OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n = 1300) and DONs (n = 1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.