NURSING STUDIES: PROMOTERS AND BARRIERS FOR ADHERENCE TO CLINICAL PRACTICE GUIDELINES AMONG NURSES

Abstract

Clinical practice guidelines (CPGs) are designed to improve the care and safety of patients in hospitals. This thesis explores the promoters and barriers for CPG adherence among nurses. The research is based on a combination of a systematic literature review, qualitative research and a quantitative study. The systematic literature review included searching three data bases, namely, the British Nursing Index (BNI), Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The qualitative research study included one-to-one interviews and focus groups. The quantitative study consisted of a questionnaire distributed to nurses to extend and check the findings of the qualitative studies.
The systematic literature review revealed that the attitude of doctors to any CPG is influenced most by the level of their agreement with the guideline and by its applicability in practice. The adherence of nurses to CPGs is influenced most by the support and feedback they receive and by team interactions.
A previous framework for CPG adherence by doctors has been produced by Cabana (1999) based on a literature review. This thesis extends that framework to nurses, and adapts it on the basis of my original research findings. Three principal themes emerged from the qualitative studies; namely, nurses’ attitudes to CPGs, their knowledge of CPG and external factors that influence CPG adherence.
Within these, the most prominent promoters of CPG adherence were nurses’ sense of their accountability, professional values and self-efficacy, as well as managerial monitoring and belief that a CPG would achieve the expected desirable outcome. The last of these depended to a large extent on nurses’ trust in the credibility of the guideline authors.
The main barriers to CPG adherence were lack of knowledge about the guidelines caused by insufficient time to read them, poor presentation and inadequate dissemination of CPGs and the low priority given to training within a nurse’s schedule. Other barriers included lack of staff resources to apply CPGs, the exigencies of individual patient problems and wishes, the frequent movement of nurses between specialisms and a general failure to involve nurses in drafting the guidelines. All these results were confirmed by the results of a questionnaire survey.
The revised framework presented here could help health care organisations, medical educators, policy makers and managers to develop better models for CPG development and awareness, especially among nurses, and to have a greater insight into the factors that promote or inhibit CPG adherence. Based on the framework, recommendations are made to help these groups of people, and nurses themselves, improve nurses’ adherence to CPGs. These are presented below, and are found as Table 7.1 in the thesis.