Facilitators of and barriers to the clinical implementation of evidence-based nursing guidelines based on the Consolidated Framework for Implementation Research: A multisite survey

Abstract

Objective

This study aimed to explore the facilitators of and barriers to the clinical translation of evidence-based nursing guidelines.

Methods

A convergent mixed-methods study design. First, 206 nurses from 12 hospitals were selected as study participants, and the Chinese version of the Organizational Readiness to Change Assessment (ORCA) scale was administered to assess the current readiness for guideline implementation. Subsequently, for the qualitative study, purposive sampling was used to select 15 nurses from the quantitative study sample for semistructured interviews. The framework analysis method was applied to code the transcribed texts using the Consolidated Framework for Implementation Research (CFIR), and thematic analysis was employed to identify facilitators and barriers to guideline implementation. Finally, all facilitating and barrier factors were systematically synthesized, and implementation strategies were matched using the Consolidated Framework for Implementation Research–Expert Recommendations for Implementing Change (CFIR–ERIC) tool.

Results

The organizational change readiness score was moderate-to-high (248.77 ± 33.35). The quantitative study identified 25 facilitating factors (such as the scientific rigor of guideline implementation and a positive departmental culture) and 16 barriers (including insufficient resources to address patient awareness or needs and inadequate communication among team members). The qualitative study identified 25 facilitating factors (such as high self-efficacy in evidence-based practice and leadership support) and 11 barriers (such as implementation complexity and resource constraints). From a mixed-methods analysis, the top three barriers were identified as a lack of incentives, insufficient resources, and interdepartmental communication barriers. Based on the CFIR-ERIC mapping, implementation recommendations targeting the main barriers were identified, including tailoring implementation strategies, modifying incentive mechanisms or compensation structures, and establishing communication networks among team members.

Conclusion

This study systematically revealed, through a mixed-methods approach, the current status of nurses’ readiness to participate in guideline implementation in China, as well as the facilitating factors and barriers. In the future, targeted strategies should be developed based on the identified barriers to promote the sustained implementation of guidelines.

What is known?

• •Evidence-based nursing can guide nurses at the theoretical level to attach importance to clinical practice guidelines for diseases, thereby optimizing nursing and having important implications for evidence-based nursing practices.
• •Previous studies have shown that the most common obstacles to implementing guidelines are the lack of education and training, overly simplistic wording of the recommendations in guidelines, and differences among guidelines regarding the same topic.
• •The current evidence mainly originates from single-method designs. Still, it fails to extract and identify fully the factors that promote and hinder the application of evidence-based nursing guidelines in China.

What is new?

• •The assessment of organizational change readiness is crucial for guideline implementation. This study used the Chinese version of the Organizational Change Readiness Assessment Scale to investigate the facilitators and barriers to guideline implementation.
• •This study adopted a convergent mixed research design to explore the facilitators of and barriers to the implementation of evidence-based nursing guidelines.
• •The mixed-methods research demonstrates concordance between quantitative surveys and qualitative experiences, providing evidence for formulating targeted implementation strategies for the future.

1. Introduction

Clinical practice guidelines (CPGs) serve as the primary vehicle for translating high-quality research evidence into clinical practice, aiming to standardize care, reduce unwarranted variation, and optimize patient outcomes [1]—the vitality of CPGs lies in their implementation. Whether a large number of published guidelines can play a major role in clinical practice and achieve sufficient value depends on the actual application of their recommendations [2]. However, their development and publication do not guarantee their uptake. Translating evidence into practice is a complex process. Previous study has identified numerous isolated factors influencing guideline adoption. Such factors include the lack of financial resources, insufficient staff training, or poor organizational support [3]. A comprehensive understanding of multilevel facilitators and barriers within specific clinical contexts is urgently needed to systematically break the bottleneck of guideline implementation.

The Registered Nurses’ Association of Ontario (RNAO) is globally recognized for developing evidence-based best practice guidelines (BPGs) [4]. The RNAO launched the Best Practice Spotlight Organization® (BPSO®) designation to facilitate the systematic uptake and sustainability of guidelines. The BPSO® initiative is a dynamic partnership wherein healthcare organizations formally commit to implementing and evaluating multiple BPGs through a rigorous, multiyear capacity-building process [5]. In China, evidence-based nursing (EBN) has advanced rapidly, with several leading Class A tertiary hospitals successfully achieving BPSO® designation. Each hospital selects and implements different BPGs for clinical practice according to its specific context, with the aim of improving patient outcomes. The most commonly adopted guidelines include Transitions in Care and Services, People-Centred Care, Facilitating Client-Centred Learning, Pain: Prevention, Assessment and Management, and Preventing Falls and Reducing Injury from Falls. However, despite the structured support and resources inherent in the BPSO® Model, our clinical observations across eight Chinese BPSO®-designated hospitals revealed remarkable variations in implementation fidelity and sustainability. Furthermore, when incorporating perspectives from non-BPSO® institutions that have also attempted to implement guidelines, a critical consensus emerged: merely possessing high-quality guidelines, or even a formal institutional mandate, does not guarantee successful clinical integration [6]. This reality underscores that systematically identifying the complex, context-specific factors influencing implementation is a practical prerequisite for advancing EBN within and outside the BPSO® network.

Evaluating organizational readiness for change (ORC) is essential before introducing complex interventions, like clinical guidelines. ORC reflects the collective resolve and capacity of organizational members to implement change, serving as a critical predictor of implementation success [7]. An overarching theoretical framework is required to assess readiness and its determinants rigorously. The Consolidated Framework for Implementation Research (CFIR) is one of the most widely recognized determinant frameworks in implementation science, comprising multiple domains that interact to influence implementation effectiveness [8]. Notably, each survey item of the Organizational Readiness to Change Assessment (ORCA) scale maps perfectly onto CFIR constructs, providing a robust quantitative tool for baseline evaluation [9]. Under the guidance of the CFIR, interview guides relevant to the implementation context can be developed using the CFIR’s interview guide tools. Qualitative data are collected through semistructured interviews, and the CFIR is subsequently used for analysis [10]. Using a convergent mixed-methods research design, we employed questionnaires and semistructured interviews to identify factors that promote and hinder the application of evidence-based nursing guidelines in China.

Furthermore, merely identifying barriers is insufficient for driving change. The CFIR–Expert Recommendations for Implementing Change (ERIC) matching tool enables researchers to systematically translate identified CFIR-based barriers into targeted, actionable implementation strategies [11]. Ultimately, by mapping these determinants onto the CFIR–ERIC compilation, we provide a tailored blueprint of implementation strategies to bridge the evidence-to-practice gap in Chinese healthcare settings.

2. Methods

This study employed a convergent mixed-methods design [12] to explore the facilitators and barriers to the implementation of clinical guidelines.

2.1. Quantitative research

2.1.1. Study design and participants

This cross-sectional study adhered to the guidelines of Strengthening the Reporting of Observational Studies in Epidemiology [13]. From June to December 2024, using convenience sampling, the study recruited nursing managers and clinical nurses involved in implementing the guidelines from the nursing departments and clinical wards of 12 Class A tertiary hospitals across Beijing, Gansu, Henan, Guangdong, Xinjiang, Ningxia, and Guizhou. These include 8 hospitals accredited by the BPSO®. Inclusion criteria were as follows: nursing managers and clinical nurses participating in guideline implementation throughout the hospital. The guidelines included were limited to nursing-related interventions. Exclusion criteria were as follows: non-hospital nurses working in the hospital (such as visiting nurses) and nurses who were not working in the hospital for various reasons during the investigation period (such as leaving for further studies and going on sick or personal leave).

2.1.2. Sample size calculation

Kendall’s sample size estimation method states that the number of observations should be at least 5 to 10 times the number of variables [14]. This study included 12 general data variables and three variables related to the three dimensions of evidence, context, and promoting factors, for a total of 15 variables. Therefore, the theoretical sample size of this study is approximately 150 cases. Given a 10 % sample loss rate, this study determined that at least 167 research participants must be included.

2.1.3. Measures

ORCA was developed in 2009 by Professor Helfrich and colleagues in the United States, based on the Promoting Action on Research Implementation in Health Services model [9]. The English version of the scale comprises 77 items, including three main scales and 19 subscales. The three main scales are evidence, context, and facilitators, comprising four, six, and nine subscales, respectively. The scale was adapted into Chinese by the Chinese scholar Qin [15]. Item selection was based on classical test theory by using the item–total correlation coefficient (r ≥ 0.4) and the critical ratio (CR ≥ 3.0) as criteria, resulting in the removal of items 1, 2, 7, and 11, leaving 73 items. The Cronbach’s α coefficient for the Chinese version of the ORCA scale is 0.915, with the evidence, context, and facilitator dimensions having Cronbach’s α coefficients of 0.973, 0.990, and 0.992, respectively. The scale has good content validity, with an S-CVI of 0.831 and an I-CVI of 0.857-1.000.

2.1.4. Data collection and quality control

All quantitative data were collected through an online survey platform. Before questionnaire distribution, anonymous surveys were conducted after participants were informed and signed informed consent forms. Research participants were strictly selected for the survey in accordance with inclusion and exclusion standards. Electronic questionnaires were distributed through Wenjuanxing. The purpose of this research was stated at the beginning of the questionnaire. All questions were compulsory, and each IP address could answer only once.

2.1.5. Data analysis

Quantitative studies were analyzed using SPSS 26.0. The count data were described by using frequency, rate, and composition ratio. Measurement data that met the normal distribution were described as Mean ± SD, whereas those that did not meet the normal distribution were described by using median and interquartile range. Software was employed to calculate the score of each subscale and entry.

2.2. Qualitative research

2.2.1. Study participants

This research employed purposive sampling. In accordance with the principle of maximum differentiation, respondents were selected from quantitative studies for semistructured interviews. One to three nurses were selected from each of the eight hospitals that had obtained BPSO® certification for interviews. The sample size for interviews was determined based on the criteria of thorough interviews and saturation of information and data. The interview was stopped when no new topics emerged.

2.2.2. Interview outline

The CFIR-based interview outline contained the items outlined below. 1) Intervention characteristics. Is the implementation plan of this guideline complex? Which parts of the plan need to be modified? What other aspects of information and evidence need to be supplemented for this plan? 2) Outer/inner setting. What factors will affect the continuous application of this guideline? What other support resources are needed? Has the department formulated implementation goals related to this guideline? Will the department regularly provide feedback on the progress of the goals? 3) Individual characteristics. What work are you responsible for in the implementation of the guideline? How important do you think this guideline is to the patients in our department and the department itself? How confident are you in implementing this guideline? 4) Process. What do you think of the current application status of this guideline? Does your department regularly reflect on and evaluate the implementation of this guideline?

2.2.3. Data collection and quality control

Qualitative research was conducted through full audio recordings of interviews and written records. Interviews were conducted both online (via Tencent Meeting) and face-to-face in quiet, private locations. The framework analysis method was applied to code the transcribed texts using the CFIR, and thematic analysis was used to identify facilitators and barriers to guideline implementation. Each interview lasted 25–30 min. Before the interview, the purpose and content were explained to participants. Audio recordings were transcribed within 24 h for analysis. Interviewers mastered interview methods and skills through relevant literature and systematic training. A detailed interview outline was developed and revised through preinterviews, including opening, main body, and closing questions. During interviews, a combination of open- and closed-ended questions was used, with appropriate follow-up when responses were vague or incomplete. Interview content was organized immediately after completion, and transcripts were verified for accuracy.

2.2.4. Data analysis

Targeted content analysis was conducted using CFIR domains and structures [16]. Two researchers encoded the transcribed text line by line or segment by segment, following the CFIR coding manual, to identify concepts related to the CFIR field and structure. Then, descriptive statistics were conducted on the coding within each CFIR domain and structure, calculating the frequency of each structure and the relationships between structures. Finally, the analysis of the CFIR field and structure was clearly presented in the research report. Data analysis was conducted using NVivo 12.

2.3. Mixed research

After separately analyzing quantitative and qualitative data, the findings were analyzed using the following four patterns, integrating two methods: complementarity, convergence, inconsistency, and silence [17]. These patterns mutually explained or clarified one another, thereby broadening our understanding of the various factors influencing the implementation of evidence-based nursing guidelines [18].

2.4. Ethical considerations

This study has been reviewed by the Ethics Committee of the Second Hospital of Lanzhou University (2023A-665). Researchers adhered to the principles of beneficence and nonmaleficence, confidentiality of information, and fairness and reasonableness, and obtained signed informed consent forms after subjects were informed of the relevant research information.

3. Results

3.1. Basic characteristics of research participants

In the quantitative study, we distributed 210 questionnaires, of which four were excluded because their answers were extremely similar. A total of 206 valid questionnaires were retrieved, yielding an effective recovery rate of 98.1 %. The 206 respondents were mainly aged 31–40 years old (50.5 %). They included nine males (4.4 %) and 197 females (95.6 %). The specific results of the demographic data are shown in Table 1. In the qualitative study, we ultimately conducted semistructured individual interviews with 15 nurses. The nurses ranged in age from 29 to 46 years, and their work experience ranged from 4 to 25 years. The characteristics of the research participants are shown in Table 2.

Table 1.

General information of the participants (n = 206).

Variables	n	%
Gender
Female	197	95.6
Male	9	4.4
Age (years)
21–30	67	32.5
31–40	104	50.5
41–50	32	15.5
> 50	3	1.5
Educational background
Junior college	3	1.5
Undergraduate	148	71.8
Postgraduate	55	26.7
Working years (years)
≤ 5	56	27.2
6–10	40	19.4
11–15	62	30.1
16–20	26	12.6
> 20	22	10.7
Time of participation in the implementation of the guideline (years)
≤ 1	67	32.5
2	48	23.3
3	30	14.6
4	10	4.9
≥ 5	51	24.7
Positional titles
Junior	65	31.6
Intermediate	117	56.8
Senior	24	11.6
Post
Nurse	159	77.2
Head nurse	31	15.0
Chief head nurse	4	1.9
Director of Nursing Department	1	0.5
Others	11	5.4
Have you participated in the implementation of the guide training?
Yes	161	78.2
No	45	21.8

Note: Others include the deputy director of the nursing department, and the nursing teaching assistant.

Table 2.

Personal characteristics of study participants (n = 15).

Number	Gender	Age (years)	Education	Professional ranks	Position	Working time (years)	Duration of participation in the guideline implementation (years)
N1	Female	40	Master's degree	Senior	Head nurse	17	15–20
N2	Female	46	Undergraduate	Intermediate	nurse	22	≥20
N3	Female	43	Master's degree	Senior	nurse	13	11–15
N4	Female	43	Master's degree	Senior	Head nurse	25	≥5
N5	Female	31	Master's degree	Junior	Nurse	4	2
N6	female	40	Undergraduate	Senior	Head nurse	16	≥5
N7	Female	41	Master's degree	Intermediate	Head nurse	12	≥5
N8	Female	36	Master's degree	Senior	Head nurse	10	4
N9	Female	41	Undergraduate	Intermediate	Head nurse	17	3
N10	Female	32	Master's degree	Intermediate	Nurse	5	≥5
N11	Female	38	Master's degree	Intermediate	head nurse	9	≥5
N12	Female	40	Master's degree	Senior	Nurse	12	≥5
N13	Female	38	Undergraduate	Intermediate	Head nurse	20	≥5
N14	Female	29	Master's degree	Junior	Nurse	4	2
N15	Female	40	Undergraduate	Intermediate	Head nurse	16	2

3.2. Results of the quantitative survey

3.2.1. Current situation of domestic nurses’ readiness to participate in organizational change projects

The total score on the ORCA scale was 248.77 ± 33.35, placing it in the upper-middle range. The evidence dimension scored 3.44 ± 0.55 (highest), the facilitator dimension scored 3.41 ± 0.56 (moderate), and the contextual factor dimension scored 3.35 ± 0.57 (lowest).

3.2.2. Exploration of the facilitators of and barriers to guideline implementation through the matching relationship between the CFIR and ORCA scale

The ORCA tool comprises three domains (evidence, context, and facilitators). Each ORCA survey item corresponds to one CFIR structure (Appendix A) [19]. Appendix B presents the facilitators and barriers derived from the alignment between CFIR domains/structures and ORCA items, along with their respective scores. The analysis ultimately identified 41 influencing factors (25 facilitators and 16 barriers), covering all four CFIR domains and 20 structural dimensions.

3.2.3. Intervention characteristics

We identified three contributing factors in the three structural frameworks of CFIR intervention characteristics (Appendix B). Most nurses consider the implementation of guidelines to be supported by RCTs and scientific evidence. The primary relative advantage of these guidelines lies in delivering more benefits than drawbacks for patients. Furthermore, the adoption of guidelines is bolstered by clinical practice experience within implementing institutions.

3.2.4. Outer setting

We found three facilitators and one barrier (Appendix B) within the structure of patient needs and resources. Regarding facilitators, guidelines were widely accepted by patients in pilot studies, with their implementation fully considering patients’ needs and preferences within hospitals. Leaders who proactively seek methods to enhance patient education and increase treatment participation also serve as facilitators, thereby promoting guideline implementation. Barriers include insufficient resources to consider patient awareness/necessities when implementing selected plans.

3.2.5. Inner setting

We identified 12 facilitators and 11 barriers across the 11 structural elements of the CFIR (Appendix B). The facilitators primarily include leadership clarifying the responsibilities and authority of clinical managers and staff; leadership promoting team building to address clinical care challenges; employees demonstrating personal accountability for improving patient care and treatment outcomes; staff willingness to embrace process changes in clinical practice; and alignment between guideline implementation and patient-centered clinical practices. The main barriers include communication deficiencies between clinical service departments, as promoted by leaders; communication between project advocates and team members; employee incentives; attention to employees’ opinions and suggestions in the implementation plan for interventions; and a lack of priority to ensure interventions’ success.

3.2.6. Process

We identified seven facilitators and four barriers (Appendix B) among the five structural components in implementation. The facilitators include clearly defined roles and responsibilities in the intervention plan, a well-documented task description and timeline, clearly delineated roles and duties for team members, and shared accountability among team members for project success. Barriers include absent project schedules and deliverables, insufficient involvement of quality managers in project planning and implementation, limited authority for clinical advocates to work (implement), and inadequate patient feedback on proposed/implemented changes.

3.3. Results of the qualitative interview

3.3.1. Identification of influencing factors

Our interview results showed that only 36 factors, including 25 facilitators and 11 barriers, affected guideline implementation. These facilitators and barriers were distributed in 29 structures across the five areas of the CFIR (Appendix C).

3.3.2. Intervention characteristics

Among the six structural components of CFIR intervention features, we found that three are facilitators and three are barriers (Appendix C). Many experts supported guideline implementation and praised the quality and strength of the evidence. The main relative advantage of guidelines lies in their scientific rigor and practicality compared with traditional intervention programs.

Barriers included the complexity of implementation, the need for context-specific adjustments, and the costs of staffing and time commitments. An interviewee (N5) pointed out that “The guidelines were initially developed based on international practices, and localized implementation in China faces certain resistance.” This comment highlights the need for context-specific adaptation. Additionally, interviews revealed that developing and implementing intervention projects increased departmental burdens, hindering smooth progress. A participant (N4) answered, “Assembling a dedicated guideline implementation team and establishing standardized procedures requires substantial human, material, and financial resources, along with continuous project funding support. Without these, it would significantly increase the department's financial burden.”

3.3.3. Outer setting

Among the four structural components of the Outer setting, we identified three as facilitators and two as barriers (Appendix C). Regarding facilitators, guideline implementation effectively meets patients’ treatment needs, with hospital leadership providing support to ensure sustained compliance. Additionally, the guideline implementation team regularly updates its superiors on progress through online meetings.

Barriers include competitive pressures from other projects and the absence of incentive mechanisms. Participants noted that hospitals are simultaneously advancing other research initiatives, which may negatively affect guideline adherence. One interviewee (N1) replied, “Apart from guideline implementation, I'm also handling applications and approvals for other research projects, making it difficult to focus on guideline adoption fully.” Importantly, interviews revealed that the lack of a reward system for guideline implementation could be a significant barrier. One participant (N12) pointed out, “Currently, there’s no formal incentive mechanism to motivate team members, which hinders sustainable guideline execution.”

3.3.4. Inner setting

We identified 11 facilitators and three barriers among the 11 structural elements of the CFIR Inner setting (Appendix C). Participants in the interviews highlighted several facilitators: regular reporting and discussions, alignment with hospital culture and strategies, improved guideline implementation, integration into daily operations, policy incentives, consistent goals and feedback, willingness to try new approaches, a positive learning environment, collective training and learning, guideline implementation supervision, and comprehensive guideline knowledge. Most participants believed that strong leadership support and encouragement facilitate the implementation of intervention programs. A participant (N10) commented, “Leadership supported us in this project. Team leaders and head nurses held regular meetings to monitor progress. We took this task very seriously.” Additionally, interviews revealed that nurses had high familiarity with guideline-related knowledge, laying a solid foundation for implementation. One respondent (N2) stated, “Nursing staff involved in guideline implementation have more work experience and higher qualifications, making them more familiar with evidence-based knowledge and implementation procedures, which contributed to smoother execution.”

Barriers include staffing mismatches, prioritizing routine clinical duties over guideline implementation, and insufficient resources. Many nurses feel that guideline compliance is not their primary focus. Those responsible for implementing guidelines often have to set aside personal time after completing daily tasks to push the process forward. “Our regular workloads are already exhausting,” one participant (N8) admitted, “but we are still forced to use our own downtime to drive guideline adoption.” Furthermore, poor team coordination and understaffing further hinder progress in guideline implementation.

3.3.5. Individual characteristics

Four facilitators and two barriers were found among the four structures of personal characteristics (Appendix C). Facilitators include alignment with personal beliefs, commitment to achieving organizational goals, and nurses’ perseverance and sense of responsibility. Interviews revealed that participants with high confidence in their capabilities are likely to accept intervention plans. Even when facing conflicts with their work tasks or increased personal burdens, they demonstrated the courage to complete plans. One participant (N9) shared that “I enjoy this learning process. The more I learn, the better I can drive implementation.” Barriers include a lack of confidence and enthusiasm in implementation. Inexperienced nurses exhibited weak motivation during implementation. One respondent (N15) admitted that “I lack sufficient confidence in implementing the guidelines because I find it challenging. We’re already exhausted, and nurses are unwilling to continue promoting the application of these guidelines.”

3.3.6. Process

Implementation encompasses four structural components, including four facilitators and one barrier (Appendix C). Facilitators include strong planning, full commitment, clinical champions, and regular reflective evaluations. Most participants indicated that organizations typically establish implementation goals and plans before adopting the guideline. A participant (N10) answered, “We developed a concrete implementation plan three to six months before the guidelines were implemented.” Barriers involve declining execution effectiveness over time. While nurses initially demonstrated strong motivation to implement guidelines, many later struggled to meet deadlines. A participant (N11) shared that “After reaching a certain stage of guideline implementation, team members often became lax, especially when encountering challenges like the COVID-19 pandemic that severely disrupted schedules. Compared to earlier phases, execution rates declined significantly, leading to stagnation in guideline implementation.”

3.4. Results of mixed studies

We employed a mixed-methods approach combining quantitative and qualitative research to explore facilitators and barriers to guideline implementation within the CFIR. The quantitative analysis identified 41 influencing factors (25 facilitators and 16 barriers), whereas the qualitative analysis revealed 36 factors, including 25 facilitators and 11 barriers. By summarizing these factors, we identified their commonalities and differences and matched improvement strategies in accordance with the CFIR–ERIC roadmap (Table 3) (Appendix D).

Table 3.

Commonalities and differences in factors influencing guidelines implementation.

Domain	Quantitative research	Qualitative research	Improvement strategy
Intervention characteristics	Validity and scientific nature of evidence (facilitator)		Customize implementation strategy
	Benefits to patients (facilitator)	Difficult situational adaptation (barrier), high cost (barrier)
Outer setting	Meeting patient needs(facilitator), lack of incentive mechanisms(barrier)		Adjust incentive measures/salary structure
	Insufficient resources for patient awareness/demand (barrier)	Competitive pressure from other projects(barriers)
Inner setting	Active leadership participation, policy support, a positive departmental culture, an encouraging learning environment, insufficient available resources		Build a communication network among team members
	Insufficient team member communication (barrier)	Inappropriate staffing arrangements (barrier), high priority of clinical work (barrier)
Characteristics of individuals	NA	Dedicated to achieving organizational goals (facilitator), later lack of enthusiasm (barrier)	Conduct ongoing training and regular monitoring of implementation
Process	High planning (facilitator), regular reflection and evaluation (facilitator)		Obtain feedback from patients and their families
	Insufficient patient feedback (barrier)	Decline in post-execution performance (barrier)

Note: NA = not applicable.

4. Discussion

In this study, the total preparation score of clinical nurses participating in the organizational change initiatives was in the upper-middle range. The evidence dimension received the highest score, the facilitator dimension received a medium score, and the contextual factors dimension received the lowest score. This suggests that current projects/guidelines are supported by relatively high-quality evidence and available facilitators, while internal and external barriers remain. These barriers may reflect localization challenges of internationally developed guidelines and insufficient hospital/departmental incentives for nurse participation. Previous research [20] suggested that evidence-based practice programs should adapt to local conditions and cultural contexts, align with specific clinical scenarios, and highlight unique advantages to facilitate guideline implementation. Amuri et al. [21] found that 64.4 % of nurses reported inadequate time for evidence-based nursing initiatives. Yu et al. [22] discovered that nurses' rich theoretical knowledge contributes to delivering high-quality care. Therefore, strengthening guidance and training for nurses, improving nurses’ theoretical understanding of guidelines, and ultimately elevating care quality are crucial to enhancing guideline implementation.

Quantitative results indicated that nurses’ recognition of the scientific validity and patient benefits of guidelines (ORCA item average score >4) serves as a core facilitator, aligning with Helfrich's theory, which states that “evidence strength determines change acceptance [9].” However, guideline complexity and localization adaptation needs pose major barriers. Therefore, in accordance with the CFIR–ERIC framework, customized implementation strategies are required. Guideline implementers are recommended to consider usage scenarios comprehensively when tailoring implementation approaches for hospitals and departments to local medical practices and patient realities [23]. Interview findings demonstrate participants’ unanimous trust in the guideline implementation project, praising its quality and the strength of the evidence. Regarding implementation environments, participants emphasized that projects should adapt to local conditions and culture, address specific clinical contexts, highlight unique advantages, and facilitate the translation of guidelines into practice. This result aligns with the research findings of Fu et al. [24], who noted that evidence application should incorporate domestic context through localization, using evidence-based standards to enhance clinical quality. While quantitative and qualitative studies have demonstrated that the validity and scientific rigor of guideline-derived evidence can enhance implementation, previous research by Tian et al. [25] identified three primary barriers: inadequate user-friendliness (70.2 %), insufficient access channels (64.3 %), and restricted accessibility (56.9 %). These findings indicate that CPGs remain underutilized in current healthcare settings, with considerable challenges in their acquisition. Establishing a national guideline database is crucial to improving guideline quality and facilitating their wide adoption and application to address the above issues.

The Internal and External Factors theory in the CFIR framework posits that these factors are dynamic and can be transformed and adjusted in response to actual circumstances [26]. In the Outer setting, quantitative research identified promoting factors as guidelines that were widely accepted by patients during pilot studies, implementation that considered hospital patients’ needs and preferences, and leadership that proactively sought methods to enhance patient education and increase treatment participation. The main barrier was insufficient resources for patient awareness and needs during program implementation. Internally, leadership involvement and goal feedback mechanisms (such as regular performance evaluations) markedly improved nurse preparedness. However, uneven resource allocation and inefficient cross-departmental communication became bottlenecks. Our qualitative research findings align with these conclusions. Interviews revealed that internal and external promoting factors mainly included meeting patients’ treatment needs, leadership support, and an in-depth understanding of guideline-related knowledge. In contrast, barriers primarily involved inadequate resources, the lack of incentive mechanisms, and negative peer pressure. This result aligns with the findings of Liao et al. in their comprehensive review of CPG implementation factors [27]. Therefore, in accordance with the CFIR–ERIC framework, measures, such as modifying incentive structures/compensation packages and building communication networks among team members, can improve implementation environments.

The following approaches can be adopted to address implementation barriers in internal and external settings. 1) At the management level, leaders should actively participate in project transformation processes, encouraging employees to provide timely feedback when encountering issues. They must also motivate staff to foster a positive departmental culture [28]. 2) At the organizational level, hospitals and departments should establish detailed implementation standards for guidelines to advance their execution systematically. Organizations should implement tangible and intangible incentives. For instance, linking guideline implementation to individual performance could provide external motivation [29], as CFIR theory suggests, to motivate team members [26]. Additionally, organizations should prioritize staff training to stimulate intrinsic motivation, enhance communication among employees, and strengthen interdisciplinary team cohesion. 3) At the resource level, hospitals should improve infrastructure with adequate funding, personnel support, and facilities for guideline implementation. Educational materials can be distributed electronically or in physical form to deepen understanding [30]. 4) At the communication level, leaders should promote improved interdepartmental and intrateam communication to enhance team cohesion. High-quality working relationships that alignment of common goals with guideline implementation must be established [31].

High self-efficacy is the primary driving factor among personal characteristics. Nurses can enhance their self-efficacy by improving job competence, boosting confidence, and meeting individual learning needs [32]. Ozdemir et al. [33] found a significant positive correlation between nurses’ general self-efficacy levels and job satisfaction. The main barrier mentioned in interviews was the decline in implementers’ initiative during the later stages of guideline implementation. According to the CFIR–ERIC framework, continuous training and regular progress checks are necessary. Therefore, departments are recommended to strengthen staff training to improve team members’ understanding of guidelines, enhance individual implementation capabilities and confidence, and boost self-efficacy.

In accordance with the CFIR–ERIC framework, measures, such as obtaining feedback from patients and families, could be implemented to improve outcomes while enhancing project progress tracking. The study emphasized stakeholder involvement in guideline implementation [34]. Stakeholder feedback can be collected at any stage of implementation, aligned with project requirements and objectives. Qualitative research indicated that during the mid-to-late stages of guideline implementation, COVID-19 outbreaks and reduced nurse execution capabilities created multiple barriers to sustainable implementation. Increasing the number of nurses involved in guideline implementation and further refining their responsibilities to enhance execution capabilities are recommended to address the above issue [35].

We employed the CFIR to investigate the facilitators of and barriers to implementing evidence-based nursing guidelines. Our study has the following limitations: regarding the sample, we primarily focused on nurses and did not survey doctors or other stakeholders involved in clinical organizational change. This situation resulted in insufficient sample representation, necessitating further investigation among medical professionals and related groups. Time constraints prevented the use of longitudinal surveys and qualitative interviews to assess nurses’ preparedness and the contributing factors to their participation in organizational change at different time points. Future research could conduct long-term longitudinal tracking studies to examine the current status and influencing factors of nurses’ engagement in organizational transformation.

5. Conclusions

This mixed study found that the implementation of evidence-based nursing guidelines in China is influenced by multiple factors, including intervention characteristics (evidence, implementation context, and implementation cost), external and inner settings (communication, available resources, policies, departmental culture, and learning environment), personal characteristics (personal efficacy), and implementation (planning, reflection, and evaluation). These findings emphasize the need to change implementation incentives, provide sufficient resources, and strengthen interdepartmental communication. They also provide a theoretical basis for clinical nursing interventions. Future research can further explore targeted intervention measures to enhance the effectiveness and sustainability of guideline implementation.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Peiwei Qin: Writing - original draft, Writing - review & editing, Visualization, Methodology, Software, Investigation, Formal analysis, Data curation, Project administration, Conceptualization. Qiuru Liu: Writing - original draft, Writing - review & editing, Visualization, Software, Formal analysis, Data curation. Haixia Wang: Writing - original draft, Writing - review & editing, Visualization, Methodology, Formal analysis, Resources, Project administration, Conceptualization, Supervision. Zeyu Li: Writing - original draft, Writing - review & editing, Visualization, Software, Formal analysis, Data curation. Junfang Shi: Writing - original draft, Writing - review & editing, Visualization, Software, Formal analysis, Data curation. Qiongfang Cui: Writing - original draft, Writing - review & editing, Formal analysis. Yaxin Dai: Writing - original draft, Writing - review & editing, Formal analysis. Xing Wu: Writing - original draft, Writing - review & editing, Formal analysis. Peifen Ma: Writing - original draft, Writing - review & editing, Visualization, Methodology, Formal analysis, Funding acquisition, Resources, Project administration, Conceptualization, Supervision.

Funding

Gansu Provincial Health Industry Science and Technology Program (grant number: GSWSQN 2024-12).

Declaration of competing interest

The authors have declared no conflict of interest.

Appendices. Supplementary data

The following are the Supplementary data to this article: