
==== Front
BMC Health Serv Res
BMC Health Serv Res
BMC Health Services Research
1472-6963
BioMed Central London

39300423
11561
10.1186/s12913-024-11561-4
Research
Barriers and facilitators of the nurse providing evidence-based preoperative visit-care for transcatheter aortic valve replacement: a mixed-methods study based on an evidence application setting
Wei GuanXing 1
Tan JunYang 2
Ma Fang 3
Yan Han 1
Wang XiTing 1
Hu QiuLan 4
Wei Wei 5
Yang MingFang 3
Bai YangJuan Baiyangjuan300325@126.com

1
1 https://ror.org/02g01ht84 grid.414902.a 0000 0004 1771 3912 Cardiology Department, The First Affiliated Hospital of Kunming Medical University, No. 295, Xichang Road, Kunming, 650032 China
2 https://ror.org/05tv5ra11 grid.459918.8 Cardiology Department, People’s Hospital of Yuxi City, Yuxi, China
3 https://ror.org/02g01ht84 grid.414902.a 0000 0004 1771 3912 Department of Nursing, The First Affiliated Hospital of Kunming Medical University, Kunming, China
4 https://ror.org/02g01ht84 grid.414902.a 0000 0004 1771 3912 Geriatric Intensive Care Unit Department, The First Affiliated Hospital of Kunming Medical University, Kunming, China
5 https://ror.org/02g01ht84 grid.414902.a 0000 0004 1771 3912 Digestive Surgery Department, The First Affiliated Hospital of Kunming Medical University, Kunming, China
19 9 2024
19 9 2024
2024
24 11014 6 2024
9 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Preoperative visit-care for transcatheter aortic valve replacement (TAVR) plays a crucial role in improving the quality of care and patient safety. However, preoperative care for TAVR patients is still in its early stages in China, with the care often being experience-based. The application of relevant evidence in nursing practice is necessary. Little is known regarding the facilitators and barriers to apply and compliance to the evidences about preoperative visit-care for TAVR in nursing.

Methods

The Nurse’s Compliance Checklist was used to investigate the evidence-based compliance of nurses (n = 21) who worked in the TAVR team in the evidence-based implementation setting. Meanwhile, an Evidence-Based Practice Beliefs Scale, and Influencing Factors Checklist were used to investigate all nurses (n = 66) who work in the same setting. Stakeholders (Middle and senior-level nursing administrators, frontline clinical nurses, and patients) interview was carried out to further disclose the barriers and facilitators in the process of evidence-based practice.

Results

The results of this study showed that only 1 evidence implemented fully (100%) by nurses, 3 evidences with 0% implementation rate, and implementation rate of the other evidences were 9.5∼71.4%. The overall score of nurses’ evidence-based nursing belief level was (3.52 ± 0.82). Three domains of barriers were identified: the Context Domain included lack of nursing procedures, inadequate health education materials, insufficient training; the Practitioner Domain included insufficient attention, lack of relevant knowledge, high work pressure and uncertainty of expected results, and Patient Domain included lack of relational knowledge. Facilitating factors included leadership support, nurse’ high evidence-based nursing belief, high executive ability and enthusiasm for learning.

Conclusion

The study indicated that the nurses’ compliance of evidence-based practice in preoperative visit-care for TAVR was in lower level. There were some factors influencing the application of the evidences. The study revealed potential modifiable barriers to the successful implementation of evidence-based preoperative visit-care, including a lack of preoperative visit- care routine, related knowledge and training. Leadership support and nurse training should be considered to improve nurses’ compliance with evidence-based practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11561-4.

Keywords

Barriers
Evidence-based preoperative visit-care
Facilitators
Nursing
Transcatheter aortic valve replacement
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmc Text box 1. Contributions to the literature	
(i) This study investigate how cultural beliefs and practices in China impact the implementation of evidence-based preoperative visit-care.	
(ii) Our study explored how evidence-based preoperative visit-care can be integrated into the existing healthcare infrastructure in China, identifying potential systemic barriers and facilitators.	

Introduction and background

Aortic stenosis (AS) is one of the common valve diseases in China [1]. In developed western countries, AS has the third highest prevalence among cardiovascular diseases, following coronary artery disease and hypertension [2]. The prevalence of AS increases exponentially with age, ranging from 0.2% in the 50–59 age group, 1.3% in the 60–69 age group, 3.9% in the 70–79 age group, to 9.8% in the 80–89 age group [3]. Currently, there are no pharmacological treatment methods available for AS, and surgical replacement has always been the only treatment option. Transcatheter aortic valve replacement (TAVR), which was first performed in 2002, has become the primary method for treating AS [4]. It is the preferred treatment option for high-risk surgical patients [5]. The TAVR is an effective treatment for severe AS in the elderly, and it has advantages such as small surgical incision, short operation time, no need for cardiopulmonary bypass, and fast postoperative recovery for patients [1, 6, 7]. However, the majority of patients undergoing TAVR surgery are elderly and have multiple comorbidity which leads to high risk or contraindicated for surgery. Additionally, due to the invasive nature of cardiac intervention surgery, it may cause stress responses in patients, leading to preoperative tension, anxiety, and even possible unfavorable intraoperative outcomes or postoperative complications [8, 9]. Study conducted in the European region has shown that the prevalence of preoperative anxiety among surgical patients varies from 27–80% [10]. These factors may affect the surgery and prognosis, resulting in prolonged hospitalization and delayed discharge [11]. Therefore, thorough preoperative assessment and preparation are paramount. People who are in good physical and mental preparation for surgery usually experience surgery more easily due to more relaxation [11].

Preoperative visit-care is a nursing practice process that involves a comprehensive assessment and health education for surgical patients. As a part of perioperative care, visit-care form the foundation for the physical and emotional readiness of patients, and have a positive impact on the entire anesthesia-surgery process [12]. Furthermore, preoperative visit-care provides patients with the opportunity to express their concerns and fears about waiting for the surgery and the postoperative recovery process [13, 14]. Torres et al. [15] pointed out that improving the readiness of patients for surgery has a positive impact on establishing surgical confidence and capability, as well as the outcome of the surgery. Currently, the concept regarding this procedure has shifted from a focus on the question “how do we perform TAVR” to “how do we care for TAVR patients” [16]. Standardized preoperative visit-care can help alleviate the preoperative fears and anxieties of TAVR patients, improve their compliance with medical advice, meanwhile, it would facilitate operation smoothly [14]. Therefore, it is highly necessary to provide evidence-based standardized preoperative visits-care for patients receiving TAVR.

Standardized preoperative visit-care should be evidence-based. Evidence-based practice (EBP) can be defined as “the process of delivering patient-centered care by understanding and translating the best scientific evidence into practice and integrating that knowledge with clinical expertise, patients’ value and wishes” [17]. It is the direction of nursing practice development, and extensive research has confirmed that EBP promoted safe and high-quality patient care [18]. Perioperative care based on the best evidence had been proven to provide safer and higher standards of care [19, 20]. The study by Gao MM et al. [21] suggested that EBP nursing interventions were effective at preventing pressure ulcers in patients with stroke, delaying the onset of pressure ulcers and improving their quality of life. The study conducted by Dong L et al. [22] also indicated that EB nursing could reduce complications and negative emotions in patients undergoing hip replacement surgery, as well as improved their physical function. EBP may also help reduce healthcare expenditures [20]. Therefore, it is necessary and important to conduct evidence-based preoperative visit-care for TAVR patients.

However, applying evidences into clinical practice is an ongoing challenge [23]. The study indicated that the difficulty and complexity of implementing evidence-based practice were far greater than the formulation of evidence-based practice [24]. Nurses’ compliance with EBP is an important indicator of verifying the clinical translation of evidence into effectiveness [25]. Low compliance limits the effectiveness of implementing evidence-based practices [26]. A study on the factors influencing nurses’ assessment and management of patient pain revealed that nursing workload, patient instability, patients’ inability to communicate, and lack of availability of pain assessment tools as the most frequent barriers affecting the implementation of practice [27]. While the influence factors of evidenced-based application are different in different settings due to different culture. Therefore, the investigation and analysis of nurses’ evidence-based compliance status and influencing factors should be based on the setting where the evidences of preoperative visit-care for TAVR are applied. As TAVR is an emerging medical Procedure in the Chinese healthcare field, there is a limited number of centers with independent TAVR capabilities, resulting in a relatively small cumulative number of TAVR [9]. The nursing care for TAVR is still in early stage, most of the nursing practices are based on empirical knowledge even neglecting the preoperative visit-care to TAVR patients which merges it into general nursing care [28, 29]. In China, there is a significant lack of evidence-based nursing research regarding preoperative visit-care for TAVR patients, and very little is known about the existing barriers and facilitators in this aspect. Studies reported that nurses often used their peers as source of knowledge [30], which was irresponsible for patient safety. The assessment and analysis of barriers and facilitators is an important prerequisite for developing effective strategies to promote implementation and is one of the key steps in conducting evidence-based clinical translation project [31]. Therefore, there is an urgent need to investigate the nurses’ compliance status in preoperative visit-care for TAVR and identify the barriers and facilitators to promote the implementation of standardized preoperative visit-care.

Theoretical framework

Implementation science acknowledges that multiple factors can influence translation of evidence into practice [32]. The Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, developed by Professor Kitson and her team at the Royal College of Nursing Research Institute in 2016, is an updated version of the PARIHS framework [33, 34]. This model is commonly used to identify pre-implementation barriers and facilitators in research and guide quality improvement efforts [35–37]. It identifies successful implementation as the interaction of four key elements: innovation, recipients, context, and facilitation [38]. The core component of successful implementation is facilitation, it helps identify and overcome the various contextual factors that may hinder the implementation of innovation [39]. During the design and implementation stages of this study, these four key elements were thoroughly considered to explore the barriers and facilitators which nurses faced when implementing evidence-based preoperative visit-care for TAVR.

Aim

This study aims to (1) investigate the current compliance with evidence of nurses by identifying the gap between current practice and evidence; and (2) identify the barriers and facilitators of evidence-based practice for TAVR preoperative visit-care in clinic in the cardiology department where the EBP were implemented, in a tertiary hospital in Yunnan Province, in China.

Methods

Design

This study used a mixed research method with combining quantitative and qualitative methods [40]. We also used triangulation methods to strengthen our study. (i) Researchers used Checklists and Scale to investigate the nurses’ compliance status with evidence- based practice, and the barriers and facilitators of the implementation. (ii) Meanwhile, stakeholder interviews were conducted to further identify barriers and facilitators. (iii) Finally, we held a group meeting to discuss the quantitative and qualitative results. The inclusion criteria for the group meeting participants and their basic characteristics were in additional file1. The consolidated criteria for mixed research checklist was used [41].

Participants and data collection methods

The quantitative phase of the study, a convenience sample was used. The participants were nurses working in the cardiology department of a Class A tertiary hospital in Yunnan Province, China, where implements the evidence-based practice of TAVR preoperative visit-care in clinic. Inclusion criteria: the study includes nurses who are currently working in the department, including registered nurses involved in nursing management and clinical nursing. Participants should have at least 1 year of work experience in the department and should be informed and willing to participate in the study. Exclusion criteria: Nurses who are on study leave, maternity leave during the study period are excluded. Also, nurses who are undergoing rotational training or those who joined the department during the study period are not included. In the end, 66 nurses (including 21 from the TAVR team) participated in the survey. The collect of quantitative data, (i) Evidence-based compliance: A checklist developed based on the previous best evidences of TAVR preoperative visit-care summarized by research team was used to investigate the evidence-based compliance of nurses (n = 21) who worked in TAVR team, through methods such as on-site observation, reviewing record books, or interview. (ii) The Evidence-Based Practice Beliefs Scale and Influencing Factors Checklist were used to investigate all nurses (n = 66) who work in the evidence-based implement department. Data was collected through on-site distribution and retrieval of questionnaires.

The qualitative phase, we selected the sample using the maximal variability sampling frame approach. Based on the above inclusion and exclusion criteria, nurses who had different positions as nurse managers of ward, clinical front line nurses in TAVR group, and different length of work and professional titles as stakeholders were interviewed. Patients in different educational backgrounds and ages who have undergone TAVR as stakeholders were interviewed in this study. An experienced investigator(XT W) recruited patients. A list of potential participants was first identified by reviewing patients’ records. Then, patients were invited by phone or face-to-face. The inclusion criteria for patients: age over 18 years old; undergone TAVR; without mental illness. Exclusion criteria: the condition is serious (Severe dyspnea, frequently worsening chest pain, and syncope); reject the invitation. Two principal researchers (JY T, GX W) conducted the interviews, both of whom had systematic qualitative research training. The interviews were conducted in the offices or lounges of the interviewees’ respective departments. The audio recording was used for data collection with interviewees’ consent. Each interview last at least 30 min. The interview lasted until no new themes emerged, and the information was saturated. The interviewers were not previously known to the participants. The study obtained informed consent from all participants. Data collection occurred between June and September 2022.

Data collection tool

Nurses’ compliance checklist

This checklist was developed based on the best evidence-based summarize form previous study about preoperative nursing visits for TAVR [42]. It was used to investigate nurses’ compliance with evidence-based of preoperative visit-care for TAVR. There was a total of 24 items in this checklist. Among them, two items (Indicator1-1,1–2) of them were used to review the nursing organizational level’s compliance with evidence; the other items were relevant indicators regarding evidence-based preoperative visit-care for TAVR: [1] Preoperative assessment [2], Preoperative health education [3], Preoperative psychological care. “fully completed”, “Partially completed” and “Not done” were used to judge the compliance of nurses with each indicator. [Refer to supplementary files: Additional file 2]

Evidence-based practice beliefs scale

The Chinese version of the Evidence-Based Practice Beliefs Scale was used in this study. It was developed by Melnyk et al. [43] and validated by Mao Qiuting et al. [44]. The scale contains 16 items, and the 3 factors model fits well, the Cronbach’ s α is 0.895 [44]. A 5-point Likert scale was adapted ranging from “1 = strongly disagree” to “5 = strongly agree”. Items 11 and 13 were reverse scored. Higher score indicated a higher level of belief in evidence-based practice.

Influencing factors checklist (IFC)

Based on literature review and the i-PARIHS theory framework, the IFC was developed by research team. It was used to investigate the barriers and facilitators of this evidence-based implementation in this clinic. There was a total 17 barriers and 7 facilitators. Nurses selected items they believed to be barriers or facilitators. [Refer to supplementary files: Additional file 2]

Guides of qualitative interviews for stakeholder interviews

The interview guides were developed based on the i-PARIHS framework to capture the barriers and facilitators that existed among stakeholders in the effective implementation of evidence-based preoperative visit-care. Two semi-structured interviews were designed, one for nurses and one for patients.

Data analysis

The entry and analysis of quantitative data were carried out by two experienced researchers (Y H, XT W) by using SPSS 22.0 software. Statistical descriptions were conducted using frequencies, percentages (%), and means ± standard deviations (‾x ± s). Qualitative data were analyzed by two experienced researchers (GX W, JY T) using both inductive and deductive approaches for thematic analysis [45]. Step: [1] Achieve familiarity with data: two researchers listened to recordings multiple times, and re-read the transcripts to gain a thorough overview of the data set. Passages from the interview transcripts were matched to the i-PARIHS framework elements (innovation, context, recipients, facilitation) [2]. Producing Initial Codes: Data were identified into initial inductive codes, data-driven process by two researchers [3]. Similar codes were combined to produce a general theme [4]. Two additional researchers joined in reviewing the codes and categories to identify themes [5]. Defining and naming themes; [6] All authors agree the defined themes. Based on the results of the quantitative and qualitative research, a group meeting was then held to conduct a brainstorming analysis of items with less than 100% compliance to identify barrier and facilitators according to the i-PARIHS framework.

Results

General information about nurses

Sixty-six nurses were invited to participate in this study. The nurses had an average age of (34.89 ± 6.56) years and an average work experience of (13.16 ± 7.56) years. Among them, the average work experience of the nurses who worked in the cardiology department was (12.23 ± 7.15) years (refer to Table 1). In stakeholder interviews, a total of 5 nurses (2 head nurses and 3 clinic nurses) and 2 TAVR patients were interviewed in this study (refer to Table 2).

Table 1 General characteristics of nurses (n = 66)

Items	Category	sample size(n)	Percentage(%)	
Gender	Male	0	0.0	
	Female	66	100.0	
Education level	Master’s degree	2	3.0	
	Bachelor’s degree	64	97.0	
	College diploma	0	0.0	
Professional title	Head nurse	0	0.0	
	Deputy head nurse	4	6.1	
	Supervising nurse	30	45.5	
	Nurse Practitioner	27	40.9	
	Nurse	5	7.6	
Position title	Assistant Nurse Manager	4	6.1	
	Nursing Unit Manager	10	15.2	
	Nurse	52	72.7	

Table 2 General characteristics of stakeholders (n = 7)

participant	Gender	age	Education level	Professional title	Position title	working years	Years of work in cardiology department	
Nurse 1	Female	49	Bachelor’s degree	Associate Senior	Head nurse	29	29	
Nurse 2	Female	44	Bachelor’s degree	Associate Senior	Deputy Head nurse	20	19	
Nurse 3	Female	50	Bachelor’s degree	Associate Senior	Nursing Unit Manager	32	32	
Nurse 4	Female	43	Bachelor’s degree	Intermediate	Nursing Unit Manager	25	25	
Nurse 5	Female	43	Bachelor’s degree	Intermediate	Nursing Unit Manager	20	20	
Patient 1	Female	60	junior high school diploma	farmer	/	/	/	
Patient 2	Male	85	Bachelor’s degree	retirement	/	/	/	

Nurses’ evidence-based practice beliefs

This study distributed a total of 66 questionnaires and collected all of them, resulting in a 100% questionnaire response rate. After excluding 4 questionnaires with lower quality (1 was incomplete and 3 had all answers selected as the same option), the effective questionnaire response rate was 93.9%. The statistical analysis indicated that the overall evidence-based nursing belief score for the nurses was (3.52 ± 0.82) points (refer to Table 3).

Table 3 Nurses’ evidence-based practice beliefs

Dimension	Included items	Maximum	Minimum	Score
(‾x ± s )	
Level of evidence-based practice knowledge	2、3、6、

7、8

	1	5	3.44 ± 0.80	
Level of evidence-based practice skills	10∼16	1	5	3.35 ± 0.83	
Level of evidence-based practice attitude	1、4、5、9	1	5	3.93 ± 0.72	
Overall level of evidence-based nursing beliefs	1∼16	1	5	3.52 ± 0.82	

The results of influencing factors (barriers and facilitators)

All 66 nurses were given the Influencing Factors Checklist, and the response rate reached 100%. The nurses identified four main facilitators: Leadership support (55.46%), Nurses’ high learning enthusiasm (57.42%), Good teamwork atmosphere in the department (50.44%), Nurses’ high execution ability (65.29%). Lack of relevant knowledge was considered to be the main barrier (refer to Table 4).

Table 4 Nurses’ selection of factors influencing evidence-based practice result

barriers	Rate
(%)	barriers	Rate
(%)	Facilitators	Rate
(%)	
Lack of relevant knowledge	52.94	Uncertainty about expected outcomes	16.64	Nurses ’ high execution ability	65.29	
Lack of attention to nurses	51.82	clinical thinking rigidity	15.34	Nurses’ high learning enthusiasm	57.42	
 Lack of relevant training in the department	35.88	Lack of emphasis from managers	14.68	Leadership support	55.46	
Labor shortage	33.04	Tense relationship between nurses and patients	10.25	Good teamwork atmosphere	50.44	
Low patient/family compliance	29.42	The conditions are limited	9.06	Nurses have a strong ability to accept new technologies	45.09	
Lack of relevant nursing documentation	27.73	Lack of relevant equipment and resources	7.21	The nurse-patient relationship is harmonious	33.04	
 Lack of relevant regulations in the department	27.48	Responsibility for adverse events	4.85	Motivational policies	22.99	
High work pressure	21.66	The content is complex and difficult to do	4.82			
Low level of doctor’s cooperation	20.05			

The results of nurses’ compliance with evidence-based practice

After reviewing the TAVR team’s nursing through on-site observations and interviews, it was found that the department lacked relevant nursing procedures and routines. In the past 5 years, only 3 training sessions have been conducted for the surgical team, falling short of the frequency of training twice a year (refer to Table 5). On the whole, only one indicator had a compliance rate of 100%, while three indicators [2–9] had a compliance rate of 0% (refer to Tables 5 and 6).

Table 5 Results of baseline review at organizational level

Review indicators	Execution rate	
Indicator 1–1:Team members should receive relevant training on TAVR twice a year.	30%	
Indicator 1–2:The nurses in the team must be specialized nurses with at least 3 years of working experience.	100%	

Table 6 The results of nurses’ compliance with evidence-based (n = 21)

Review indicators	Fully
completed
(%)	Partially completed
(%)	Unfinished
(%)	
Indicators1-3: During the preoperative visit-care, nurses should communicate well with the multidisciplinary team.	33.3	52.4	14.3	
Indicators2-4: The nurses should ask the patient about the history of operation, medication and allergy during the preoperative visit.	19.0	4.7	76.2	
Indicators2-6: During the preoperative visit-care, the nurses should check and confirm whether the patient has perfected all preoperative examinations, including blood routine, liver function, renal function, blood coagulation spectrum, blood type, electrolyte, trans-thoracic echocardiography, computed tomography (CT), etc.	14.3	23.8	61.9	
Indicators2-7: Nurses should conduct a comprehensive evaluation of patients during preoperative visit-care——physical frailty.	0	0	100	
Indicators2-8: Nurses should conduct a comprehensive assessment of patient during preoperative visit-care——independence of activities of daily living (ADL)	0	0	100	
Indicators2-9: Nurses should conduct a comprehensive assessment of patients during preoperative visit-care——nutritional status assessment.	0	0	100	
Indicators2-10: Nurses should evaluate the skin integrity, scabs, stains, rashes and hairs at the surgical site during preoperative visits.	52.4	0	47.6	
Indicators2-11: During the preoperative visit-care, the nurse should check the venous access of the patient’s upper limb and whether to choose more than 20G indwelling needle.	23.8	23.8	52.4	
Indicators2-12: During the preoperative visit, nurses should check whether the position of the indwelling needle avoids the puncture point of the radial artery and is as close to the median elbow vein as possible.	9.5	4.7	85.7	
Indicators2-13: During the preoperative visit-care, nurses should confirm whether the patient has any adverse reactions to preoperative medication.	19.0	4.7	76.2	
Indicators2-14: During the preoperative visit-care, nurses should confirm whether the blood has been prepared as directed by the doctor.	33.3	0	66.7	
Indicators3-15: Nurses should introduce the purpose of TAVR to patients and their families during preoperative visit-care.	28.6	0	71.4	
Indicators3-16: During the preoperative visit-care, nurses introduced the anaesthesia-related matters of TAVR operation to the patients and their families.	52.4	9.5	38.1	
Indicators3-17: During the preoperative visit-care, nurses introduced the process of TAVR to the patients and their families.	23.8	9.5	66.7	
Indicators3-18: During the preoperative visit-care, nurses introduced the matters needing attention to the cooperation of TAVR operation to the patients and their families.	61.9	0	38.1	
Indicators3-19: Nurses should provide psychological care for patients during preoperative visit-care, so as to help relieve their stress and reduce their nervousness.	71.4	4.7	23.8	
Indicators3-20: During the preoperative visit-care, nurses should inform the patient about the prepping of the skin on the day of surgery. The prepping area includes the chest area and perineum, with the prepping range extending upwards to the neck, reaching the midline of the axilla on both sides, and extending downwards to the upper 1/3 of the thigh.	33.3	52.4	14.3	
Indicators3-21: During the preoperative visit-care, the nurses should inform the patient to fast for 8 h and refrain from drinking water for 2 h before the surgery.	52.4	42.9	4.7	
Indicators3-22: During the preoperative visit-care, nurses should inform the patient to follow the doctor’s advice for immobilizing both lower limbs after the surgery.	52.4	0	47.6	
Indicators3-23: During the preoperative visit-care, nurses should inform the patient and their family that during the immobilization period, they can perform toe exercises to prevent blood clot formation.	47.6	0	52.4	
Indicators3-24: During the preoperative visit-care, nurses should inform the patient about early mobilization after surgery to prevent blood clot formation.	14.3	0	85.7	
Indicators3-25: During the preoperative visit-care, nurses should provide patients with postoperative rehabilitation education, including comprehensive rehabilitation management such as medications, exercise, nutrition, mental health, sleep, and smoking cessation, and emphasize the importance of long-term follow-up.	9.5	38.1	52.4	

The results of Stakeholder interview

The interview mainly revealed the barriers in the process of evidence-based implementation of preoperative visit-care to TAVR. Three themes and seven sub-themes were identified: [1] unfavorable setting conditions; [2] lack of confidence and extra energy for change; [3] patient factors.

Theme 1: Unfavorable setting conditions

This theme described some situations that were not conducive to the implementation of evidence- based practices in the setting. Participants described that the department did not pay enough attention to nurses’ participation in preoperative visit-care for TAVR and did not put nursing in an important position. At the same time, there was a lack of preoperative visit-care related nursing process and assessment tools.Context: subtheme1 —— Insufficient attention to preoperative visit-care for TAVR.

The hospital did not introduce TAVR until 2018. Before 2022, we had approximately 10 to 20 TAVR procedures annually. In 2023, the number reached 50. Although the number of TAVR has increased in recent years, the overall number of TAVR operations is still relatively low compared with other interventional procedures. As a result, the preparation and attention given to preoperative visit-care are insufficient. As the nurses described:

“The setting shows insufficient attention and a lack of care on preoperative visit-care for TAVR. Many nurses may not have the opportunity to interact with patients who have undergone TAVR procedures, leading to limited practical experience and inadequate attention.” (Nurse 1).

“TAVR is a new procedure, and doctors pay extremely high attention to it, basically undertaking most of the workload. Regarding nursing, the attention given to preoperative visit-care for TAVR is moderate.” (Nurse 3).

Furthermore, the implementation of TAVR-related treatment was mainly led by doctors, with nurses following medical orders and providing support. The subjective initiative in nursing work was inadequate. As a nurse described:

“We usually communicate sparingly with patients, especially regarding negative aspects that may lead to patients’ anxiety, like complications. If there is a discrepancy between what we say and what the doctor says to patients, it will have an adverse impact on our work. Our primary task remains to follow the doctor’s instructions in preparing for the operation.” (Nurse2)Context: subtheme2 —— Achieving interdisciplinary collaboration was difficult.

Since the number of TAVR procedures is relatively tiny, only our department attaches importance to the preoperative visit-care for TAVR. It was challenging to mobilize the workforce and resources of other departments. As the participants mentioned in the interviews, it was very difficult to achieve multidisciplinary cooperation without the support of hospital leaders.

“Interdisciplinary teamwork is challenging because it requires the support of departments such as cardiac surgery, nutrition, and anesthesiology. Due to the relatively small number of current procedures, the preoperative visit-care for TAVR has yet to be valued and recognized by other departments and leaders.” (Nurse 1)Innovation: Subtheme3 —— Lack of relevant nursing routine and assessment tools.

There was a lack of guideline and nursing routine of preoperative visit-care for TAVR. During the interviews, some nurses revealed that the lack of a preoperative visit-care routine was a significant barrier. Nurses’ experience in caring for TAVR patients came from other interventional surgeries, resulting in a lack of targeted nursing.

“Some surgeries have comprehensive nursing procedures, routines, and standards, but there are no such procedures or routines for TAVR.” (Nurse1).

“We don’t have guidelines for preoperative visit-care for TAVR like the surgical standards doctors have, so we don’t know what to do.” (Nurse 3).

The participants revealed that in applying the evidence-based preoperative visit-care for TAVR to clinical practice, there was a lack of corresponding assistance tools, such as the nursing record form, the frailty assessment tools, and 20G indwelling needles. The lack of these tools hindered the implementation and detection of preoperative visit-care.

“We have now reached a consensus with the doctors that a 20G indwelling needle should be used for the patient before the TAVR. However, the indwelling needles equipped in the department are still 24G, and our nurses also use 24G more often for the patients.” (Nurse3).

“Our department doesn’t have frailty assessment tools, and I think we need a particular nursing record form to detect the implementation effect of evidence-based preoperative visit-care.” (Nurse5)

Theme 2: Lack of confidence and extra energy for change

For a long time, nurses have been providing care according to the instructions of doctors. The effect of evidence-based preoperative visit-care remained unknown, which led to a lack of confidence among some participants. Meanwhile, almost all the participants mentioned the barrier of a heavy workload.

Recipient: Subtheme1 —— Work pressure was high.

Participants stated that the clinical workload was too heavy, and the work pressure was high, so it was difficult to have extra energy and time to carry out preoperative visits.

“No one conducts preoperative visit-care for TAVR patient specifically. We usually do it when giving medications, making ward rounds or monitoring patients conditions. Since we still have other patients to care for, we don’t have time to carry out preoperative visit-care specifically.” (Nurse4)Recipient: Subtheme2 —— Uncertainty about the expected effect of the change.

In the early stage of the implementation of evidence-based preoperative visit-care, the participants said that they were not sure about the effects of the preoperative visit-care for TAVR patients, like frailty assessment. They also indicated that they lacked professional support to evaluate the effect.

“It is still uncertain whether the preoperative assessment of the patient’ s physical frailty has any guiding significance for the patient’s disease, right?” (Nurse3).

“We lack professional personnel to assess and monitor whether nurses have carried out preoperative visits and to analyze the implementation effects.” (Nurse4).

Theme 3: Patient factors

Whether in interviews with nurses or patients, the participants mainly indicated that the patients’ ability to accept health knowledge and their preoperative psychology were two important factors affecting evidence-based preoperative visit-care.Recipient: Subtheme1——The acceptance level of health education is different.

Some patients had a relatively lower capacity to comprehend health education due to factors such as their age, experiences, and educational background. Therefore, there were participants hold the view that it was necessary to involve the patient’s family members in the process of preoperative health education.

“As the acceptance ability of each patient varies due to the level of education, it is necessary for family members to be involved in health education.” (Nurse3).

Some patients even had no desire to have health knowledge related to the procedure.

“I do not want to know this details. We will follow the doctor’s instructions. All of you are here for our health, and I will cooperate willingly.” (Patient 1).

While, there were patients who were willing to learn about the relevant knowledge of the procedure to facilitate better cooperation and postoperative recovery.

“Go ahead, then… Actually, my major in college is somewhat related to medicine, so I can understand the knowledge you’ re sharing .” (Patient 2)Recipient: Subtheme2——Preoperative anxiety.

According to what the participants revealed, many patients were prone to experience feelings of nervousness and fear prior to operation. Excessive health education might further intensify their anxiety. Therefore, it was important to customize health education to meet the individual needs of each patient.

“The more you talk, the more nervous he may become, even making the patient feel fearful.” (Nurse3).

More psychological counseling was needed for patients. Avoid forcing patients to accept the truth, as it may scare them.

“Please don’ t let me know, knowing it will make me scared and create psychological pressure. Don’ t let it affect my mood.” (Patient 1).

Integration of barriers and facilitators

Based on the quantitative and qualitative research results, we held a group meeting to integrate the barriers and facilitators. First, we disclosed the barriers and facilitators of items with compliance rates less than 100% following the i-PARlHS framework. Then, we classified the barriers and facilitators identified in the survey and interview according to the i-PARIHS framework. In addition, we put forward some corresponding improvement strategies for some modifiable barriers (refer to Table 7).

Table 7 Barriers andfacilitatorss-mapped in the i-PARlHS Framework

Review Indicators	Barriers	Facilitators	Strategies	
1–1、1–2、1–3	 C: Insufficient training for nurses

C: Lack of nursing procedures

R: Nurses lack sufficient emphasis on preoperative visit-care for TAVR

R: Nurses face high clinical work pressure

	F:

1. Managers attach great importance to it

2. Nurses show a high enthusiasm for learning new technologies and knowledge

3. The department has three full-time postgraduate students who have undergone systematic evidence-based training. They are able to develop relevant nursing protocols and regulations based on the latest evidence, and provide training for nurses.

	Develop the 《Routine Nursing Protocol for TAVR Preoperative Visit-care》provide training to nurses on the relevant content, and establish a comprehensive training system.	
2–4、2–5、2–6、2–7、2–8、2–9、2–10、2–11、2–12、2–13、2–14	I: The evidence failed to translate into easily adoptable processes

C: Lack of relevant assessment tools(frailty assessment tools) and materials (20G indwelling needle)

R: Nurses lack relevant knowledge of TAVR preoperative visit-care (such as content, significance and evaluation methods)

R: Nurses’ uncertainty about the effect of change

	F:

1. Nurses have a high level of evidence-based practice belief.

2. The department holds nurses’ morning meetings every day, weekly medical and nursing meetings, and regular business study every month. These provide opportunities for repeated training, as well as timely reflection and review for nurses

	1. Design the “TAVR Preoperative Visit-care Form” and require nurses to use it

2. Include the relevant content of TAVR preoperative patient assessment in the training

3. The department introduces the Frailty Scale to assess patients’ frailty and provides training on how to use it

4. Increase the equipment of 20G indwelling needles

	
3–15、3–16、3–17、3–18、3–19、3–20、3–21	I: The evidence is not translated into a form that can be used directly.

R: Lack of knowledge regarding TAVR-related health education

	F:

1. There is an evidence-based practice team in the department, which can produce specific processes and methods for evidence conversion.

2. Nurses in department have rich experience in health education.

	1. Compilation of the “TAVR Patient Health Education Handbook”

2. Incorporate TAVR-related health education knowledge into the training

	
3–22、3–23、3–24、3–25	R: Nurses lack knowledge about post-TAVR activities and rehabilitation

C: The doctor has a low degree of cooperation

R: Low level of knowledge among patients/family members

	F:

The department has a harmonious collaborative atmosphere, and the doctors are very supportive of this evidence-based nursing practice.

	1. To deepen patients’ understanding, a combination of oral explanations and health handbooks are used for patient education.

2. Compile the “ TAVR Patient Health Education Handbook”

3. Invite the TAVR team physicians to collaborate in determining the content of the “TAVR Patient Health Education Handbook”

	
I: innovation; R: Recipient; C: Context; F: Facilitation

Discussion

The study revealed a significant gap between clinical practice and best evidence, and identified the barriers and facilitators of evidence-based preoperative visit-care for TAVR according to the i-PARIHS framework. Additionally, the study provided a baseline of barriers and facilitators that hospitals could utilize to identify areas in need of improvement at the innovation, recipient, and context.

Compliance status of the nurse providing evidence-based preoperative visit-care for TAVR

Based on our assessment findings, a significant gap existed between the department’s clinical practice and evidence. The current compliance of nurses’ evidence-based compliance was far from ideal. The discussion conducted during the group meeting indicated that the items with relatively high compliance rates were akin to routine care or were implemented in accordance with doctors’ orders. The implementation rate of these items, such as the assessment of the patient’s nutritional status, frailty and ADL for patients before the TAVR, was 0%. As the nurses revealed, there were no corresponding assessment tools in the department, and no one told them to do this. The lack of relevant support tools and knowledge was the main reason for the low implementation rate among nurses. The department should contemplate providing the necessary assessment tools and conducting training for nurses to enhance compliance.

Barriers and facilitators

Barriers in context

Context has been considered as a significant determinant of evidence-based practice [46]. It refers to the micro-, meso-, and macro-levels that can impact implementation [46]. A favorable practice environment includes a supportive organizational systems, appropriate skill sets, effective staff relationships et al. [47]. However, in our study, there are several barriers related to the context: Insufficient training for nurses, Lack of nursing procedures, Lack of relevant assessment tools and interdisciplinary collaboration.

Evidence-based practice is a technical process that requires proper training of nurses [48]. Training has potential knowledge translation intervention functions, it can help overcome barriers associated with psychological capability and automatic motivation [23]. Successful training could motivate the nurse to practice more [49]. Study has shown that nurses gain confidence in daily practice after training [49].

Collaborative practice has been identified as an essential element in facilitating the implementation of EBP [50, 51]. When collaborating with others to seek information, especially in urgent situations, the speed and convenience of accessing the necessary information greatly increases [52]. For elderly patients with AS, interdisciplinary collaboration nursing is very important [53]. The level of collaboration between medical staff needs to be improved. Previous study has shown that surgeons and anesthesiologists are reluctant to allow nurses to visit patients in preoperative because they are concerned about nurses conveying excessive information to patients [54]. In our study, we also found that nurses are worried about disclosing too much surgical information to patients or being at odds with doctors. Although it has been reported that providing patients with surgical information can reduce their anxiety and meet their nursing needs [55, 56].

Additionally, It has to be mentioned that the status of nurses in China, the nursing profession as an independent discipline has not been fully recognized by the society and hospital administrators [57]. Nursing work is still regarded as an auxiliary work subordinate to doctor’ s instructions, which leads to the neglect of the importance of nursing. Nurses working in the department are in an unfavorable situation, and evidence-based practice is adversely affected.

Barriers in innovation

Innovation refers to the new knowledge that is introduced [46]. Our research revealed that the current preoperative visit content for TAVR in the department was relatively arbitrary and lacked evidence-based support. Furthermore, failure to translate evidence into easy-to-use and convenient procedures was considered to be major barriers. There was an urgent need for standardized and directly available preoperative visit-care procedures for TAVR to consistently achieve excellent outcomes, patient experience, and project efficiency [58].

Barriers in recipient (nurses and patients)

Previous studies had shown that time constraints, understaffing, and lack of resources were obstacles to EBP implementation [23, 59, 60]. The four most frequently identified barriers for nurses in this study were insufficient attention to evidence-based practice, lack of relevant knowledge, high work pressure and uncertainty of expected results. Kernohan et al. [61] implied that professionals who have an uncertain attitude to the value of the research are less likely to implement EBP. The relatively low level of knowledge related to preoperative visit-care for TAVR among nurses was a major barrier, which was consistent with the conclusion of Frances et al. [62]. Given that knowledge was modifiable, this provides valuable targets for future interventions and implementation strategies to promote evidence-based preoperative visit-care for TAVR in clinical practice.

Dissatisfaction with heavy workload is a significant problem reported by nurses [27, 63]. Our research also indicated that, because of the heavy workload, nurses were reluctant to spend time to conducting preoperative visit-care. The nurses’ work is often complex, with constant distractions and interruptions [64, 65], which will be detrimental to the implementation of evidence-based nursing. Especially in a large department like the cardiology department, nurses faced many distractions. These distractions had reduced the nurses’ work efficiency, which means that it took more time to complete the same tasks, resulting in a seemingly larger workload and also increasing the work pressure. In order to address these factors, strategies to reduce interruptions should be explored, such as equipping nurses with skills to overcome distractions from patients and other staff members [62].

The main barrier of patients was a lack of operation knowledge. It is necessary to consider the inclusion of some patients’ family members in the educational scope. Besides, patients with preoperative anxiety and depression should be of particular concern. Providing too much surgical-related information to these patients may exacerbate their stress and anxiety which is consistent with the findings of the study conducted by Lim and Berger, et al. [66, 67].

Facilitators

Previous studies have shown that leadership support, quality management-centric organizational culture, education/training, and adequate access to resources play an important role in involving nurses in quality management [68]. Our study identified that leadership support, nurses’ high enthusiasm for learning, good teamwork atmosphere and nurses’ high execution ability were the main promoting factors.

Leadership support is considered to be the most common facilitator [69]. In the process of evidence-based clinical implementation, leadership plays a crucial role [70]. Leaders should create a favorable environment for nurses to carry out evidence-based nursing and give nurses the opportunity to perform. The study of Shirey et al. showed that “improving the work environment of nurses is the daily task of managers [71].”

The nurses’ belief level in evidence-based practice in this setting was acceptable, with an average score of (3.52 ± 0.82), which was at a medium level, and it is higher than that in Norway (3.45 ± 0.56) [72, 73]. This indicates that clinical nurses recognize the value of evidence-based practice and believe in its significance in improving clinical practice and patient outcomes. Facilitation is the core component of successful implementation and requires someone “being” a facilitator [36]. In our study, the evidence-based practice team in the department can be regarded as facilitators. They are responsible for tasks such as summarizing the best evidence, providing training, and improving quality.

The main strength of our study was the triangulation in methods (interviews, surveys, group meetings). The participants in our interviews were nurses and patients with diverse backgrounds. This is conducive to comprehensively probing into the barrier and facilitator factors and, thereby, is helpful for formulating acceptable and practical implementation strategies. Additionally, the application of the i-PARIHS theory guarantees a sound theoretical perspective. This theory is frequently utilized to identify the barriers and facilitators in implementation research. However, using the theory may limit our attention to certain elements within the model during data collection and analysis. Nevertheless, this applies to all theoretical frameworks. Our study revealed that doctors also had an impact on the implementation of evidence-based nursing. In the future research, maybe we should consider taking doctors as research objects. Finally, our study was conducted in only one hospital, although it is the largest medical institution in Yunnan Province, China. However, in evidence-based implementation, the importance of setting cannot be ignored, so the external validity of our study may be limited.

Conclusions

Our results provide in-depth information on the barriers and facilitators of evidence-based preoperative care-visit for TAVR. The study also provides a baseline of barriers and facilitators that hospitals can use to identify areas for improvement. Leadership support, nurses’ high belief in evidence-based practice and high execution ability proved to be essential to facilitate the implementation. However, several barriers were also identified that prevented nurses implementing evidence-based practice including lack of relevant knowledge and procedures, high work pressure, uncertainty of expected results and so on. The results of this study indicate that converting evidence into easily implementable procedures is an important prerequisite for evidence-based practice. Without leadership support and relevant training, pre-TAVR evidence-based visits-care are difficult to achieve. In order to provide patients with evidence-based and scientifically effective services, continuous dynamic review and adjustment are necessary during the clinical application of evidence.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

Supplementary Material 4

Acknowledgements

We sincerely thank the support of the Cardiology Department at The First Affiliated Hospital of Kunming Medical University, Kunming, China for this study, and we thank all the patients and staff who participated in the research. Special thanks to the experts and nurses of the evidence-based practice team of the Department of Cardiology for their help in the development of the Nurses’ Behaviors Checklist.

Author contributions

GX W, JY T, F M and QL H conceived the design of the study. GX W, JY T, H Y and XT W collected and analyzed the Quantitative and qualitative data. The first draft of the paper was completed by JY T and GX W. W W, and MF Y substantively revised it. Supervision: YJ B (Correspondence author). All authors read and approved the final manuscript.

Funding

No funding source was used for this research study. We thank the participants who volunteered in this study.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

Ethics and consent to participate was approved. It has been performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the First Affiliated Hospital of Kunming Medical University (2022-L-58). The study obtained informed consent from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

AS Aortic stenosis

ADL Activities of Daily Living

EBP Evidence-based practice

IFC Influencing Factors Checklist

TAVR Transcatheter aortic valve replacement

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

GuanXing Wei and JunYang Tan contributed equally to this work.
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