Review
Barriers and facilitators of nurses’ use of clinical practice guidelines: An integrative review

https://doi.org/10.1016/j.ijnurstu.2016.03.006Get rights and content

Abstract

Background

Preventable harm continues to be one of the leading causes of patient death. Each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism. However, as shown in the recent reduction in hospital acquired infections, the number of deaths could be reduced if healthcare providers used evidence-based therapies, which are often included in clinical practice guidelines (CPGs).

Purpose

The purpose of this integrative review is to appraise and synthesize the current literature on barriers to and facilitators in the use of clinical practice guidelines (CPGs) by registered nurses.

Design

Whittemore and Knafl integrative review methodology was used. Primary quantitative and qualitative studies about the nurses’ use of CPGs and published in peer-reviewed journals between January 2000 and August 2015 were included.

Methods

The Critical Skills Appraisal Program (CASP) was used to critically appraise the quality of sixteen selected quantitative and qualitative studies.

Results

Internal factors were attitudes, perceptions, and knowledge whereas format and usability of CPGs, resources, leadership, and organizational culture were external factors influencing CPG use.

Conclusion

Given each barrier and facilitator, interventions and policies can be designed to increase nurses’ use of CPGs to deliver more evidence based therapy. In order to improve the use of CPGs and to ensure high quality care for all patients, nurses must actively participate in development, implementation, and maintenance of CPGs.

Section snippets

Integrative review: barriers and facilitators of nurses in their use of clinical practice guidelines

Preventable harm, most commonly defined as “a harm with an identifiable and modifiable cause” (Nabhan et al., 2012, p. 5), continues to be one of the leading causes of death; each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism related to lapses in care (Andel et al., 2012, James, 2013). These instances of preventable harms cost the United States one trillion dollars per year or about one third of annual healthcare

Literature search

The literature about nurses’ use of clinical practice guidelines was searched using a methodology delineated by Whittemore and Knafl (2005). The following databases were used for search: PubMed, the Cumulative Index to Nursing and Allied Health Literature, ProQuest, Medline, also known as Web of Science, and Embase. We performed the initial literature search in March and April 2014, and updated the search in December 2015 and January 2016. The keywords and MeSH terms in Table 1 were determined

Search results

The initial search identified 15,829 articles, which were reduced to 13,582 after removing duplicates. First, the titles were reviewed for relevancy, resulting in reducing the number of articles to 989. Then the abstract of each article was reviewed with the inclusion and exclusion criteria applied, further narrowing the selection to 52 articles. Finally, after full text review, we identified 16 articles that met all the inclusion and exclusion criteria. The 36 articles were excluded because

Discussion

Even though many of barriers and facilitators that nurses face share commonality with other healthcare providers, nurses also face their unique challenges such as resource availability including staffing and equipment availability. In a systematic review of physicians’ barriers to the use of clinical practice guidelines, Cabana et al. (1999) found that awareness, familiarity and agreement with clinical practice guidelines, self-efficacy, outcome expectancy, and ability to overcome the

Conclusions

Well-conducted integrative reviews can stimulate further research (Torraco, 2005). In this integrative review, we analyzed primary quantitative and qualitative studies to identify the internal and external barriers and facilitators to the use of clinical practice guidelines for nurses. Attitudes, perceptions, and knowledge were identified as the internal barriers and facilitators, whereas clinical practice guidelines, resources, leadership and organizational culture were the external barriers

Acknowledgement

Special acknowledgment to Dr. Susan Sullivan-Boyai at New York University, College of Nursing.
Conflict of interest. None declared.
Funding. No funding was received for the preparation or writing of this manuscript.

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      The identified barriers and facilitators from this study are supported by previous CPG adherence research. “Investing in specialized training” was shown to increase guideline adherence (Greenberg et al., 2018; Ladeira et al., 2017; Quatman-Yates et al., 2020; Stache et al., 2016), while lack of “resources and organizational constraints” (Bierbaum et al., 2020; Jun, Kovner, & Stimpfel, 2016; Ladeira et al., 2017; Quatman-Yates et al., 2020; Stache et al., 2016) and reduced “confidence and lack of knowledge” (Jun et al., 2016) were identified as barriers to adherence. Though a large part of CPG adherence may be through an internal locus, facility resources and the ability to specialize in clinical practice could also provide future support for adherence.

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    References marked with an asterisk indicate studies included in the integrative review.

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