain, material resources represented a critical facilitator. Participants confirmed that departments possessed the necessary infrastructure, physical space, and equipment to support discharge preparation services. In contrast, incompatibility, inadequate incentive systems, and lack of collaboration emerged as major barriers. Participants perceived misalignment between the intervention protocol and existing workflows, consistent with findings from Beck et al. ( 26 ). This highlights the need to consider practical contexts during implementation to ensure protocol compatibility, while using education and communication to enhance healthcare professionals' acceptance of change and increase implementation engagement. Within CFIR, "incentives" encompass both tangible and intangible rewards ( 13 ). In this study, participants noted the absence of billing codes for discharge preparation services, preventing revenue generation or enhanced individual performance metrics. Hospital administrators had yet to establish relevant incentive mechanisms, resulting in low engagement among healthcare professionals. We recommend establishing reasonable incentive systems to increase departmental revenue and individual performance, and to provide opportunities for external training and career advancement. Although multidisciplinary teams (MDTs) exist, fragmented communication and collaboration during implementation—due to busy schedules, ambiguous role delineation, and lack of institutional oversight—prevented teams from leveraging their full potential, aligning with findings from Li ( 32 ) and Sarah ( 33 ). Multidisciplinary collaboration is also constrained by resource limitations and time pressures, as effective teamwork requires adequate time, staffing, and material resources that may be scarce in clinical settings, potentially compromising implementation outcomes. Research indicates that team-based education helps MDT members value diverse perspectives and fosters mutual trust and respect ( 26 ); such programs effectively cultivate positive learning and collaborative cultures within implementation teams ( 34 ). MDTs should therefore adopt a patient-centered approach, clarifying role division in assessment, discharge planning, and follow-up, while establishing mutual respect and clear communication strategies. Quality control groups should be formed to promote highly cooperative, efficient, and collaborative teams. In the Individual Characteristics domain, leadership support and intervention motivation were identified as important facilitators. Protocol implementation represents a "top-down" organizational behavior, with leadership, champions, and frontline nurses serving as critical links in the translation chain ( 35 ). Leadership support and potential material or symbolic rewards constitute important implementation drivers ( 36 ). We therefore recommend enhanced leadership engagement and support, using multiple incentive strategies to improve healthcare professionals' motivation. Poor patient compliance and insufficient capacity among caregivers and nurses emerged as critical barriers, potentially related to patients' cultural backgrounds, health beliefs, and service awareness. Personalized education and communication strategies are needed to improve patient adherence. While some caregivers lacked relevant care knowledge, nurses also demonstrated insufficient theoretical knowledge and practical experience. Caregiver support positively impacts patient health outcomes ( 37 ); enhancing caregiver competency can improve patients' self-care capacity. This underscores the need for strengthened caregiver training, recognition of their pivotal role in clinical practice, and comprehensive patient education about disease management to foster understanding of discharge preparation services' importance and thereby gain support and cooperation ( 38 ). Additionally, improving healthcare professionals' competencies is essential to ensure service quality and effectiveness. Our study indicates that training and education must incorporate robust evaluation and oversight mechanisms to better assess learning outcomes and consolidate discharge preparation knowledge and skills ( 39 ). A scoping review of 99 studies identified training, education, and feedback to providers as the most common strategies for improving compliance with new interventions ( 40 ). To develop implementation strategies tailored to our local healthcare system, future work will consider mapping our CFIR-based findings to the Expert Recommendations for Implementing Change (ERIC). ERIC represents a well-established compilation of implementation strategies ( 41 ). Using the CFIR-ERIC implementation strategy matching tool, the recommendations proposed in this study can be supplemented with additional implementation strategies ( 42 ). Finally, implementation strategies can be refined and finalized through Delphi stakeholder consensus to facilitate the adoption of the discharge preparation service protocol. Strengths and limitations This study has several strengths. First, it employed the Consolidated Framework for Implementation Research (CFIR) as its theoretical framework, utilizing CFIR comprehensively across data collection, data analysis, and data interpretation. Second, the simultaneous inclusion of three core stakeholder groups—patients, caregivers, and nurses—enhanced the credibility and contextual richness of our findings. Nevertheless, several limitations must be acknowledged. First, the perspectives of other key stakeholders, such as physicians, were not captured, which may have constrained the diversity and richness of the data. Second, this study was conducted in a single tertiary hospital in China with a relatively small sample size, thereby limiting generalizability. Finally, as a pre-implementation study, it was unable to utilize the complete CFIR structure (i.e., the Implementation Process domain was excluded). Despite these limitations, the findings hold significant implications for future research and clinical practice. We plan to implement the discharge preparation service protocol for elderly patients with multimorbidity and will use this study as baseline data to compare barriers and facilitators identified during and after implementation, thereby enhancing the sustainability and effectiveness of the protocol. Conclusions In summary, this study employed the Consolidated Framework for Implementation Research (CFIR) to conduct a comprehensive, systematic analysis of barriers and facilitators to implementing a discharge preparation service protocol for elderly patients with multimorbidity across four domains: Intervention Characteristics, Individual Characteristics, Inner Setting, and Outer Setting. These influencing factors are multifaceted and complex. Therefore, identifying barriers and facilitators prior to implementation constitutes a critical success factor. Future research should focus on developing implementation strategies that address obstacles across different dimensions to enhance sustainability and adoption rates. Declarations Ethics approval and consent to participate This study was approved by the Medical Ethics Committee of the Seventh Affiliated Hospital of Xinjiang Medical University (Approval No: 20250925-001). All procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki (43) . Written informed consent was obtained from all participants, including consent for publication of anonymized quotations. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by the Health Commission of the Xinjiang Uygur Autonomous Region, “Tianshan Talents” Program for High-Level Talent Development in Medical and Healthcare, [TSYC202301A054], and the Xinjiang Uygur Autonomous Region Institute of Hospital Management, the Open Project Key Project, [No. YGYJ20250]. The funding bodies were not involved in the design of the study, the collection, analysis, and interpretation of data or the preparation of the manuscript. Author contributions The research team consisted of four master's-level nursing students, one dedicated senior nurse, and one associate professor. X.W., X.Y., S.S.D., J.H.L. and Y.J.F. designed the study. X.Y. and S.S.D. conducted the interviews. X.Y. and S.S.D. coded the data once transcribed and conducted the content analysis independently. Y.X.Y., J.H.L. and Y.J.F. prepared the manuscript. R.Z. and N.M. coordinated with department head nurses and organized regular project meetings. X.W. and P.Y oversaw overall implementation. All authors edited and reviewed the manuscript and approved the final version for submission. Acknowledgments Thanks to all the participants who kindly gave us their time and shared their valuable insights. References Skou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, et al. Multimorbidity Nat Rev Dis Primers. 2022;8(1):48. McAiney C, Markle-Reid M, Ganann R, Whitmore C, Valaitis R, Urajnik DJ, et al. Implementation of the Community Assets Supporting Transitions (CAST) transitional care intervention for older adults with multimorbidity and depressive symptoms: A qualitative descriptive study. PLoS ONE. 2022;17(8):e0271500. Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. Health, functioning, and disability in older adults–present status and future implications. Lancet. 2015;385(9967):563–75. Pruchno RA, Wilson-Genderson M, Heid AR. 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Implementing evidence into practice: How to evaluate the applicability of evidence. J Nurses Train. 2020;35(13):1193–6. Fu BQ, Zhong CC, Wong CH, Ho FF, Nilsen P, Hung CT, et al. Barriers and Facilitators to Implementing Interventions for Reducing Avoidable Hospital Readmission: Systematic Review of Qualitative Studies. Int J Health Policy Manag. 2023;12:7089. Lehn SF, Thuesen J, Bunkenborg G, Zwisler AD, Rod MH. Implementation between text and work-a qualitative study of a readmission prevention program targeting elderly patients. Implement Sci. 2018;13(1):38. McEwan K, Sanders T, Carr S, Graaf PV, Jones S, Aquino MRJ, et al. Co-Producing Personalised Discharge Planning: Developing a Toolkit to Improve Caregiver Involvement in Hospital Transitions. Health Expect. 2025;28(6):e70483. Dalcól C, Tanner J, de Brito Poveda V. Digital tools for post-discharge surveillance of surgical site infection. J Adv Nurs. 2024;80(1):96–109. Wang J, Zhang Y, Rao Q, Liu C, Du H, Cao X, et al. Factors affecting the readiness for hospital discharge of initially treated pulmonary tuberculosis patients in China: a phenomenological study. BMC Public Health. 2024;24(1):2312. Smith H, Grindey C, Hague I, Newbould L, Brown L, Clegg A, et al. Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays. Health Expect. 2022;25(6):2628–44. Li L, Hou Y, Kang F, Li S, Zhao J. General phenomenon and communication experience of physician and nurse in night shift communication: A qualitative study. J Nurs Manag. 2020;28(4):903–11. Riddle SW, Sherman SN, Moore MJ, Loechtenfeldt AM, Tubbs-Cooley HL, Gold JM, et al. A Qualitative Study of Increased Pediatric Reutilization After a Postdischarge Home Nurse Visit. J Hosp Med. 2020;15(9):518–25. Eddy K, Jordan Z, Stephenson M. Health professionals' experience of teamwork education in acute hospital settings: a systematic review of qualitative literature. JBI Database Syst Rev Implement Rep. 2016;14(4):96–137. Fu Y, Wang CQ, Hu Y, et al. Development and validation of a rating scale for barriers to and facilitators of evidence-based nursing implementation. J Nurs Sci. 2022;37(11):5–8. Mitchell SE, Martin J, Holmes S, van Deusen Lukas C, Cancino R, Paasche-Orlow M, et al. How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions. J Healthc Qual. 2016;38(2):116–26. Kamp T, Stevens M, Van Beveren J, Rijk PC, Brouwer R, Bulstra S, et al. Influence of social support on return to work after total hip or total knee arthroplasty: a prospective multicentre cohort study. BMJ Open. 2022;12(5):e059225. Lee SY, Amatya B, Judson R, Truesdale M, Reinhardt JD, Uddin T, et al. Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal. Brain Inj. 2019;33(10):1263–71. Horntvedt MT, Nordsteien A, Fermann T, Severinsson E. Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Med Educ. 2018;18(1):172. Gilhooly D, Green SA, McCann C, Black N, Moonesinghe SR. Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review. Implement Sci. 2019;14(1):47. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. Waltz TJ, Powell BJ, Fernandez ME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci. 2019;14. World Medical. Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 25 Feb, 2026 Reviews received at journal 20 Feb, 2026 Reviews received at journal 18 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 06 Feb, 2026 Reviewers agreed at journal 06 Feb, 2026 Reviewers invited by journal 30 Jan, 2026 Editor invited by journal 29 Jan, 2026 Editor assigned by journal 27 Jan, 2026 Submission checks completed at journal 27 Jan, 2026 First submitted to journal 24 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8688559","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583198264,"identity":"50ae644c-12ce-48bf-b060-3f609dcd2c20","order_by":0,"name":"Xing 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18:08:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8688559/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8688559/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101753065,"identity":"1f20c1a3-ff41-4987-b496-30ab47f96592","added_by":"auto","created_at":"2026-02-03 10:39:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1349326,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8688559/v1/4229e21e-6775-4a6d-b0ba-fc32fa694fe9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to the Implementation of Discharge Preparation Services for Elderly Patients with Multimorbidity—A Qualitative Study Using the Consolidated Framework for Implementation Research (CFIR)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe co-occurrence of two or more chronic conditions, termed multimorbidity (also referred to as multiple chronic conditions or chronic disease multimorbidity)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), is associated with increased risks of premature mortality, hospitalization, and prolonged length of stay compared with single chronic disease(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). As population aging extends life expectancy, the prevalence of multimorbidity rises sharply with advancing age(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Among Chinese older adults, the prevalence of multimorbidity reaches 65.14%(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), with 20%\u0026ndash;22% of these patients experiencing unplanned readmission within 30 days post-discharge(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This substantially impedes patients' activities of daily living and disease self-management while escalating healthcare costs(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDischarge Preparation Service (DPS), a continuum-of-care model originating in the United States, enhances patients' readiness for discharge and self-care capabilities, ensuring continuous and comprehensive post-discharge care, reducing readmission and recurrence rates, shortening hospital stays, and improving patient satisfaction(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Implementing comprehensive and standardized DPS is particularly imperative for optimizing health outcomes and disease management in older adults with multimorbidity(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo improve health outcomes for this population, our research team previously conducted a systematic evidence review and developed a DPS protocol encompassing admission screening and assessment, inpatient planning and intervention, pre-discharge preparation and referral, and post-discharge follow-up and support. However, a substantial gap persists between evidence-based recommendations and clinical practice. How to systematically identify implementation barriers and optimize the intervention using evidence-based approaches represents a critical challenge that must be urgently addressed(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Consolidated Framework for Implementation Research (CFIR) represents one of the most widely employed determinant frameworks in implementation science(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). CFIR comprises five domains\u0026mdash;Innovation, Outer Setting, Inner Setting, Individuals, and Implementation Process\u0026mdash;encompassing 48 constructs and 19 sub-constructs[13]. Collecting target populations' expectations regarding the clinical intervention and their perceptions of implementation determinants prior to execution facilitates the selection and tailoring of implementation strategies, thereby enhancing the likelihood of successful adoption(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Utilizing theoretical frameworks in empirical research contributes to building a comprehensive knowledge base for effective implementation(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Therefore, CFIR was selected as the theoretical framework for this study. Using qualitative research, we explored key barriers and facilitators to protocol implementation from the perspectives of healthcare professionals, patients, and caregivers, providing a foundation for developing implementation strategies and informing evidence-based DPS for older adults with multimorbidity.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study is part of a larger project aimed at exploring the barriers and facilitators to implementing a discharge readiness service protocol for elderly patients with multimorbidity, thereby providing an evidence-based reference for improving discharge preparation services for this population. As this study was conducted prior to protocol implementation, we excluded the Implementation Process domain and utilized the remaining four CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals) as the theoretical framework for developing the interview guides (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Following a comprehensive literature review and team discussions, we formulated two initial interview guides\u0026mdash;one for healthcare professionals and another for patients and caregivers\u0026mdash;adhering strictly to the CFIR Interview Guide (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Pilot interviews were conducted with one healthcare professional, one patient, and two caregivers using the initial guides. Based on the pilot findings and input from content experts and research team members through in-depth discussions, the guides were revised to produce the final interview guides (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003einterview guide\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003einterviewee\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterview content\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.Have you ever encountered a patient who came back to the hospital a few days after being discharged? Why do you think it is?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.What do you know about discharge readiness services for older patients with comorbidities? (Evaluate with 0\u0026thinsp;~\u0026thinsp;10 points)? What do you think of it?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.Compared with the department's current 'discharge education', what aspects of this discharge preparation service plan make you feel 'more worth doing'? What are the advantages and disadvantages?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.How confident are you in the successful implementation and application of the intervention? (Evaluated on a scale of 0\u0026thinsp;~\u0026thinsp;10)? What knowledge and skills do you currently need to supplement to successfully implement the intervention?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.What aspects of the intervention plan do you think are prone to execution deviations, and what changes need to be made to successfully implement them?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.What do you think about the quality of the evidence and effectiveness of the intervention program?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.Are interventions complex to implement and in what ways?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.What are the costs associated with the implementation of the intervention? It can be started from three perspectives: people, money and materials\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.Do you think the department currently has sufficient resources to implement and manage interventions (e.g., number of beds, nurse manpower, level of informatization)? What is missing?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.How much do you think the department needs to implement the intervention? Is it urgent and why?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.Do you know if other hospitals or other departments have implemented similar interventions, and will they give the department a competitive advantage compared to them?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.Can relevant medical and nursing institutions and home care platforms effectively undertake referrals? What are the docking pain points?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.How are your relationships with your colleagues, leaders, patients? Do you collaborate and communicate with them when they encounter difficulties in implementing the intervention program?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.What do you think of the organizational culture of the department? (e.g., what values and nursing concepts are there), and will it affect the implementation of the intervention?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.Is the intervention consistent with your current work pattern? Does the meaning and value of the intervention program align with your values, needs, and direction of your efforts? If not, please give the corresponding suggestions or reasons.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.Does the scheduling, authorization, and collaboration process give you enough time and authority to implement the intervention? Please give an example.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.How much has the intervention helped you with your personal career growth or bonus? What drives you the most?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.How will you mobilize active participation in discharge readiness service interventions?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.Overall, what factors do you think might facilitate/hinder the implementation of this intervention?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient / Caregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.Have you ever had a patient come back to the hospital shortly after being discharged? Why do you think it is?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.Are you confident that you can take care of yourself or your family after you leave the hospital? (Evaluated with 0\u0026thinsp;~\u0026thinsp;10 points). Need more help?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.Do you have the time, energy, transportation and other conditions to complete the discharge preparation service? What is missing?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.Who would like to be in charge of this service? (such as responsible nurses, bed doctors, social workers)?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.How do you feel that the discharge preparation services are provided to you according to the content of the intervention compared to when you were discharged from the hospital before? Does it match the actual needs of you and your family?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.In your opinion, what should be included in an ideal discharge preparation service?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.Do you think society and medical staff pay attention to the care and discharge experience of patients after discharge?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.Do you know about medical resources in your community or region? Do you think these resources will meet your or your patient's recovery and care needs?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.Do you feel like healthcare professionals have time to prepare you for discharge?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.How do you think the medical team within the hospital (e.g., doctors, nurses, rehabilitators, etc.) should collaborate in the discharge preparation service? Have you ever experienced poor collaboration among your healthcare team?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.If the ward provides you with a missionary video, QR code, or paper list, which form is the most acceptable to you?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.How often do you expect to receive a return call from the hospital after discharge? What feedback do you want to know the most (blood pressure/medication/exercise)?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.What else do you think needs to be explored further?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and sample\u003c/h3\u003e\n\u003cp\u003e To maximize sample variation, we employed purposeful sampling to recruit healthcare professionals with diverse professional ranks, educational levels, and years of experience; patients with varying numbers and types of chronic conditions; and caregivers of different ages and care durations. This strategy ensured a rich and complementary information base. Participants\u0026mdash;healthcare professionals, older patients with multimorbidity, and their caregivers\u0026mdash;were recruited from a tertiary geriatric hospital in Xinjiang between November and December 2025. Sample size was determined following Hennink(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) et al .'s recommendations for qualitative research and guided by the principle of data saturation; specifically, data collection ceased when no new information emerged during analysis, thereby establishing the final sample size.\u003c/p\u003e \u003cp\u003eThree participant groups were recruited:\u003c/p\u003e \u003cp\u003e1. medical staff\u003c/p\u003e \u003cp\u003eInclusion criteria: (i) Regular staff with licensed physician or nurse practitioner qualifications; (ii) Minimum of 1 year clinical experience with no intention to resign within the next 3 months; (iii) Voluntary participation with informed consent.\u003c/p\u003e \u003cp\u003eExclusion criteria: On leave due to health or other reasons within the past month.\u003c/p\u003e \u003cp\u003e2. Older Adults with Multimorbidity\u003c/p\u003e \u003cp\u003eInclusion criteria: (i) Aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years; (ii) Diagnosed with \u0026ge;\u0026thinsp;2 chronic conditions; (iii) ADL score (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) (Activities of Daily Living)\u0026thinsp;\u0026lt;\u0026thinsp;100, indicating need for long-term caregiver support; (iv) Capable of expressing intentions clearly and willing to participate.\u003c/p\u003e \u003cp\u003eExclusion criteria: Currently participating in other research studies.\u003c/p\u003e \u003cp\u003e3. Primary Caregivers\u003c/p\u003e \u003cp\u003eInclusion criteria: (i) Aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (ii) Primary caregiver for the patient, providing care\u0026thinsp;\u0026ge;\u0026thinsp;4 hours daily for \u0026ge;\u0026thinsp;2 months; (iii) Normal cognitive function with capacity for comprehension and communication; (iv) Voluntary participation with informed consent.\u003c/p\u003e \u003cp\u003eExclusion criteria: Currently participating in other research involving themselves or their family.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected through face-to-face semi-structured interviews conducted in quiet office or ward settings to minimize environmental distractions and facilitate focused communication. Prior to each interview, we explained the study's purpose, significance, and procedures, and obtained written informed consent. Researchers maintained a neutral stance, employing techniques such as repetition, probing, and clarification as appropriate while emphasizing the necessity of audio recording. Interviews were scheduled 1\u0026ndash;2 days before discharge, lasting 25\u0026ndash;30 minutes each. During interviews, researchers simultaneously observed participants' facial expressions and body language to enhance interpretation of their responses.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll research team members completed comprehensive training in qualitative research methodology covering foundational theory, interview techniques, data coding, and analytical processes. This training ensured proficiency in interview techniques and provided a solid theoretical foundation for the study. Within 24 hours after each interview, two research team members (X.Y. and S.S.D.) transcribed the audio recordings verbatim into Microsoft Word documents and supplemented them with field notes. Data were organized and managed using NVivo 15.0 software. The transcripts, originally prepared in Chinese, were subsequently translated into English; a bilingual researcher (X.W.) carefully reviewed the translations to ensure accuracy and completeness. Two team members (X.Y. and S.S.D.) independently coded, categorized, and analyzed the data according to the CFIR codebook (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Throughout the coding process, the research team held regular meetings to review coded segments line-by-line, discuss discrepancies, and achieve consensus to ensure coding consistency. The manuscript was prepared in accordance with the Standards for Reporting Qualitative Research (SRQR) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Additionally, coded constructs were classified as facilitators, barriers, and neutral factors based on the CFIR evaluation criteria (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were no participant withdrawals. Based on the principle of data saturation, this study enrolled a total of 30 participants, comprising 18 medical staff, 6 patients, and 6 caregivers. The general characteristics of the study participants are presented in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The analysis yielded four primary themes (consistent with the initial primary themes) and 20 secondary themes (derived from the constructs of CFIR 2.0). A total of 27 influencing factors were ultimately identified, including 11 facilitators, 14 barriers, and 2 neutral factors, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information on medical staff\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEducational\u003c/p\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eprofessional title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eduty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003elevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWorking years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupervisor nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupervisor nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHead nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupervisor nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupervisor nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHead nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupervisor nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHead nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNurse practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChief Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepartment Head\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAssociate Chief Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ephysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ephysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information about patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEducational\u003c/p\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMultimorbidity ( species )\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe course of disease ( years )\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003cp\u003eExpense\u003c/p\u003e \u003cp\u003ePayment\u003c/p\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLong-\u003c/p\u003e \u003cp\u003eTerm Residence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eprimary caregivers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHing school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypertension\u0026thinsp;+\u0026thinsp;coronary atherosclerosis\u0026thinsp;+\u0026thinsp;osteoporosis\u0026thinsp;+\u0026thinsp;rheumatism\u0026thinsp;+\u0026thinsp;prostatic hyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003cp\u003emedical care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003espouse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiabetes\u0026thinsp;+\u0026thinsp;coronary atherosclerosis\u0026thinsp;+\u0026thinsp;angina pectoris\u0026thinsp;+\u0026thinsp;hypertension\u0026thinsp;+\u0026thinsp;cerebral infarction\u0026thinsp;+\u0026thinsp;lumbar disc herniation\u0026thinsp;+\u0026thinsp;prostatic hyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003cp\u003emedical\u003c/p\u003e \u003cp\u003einsurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTowns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003echild\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypertension\u0026thinsp;+\u0026thinsp;atherosclerosis\u0026thinsp;+\u0026thinsp;angina pectoris\u0026thinsp;+\u0026thinsp;chronic obstructive pulmonary disease\u0026thinsp;+\u0026thinsp;respiratory failure\u0026thinsp;+\u0026thinsp;cervical spondylosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003cp\u003emedical\u003c/p\u003e \u003cp\u003einsurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTowns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003enursing worker\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiabetes\u0026thinsp;+\u0026thinsp;chronic renal insufficiency\u0026thinsp;+\u0026thinsp;cataracts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003cp\u003emedical\u003c/p\u003e \u003cp\u003einsurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTowns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003espouse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypertension\u0026thinsp;+\u0026thinsp;varicose veins in the lower extremities\u0026thinsp;+\u0026thinsp;sleep disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003cp\u003emedical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTowns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003espouse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHing school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypertension\u0026thinsp;+\u0026thinsp;atherosclerosis\u0026thinsp;+\u0026thinsp;angina pectoris\u0026thinsp;+\u0026thinsp;chronic gastritis\u0026thinsp;+\u0026thinsp;osteoporosis\u0026thinsp;+\u0026thinsp;hyperlipidemia\u0026thinsp;+\u0026thinsp;fatty liver\u0026thinsp;+\u0026thinsp;chronic cholecystitis\u0026thinsp;+\u0026thinsp;hypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003cp\u003emedical care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTowns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003echild\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information about caregivers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEducational Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRelationship with patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDaily patient care hours ( hours)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003echild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003enephew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003echild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003echild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ejunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003echild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003espouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of influencing factors for the implementation of discharge preparation service plan for elderly patients with multimorbidity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eterritory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecomponent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003einfluencing factors\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einnovation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence-Base\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe program is supported by robust evidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdaptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eneutral factor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe program can be adjusted according to the actual situation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrialability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe program be piloted in the wards.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplexity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe process of developing the program is more complicated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncrease in labor costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eouter setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal Attitudes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLimited follow-up opportunities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal Conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe patient lives in a remote area and has no access to transportation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow institutional trust in community healthcare facilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicies \u0026amp; Laws\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImperfect policies and models\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExternal Pressure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ewill give the department or hospital a competitive advantage.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInner setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructural Characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe department has the environment and conditions to realize the plan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurses have a vague concept of discharge readiness services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelational Connections and communications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe hospital has built a multidisciplinary team\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultidisciplinary teams lack cooperation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCulture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedical staff have patient-centered values and concepts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTension for Change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eneutral factor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRespondents have different views on the urgency of change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompatibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThere are some similarities between the program and the usual workflow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe plan does not correspond to the actual circumstances.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncentive Systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIt can promote personal growth.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLack of material incentives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccess to Knowledge \u0026amp; Information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome nurses are reluctant to participate in the training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eindividuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInnovation Recipients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePoor compliance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThere is a need for discharge preparation services and related knowledge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCapability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCaregivers lack relevant care knowledge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSome nurses lack solid theoretical knowledge and practical experience\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeadership support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePotential material or moral encouragement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme one: Innovation\u003c/h2\u003e \u003cp\u003e\u003cb\u003eSubtopic 1 Evidence-Base\u003c/b\u003e (Facilitator) generally believed that the program derived from the evidence summary was reliable. D1 and N5 noted: \u0026ldquo;The plan is based on the previous evidence summary, including high-quality guidelines and expert consensus at home and abroad, which makes me feel that the plan is trustworthy.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 2 Adaptability\u003c/b\u003e (Neutral factor) Some respondents believe that the program can be adjusted according to the actual situation N4 explained: \u0026ldquo;About referral services, regular comprehensive evaluation after discharge seems not easy to achieve, appropriate adjustments can be made to facilitate the implementation.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 3 Trialability\u003c/b\u003e (Facilitator) Respondents generally believe that discharge preparation services can be piloted in the ward. N2 and N14 noted: \u0026ldquo;It can be tried in advance, and it can be very mature to do this content for more patients in the later period.\u0026rdquo; N5 started: \u0026ldquo;feels that it can be gradual, and suddenly it may increase a lot of work.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 4 Complexity\u003c/b\u003e (Barrier) Some respondents thought that the process of carrying out discharge preparation service was more complicated. N11 and N14 explained: \u0026ldquo;fixed on patients discharged from hospital after seven days, one month, three months of follow-up, if the patient is more, there may be no way to accurately follow-up time.\u0026rdquo; D2, N1 and N9 explained: \u0026ldquo;We are now in a group system, and there are limitations in the level of nurses. Nurses are responsible for the entire process of patients from admission assessment to discharge follow-up, which is not easy to complete.\u0026rdquo; N6 noted: \u0026ldquo;The patient is older and has a variety of chronic diseases. It is somewhat complicated to provide personalized discharge preparation services according to the patient 's condition. \u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 5 Cost\u003c/b\u003e (Barrier) Respondents generally believe that the implementation of discharge preparation services will increase labor costs. N2 and N4 explained: \u0026ldquo;The ratio of personnel is insufficient, and in this case, if more people are selected to prepare for the discharge preparation service, the difficulty may be greater.\u0026rdquo; N10 and N12 started: \u0026ldquo;Every day everyone is busy with trivial work, which is not enough to support more work to complete related discharge preparation services.\u0026rdquo; C1 noted: \u0026ldquo;I see they are sometimes busy running, sometimes delayed off work, I think it is not enough manpower, give me the feeling if you add some tasks to him is very difficult.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme two: Outer Setting domain\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eSubtopic 6 Local Attitudes\u003c/b\u003e (Barrier) Limited follow-up opportunities. N11: \u0026ldquo;To prevent being deceived, patients and their carers may sometimes refuse to answer follow-up calls.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 7 Local Conditions\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Geographic barriers due to remote residence locations (Barrier). N8 explained: \u0026ldquo;Some patients come from southern Xinjiang, so they're in a hurry to catch the train after discharge.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Low institutional trust in community healthcare facilities (Barrier). Participants expressed low confidence in the professional competence of community healthcare providers, which discouraged patients from seeking care at these institutions. P4 stated: \u0026ldquo;Facilities like health centers, service stations, and some county-level hospitals\u0026mdash;not to mention those that don't meet tertiary standards\u0026mdash;nearly cost me my life on several occasions.\u0026rdquo; C3 noted: \u0026ldquo;Community institutions don't really focus on daily chronic disease management or fall prevention for older adults; at least I've never seen such services in our community.\u0026rdquo; N1 observed: \u0026ldquo;Among nursing homes, some have comprehensive medical facilities, while others simply hire staff to feed the elderly\u0026mdash;just to keep them from starving.\u0026rdquo; D2, D4: \u0026ldquo;Community hospitals may have difficulties in effective referral and lack certain medical and rehabilitation equipment.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 8 Policies \u0026amp; Laws\u003c/b\u003e (Barrier) Some participants identified inadequacies in referral policies and models (barrier factor). N10 stated: \u0026ldquo;We are not in a position to recommend specific hospitals due to conflict-of-interest concerns. Currently, the policy remains incomplete in various aspects, creating certain difficulties in the referral process.\u0026rdquo; C4: \u0026ldquo;My father has multiple chronic conditions. When he needs to go to a specialized ward such as endocrinology, the doctors there only focus on endocrine issues and tend to ignore or superficially manage other problems. This elderly man had a severe urinary tract infection\u0026mdash;why was he discharged without proper treatment, resulting in ICU admission just five days after returning home? Moreover, every hospital visit requires numerous tests, and when transferring between departments, the next department refuses to accept our patient even though the previous one had already completed all the examinations.\u0026rdquo; D2: \u0026ldquo;Since the DRG (Diagnosis-Related Groups) payment system is currently implemented, there are various policy restrictions on treatment.\u0026rdquo; D1: \u0026ldquo;The current three-tier referral system is poorly implemented.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u003cb\u003eSubtopic 9 External Pressure\u003c/b\u003e (Facilitator) Participants widely acknowledged that implementing discharge preparation services would confer competitive advantages on departments or hospitals. N6 stated: \u0026ldquo;This will improve patient satisfaction and make them perceive us as more professional, resulting in greater recognition.\u0026rdquo; N10 noted: \u0026ldquo;Discharge preparation services are well-established in developed countries and regions; implementing them would certainly give our department a competitive edge and generate positive social impact.\u0026rdquo; D2 and N9 added: \u0026ldquo;Higher satisfaction also increases patient loyalty, meaning patients become more willing to seek treatment from the same provider, department, or hospital.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eTheme three: Inner Setting domain\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eSubtopic 10 Structural Characteristics\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Physical Infrastructure (facilitator). Dedicated infrastructure and conditions for implementing discharge preparation services and comprehensive geriatric assessment were available. N8 stated: \u0026ldquo;Currently, our ward has a dedicated comprehensive geriatric assessment room equipped with instruments such as a body composition analyzer.\u0026rdquo; P5, P6: \u0026ldquo;The hospital ward has a good environment and can meet my various activity requirements.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Work Infrastructure (barrier). Some clinical nurses had a vague understanding of the discharge preparation services concept. N2 noted: \u0026ldquo;Many nurses in our hospital and other hospitals have never heard of the term 'discharge preparation services'.\u0026rdquo; N12 added: \u0026ldquo;I recently joined the geriatrics department; on a scale of 0\u0026ndash;10, my understanding of discharge preparation services for elderly patients with multimorbidity would be only one point.\u0026rdquo; N6, N14: \u0026ldquo;There is currently a lack of a clear flow chart for discharge readiness services.\u0026rdquo; N13: \u0026ldquo;At present, the department does not have discharge manuals, videos and other materials related to elderly comorbid patients, and may need to be produced.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u003cb\u003eSubtopic 11 Relational Connections and communications\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Multidisciplinary collaboration infrastructure (facilitator). The hospital had established systems for multidisciplinary consultations, and some departments had formed dedicated multidisciplinary teams. N1 noted: \u0026ldquo;The department director has established a multidisciplinary team, and pharmacists and rehabilitation specialists participate in joint ward rounds during morning handovers.\u0026rdquo; N5, N7, and N8 highlighted supportive team dynamics: \u0026ldquo;If I encounter difficulties with a task, I can request the head nurse to reassign staff or help mediate the situation.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Fragmented multidisciplinary collaboration (barrier). Some participants reported challenges in coordinated teamwork. N4 explained: \u0026ldquo;Due to factors such as different work locations, it is rare for multidisciplinary team members to convene and discuss a single patient.\u0026rdquo; N7 added: \u0026ldquo;Communication with pharmacists and rehabilitation therapists is limited.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 12 Culture\u003c/b\u003e (Facilitator) Medical staff have patient-centered values and concepts. P5, C6: \u0026ldquo;My attending doctor is very kind, and I really enjoy communicating with her.\u0026rdquo; C4: \u0026ldquo;Besides excellent medical skills, medical ethics and professionalism are also essential. I think the healthcare staff at this hospital excel in this area\u0026mdash;I'd travel here from anywhere for treatment.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 13 Tension for Change\u003c/b\u003e (Neutral factor) Participants held divergent views regarding the urgency of implementing the change. Proponents emphasized its necessity: N6 stated, \u0026ldquo;If we aim to enhance our service quality and patient satisfaction, I believe it is very much needed,\u0026rdquo; while N10 asserted, \u0026ldquo;I consider discharge preparation services necessary for every patient.\u0026rdquo; In contrast, N9 expressed reservations: \u0026ldquo;It is not particularly urgent. First, we have no prior exposure to these initiatives; second, we are currently engaged in another project.\u0026rdquo; N1 and N7 noted: \u0026ldquo;ongoing incremental efforts: \"We are also attempting to develop educational videos to provide patient guidance.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 14 Compatibility\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Congruence with existing clinical workflows (facilitator). D4,N7 and N13 noted: \u0026ldquo;Mostly consistent, because we are doing these things too, but not exactly following this pattern.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Perceived misalignment between the protocol and clinical reality (barrier). N7 and N14 explained: \u0026ldquo;Typically, patients are notified of discharge on the same morning. Many simply want to leave immediately after receiving their discharge documentation and are unwilling to listen to explanations, let alone undergo pre-discharge assessments.\u0026rdquo; N1 noted: \u0026ldquo;Comprehensive geriatric assessment requires considerable time to complete. Even when offered free of charge, patients are reluctant because they perceive it as wasting their time.\u0026rdquo; D4 and N11 explained: \u0026ldquo;Patients are unwilling to return to the hospital specifically for post-discharge comprehensive assessment, nor do we conduct home-based evaluations.\u0026rdquo; C3 noted: \u0026ldquo;Regular comprehensive assessments after discharge\u0026mdash;essentially, patients only return when they themselves feel unwell, correct?\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 15 Incentive Systems\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Professional development opportunities (facilitator). Participants identified potential for knowledge acquisition and skill enhancement. N3 and N11 stated: \u0026ldquo;In the process of promoting this initiative, I would naturally gain more knowledge in this area.\u0026rdquo; D3 and N1 noted: \u0026ldquo;Systematically reviewing a patient's condition from start to finish reinforces my own memory and builds clinical experience.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Absence of material incentives (barrier). D2 and N6 explained: \u0026ldquo;Since this generally does not involve chargeable services, it may increase workload without corresponding enhancement in performance-based compensation.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 16 Access to Knowledge \u0026amp; Information\u003c/b\u003e(barrier) Some participants expressed unwillingness to engage in training activities. N2 identified procedural uncertainties: \u0026ldquo;How to train nurses in discharge preparation services and how to assess training competency remain unclear.\u0026rdquo; N1 highlighted practical constraints: \u0026ldquo;Training will inevitably encroach upon our off-duty time.\u0026rdquo;\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme four: Individual domain\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSubtopic 17 Innovation Recipients\u003c/b\u003e (barrier) Participants widely perceived poor adherence among patients and caregivers. D3, N1, N2, and N5 noted: \"Patients have their own established behaviors and mindset; even when instructed, they fail to comply or cooperate.\u0026rdquo; P2 and C3 reported: \u0026ldquo;Elderly patients, particularly those over 80, are stubborn and confused; they simply disregard our advice and do as they please.\u0026rdquo; N3 and D4 observed: \u0026ldquo;Some patients are more inclined to listen to physicians while ignoring nurses.\u0026rdquo; D1 and C4reported: \u0026ldquo;Some patients have family conflicts, and caregivers do not want to take care of patients, so no matter how much medical staff trains caregivers, it is useless.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 18 Need\u003c/b\u003e (facilitator) Expressed need for discharge preparation services and related knowledge. P1, P3, and C2 stated: \u0026ldquo;We hope to receive follow-up calls after discharge asking about our condition, recovery progress, medications, and so on.\u0026rdquo; P2 AND P5 noted: \u0026ldquo;I hope to receive a call from my attending physician after discharge, as he best understands my condition.\u0026rdquo; N11reported: \u0026ldquo;My own understanding in this area is insufficient, so I believe I should learn more about these aspects.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtopic 19 Capability\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Deficient caregiver knowledge (barrier). Participants identified gaps in family caregivers' professional knowledge and technical skills. N10 explained: \u0026ldquo;Family caregivers lack professional knowledge and caregiving skills; improper patient repositioning results in pressure ulcers.\u0026rdquo; N1 and N2 noted: \u0026ldquo;Patient readmissions sometimes result from family caregivers' negligence.\u0026rdquo; D3, N6 and N8 stated: \u0026ldquo;In China, it is common for adult children to care for elderly parents. When several children take turns caring for a patient, some caregivers are aware of the health education content while others are not.\u0026rdquo; C5 and N14 noted: \u0026ldquo;Different caregivers have varying levels of caregiving ability, and the information obtained during follow-up is not necessarily accurate.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Insufficient nurse theoretical knowledge and clinical experience (barrier). Participants acknowledged limitations in their own competencies. N2 stated: \u0026ldquo;When providing health education to patients, I can offer some information, but there remain areas where my teaching is inadequate.\u0026rdquo; N4 and N3 observed: \u0026ldquo;Most nurses in the ward are relatively junior and lack understanding of disease progression and subsequent changes in patient conditions.\u0026rdquo; N1 added: \u0026ldquo;Typically, the department chief or head nurse provides suggestions, as my own knowledge is limited in its ability to help patients.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u003cb\u003eSubtopic 20 Motivation\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Leadership support (facilitator). Participants highlighted institutional backing for discharge preparation services. N10 stated: \u0026ldquo;We really want to make hospital preparation services to benefit the patient and reduce his re-hospitalization, rather than doing it for scientific research.\u0026rdquo; N8 and N14 stated: \u0026ldquo;Our department director is quite supportive, and our department is already implementing similar initiatives.\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Potential for professional recognition and economic benefits (facilitator). Participants anticipated both symbolic and tangible rewards. N4 noted: \u0026ldquo;If patients are highly satisfied, they might present me with a banner of appreciation.\u0026rdquo; N9 and N14 noted: \u0026ldquo;Although readmission rates may decrease, when patients require hospitalization again, they will still choose our hospital. Moreover, other patients may seek care here after hearing about our quality services. With increased patient volume and workload, there may be enhanced economic benefits.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo ensure the rigor of intervention design and implementation, this study employed qualitative research prior to protocol implementation to explore barriers and facilitators across the four CFIR domains: Intervention Characteristics, Outer Setting, Inner Setting, and Individual Characteristics.\u003c/p\u003e \u003cp\u003eIn the Intervention Characteristics domain, our findings identified reliable evidence sources and applicability as key facilitators. Clinical nurses' willingness to adopt new interventions is contingent upon these factors, demonstrating that a robust evidence base is a critical driver of practice change. When translating research into clinical practice, investigators must prioritize the core concept of \"evidence-based practice,\" as credible, valid, and generalizable evidence forms the foundation for clinical decision-making (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Conversely, intervention complexity and increased costs emerged as significant barriers. Since the protocol was derived from evidence in high-quality domestic and international studies, some components may not align with local contexts. Indeed, participants noted that the protocol requires adaptation to real-world circumstances, underscoring the need for localized, individualized translation to ensure applicability across diverse clinical settings (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Increased complexity renders implementation processes cumbersome (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Focusing on core intervention components deemed essential for achieving better outcomes represents a potential strategy for simplification; designing well-supported clinical pathways or deconstructing complex interventions into more manageable components for stepwise adoption can also mitigate complexity (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Discharge preparation service implementation involves multiple steps and necessitates substantial human resource investment; insufficient staffing may compromise service accessibility and continuity. Optimizing workflows and rationalizing human resource allocation are therefore critical for successful implementation (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Beyond maximizing human resource utilization through competency-based training and rational scheduling, future research and practice should explore how technological tools or collaborative models can reduce complexity and costs. For example, utilizing mobile applications or virtual reality technologies to support discharge preparation could effectively address current human resource shortages (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the Outer Setting domain, external pressure emerged as a powerful facilitator. Within the CFIR framework, external pressure refers to driving forces originating from the external environment (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The competitive advantage that discharge preparation services would confer upon departments or hospitals demonstrates their strategic importance, offering potential for positive social impact and economic benefits over the long term. Local conditions, community attitudes, and absence of referral policies constituted important barriers. Insufficient caregiver understanding of patient conditions compromised follow-up data reliability, likely reflecting inadequate communication and education mechanisms. Additionally, transportation difficulties in remote areas and low public trust in community healthcare institutions limited service implementation (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). We therefore recommend strengthening capacity building within community healthcare facilities to enhance their role in managing elderly patients with multimorbidity, and improving caregiver health literacy through multiple channels (e.g., community outreach, online education). Comprehensive policy support can safeguard service implementation by reducing operational barriers (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e); thus, we urge relevant authorities to refine referral policies and clarify responsibilities and collaborative mechanisms across healthcare levels to facilitate effective discharge preparation for this population.\u003c/p\u003e \u003cp\u003eIn the Inner Setting domain, material resources represented a critical facilitator. Participants confirmed that departments possessed the necessary infrastructure, physical space, and equipment to support discharge preparation services. In contrast, incompatibility, inadequate incentive systems, and lack of collaboration emerged as major barriers. Participants perceived misalignment between the intervention protocol and existing workflows, consistent with findings from Beck et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This highlights the need to consider practical contexts during implementation to ensure protocol compatibility, while using education and communication to enhance healthcare professionals' acceptance of change and increase implementation engagement. Within CFIR, \"incentives\" encompass both tangible and intangible rewards (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In this study, participants noted the absence of billing codes for discharge preparation services, preventing revenue generation or enhanced individual performance metrics. Hospital administrators had yet to establish relevant incentive mechanisms, resulting in low engagement among healthcare professionals. We recommend establishing reasonable incentive systems to increase departmental revenue and individual performance, and to provide opportunities for external training and career advancement. Although multidisciplinary teams (MDTs) exist, fragmented communication and collaboration during implementation\u0026mdash;due to busy schedules, ambiguous role delineation, and lack of institutional oversight\u0026mdash;prevented teams from leveraging their full potential, aligning with findings from Li (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and Sarah (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Multidisciplinary collaboration is also constrained by resource limitations and time pressures, as effective teamwork requires adequate time, staffing, and material resources that may be scarce in clinical settings, potentially compromising implementation outcomes. Research indicates that team-based education helps MDT members value diverse perspectives and fosters mutual trust and respect (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e); such programs effectively cultivate positive learning and collaborative cultures within implementation teams (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). MDTs should therefore adopt a patient-centered approach, clarifying role division in assessment, discharge planning, and follow-up, while establishing mutual respect and clear communication strategies. Quality control groups should be formed to promote highly cooperative, efficient, and collaborative teams.\u003c/p\u003e \u003cp\u003eIn the Individual Characteristics domain, leadership support and intervention motivation were identified as important facilitators. Protocol implementation represents a \"top-down\" organizational behavior, with leadership, champions, and frontline nurses serving as critical links in the translation chain (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Leadership support and potential material or symbolic rewards constitute important implementation drivers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). We therefore recommend enhanced leadership engagement and support, using multiple incentive strategies to improve healthcare professionals' motivation. Poor patient compliance and insufficient capacity among caregivers and nurses emerged as critical barriers, potentially related to patients' cultural backgrounds, health beliefs, and service awareness. Personalized education and communication strategies are needed to improve patient adherence. While some caregivers lacked relevant care knowledge, nurses also demonstrated insufficient theoretical knowledge and practical experience. Caregiver support positively impacts patient health outcomes (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e); enhancing caregiver competency can improve patients' self-care capacity. This underscores the need for strengthened caregiver training, recognition of their pivotal role in clinical practice, and comprehensive patient education about disease management to foster understanding of discharge preparation services' importance and thereby gain support and cooperation (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Additionally, improving healthcare professionals' competencies is essential to ensure service quality and effectiveness. Our study indicates that training and education must incorporate robust evaluation and oversight mechanisms to better assess learning outcomes and consolidate discharge preparation knowledge and skills (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). A scoping review of 99 studies identified training, education, and feedback to providers as the most common strategies for improving compliance with new interventions (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo develop implementation strategies tailored to our local healthcare system, future work will consider mapping our CFIR-based findings to the Expert Recommendations for Implementing Change (ERIC). ERIC represents a well-established compilation of implementation strategies (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Using the CFIR-ERIC implementation strategy matching tool, the recommendations proposed in this study can be supplemented with additional implementation strategies (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Finally, implementation strategies can be refined and finalized through Delphi stakeholder consensus to facilitate the adoption of the discharge preparation service protocol.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. First, it employed the Consolidated Framework for Implementation Research (CFIR) as its theoretical framework, utilizing CFIR comprehensively across data collection, data analysis, and data interpretation. Second, the simultaneous inclusion of three core stakeholder groups\u0026mdash;patients, caregivers, and nurses\u0026mdash;enhanced the credibility and contextual richness of our findings.\u003c/p\u003e \u003cp\u003eNevertheless, several limitations must be acknowledged. First, the perspectives of other key stakeholders, such as physicians, were not captured, which may have constrained the diversity and richness of the data. Second, this study was conducted in a single tertiary hospital in China with a relatively small sample size, thereby limiting generalizability. Finally, as a pre-implementation study, it was unable to utilize the complete CFIR structure (i.e., the Implementation Process domain was excluded).\u003c/p\u003e \u003cp\u003eDespite these limitations, the findings hold significant implications for future research and clinical practice. We plan to implement the discharge preparation service protocol for elderly patients with multimorbidity and will use this study as baseline data to compare barriers and facilitators identified during and after implementation, thereby enhancing the sustainability and effectiveness of the protocol.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, this study employed the Consolidated Framework for Implementation Research (CFIR) to conduct a comprehensive, systematic analysis of barriers and facilitators to implementing a discharge preparation service protocol for elderly patients with multimorbidity across four domains: Intervention Characteristics, Individual Characteristics, Inner Setting, and Outer Setting. These influencing factors are multifaceted and complex. Therefore, identifying barriers and facilitators prior to implementation constitutes a critical success factor. Future research should focus on developing implementation strategies that address obstacles across different dimensions to enhance sustainability and adoption rates.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Ethics Committee of the Seventh Affiliated Hospital of Xinjiang Medical University (Approval No: 20250925-001). All procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki\u003csup\u003e(43)\u003c/sup\u003e. Written informed consent was obtained from all participants, including consent for publication of anonymized quotations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Health Commission of the Xinjiang Uygur Autonomous Region, \u0026ldquo;Tianshan Talents\u0026rdquo; Program for High-Level Talent Development in Medical and Healthcare, [TSYC202301A054], and the Xinjiang Uygur Autonomous Region Institute of Hospital Management, the Open Project Key Project, [No. YGYJ20250]. The funding bodies were not involved in the design of the study, the collection, analysis, and interpretation of data or the preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team consisted of four master\u0026apos;s-level nursing students, one dedicated senior nurse, and one associate professor. X.W., X.Y., S.S.D., J.H.L. and Y.J.F. designed the study. X.Y. and S.S.D. conducted the interviews. X.Y. and S.S.D. coded the data once transcribed and conducted the content analysis independently. Y.X.Y., J.H.L. and Y.J.F. prepared the manuscript. R.Z. and N.M. coordinated with department head nurses and organized regular project meetings. X.W. and P.Y oversaw overall implementation. All authors edited and reviewed the manuscript and approved the final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to all the participants who kindly gave us their time and shared their valuable insights.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSkou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, et al. Multimorbidity Nat Rev Dis Primers. 2022;8(1):48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAiney C, Markle-Reid M, Ganann R, Whitmore C, Valaitis R, Urajnik DJ, et al. Implementation of the Community Assets Supporting Transitions (CAST) transitional care intervention for older adults with multimorbidity and depressive symptoms: A qualitative descriptive study. PLoS ONE. 2022;17(8):e0271500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChatterji S, Byles J, Cutler D, Seeman T, Verdes E. 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Implement Sci. 2015;10:21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaltz TJ, Powell BJ, Fernandez ME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci. 2019;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical. Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Elderly, multimorbidity, discharge preparation services, Comprehensive framework for implementation research, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8688559/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8688559/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo explore barriers and facilitators to implementing a discharge preparation program for elderly patients with multimorbidity, and to inform improvements in this service.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe developed semi-structured interview guides based on the Consolidated Framework for Implementation Research (CFIR). Using purposive sampling, we recruited 18 medical staff from a tertiary hospital in Urumqi and conducted interviews with 6 patients and 6 caregivers from the same hospital's service population between November and December 2025. Data were analyzed deductively using CFIR as the coding framework. NVivo 15.0 was used for data management and analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe findings encompassed 20 constructs across the four CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals), identifying 11 facilitators, 14 barriers, and 2 neutral factors. Key implementation facilitators included a reliable evidence base, favorable environmental conditions and resources, multidisciplinary team establishment, and leadership support. Primary barriers comprised intervention complexity, increased labor costs, incomplete policies and models, lack of financial incentives, and poor compliance.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe implementation of discharge preparation services for elderly patients with multimorbidity is influenced by multiple factors. Developing targeted strategies to address identified barriers is essential for facilitating successful implementation.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to the Implementation of Discharge Preparation Services for Elderly Patients with Multimorbidity—A Qualitative Study Using the Consolidated Framework for Implementation Research (CFIR)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 10:48:28","doi":"10.21203/rs.3.rs-8688559/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-25T10:44:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-20T09:13:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T03:10:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T11:24:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69463449476613040503787746991148489562","date":"2026-02-09T01:14:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70145325387220772820800897192274555880","date":"2026-02-08T14:04:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150370087937403493593839598562065762610","date":"2026-02-06T13:41:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5551901643537761725959043580780653320","date":"2026-02-06T13:14:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-30T15:52:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-29T12:55:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T08:58:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-27T08:58:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-24T17:58:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d5d30837-360b-456a-ae17-5f1538b47fd4","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T22:53:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 10:48:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8688559","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8688559","identity":"rs-8688559","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}