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Int J Nurs Stud. 2014 Feb;51(2):289-99. doi: 10.1016/j.ijnurstu.2013.06.019. Epub 2013 Jul 30.

The nursing work of hospital-based clinical practice guideline implementation: an explanatory systematic review using Normalisation Process Theory.

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Faculty of Health Sciences, University of Southampton, Building 67 (Nightingale), University Road, Highfield, Southampton SO17 1BJ, UK. Electronic address:
Faculty of Health Sciences, University of Southampton, Building 67 (Nightingale), University Road, Highfield, Southampton SO17 1BJ, UK.



To investigate the dynamics of nurses' work in implementing Clinical Practice Guidelines.


Hybrid: systematic review techniques used to identify qualitative studies of clinical guideline implementation; theory-led and structured analysis of textual data.


CINAHL, CSA Illumina, EMBASE, MEDLINE, PsycINFO, and Sociological Abstracts.


Systematic review of qualitative studies of the implementation of Clinical Practice Guidelines, analysed using Directed Content Analysis, and interpreted in the light of Normalisation Process Theory.


Seven studies met the inclusion criteria of the review. These revealed that clinical practice guidelines are disposed to normalisation when: (a) They are associated with activities that practitioners can make workable in practice, and practitioners are able to integrate it into their collective workflow. (b) When they are differentiated from existing clinical practice by its proponents, and when claims of differentiation are regarded as legitimate by their potential users. (c) When they are associated with an emergent community of practice, and when members of that community of practice enrol each other into group processes that specify their engagement with it. (d) When they are associated with improvements in the collective knowledge of its users, and when users are able to integrate the application of that knowledge into their individual workflow. And, (e) when nurses can minimise disruption to behaviour norms and agreed professional roles, and mobilise structural and cognitive resources in ways that build shared commitments across professional boundaries.


This review demonstrates the feasibility and benefits of theory-led review of studies of nursing practice, and proposes a dynamic model of implementation. Normalisation Process Theory supports the analysis of nursing work. It characterises mechanisms by which work is made coherent and meaningful, is formed around sets of relational commitments, is enacted and contextualised, and is appraised and reconfigured. It facilitates such analysis from within the frame of nursing knowledge and practice itself.


Clinical guidelines; Directed Content Analysis; Implementation; Normalisation Process Theory; Nursing work; Practice theory; Qualitative synthesis; Systematic review

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