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  • Primary Health Care Research & Development, Volume 13, Issue 1
  • January 2012, pp. 48-59

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

  • Ann McKillop (a1), Jackie Crisp (a2) (a3) and Kenneth Walsh (a4)
  • DOI:
  • Published online: 13 October 2011

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:
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This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

A. Bandura 2000: Exercise of human agency through collective efficacy. Current Directions in Psychological Science 9, 7578.

A. Bandura 2006: Toward a psychology of human agency. Perspectives on Psychological Science 1, 164180.

A. Beauchamp , A. Peeters , R. Wolfe , G. Turrell , L.R. Harriss , G.G. Giles , D.R. English , J. McNeil , D. Magliano , S. Harrap , D. Liew , D. Hunt A. Tonkin 2010: Inequalities in cardiovascular disease mortality: the role of behavioural, physiological and social risk factors. Journal of Epidemiology and Community Health 64, 542548.

J.R. Betancourt , A.R. Green , J.E. Carrillo E.R. Park 2005: Cultural competence and health care disparities: key perspectives and trends. Health Affairs 24, 499508.

M. Brouwers , S. Hanna , M. Abdel-Motagally J. Yee 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.

M. Cypress 2004: Looking upstream. Diabetes Spectrum 17, 249253.

D. D'Amour , M. Ferrada-Videla , L. San Martin Rodriguez M.-D. Beaulieu 2005: The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. Journal of Interprofessional Care 19, 116131.

D.M. Daley 2009: Interdisciplinary problems and agency boundaries: exploring effective cross-agency collaboration. Journal of Public Administration Research and Theory 19, 477493.

S. Dopson , L. Fitzgerald , E. Ferlie , J. Gabbay L. Locock 2002: No magic targets! Changing clinical practice to become more evidence-based. Health Care Management Review 27, 3547.

M.H. Durie 2003: The health of indigenous people. British Medical Journal 326, 510511.

P. Factor-Litvak A. Sher 2009: Invited commentary: coming out of the box. American Journal of Epidemiology 169, 11791181.

I. Gaboury , L. M. Lapierre , H. Boon D. Moher 2011: Interprofessional collaboration within integrative healthcare clinics through the lens of the relationship-centered care model. Journal of Interprofessional Care 25, 124130.

J. Gervas , B. Starfield I. Heath 2008: Is clinical prevention better than cure? The Lancet 372, 19971999.

D.S. Goldberg 2009: In support of a broad model of public health: disparities, social epidemiology and public health causation. Public Health Ethics 2, 7083.

I.D. Graham , J. Logan , M.B. Harrison , S. Straus , J. Tetroe , W. Casswell N. Robinsons 2006: Lost in knowledge translation: time for a map? Journal of Continuing Education in the Health Professions 26, 1324.

J.M. Grimshaw , R. Thomas , G. MacLennan , C. Fraser , C. Ramsay , L. Vale , P. Whitty , M. Eccles , L. Matowe , L. Shirran , M. Wensing , R. Dijkstra C. Donaldson 2004: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment 8, iii72.

R. Grol J. Grimshaw 2003: From best evidence to best practice: effective implemenation of change in patients’ care. The Lancet 362, 12251229.

M. Hefford , P. Crampton J. Foley 2005: Reducing health disparities through primary care reform: the New Zealand experiment. Health Policy 72, 923.

S. Hrisos , M.P. Eccles , J.J. Francis , H.O. Dickinson , E.F. Kaner , F. Beyer M. Johnston 2009: Are there valid proxy measures of clinical behaviour? A systematic review. Implementation Science 4, 37. DOI:10.1186/1748-5908-4-37.

L. Keller , S. Strohschein , B. Lia-Hoagberg M. Schaffer 2004: Population-based public health interventions: practice-based and evidence-supported. Part 1. Public Health Nursing 21, 453468.

D. Kim , I. Kawachi , S. VAnderhoorn M. Ezzati 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.

A. Kitson 2009: Knowledge translation and guidelines: a transfer, translation or transformation process? International Journal of Evidence-Based Healthcare 7, 124139.

K. Manley 2004: Transformational culture: a culture of effectiveness. In McCormack, B., Manley, K. & Garbett, R., editors, Practice development in nursing. Oxford, England: Blackwell, 5182.

K. Manley 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.

K. Manley , A. Titchen S. Hardy 2009: Work-based learning in the context of contemporary health care education and practice: a concept analysis. Practice Development in Health Care 8, 87127.

M. Marmot 2003: Understanding social inequalities in health. Perspectives in Biology and Medicine 46, S9S23.

M. Marmot 2007: Achieving health equity: from root causes to fair outcomes. The Lancet 370, 11531163.

B. McCormack T. McCance 2010: Person-centred nursing. Oxford: Wiley-Blackwell.

C.L. McWilliam , A. Kothari , C. Ward-Griffin , D. Forbes B. Leipert 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.

M. Miller N. Kearney 2004: Guidelines for clinical practice: development, dissemination and implementation. International Journal of Nursing Studies 41, 813821.

D.C. Mohr , G.J. Young , M. Meterko , K.L. Stolzmann B. White 2011: Job satisfaction of primary care team members and quality of care. American Journal of Medical Quality 26, 1825.

S. Nairn 2009: Social structure and nursing research. Nursing Philosophy 10, 191202.

M. Parker 2005: False dichotomies: EBM, clinical freedom, and the art of medicine. Journal of Medical Ethics; Medical Humanities 31, 2330.

R. Randell , N. Mitchell , C. Thompson , D. McCaughan D. Dowding 2009: From pull to push: understanding nurses’ information needs. Health Informatics Journal 15, 7585.

D.W. Roblin , D.H. Howard , Ren Junling E.R. Becker 2011: An evaluation of the influence of primary care team functioning on the health of medicare beneficiaries. Medical Care Research and Review 68, 177201.

J. Rycroft-Malone 2006: The politics of the evidence based practice movements: legacies and current challenges. Journal of Research in Nursing 11, 95108.

J. Rycroft-Malone 2008: Evidence-informed practice: from individual to context. Journal of Nursing Management 16, 404408.

K.G. Shojania J.M. Grimshaw 2004: Still no magic bullets: pursuing more rigorous research in quality improvement. American Journal of Medicine 116, 778780.

H. Soubhi , E.A. Bayliss , M. Fortin , C. Hudon , M. Van den Akker , R. Thivierge , N. Posel D. Fleiszer 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.

G. Sullivan , D. Blevins M. Kauth 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.

D.R. Thomas 2006: A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation 27, 237246.

R.C. Thurston , L.D. Kubzansky , I. Kawachi L.F. Berkman 2005: Is the association between socio-economic position and coronary heart disease stronger in women than in men? American Journal of Epidemiology 162, 5765.

K. Walsh , C. Moss , J. Lawless , R. McKelvie L. Duncan 2008: Puzzling practice: a strategy for working with clinical practice issues. International Journal of Nursing Practice 14, 94100.

C. Pope , S. Ziebland N. Mays 2000: Qualitative research in health care: Analysing qualitative data. BMJ 320, 114116.

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Primary Health Care Research & Development
  • ISSN: 1463-4236
  • EISSN: 1477-1128
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