Abrahamson, Kathleen A. PhD, RN; Fox, Rebekah L. PhD; Doebbeling, Bradley N. MD, MSc, FACP
It's well known that often there is a “knowledge translation” gap between the care that patients receive and the evidence for best practice.1 Clinical practice guidelines exist largely to help clinicians close that gap. But guidelines are only as useful as the extent to which they're used. In this study, we sought to better understand the facilitators and barriers to guideline use among nurses.
The Institute of Medicine defines clinical practice guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”2 Essentially, such guidelines are tools designed to provide structured guidance about evidence-based care and to decrease variability in health care delivery. Frequently, they are presented as step-by-step flowcharts or algorithms that can guide clinical decision making and care planning. When used by direct care providers, clinical practice guidelines encourage the consistent, efficient application of scientific evidence.1, 3, 4
The majority of the research on the development, implementation, and use of clinical practice guidelines has focused on physician behavior. Yet nurses play a large role in patient assessment, clinical decision making, and guideline implementation. Indeed, one study of staff at 27 hospitals found that, when asked to identify which profession was primarily responsible for ensuring patient safety, “96% of nurses and more than 90% of physicians, administrators, and pharmacists assigned primary responsibility to nurses.”5 Clearly it's important that nurses contribute to guideline development and take a leadership role in implementing guidelines that fall within their scope of practice.
Research conducted among both physicians and nurses suggests some general differences in attitudes toward and usage of clinical practice guidelines. A survey of Canadian clinicians found that, compared with physicians, nurses reported using guidelines more frequently, considered guideline consistency with current practice more relevant, and found guideline endorsement by a colleague less relevant.6 Another study of ICU clinicians found that nurses had significantly more positive attitudes toward and greater knowledge of clinical practice guidelines than physicians.3
Our reasons for studying nurses' use of clinical practice guidelines in greater depth were threefold. First, of the clinicians on a patient's interdisciplinary care team, nurses have a significant responsibility to ensure patient safety. Second, clinical practice guidelines directly address specific aspects of nursing practice. Lastly, as Koh and colleagues have noted, to be effective, “implementation strategies need to be tailored to the local context; no single approach will have universal applicability.”7 A better understanding of how nurses' work environments affect guideline use is thus needed; but this has received little attention from researchers.4, 7, 8
For this study, using data collected for an earlier parent project, we examined text responses to two open-ended survey questions asking nurses about facilitators and barriers to guideline use in their daily practice. We then analyzed their responses to discover what nurses identify as facilitators and barriers, categorized these as either internal or external to an individual nurse's control, determined their prevalence, identified emergent themes, and considered these findings in relation to earlier research.
Guideline implementation and use are complex processes. In several studies conducted with physicians, nurses, or mixed groups of clinicians, participants have identified numerous specific factors that can facilitate or inhibit guideline implementation and use.4, 9-11 Internal factors are those that exist within the practitioner, such as knowledge of clinical practice guidelines, attitudes about the practice change, and motivation or lack of motivation to do so. External factors are those that exist outside the practitioner. These might be intrinsic to a patient case, the work environment, the organization, or the guideline itself.
Internal and external barriers. One important internal barrier to guideline use is a lack of awareness that a guideline exists.6, 9, 10, 12, 13 Another internal barrier cited by busy practitioners working in clinical settings is a lack of familiarity with a guideline's content or with the relevant research literature.6, 7 On the other hand, there is evidence that clinicians who are familiar with both the guideline and the relevant research might disagree with the guideline's interpretation.9, 10, 12
Clinicians have also expressed concern that the uniformity of clinical practice guidelines encourages “cookbook” or formula-driven medicine.3, 14 If clinicians feel their current practice is adequate, they may lack the motivation to adopt a guideline's recommendations.9, 10 And many practitioners report relying on colleagues for decision support, a practice that may decrease the use of evidence-based guidelines and increase reliance on experience-based decision making.10, 15
One external barrier to guideline use is a confusing or overly complicated guideline format.3, 9, 14, 16 Computer-related barriers include extensive, time-consuming documentation and difficulty in those with limited computer skills.17 Interestingly, a lack of computer access has also been cited as an impediment to guideline use.17
The inherent lack of time in busy clinical settings has been identified as a significant external barrier.3, 13, 14, 17 Similarly, heavy workloads and difficulty reconciling patient health status with guideline recommendations may pose barriers to consistent use of clinical practice guidelines.7, 18 Some practitioners have cited a lack of resources as impeding their ability to carry out guideline recommendations.7, 13, 14 For example, a recommendation to use a bed alarm for patients at high risk for falls isn't useful if no bed alarms are available.
Inadequate support from administration or peers can impede guideline implementation efforts.8 A lack of endorsement for a guideline by opinion leaders may adversely affect its acceptance and use.6, 10, 15 Resistance from patients and their families to guideline-recommended care measures can decrease guideline adherence as well.10, 14 In short, previous research conducted with physicians, nurses, or mixed groups of clinicians has identified numerous internal and external barriers to guideline implementation and use.
Internal and external facilitators. Research has also identified facilitators to guideline implementation and use. An Australian survey asked nurses to name the “greatest facilitators to research utilization”; the researchers found that “availability of more time to review and implement research findings, availability of more relevant research, and colleague support”—all external facilitators—were most often reported.13
Goossens and colleagues sought to understand the relationship between learning style and guideline use for Dutch physicians and nurses.8 They found that physicians were more willing to adopt a guideline when it was based on good evidence, supported by staff, and dealt with “an interesting subject.” Nurses were more likely to adopt a guideline if they were interested in its subject, if the guideline had been developed “within their own discipline,” and if the guideline was supported by staff.
Clinical practice guideline use among nurses. Although there has been relatively little research on guideline use specifically among nurses, some barriers have been identified. Lyons and colleagues, investigating the role of information technology in guideline implementation among nurses, physicians, and administrators, found that nurses identified lack of time and lack of access to computers as significant barriers to guideline utilization.17 Koh and colleagues, surveying nurses in Singapore, found that 73% said they lacked the material resources necessary to implement a clinical practice guideline addressing fall prevention.7 A study by Sinuff and colleagues found that a lack of awareness that a guideline existed and a lack of familiarity with guideline content or research findings were major barriers.6
A Scottish study of the use of nursing best practice statements by 15 nursing leaders involved in their development found that even for this group, implementation was challenging.4 Barriers included lack of time and other resources, lack of training, resistance to change, and lack of “local champions.” It stands to reason that, for guideline implementation and use to be optimal, more research evidence specifically from the unique perspective of nurses is essential.
Some facilitators to guideline use among nurses have also been identified. Lyons and colleagues found that “widespread accessibility to computers and online guideline features” were important facilitators.17 A study conducted with nurses and other health care staff at four nursing homes found that incorporating guideline recommendations “into training materials, standing orders, customizable data collection forms, and regulatory reporting activities” facilitated guideline use.19
In formulating our research questions, we considered that health care delivery is dynamic, complex, and often unpredictable; we also recognized that the experiences of nurses differ from those of other health care providers and merit our attention. Improvements in health care delivery processes are likely to emerge in part from the innovations of those in direct contact with patients—such as nurses. Implementation of clinical practice guidelines requires an understanding of the user's perspective to be successful.20 By asking nurses directly to identify facilitators and barriers to guideline use, we hoped to obtain information about the nurse's perspective that will help in the design of future implementation projects.
Three specific questions inspired our research:
* What do nurses identify as barriers to the use of clinical practice guidelines?
* What do nurses identify as facilitators to the use of clinical practice guidelines?
* How do nurse-identified barriers and facilitators differ from those identified by other health care providers in previous research?
Clinical Practice Guidelines at VA Facilities
For several reasons, the Veterans Health Administration (VHA) system is an advantageous setting in which to study the use of clinical practice guidelines. Since 1996, the VHA has been implementing and using clinical practice guidelines, and has won recognition for its efforts.17, 22, 23 Many of these guidelines are developed by a national task force made up of Veterans Affairs (VA) and Department of Defense (DoD) experts, with input from physicians, nurses, clinical pharmacists, and others. (For more on the task force, visit http://bit.ly/GN9N3A.) All guidelines used by the VA and DoD are evidence-based and nationally consistent across all VA and DoD facilities. Multiple performance measures based on these guidelines are monitored through a chart audit system.17 The VA shares data on guideline adherence and other key performance measures within and across its facilities.17, 24, 25
Data for this study were provided by a parent project, a survey conducted in 2003 to investigate organizational factors influencing the use of clinical practice guidelines among physicians, nurses, advanced registered NPs, and physician assistants (PAs) working within 143 Veterans Affairs (VA) medical centers. The survey addressed implementation strategies and provider adherence for three sets of guidelines: those for chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. See Methods: The Parent Project for more details.
Our sample. Because the research questions addressed by our analysis deal with the work environments of nurses providing patient care, only RNs in direct care roles were included, resulting in a sample of 973 RNs. Of these, 575 RNs from 134 VA medical centers provided responses to two open-ended questions about the use of clinical practice guidelines (referred to as CPGs in the survey):
* Question 23: “What are the facilitators to CPG use?”
* Question 24: “What are the barriers to CPG use?”
Thus, the final sample size for our qualitative analysis of open-ended responses to those two questions was 575.
Analysis. In order to move beyond merely counting words to examining the intensity and relevance of survey responses, in 2009 and 2010 we performed a conventional content analysis on responses to these two open-ended survey questions. As Hsieh and Shannon have described, a conventional content analysis uses inductive category development (rather than a directed or summative content analysis), such that coding categories emerge directly from the data; this method allowed us to gain a richer understanding of the phenomena.21
Two of us (KAA and RLF) initially read through the data to gain a better understanding of the responses as a whole, then reread the data, taking notes and independently creating preliminary lists of coding categories or themes. The two lists were then compared to identify and clear up any discrepancies within the coding scheme. Each of us then recoded data for 10% of the sample, based on the agreed-upon coding categories, and discussed the findings in an effort to achieve intercoder reliability. Because thematic consensus wasn't reached with the initial 10% of the sample, data for an additional 10% were recoded and discussed, and this yielded consensus. We then coded the remaining responses independently, with the understanding that some responses might require adjustment to or amendment of the existing categories.
The coded data were then grouped into four subcategories—“internal facilitators,” “external facilitators,” “internal barriers,” and “external barriers”—based on whether a response reflected a facilitator or a barrier and whether this was internal or external to a nurse's control. Responses were further grouped into the subcategories of “attitude-based,” “knowledge-based,” “organizational characteristics,” and “patient characteristics,” based on findings from previous research that investigated guideline use among physicians.9 Because the data were in free-text form and individual nurses' responses varied in length and content, when the text indicated multiple barriers or facilitators, the response was coded into multiple categories. See Tables 1 and 2 for coding categories.
Methods: The Parent Project
At each of the 143 Veterans Affairs (VA) medical centers, which were selected to form a nationally representative sample, a minimum of eight physicians, eight nurses, and four NPs or physician assistants (PAs) (or both), if available, were randomly selected and contacted. The VA's Paid Database (consisting of employees paid directly by the VA or the U.S. Treasury) was used for sampling; its occupational codes vary, depending on how specific positions are coded locally.
Providers were selected from both inpatient units and ambulatory care clinics, although the sampling primarily focused on outpatient settings because other aspects of the parent project dealt primarily with preventative and primary care issues, which would be more frequently addressed in outpatient settings. A stratified random sampling approach was designed to obtain a representative sample of providers from each professional category and to permit the researchers to determine differences between professions with adequate statistical power. This yielded a total sample of 4,621 direct care physicians, nurses, NPs, and PAs. Providers who were no longer providing direct care or who had left the facility (n = 394) were removed. The final sample consisted of 4,227 providers, including 1,770 physicians, 1,643 nurses, and 814 NPs or PAs. (The last two categories were collapsed, because facilities typically employed either NPs or PAs but not both.) (For more on the parent project, contact the authors.)
In their written comments, over 20% of the 575 RNs in our sample identified the following categories as important to facilitating the use of clinical practice guidelines: education/orientation/training (37%), communication (27%), and time/staffing/workload (21%). For example, 21% of nurses gave a response indicating that their ability to use guidelines was assisted by having adequate time and a manageable workload. Fewer than 5% of the sampled nurses identified the following categories as important to facilitating guideline use: budget/resources (4%), general organizational climate (4%), MD support (3%), and flexibility/willingness to change practice (1%). See Table 3 for the frequencies with which nurses identified facilitators, by category.
Over 20% of the sampled nurses identified the following as categories in which there were barriers to the use of guidelines: time/staffing/workload (44%), education/orientation/training (25%), and communication (22%). For example, 44% of nurses gave a response indicating that their ability to use guidelines was impeded by a lack of time and a heavy workload. Fewer than 5% of the sampled nurses identified the following as categories in which there were barriers to guideline use: patient adherence (4%), flexibility/willingness to change practice (4%), lack of needed equipment (4%), availability of clinical practice guidelines (3%), budget/resources (3%), patient complexity (2%), information overload (1%), and reminders (1%). See Table 4 for the frequencies with which nurses identified barriers, by category.
External versus internal facilitators. External facilitators—those outside the control of the individual nurse—were identified by 94% of the sampled nurses, and 50% identified more than one external facilitator. In comparison, only 11% of nurses identified internal facilitators—those within the individual nurse's control—and fewer than 1% mentioned more than one internal facilitator. All of the five most frequently mentioned facilitators were external: two were knowledge-based (education/orientation/training and communication), two were organization-based (time/staffing/workload and staff input), and one was attitude-based (administrative support). Over half of the sample (57%) identified at least one external facilitator in the organizational characteristics category. Similarly, over half (53%) identified at least one external facilitator in the knowledge-based category. The most frequently mentioned internal facilitator, identified by 11% of the sample, was attitude-based: nurses' perceived need for decision support. That is, 11% of the sampled nurses indicated that having a guideline helped meet their need for decision support. Thirty-nine percent of the sample mentioned a facilitator that was directly related to guideline characteristics or quality.
External versus internal barriers. External barriers were identified by 91% of the sampled nurses, with 53% identifying more than one external barrier. Internal barriers were identified by only 10% of the sampled nurses, with fewer than 1% noting more than one. All of the five most frequently mentioned barriers were external: two were organization-based (time/staffing/workload and technology), two were knowledge-based (education/orientation/training and communication), and one was attitude-based (administrative support). Notably, almost half of the sample (44%) identified inadequate time or staffing or a heavy workload to be a barrier to the use of guidelines, and 67% identified a barrier that was related to organizational characteristics. Thirty percent identified a barrier that was directly related to guideline characteristics or quality. Only 6% noted a barrier that was directly related to patient adherence or complexity.
Our findings indicate that a majority of both facilitators and barriers to guideline use are external, with an emphasis on social and organizational factors. That emphasis may reflect the importance of the workplace environment for direct-care nurses. These findings also support those of some earlier studies, which indicated that social and organizational factors are critical to effective guideline implementation and use. But our results also differ from those of other studies, which found that, particularly among physicians, internal attitudes are central to such efforts.
Barriers related to a guideline's characteristics are often the easiest to address; yet it's the social or organizational barriers to guideline use that are likely to be more important.16 The importance of the social and organizational context was reflected in the responses provided by our sample. The vast majority of nurses' responses concerned workplace conditions such as time, workload, availability of education, communication among clinicians, and administrative support. The percentage of nurses who mentioned budgets, funding, or the availability of resources (apart from staffing) was quite low; but this likely reflects the fact that we sampled direct care nurses, who rarely deal with such matters. Administrative nurses, who would be more likely to address these as important factors, were not included in our sample. Moreover, while staffing, time, and workload are indirectly related to funding, they're also factors in issues such as the care-delivery model, unit organization, and scheduling methods. Thus, the common perception that inadequate funding is the primary barrier to guideline implementation was not confirmed by our analysis.
The nurses in our sample appeared to view sufficient education, effective communication, and adequate time as the primary factors necessary for successful guideline implementation. Interestingly, in contrast to what some other studies have found, the nurses in this sample did not cite lack of awareness of a guideline's existence as a primary barrier to use. Possible explanations for their apparent awareness of clinical practice guidelines include this study's use of a VA-specific sample; VA medical centers were relatively early to adopt the use of such guidelines (see Clinical Practice Guidelines at VA Facilities 17, 22-25). Moreover, this analysis used only free-text data, and nurses who lacked awareness of clinical practice guidelines might have been less motivated to respond to the two open-ended questions.
Some of the categories mentioned less frequently also warrant attention. Cooperative teamwork was mentioned as a facilitator by 14% of the sampled nurses. This suggests the importance of involving nurses in planning a guideline's implementation and in promoting its use. Although relatively few nurses mentioned the importance of automated clinical reminders and the availability of technology (computers and computerized forms) as facilitators, these factors are also worth considering. It's important to design information and reminder systems that will best support guideline use by nurses. Furthermore, it's essential that nurses engage in dialogue with physicians and other advanced practitioners to determine the most appropriate use of guidelines and other research evidence. Of course, nurses must remain within the scope of their practice and take direction from clinicians with advanced licensure. When a physician or other advanced practitioner elects not to use a guideline, the nurse must complete the orders as directed. But to ensure understanding and consistent high-quality care, feedback concerning the physician's decision to ignore the guideline should be communicated to the nurse.
The complexity of guideline implementation was reflected in the large number of categories, many with only a few responses, that emerged from the free-text data. There was no clear consensus in the nurses' responses regarding factors that act as facilitators or barriers to guideline implementation. While some thematic categories (such as education/orientation/training and time/staffing/workload) emerged frequently, the majority were identified by fewer than 10% of the sample. Because responses to the two survey questions were free-text with no prompting, the wide range of categories does not indicate that those mentioned less frequently are unimportant. Rather, it's likely that each theme mentioned was highly salient to the nurses who mentioned it. While some facilitators and barriers are notably more recurrent than others, no one or two themes encompass the complexity of guideline implementation. There is no easy answer here to the question of how best to integrate the use of evidence-based guidelines into the many facets of nursing work.
Our findings are generally consistent with those of previous researchers who have investigated guideline implementation using physician-only or interdisciplinary samples. But there are some notable differences. Previous studies have found that physicians often believe that the research underlying guidelines is not sound, that decision support is unnecessary, or that current practice doesn't need to be changed—all of which pose significant barriers to guideline implementation.9, 10, 12, 26 Although these barriers were mentioned by some of our sampled nurses, overall, internal and attitudinal factors emerged much less frequently than external and social or organizational factors. It's possible that this disparity reflects significant differences in the work dynamics and responsibilities of physicians and nurses.
Strikingly, the majority of external facilitators and barriers noted in nurses' responses were not directly related to either patient or guideline characteristics. The latter difference varies from previous study findings, in which some clinicians have found guidelines too complex,14 too oversimplified,15 or too cumbersome3 to use.
Limitations. This study had several potential limitations. First, it involved nurses working within the VA system; results may not be generalizable to nurses working in other health care organizations and facilities, especially since the VA system has won recognition for its use of clinical practice guidelines. Second, the analyzed responses reflect only the views of those nurses who completed the open-ended portion of the parent project survey. Nonrespondents may have views that differ from those of respondents, and might have felt less motivated to answer questions 23 and 24. Third, the amount of provided text varied, with some nurses providing a large amount of data involving several thematic categories and others providing very little. Individual respondents did not contribute equally to the findings. Finally, in developing thematic categories from the data, the coders made decisions about which responses belonged in which categories. But some responses could logically be interpreted as belonging to multiple categories, and it's possible that some were miscategorized. For instance, a reference to a lack of information implies a lack of communication; it might also imply ineffective teamwork. Although we made every effort to ensure intercoder reliability and limit the influence of researcher bias, subjective interpretation is a potential limitation of any qualitative investigation.
The implementation of clinical practice guidelines in a manner that encourages their use by clinicians remains an ongoing challenge. The adoption and use of guidelines by practitioners isn't automatic. Active implementation efforts and evaluation of guideline use are necessary. Previous research addressing physicians' use of clinical practice guidelines indicates that even when physicians convey positive feelings about guidelines, they may be reluctant to use them.10, 15 This study sought to fill a gap in the literature by analyzing open-ended, written responses provided by a national sample of staff nurses.
Health care leaders seeking to improve clinical practice guideline use among nurses should ensure that facilitators and barriers—particularly those that are social and organizational in nature—are considered and addressed. For example, ensuring that nurses have adequate time and sufficient information to carry out guideline-recommended care is likely to improve guideline use. Because nurses must remain within the scope of their practice and take direction from physicians or other clinicians with advanced licensure, effective interdisciplinary communication and teamwork are also essential. Ideally, nurses should be involved at all stages of guideline development, implementation, and use.
It's important to remember that, while clinical practice guidelines provide concise access to research evidence, they can become outdated quickly. Frequent reevaluation is required to determine a guideline's validity and applicability in a specific clinical setting. Although the use of clinical practice guidelines is an important step in applying evidence to practice, nurses must still be able to understand and evaluate the current research literature and apply relevant findings to practice as well.
Future research. Although some of the research on guideline use addresses barriers and facilitators separately, often subjects are asked to report only barriers; a barrier's opposite is then considered to be a facilitator. In some cases, such assumptions might be accurate, but when they aren't, they can hamper our efforts to promote guideline use. For example, if a reported barrier to guideline use is “lack of time,” simply allotting more time may not help if the time made available isn't convenient for the user. Future research should treat barriers and facilitators as separate variables. We also recommend that future research employ multiple methods of data collection—interviewing, surveying, content analysis of charts, and other methods—within the same population, in order to gain a more in-depth understanding of guideline utilization.
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For 26 additional continuing nursing education articles on research topics, go to www.nursingcenter.com/ce.
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