Factors influencing best-practice guideline implementation: lessons learned from administrators, nursing staff, and...

Clinical practice guidelines are promising tools for closing the research evidence-practice gap, yet effective and timely implementation of guidelines into practice remains fragmented and inconsistent. Factors influencing effective guideline implementation remain poorly understood, particularly in nursing. A sound understanding of barriers and facilitators is critical for development of effective and targeted guideline implementation strategies.

This paper reports the perceptions of administrators, staff, and project leaders about factors influencing implementation of nursing best practice guidelines.

Twenty-two organizations, in clusters of two to five, implemented one of seven guidelines in acute, community and long-term care settings. The topics were client centered care, crisis intervention, healthy adolescent development, pain assessment, pressure ulcers, supporting and strengthening families and therapeutic relationships. Fifty-nine administrators, 58 staff and 8 project leaders participated in post implementation semi-structured telephone interviews. Qualitative thematic analysis was conducted.

Factors at individual, organizational and environmental levels were identified as influencing guideline implementation. Facilitators included learning about the guideline through group interaction, positive staff attitudes and beliefs, leadership support, champions, teamwork and collaboration, professional association support, and inter-organizational collaboration and networks. Barriers included negative staff attitudes and beliefs, limited integration of guideline recommendations into organizational structures and processes, time and resource constraints, and organizational and system level change. Similarities and differences in perceptions of these factors were found among staff, project leaders and administrators.

Best practice guideline implementation strategies should address barriers related to the individual practitioner, social context, and organizational and environmental context, and should be tailored to different groups of stakeholders (i.e., nursing staff, project leaders and administrators). Health care administrators need to recognize the "real" costs and complexity associated with successful implementation of guidelines and the need to ensure corporate commitment at the onset.