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

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.

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.

PRISMA flow diagram.

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

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
Aloush2017	To evaluate the effect of the VAP (Ventilator-Associated Pneumonia)prevention guidelines education on nurses’ compliance	QUAN	RCT2-group posttest onlydesign	JordanI 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		WORKLOADFactors influencing compliance in the entire group:-number of beds per unit (fewer beds)nurse to patient ratio
Cahill2014	To improve adherence to critical care nutrition guidelines for theprovision of enteral nutrition	QUAN	RCTBefore-after study	USAICU (Intensive Care Unit): minimum of 8 beds, affiliated with a registered dietitian, located in North AmericaA total of 182 critical care staff (134) (74% nurses) responded at T0, and 118 (79% nurses) at follow up	ATTITUDETrust in prescription, fear of adverse events	ENVIRONMENTALDelivery of Enteral Nutritionto the Patient, delays in prescription, lack of supplies (feeding tubes)
De Meyer2018	To study the effectiveness of tailored repositioning and a turning and repositioning system on nurses’ compliance to repositioning frequencies.	QUAN	RCTMulticentre, cluster, three‐arm, randomized, controlled pragmatic trial	Europe16 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 geriatricwards and 8 rehabilitation wards	ATTITUDEResistance to the adoption of new practices (moderate-not present)	WORKLOADlower back strain (moderate)
Förberg2016	To investigate theeffects 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	RCTCluster Randomised Trial	SwedenInpatient units with access to the PVC template in the EPR systemto document PVCsRNs Intervention group (IG) T0: 108RNs Control group (CG) T0: 104RNs Intervention group (IG) T1: 106RNs Control group (CG) T1: 102		ENVIROMENTALRNs workContext (leadership, work culture, and evaluation- the use of data to provide feedback on the unit’s performance).Work culture scoring higher in IG.
Friese2019	To evaluate whether a web-based educational intervention improved Personal Protective Equipment (PPE) use among oncology nurses who handle hazardous drugs	QUAN	RCTCluster randomized controlled trial	USA12 ambulatory oncology settings396 nurses, (257 completed baseline and primary endpoint survey)RNs Intervention group (IG) (n 121): one-hour educational module on PPE use with quarterly remindersRNs Control group (CG) (n 136): control intervention + tailored messages to address perceived barriers and quarterly data gathered on hazardous drugRNs in IG reported higher workloads (6.2 patients vs 5.0)		ENVIROMENTALpractice environments, safety behavior, organizational factors, Structural barriers to partecipation, access to web-based contents,WORKLOADworkload 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.
Holmen2016	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- RCTQuasi-experimental design	RwandaA 160-bed, non-referral hospital in Gitwe12 physicians and 54 nurses		ENVIRONMENTALresources, lack of supplies (water)
Snelgrove-Clarke2015	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	RCTPragmatic randomized controlled trial	CanadaBirthing unit of teaching hospital in AtlanticAll 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’ ATTITUDEclinical characteristicsfetal heart rate, type of analgesia (both enablers and inhibitors)ENVIRONMENTALresources: supplies: doppler availability; policy
Alhassan2019	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	Ghanaprofessional (n = 89) and auxiliary (n = 24) nurses	KNOWLEDGEAccessibility:limited opportunities for in-service trainings, insufficiency of nasogastric tube feeding protocols on the wards.	ENVIRONMENTALlack of supplies: inadequatesupply of the re-requisite nasogastric tubesPATIENTS- CAREGIVERS’ ATTITUDEopposition from relatives of patients
Aloush2018	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	JordanICUs of 15 hospitals171 nurses, 81% female, mean age 32.5 y.o., 43% no prevoious education about CLABSI		ENVIRONMENTAL FACTORSLack of suppliesWORKLOADNurse-patient ratio (better 1:1)
Avedissian2018	To describe the current practices in the management of severe allergies and anaphylaxis by Lebanese nursesworking in schools and day cares and to explore the perceived need for a protocol to manage anaphylaxisreaction	QUAN	Observational Study Cross-sectional survey	Lebanon59 school and 126-day care nursesparticipated	KNOWLEDGELack of training, educationATTITUDESMotivationHesitance
Burkitt2010	To assess the effect of a multicenter methicillin-resistantStaphylococcus aureus (MRSA) prevention initiative on changes in employees’ knowledge, attitudes, and practices	QUAN	Observational Study cross-sectional study	USAnurses (38%), allied health professionals(30%), other support staff (24%), and physicians (9%) under age 50 years(57%)	KNOWLEDGE/ATTITUDESAwareness/agreement hand cleansing causesdamage to skin	WORKLOADToo busy
Cato2014	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.	USA14,115 patient encounters and 185 nurses enrolled	KNOWLEDGE AND SKILLS (Family and Pediatric, Adult Nurses Practitioners)	EXTRINSIC FACTORS-PATIENTS-CAREGIVERS’ ATTITUDEAttitudes (preferences, inabilities) Women, African American, payer source
Chavali2014	To improve Hand Hygiene (HH) compliance among all health care staff.To assess adherence to HH among nurses and allied healthcareworkers, 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.	Indianursing staff (n = 28)and allied healthcareworkers (n = 10)		ENVIRONMENTAL FACTORSLack of supplies (hand rub)Lack of resources (nurses’ shortage)WORKLOADPressure
Cotta2014	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	Australia331 respondents (24% physicians, 18% surgeons, 24% anaesthetists, 32% nurses and 3% pharmacists	KNOWLEDGElack of awareness (problem in other hospitals, do not want to participate in AMS interventions), lack of familiarity
Damush2017	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	USAVeterans Administration Medical Centers having an annual volume of ≥25 patients with a TIA or minor stroke.	KNOWLEDGEinadequate staff education	ENVIROMENTALOrganizational 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.	Sweden56 operating departments	ATTITUDESMotivationAgreement (it was not a routine to do…)	ENVIRONMENTALResources, time equipment, suppliesPATIENTS- CAREGIVERS’ ATTITUDEPreferences (feeling warm or having a temperature)
Harillo-Acevedo2019	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-sectionalStudyImplementationof breastfeedingCPG	SpainAll health care professionals of all categories working in maternal and/or pediatric care: 164 preimplementation and 152 postimplementation	SENSE OF BELONGINGSocial pressures to enact a behavior.ATTITUDESSelf-efficacy
Huang2019	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 EnteralNutrition (EN) practice in Intensive Care Unit (ICU).	QUAN	Observational Study Cross‐sectional descriptive study.	China808 nurses recruited	KNOWLEDGELack of time for training	ENVIRONMENTALOrganizational constraints (delay in physicians)PATIENTS- CAREGIVERS’ ATTITUDEDiarrhea
Huis2013	To examine which components of two hand hygiene improvementstrategies were associated with increased nurses’ hand hygiene compliance.	QUAN	Observational Study Process evaluation of a cluster randomized controlled trial	The Netherlands67 nursing wardsin three Dutch hospitals	MOTIVATIONTrust, self-efficacy related to experienced feedback, social influence within teams	ENVIROMENTALleadership (team and leaders-directed strategy)
Jansson2013	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.	Finlandcritical care nurses (n = 101)	KNOWLEDGE:Lack of knowledge, guidance	ENVIRONMENTAL:Lack of time, resources, staff
Jho2014	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	KoreaA total of 333 questionnaires (149 physicians and 284 nurses) were analyzed	KNOWLEDGEInsufficient knowledge	ENVIRONMENTAL FACTORSlack of time.Perceived malpractice: insufficient communication with patients or with physician (contacting physician for prescription of Opioid).Lack of supplies: Medication and intervention costsPATIENTS- CAREGIVERS’ ATTITUDEReluctance to report painReluctance to take opioid
Kiyoshi-Teo2014	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	USA576 critical care nurses	ATTITUDESuser attitude scaleKNOWLEDGEawareness, level of prioritization	ENVIRONMENTALTime availability
Kowitt2013	To identify factors associated with hand hygiene compliance during a multiyear period of intervention.	QUAN	Observational studyInfection control implemented hospital-wide hand hygiene initiatives	USANurses, Physician, Technical Staff, Support staffCalculated as: n of hand hygiene opportunities for each staff member	KNOWLEDGEVolume of information, educational campaignATTITUDEBetter after living patient’s room	WORKLOADBetter compliance during night shift/weekendENVIROMENTALOrganizational factors (Intesive Care Unit and pediatric wards)
Løyland2015	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 studyWorld Health Organization’s ‘5 Moments for HandHygiene’ validated observation tool to record indications for hand hygiene and adherence	USADirect providers of health, therapeutic and rehabilitative care, and other staff responsiblefor social and academic activities.Nurses 207 on a total of 847 providers (24.4%)	ATTITUDESSomeone used to or not, use of phone in contact precautions roomsKNOWLEDGEconfusion about which PPEshould be worn for different types of isolation precautions	ENVIRONMENTALFear of punishment, use ofdispensers or sinks is impractical while working, shared rooms among residents with infectionsWORKLOADHH was particularlychallenging when working alone with groups of residentsPATIENTS- CAREGIVERS’ ATTITUDEParents kissing or having close contacts with children
Muller2015	The authors evaluated whether Emergency Department (ED) crowding is associated withreduced hand hygiene compliance among health care workers	QUAN	Observational studyA trained observer randomly selected a specific ED room or bay and observed all staff providing care in that area for a 20-minute period	CanadaNurses, Physicians and other staff providing care in ED	ATTITUDEBetter after patient contact	ENVIRONMENTALCrowding in EDWORKLOADHigher Nursing Hours
Omran2015	To explore the knowledge, experiences, and perceived barriers to Colorectal cancer (CRC) screening among HCPs working in primarycare settings	QUAN	Observational study Descriptive cross-sectional design	Jordan236 HCPs (Health Care Providers)(45.8 %) nurses, physicians (45.3 %), and others (7.2 %)	KNOWLEDGELack of awareness about CRC screening test lack of policy/protocol on CRC screening	PATIENTS- CAREGIVERS’ ATTITUDEFear for diagnosisENVIRONMENTALLack of resources:shortage of trained HCPs to conduct invasive screening
Rodrigues2018	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	Brazil366 physicians andnurses working in PNC	KNOWLEDGELack ofATTITUDESprofessional difficulties (Difficulties in approaching and treating the sexual partner of an infected pregnant woman)	PATIENTS- CAREGIVERS’ ATTITUDEnonattendance of the partner to the service, late onset of PNC, and nonadherence of the pregnant womanto the testing or treatmentENVIRONMENTALOrganizationaldelays in identification and treatment
Rodríguez Aparicio2019	To identify the barriers and drivers fo r adherence to the care bundle in order to prevent complications associated withvascular access devices.	QUAN	Observational Study Descriptive cross-sectional study	Spain150 participants, with a participation rate of 31% (150/483): 80% were anurse (n = 120) and 20%doctor (n = 30)	ATTITUDESAge (older and younger), experience, lack of compliance and agreement and commitment to the CPGKNOWLEDGELack of training
Senanayake2018	To assess whether a more context-specific modified version of WHO SafeChildbirth Checklist (mSCC) would result in improved adoption rate	QUAN	ProspectiveObservational studyLevel of acceptance was assessed using a self-administered questionnaire study	Sri LankaNurses and Midwives in 2 University Obstetrics Unit (18 vs 12 in DSHW) (20 vs 8 in THMG + 8 Doctors)	ATTITUDESMotivation (lack of enthusiasm)KNOWLEDGEinadequate training	WORKLOADLack of staffENVIRONMENTALOrganizational lack of accountability. Lack of supervision from Institutional Level
Spångfors2020	To describe registered nurses’ perceptions, experiences and barriers for using the National Early Warning Score in relation to their work experienceand medical affiliation	QUAN	Observational study Web-based questionnaire study	Sweden3,165 registered nurses working in general somatic hospital wards, Emergency Departments(ED) and the Cardiac High Dependency Unit (CHDU)	ATTITUDESTrust (lack of response from doctor), lack of added value to the situation	WORKLOADlack of timeCPG STRUCTUREToo much time to document
Stahmeyer2017	To determine the number of hand hygiene opportunities (HHOs), compliance rates, and time spent on hand hygiene in intensive care units	QUAN	Observational studyN of opportunities, timing of 300 hands disinfections	GermanyHHO 81.1% nurses, 15.8 Physician, 3.1% Others		ENVIRONMENTALLack of resourcesWORKLOADTime
Tinkle2016	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	USAWomen’s health providers in New Mexico, including nurse practitioners (57.7%), certified nurse-midwives (12%), and family practice and obstetrician/gynecologist physicians (30.3%)		ENVIRONMENTALOrganizational (Lack of Time, Lack of Supplies, lack of staff, reimbursementPATIENTS- CAREGIVERS’ ATTITUDEAcceptability
Tomaszek2018	To compare knowledge and compliance with good clinicalpractices regarding control of postoperative pain among nurses, to identify the determinantsof nurses’ knowledge and to define barriers to effective control ofpostoperative pain	QUAN	Observational Study Cross-sectional study	Poland257 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	KNOWLEDGElack of (both physicianand nurse)ATTITUDESNot practical to apply (inability to modify the protocol of pain treatment) lack of standard procedures for pain assessment and controlMotivationdiscomfort associated with too frequent referral to a physician, lack of autonomy in prescribinglack 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 Netherlands360 ICU health care professionals (nurses (79%), physicians and delirium consultants)	KNOWLEDGE(Deficit, low familiarity with CPG)ATTITUDESBeliefs that’s not preventable, lack of trust in reliabilitySENSE OF BELONGINGLack of collaboration and trust	CPG STRUCTUREDisbelief that it would be optimal for patients, is cumbersome or inconvenient in daily practiceENVIRONMENTALOrganizationLack of time
Currie2019	To identify factors which influence staff compliance with hospital MRSA screening policies	MIXED	Sequential mixed-methods design	UKWard based nursing staff: 38	KNOWLEDGEenabler: awareness about consequence, values and beliefs	ENVIRONMENTALLack of time and patients flow pressuresOrganizational: enabler; audit, feedback, compliance
Ersek2014	To identify facilitators and barriers that affected the success of an intervention aimed at promoting the adoption of evidence-based pain managementprotocols into Nursing Homes(NHs)	MIXED	Mixed methods studyFocus group interviewsQuantitative methods	USAconvenience sample of four NHs (17 RNs, three licensed practicalnurses, one advanced practice RN, and two certified nursing assistants)	ATTITUDESprovider mistrust of nurses’ judgment	ENVIRONMENTALResources: lack of facilities, salary, benefitsOrganizational: turnover, regulatory issues, policies, administrative support, staff consistency
Garcia2016	To explore health care workers identified barriers to cervical cancer screening in rural Southwest Virginia	MIXED	Mixed methods studyTelephone-basedstructured interviews and conventional content analysis	USASampleOffice manager (50%) or a registered nurse (34%)		PATIENTS- CAREGIVERS’ ATTITUDEfear, comfort, lack of education, lack ofpriority, insurance, cost, or transportation
Heidke2020	To report on registered nurses’ adherence to current Australianhealth behaviour recommendations	MIXED	Mixed methods studyFour health risk factors were examined: diet, smoking, physical exercise and alcohol consumption+ BMI	Australia23 registered nurses	ATTITUDEMotivation (family commitments)	WORKLOAD(Shifts, n of hours)
Hilton2016	To determine the views of nurses and on the feasibility of implementing current evidence-based guidelinesfor oral care, examining barriers and facilitators to implementation	MIXED	Mixed methods studyOnline survey of 35 nurses and residential care workers, verifiedand expanded upon by one focus group of six residential care workers	Australia45 nurses and residential care workers, 35 surveys included.	ATTITUDEOral care is viewedas a low priority, negative attitude of the staffKNOWLEDGELack of training, education	ENVIRONMENTALLack of Supplies: access to proper materials, and human resources (dentists) and family participation as a facilitatorInadequate staffing, lack of timePATIENTS- CAREGIVERS’ ATTITUDEresident’s teeth were a barrier, poor behaviour, non-compliance, or lack of participation with oral care, dysphagia
Katz2016	To identify barriers and facilitators to implementation of smoking cessation in Veterans general medicine units	MIXED	Mixed methods study20-item decisional balance survey and 2 items that asked nurses to rate their self-efficacy and satisfaction in helping patients to stop smoking	USA164 nurses surveyed and conducted semistructured interviews in a purposeful sample of 33 nurses	ATTITUDESelf-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’ ATTITUDEResistance
Knops2010	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 studyWhile long-term adherence was audited, focus groups were launched to explore nurses’ perceptions of barriers and facilitatorsregarding long-term adherence to their guideline	The Netherlands15 Nurses and 44 oncologists	SENSE OF BELONGINGReminded each other/ favorable social context	ENVIRONMENTALResources: Time (saved them a lot of time and trouble)CPG STRUCTUREBarriers: 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
McIntosh2017	To describe healthcare providers’ perspectives on the facilitators of and barriers to adhering to pediatric diabetes treatment guidelines	MIXED	Mixed methods studyElectronic Survey + qualitative interviews	Canadaphysicians 41%, nurses 29%, dietitians 22%, others	SENSE OF BELONGINGworking collectively provincially; (e.g. telehealth)	ENVIRONMENTALinadequate 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-Versloot2012	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 studyPatient records were retrospectively examined to measure guideline adherence. Data on influencing factors were collected in focus groupmeetings for nurses and doctors	The Netherlands47 RN + 42 doctors	ATTITUDEBelief in the advantages of the guideline lack of self-efficacySENSE OF BELONGINGstrong staff support	CPG STRUCTURE(Characteristic, contradictory)controversial nature of the guideline
Wolfensberger2018	To identify the optimal behavior leverage to improve Ventilator-Associated Pneumonia (VAP) prevention protocol adherence	MIXED	Mixed methods studyAdherence measurements to assess 4 VAP prevention measures and qualitative analysis ofsemi-structured interviews	Switzerland42 nurses and 4 physicians	ATTITUDEMotivation (reflective motivation, perceived seriousnessSelf-efficacyLevel of Agreement side-effects of prevention measures	ENVIRONMENTALOrganizational lack of resources equipment and staffing
Arzimanoglou2014	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 neurologistsand neurologists, 28 community pediatricians, and 15 epilepsiesnurses, in the UK and Sweden only)	KNOWLEDGELack of familiarity, lack of awareness; accessibility	PATIENTS- CAREGIVERS’ ATTITUDECaregiver’s attitudes, insufficient training; lack of training and fear (teachers, etc.)
Bayuo2017	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 ClinicalEvidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool	GhanaProject team was predominantly constituted by nurses (3 units), as well as from 2 surgeons and a clinical fellow.	KNOWLEDGEInformation accessibilityATTITUDEOutcomes expectancy	ENVIRONMENTALOrganizational constraints
Dogherty2013	To describe the tacit knowledge regarding facilitation embedded in the experiences of nurses implementing evidence into practice.	QUAL	Qualitative studyIn-depth analysis	Canadapurposive sample- 20 nurses from across Canada, including nurses from across the continuum of care and working with different clinical populations	FacilitatorsATTITUDEMotivation self-efficacy (focus on); sense of belonging (partnership, teamwork)EXTRINSIC FACTORS-CPG STRUCTURE(Characteristics accessibility, relevance, adaptation)BarriersATTITUDESENSE OF BELONGING and self-efficacy (poor engagement)	ENVIRONMENTALResources (lack of), conflict, contextual factors, sustainability
Efstathiou2011	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	Cyprus30 nurses (93.7%)participated (26 females, 4 males)	ATTITUDENegative influence of protective equipmentProvision of nursing care to children not perceived as dangerous.Influence on nurses’ appearancePsychological factors embarrassmentWorking experience (more confidence)Physician’s influence (also not wearing protection)	ENVIRONMENTALlack of supplies, Availability of equipment time Too busy, lack of nursing personnel, implementation of guidelines is time consumingOrganizational constraints, Perceived increase in malpractice Emergency situationPATIENTS- CAREGIVERS’ ATTITUDEPatients’ discomfortAnxiety, sorrow
Lai2019	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 ClinicalEvidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool	China18 nurses	KNOWLEDGELack of knowledge	ENVIRONMENTALlack of supplies, resources (screening tools)
Lin 2019	To identify the facilitators of and barriers to nurses’ adherence to evidence basedwound care clinical practice guidelines (CPGs) in preventing surgical site infections (SSIs)	QUAL	Qualitative study incorporating ethnographic data collection techniquesSemi-structured individual interviews and focus groups (N = 20), and examination of existing hospital policy and procedure documents.	Australiaconvenience sampleof 20 nurses who were at work onthe days they conducted focus groups	KNOWLEDGEFacilitatorsParticipants’ active information‐seeking behavior clear understanding of the importance of aseptic techniqueBarriersParticipants’ knowledge and skills deficits regarding application of aseptic technique principles in practiceAccessibility: availability of the hospital’s wound care procedureDocuments	PATIENTS- CAREGIVERS’ ATTITUDEFacilitatorspatient participation in wound careBarrierstiming of patient education
Lu2015	To examine the current practices for managing emergency equipment in a tertiary mental health institutionTo determine the strengths and limitations of the existing practice/process.	QUAL	Evidence implementation project with Joanna Briggs Institute Practical Application of ClinicalEvidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tool	SingaporeMembers with experience in various mental health settings andwith a role in checking andmaintaining the inventory ofemergency supplies and equipment	KNOWLEDGELack of training, experience	ENVIRONMENTALCharacteristic and organizational factors: inadequate knowledge and awareness ofthe organization’s policy; lack of exposure and skills in operating emergency equipment in the psychiatric setting
Makhado2018	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 designFour semi-structured focus group interviews were conducted	South Africa24 NIMART nurses	KNOWLEDGEInsufficient knowledge or lack of awarenessATTITUDESLack of agreement with guidelines, poor motivation resistance to change
Meurer2011	To describe barriers to thrombolytic use in acute stroke care	QUAL	Qualitative StudyFocus groups and structured interviews (pre-specified taxonomy to characterize barriers)	USAPhase 1 focus group andinterviews of emergency physicians (65), nurses (62), neurologists (15), radiologists (12), hospital administrators(12), and three others (hospitalists and pharmacist).	KNOWLEDGEFamiliarity with, agreement, awarenessATTITUDESMotivation to adhere to the guidelines, lack of self-efficacy and outcome expectancy	ENVIRONMENTALavailability of intensive care units, ED crowding, pharmacy or radiologyPATIENTS- CAREGIVERS’ ATTITUDEfailure to recognize symptoms, preference to arrivevia car instead of ambulance, delayed presentationCPG STRUCTUREcharacteristics, issues with thestructure or content
Munce2017	To understand the factors influencingthe implementation of the recommended treatments and Knowledge Translation(KT) interventions (stroke rehabilitationguidelines).	QUAL	Qualitative studyTelephone focus groups were selected because ofthe geographic dispersion	CanadaPurposive sampling was usedto recruit equal numbers ofparticipants across professional groups(11 nurses, 11 therapists, 11 clinical managers), randomization arms(facilitated KT intervention or passive KT intervention), and geographic locations	ATTITUDESAgreement: clear and practical to follow implementation of recommendations. Barrier when unclear, too generalKNOWLEDGEFamiliarity with CPG (having some recommendations already in use) lack of familiarity as a barrier (lower volume of patients)SENSE OF BELONGINGTeam communication and interdisciplinary collaboration	ENVIRONMENTALbarrier lack of time (time pressure), lack of space and equipmentWORKLOADlack of staff or staff turnover
Presseau2017	To inform how to deploy the Individualized Dialysis Temperature (IDT) across many hemodialysis centers, we assessed hemodialysis physicians’ and nurses’ perceived barriers and enablers toIDT use.	QUAL	Qualitative studyPhone InterviewTwo topic guides using the Theoretical Domains Framework (TDF) to assess perceivedbarriers and enablers	Canadanine physicians and nine nurses from 11 Ontario hemodialysis centers	KNOWLEDGEAwareness of CPGATTITUDEBenefits and motivation, optimism, reinforcements (It’s a little priority at this point)SENSE OF BELONGINGRole identity, beliefs about capabilities; forgetting toprescribe or set IDT	ENVIRONMENTALAvailability of resources (thermometer for dialysis.)WORKLOADReducing episodes of hypotension during dialysis can decrease workloadPATIENTS- CAREGIVERS’ ATTITUDEPatient factors: comfort, emotions (Patients may feel too cold on cooler dialysate temperatures)
Stenberg2011	To describe influences on health care professionals’ attitudes to CPGs for preventing falls and fall injuries	QUAL	Qualitative studyQualitative approach with focus group.Texts were analyzed using manifest and latent content analysis.	Sweden23 HCPPhysicians (4), registered nurses (15), physiotherapists (3), and 1occupational therapist	ATTITUDEMotivation: 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	ENVIRONMENTALInfluence of social factors community obligations (consider laws and regulations in their decision-making) and organizational (leadership with clear priorities)
van de Steeg2014	To identify and classify barriers to adherence by nurses to a guideline on delirium care.	QUAL	Qualitative studyOpen-ended interviews were conducted with a purposive sample of 63 research participants	The Netherlands28 nurses, 18 doctors and 17 policy advisors	ATTITUDEMotivation (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.KNOWLEDGENurses 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	ENVIRONMENTALOrganizational: 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 Berg2019	To identify barriers and gather improvement suggestions throughsemi-structured in-depth interviews conducted with 24 professionals working in oncofertility care	QUAL	Qualitative studySemi-structured in-depth interviews	The Netherlands24 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 ANDATTITUDELack 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.	ENVIRONMENTALOrganizational unavailable written information, disagreement on who is responsible for discussing infertility risks).Patients’ attitude: focus on survivingCancer; HCPs feel that patients do not place fertility high on their priority list because they are focused on surviving cancer
Weller2020	To identify health professionalperspectives about using Venous Leg Ulcer (VLU) CPGs to guide the management of people with VLUs in primary care	QUAL	Qualitative studySemi-structured face-to-face and telephoneinterviews with health professionals, GPs, and PNs	Australiaand snowball sampling strategiesto recruit the participants. 15 GPs (43%) and 20 PNs (57%), includingtwo Aboriginal health nurses (6%), who worked in primary health care settings	KNOWLEDGELack of knowledge and Skills, lack of awareness, ATTITUDESLack of trust and motivation (better what was done in the past)SENSE OF BELONGINGteamwork, collaboration	ENVIRONMENTLack of supplies (print andelectronic versions of theVLU CPGs)
Yanke2018	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 studyFour focus groups were conducted 1 with attending physicians, 1 with resident physicians, and 2 with RNs and HTs (n 7)	USAconvenience sample consisted of attending hospitalist physicians, internal medicine resident physicians, and registered nurses(RNs) and health technicians (HTs) employed at our VA hospital		ENVIRONMENTALOrganizational 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.

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.