A literature review exploring reasons why nurses prescribed palliative oxygen therapy in non-hypoxaemic patients suggested there are numerous factors relating to adherence to guidelines in clinical practice (Collis, 2018). A wider literature review of nurses' adherence to clinical guidelines suggested a lack of adherence is common in many specialties, not only in oxygen prescription. Only one study was located that focused on UK nurses' adherence to clinical guidelines (Puffer and Rashidian, 2004).
Relevant studies show similar reasons for non-adherence, including the following common themes:
Reviewing the literature on barriers to adherence to guidelines suggests that the term ‘guidelines’ is commonly understood – the term is not questioned or challenged in any of the studies located. It should be noted that most dictionaries offer two separate definitions, including the Oxford Learner's Dictionaries (2025):
It is proposed that a potential barrier to adherence is that nurses may not view guidelines as mandatory and instead see them more as a tool for guidance.
Therefore, there is a need to investigate how nurses understand the term ‘guidelines’; in addition, as previously stated, there is recognition of a lack of studies focused on the reasons for UK nurses not adhering to guidelines. This study therefore aimed to explore both of these areas of interest by way of a focus group composed of a sample of UK nurses. Nurse educators were chosen for convenience. By the nature of their role, nurse educators are involved in student nurses' learning of clinical decision-making skills, so their own understanding and interpretation of key concepts may have a wide impact.
Methods
Study design
Approval to conduct the study was obtained from the local university ethics committee. The underpinning philosophy for this research was interpretive phenomenological analysis (IPA) (Smith et al, 2022). This emphasises understanding the participants' perception of the chosen phenomenon, which is the aim of this research. IPA further recognises that this is only the participants' interpretation of the world they live in, and the researcher will apply an interpretation to the participants' interpretations. In other words, the researcher will use their own experience and understanding to make sense of the participants' responses. Reflexivity has been a key part of data analysis, in recognition that putting aside or ‘bracketing’ the researcher's own views, beliefs and understanding is not possible (Smith et al, 2022).
A focus group was the chosen method of data collection for this study. This form of interview, which was held online, allowed the researcher to guide a discussion and also took advantage of group dynamics, encouraging rich discussion in an economical manner (Polit and Beck, 2021). Typically, fairly homogeneous groups are selected to help make a comfortable group dynamic (Creswell, 2013; Polit and Beck, 2021). In this research, nurse academics in one institution were sampled.
Participants
IPA requires small participant numbers due to the depth of analysis required (King et al, 2019; Ellis, 2022) and therefore the researcher used a purposive convenience sampling strategy to recruit nurse lecturers at a local university with a target sample size of four to six participants. An email invitation with a participant information sheet was sent to all nurse educators in a local university; approximately 100 academics were eligible to take part in the study. Twelve nurse academics responded and were subsequently sent an informed consent form to complete and return; six forms were returned and therefore a focus group interview was arranged for six participants. On the day, five nurse academics attended.
Data collection
The focus group interview lasted 1 hour and 25 minutes. The interview was held via Microsoft Teams and the embedded captioning tool was used. The interview was further transcribed to amend inaccuracies in captioning and to replace participant names with pseudonyms.
Analysis
Data analysis was undertaken using the IPA process described by Smith et al (2022). In practice, a handwritten analysis was undertaken and involved the following steps:
The next steps of analysing other cases and developing group experiential themes would be followed if further focus group interviews had been undertaken; in this case, only one focus group was possible due to the time available for a small practice development project.
Author's perspective
The researcher recognised that he would apply his own interpretation to the participants' interpretations, as described by Smith and Osborn (2015). To mitigate the effects of this, the researcher kept a reflexive diary throughout the process. The researcher also recognised the impact of existing professional relationships between the interviewer and interviewees, and this was considered during data analysis through reflexive diary entries.
Results
The analysis resulted in the identification of three personal experiential themes (PETs) (Smith et al, 2022):
Lack of consensus regarding a definition of ‘guideline’
Guidelines were often perceived by the nurse academic participants as guidance or a guide to practice:
‘[A guideline] guides and tells me what I should be doing.’
They are: ‘not written in stone’ or ‘regulatory in terms of the law’. Some nurses often use the word ‘guideline’ synonymously with ‘rule’:
‘You've got some guidelines that are kind of mandatory in that you wouldn't deviate from them ever.’
However, when rules and regulations were further discussed one participant said:
‘Do you think that's like regulations, though? Because as soon as somebody says that word to me, I think, oh, oh, I've got to do it that way then. Whereas if something's like a policy or a guideline, I think there's room for manoeuvre.’
Another said:
‘It just comes down to what I would class in my mind as a rule and something that is up for interpretation.’
This suggests that guidelines are viewed as flexible.
Discussion about the definition of the term guidelines being the same as, or different from, other terms such as rule, regulation, or instruction, suggested there was no consensus regarding understanding and interpretation of the term. Another term, ‘policy’, was also used by some nurses as a synonym. One nurses academic said:
‘You say guidelines and policy, they're a bit similar in that you know they're both guidance.’
Others said:
‘I'm finding it quite hard to differentiate between a guideline and a policy.’
‘So I don't know that it's guidelines or policy, is that the same thing?’
Therefore the participants had differing, and even contradictory, definitions of this key term used in clinical practice.
Barriers to guideline adherence
Nurses are accustomed to using guidelines in clinical practice and generally adhere to them in their practice, as one nurse academic noted:
‘That was your Bible, that's what you went by.’
However, there are many barriers to guideline adherence. Resistance to new guidelines that require a change in practice can be a cause of anxiety, as participants explained:
‘Resistance to the change in the guidelines because of staff 's own, um, anxieties.’
‘Lot of resistance to that because they felt that they hadn't got the knowledge that was required.’
‘They weren't capable of doing that because they'd never done it before.’
The need for training and educational support prior to new guidelines being introduced is suggested by the researcher as a way to reduce this anxiety and therefore increase adherence.
In addition to this passive non-adherence, nurses may actively refuse to adhere to guidelines when they feel that the reasons for change are not explicit, as one participant explained:
‘[If] it was a rule that didn't make sense. Um, you know, we'll be quite keen to fight against it.’
Some nurses may resist new guidelines as they are not interested in changing their practice. One participants said:
‘[They] can't be bothered about having to have learned new things and have everything changed when they're happy doing things the way that they are.’
Other reasons given for nurses resisting new guidelines were:
‘Someone just not wanting to do that.’
and simply:
‘We've always done it like this.’
Nurses working in more than one area, or even for more than one healthcare provider, may find guidelines differ between them and therefore it is not possible to adhere to both sets of guidance. One participant said it was like having ‘kind of two masters’ leading to:
‘Two sets of guidelines. So, everything you're working to has two sets … and they don't always match.’
As with change management more generally, the requirement to change established practice can be a barrier to nurses feeling able to, or wanting to, follow a new clinical guideline.
Impact on professional judgement
The nurse academics suggested there were many benefits of using clinical guidelines, including standardisation of procedures and ensuring practice remains evidence based. Another benefit proposed for nurses was that they:
‘Take a bit of the fear of decision-making off them.’
The impact guidelines have on nurses' clinical decision-making and professional judgement is significant and may act as another barrier for adherence to guidelines in practice. One key term used by nurses to summarise this professional judgement was the ‘experience’ that comes from working as a nurse, as one participant explained:
‘The guideline guidance might say to do that but actually we know that isn't the right thing to do because of the kind of experience [we have].’
Another participant said:
‘The guidelines are there to say this is what should happen. But then yes, there should be that professional judgement and that kind of experience.’
Another participant commented that more junior nurses might:
‘[Have an] inability sometimes, I think, to deviate from the guidelines, you know, not using that professional judgement.’
Nurses using their experience and judgement to support the best interest of patients is a proposed reason for deciding to not use published guidelines when making decisions about patient care, as the participants explained:
‘You've got to act in the patient's best interest.’
‘Acting as an advocate for our patient, and being humans.’
‘[Having] consideration for the patient as well.’
‘I've only ever really deviated from policy or guidance when it's been for the patient's benefit or what I saw as being in the patient's best interest.’
Patient choice was also a factor in clinical decision-making:
‘That's where either the individual's clinical judgement and experience, or even the patient's choice comes into it.’
With experience also comes the ability to know whether or not guidelines must be followed, as one participant said:
‘I know where there's a bit of leeway.’
Clinical experience provides nurses with a level of intuition that is used when making clinical decisions, regardless of guidelines:
‘Yes, there are guidelines but don't ever forget your intuition because that is important as well. You've got a niggle, don't ignore it.’
‘You've got a gut instinct for a reason. You've seen enough people.’
Professional judgement is often employed by nurses in decision-making, although the risks of favouring this over clinical guidelines was understood, as one participant noted:
‘Having to explain yourself in a court of law and whether or not you would feel that you would be supported in following your own clinical judgement.’
The nurse educators viewed professional judgement as important both in clinical practice and in their academic role. They felt that the flexibility required for undertaking roles requiring multivariable decision-making means that guidelines cannot always be fully adhered to in practice. One participant noted:
‘If there was no room for manoeuvre, then you wouldn't need us, you could just teach it all by a computer program.’
Discussion
In this research study, nurse academics at one UK institution discussed their understanding of the term ‘guidelines’ with regard to clinical practice. The terms ‘clinical practice guidelines’, ‘protocols’ and ‘care pathways’ are frequently used in health care but without clear definitions or the differences between these terms being made clear (Kredo et al, 2016). Clinical practice guidelines generally deal with clinical conditions and include best-practice statements (Woolf et al, 1999), whereas protocols may be seen as explicitly prescribing processes to use in practice (Kredo et al, 2016). However, there is no consensus in the literature as to how any of these terms should be understood by health professionals. Whichever term is used, there is evidence that strategies to implement new research and evidence into clinical practice result in improvement in care outcomes (Grimshaw et al, 2012).
The focus group research showed that not only did each of the nurses understand, or at least define, ‘guidelines’ differently, but some of the nurses used contradictory language when defining the term. At times they described guidelines as purely guidance and at other times as something that must be followed. If guidelines are viewed as guidance only then it is unsurprising that nurses may not view adherence as mandatory. This may be problematic if it is assumed that new evidence will be adopted in practice by the publication and implementation of new clinical guidelines because nurses may not realise that adherence is expected. The focus group suggested that even when guidelines are seen as a ‘rule’ or ‘instruction’ then nurses still may not choose to follow them when they believe it would not result in the desired outcome, such as not being in patients' best interests.
Lack of consensus on the meaning of guidelines may be a barrier for adherence in practice for the reasons discussed, but the data analysis identifies other barriers that impact nurses' decision-making in practice. Although the barriers suggested by the nurses: anxiety about changing practice, not understanding the rationale for change, apathy, and contradictory guidance, are not referred to in the literature as nursing barriers to adopting clinical guidelines, they are all identified in the literature as reasons for doctors' reluctance to adhere to guidelines (Bosse et al, 2006). Changes in the roles of health professionals in recent years, especially changes to nurses' roles in the UK, or less research focusing on nursing practice, may explain the reasons for this lack of inclusion.
Professional scepticism or concern about losing autonomy is identified in the literature for nurses not adhering to guidelines in practice (Helseth et al, 2017; Törmä et al, 2021). This seems to be a significant barrier and the nurse academics spoke of often using their own experience and ‘intuition’ in clinical decision-making. Intuition should not be understood as simply a ‘hunch’ and may more accurately be defined as a process for decision-making based on prior knowledge and previous clinical experience and is a form of evidence based on experience used alongside research-based evidence (Melin-Johansson et al, 2017). If guidelines are viewed as recommended practice, rather than mandated, then experienced nurses using their intuition rather than adhering strictly to guidelines when planning care for a patient may be the appropriate course of action. This leads to the question of what constitutes an ‘experienced’ nurse; would this be one with many years of working in the same field or require a range of professional experiences in certain settings?
The outcomes from the focus group largely reflect the literature regarding barriers to adherence to clinical guidelines for health professionals, although the literature focuses on doctors rather than nurses. The lack of consensus of what ‘guidelines’ are as opposed to policies, rules or regulations, and how this may influence the decision to follow the guidelines when making clinical decisions, is an area that is not discussed widely in healthcare literature.
Strengths and limitations
A convenience sampling strategy was used to recruit participants in the university in which the researcher is employed; this may have affected the interview dynamics and results (Jager, et al, 2017). Mitigation was attempted by being transparent about these existing relationships and by using a reflexive diary throughout the study.
Conclusion
In this research study, the nurse academics' discussion showed there was no consensus about the meaning of the term ‘guidelines’. It is suggested that their understanding of the term may influence their decision whether to follow guidelines when making clinical decisions. When guidelines are viewed as ‘recommendations’ rather than ‘rules’ then nurses may be inclined to use their own intuition and experience instead when decision-making. Even when guidelines are seen as mandatory, nurses may choose not to adhere to them when they feel the potential outcome is not in their patients' best interests.
Replicating the study with a wider group of nurses with different levels of experience, both in terms of time served and a variety of specialties, would serve as a useful comparison for this study. Further research is also recommended to explore nurses' experiences of using ‘intuition’ in clinical decision-making.
General barriers to implementing guidelines in practice may be mitigated by standard change-management techniques, and ensuring a robust system of training and education is in place. The findings of this study, in addition to the suggested further research, may offer clear direction for policy development and training to help address the identified barriers to adhering to guidelines and the associated potential risks in clinical practice.