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Barriers and facilitators to guideline-recommended care of benign paroxysmal positional vertigo in the ED: a qualitative study using the theoretical domains framework
  1. Sally Bradshaw1,2,3,
  2. Marnie Graco3,4,5,
  3. Anne Holland3,4,6
  1. 1 Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
  2. 2 School of Allied Health, La Trobe University, Bundoora Campus, Melbourne, Victoria, Australia
  3. 3 Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia
  4. 4 Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
  5. 5 Department of Physiotherapy, School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
  6. 6 Respiratory Research, Central Clinical School, Monash University, Melbourne, Victoria, Australia
  1. Correspondence to Ms Sally Bradshaw, Physiotherapy and Emergency departments, Alfred Health, Melbourne, VIC 3004, Australia; s.bradshaw{at}


Background Benign paroxysmal positional vertigo (BPPV) is a common presentation to the ED. Evidence suggests low adherence to guideline-recommended care, but the reasons underlying this are poorly understood. This study used the theoretical domains framework (TDF) to explore the barriers and facilitators to medical and physiotherapy clinical practices in the management of BPPV in an Australian metropolitan ED.

Methods From May to December 2021, semistructured interviews were conducted with 13 medical staff and 13 physiotherapists who worked at an ED in Melbourne, Australia. Interviews used the TDF to explore the perceived barriers and facilitators to the delivery of guideline-recommended assessment and treatment techniques for BPPV. Data were analysed thematically to identify relevant domains and generate themes and belief statements.

Results Fifteen belief statements representing eight domains of the TDF were identified as key factors in the management of BPPV in the ED. The most prominent domains were knowledge and skills due to their conflicting belief statements between professions concerning education, skill development and self-confidence; memory, attention and decision processes for the perceived complexity of the presentation including difficulty recalling diagnostic and treatment techniques; and environmental context and resources for their shared belief statements concerning time and workload pressures. The availability of vestibular physiotherapy was considered both a barrier and facilitator to the delivery of recommended care by medical staff, but a barrier to independent practice as it unintentionally limited the opportunities for skill development in medical staff.

Conclusion Several modifiable barriers and facilitators to the management of BPPV in the ED have been identified. Differences were observed between the professional groups, and these findings will guide a future intervention to improve the use of guideline-recommended assessment and treatment techniques for BPPV in ED.

  • qualitative research
  • clinical management
  • guideline
  • emergency department

Data availability statement

Data are available upon reasonable request. De-identified interview and coding framework data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request. De-identified interview and coding framework data are available upon reasonable request.

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  • Handling editor Aileen McCabe

  • Contributors The idea was conceived by SB, MG and AH. SB collected the data and prepared the manuscript. MG and AH provided considerable assistance in study design and analysis, and revised the manuscript. SB accepts full responsibility for the work, had access to the data and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.