Practice guidelines need to address the ‘how’ and the ‘what’ of implementation

Ann McKillopa1 c1, Jackie Crispa2a3 and Kenneth Walsha4

a1 Senior Lecturer, Faculty of Medical and Health Sciences, School of Nursing, The University of Auckland, New Zealand

a2 Professor of Child and Adolescent Nursing, Sydney Children's Hospital and Faculty of Nursing, Midwifery and Health, University of Technology, Sydney

a3 Conjoint Professor, University of New South Wales, Australia

a4 Professor of Nursing, Practice Development, Nursing Development and Research Unit, South East Sydney and Illawarra Area Health Service and School of Nursing, Midwifery and Indigenous Health, University of Wollongong, Australia


Aim The aim of this study was to explore the realities of everyday nursing practice associated with the implementation of a guideline for the assessment and management of cardiovascular risk.

Background The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable and, in spite of much investigation, remains resistant to explanation of what works and why. Exploration of the nature of guideline implementation has the potential to illuminate the complexities of guideline implementation by focussing on the nature of practice. Nurses are well placed at the front line of primary health care to contribute to an understanding of how guideline implementation plays out in their everyday practice.

Methods Qualitative description was used, involving focus groups and interviews with 32 participants (20 nurses, four doctors, five managers and three funder/planners), to explore the use of a guideline in everyday primary health-care practice. Thematic analysis of data was managed through an inductive process of familiarisation, coding, categorising and generation of themes.

Findings Four themes were generated from the data portraying the realities of guideline implementation for primary health-care nurses: self-managing patient, everyday nursing practice, developing new relationships in the health team and impact on health-care delivery. The findings reveal that, even with the best of intentions to implement the guideline, health professionals were frustrated and at a loss as to how to achieve that in practice. Consequently, cardiovascular risk assessment and management was uneven and fragmented. Primary health-care practice environments vary so much that solutions to the difficulties of implementing evidence into practice requires context-specific solution-finding through collaborative teamwork. Furthermore, the attention of guideline developers, health-care policymakers, funders and researchers requires direct focus on the ‘how’ and the ‘what’ of evidence implementation.

(Received December 13 2010)

(Accepted August 07 2011)

(Online publication October 13 2011)


c1 Correspondence to: Dr Ann McKillop, Senior Lecturer, School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand. Email: