Evaluating the Implementation of Strategies to Improve Evidence‐Based Surgical Care: A Focus Group Study

ABSTRACT

Aim

To evaluate healthcare professionals' perspectives on factors that lead to success in the implementation of strategies to strengthen evidence‐based surgical nursing care.

Design

A qualitative study design with focus group interviews, according to Krueger and Casey in a surgical department at a university hospital in Sweden.

Methods

Four focus groups were conducted with 18 participants, including specialist nurses in surgical care, registered nurses and assistant nurses. Data were collected in February–March 2024. A semi‐structured interview guide was used, and data were analysed using qualitative content analysis.

Results

Three themes with seven subthemes were developed to capture the evaluation of health care professionals' perspectives of the implementation strategies to strengthen evidence‐based surgical nursing care. The themes were (1) Roles and leadership, (2) Engagement in the implementation, and (3) Facilitators and barriers to implementation. The implementation has meant the transition from theory to practice and integrating new routines into the surgical department. It was a learning process where the health care professionals needed to familiarise themselves with new concepts and working methods. The positive outcome of the project and support from the nursing leadership were important facilitators in the implementation process.

Conclusions

The implementation of new ways of working was a complex process with both resistance and learning, but it ultimately led to positive changes in the surgical care environment.

Implications for the Profession and Impact

The project has entailed that specialist nurses in surgical care have increased nursing power in the department and extended responsibilities. Support from the head of the department and the management team has been crucial to being able to carry out the project, and the implementation of activities in small steps has been successful.

Reporting Method

Adhered to the SRQR guidelines.

Patient or Public Contribution

No patient or public contribution.

Summary.

• What does this paper contribute to the wider global clinical community?

  • ○
    The implementation of strategies to strengthen evidence‐based surgical nursing was a complex process, involving both resistance and learning outcomes, ultimately leading to positive changes in the surgical care environment.
  • ○
    The project has resulted in specialist nurses in surgical care achieving secure working conditions, increased nursing authority within the department and extended responsibilities, thereby strengthening evidence‐based surgical nursing.
  • ○
    Support from the head of the department and nursing leadership has been crucial for the implementation of the activities and the successful completion of the project.

1. Introduction

The implementation of evidence‐based surgical nursing interventions presents significant challenges, particularly when altering clinical routine practices to achieve excellence in surgical nursing in accordance with nursing core competencies. The context in which these interventions are performed appears to be crucial in relation to implementation science (Rogers et al. 2020). While nursing researchers are highly proficient at generating new evidence to inform healthcare, they are sometimes less effective at translating this new knowledge into clinical practice. Successful implementation of evidence‐based activities into practice is described as a function of the interplay of core elements: the nature of the evidence, the environment and the way the process is facilitated (Kitson et al. 1998).

2. Background

There is substantial evidence evaluating knowledge translation and implementation. The process of translating research‐based knowledge into practice appears to be challenging (May et al. 2016). In our focus group study, we aimed to explore healthcare professionals' perspectives on the implementation activities in a nursing project. Hospital settings are often complex and challenging for operationalising care processes. Despite organisations' ethical and professional responsibility to contribute to patient care, the organisation and the profession through new knowledge, innovations and improvements (American Nurses Credentialing Center 2020), complexity remains a significant barrier. Complexity is described as a component of the evidence and the resulting innovations (innovation complexity), the implementation processes for the integration of innovations (implementation complexity) and the characteristics of the clinical care environment (context complexity). Innovation complexity occurs when the desired practice change involves multiple steps, stakeholders and requires actions across groups within the specific organisation (Petticrew et al. 2013). The Promoting Action on Research Implementation in Health Services (PARIHS) theoretical framework guided this study. The framework conceptualises successful implementation into complex healthcare practice, which this study aims to achieve (Rycroft‐Malone 2004; Bergström et al. 2020).

The complexity encompasses the processes and interventions initiated to operationalise new knowledge into clinical practice. Existing practices, multidimensional professional relationships and diverse settings within an organisation contribute to this complexity (McCormack et al. 2002). Healthcare systems and organisations are previously known to be complex environments for knowledge translation. Local practice cultures, disciplinary norms, political influences and hierarchical structures add to this complexity (Novotná et al. 2012). All these factors may lead to incomplete implementation outcomes and a return to pre‐implementation behaviours in the clinical context, affecting the implementation process (Nilsen and Bernhardsson 2019).

Healthcare professionals' responses to change may be critical for facilitating the implementation of new organisational and workplace changes in healthcare. Due to the fast pace and high number of changes in the healthcare sector, where many healthcare professionals have negative experiences, it is important to consider the underlying influences on healthcare professionals' implementation intentions and behaviours (Nilsen and Bernhardsson 2019). In the framework of change responses, Coetsee (1999) describes seven different responses to organisational and workplace changes: aggressive resistance, active resistance, passive resistance, indifference, support, involvement and commitment. Change response is conceptualised as a tridimensional attitude composed of three components: cognitive, referring to opinions about changes; affective, referring to feelings about changes; and behavioural, referring to actions taken (Coetsee 1999). Changes initiated by healthcare professionals themselves or those featuring their active input are more likely to be met with indifference or passive resistance and thus more likely to be accepted. Another facilitator of successful change is when changes are well founded and well communicated (Nilsen et al. 2019).

A surgical department in a university hospital is a complex, multiprofessional care setting that requires collaboration between professionals and patients to achieve high‐quality and safe care. There is a significant risk that a focus on efficiency may negatively impact patient safety. Research and nursing professional codes highlight the importance of a more person‐centred approach (American Nurses Credentialing Center 2020). The fast pace of work and the high surgical patient flow in inpatient care can lead to unlicensed professional groups taking over tasks from licensed nursing professionals, which can predispose the organisation to unnecessary challenges. To ensure that patients receive high‐quality, safe surgical care, a project was initiated with various activities to ensure evidence‐based surgical nursing.

These activities are grounded in concepts that are closely linked to patient outcomes and nursing quality. Evidence‐based practice involves the integration of clinical expertise, patient values and the best scientific evidence in patient care. Person‐centred care focuses on the individual needs, values and preferences of patients, ensuring that care is tailored to each person, which can enhance patient participation and overall satisfaction. Evidence‐based surgical nursing is founded on the core competencies of nursing within this project. These core competencies encompass the skills, professional knowledge and abilities that nurses require to provide effective, safe and empathetic care to surgical patients in the health care team (Dogherty et al. 2010; Dolezel et al. 2021; Kitson et al. 1998).

The project was developed in line with current Swedish legislation, which emphasises person‐centred care and patient involvement (Sveriges riksdag 2014). The background to the project and interventions was a nurse exodus in recent years, leading to closed care beds and an increased number of temporary nurses. Assistant nurse competence has also decreased in the wards as many experienced assistant nurses have retired or chosen to leave for other reasons. Reduced competence among both nurses and assistant nurses has made it difficult to uphold ‘world‐class care’ with high patient safety, the goal of a university hospital. The project aimed to strengthen evidence‐based surgical nursing care in this setting.

3. The Study

3.1. Aim

This inductive focus group study aimed to evaluate healthcare professionals' perspectives on factors that lead to success in the implementation of strategies to strengthen evidence‐based surgical nursing care.

3.2. Research Question

Which strategies in the implementation process are related to facilitating and barriers in strengthening evidence‐based surgical nursing care?

4. Methods

4.1. Design

A qualitative study design with focus group interviews according to Krueger and Casey's (2015) practical guide for focus group practice was undertaken to obtain inductive rich data. The study was guided by The Standards for Reporting Qualitative Research (SRQR) (O'Brien et al. 2014).

4.2. Theoretical Framework

We used the Promoting Action on Research Implementation in Health Services (PARIHS) theoretical framework in this study. The framework conceptualises successful implementation into clinical/healthcare practice, which this study aims to achieve. The three core components of the framework—evidence, context and facilitation emphasise—the successful incorporation of research into clinical surgical practice. Evidence‐based nursing practice involves the integration of clinical expertise, patient values, the best scientific evidence and the practical implementation of these elements in patient care. The quality of evidence is not the only important factor; it is also about the clinical context in which the evidence is introduced and facilitated (Kitson et al. 1998; Rycroft‐Malone 2004; Bergström et al. 2020).

4.3. Study Setting and Recruitment

To elevate the quality of nursing care, strategies to strengthen evidence‐based surgical nursing in a university hospital setting were implemented, aiming to create an attractive work environment. This is in line with the concepts presented in the background. The clinic should be permeated by a person‐centred culture with person‐centred working methods, increasing the opportunity for collaboration in teams where everyone's skills are valued equally, as well as enhancing professional security and providing opportunities for personal development. The activities to strengthen person‐centred care, professional safety and development in the surgical nursing project were influenced by previous nursing evidence in line with Magnet Hospital standards (Wilson et al. 2015; American Nurses Credentialing Center 2020; Forsberg 2022; Forsberg 2024) (see Table 1). The activities included expanded continuous work to achieve quality goals, such as nursing quality indicators and team dialogue. The project leaders were two experienced nurses with PhD degrees, the first and last authors.

TABLE 1.

Evidence‐based surgical nursing: activities in the project related to person‐centred care, professional safety/development and teamwork.

Evidence‐based surgical nursing
	Person‐centred care	Teamwork	Professional safety/development
Specific activities	Head‐to‐toe assessment daily	Clarification of responsibilities between nurse and assistant nurse is implemented and can be used daily as a support in teamwork	Introduction programme for new nurses in the clinic based on the core competencies for new graduated nurses in their first year
	Nursing round (focus on person‐centred care and the patients' preferences and specific supportive care needs) as a routine at each ward, every week	Create meeting places for collaboration in teams at least once a month	Clinical coach/mentor programme for new graduated nurses in their first years
	Nursing/individual care plans for all complex patients, those who have been treated in the ICU or have been treated at the ward for > 5 days	Collaboration between different groups in the clinic. Healthcare professionals in both inpatient and outpatients and in different disciplines.	Supervision for newly graduated nurses, 2 h per month during the first 18 months
	Bedside rounds with a focus on the patient‐specific situation, with the entire care team in dialogue with the surgical patient (all professionals in the care team) daily	Specific allocated week with focus on nursing and the core competencies, for the entire clinic and team‐members, one week 2 times/year	Nursing Academy for the Clinic's Nurses to enhance evidence‐based nursing and professional discussion about research (e.g., journal clubs, presentations of important nursing surgical nursing topics) at least 5 times/year
	Bedside reporting between shifts to achieve safe and person‐centred handover between shifts daily	Time allocated and scheduled for ethical discussions with the whole team at least four times per year	Professional development and strategic planning days for specialist nurses 2 days/year
	Pedagogical conversations, what is important for the patient, increased awareness of the patient's preferences about their situation and wishes for their care. As a goal for all elderly and multi‐morbid patients but also for those who have been treated in the ICU or have been treated at the ward for > 5 days
	Patient‐responsible nurse in the form of specialist nurse in the clinical ward Monday–Friday. To ensure continuity and support the care team in complex supportive care needs.

The participants were selected through purposeful sampling (Krueger and Casey 2015) and included specialist nurses in surgical care (SNSCs), registered nurses (RNs) and assistant nurses (ANs) from one surgical department at a university hospital in Sweden.

4.4. Inclusion Criteria

The inclusion criteria required that participants had worked at the department during the project's implementation period and had more than 2 years of experience in surgical care.

4.5. Data Collection

Data were collected between February 2024 and April 2024 using a semi‐structured interview guide to encourage discussion (Krueger and Casey 2015). This guide was based on questions regarding the implementation of the project. Before initiating the focus group discussion, participants were informed about the study's aim and given a brief overview of the project's aims and goals. Participants were then asked demographic questions. The focus group discussion setup was guided by the principles outlined by Krueger and Casey (2015), and the interview guide included opening, introductory, transition, key and ending questions, as detailed in Table 2.

TABLE 2.

The interview‐guide.

Opening question	Role in implementation: Outline your responsibilities in the project
Introductory question	Experiences with activities: Describe your experiences with the project's activities
Transition and key questions	Opportunities and strengths: Discuss encountered opportunities and strengths
	Challenges: Highlight daily work challenges related to the project
	Facilitation of implementation: Suggest ways to ease activity implementation
	Person‐centred care: Identify key activities for person‐centred care and their impact on patient relationships
	Team collaboration: Describe improvements in team collaboration
	Professional security and development: Explain how the project enhances professional security and personal development
Ending questions	Key highlights: Point out the most important aspects of the project
	Additional insights: Mention any other important points

The opening question was intended to make participants feel comfortable and start talking. The interview session continued with an introductory question that included the experience of implementing the project. In the transition and key questions, participants were asked to reflect on the implementation of different activities to strengthen person‐centred care, team collaboration, professional safety and development. The final question asked participants to reflect on the discussion and mention the most important topic from everything they had discussed. Interviews were moderated by an experienced qualitative researcher (RN, PhD), the second author, who had no prior relationship with the participants in the study. During the interviews, the moderator took field notes and asked follow‐up questions such as, ‘Can you please tell me more about that?’ or ‘What do you mean?’ to encourage participants to elaborate on their stories and for clarification (Krueger and Casey 2015). The moderator's impression was that the activity in each group was lively, with participants sharing their experiences with each other in a supportive way. The first interview was conducted as a pilot focus group to test the interview guide and the roles of the moderator. A few changes were made to the interview guide after the pilot interview, such as changing the order of certain questions to facilitate the flow. However, no changes were made to the content or formulation of the questions in the interview guide. The pilot interview was later included in the analysis. The interviews were conducted in Swedish, audio‐recorded and transcribed verbatim. They took place in a conference room at the hospital and lasted between 67 and 79 min (mean 74 min). The transcripts included a data corpus of 180 pages.

4.6. Data Analysis

The data were analysed according to Krueger and Casey's (2015) description of analysing focus groups. The analysis started in connection with the first interview, with data collection and analysis occurring concurrently. All authors participated in the analysis, which began with listening to all the interviews and reading all transcripts to become familiar with the data. To address the aim and research question, the analysis process started with coding the transcribed text from all interviews. Similar codes were labelled and grouped into clusters. These codes and clusters were then categorised into different themes; an example of the analytical process is described in Table 3. Throughout the analysis, the authors continually returned to the study's purpose to ensure that themes and subcategories responded to the purpose of the study. The results were derived from the frequency of how often and how many participants mentioned a concept, how engaged the participants were in their responses, the level of detail revealed, and the similarity of participants' opinions in different answers. The authors worked on the coding process and categorisation individually at first and then together through joint discussion until consensus was reached (triangulation). The themes were then strengthened by quotations for transparency (Krueger and Casey 2015). The quotations in the results were translated verbatim from Swedish to English. No software tools were used in the analysis.

TABLE 3.

Example of analytical process.

Excerpt from unit of analysis	Open coding	Subcategory	Theme
I feel that each other's competence and area of responsibility have become clearer…and this clarity has made it easier to understand each other and facilitate collaboration	Clearer division of responsibilities	Positive outcomes	Facilitators and barriers to implementation

4.7. Ethical Consideration

The study was approved by the head of the department. International ethical guidelines were followed, and participation was voluntary. Oral and written informed consent was obtained before the focus group interviews started. Participants were informed that they could withdraw from the study at any time without providing reasons. Data presentation ensured the anonymity of participants in both the demographics and results sections. The study was conducted in accordance with the Declaration of Helsinki (2013). Ethical approval was not applied due to interviews with healthcare professionals, which did not involve actions applicable to the Ethical Review of Research Involving Humans (2003:460). No data, as defined in the General Data Protection Legislation (GDPR), were collected.

4.8. Rigour and Reflexivity

Lincoln and Guba's (1985) framework of trustworthiness in qualitative research was used. The credibility of the interview guide was assured through a pilot interview (Lincoln and Guba 1985). The interviewer, an experienced qualitative researcher with no prior relationship with the informants (completely neutral), conducted the interviews. The first and last authors, who have extensive clinical experience in surgical care and have facilitated several project activities, were not involved in data collection. All authors are experienced in qualitative research. To ensure the study's credibility, the analysis followed the method step by step, with the authors conducting the analysis by triangulation (Lincoln and Guba 1985). During the analysis, the authors aimed to view the text as objectively as possible (Krueger and Casey 2015). However, the first and last authors' deep pre‐understanding of the surgical department environment may have influenced the interpretations of the data. A higher level of data abstraction occurred during the reorganisation and re‐contextualization of the themes (Lindgren et al. 2020). Describing the analysis process and using quotations representing all participants strengthened the study's dependability. Transferability was established through a thorough description of the data collection and analysis procedure. Confirmability was strengthened by comparing the findings with previous studies and having the findings reviewed by all co‐authors through triangulation (Lincoln and Guba 1985). To protect the informants, there are no specific focus groups mentioned in the results/quotations, only professional affiliation.

5. Findings

Four focus groups were conducted, each with three to six participants. Two of the groups included specialist nurses, one group included registered nurses and one group included assistant nurses. The participants' characteristics are further described in Table 4.

TABLE 4.

Participants characteristics.

Participant characteristics	N = 18
Sex, female	16
Age, years in mean (range)	41 (30–64)
Healthcare profession
Specialist nurses in surgical care	9
Registered nurse	3
Assistant nurse	6
Year of professional work experience in mean (range)	15 (5–30)

In the focus‐group interviews, several findings related to better working conditions for the health care professionals in surgical care were identified. The implementation of the project and its included activities strengthened the transition from theory to practice, integrating new routines into the surgical department.

In total, three themes with seven corresponding subthemes were developed to capture the evaluation of healthcare professionals' perspectives on factors that lead to success in the implementation of strategies to strengthen evidence‐based surgical nursing care, Figure 1.

FIGURE 1.

Themes and subthemes.

5.1. Theme 1

Roles and leadership

5.1.1. View of Roles and Leadership in the Project

The participants in the study described that they had different roles, tasks and responsibilities in the project. Some of the SNSCs described that they were responsible for the implementation of the project and that they were the extended arm of the project leaders, while others described that they were involved in different parts of the project but had no overall responsibility.

After all, we have had the most responsibility for implementing the new working methods. We were provided with a lot of the theoretical background of the research, but we were given quite a lot of responsibility to try and put it into practice ourselves.(SNSC)

The SNSCs also acted as role models and conducted lessons and training activities during the project. The RNs participated in the design of certain activities and engaged in discussions. The ANs experienced a disadvantaged role in the project. Participants in all the different groups who were not directly involved in the implementation process expressed a sense of ambiguity about roles and responsibilities in the project.

But then and there, when this (project) was going to be launched, I don't think… there were so many people who felt that this…it was kind of a big deal and it was a bit unclear…what it was like, what roles they would have and even myself.(SNSC)

Often, it was the SNSCs who had to stand up for the project, even if they were not the ones responsible for the entire project. Everyone in the project management team were experienced SNSCs, which meant that not everyone felt involved in the project. However, it was the SNSCs who had the knowledge in implementation, improvement work and evidence‐based care, which was a prerequisite for managing the implementation of such an extensive project.

I think that the specialist nurses are the ones who keep up with all these activities. They have more knowledge in implementation, improvement work, and evidence‐based practices.(RN)

5.1.2. Learning Process and Togethership

It was a learning process where the health care professionals needed to familiarise themselves with new concepts and working methods. The positive outcome of the project, as well as support from the nursing leadership, were important facilitators in the implementation process. Unclear goals, lack of communication and negative attitudes were threats to successful implementation. During the learning process of implementation, the SNSCs emphasised the importance of strengthening the team, creating a better environment for person‐centred care and fostering a sense of ‘we’ to learn, develop together and achieve the goals. The implementation took time, and in the beginning, it was a downhill slope that later became an acceptance of a clear way of working.

It was a tough period because there was a bit of a bad atmosphere. But I think we came out of it with a lot…it led to something really good in the end.(SNSC)

5.2. Theme 2

Engagement in the implementation

5.2.1. To Get Everyone Involved

Introducing new working methods was challenging, especially for experienced healthcare professionals who already had established routines. However, some activities related to person‐centred care were easier to introduce when the employees had more work experience.

By talking more with the patient and focusing on person‐centered care, it turns out that the patient can teach us a lot too. By explaining why we look at certain things, they can question more about their body and their care…Patients are very different, some are very questioning, and some are more like ‘I trust you’. So, it's important to empower them to understand why things are the way they are and to be able to question that.(SNSC)

Some lectures before the start of the project were perceived as degrading, creating a feeling that the ANs were not as valuable as the RNs. There was also a perception that the project's main focus was solely on the RNs. The experienced ANs have contributed significantly to the department during a long‐term nursing shortage, which makes them feel forgotten when the project focuses only on the RNs. They experienced that the project led to a deteriorated work environment and increased gaps between RNs and ANs. The experienced ANs felt that the new routines did not contribute to their development and that the new employees did not receive enough support to become independent.

We were extremely slowed down when this project started because there was a big focus on the role of the nurse and their responsibilities.(AN)

5.2.2. Experience of Unclear Aim and Goal of the Project

At the beginning of the implementation, it was difficult to perceive the project as a cohesive whole; rather, it was viewed as a series of activities that needed to be implemented. The project has had different focuses and names throughout its journey, making the transition from theory to practice challenging. Additionally, concretising and conveying the project's vision and goals to the entire group of professionals was difficult.

Where the project came from didn't really reach everyone in the wards. I felt there was some talk like, ‘What have the specialist nurses come up with now?’ Although it wasn't really our project from the beginning, we were just implementation leaders, it seemed to me that they thought this was something we had invented and wanted to introduce. So, understanding the foundation of the project, why we are doing this, where it comes from, what the goals are, and why we are making all these changes and efforts, was crucial.(SNSC)

Lack of understanding of the project's purpose led to confusion and frustration. The RNs emphasised the importance of having a clear rationale for new working methods; otherwise, these methods were perceived as burdensome. Similarly, those who experienced well‐functioning working methods before the project found it difficult to understand the purpose of implementing certain activities. Some participants, particularly the ANs, found the implementation to be unsuccessful and unclear. Discussions and defences of the new working methods aimed at increasing patient safety and improving the work environment were common during the process. These discussions sometimes led to a negative atmosphere and a lack of engagement within the working group.

Because it was never communicated that this implementation idea was being developed, we only understood that we were going to a training or…some attractive workplace. It wasn't clearly explained. No one had forewarned us that this would start. There was no clear basis for what would be done.(AN)

5.3. Theme 3

Facilitators and barriers to implementation

5.3.1. Positive Outcomes

The positive outcome of the project facilitated its implementation, and the participants experienced that the project clarified evidence‐based nursing at the surgical department. It provided an opportunity to structure working methods that already existed but had not been successfully implemented before. The participants noted that activities aimed at achieving person‐centred care could contribute to both increased quality of care and patient safety, becoming a driving force to advance the project activities. The project activities made it clearer how to manage the team and ensured that the right person was performing the right task.

I feel that each other's competence and area of responsibility have become clearer…and this clarity has made it easier to understand each other and facilitate collaboration. I feel that I have a responsibility within the team of the day. Now I feel less pressure to do things that the assistant nurse can do. It has simply become easier to manage work.(SNSC)

Nursing rounds have been implemented and are working well, while some activities in the project need further implementation to function effectively. Several activities conducted resulted in positive outcomes for both the patients and team collaboration.

I believe that team cooperation has significantly improved, particularly due to the nursing rounds, which are distinctly team‐based activities, and the nursing week. During the last nursing week, we even focused on team collaboration as a theme, which has greatly enhanced team dynamics. (SNSC)

The implementation of the induction programme for newly graduated nurses was seen as successful and easy to implement. The introduction programme was perceived to reduce stress and stimulate safety by providing structured support, allowing newly graduated nurses to acclimate to their roles. A customised induction programme will also be introduced for ANs.

The introductory program has worked very well. I haven't spoken to everyone, but most of them seem very happy that they are getting a good start in the department. Many come as recent graduates, and they are a bit scared. They get to start working, and it feels safer when they receive such a good introduction.(RN)

The work environment has improved significantly for the SNSCs during the project, as they have been recognised and rewarded by the management. They have had time to work together as a group, and their skills have been used effectively. Similarly, the RNs describe an improved work environment, even if it was not solely due to the project. Although not all activities have been successful, the participants believe that it is a positive sign that the management at the surgical department has made this significant investment in implementing evidence‐based nursing.

So N.N (the head of the department) is likely the one who initiated this from the beginning. She explicitly addressed the professionals, stating: ‘We will do what is best for you’, which made us feel prioritized. She emphasized that everyone would have the opportunity to attend training courses, regardless of the cost. Everyone should be allowed to participate in various activities, including specialist training if desired.(RN)

5.3.2. Nursing Leadership and Evidence‐Based Nursing

An important facilitating factor in the implementation was the nursing leadership and support from the head of the department. Their prioritisation and defence of the project were crucial benefits in the process. The project has more clearly defined the nursing structure at the clinic, and it is encouraging that evidence‐based nursing is highlighted as a priority. Time was allocated for the project managers and the SNSCs to work on the project.

Now that they have switched to a clearer nursing management structure, there is a good organization at the clinic. The time we have spent in the group of nurse specialists has helped the implementation and the project move forward.(SNSC)

Education and participation in courses and conferences have been prioritised to a greater extent, which is appreciated by the participants and motivates them to continue working with evidence‐based nursing. Likewise, engaged specialist nurses in surgical nursing were an inspiration for the RNs and served as a driving force for the implementation of evidence‐based nursing.

We have committed specialist nurses who are proactive and don't just sit on their hands and say yes. They are actively seeking out opportunities and are a truly committed group.(RN)

The project also led to a discussion about what nursing is and clarified the differences between basic nursing and specific nursing. The RNs described that the implementation of activities went very quickly at the beginning, making it difficult to keep up. Activities that involved fewer people, such as introducing nursing rounds, were easier to implement. Another key experience was the importance of making new routines visible and concrete to facilitate implementation.

If we look at implementing ‘head‐to‐toe’ for all nurses in both wards, then maybe we are talking about 50 or 60 people. I have no idea, but it is a much more difficult implementation. Nursing rounds were a huge effort…We just needed time, and as long as we had time, it was really easy to implement. It's the same time every week…It's an easy thing, and it's always easier to implement things in small groups. (SNSC)

Committed nursing leadership that led the SNSCs and believed in them was a benefit in the implementation. At the same time, the project leader was sometimes perceived to be far removed from bedside nursing. Role models and individuals in the wards who functioned as facilitators were crucial for getting the activities implemented. The experience also indicated that some activities required more support than others to continue functioning.

5.3.3. Implementation Barriers

To succeed with the implementation, the project's activities needed to be adapted to the current routines in the wards. Regular communication with employees about the project has been challenging in a workplace where many employees work irregularly. During the implementation of the project, other activities at the department had to take a back seat, as it was not possible to implement too much at once.

And I actually have to say that about this project, even though these are great activities, it took a lot of focus away from other things that were already implemented and from focus areas that we've been working on and were almost ready to implement.(SNSC)

Ambiguities in the project, such as unclear roles and goals, affected participants' attitudes and behaviours. A negative attitude toward the project posed a challenge that adversely impacted its implementation.

But I know there were some discussions. Some professionals weren't very happy, they weren't…and it affected the implementation itself that because some were very negative. (RN)

The project introduced increased structure in evidence‐based nursing, which meant that there was less freedom to continue working as before. This led to ANs feeling that they could not develop in their roles as they had previously. Another threat during the implementation was the personal characteristics of professionals who did not like the activities.

You are questioned, and I sometimes think that your development is a bit hindered because we have pointed out, for example, the placement of a peripheral venous catheter. It would have made things easier.(AN)

6. Discussion

This inductive focus group study aimed to evaluate healthcare professionals' perspectives on factors that lead to success in the implementation of strategies to strengthen evidence‐based surgical nursing care. Based on our findings, the clinical experience in the research group, and the literature, we have suggested various strategies for healthcare professionals to facilitate implementation.

The transition from our theoretical frameworks PARIHS to practical applications in the surgical department represents a significant shift in healthcare practice. This implementation process required healthcare professionals to adapt to new routines and methodologies, which were facilitated by positive project outcomes and robust support from nursing leadership. However, the process was not without challenges, including unclear goals, communication barriers and negative attitudes, which posed threats to successful implementation. This is shown in the result of the last theme on barriers.

In the project, we notice strategies to address barriers and facilitators. We convened facilitators and stakeholder representatives from the department and continuously discussed the baseline results in contrast to our visionary clinical goals. The three core components in PARIHS were covered: the identification of barriers and facilitators. To minimise barriers and enable facilitators, we perform small steps forward (micro‐level implementation strategy) to better support a successful implementation strategy in accordance with recommendations (Moullin et al. 2020; Freitas de Mello et al. 2024). The strategy included continuous reminders, active dialogue with the management team and interdisciplinary education, meetings, monitoring of the project and feedback.

The findings from the implementation process underscore the pivotal role of clear communication, well‐defined goals and positive attitudes in achieving successful outcomes. Initial resistance and challenges gradually transitioned to acceptance and the integration of new practices, exemplifying the dynamic nature of change management within healthcare settings. Effective communication within the team and between healthcare professionals and patients is acknowledged as a core clinical skill of significant importance (Macdonald‐Wicks and Levett‐Jones 2012). The experience of unclear roles and responsibilities in the project, along with a lack of understanding of the purpose, could be a result of the challenges in moving from theory to practice. A study of Karlsson et al. (2019) showed that bedside nurses had difficulties understanding the concept of evidence‐based nursing and viewed it as an academic concept used in nursing schools but not in practice. This perception may hinder the implementation of new research findings in nursing (Karlsson et al. 2019).

The project's positive outcomes, particularly in clarifying evidence‐based surgical nursing, served as significant facilitators. These outcomes helped structure existing working methods and contributed to improved quality of care and patient safety, driving the project forward. The successful implementation of nursing rounds and introduction programmes for new nurses were notable achievements, although some activities required further refinement.

Previous studies have addressed factors that enhance nurses' clinical competence and improve patient outcomes, similar to our results. They highlight the importance of interventions aimed at promoting supportive work environments, continuous education and the development of critical thinking skills among nurses to optimise their clinical competencies (Almarwani and Alzahrani 2023). We observed similar positive effects during our project and in our findings, where all activities encompassed both development and professional pride in conducting evidence‐based nursing for the best interests of the patients in focus. Positive nursing outcomes were a driving force to continue the project even though the implementation process was a roller coaster and not always an easy task. The meaning of work is an important driving force for specialist nurses to remain within the surgical departments (Drott et al. 2023). Positive outcomes in the current project increased the feeling of meaningful work.

The theoretical framework PARIHS used in our study enabled a comprehensive assessment of our current implementation strategies, and we continuously identified key gaps and tailored our targeted improvements. PARIHS could also be used in future implementation activities; however, further clarification of our facilitation processes would improve the theoretical framework's utility in clinical practice. Our project activities were effectively integrated into surgical clinical practice through a careful implementation strategy, utilising our available resources. The high‐level competence of the nurses improved the quality of the results of the project. However, it is of importance that these positive results can be maintained over time, and long‐term evaluations are needed to verify this. Previous evidence shows that deficits in hospital care quality and competence an common international challenges. Improvement of hospital work environments can be an economic strategy to improve safety and quality in hospital care and to increase patient and nurses' satisfaction (Aiken et al. 2012).

The study underscored the importance of nursing leadership in fostering an environment conducive to evidence‐based practices. The leadership's willingness to invest in such a significant project was seen as a positive and progressive step. Pragmatic solutions for evidence‐based practice have been shown in previous evidence‐building and successful sustainability within organisations, with frontline nurse feedback, commitment and partnership with nursing leaders playing crucial roles (Crawford et al. 2023). Our findings align with the result from Mathew et al. (2024), which stated that evidence‐based practice is a hallmark of nursing excellence, but its implementation is a complex and challenging process. Leadership is essential in the implementation of evidence‐based practice to facilitate necessary resources and time to complete the process. A recently published study has demonstrated that focusing on nurses' strengths is crucial for nurse managers to understand their individual competencies and allocate tasks accordingly. Support and empowerment reduce time pressure among highly qualified nurses but may also increase it among less qualified ones (Chang et al. 2025). Evidence‐based practice cannot become a reality without leaders being engaged, supportive and persistent (Mathew et al. 2024). The SNSCs stated that having time to work on the project was crucial for making progress in the implementation. They also appreciated that the head of the department supported and defended the project. They described a better work environment, where their role was supported by nursing leaders, and they were given time to work together in their group and with the project. The surgical units at the hospital need to reflect on how to utilise the competence of specialist nurses in surgical care and how nursing leaders can support them in their roles (Jakobsson et al. 2023; Drott et al. 2023).

The improved work environment for RNs attributed to the project indicates that well‐structured implementation processes can lead to enhanced job satisfaction and professional development. Our findings agree with evidence‐based practice models and research from Magnet‐designated hospitals, where engaged and educated nurses who enculturate, support and sustain evidence‐based practices facilitate advancing nursing practice. Furthermore, it improved patient care and safety, better work environment‐related outcomes and cost‐effectiveness (Speroni et al. 2020; Griffiths et al. 2023).

Negative attitudes significantly impacted the implementation process (interpreted as barriers) in several ways. Negative attitudes and a lack of effective communication led to misunderstandings and unclear expectations, further complicating the implementation. The presence of negative attitudes affected team morale. When some members were not supportive or enthusiastic about the changes, it created a less collaborative and more stressful working environment. This lack of engagement hindered the overall effectiveness of the implementation and delayed the achievement of project goals. Nilsen et al. (2019) describe that positive attitudes toward change are more likely if healthcare professionals themselves initiate the changes. (Nilsen et al. 2019). The studied project was initiated by the department manager, and the purpose was initially unclear, which may have affected the employees' attitudes. Addressing these negative attitudes through clear communication, supportive leadership and demonstrating the benefits of the new practices was crucial in overcoming these challenges and ensuring the project's successful implementation.

Communication and attitudes in the healthcare team that respect and meet patients' and relatives' supportive care needs are essential in promoting positive care outcomes and quality of care; therefore, a significant component to achieve person‐centred care. Achieving person‐centred care and healthy communication in clinical interactions is complex and can be environmental/context and personal/behavioural due to barriers (Kwame and Petrucka 2021).

Our implementation strategy focuses on the localised execution of the broader plan and our goals with evidence‐based surgical nursing. We emphasise specific actions within the project, the allocation of resources and the necessary adjustments at various levels to ensure effective implementation. We observed that some actions were executed too quickly, jeopardising broad‐based participation. Involving a wide range of stakeholders in the planning process ensures diverse perspectives. However, this approach requires a careful balance of time, as excessive resistance can hinder progress. Empowered local leaders and teams make decisions that best fit their unique contexts, which are considered a strength in the implementation process.

The project's success in integrating evidence‐based nursing practices within the surgical department underscores the importance of strategic leadership, clear communication and positive reinforcement. While challenges such as role ambiguity and initial resistance were significant, the overall positive outcomes and improved work environment highlight the potential for similar projects to enhance healthcare delivery and professional development. A successful way to achieve professional development is by adopting a goal‐driven environment where leadership and the organisation actively work to achieve goals together. Quality indicators and feedback from surgical patients in various forms may increase efficiency and focus on value‐creating surgical care. This approach has also been shown in previous studies to be valuable for implementation in hospitals (Van Staalduinen et al. 2022; Aiken et al. 2014).

The implications of our findings include improved surgical care, contributing to a more robust and efficient surgical care environment. The project's success highlights the importance of management support and a phased implementation strategy, which can serve as a model for similar initiatives in other departments or institutions. Ensuring strong backing from leadership is crucial for the success of new initiatives, and adopting a step‐by‐step approach can help manage resistance and facilitate smoother transitions. Providing opportunities for nurses to expand their roles can lead to increased job satisfaction and better surgical patient care.

6.1. Strengths and Limitations

The study has strengths. First, the study effectively demonstrated the transition from theory to practice, integrating new routines and concepts into the surgical department and leading to tangible improvements in the clinical surgical care environment. The positive outcomes were significantly facilitated by strong support from nursing leadership, highlighting the importance of management in successful implementation. Our use of a qualitative design provided in‐depth insights into the implementation process and its impact on person‐centred care and professional development. Our approach from the beginning was to include SNSC, RN and AN to ensure diverse perspectives. However, the sample is heavily skewed toward specialist nurses, and this may bias the findings toward the SNSCs' experiences. RNs and ANs who participated in the interviews were the minority, and a larger proportion of them could have affected the findings in different directions. At the time of the recruitment process, a shortage of RNs and ANs in the department was a fact and influenced the sampling process. The shortage of experienced ANs who were available to recruit according to the inclusion criteria was limited. The results may be influenced by the SNSCs' experiences, especially since they have higher academic education in nursing and experience in conducting evidence‐based care. Additionally, there is a limitation with the gender distribution in the interviews, as more male participants would have been preferable. However, the number of men is limited, reflecting the sex distribution in nursing professions at the clinic. Another challenge was that the project was initiated during the COVID‐19 pandemic, which made it challenging for the project manager to allocate time. However, the shortage of RNs at that time was serious and threatened patient safety, which meant that the department chose to start the project despite the unsuitable conditions related to staffing and the pandemic.

6.2. Further Research

This study evaluates healthcare professionals' experiences of the implementation, serving as an initial step in assessing the project. However, this timeframe may not capture long‐term perspectives. Therefore, further research with extended follow‐up and longitudinal studies is necessary to understand the sustained impact of person‐centred care and professional development initiatives on patient outcomes, experiences and healthcare professionals' satisfaction. Comparing the implementation processes and outcomes across different surgical departments and hospitals to identify best practices and common challenges will be valuable. Additionally, investigating ways to refine and optimise the implementation strategies to enhance their effectiveness and efficiency in various surgical clinical settings is recommended.

7. Conclusions

The implementation of new working methods in the surgical care environment was a complex process marked by both resistance and learning. However, it ultimately led to significant positive changes. The project notably enhanced the security and confidence of specialist nurses in their work conditions, increased the nursing capacity within the department, and expanded their responsibilities. Crucially, the support and time provided by the head of the department and the management team were instrumental in the project's success. The step‐by‐step implementation approach proved effective. Novel contributions included specialist nurses feeling more secure and confident in their roles, the department seeing a boost in nursing power, and the nurses taking extended responsibilities, enriching their roles.

Author Contributions

Karolina Härle: conceptualisation, data curation, data analysis, methodology, visualisation, writing – original draft, writing – review and editing. Carina Wennerholm: data collection, data curation, data analysis, methodology, visualisation, writing – original draft, writing – review and editing. Jenny Drott: conceptualisation, data curation, data analysis, methodology, visualisation, writing – original draft, writing – review and editing.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data in this paper cannot be shared publicly to protect the privacy of the professionals who participated in the study. The qualitative nature of the experiences is personal, and removing identifying information from individual transcripts may still breach confidentiality.