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Acta Bio Medica : Atenei Parmensis logoLink to Acta Bio Medica : Atenei Parmensis
. 2022 Jul 1;93(3):e2022252. doi: 10.23750/abm.v93i3.12942

Extrinsic and intrinsic factors acting as barriers or facilitators in nurses’ implementation of clinical practice guidelines: a mixed-method systematic review

Chiara Gallione 1,2,, Michela Barisone 1, Antonella Molon 2, Moreno Pavani 2, Cristina Torgano 2, Erika Bassi 1,2, Alberto Dal Molin 1,2
PMCID: PMC9335442  PMID: 35775756

Abstract

Background and aim of the work:

Greater evaluations are needed to identify barriers or facilitators in nurses’ guidelines adherence. The current review aims to explore extrinsic and intrinsic factors impacting nurses’ compliance.

Methods:

Mixed-method systematic review with a convergent approach, following the PRISMA checklist and the JBI Mixed Methods Review Methodological Guidance was conducted. MEDLINE, Embase, CINAHL were systematically searched, to find studies published between 2010 and 2021, including qualitative, quantitative or mixed-methods articles.

Results:

Sixty studies were included, and the major findings were analysed by aggregating them in two main themes: intrinsic and extrinsic factors. The intrinsic factors were: a) knowledge and skills; b) attitudes of health personnel; c) sense of belonging towards guidelines. The extrinsic factors were: a) organizational and environmental factors; b) workload; c) guidelines structure; d) patients and caregivers’ attitude.

Conclusions:

The included studies report lack of resources, among environmental factors, as the main barrier perceived. Nurses, who are at the forefront in addressing the direct application of knowledge and skills to ensure patient safety, have a higher perception of this kind of barriers than other healthcare personnel. Potential facilitators emerged in the review are positive feedback and reinforcements at the workplace, either from the members of the team or from the leaders. Moreover, the level of active participation of the patient and caregiver could have a positive impact on nurses’ guidelines adherence. Guidelines implementation remains a complex process, resulting in a strong recommendation to support health policymakers and nursing leaders in implementing continuing education programs. (www.actabiomedica.it)

Keywords: clinical practice guideline, adherence, guideline, barrier, advanced practice nursing, mixed-method review, systematic review

Introduction

Clinical Practice Guidelines (CPGs) are systematically developed statements that aim to assist healthcare practitioners and patient decisions, regarding the definition of the most appropriate care for specific circumstances (1). Despite the broad consensus on the use of guidelines and the tools to develop and adapt them, they are not always applied and their impact on clinical practice is not as strong as it should be. Several studies (2-5) have shown that guidelines have only been moderately effective in changing the care process and that there is still space for the improvement of their implementation. Moreover, other studies (6,7) have shown that quite often recommendations aren’t properly adopted, resulting in the possibility that patients will not benefit from an evidence-based practice.

A wide variety of strategies are used to implement guidelines (7), but most of them do not refer to a careful assessment of the reasons why some interventions have failed while others have been successful. To understand and choose the interventions that may be most effective, it is reasonable to start with a model of behaviour (8) in order to capture the range of mechanisms usually involved in change, including the internal (psychological and physical) and external ones (environmental).

Michie et al. (8) depicted a framework for understanding behaviour called the ‘COM-B’ system, where Capability, Opportunity, and Motivation interact to generate behaviour that in turn influences these components. Motivation refers to all those brain processes that stimulate and direct behaviour, including habitual processes, emotional responding, as well as analytical decision-making.

Typically, theories of motivation differentiate between intrinsic and extrinsic motivation. Intrinsic motivation is characterized by taking behaviours for their own sake, while extrinsic motivation is characterized by taking actions aimed at a specific outcome such as noticeable rewards, social approval, demonstrating something to oneself or maintaining correspondence among one’s values and behaviours. Many behaviours, particularly those relevant to health promotion (e.g., quitting smoking), disease prevention (e.g., attending screening) or disease management (e.g., comply with medical prescriptions) are extrinsic in nature, but a continuum can be hypothesized for their internalization according to Ryan and Deci’s Self-Determination Theory (SDT). Behaviours become regulated or evaluated more autonomously over time, with an active process that tries to transform an extrinsic reason into personally endorsed values, absorbing behavioural regulations that were originally extrinsic (9).

Considering healthcare workers, intrinsic motivation has been extensively studied in the field of Behavioural Economics (10) and subsequently taken up by the SDT, according to which individuals are intrinsically motivated because they feel satisfied by the simple fact to carry out an activity autonomously. In addition to intrinsic motivation, extrinsic motivation also plays an important role. According to Berdud et al. (10), recognition in the workplace, involvement in activities for professional development, or engagement in research projects constitute a nonmonetary extrinsic incentive that needs to be considered by health policy makers and managers.

The areas explored by previous reviews concern mainly medical staffs or healthcare workers in general and identified six main extrinsic factors that could act as barriers or facilitators for adopting CPGs: 1) specific characteristics of the guideline (level of clarity and credibility), 2) staff skill mix (level of specialisation, knowledge, etc.), 3) patients’ characteristics (level of attitudes, sociocultural background, etc.), 4) work environment (leadership, teamwork, etc.), 5) health policies (time, financial management, etc.), 6) strategies used to promote adherence. All these aspects can have repercussions on the health professionals and therefore on nurse staff, representing both barriers and facilitators to the adoption of CPGs (2-5).

Nurses are increasingly expected to provide evidence-based care intended to enhance the quality of care. A growing number of nursing guidelines are being published to reduce unwarranted variation in healthcare delivery, but there is still a gap in the knowledge translation process, and the level of adherence to CPGs recommendations has proven to be suboptimal (7,11,12). Bridging the gap between theory and practice is a core responsibility of the nursing scope of practice. A wider understanding of the intrinsic and extrinsic factors acting as barriers or facilitators is needed to improve the nurses’ adherence to CPGs.

Aim

The present study aims to explore and synthesize the available literature on extrinsic and intrinsic factors acting as barriers or facilitators in nurses’ implementation of CPGs, using a mixed-method systematic review with a convergent integrated approach.

Methods

Study Design

To better identify the reasons why some CPGs’ implementation processes fail, and others succeed, a mixed-method systematic review was conducted (13), therefore considering quantitative, qualitative and mixed methods studies. The mixed-methods approach allows to explore diverse perspectives and to understand the existing relationships among complex phenomena, like new care pathway implementation or CPGs’ adoption. Integrated methodologies directly bypass separate quantitative and qualitative synthesis combining both forms of data into a single mixed-methods synthesis, with a convergent integrated approach (14,15).

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (16) and the JBI Mixed Methods Review Methodological Guidance (15). The protocol of the present review was registered on PROSPERO, the International Prospective Register of Ongoing Systematic Reviews (CRD42021230808). No amendments to the PROSPERO protocol were required at the time of registration.

Search strategy

A comprehensive database search consulting MEDLINE (via PubMed), Embase and CINAHL was undertaken by two authors, including qualitative, quantitative or mixed-methods primary studies, aiming to identify barriers and facilitators to CPGs’ implementation in any healthcare setting, involving nurses, and published in any language from January 2010 to February 2021. Studies including other health professionals were also considered only if specific data on nursing staff could be extracted.

The time limit was set to 2010 considering that the available literature on the review topic has begun to increase about 10 years ago. No restrictions were applied in terms of patients’ characteristics while, in terms of study design, case series and case reports were excluded. The search strategy was tracked in Table 1.

Table 1.

Search strategy (30 Nov 2020-3 Feb 2021)

Database Search Employed string Number of results obtained
PubMed 1 (‘practice guideline’/exp OR ‘practice guideline’) AND (‘protocol compliance’/exp OR ‘protocol compliance’) AND (‘nursing’/exp OR nursing) 183
PubMed 2 (((clinical practice guideline [MeSH Terms])) AND (adherence, guideline [MeSH Terms])) AND (advanced practice nursing [MeSH Terms]) 1
PubMed 3 (((barrier*)) OR (facilitator*)) AND (adherence, guideline [MeSH Terms]) 262
PubMed 4 (((barrier*) OR (facilitator*)) AND (adherence, guideline [MeSH Terms])) AND (advanced practice nursing [MeSH Terms]) 1
PubMed 5 ((motivation [MeSH Terms]) AND (clinical practice guideline [MeSH Terms])) AND (adherence, guideline [MeSH Terms]) 9
PubMed 6 ((motivation [MeSH Terms]) AND (clinical practice guideline [MeSH Terms])) AND (advanced practice nursing [MeSH Terms]) 0
PubMed 7 ((clinical practice guideline [MeSH Terms]) AND (implementation plan, annual [MeSH Terms])) AND (adherence, guideline [MeSH Terms]) 0
PubMed 8 (((clinical practice guideline [MeSH Terms]) AND (implementation plan, annual [MeSH Terms])) AND (adherence, guideline [MeSH Terms])) 26
PubMed 9 ((clinical practice guideline [MeSH Terms]) AND (enablers [MeSH Terms])) AND (advanced practice nursing [MeSH Terms]) 0
Embase 10 (‘nurse’/exp OR nurse) AND (‘practice guideline’/exp OR ‘practice guideline’) AND (‘protocol compliance’/exp OR ‘protocol compliance’) 86
Cinahl 11 AB (adherence or compliance) AND AB (guidelines or protocols or practice guideline or clinical practice guideline) AND AB ( nurse or nurses or nursing ) AND AB (barriers or obstacles or challenges ) 302

Study selection and quality appraisal process

After removing the duplicates, two authors independently screened each article by titles and abstracts for excluding the studies that did not meet the review’s inclusion/exclusion criteria. The measurement of investigators’ agreement for categorical data was calculated with Cohen’s Kappa (17).

Full texts of the eligible studies were retrieved and then critically appraised for methodological quality using the Mixed Method Appraisal Tool (MMAT) (18,19). The MMAT is a critical appraisal tool designed for the appraisal stage of systematic mixed studies reviews allowing the evaluation of the methodological quality of five categories of studies: qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies.

Two authors performed the methodological evaluation and, in case of disagreement, a consensus discussion with a third author was planned to align possible different views in performing the evaluation.

Data extraction and synthesis

Two authors independently extracted data from the articles of the eligible studies using a standardised Excel data extraction form. Data extracted included publication details, the aim of the study, research paradigm/design, setting/sample and major findings meant as extrinsic/intrinsic factors acting as barriers or facilitators. For the purpose of this mixed method review, the main results were also graphically synthesised according to the theoretical domains adopted (4,20) and the integrated analysis of the major findings.

Results

As described in Figure 1, the electronic searches identified 870 records from the developed queries (n=482 PubMed; n=86 EMBASE; n=302 CINAHL). After removing the duplicates (n=44), two authors screened 826 titles and abstracts. In this phase, 712 records were excluded. Of the remaining 114 studies, 50 were excluded after reading the full text because the samples did not include the target population (other health professionals were included such as physicians, physiotherapists, and midwives, but not nurses), one article was in press, three were not available.

Figure 1.

Figure 1.

PRISMA flow diagram.

At the end of the study selection process, 60 studies were included in the present review. After the title/abstract screening phase, the level of agreement between the two reviewers was 0.98 according to the Cohen’s Kappa (21). The disagreement regarding the inclusion of the unclear studies was solved discussing with a third author. The overall quality, appraised using the MMAT, settles on a good level. The evaluation of the methodological quality is reported in Figure 2a and 2b.

Figure 2a.

Figure 2a.

Evaluation of the methodological quality with Mixed Methods Appraisal Tool (studies 1-34).

Figure 2b.

Figure 2b.

Evaluation of the methodological quality with Mixed Methods Appraisal Tool (studies 35-60).

Description of the included studies

The present mixed method review included 60 studies: 34 quantitative, 16 qualitative and 10 mixed-methods. To provide a wider view of the issue, three implementation projects (22-24) were also included and analysed among the qualitative paradigms. The main characteristics and results of the included studies are available in Tab. 2.

Table 2.

Synopsys of the included studies

Pubblication details Principal aim of the study Research paradigm Research design/method Setting and Sample Major findings
INTRINSIC FACTORS EXTRINSIC FACTOR
Aloush
2017
To evaluate the effect of the VAP (Ventilator-Associated Pneumonia)
prevention guidelines education on nurses’ compliance
QUAN RCT
2-group posttest only
design
Jordan
I group underwent an intensive VAP education course (n 60, 1 dropped out), whereas the C group participants received nothing (n 60, 17 withdrew)
Mean age: 31 ± 5.6
WORKLOAD
Factors influencing compliance in the entire group:
-number of beds per unit (fewer beds)
nurse to patient ratio
Cahill
2014
To improve adherence to critical care nutrition guidelines for the
provision of enteral nutrition
QUAN RCT
Before-after study
USA
ICU (Intensive Care Unit): minimum of 8 beds, affiliated with a registered dietitian, located in North America
A total of 182 critical care staff (134) (74% nurses) responded at T0, and 118 (79% nurses) at follow up
ATTITUDE
Trust in prescription, fear of adverse events
ENVIRONMENTAL
Delivery of Enteral Nutrition
to the Patient, delays in prescription, lack of supplies (feeding tubes)
De Meyer
2018
To study the effectiveness of tailored repositioning and a turning and repositioning system on nurses’ compliance to repositioning frequencies. QUAN RCT
Multicentre, cluster, three‐arm, randomized, controlled pragmatic trial
Europe
16 northern Europe hospitals-29 wards (Convenience sample)
502 nurses trained and a total of 227 patients (mean age 80.7 years, SD 11.4), mean Braden Scale 12.9 (SD 2.4);
8 intensive care units, 13 geriatric
wards and 8 rehabilitation wards
ATTITUDE
Resistance to the adoption of new practices (moderate-not present)
WORKLOAD
lower back strain (moderate)
Förberg
2016
To investigate the
effects of implementing a CPG for Peripheral Venous Catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs (Electronic Patient Records), on PVC-related complications and on RNs’self-reported adherence.
QUAN RCT
Cluster Randomised Trial
Sweden
Inpatient units with access to the PVC template in the EPR system
to document PVCs
RNs Intervention group (IG) T0: 108
RNs Control group (CG) T0: 104
RNs Intervention group (IG) T1: 106
RNs Control group (CG) T1: 102
ENVIROMENTAL
RNs work
Context (leadership, work culture, and evaluation- the use of data to provide feedback on the unit’s performance).
Work culture scoring higher in IG.
Friese
2019
To evaluate whether a web-based educational intervention improved Personal Protective Equipment (PPE) use among oncology nurses who handle hazardous drugs QUAN RCT
Cluster randomized controlled trial
USA
12 ambulatory oncology settings
396 nurses, (257 completed baseline and primary endpoint survey)
RNs Intervention group (IG) (n 121): one-hour educational module on PPE use with quarterly reminders
RNs Control group (CG) (n 136): control intervention + tailored messages to address perceived barriers and quarterly data gathered on hazardous drug
RNs in IG reported higher workloads (6.2 patients vs 5.0)
ENVIROMENTAL
practice environments, safety behavior, organizational factors, Structural barriers to partecipation, access to web-based contents,
WORKLOAD
workload demands, limited time for participants to view materials during their scheduled shift, and vague or unclear institutional policies on gowns, eye protection, and respirator use when handling hazardous drugs.
Holmen
2016
To improve Hand Hygiene (HH) compliance among physicians and nurses in a rural hospital in sub-Saharan Africa (SSA) using the World Health Organization’s (WHO’s) Guidelines on Hand Hygiene in Health Care QUAN quasi- RCT
Quasi-experimental design
Rwanda
A 160-bed, non-referral hospital in Gitwe
12 physicians and 54 nurses
ENVIRONMENTAL
resources, lack of supplies (water)
Snelgrove-Clarke
2015
To determine the effects of an Action Learning intervention on nurses’ use of a Fetal Health Surveillance (FHS) guideline during labor of women who were low risk on admission. QUAN RCT
Pragmatic randomized controlled trial
Canada
Birthing unit of teaching hospital in Atlantic
All nurses working in the birth unit were invited to participate in the study.
Exclusion criterion was nurses who were on leave (n=62)
PATIENTS- CAREGIVERS’ ATTITUDE
clinical characteristics
fetal heart rate, type of analgesia (both enablers and inhibitors)
ENVIRONMENTAL
resources: supplies: doppler availability; policy
Alhassan
2019
To explore self-rated adherence to standard protocols on nasogastric tube feeding among professional and auxiliary nurses and the perceived barriers impeding compliance to these standard protocols. QUAN Observational Study Descriptive analytical cross-sectional study Ghana
professional (n = 89) and auxiliary (n = 24) nurses
KNOWLEDGE
Accessibility:
limited opportunities for in-service trainings, insufficiency of nasogastric tube feeding protocols on the wards.
ENVIRONMENTAL
lack of supplies: inadequate
supply of the re-requisite nasogastric tubes
PATIENTS- CAREGIVERS’ ATTITUDE
opposition from relatives of patients
Aloush
2018
To assess nurses’ compliance with Central Line Associated Bloodstream Infection (CLABSI) prevention guidelines related to maintenance of the central line and the predictors of compliance QUAN Observational Study Descriptive cross-sectional design Jordan
ICUs of 15 hospitals
171 nurses, 81% female, mean age 32.5 y.o., 43% no prevoious education about CLABSI
ENVIRONMENTAL FACTORS
Lack of supplies
WORKLOAD
Nurse-patient ratio (better 1:1)
Avedissian
2018
To describe the current practices in the management of severe allergies and anaphylaxis by Lebanese nurses
working in schools and day cares and to explore the perceived need for a protocol to manage anaphylaxis
reaction
QUAN Observational Study Cross-sectional survey Lebanon
59 school and 126-day care nurses
participated
KNOWLEDGE
Lack of training, education
ATTITUDES
Motivation
Hesitance
Burkitt
2010
To assess the effect of a multicenter methicillin-resistant
Staphylococcus aureus (MRSA) prevention initiative on changes in employees’ knowledge, attitudes, and practices
QUAN Observational Study cross-sectional study USA
nurses (38%), allied health professionals
(30%), other support staff (24%), and physicians (9%) under age 50 years
(57%)
KNOWLEDGE/ATTITUDES
Awareness/agreement hand cleansing causes
damage to skin
WORKLOAD
Too busy
Cato
2014
To describe the predictors of nurse actions in response to a mobile health Decision Support System (mHealth DSS) for guideline-based screening and management of tobacco use. QUAN Observational Study Observational design focused on experimental arm of a randomized, controlled trial. USA
14,115 patient encounters and 185 nurses enrolled
KNOWLEDGE AND SKILLS (Family and Pediatric, Adult Nurses Practitioners) EXTRINSIC FACTORS-
PATIENTS-CAREGIVERS’ ATTITUDE
Attitudes (preferences, inabilities) Women, African American, payer source
Chavali
2014
To improve Hand Hygiene (HH) compliance among all health care staff.
To assess adherence to HH among nurses and allied healthcare
workers, at the end of the training year.
QUAN Cross-sectional observational study.
1500 HH opportunities were observed.
Among 38 healthcare workers, 28 were nurses (73.6%) and 10 (26.3%) other healthcare workers.
India
nursing staff (n = 28)
and allied healthcare
workers (n = 10)
ENVIRONMENTAL FACTORS
Lack of supplies (hand rub)
Lack of resources (nurses’ shortage)
WORKLOAD
Pressure
Cotta
2014
The aim of this study was to describe perceptions and attitudes towards antimicrobial resistance, antimicrobial use, AMS (Antimicrobial Stewardship)
interventions, and willingness to participate
QUAN Observational Study Quantitative Survey, descriptive study Australia
331 respondents (24% physicians, 18% surgeons, 24% anaesthetists, 32% nurses and 3% pharmacists
KNOWLEDGE
lack of awareness (problem in other hospitals, do not want to participate in AMS interventions), lack of familiarity
Damush
2017
To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA (Transient Ischemic Attack) QUAN Observational Study Cross-sectional, observational study USA
Veterans Administration Medical Centers having an annual volume of ≥25 patients with a TIA or minor stroke.
KNOWLEDGE
inadequate staff education
ENVIROMENTAL
Organizational constraints (access brain imaging, lack of coordination, resource constraint, rotating pool of house staff)
Gustafsson 2016 To determine if nurse anesthetists (NAs) have access, knowledge, and adhere to recommended guidelines to maintain normal body temperature during the perioperative period. QUAN Observational Study Descriptive survey design. Sweden
56 operating departments
ATTITUDES
Motivation
Agreement (it was not a routine to do…)
ENVIRONMENTAL
Resources, time equipment, supplies
PATIENTS- CAREGIVERS’ ATTITUDE
Preferences (feeling warm or having a temperature)
Harillo-Acevedo
2019
To determine the effect of implementing a breastfeeding clinical practice guideline on factors associated with breastfeeding support by health care professionals, adopting a Theory of Planned Behavior approach. QUAN Observational Study Cross-sectional
Study
Implementation
of breastfeeding
CPG
Spain
All health care professionals of all categories working in maternal and/or pediatric care: 164 preimplementation and 152 postimplementation
SENSE OF BELONGING
Social pressures to enact a behavior.
ATTITUDES
Self-efficacy
Huang
2019
To investigate the barriers in administering enteral feeding to critically ill patients from the nursing perspective. To provide tailored interventions for addressing identified barriers and propose an optimal Enteral
Nutrition (EN) practice in Intensive Care Unit (ICU).
QUAN Observational Study Cross‐sectional descriptive study. China
808 nurses recruited
KNOWLEDGE
Lack of time for training
ENVIRONMENTAL
Organizational constraints (delay in physicians)
PATIENTS- CAREGIVERS’ ATTITUDE
Diarrhea
Huis
2013
To examine which components of two hand hygiene improvement
strategies were associated with increased nurses’ hand hygiene compliance.
QUAN Observational Study Process evaluation of a cluster randomized controlled trial The Netherlands
67 nursing wards
in three Dutch hospitals
MOTIVATION
Trust, self-efficacy related to experienced feedback, social influence within teams
ENVIROMENTAL
leadership (team and leaders-directed strategy)
Jansson
2013
To explore critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia QUAN Observational Study Quantitative cross-sectional survey. Finland
critical care nurses (n = 101)
KNOWLEDGE:
Lack of knowledge, guidance
ENVIRONMENTAL:
Lack of time, resources, staff
Jho
2014
To evaluate knowledge, practices and perceived barriers regarding cancer pain management among physicians and nurses in Korea QUAN Observational Study Questionnaire developed on Cancer Pain Management Guideline Korea
A total of 333 questionnaires (149 physicians and 284 nurses) were analyzed
KNOWLEDGE
Insufficient knowledge
ENVIRONMENTAL FACTORS
lack of time.
Perceived malpractice: insufficient communication with patients or with physician (contacting physician for prescription of Opioid).
Lack of supplies: Medication and intervention costs
PATIENTS- CAREGIVERS’ ATTITUDE
Reluctance to report pain
Reluctance to take opioid
Kiyoshi-Teo
2014
To identify factors that influence adherence to guidelines for prevention of ventilator-associated pneumonia, with a focus on oral hygiene, head-of-bed elevation and spontaneous breathing trials QUAN Observational study Cross-sectional descriptive study USA
576 critical care nurses
ATTITUDES
user attitude scale
KNOWLEDGE
awareness, level of prioritization
ENVIRONMENTAL
Time availability
Kowitt
2013
To identify factors associated with hand hygiene compliance during a multiyear period of intervention. QUAN Observational study
Infection control implemented hospital-wide hand hygiene initiatives
USA
Nurses, Physician, Technical Staff, Support staff
Calculated as: n of hand hygiene opportunities for each staff member
KNOWLEDGE
Volume of information, educational campaign
ATTITUDE
Better after living patient’s room
WORKLOAD
Better compliance during night shift/weekend
ENVIROMENTAL
Organizational factors (Intesive Care Unit and pediatric wards)
Løyland
2015
To describe hand-hygiene practices in Pediatric Long-Term Care (pLTC) facilities and to identify observed barriers to, and potential solutions for, improved infection prevention. QUAN Observational study
World Health Organization’s ‘5 Moments for Hand
Hygiene’ validated observation tool to record indications for hand hygiene and adherence
USA
Direct providers of health, therapeutic and rehabilitative care, and other staff responsible
for social and academic activities.
Nurses 207 on a total of 847 providers (24.4%)
ATTITUDES
Someone used to or not, use of phone in contact precautions rooms
KNOWLEDGE
confusion about which PPE
should be worn for different types of isolation precautions
ENVIRONMENTAL
Fear of punishment, use of
dispensers or sinks is impractical while working, shared rooms among residents with infections
WORKLOAD
HH was particularly
challenging when working alone with groups of residents
PATIENTS- CAREGIVERS’ ATTITUDE
Parents kissing or having close contacts with children
Muller
2015
The authors evaluated whether Emergency Department (ED) crowding is associated with
reduced hand hygiene compliance among health care workers
QUAN Observational study
A trained observer randomly selected a specific ED room or bay and observed all staff providing care in that area for a 20-minute period
Canada
Nurses, Physicians and other staff providing care in ED
ATTITUDE
Better after patient contact
ENVIRONMENTAL
Crowding in ED
WORKLOAD
Higher Nursing Hours
Omran
2015
To explore the knowledge, experiences, and perceived barriers to Colorectal cancer (CRC) screening among HCPs working in primary
care settings
QUAN Observational study Descriptive cross-sectional design Jordan
236 HCPs (Health Care Providers)
(45.8 %) nurses, physicians (45.3 %), and others (7.2 %)
KNOWLEDGE
Lack of awareness about CRC screening test lack of policy/protocol on CRC screening
PATIENTS- CAREGIVERS’ ATTITUDE
Fear for diagnosis
ENVIRONMENTAL
Lack of resources:
shortage of trained HCPs to conduct invasive screening
Rodrigues
2018
To verify the knowledge and practices of health professionals working in Prenatal Care (PNC) related with syphilis during pregnancy and to identify the main barriers to the implementation of protocols for the control of this disease. QUAN Observational study Cross‐sectional study Brazil
366 physicians and
nurses working in PNC
KNOWLEDGE
Lack of
ATTITUDES
professional difficulties (Difficulties in approaching and treating the sexual partner of an infected pregnant woman)
PATIENTS- CAREGIVERS’ ATTITUDE
nonattendance of the partner to the service, late onset of PNC, and nonadherence of the pregnant woman
to the testing or treatment
ENVIRONMENTAL
Organizational
delays in identification and treatment
Rodríguez Aparicio
2019
To identify the barriers and drivers fo r adherence to the care bundle in order to prevent complications associated with
vascular access devices.
QUAN Observational Study Descriptive cross-sectional study Spain
150 participants, with a participation rate of 31% (150/483): 80% were a
nurse (n = 120) and 20%
doctor (n = 30)
ATTITUDES
Age (older and younger), experience, lack of compliance and agreement and commitment to the CPG
KNOWLEDGE
Lack of training
Senanayake
2018
To assess whether a more context-specific modified version of WHO Safe
Childbirth Checklist (mSCC) would result in improved adoption rate
QUAN Prospective
Observational study
Level of acceptance was assessed using a self-administered questionnaire study
Sri Lanka
Nurses and Midwives in 2 University Obstetrics Unit (18 vs 12 in DSHW) (20 vs 8 in THMG + 8 Doctors)
ATTITUDES
Motivation (lack of enthusiasm)
KNOWLEDGE
inadequate training
WORKLOAD
Lack of staff
ENVIRONMENTAL
Organizational lack of accountability. Lack of supervision from Institutional Level
Spångfors
2020
To describe registered nurses’ perceptions, experiences and barriers for using the National Early Warning Score in relation to their work experience
and medical affiliation
QUAN Observational study Web-based questionnaire study Sweden
3,165 registered nurses working in general somatic hospital wards, Emergency Departments
(ED) and the Cardiac High Dependency Unit (CHDU)
ATTITUDES
Trust (lack of response from doctor), lack of added value to the situation
WORKLOAD
lack of time
CPG STRUCTURE
Too much time to document
Stahmeyer
2017
To determine the number of hand hygiene opportunities (HHOs), compliance rates, and time spent on hand hygiene in intensive care units QUAN Observational study
N of opportunities, timing of 300 hands disinfections
Germany
HHO 81.1% nurses, 15.8 Physician, 3.1% Others
ENVIRONMENTAL
Lack of resources
WORKLOAD
Time
Tinkle
2016
To assess the adherence of women’s health providers in New Mexico to the Women’s Preventive Services Guidelines, now covered as part of the Affordable Care Act, and to examine how providers’ knowledge, attitudes, and external barriers are associated with adherence to these clinical guidelines. QUAN Observational Study Cross-sectional, descriptive survey USA
Women’s health providers in New Mexico, including nurse practitioners (57.7%), certified nurse-midwives (12%), and family practice and obstetrician/gynecologist physicians (30.3%)
ENVIRONMENTAL
Organizational (Lack of Time, Lack of Supplies, lack of staff, reimbursement
PATIENTS- CAREGIVERS’ ATTITUDE
Acceptability
Tomaszek
2018
To compare knowledge and compliance with good clinical
practices regarding control of postoperative pain among nurses, to identify the determinants
of nurses’ knowledge and to define barriers to effective control of
postoperative pain
QUAN Observational Study Cross-sectional study Poland
257 nurses from hospitals with a “Hospital without Pain” certificate and 243 nurses from noncertified hospitals, with mean job seniority of 17.6 _ 9.6 years
KNOWLEDGE
lack of (both physician
and nurse)
ATTITUDES
Not practical to apply (inability to modify the protocol of pain treatment) lack of standard procedures for pain assessment and control
Motivation
discomfort associated with too frequent referral to a physician, lack of autonomy in prescribing
lack of sympathy to patient’s suffering
Trogrlic´
2017
Survey aimed at identifying barriers for implementation that should be addressed in a tailored implementation intervention targeted at improved ICU (Intensive Care Unit) delirium QUAN Observational Study Online survey The Netherlands
360 ICU health care professionals (nurses (79%), physicians and delirium consultants)
KNOWLEDGE
(Deficit, low familiarity with CPG)
ATTITUDES
Beliefs that’s not preventable, lack of trust in reliability
SENSE OF BELONGING
Lack of collaboration and trust
CPG STRUCTURE
Disbelief that it would be optimal for patients, is cumbersome or inconvenient in daily practice
ENVIRONMENTAL
Organization
Lack of time
Currie
2019
To identify factors which influence staff compliance with hospital MRSA screening policies MIXED Sequential mixed-methods design UK
Ward based nursing staff: 38
KNOWLEDGE
enabler: awareness about consequence, values and beliefs
ENVIRONMENTAL
Lack of time and patients flow pressures
Organizational: enabler; audit, feedback, compliance
Ersek
2014
To identify facilitators and barriers that affected the success of an intervention aimed at promoting the adoption of evidence-based pain management
protocols into Nursing Homes
(NHs)
MIXED Mixed methods study
Focus group interviews
Quantitative methods
USA
convenience sample of four NHs (17 RNs, three licensed practical
nurses, one advanced practice RN, and two certified nursing assistants)
ATTITUDES
provider mistrust of nurses’ judgment
ENVIRONMENTAL
Resources: lack of facilities, salary, benefits
Organizational: turnover, regulatory issues, policies, administrative support, staff consistency
Garcia
2016
To explore health care workers identified barriers to cervical cancer screening in rural Southwest Virginia MIXED Mixed methods study
Telephone-based
structured interviews and conventional content analysis
USA
Sample
Office manager (50%) or a registered nurse (34%)
PATIENTS- CAREGIVERS’ ATTITUDE
fear, comfort, lack of education, lack of
priority, insurance, cost, or transportation
Heidke
2020
To report on registered nurses’ adherence to current Australian
health behaviour recommendations
MIXED Mixed methods study
Four health risk factors were examined: diet, smoking, physical exercise and alcohol consumption+ BMI
Australia
23 registered nurses
ATTITUDE
Motivation (family commitments)
WORKLOAD
(Shifts, n of hours)
Hilton
2016
To determine the views of nurses and on the feasibility of implementing current evidence-based guidelines
for oral care, examining barriers and facilitators to implementation
MIXED Mixed methods study
Online survey of 35 nurses and residential care workers, verified
and expanded upon by one focus group of six residential care workers
Australia
45 nurses and residential care workers, 35 surveys included.
ATTITUDE
Oral care is viewed
as a low priority, negative attitude of the staff
KNOWLEDGE
Lack of training, education
ENVIRONMENTAL
Lack of Supplies: access to proper materials, and human resources (dentists) and family participation as a facilitator
Inadequate staffing, lack of time
PATIENTS- CAREGIVERS’ ATTITUDE
resident’s teeth were a barrier, poor behaviour, non-compliance, or lack of participation with oral care, dysphagia
Katz
2016
To identify barriers and facilitators to implementation of smoking cessation in Veterans general medicine units MIXED Mixed methods study
20-item decisional balance survey and 2 items that asked nurses to rate their self-efficacy and satisfaction in helping patients to stop smoking
USA
164 nurses surveyed and conducted semistructured interviews in a purposeful sample of 33 nurses
ATTITUDE
Self-efficacy (facilitators: reminders in the electronic medical record and readily available self-help materials/Barriers: Skepticism about effectiveness, perceived self-efficacy and normative believe about nurses’ role
ENVIRONMENTAL:
Organization: nurses’ leaders should promote smoking cessation/ resources lack of time and resources, lack of coordination.
PATIENTS- CAREGIVERS’ ATTITUDE
Resistance
Knops
2010
Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence MIXED Mixed methods study
While long-term adherence was audited, focus groups were launched to explore nurses’ perceptions of barriers and facilitators
regarding long-term adherence to their guideline
The Netherlands
15 Nurses and 44 oncologists
SENSE OF BELONGING
Reminded each other/ favorable social context
ENVIRONMENTAL
Resources: Time (saved them a lot of time and trouble)
CPG STRUCTURE
Barriers: daily clinical practice complex, too many patients on their wards who did not meet the guideline criteria, not reliable/ Facilitators: prevented patients from unnecessary diagnostic research
McIntosh
2017
To describe healthcare providers’ perspectives on the facilitators of and barriers to adhering to pediatric diabetes treatment guidelines MIXED Mixed methods study
Electronic Survey + qualitative interviews
Canada
physicians 41%, nurses 29%, dietitians 22%, others
SENSE OF BELONGING
working collectively provincially; (e.g. telehealth)
ENVIRONMENTAL
inadequate resources (i.e. funding (more diabetes nurse educators needed, mental health support 37%, long waiting times 34%), Time interaction with patients e.g for building trust
Storm-Versloot
2012
To find out whether a successful multifaceted implementation approach of a local evidence-based guideline on postoperative body temperature measurements (BTM) was persistent over time, and which factors influenced long-term adherence MIXED Mixed methods study
Patient records were retrospectively examined to measure guideline adherence. Data on influencing factors were collected in focus group
meetings for nurses and doctors
The Netherlands
47 RN + 42 doctors
ATTITUDE
Belief in the advantages of the guideline lack of self-efficacy
SENSE OF BELONGING
strong staff support
CPG STRUCTURE
(Characteristic, contradictory)
controversial nature of the guideline
Wolfensberger
2018
To identify the optimal behavior leverage to improve Ventilator-Associated Pneumonia (VAP) prevention protocol adherence MIXED Mixed methods study
Adherence measurements to assess 4 VAP prevention measures and qualitative analysis of
semi-structured interviews
Switzerland
42 nurses and 4 physicians
ATTITUDE
Motivation (reflective motivation, perceived seriousness
Self-efficacy
Level of Agreement side-effects of prevention measures
ENVIRONMENTAL
Organizational lack of resources equipment and staffing
Arzimanoglou
2014
To explore how prolonged convulsive seizures in children are managed (status epilepticus CPG) when they occur outside of the hospital QUAL Qualitative study Exploratory telephone survey Multicentric study:
seven EU countries (Belgium, France, German, Italy, Spain, Sweden, and UK)
128 HCP, (85 pediatric neurologists
and neurologists, 28 community pediatricians, and 15 epilepsies
nurses, in the UK and Sweden only)
KNOWLEDGE
Lack of familiarity, lack of awareness; accessibility
PATIENTS- CAREGIVERS’ ATTITUDE
Caregiver’s attitudes, insufficient training; lack of training and fear (teachers, etc.)
Bayuo
2017
To identify pain management practices in the burn’s units of Komfo Anokye Teaching Hospital, compare these approaches to best practice, and implement strategies to enhance compliance to standards QUAL Evidence implementation project with Joanna Briggs Institute Practical Application of Clinical
Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool
Ghana
Project team was predominantly constituted by nurses (3 units), as well as from 2 surgeons and a clinical fellow.
KNOWLEDGE
Information accessibility
ATTITUDE
Outcomes expectancy
ENVIRONMENTAL
Organizational constraints
Dogherty
2013
To describe the tacit knowledge regarding facilitation embedded in the experiences of nurses implementing evidence into practice. QUAL Qualitative study
In-depth analysis
Canada
purposive sample- 20 nurses from across Canada, including nurses from across the continuum of care and working with different clinical populations
Facilitators
ATTITUDE
Motivation self-efficacy (focus on); sense of belonging (partnership, teamwork)
EXTRINSIC FACTORS-
CPG STRUCTURE
(Characteristics accessibility, relevance, adaptation)
Barriers
ATTITUDE
SENSE OF BELONGING and self-efficacy (poor engagement)
ENVIRONMENTAL
Resources (lack of), conflict, contextual factors, sustainability
Efstathiou
2011
To study the factors that influence nurses’ compliance with Standard Precaution in order to avoid occupational exposure to pathogens QUAL Qualitative study Focus group approach Cyprus
30 nurses (93.7%)
participated (26 females, 4 males)
ATTITUDE
Negative influence of protective equipment
Provision of nursing care to children not perceived as dangerous.
Influence on nurses’ appearance
Psychological factors embarrassment
Working experience (more confidence)
Physician’s influence (also not wearing protection)
ENVIRONMENTAL
lack of supplies, Availability of equipment time Too busy, lack of nursing personnel, implementation of guidelines is time consuming
Organizational constraints, Perceived increase in malpractice Emergency situation
PATIENTS- CAREGIVERS’ ATTITUDE
Patients’ discomfort
Anxiety, sorrow
Lai
2019
To promote evidence-based practice in screening for delirium in patients in palliative care QUAL Evidence implementation project with Joanna Briggs Institute Practical Application of Clinical
Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool
China
18 nurses
KNOWLEDGE
Lack of knowledge
ENVIRONMENTAL
lack of supplies, resources (screening tools)
Lin 2019 To identify the facilitators of and barriers to nurses’ adherence to evidence based
wound care clinical practice guidelines (CPGs) in preventing surgical site infections (SSIs)
QUAL Qualitative study incorporating ethnographic data collection techniques
Semi-structured individual interviews and focus groups (N = 20), and examination of existing hospital policy and procedure documents.
Australia
convenience sample
of 20 nurses who were at work on
the days they conducted focus groups
KNOWLEDGE
Facilitators
Participants’ active information‐seeking behavior clear understanding of the importance of aseptic technique
Barriers
Participants’ knowledge and skills deficits regarding application of aseptic technique principles in practice
Accessibility: availability of the hospital’s wound care procedure
Documents
PATIENTS- CAREGIVERS’ ATTITUDE
Facilitators
patient participation in wound care
Barriers
timing of patient education
Lu
2015
To examine the current practices for managing emergency equipment in a tertiary mental health institution
To determine the strengths and limitations of the existing practice/process.
QUAL Evidence implementation project with Joanna Briggs Institute Practical Application of Clinical
Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool
Singapore
Members with experience in various mental health settings and
with a role in checking and
maintaining the inventory of
emergency supplies and equipment
KNOWLEDGE
Lack of training, experience
ENVIRONMENTAL
Characteristic and organizational factors: inadequate knowledge and awareness of
the organization’s policy; lack of exposure and skills in operating emergency equipment in the psychiatric setting
Makhado
2018
To explore and describe barriers to treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy and anti-TB treatment QUAL Qualitative exploratory descriptive design
Four semi-structured focus group interviews were conducted
South Africa
24 NIMART nurses
KNOWLEDGE
Insufficient knowledge or lack of awareness
ATTITUDES
Lack of agreement with guidelines, poor motivation resistance to change
Meurer
2011
To describe barriers to thrombolytic use in acute stroke care QUAL Qualitative Study
Focus groups and structured interviews (pre-specified taxonomy to characterize barriers)
USA
Phase 1 focus group and
interviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators
(12), and three others (hospitalists and pharmacist).
KNOWLEDGE
Familiarity with, agreement, awareness
ATTITUDES
Motivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy
ENVIRONMENTAL
availability of intensive care units, ED crowding, pharmacy or radiology
PATIENTS- CAREGIVERS’ ATTITUDE
failure to recognize symptoms, preference to arrive
via car instead of ambulance, delayed presentation
CPG STRUCTURE
characteristics, issues with the
structure or content
Munce
2017
To understand the factors influencing
the implementation of the recommended treatments and Knowledge Translation
(KT) interventions (stroke rehabilitation
guidelines).
QUAL Qualitative study
Telephone focus groups were selected because of
the geographic dispersion
Canada
Purposive sampling was used
to recruit equal numbers of
participants across professional groups
(11 nurses, 11 therapists, 11 clinical managers), randomization arms
(facilitated KT intervention or passive KT intervention), and geographic locations
ATTITUDES
Agreement: clear and practical to follow implementation of recommendations. Barrier when unclear, too general
KNOWLEDGE
Familiarity with CPG (having some recommendations already in use) lack of familiarity as a barrier (lower volume of patients)
SENSE OF BELONGING
Team communication and interdisciplinary collaboration
ENVIRONMENTAL
barrier lack of time (time pressure), lack of space and equipment
WORKLOAD
lack of staff or staff turnover
Presseau
2017
To inform how to deploy the Individualized Dialysis Temperature (IDT) across many hemodialysis centers, we assessed hemodialysis physicians’ and nurses’ perceived barriers and enablers to
IDT use.
QUAL Qualitative study
Phone Interview
Two topic guides using the Theoretical Domains Framework (TDF) to assess perceived
barriers and enablers
Canada
nine physicians and nine nurses from 11 Ontario hemodialysis centers
KNOWLEDGE
Awareness of CPG
ATTITUDE
Benefits and motivation, optimism, reinforcements (It’s a little priority at this point)
SENSE OF BELONGING
Role identity, beliefs about capabilities; forgetting to
prescribe or set IDT
ENVIRONMENTAL
Availability of resources (thermometer for dialysis.)
WORKLOAD
Reducing episodes of hypotension during dialysis can decrease workload
PATIENTS- CAREGIVERS’ ATTITUDE
Patient factors: comfort, emotions (Patients may feel too cold on cooler dialysate temperatures)
Stenberg
2011
To describe influences on health care professionals’ attitudes to CPGs for preventing falls and fall injuries QUAL Qualitative study
Qualitative approach with focus group.
Texts were analyzed using manifest and latent content analysis.
Sweden
23 HCP
Physicians (4), registered nurses (15), physiotherapists (3), and 1
occupational therapist
ATTITUDE
Motivation: experiencing a course of events (falls and fall injuries, from severe trauma such as subarachnoid bleeding and hip fractures to smaller chafes and bruises)
Experiencing the benefit previous negative consequences had been reduced or eliminated and, thereby, replaced by positive outcomes since they startedto use the CPG for fall prevention.
Individual Resources: being motivated
ENVIRONMENTAL
Influence of social factors community obligations (consider laws and regulations in their decision-making) and organizational (leadership with clear priorities)
van de Steeg
2014
To identify and classify barriers to adherence by nurses to a guideline on delirium care. QUAL Qualitative study
Open-ended interviews were conducted with a purposive sample of 63 research participants
The Netherlands
28 nurses, 18 doctors and 17 policy advisors
ATTITUDE
Motivation (lack of motivation - nurses - lack of clarity of the benefits and goals of screening, results of screening are not directly visible; screening not being part of the essential care for older persons.
KNOWLEDGE
Nurses conveyed that they had sufficient knowledge and skills to use the screening instrument to identify at risk patients, but Doctors mainly emphasized the importance of additional education for nurses on delirium screening and treatment
ENVIRONMENTAL
Organizational: The social pressure to screen all older patients appears to be limited: it is generally accepted among nurses that other activities take precedent over screening
van den Berg
2019
To identify barriers and gather improvement suggestions through
semi-structured in-depth interviews conducted with 24 professionals working in oncofertility care
QUAL Qualitative study
Semi-structured in-depth interviews
The Netherlands
24 professionals working in oncofertility care (Specialized oncology nurse (4%)
Specialized breast cancer nurse (17%); Medical oncologist (29%)
Surgical oncologist (29%)
Gynaecological oncologist (8%)
Haematologist (4%) Reproductive gynaecologist (8%)
KNOWLEDGE AND
ATTITUDE
Lack of awareness, knowledge, time, and attitude: less aware of discussing fertility in patients who are of a higher age, who have children, who don’t have a (clear) wish to conceive or who have a poor cancer prognosis.
ENVIRONMENTAL
Organizational unavailable written information, disagreement on who is responsible for discussing infertility risks).
Patients’ attitude: focus on surviving
Cancer; HCPs feel that patients do not place fertility high on their priority list because they are focused on surviving cancer
Weller
2020
To identify health professional
perspectives about using Venous Leg Ulcer (VLU) CPGs to guide the management of people with VLUs in primary care
QUAL Qualitative study
Semi-structured face-to-face and telephone
interviews with health professionals, GPs, and PNs
Australia
and snowball sampling strategies
to recruit the participants. 15 GPs (43%) and 20 PNs (57%), including
two Aboriginal health nurses (6%), who worked in primary health care settings
KNOWLEDGE
Lack of knowledge and Skills, lack of awareness, ATTITUDES
Lack of trust and motivation (better what was done in the past)
SENSE OF BELONGING
teamwork, collaboration
ENVIRONMENT
Lack of supplies (print and
electronic versions of the
VLU CPGs)
Yanke
2018
In this qualitative, descriptive project, 4 focus groups were convened over a 5-month period to identify work system barriers and facilitators to implementation of the VA CDI bundle QUAL Qualitative study
Four focus groups were conducted 1 with attending physicians, 1 with resident physicians, and 2 with RNs and HTs (n 7)
USA
convenience sample consisted of attending hospitalist physicians, internal medicine resident physicians, and registered nurses
(RNs) and health technicians (HTs) employed at our VA hospital
ENVIRONMENTAL
Organizational constraints (testing or obtaining the sample), lack of supplies (soap dispenser or working sinks for hand Hygiene)
Culture of institutional support for CIP (contact isolation precautions) compliance and support for independent RN C difficile testing and decision-making

CPG: Clinical Practice Guidelines

HCP: Health Care Professional

GP: General Practitioner

RN: Registered Nurse

RCT: Randomised Controlled Trial

QUAN: Quantitative

QUAL: Qualitative

MIXED: Mixed-Method

Integrated analysis of the major findings

After the data extraction phase, the major findings from each study were analysed by aggregating them into two main themes: Intrinsic and Extrinsic Factors. The Intrinsic Factors were then analysed considering the following subthemes: a) knowledge and skills; b) attitudes of health personnel; c) sense of belonging towards guidelines. The Extrinsic Factors were analysed taking into account the following subthemes: a) organizational and environmental factors; b) workload; c) CPGs’ structure; d) patients and caregivers’ attitudes.

For this mixed-method systematic review, a graphic synthesis of the main results was developed (Fig.3).

Figure 3.

Figure 3.

Aggregate analysis of Barriers and Facilitators in nurses’ implementation of CPGs

It aims to give both a qualitative and a quantitative perspective to answer the main research question. The synthesis provided in figure 3 combines the main themes and subthemes adopted with the number of studies that take them into account. Indeed, the area of each theme and subtheme is proportional to the number of studies that report about them.

Intrinsic Factors

Knowledge and skills

Knowledge and skills may represent a facilitating factor for the implementation of CPGs. On the other hand, their lack or inaccessibility could represent an important barrier. Kowitt et al. (25) highlight as educational programmes for infection control implemented hospital-wide (e.g., hand hygiene initiatives) may increase nurses’ overall compliance. Lin et al. (26) identify knowledge and skills as facilitators for the adoption of evidence-based CPGs in preventing surgical site infections: a clear understanding of aseptic techniques together with a proactive attitude toward information seeking can improve the adherence to CPGs in wound care. Conversely, the lack of training when implementing new CPGs can lead nurses to a sense of disorientation and inadequacy, acting as a strong barrier to the CPGs adoption. Senananyake et al. (27) identify lack of education and training as a barrier to effective implementation of a WHO checklist for safe childbirth in Sri Lanka. Similarly, Damush et al. (28) report that nursing staff providing guideline-based care to transient ischemic attack patients in U.S. Veterans Administration Medical Centres perceive inadequate knowledge.

Lack of training and experience is one of the most debated topics, also reported by Lu et al. (24) in describing current practices for managing emergency equipment in a tertiary mental health institution: the authors stress the importance of testing and retraining to maintain the acquired skills. Similar results have been shown in other studies conducted in a wide range of settings, such as cancer and postoperative pain management, oral health care, vascular access management, delirium screening, hand hygiene, and sexually transmitted diseases (23, 29-38). Many authors stress the importance of information accessibility, CPGs familiarity (22,25,39-43) and nursing staff awareness, either demonstrated or perceived (44-51). Jansson et al. (52), in a study on the prevention of ventilator-associated pneumonia, focus on the lack of guidance as one of the main self-reported barriers towards evidence-based guidelines.

The only divergent opinion is reported in Aloush’s study (53), a randomized controlled trial showing that there is no statistically significant difference in CPG compliance between nurses who have received education on ventilator-associated pneumonia and those who have not.

Attitude of the health personnel

Another important intrinsic factor retrieved from the included study is the attitude of the health personnel. Attitude can be intended as trust and motivation toward CPGs, outcomes expectation, perceived self-efficacy, resistance to adopting new practices (30,33,36,37, 39, 44, 49, 51, 54-60), lack of enthusiasm (29, 32), lack of reinforcements (48), poor engagement (61), fear of adverse events (35, 62-64).

Huis (65) highlights how nurses’ hand hygiene compliance is positively correlated with feedback on their performance: feeling solicited by colleagues to maintain proper hand hygiene behaviour is an aspect of the social component that correlates positively with changes in adherence to CPGs. Another motivating factor identified is the attitude towards patient contact (22,31,66): nurses show greater compliance with hand hygiene performed after patient contact than hand hygiene performed before approaching patients.

Sense of Belonging

The sense of belonging involves the feeling, belief and expectation that one is included in the group and has a place there. It concerns the sense of acceptance and willingness to sacrifice oneself for the group (67-69).

Regarding sense of belonging, Knops et al. (67) emphasize the importance of a favourable social context and Dogherty et al. (61) highlight the importance of partnership and teamwork. In Munce et al. (41), team communication and interdisciplinary collaboration emerged as facilitating factors for stroke rehabilitation CPGs implementation. Participants in Weller’s research (51) identified teamwork, collaboration and shared decision making as the elements that enhance the sense of belonging and the achievement of common goals. Similarly, in McIntosh et al. (70) working collectively at a provincial level was the main theme identified by the health providers to overcome the barrier to paediatric diabetes CPGs adherence.

In Presseau et al. (48), the sense of belonging is undermined by the lack of professional role identity: in fact, nurses report having to adapt exclusively to doctor’s orders. These results partially overlap with those of Harillo-Acevedo et al. (69) and other studies on lack of cooperation and trust (33,54).

Extrinsic Factors

Environmental and organizational factors

The most frequently identified factors that hindered the use of CPGs were the environmental ones such as lack of resources, environmental characteristics, organizational constraints, and leadership style. Of the 60 studies analysed, 47 considered environmental factors as barriers or facilitators to CPGs adherence. Resources can be represented by availability of drugs, supplies, appropriate instrumentation (23,28,29,32,42,48,51,57,58,60,61,63,71-77), time (29,32,33,41,46,49,50,52,57,70,74,75) or cost reimbursement, e.g., the lack of community resources for referral to specific services (74).

Environmental characteristics and organizational constraints could represent a big issue in CPGs implementation and a challenge to be faced through educational and organizational interventions, as well as leadership support. Crowding (39,66), lack of coordination (28,56) or supervision from the institutional level (27,49) are factors that must be managed. Leadership style correlates positively with changes in nurses’ compliance (65) and in defining priorities (62) as the workplace culture play an important role in terms of facilitating factor (78).

Workload

The workload represents an extrinsic factor emphasized by many studies and, even if it refers to the environmental/organizational factors, in the present review it has been analysed separately.

Aloush’s studies describe a strong relationship in terms of number of beds per unit and nurse-to-patient ratio, as a factor influencing the compliance of the entire nursing staff (53,71). Nursing personnel working in units with fewer beds and a 1:1 nurse to patient ratio had statistically significant higher compliance scores than those employed in units with more beds and a 1:2 nurse to patient ratio. Muller (66) comes to different conclusions, saying that daily patient volumes and nursing working hours are not associated with hand hygiene compliance, but it could be seen better compliance during the night shifts and the weekend (25). However, the shortage of nursing staff that means a) to downsize the time available to follow the recommendations, b) to be often alone during the working shift, c) to feel a higher work pressure, are all widely discussed factors that greatly affect guidelines adherence (27,31,41,44,48,49,51,64,72,79-81).

CPGs’ structure

Few studies, among the ones included in the present review, reported guideline characteristics such as trustworthiness, clarity, and degree of complexity as potential barriers to adherence. The studies describe the lack of guideline familiarity as a large component of the above-mentioned barriers (39), too much time required to document properly the recommended actions of care (64), poor accessibility or lack of structural resources (51,61) poor usefulness in daily practice (33,67), contradictory content, lack of clarity or poor usability (49, 54).

Patients and caregivers’ attitude

A widely debated aspect concerns possible frailties or difficulties shown by patients regarding the application of the CPGs recommendations; the present review also considers the possible barriers acted by the patients’ caregivers.

Features such as gender, ethnicity, attitudes, or payer source can affect the patient and even the nurse in adhering to guideline-based screening campaigns, such as those for smoking described by Cato (38) or Katz (56). A facilitator for nurses has always been the level of active participation shown by the patient (26). On the other side, an attitude of reluctance, such as rejection to rely on opioids for pain control, may be a barrier to appropriate care management (29). The patient is not always able to follow the directions causing involuntary delays in the provision of care (32,39,52,70), not feeling comfortable with them (47-49,57,74,75,82) or not considering them a priority (60). Moreover, in some cases, the clinical characteristics do not allow the guidelines to be applied (43,73).

Concerning the caregivers, they play a very important role in paediatric studies. Arzimanoglou et al. (40) report that in children affected by convulsive seizures the caregivers (teachers) show resistance, fear and a lack of systematic training. Løyland et al. (31) report that, in case of hospitalization, hygiene measures are conditioned by parents kissing or having close contact with their children. In general, it is sometimes possible to witness an opposing attitude from the relatives (42) and, in the case of venereal diseases such as syphilis, a lack of adherence of the partner conditioning the success of the treatments (34).

Conclusion

The present mixed-method review has shown that intrinsic and extrinsic factors in CPGs implementation are almost equally distributed in the included studies, with a slight prevalence of the latter (Fig.3). Among extrinsic factors, the environmental ones are prevalent, while among intrinsic factors, attitude and skill-knowledge are equally represented. Intrinsic and extrinsic factors could either play the role of barriers or facilitators, as also emerged from the previous integrative review by Jun et al (12). Considering nursing personnel, the studies included in the present review report the lack of resources as the main barrier perceived by nurses. Particularly, in low-income countries, lack of supplies remains one of the major problems (e.g., water for performing hand hygiene) and nurses, who are at the forefront in addressing the direct application of knowledge and skills to ensure patient safety, have a higher perception of this kind of barrier than other healthcare personnel (20).

On the other hand, the results of the present review highlight a series of potential facilitators such as having good feedback at the workplace, positive reinforcements, either from the members of the team or from the leaders. Leadership, but also the level of active participation of the patient and caregiver in care processes could have a positive impact. Indeed, the present review considers also factors related to patients and caregivers’ behaviours that could be perceived as possible barriers/facilitators by nurses.

A possible limitation of the present study is the choice to include all care settings and nursing fields. This choice is because the authors’ goal was to provide a broad perspective of the review topic. Indeed, choosing a mixed-method approach, that represents an element of novelty of the present review, has allowed a wider understanding of the phenomenon. Considering not only quantitative studies, but also qualitative and mixed methods has provided multiple perspectives of the factors related to CPGs implementation and adherence.

Another limitation that emerged in conducting the present review is the extraction of data pertaining specifically to nursing staff. The purpose of this study was to synthesize the available literature on extrinsic and intrinsic factors that act as barriers or facilitators in CPG implementation, focusing on nursing staff, but the process of knowledge translation and guideline adoption is mostly reported as a team-related issue.

Proactive identification of barriers and facilitators is a key factor in developing and implementing strategies to increase guidelines adherence. Anyway, CPGs’ implementation remains a complex process, which can only be based on policies promoted at a managerial level, within the framework of continuing education programs for nursing staff and in a context of shared goals (12,83,84). Moreover, a similar pathway to raising awareness about the importance of CPGs adherence should be provided in undergraduate and postgraduate education, also by defining specific assessment measures, as there are distinctive differences in the factors influencing students’ clinical decision making compared with that of registered nurses regarding the use of CPGs (85).

As aforementioned, implementing and maintaining a high level of adherence to CPGs over time is a complex process, resulting in a strong recommendation to support health policymakers and nursing leaders in promoting both core and continuing education programs.

Acknowledgements

I would like to express my very great appreciation to Prof. Follenzi, Course Coordinator of the PhD. Program in “Food, Health and Longevity”, for giving me this opportunity.

Funding Statement

This study was partially funded by the Italian Ministry of Education, University and Research Translational Medicine, Università del Piemonte Orientale.

Conflict of Interest:

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

Authorship statement

All listed authors meet the authorship criteria and agree with the content of the manuscript.

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