Skip to main content

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

  • Ann McKillop (a1), Jackie Crisp (a2) (a3) and Kenneth Walsh (a4)

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.


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.


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.


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.

Corresponding author
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:
Hide All
Bacal K., Jansen P.Smith K. 2006: Developing cultural competency in accordance with the Health Practitioners Competence Assurance Act. New Zealand Family Practice 33, 305309.
Bandura A. 2000: Exercise of human agency through collective efficacy. Current Directions in Psychological Science 9, 7578.
Bandura A. 2006: Toward a psychology of human agency. Perspectives on Psychological Science 1, 164180.
Baum F. 2007: Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health. Global Health Promotion 14, 9095.
Beauchamp A., Peeters A., Wolfe R., Turrell G., Harriss L.R., Giles G.G., English D.R., McNeil J., Magliano D., Harrap S., Liew D., Hunt D.Tonkin A. 2010: Inequalities in cardiovascular disease mortality: the role of behavioural, physiological and social risk factors. Journal of Epidemiology and Community Health 64, 542548.
Betancourt J.R., Green A.R., Carrillo J.E.Park E.R. 2005: Cultural competence and health care disparities: key perspectives and trends. Health Affairs 24, 499508.
Brouwers M., Hanna S., Abdel-Motagally M.Yee J. 2009: Clinicians’ evaluations of, endorsements of, and intentions to use practice guidelines change over time: a retrospective analysis from an organized guideline program. Implementation Science 4, 34. DOI:10.1186/1748-5908-4-34.
Cram F., Smith L.Johnstone W. 2003: Mapping the themes of Maori talk about health. New Zealand Medical Journal 116. Retrieved 10 October 2009 from
Cypress M. 2004: Looking upstream. Diabetes Spectrum 17, 249253.
D'Amour D., Ferrada-Videla M., San Martin Rodriguez L.Beaulieu M.-D. 2005: The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. Journal of Interprofessional Care 19, 116131.
Daley D.M. 2009: Interdisciplinary problems and agency boundaries: exploring effective cross-agency collaboration. Journal of Public Administration Research and Theory 19, 477493.
Daniels N., Kennedy B.Kawachi I. 2000: Is inequality bad for our health?. Boston, MA: Beacon Press.
Dicenso A., Guyatt G.Ciliska D. 2005: Evidence-based nursing: a guide to clinical practice. St. Louis, MO: Elsevier Mosby.
Dopson S., Fitzgerald L., Ferlie E., Gabbay J.Locock L. 2002: No magic targets! Changing clinical practice to become more evidence-based. Health Care Management Review 27, 3547.
Durie M.H. 2003: The health of indigenous people. British Medical Journal 326, 510511.
Edgecombe G.Stephens R. 2010: Healthy communities: the evolving roles of nursing. In Daly, J., Speedy, S. and Jackson, D., editors, Contexts of Nursing, third edition. Sydney, Australia: Churchill Livingstone, 274286.
Factor-Litvak P.Sher A. 2009: Invited commentary: coming out of the box. American Journal of Epidemiology 169, 11791181.
Gaboury I., M. Lapierre L., Boon H.Moher D. 2011: Interprofessional collaboration within integrative healthcare clinics through the lens of the relationship-centered care model. Journal of Interprofessional Care 25, 124130.
Gervas J., Starfield B.Heath I. 2008: Is clinical prevention better than cure? The Lancet 372, 19971999.
Goldberg D.S. 2009: In support of a broad model of public health: disparities, social epidemiology and public health causation. Public Health Ethics 2, 7083.
Graham I.D., Logan J., Harrison M.B., Straus S., Tetroe J., Casswell W.Robinsons N. 2006: Lost in knowledge translation: time for a map? Journal of Continuing Education in the Health Professions 26, 1324.
Grimshaw J.M., Thomas R., MacLennan G., Fraser C., Ramsay C., Vale L., Whitty P., Eccles M., Matowe L., Shirran L., Wensing M., Dijkstra R.Donaldson C. 2004: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment 8, iii72.
Grol R.Grimshaw J. 2003: From best evidence to best practice: effective implemenation of change in patients’ care. The Lancet 362, 12251229.
Grol R.Wensing M. 2004: What drives change? Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia 180, S57S60.
Hefford M., Crampton P.Foley J. 2005: Reducing health disparities through primary care reform: the New Zealand experiment. Health Policy 72, 923.
Hrisos S., Eccles M.P., Francis J.J., Dickinson H.O., Kaner E.F., Beyer F.Johnston M. 2009: Are there valid proxy measures of clinical behaviour? A systematic review. Implementation Science 4, 37. DOI:10.1186/1748-5908-4-37.
Hulscher M.E.J., Wensing M., Weijden T.V.D.Grol R. 2005: Interventions to implement prevention in primary care. The Cochrane Database of Systematic Reviews 4. CD000362.
Jackson A.Bluteau P. 2011: Interprofessional education, collaborative practice and primary care. InnovAiT 4, 230235.
Keller L., Strohschein S., Lia-Hoagberg B.Schaffer M. 2004: Population-based public health interventions: practice-based and evidence-supported. Part 1. Public Health Nursing 21, 453468.
Kim D., Kawachi I., VAnderhoorn S.Ezzati M. 2008: Is inequality at the heart of it? Cross-country associations of income inequality with cardiovascular diseases and risk factors. Social Science and Medicine 66, 17191732.
Kitson A. 2009: Knowledge translation and guidelines: a transfer, translation or transformation process? International Journal of Evidence-Based Healthcare 7, 124139.
Kuronen R., Jallinoja P., Airola R.Patja K. 2010: Educational implementation programme of guidelines on cardiovascular risk factors: an analysis of changes in familiarity, use and attitudes. Primary Health Care Research & Development 11, 241249.
Maniapoto T.Gribben B. 2003: Establishing a Maori case management clinic. New Zealand Medical Journal 116, 328, available at
Manley K. 2004: Transformational culture: a culture of effectiveness. In McCormack, B., Manley, K. & Garbett, R., editors, Practice development in nursing. Oxford, England: Blackwell, 5182.
Manley K. 2008: ‘The way things are done around here’ – developing a culture of effectiveness: a pre-requisite to individual and team effectiveness in critical care. Australian Critical Care 21, 8385.
Manley K., Titchen A.Hardy S. 2009: Work-based learning in the context of contemporary health care education and practice: a concept analysis. Practice Development in Health Care 8, 87127.
Marmot M. 2003: Understanding social inequalities in health. Perspectives in Biology and Medicine 46, S9S23.
Marmot M. 2007: Achieving health equity: from root causes to fair outcomes. The Lancet 370, 11531163.
Marmot M. 2010: Fair society, healthy lives: the Marmot review. London: Department of Health.
McCormack B.McCance T. 2010: Person-centred nursing. Oxford: Wiley-Blackwell.
McCormack B., Manley K.Walsh K. 2008: Person-centred systems and processes. In Manley, K., McCormack, B. and Wilson, V., editors, International practice development in nursing and healthcare. Oxford, England: Blackwell.
McWilliam C.L., Kothari A., Ward-Griffin C., Forbes D.Leipert B. 2009: Evolving the theory and praxis of knowledge translation through social interaction: a social phenomenological study. Implementation Science 4, 26. DOI: 10.1186/1748-5908-4-26.
Miller M.Kearney N. 2004: Guidelines for clinical practice: development, dissemination and implementation. International Journal of Nursing Studies 41, 813821.
Mohr D.C., Young G.J., Meterko M., Stolzmann K.L.White B. 2011: Job satisfaction of primary care team members and quality of care. American Journal of Medical Quality 26, 1825.
Morse J., Barrett M., Mayan M., Olson K.Spiers J. 2002: Verification strategies for establishing reliability and validity in qualitative research. International Journal of Qualitative Methods 1, 1322.
Nairn S. 2009: Social structure and nursing research. Nursing Philosophy 10, 191202.
Neuwelt P., Matheson D., Arroll B., Dowell A., Winnard D., Crampton P., Sheridan N.Cumming J. 2009: Putting population health into practice through primary health care. New Zealand Medical Journal 122. Retrieved 6 July 2010 from
New Zealand Guidelines Group. 2003: The assessment and management of cardiovascular risk. Wellington, New Zealand.
Parker M. 2005: False dichotomies: EBM, clinical freedom, and the art of medicine. Journal of Medical Ethics; Medical Humanities 31, 2330.
Pope C., Ziebland S.Mays N. 2000: Qualitative research in health care: Analysing qualitative data. BMJ 320, 114116.
Ramsden I. 1997: Cultural safety: implementing the concept. The social force of nursing and midwifery. In Te Whaiti, P., McCarthy, M. and Durie A., editors, Mai i Rangiatea: Mapri well being and development. Auckland: Auckland University Press and Bridget Williams Books, 113125.
Randell R., Mitchell N., Thompson C., McCaughan D.Dowding D. 2009: From pull to push: understanding nurses’ information needs. Health Informatics Journal 15, 7585.
Ratima M., Brown R., Garrett N., Wikaire E., Ngawati R., Aspin C.Potaka U. 2007: Rauringa Raupa recruitment and retention of Māori in the health and disability workforce. Auckland, New Zealand, Taupua Waiora: Division of Public Health and Psychosocial Studies.
Reeves S., Zwarenstein M., Goldman J., Barr H., Freeth D., Hammick M.Koppel I. 2009: Interprofessional education: effects on professional practice and health care outcomes (Review). The Cochrane Library, Issue 4, available at
Ritchie J.Lewis J. 2003: Qualitative research practice: a guide for social science students and researchers. London/Thousand Oaks/New Delhi: Sage.
Roblin D.W., Howard D.H., Junling RenBecker E.R. 2011: An evaluation of the influence of primary care team functioning on the health of medicare beneficiaries. Medical Care Research and Review 68, 177201.
Rycroft-Malone J. 2006: The politics of the evidence based practice movements: legacies and current challenges. Journal of Research in Nursing 11, 95108.
Rycroft-Malone J. 2008: Evidence-informed practice: from individual to context. Journal of Nursing Management 16, 404408.
Schmidt K. 2011: The organization of cooperative work. London: Springer eBook, Springer.
Sharpe N. 2006: Heart health has an adverse future forecast in New Zealand: an alarm call to action across the continuum. New Zealand Medical Journal 119. Retrieved 12 October 2010 from
Shojania K.G.Grimshaw J.M. 2004: Still no magic bullets: pursuing more rigorous research in quality improvement. American Journal of Medicine 116, 778780.
Shultz T.J.Kitson A.L. 2010: Measuring the context of care in an Australian acute care hospital: a nurse survey. Implementation Science 5. available at
Smith J. 2009: Critical analysis of the implementation of the primary health care strategy and framing of issues for the next phase. Wellington, New Zealand: Ministry of Health.
Soubhi H., Bayliss E.A., Fortin M., Hudon C., Van den Akker M., Thivierge R., Posel N.Fleiszer D. 2010: Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity. Annals of Family Medicine 8, 170177.
Statistics New Zealand. 2006: QuickStats About Northland Region.
Sullivan G., Blevins D.Kauth M. 2008: Translating clinical training into practice in complex mental health systems: toward opening the ‘Black Box’ of implementation. Implementation Science 3, 33. DOI:10.1186/1748-5908-3-33.
Te Ara. 2009: Northland region population. New Zealand Government. Retrieved 21 May 2004 from
Thomas D.R. 2006: A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation 27, 237246.
Thurston R.C., Kubzansky L.D., Kawachi I.Berkman L.F. 2005: Is the association between socio-economic position and coronary heart disease stronger in women than in men? American Journal of Epidemiology 162, 5765.
Tobias M., Sexton K., Mann S.Sharpe N. 2006: How low can it go? Projecting ischaemic heart disease mortality in New Zealand to 2015. New Zealand Medical Journal 119. Retrieved 8 September 2009 from
Walsh K., Moss C.Fitzgerald M. 2006: Solution-focused approaches and their relevance to practice development. Practice Development in Health Care 5, 145155.
Walsh K., Moss C., Lawless J., McKelvie R.Duncan L. 2008: Puzzling practice: a strategy for working with clinical practice issues. International Journal of Nursing Practice 14, 94100.
Workforce Taskforce. 2008: Working together for better primary health care: Overcoming barriers to workforce change and innovation. Wellington, New Zealand: Ministry of Health.
World Health Organization. 2008a: Primary health care – now more than ever. The World Health Report. Geneva: World Health Organization.
World Health Organization. 2008b: The top ten causes of death [Online]. Retrived 10 June 2010 from
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Primary Health Care Research & Development
  • ISSN: 1463-4236
  • EISSN: 1477-1128
  • URL: /core/journals/primary-health-care-research-and-development
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 4
Total number of PDF views: 78 *
Loading metrics...

Abstract views

Total abstract views: 367 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 16th January 2018. This data will be updated every 24 hours.