1. Home
  2. Journals
  3. International Journal of Public Health Research and Epidemiology
  4. Current Issues
  Submit Manuscript

Research Article | DOI: https://doi.org/10.5281/zenodo.21405972

Barriers, Facilitators and Consensus Strategies for Implementing Nursing Protocols: Results of a Delphi Study

Tzenalis Anastasios *

Nursing Dep. University of Patras Patra, Greece

*Corresponding Author: Tzenalis Anastasios, Nursing Dep. University of Patras Patra, Greece

Citation: Tzenalis Anastasios (2026). Barriers, Facilitators and Consensus Strategies for Implementing Nursing Protocols: Results of a Delphi Study, J International Journal of Public Health Research and Epidemiology; 2 (2) 06, DOI: 10.5281/zenodo.21405972

Copyright: Tzenalis Anastasios, et al © (2026). This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 27 March 2026 | Accepted: 15 April 2026 | Published: 27 April 2026

Keywords: evidence-based practice; nursing protocols; Delphi method; nursing management; clinical guidelines; healthcare quality

Abstract

Background:

Evidence-based practice (EBP) plays a crucial role in improving the quality, safety, and effectiveness of healthcare services. Nursing protocols constitute structured clinical tools that support standardized patient care, reduce clinical variability, and promote evidence-based decision-making. Despite their recognized importance, the successful implementation of nursing protocols in clinical practice remains challenging due to organizational, educational, and professional barriers.

Aim:

The aim of this study was to investigate the implementation process of nursing protocols in hospital settings and to explore expert consensus regarding effective strategies for their development and application in clinical practice.

Methods:

A Delphi study design was employed to collect expert opinions and achieve consensus on best practices for the implementation of nursing protocols. A purposive sample of 100 healthcare professionals, including clinical nurses, clinical educators, ward managers, and nursing administrators, participated in two rounds of questionnaires. Data were analyzed using descriptive statistics and correlation measures. Consensus levels were defined using predefined agreement thresholds.

Results:

The findings demonstrated strong agreement among participants regarding the importance of structured and evidence-based nursing protocols in improving patient safety, reducing clinical errors, and enhancing interdisciplinary communication. Key facilitators of successful protocol implementation included leadership support, continuous professional education, clear organizational responsibilities, and the involvement of clinical staff in protocol development. The Delphi process resulted in a consensus-based framework consisting of 19 recommendations aimed at improving the implementation and sustainability of nursing protocols in hospital environments.

Conclusions:

The study highlights the multifactorial nature of nursing protocol implementation and emphasizes the importance of organizational support, professional education, and participatory decision-making. The proposed framework may support healthcare organizations in strengthening evidence-based nursing practice and improving the quality and safety of patient care.

References

  1. Jylhä V, Saranto K, Bates DW. Preventable adverse drug events and their causes and contributing factors: The analysis of register data. International Journal for Quality in Health Care. 2011;23(2):187–197. doi:10.1093/intqhc/mzq085
    View at Publisher | View at Google Scholar
  2. McKey CA, Bassendowski SL. Florence Nightingale: An environmental adaptation theory. Nursing Science Quarterly. 2017;30(4):297–300. doi:10.1177/0894318417723411
    View at Publisher | View at Google Scholar
  3. Kelly U, Edwards G, Shapiro SE. Nursing Policies and Protocols: Do Nurses Really Use Them? J Nurs Care Qual. 2021;36(3):217-222.
    View at Publisher | View at Google Scholar
  4. Pimenta CAM, Pastana ICASS, Sichieri K, Solha RKT, Souza W. Guia para construcao de protocolos assistenciais de enfermagem. Sao Paulo: COREN-SP; 2015.
    View at Publisher | View at Google Scholar
  5. Gomes ATL, Alves KYA, Bezerril MS, Rodrigues CCFM, Ferreira Jr MA, Santos VEP. Validation of graphic protocols to evaluate the safety of polytrauma patients. Acta Paul Enferm. 2018;31(5):504-517.
    View at Publisher | View at Google Scholar
  6. Paes GO, Santos I, Matos E, Silva LF, Freitas KS. Barriers and facilitators to the implementation of evidence-based nursing practice: An integrative review. Revista Brasileira de Enfermagem. 2015;68(5):866–873. doi:10.1590/0034-7167.2015680517i
    View at Publisher | View at Google Scholar
  7. Merriam-Webster. Delphi Method - Definition of the Delphi method. 2021.
    View at Publisher | View at Google Scholar
  8. Daly JM, Buckwalter K, Maas M. Written and computerized care plans: organizational processes and effect on patient outcomes. J Gerontol Nurs. 2002;28(9):14-23.
    View at Publisher | View at Google Scholar
  9. Bollmann M, Vanhaecht K, Bower K, et al. Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association. J Integr Care Pathw. 2006;10:28-34.
    View at Publisher | View at Google Scholar
  10. Hsu CC, Sandford BA. The Delphi technique: Making sense of consensus. Pract Assess Res Eval. 2007;12(10):1-8.
    View at Publisher | View at Google Scholar
  11. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: how to decide its appropriateness. World J Methodol. 2021;11(4):116.
    View at Publisher | View at Google Scholar
  12. Linstone HA, Turoff M. The Delphi Method: Techniques and Applications. Addison-Wesley; 2002.
    View at Publisher | View at Google Scholar
  13. Sablatzky T. The Delphi method. Hypothesis: Research Journal for Health Information Professionals. 2022;34(1).
    View at Publisher | View at Google Scholar
  14. Keeney S, Hasson F, McKenna HP. The Delphi Technique in Nursing and Health Research. John Wiley & Sons; 2011.
    View at Publisher | View at Google Scholar
  15. Skulmoski GJ, Hartman FT, Krahn J. The Delphi method for graduate research. J Inf Technol Educ Res. 2007;6(1):1-21.
    View at Publisher | View at Google Scholar
  16. Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. Am J Theor Appl Stat. 2016;5(1):1-4.
    View at Publisher | View at Google Scholar
  17. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42(5):533-544.
    View at Publisher | View at Google Scholar
  18. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 11th ed. Wolters Kluwer; 2021.
    View at Publisher | View at Google Scholar
  19. DeVellis RF. Scale Development: Theory and Applications. Sage Publications; 2016.
    View at Publisher | View at Google Scholar
  20. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. International Journal of Medical Education. 2011;2:53–55. doi:10.5116/ijme.4dfb.8dfd
    View at Publisher | View at Google Scholar
  21. American Nurses Association. Nursing: Scope and Standards of Practice. American Nurses Association; 2021.
    View at Publisher | View at Google Scholar
  22. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, Wales PW. Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-409.
    View at Publisher | View at Google Scholar
  23. McKnight PE, Najab J. Mann-Whitney U test. In: The Corsini Encyclopedia of Psychology. 2010:1-1.
    View at Publisher | View at Google Scholar
  24. World Health Organization. Ethical considerations for health policy and systems research. 2021.
    View at Publisher | View at Google Scholar
  25. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019.
    View at Publisher | View at Google Scholar
  26. Grol R, Wensing M, Eccles M, Davis D. Improving Patient Care: The Implementation of Change in Health Care. 2nd ed. Wiley-Blackwell; 2013.
    View at Publisher | View at Google Scholar
  27. Spoon D, Rietbergen T, Huis A, Heinen M, van Dijk M, van Bodegom-Vos L, Ista E. Implementation strategies used to implement nursing guidelines in daily practice: A systematic review. Int J Nurs Stud. 2023;145:104540.
    View at Publisher | View at Google Scholar
  28. Rycroft-Malone J, Seers K, Chandler J, Hawkes C, Crichton N, Allen C, et al. The role of evidence, context, and facilitation in an implementation trial: Implications for the development of the PARIHS framework. Implement Sci. 2016;11(1):23.
    View at Publisher | View at Google Scholar
  29. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.
    View at Publisher | View at Google Scholar
  30. Tomaselli G, Buttigieg SC, Rosano A, Cassar M, Grima G. Person-centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: A scoping review. BMC Med Ethics. 2023;24(1):1-10.
    View at Publisher | View at Google Scholar
  31. Lee K, Kim H, Park Y. Barriers and facilitators to implementing clinical practice guidelines in healthcare settings: A systematic review. BMC Health Services Research. 2023;23:1021. doi:10.1186/s12913-023-10021-5
    View at Publisher | View at Google Scholar
  32. LoBiondo-Wood G, Haber J. Nursing Research E-book: Methods and Critical Appraisal for Evidence-Based Practice. Elsevier Health Sciences; 2021.
    View at Publisher | View at Google Scholar
  33. Pan M, Gao W. Determinants of the behavioral intention to use a mobile nursing application by nurses in China. BMC Health Serv Res. 2021;21:1-11.
    View at Publisher | View at Google Scholar
  34. Chandran S, Jose J, Varghese S, Rani A. Digital health technologies and clinical decision support systems in nursing practice: Opportunities and implementation challenges. Journal of Nursing Management. 2022;30(8):3693–3702. doi:10.1111/jonm.13725
    View at Publisher | View at Google Scholar
  35. Backman A, Sjögren K, Lindkvist M, Lövheim H, Edvardsson D. Factors influencing the implementation of person-centred care in nursing homes: A systematic review. International Journal of Nursing Studies. 2021;115:103841. doi:10.1016/j.ijnurstu.2020.103841
    View at Publisher | View at Google Scholar
img

Harry Brooks

journal of Clinical Case Studies and Review Reports. I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office.the reviewer board were accurate and helpful regarding anu modifications for my manuscript,and the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help.it was my pleasure to contribute with your promising journal and i am looking forward for more collaboration.

img

Mark

My testimonial covering : the peer review process is qucick and effective,the support from the editorial office is very professional and friendly, quality of the Clinical Case Studies and Review Reports is scientific and publishers research.

img

Sinisa franjic

i would like to thank the editorial team for their timely responses and consideration in the publication of my paper . I would encourage to publish there research in ScienceFrontier.

img

Ritu Tiwari

I am pleased to submit my testimonials regarding the reviewer board and the editorial office. As a peer reviewer for the manuscript titled “A Novel Dissolution Method for Simultaneous Estimation of sennoside A and Sennoside B in Senna Tablet,” I was consistently impressed by the reviewers’ thorough analysis, insightful feedback, and unwavering commitment to enhancing the quality of the work. Their reviews were comprehensive and characterized by a respectful and collaborative approach, providing valuable suggestions that significantly improved the paper's outcome. Their dedication to the peer review process demonstrated their expertise and steadfast pursuit of excellence.

img

Qader Bawerdi

With all due respect, I would like to express my opinion on the peer review, editorial support, and the quality of the journal as follows: The peer review was conducted quickly and with great care, and my article was accepted for publication in less than a week. The editorial support regarding the status of the article process was excellent, and they informed me every day until the acceptance of the current status of the article version, and regarding how to answer questions, the editorial support was excellent, timely, and friendly, and they answered questions as soon as possible and did not hesitate. The quality of the journal was excellent and it made me proud to be acquainted with the journal, and I sincerely look forward to extensive scientific collaborations in any field. I hope for increasing success and pride for the International Journal of Social Science Research and Review and all scientific and knowledge-based communities. Thank you

img

Bhuvanagiri Sathya Sindhuja

"I would like to express my sincere appreciation for the opportunity to contribute to this esteemed journal. The publication process was smooth, well-coordinated, and the peer reviewers deemed highly professional. The editorial team demonstrated exceptional diligence and support at every stage, ensuring a seamless experience from submission to final publication. I am truly honored to be featured in such a reputable platform and look forward to future collaborations."

img

Safana Abdullah Algutaini

Testimonial for the Journal of Biomedical Research and Clinical Advancements It was a truly rewarding experience publishing our study, "Single-Surgeon Outcomes of Left Ventricular Aneurysm Repair in Wartime Syria: A 10-Year Retrospective Study at Damascus University Cardiac Surgery Hospital," with the Journal of Biomedical Research and Clinical Advancements. The editorial and peer-review process was both rigorous and efficient, demonstrating a high standard of academic integrity and scientific scrutiny. The journal’s commitment to open access and global health equity is evident in its support of research emerging from conflict-affected and resource-limited settings—making our work not only visible but impactful. The professionalism of the editorial team, the speed of communication, and the clarity of submission guidelines all contributed to a smooth publication process. We were particularly impressed by the quality of the publication layout and the prompt indexing of our article, which enhances its accessibility to clinicians, researchers, and policymakers worldwide. We are proud to have contributed to this journal and highly recommend it to fellow researchers seeking a reputable platform to disseminate clinically significant and globally relevant findings.

img

Sajjad Ur Rahman

It is a great pleasure and honour to write this testimonial for IJPHRE which published our article on TH for HIE in LMIC on Feb 16th, 2026 and a commentary article on the same subject on 31st January 2025. Going through the very fast, well supported and properly guided process of publication in IJPHRE was an exceptional experience. The submission was very quick; peer review was very professional and done within a reasonable and short time. The comments of the reviewers meaningfully helped to reshape the manuscript without changing the fundamental dataset and analysis. The editorial board was very helpful and supportive. The communication was clear and instant, almost on daily basis. The team of authors felt very proud of seeing its manuscript published in an international journal of very high quality and esteem in remarkably short time of almost 45 days. We highly recommend IJPHRE for publication of all kinds of original scientific research, review articles and clinical guidelines.

img

Dr Sabita Sinha

I had a very positive experience with Clinical Case Studies and Review Reports. Emma Daniel was highly professional, supportive, and responsive throughout the editorial process. Communication was clear and timely at every stage of manuscript handling. The journal maintains a smooth review process and encourages quality academic publishing. I truly appreciate the efforts of Emma Daniel and the editorial team, and I would be glad to collaborate with the journal again in the future.