This study highlights preconditions for successful guideline implementation based on oncology nurses' perceptions. Many factors influence the implementation of the guidelines at multiple levels. Therefore, future implementation strategies will be focused on a specific precondition at each level: goal congruence at the organizational level, equal partnership at the multidisciplinary level, professional self-development at the individual level, and user-friendliness at the guideline level.
There were some differences between the results of our studies and the literature. While Gurses et al. reported physician's disbelief of guidelines as a barrier to guideline implementation in their review, lack of agreement with a guideline or skepticism was not found in nurse participants in our study [26
]. Also, any patient factor, which might influence guideline implementation according to the systematic review [15
], was not identified as a precondition in our results.
In this study, goal congruence at the organizational level was revealed as an important precondition to implement guidelines. Priorities are often different between the organization and front line staff. Goal congruence is the first vital step to implementing the guidelines. The guidelines were supposed to represent a strategic change towards best practice [27
]; however, organizational factors often negatively influence guideline implementation. In this study, there were five challenges at the organizational level, which had the largest number of challenges among the four levels.
With ambiguous rationale, health care providers resist changes or easily become captivated by brand names. Funk et al. addressed the responsibility of researchers for scientific aspects, administrators for the institutional environment for research use, and practitioners for guideline implementation [28
]. In addition, disseminators of the guidelines must facilitate the change from customary practice to evidence-based practice.
Since organizations are cost-conscious, costs create obstacles for adopting the guidelines. In reality, organizations need financial incentives to change established routines. As the interviewed oncology nurses argued, reimbursement could be a strong incentive for successful guideline implementation [7
]. At the other end of the spectrum, guideline implementation should be cost-effective in principle [15
]. Proving the cost effectiveness within the framework of the insurance system would be a driving force for change, and thus it is urgent to explore such an agenda.
Working in equal partnership among multidisciplinary team members is imperative for guideline implementation at the multidisciplinary level. The hierarchy among healthcare providers impedes the use of the guidelines. Nurses as well as other staff are likely to depend on physicians or senior staff. Individual healthcare providers should be independent as professionals.
Cancer care requires a multidisciplinary team approach. With multiple disciplines involved, sharing information towards a common goal beyond the boundaries of the profession is essential, and the guidelines can be an efficient tool. Although the guidelines should be incorporated into practice upon consensus among professionals [29
], poor consensus building across multiple disciplines is a serious challenge for team care. One of the reasons behind this is that there are different norms in different disciplines, which reportedly affects team care [11
]. Discipline-specific interests may hinder understanding and respect for the perspectives of members of other disciplines. Teamwork creates a work culture that values collaboration. Equal partnership is a prerequisite for true collaboration. The need for collaborative professional work is more important than ever in the era of patient-centered care.
Professional self-development is the key at the individual level. Nurses should prepare themselves to respond to changing needs in health care, and they are responsible for their own development. The results of this study suggest that professional development to update knowledge should be incorporated as a strategy for guideline implication. This study targeted only oncology nurses who had specialty education in chemotherapy, yet even these nurses with relatively high levels of education perceived their individual abilities as limited. They are not comfortable using the guidelines or are not able to make decisions about whether the guidelines are applicable to their own patients. Melnyk et al. reported that nurses' knowledge about evidence-based practice was much lower than their beliefs that evidence-based practice improves clinical care and patient outcomes [30
Commitment is always required to introduce something new. Some nurses, however, feel detached from the guidelines, which represents their passive attitudes and limited interest. Negative staff attitudes and beliefs [5
], lack of professional accountability [31
], and lack of familiarity with the guidelines [22
] have been identified as barriers in the literature. Oncology nurses should be aware of the impact of their knowledge, morale, and behavior as professionals, and of their responsibility to utilize the guidelines [26
The oncology nurses expressed their concerns regarding the additional workload due to the adaptation of the guidelines. This hurdle could be overcome by motivation and professional commitment as a nurse as well as by support from a nursing manager and colleagues [5
]. Interestingly, a previous study noted that the practitioners in the clinic where the guideline was not used mentioned lack of time as a barrier, while those in the clinic where the guideline was used did not report this problem, probably due to the attempt to practice change [32
Lastly, further improvement of the guidelines is needed. The quality of clinical practice guidelines often varies widely [33
]. Despite a recommended external review of the draft guidelines before dissemination as a part of the development phase [6
], the current format of the guidelines is also noted as a concern because of their great length, their complicated nature, and lack of opportunity to test them [26
]. These hard-to-use and complex features of the guidelines may discourage nurses and decrease their expectations [17
]. It is feasible for guideline developers to modify the content and format of guidelines in consideration of implementability [35
]. AGREE II is a useful tool for health care providers to appraise the guideline [36
]. Indeed, when we developed the chemotherapy guideline, an external evaluation was performed using the Japanese version of AGREE [37
], the volume of the guideline and applicability to the local context persuaded us to revise the guideline draft [38
The oncology nurses voiced the need for a collaborative network with researchers who need to incorporate the views of practitioners into the development of the guidelines and support practitioners for dissemination, even after implementation. Such collaborative efforts could lead to sustainable guideline utilization.
This study has implications for policy and clinical practice. Japan has established the initiatives to improve the quality of cancer care, begun when the Cancer Control Act was approved in 2006. The use of guideline has been encouraged for standardization of treatment. Preconditions derived from practical issues at different levels identified in this study will provide policy makers with a better understanding of practitioners' perceptions, and help practitioners to implement guidelines. Organizations must understand the significance of guideline implementation and its positive consequences, and set up procedures and activities to support the goal. Furthermore, organizations should strengthen their collaborative networks with researchers to facilitate guideline implementation.