Received: 28 September 2020 | Revised: 23 January 2021 | Accepted: 27 January 2021

DOI: 10.1111/jocn.15693

ORIGINAL ARTICLE

The realities of practice change: Nurses' perceptions

Élise N. Arsenault Knudsen PhD, RN, ACNS-­BC, Clinical Nurse Specialist for Research and
Evidence-­Based Practice | Barbara J. King PhD, RN, APRN-­BC, FAAN, Associate Professor
and Center for Aging Research & Education Director | Linsey M. Steege PhD, Associate
Professor and Gulbrandsen Chair in Health Informatics & Systems Innovation

School of Nursing, University of Wisconsin

–­Madison, Madison, WI, USA
Correspondence
Élise N. Arsenault Knudsen, UW Health
–­Hospitals and Clinics, 600 Highland
Ave, Mail Code 7685, Madison, WI 53792,
USA.
Email: earsenaultknudsen@uwhealth.org
Funding information
This work was supported by the Eckburg
Research Fund within the University of
Wisconsin –­Madison, School of Nursing.
Abstract
Aims and Objectives: To explore registered nurses' perceptions of practice change
and describe factors that influence the adoption of practice changes.
Background: Nurses play a critical role in optimising patient outcomes. Healthcare or-
ganisations and nurses must do their part to achieve the Quadruple Aim, which requires
nurses to change their practice. Nurses are ideally positioned to improve patient out-
comes by changing their practice to align it with research evidence and organisational in-
itiatives; however, this experience of practice change by nurses is grossly under-­studied.
Design: A qualitative design, inductive content analysis, was used to understand
nurses' perceptions of practice change.
Methods: Eleven registered nurses, who worked in one hospital system, participated
in one-­on-­one semi-­structured interviews. The Consolidated Criteria for Reporting
Qualitative Studies (COREQ) were followed.
Findings: The 11 participants described 63 distinct experiences with practice
changes. Their experiences with and perceptions of practice change are categorised
as (1) There is A History; (2) It's A Lot of Work; (3) It Happens to Nurses; and (4) Doing
Right for the Patient.
Conclusion: Nurses experience practice change as a central part of the work they
do; it occurs frequently and multiple practice changes may co-­occur. Nurses identify
strategies, such as thoughtful planning, engaging nurses, and communicating the
rationale for and the outcomes of the practice change, to facilitate changing practice.
Relevance to Clinical Practice: Involving nurses in practice changes could alleviate
some inhibiting factors for adopting new practices. Local hospital and national policies
should explore creative and practical ways to balance the competing needs of nurses
providing direct care at the bedside and dedicated time to be engaged in practice
change initiatives. With the ongoing focus on improving patient care and optimising
patient safety, nurses should be viewed as highly valued members of the team when
designing and implementing practice changes.

KEYWORDS
content analysis, evidence-­based practice, hospital, implementation, nursing, nursing practice,
practice change

J Clin Nurs. 2021;30:1417–1428. wileyonlinelibrary.com/journal/jocn© 2021 John Wiley & Sons Ltd | 1417
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1 | I NTRO D U C TI O N
Nurses are critical to the delivery of safe, high-­quality, patient-­
centred and affordable health care (Institutes of Medicine (IOM),
2011; Salmond & Echevarria, 2017). Of the 4 million registered
nurses (hereafter nurses) (ANA, n.d.) in the United States, 30%
work in hospitals (U.S. Bureau of Labor Statistics, 2019) where they
provide the majority of direct care. Care provided by nurses has been
associated with patient outcomes such as mortality (Needleman
et al., 2019) and length of stay (Needleman & Hassmiller, 2009).
In the United States, nurses have been called to action to improve
the healthcare delivery system (IOM, 2011) by capitalising on their
primary role –­providing high-­quality cost-­effective care to improve
patient outcomes.
Responding to this call for continual improvement requires
changes in nursing practice (Salmond & Echevarria, 2017). However,
nurses' perceptions and experiences of practice change are not well
described in the literature, despite the increased accountability
nurses have for improving patient outcomes. Therefore, this article
reports on findings of individual interviews conducted with hospital
nurses to understand how they think about and experience practice
change and what factors influence their adoption.
2 | BAC KG RO U N D
Changes in nursing practice are not a new phenomenon; however,
nurses' experience with these changes are under reported. The
focus of current literature is on programmes where nurse have
led practice changes. For example, the Robert Wood Johnson
Foundation funded the Transforming Care at the Bedside Program,
which facilitated nurses and other healthcare team members to
lead quality improvement processes to improve patient outcomes
(Needleman et al., 2016). This programme was well received and
has had an impact on creating practice change (Needleman et al.,
2016). Other programmes teach nurses evidence-­based practice
(EBP) skills and provide a structure for nurses to lead change
(Balakas et al., 2013; Cullen & Titler, 2004; Fridman & Frederickson,
2014; Irwin et al., 2013). The impact of these programmes on
nurses had overwhelmingly positive findings, reporting on themes
of empowerment, satisfaction and growth (Balakas et al., 2013;
Fridman & Frederickson, 2014; Irwin et al., 2013). However, these
findings are limited to nurses who lead a practice change. Studies
have not captured the voices of hospital nurses who are asked to
change their practice, which would be more representative of most
hospital-­employed nurses.
Changes in practice are needed in order to consistently provide
optimal patient care and to improve patient outcomes. This is an
ongoing focus in the United States where patient outcomes are in-
ferior compared to other similar countries (Melnyk, Gallagher-­Ford,
Zellefrow, Tucker, Van Dromme, et al., 2018; Salmond & Echevarria,
2017). For example, about one out of every 10 patients acquire a
potentially preventable condition during hospitalisation (National
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ARSENAULT KNUDSEN et al.
What does this paper contribute to the wider
global clinical community?
• A broader understanding of hospital nurses' perceptions
of practice change, which are experienced frequently
and are often co-­occurring.
• Highlights the need for expanded approaches to
implementation, to align strategies with nurses'
experiences, to facilitate practice change and improve
patient care.
• Identifies the need for policies to assure time for nurses
to actively engage in practice change.
Patient Safety Foundation (NPSF), 2015); an outcome that could
have been prevented with evidence-­based practices. Evidence-­
based practice improves the quality of care, patient outcomes and
decreases healthcare costs (Balakas et al., 2013; Melnyk et al., 2012);
therefore, around the world it is the expectation for care delivery for
both hospitals and nurses (Renolen et al., 2018; Tucker, 2017; Wilson
et al., 2015). While there has been an international effort for nurses
to employ evidence-­based practices, multiple authors indicate that
nurses, among other healthcare disciplines, do not consistently pro-
vide care that is evidence-­based (Melnyk, Gallagher-­Ford, Zellefrow,
Tucker, Van Dromme, et al., 2018; Renolen et al., 2018; Tucker,
2017). With an eye towards improving patient care and outcomes,
the perceptions of nurses who are asked to change their practice
should be explored in order to support practice change in their daily
work.
Healthcare organisations must continue to respond to national
and local changes and do their part to achieve the Quadruple Aim
in health care (Melnyk, Gallagher-­Ford, Zellefrow, Tucker, Thomas,
et al., 2018; Williams et al., 2015). The Quadruple Aim focuses
on improving patients' care experience, populations' health and
decreasing cost, while improving health care providers work life
(Bodenheimer & Sinsky, 2014). One example of ongoing changes
in the United States is the hospital-­a cquired condition (HAC)
reduction programme, which includes payment incentives and
penalties for healthcare systems based on rates of HACs (CMS,
2020). Programmes such as this provide continual motivation for
healthcare systems to provide high-­q uality evidence-­b ased care.
Despite this, new practices are not readily adopted. It is routinely
cited that the gap between research discovery and a change in
practice is 17 years (Salmond, 2007; Tucker, 2019); others esti-
mate the gap to be between 18–­5 4 years (Hanney et al., 2015).
While individual and organisational barriers that inhibit the use
of evidence-­b ased practices are well documented in the literature
(Geerligs et al., 2018; Williams et al., 2015), our knowledge of
what influences nurses to adopt new practices must be improved.
This knowledge is needed to support nurses to adopt new prac-
tices and to close the gap between research and practice. Without
this, practice changes may be slow, not sustained, or may not even
occur (Tucker, 2019).

ARSENAULT KNUDSEN et al.
The purpose of this study was to describe nurses' perceptions of
practice change and factors that influence the adoption of practice
changes in hospital settings. Exploring hospital nurses' experiences
when asked to change their practice will provide insight for develop-
ing meaningful strategies to facilitate the uptake of new practices,
which may lead to improved nursing care processes and patient
outcomes.
3 | M E TH O D S
3.1 | Design
A qualitative design, using inductive content analysis as outlined by
Elo and Kyngäs (2008), was used to understand an under-­explored
phenomenon –­nurses' perceptions of practice change. The analysis
and the resultant categories offer new knowledge and understanding
of hospital nurses' perceptions of practice change. The reporting
of this study follows the guidelines of the Consolidated Criteria
for Reporting Qualitative Studies (COREQ) (Tong et al., 2007) (See
Appendix S1).
3.2 | Ethical considerations
This study was approved as exempt research by the Institutional
Review Board (IRB) of record and was approved by the healthcare
system in which data were obtained.
3.3 | Participants
Participants were recruited through fliers and emails at two
Magnet® (ANCC, n.d.) designated hospitals within one integrated
health system. The contact information for two researchers
(EAK, LS) was included on the flyers and in the recruitment email.
Recruitment emails were provided by the study team and distributed
by individual nurse managers to the nurses on their units. Inpatient
nurses who were interested in participating directly contacted a
member of the study team by email or phone.
Purposive sampling sought registered nurses (RNs; hereafter
nurses) who provided direct patient care, worked on inpatient (inten-
sive or general care) units at either hospital, and were willing to speak
about their experience with practice change. Nurses who worked as
core or float staff, on any shift, and with any years of experience were
eligible to participate. Traveller (or agency) nurses and nurses in lead-
ership positions (e.g. Clinical Nurse Specialists, Nurse Managers and
Administrators) were excluded. Data were collected through one-­on-­
one, in-­depth, semi-­structured interviews and a demographic ques-
tionnaire was completed at the conclusion of the interview.
Eleven nurses volunteered and consented to participate in this
study. Collectively, the 11 nurses described 63 distinct practice
changes, with a range of 3–­8 changes per participant. Consistent
|
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1419
with inductive content analysis, the study sample is not solely com-
prised of the number of individuals; rather, the sample also includes
the participants' events and experiences with a phenomenon of in-
terest (Sandelowski, 1995). For this study, the researchers sampled
nurses' multiple experiences with practice change. All nurse partic-
ipants provided direct patient care to paediatric and adult popula-
tions with a range of acuity (intensive care units, general care units),
years of nursing experience (3 to greater than 15 years) and employ-
ment at the organisation (less than 1 year to greater than 15 years).
All participants were female. Demographics are detailed in Table 1.
The research study's purpose, intent of the interviews, and assur-
ances of confidentiality and ability to withdraw at any time were de-
scribed to participants both verbally and with an information sheet.
3.4 | Data collection
Interviews were conducted between April and September of 2017 in
a private room and lasted, on average, 58 min (range 44–­68 min). To
assure trustworthiness of the data collection process, all interviews
were audio-­recorded and transcribed verbatim by a HIPAA certified
transcriptionist. Each interview's audio-­recording was compared to
the transcript to ensure the data were accurately transcribed.
Initial interview questions were open-­ended to allow partici-
pants an opportunity to describe their varied experiences of practice
change and factors that influence the ease of changing their prac-
tice. For example, participants were asked, ‘Can you tell me about a
recent practice change that you experienced as a nurse?’ and ‘What
elements make changing your practice easier or harder?’ Probing and
focused questions (e.g. can you tell me more about that?) were also
used to elicit detailed and rich descriptions of nurses' experiences
and perceptions. Further, to assure study credibility, the research
team pre-­tested open-­ended questions with two nurses who were
not participants in the study. Pre-­testing was done to determine
what types of responses the questions would yield and if responses
were relevant to the study objective (Kyngäs et al., 2020). The in-
terviews were conducted by the first author (EAK). The researchers
did not work directly with, as a member of an inpatient unit, or as a
supervisor to any participants who volunteered for the study.
After the first seven interviews were completed, two authors (EAK,
LS) completed a preliminary analysis of the data. The preliminary anal-
ysis identified consistent patterns of nurses' descriptions of practice
change. Initial findings were shared with a study team member familiar
with the project, but not part of the data collection, to establish face
validity (Elo et al., 2014). During the final four interviews, participants
were asked to share their perceptions of practice change using similar
open-­ended questions used in the initial seven interviews. To ensure
trustworthiness of the data collection, at the end of the interviews
member checking was conducted by sharing preliminary results with
participants to verify the analysis and to elaborate on findings that did
or did not align with their experiences (Elo et al., 2014; Tracy, 2010).
These four participants substantiated that the preliminary analysis
aligned with their experiences of practice change.
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1420 ARSENAULT KNUDSEN et al.

TA B L E 1 Demographic data of sample (n = 11)

Participant recruitment and data collection concluded when
Demographic item Frequency both authors (EAK, LS) agreed that no new ideas or patterns were
Years worked as a nurse (RN) shared during subsequent interviews nor were noted in field notes

0–­2 0 or journaling. Qualitative content analysis as a method does not dic-

tate a pre-­determined sample size; rather, it is recommended that
3–­5 2
data collection continue until saturation, or duplication in categories,
6–­8 3
is achieved (Elo et al., 2014).
9–­11 0
12–­14 0
>15 6
3.5 | Data analysis
Years worked as a nurse at hospital system
0–­2 3 Two researchers (EAK, LS), a nurse and a human factors engi-
3–­5 2 neer with experience in qualitative methodology, analysed study
6–­8 0 data using inductive content analysis. The three phases of induc-
9–­11 1 tive content: analysis, preparation, organising and reporting, as
12–­14 1 outlined by Elo and Kyngäs (2008) and Elo et al. (2014) were fol-
>15 4 lowed. In the preparation phase, the unit of analysis –­ nurses ex-

Type of unit
perience with practice change, was selected. During this phase, all
transcripts were read multiple times by team members to achieve
Intensive Care Unit 4
data immersion. The organising phase included open coding, cat-
General Care 2
egorisation and abstraction (Elo & Kyngäs, 2008). To be compre-
Acuity Adaptable or General Care/IMC 4
hensive and increase trustworthiness in the analysis, each author
Float 1
(EAK, LS) individually open coded all transcripts and then met
Other (1 nurse worked on 2 units) 1
to discuss, compare codes and interpretations of the data (Elo
Patient population (select all that apply) et al., 2014). After open coding was completed, the research team
Adult Medical 6 grouped similar codes into categories. Difference of opinions and
Adult Surgical 8 concerns about the categories were discussed and resolved among
Paediatric Medical 3 the two researchers. Categories and subcategories were created,
Paediatric Surgical 4 re-­examined, re-­organised, and compared to and verified with
Role the data. Decisions made during the analysis were maintained in

Nurse Clinician 8 memos. Grouping and abstraction continued until the categories
portrayed the perceptions of practice change by hospital nurses.
Charge Nurse 3
A third member of the research team (BK), a nurse researcher with
Highest degree in Nursing
expertise in qualitative methodology and knowledgeable about the
Diploma 1
study, but external to the analysis process, validated the analysis
Associate's 1
process and the final categories.
Bachelor's 8
Master's 1
Doctoral 0 4 | R E S U LT S
Age
21–­3 0 4 Overall, participants described varied types of practice changes and
31–­4 0 2 identified that practice change was a central part of the work they
41–­50 0 do. For example, some described human resource-­t ype changes,
51–­60 5 which included how nursing assignments were distributed among

>60 0
After each interview was completed, field notes and reflective
journaling were maintained by the interviewer to record impres-
sions of the interview and the data collected. This reflective process
allowed for comparison across interviews and notations of salient
points made during the interview. This also aided in minimising bi-
ases and assumptions from entering the data collection and subse-
quently the data analysis process (Bazeley, 2013; Polit & Beck, 2012).
team members, vacation selection and clocking out after the end of
the scheduled shift. At face value, human resource changes may not
seem to represent practice change; however, these changes were
described as impactful to nurses' clinical practice. The other type
of practice change described was those that directly impacted care
processes. Examples included two-­person dressing changes for cen-
tral lines, bedside shift report, and intentional and interdisciplinary
rounding. Regardless of the type of change, each was described as
something new replacing a former way of working.

ARSENAULT KNUDSEN et al.
Participants also distinguished practice changes by size, repre-
senting the degree of change or how much the change impacted
practice. Some changes were described as ‘big’ or ‘monumental’,
while others were described as ‘small’ and ‘annoying’. However,
the majority described their practice change experiences as ‘big’.
Furthermore, practice change was not described as a singular event,
but rather as a process, meaning there were steps that must be com-
pleted to transition from a previous practice to full adoption of the
new practice. One participant described this as a ‘shift in what we
were doing before. …a kind of process and it's been a huge shift in a
different way of doing things’ (P002).
Participants also indicated that practice changes occur frequently,
and sometimes too often. ‘Because the hospital will say do this, do
this, and they change again, again, again, quite often. I think we change
too frequently. We change too much’ (P003). It was not unusual for
participants to describe multiple co-­occurring practice changes that
were rolled out just a few weeks apart or sometimes at the same time.
From participants' description of their experiences with and per-
ceptions of practice change, four main categories emerged from the
data and are illustrated in Figure 1. These four categories are as fol-
lows: (1) There is A History; (2) It's A Lot of Work; (3) It Happens to
Nurses; and (4) Doing Right for the Patient. Within each category, sub-
categories were identified, adding richness and depth of the findings.
4.1 | There is a history
All nurse participants' experiences and perceptions of practice
change were contextualised by historical references. References
included years working as a nurse, previous experience with a prac-
tice change and changes in nursing practice over time. In addition
to participants describing how these reference points influenced
practice change, they also expressed a desire for their experience
to be acknowledged and valued by the hospital. Within the history
of practice changes, participants spoke to needing to remember to
do a new practice change and to forget previous practices in order
to adopt a new one. This category consists of three subcategories:
practice evolves; remembering; and forgetting.
There is A
History
Practice
evolves
Remembering
F I G U R E 1 Nurses' perceptions of
Forgetting
practice changes and the factors that
influence adopting changes
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1421
4.1.1 | Practice evolves
Participants with a greater number of years of work experience could
reflect on changes in practice and changes they have experienced in
nursing during their tenure. For example, one participant indicated:
I mean we used to…I laughingly tell people that…
if [the patient had a diagnosis] they were intubated,
they were sedated on [multiple medications] and they
weaned after their last surgery…weeks into your hos-
pitalization. Well now, ‘can we extubate them today?
He came up last night, you can extubate him?’…so it's
very different. That's a practice change.
(P001)
This historical perspective influenced how practice changes re-
lated to post-­surgical care (i.e. intubations, multiple medications) were
perceived as one change along the trajectory of changing care, rather
than a standalone practice change. Thus, the history and evolution of
nursing practice over time influences nurses' perceptions of practice
change.
Participants also reflected on their personal history with previ-
ous ways of providing patient care. Personal history with a practice
contributed to a perception of practice change being cyclic. One
participant described it this way: ‘You start one way of charting and
then it goes to a different way and then it goes to a different way,
and then, I actually had somebody tell me yesterday, I hear in a cou-
ple years we're going to start charting by exception, and I said you
mean we're going back to charting by exception?’ (P005).
In contrast, other participants with fewer years of experience
or those newly working with a patient population did not share this
historical lens of practice. Their description was different, indicating
difficulty discerning a practice change from everything simply feeling
new. One participant stated, practice changes are ‘not as glaring as I
think they would be if I'd been there longer. I think being there only
a year they tell me to change something, I'm like OK’. (P011). This
lack of historical experience influenced their perception of practice
changes simply because they did not know any other way to do it.
It’s A Lot of It Happens to Doing Right
Work Nurses for the Patient
Providing
Juggling Being told the best
possible care
Monitoring
Fitting it all in No why
helps
It has to make No voice, no Ask for
sense choice nurses' input
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When a practice was previously tried and failed and if hospital
or unit leaders neither recognised the prior attempt nor offered
new strategies to make the practice change easier to implement,
participants often felt sceptical. ‘Hope it works…this time…bedside
report, I know it's important. …but ya know, [leaders] keep coming
and talking, then we forget about it you know. Then we do it again,
again, again … it's hard to stick on us’ (P003). This cyclic nature of
the practice change without the acknowledgement of the history or
the nurses' experience with the evolving practice left nurses feeling
undervalued by the hospital. Nurses expressed desire to be sought
out to offer insight into why the practice change was not working
and leverage their experience with the change instead of presum-
ably ignoring it. One participant suggested revisiting previous prac-
tice changes, not to be punitive, but ‘to find out who, what is the
percentage that are actually doing this? And then just asking nurses
hey, what are some areas that we could change? We're still doing this
change but, what's a barrier?’ (P007).
4.1.2 | Remembering
Inherent in practice change is the notion that nurses must
transition from a previous way of doing their work to something
‘new’ or revised. This involved actively engaging in remembering
to implement the change. Having to remember the new practice
was especially challenging when performing a new care activity
was infrequent or if a long delay occurred between learning the
new practice and actually doing the new practice. One participant
described it this way: ‘So let's say, we have a new central line dressing
change protocol. So, we implemented it, we are signed off… Well if
you don't have a central line for 4 months are we going to remember
to do that when it's really busy?’ (P001). Remembering seemed to
influence nurses' rate of adopting new practices.
Receiving reminders served as aids for nurses to remember to
implement the new care practice. Reminders came in multiple forms,
including verbal communication from team members, especially the
charge nurse, and placement of visual cues in key locations on the
nursing unit or in the electronic health record. Without reminders,
participants described having to rely solely on their memories to
change their practice. However, the reliance on memory became a
fallible strategy when the realities of a busy shift and their experi-
ence and history with the practice intersected. ‘Things that make
things easier are usually reminders for me. …because even if I write
it down, I don't always remember it at that moment if you're getting
distracted’ (P004).
The frequency or prevalence of reminders prompted nurses
to recognise that the new practice required additional attention.
However, as reminders decreased, so did focused attention on
adopting the new practice. If the change had not fully assimilated
into nurses' practice it often faded into the background, further cre-
ating a sense that practice changes come and go. One participant
stated ‘…so it's interesting that some [practice changes] just come
and go…there's so many flyers…but this one was right at a nursing
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ARSENAULT KNUDSEN et al.
station…I remembered the next time I did [the practice change] it
was still sitting there and I thought I'll try and figure it out. I don't see
the flyers anymore, so I don't know…’ (P010).
When new practices are not completely integrated and remind-
ers are removed, they are less likely to be sustained. This was espe-
cially true when there were multiple changes co-­occurring. However,
some practice changes received another ‘big push’ (P001; P008) of
reminders which prompted nurses to re-­focus on the new practice.
Participants suggested that the frequency of reminders was reflec-
tive of how the organisation prioritised the new practice. If remind-
ers were removed and then reinitiated, nurses second guessed the
priority level of the change. Nurses acknowledged their memory and
history with previous implementation efforts influenced the next
cycle of practice changes. If the initial implementation was perceived
as a ‘failure’, (P005) that sentiment carried through with future prac-
tice change initiatives.
4.1.3 | Forgetting
Participants described forgetting as challenging, yet an important
part of assimilating a new practice into their workflow. Due to
nurses' experience and history with practice, they often had a hard
time forgetting the previous practice because it was ingrained
in how they provided care. ‘…so for years if I was giving this med,
somebody needed to watch the tele…it gets ingrained in your mind…
even though I know that the policy has changed, it was hard for me
to follow it because it's so ingrained in doing the other way’ (P005).
Thus, in order to remember to perform a new practice, nurses
needed to forget the old way of providing care. Nurses without a
history simply learned the new practice without needing to forget
a previous one.
4.2 | It's a lot of work
Participants described a conscious and continual effort to make
practice change happen. Because of this effort, they described prac-
tice change as being a lot of work. Practice changes are added to the
nurses' existing workload; it is in addition to what must be accom-
plished during a shift. ‘It's just yet another thing to bog you down,
one more thing to make sure you have done before you go out the
door’ (P001). This category included three subcategories: juggling;
fitting it all in; and it has to make sense.
4.2.1 | Juggling
Participants described juggling their usual work with multiple and
frequent practice changes, which occur regularly and at a high fre-
quency, making implementing the required change hard. One par-
ticipant described ‘…it was chaotic, it was really tough. It was a really
tough thing. I mean there's still a ton of kinks in all of it and we're

ARSENAULT KNUDSEN et al.
still working on a lot of them…’ (P002). Other nurses indicated that
juggling multiple co-­occurring practice changes resulted in slowing
down the full adoption of new practices. ‘So there's just been a lot
of changes and I think eventually people reach a saturation point
almost like I can't take anymore… it's hard to really follow through in
all of them’ (P007).
While nurses are juggling multiple practice changes, they also
need to juggle how other team members have adopted the new
change. For example, one participant described a practice change
where nurses were to perform the first post-­operative dressing
change, rather than physicians. In order for this to be fully integrated,
both nurses and physicians needed to adopt the new practice. ‘…it's
like [the doctors] go around [and change the dressing] and the nurse
says, they're touching my incision…it's hard because I see where
they wanna go but I see the difficulty with actually implementing it.
And then [the head] physician…he is so for it but then the residents
who are actually there, they do not want it that way…so it's difficult’
(P007). Another practice change required juggling with other nurses
working on the unit; completing a central line dressing change with
two nurses, instead of independently. Although the change in how
to perform a dressing change was described favourably, the shift in
practice required them to both prioritise the dressing change and
coordinate with another nurse on the unit to complete the task.
Participants also shared that their efforts to juggle were not rec-
ognised by the organisation. Furthermore, when new practices were
presented as something to just ‘try’, it was perceived as a lack of
recognition and respect for how much work nurses must engage in
to implement a new practice. This sense of trying a change suggests
that it has not been thoughtfully planned. One participant stated, ‘I
think really thorough planning, instead of let's try it. If it don't work,
it don't work, it's a joke…unprofessional, because we will try it and
it's hard work for us’ (P003).
4.2.2 | Fitting it all in
Participants described making practice changes as time intensive;
both to do the new practice and to fully integrate the practice
change into how they provide care. One participant states ‘…they
really are time consuming things when we start to roll them out’
(P002). Another indicates that ‘…it takes a lot longer and you need a
lot more time and energy invested in it than is typical’ (P001). Often
a new practice change must occur within a work shift and at the
same time as completing routine work. One participant stated, ‘…
they had drop-­in sessions to learn about the stuff, that was always
helpful, it was hands on. But there's not always time for that. It's
sometimes stressful to try and fit that in during a shift’ (P010).
Another nurse described ‘you need to do your eval[uation] and all
your peer evals and yet we've been high acuity and you ask yourself
when am I supposed to do these? You don't have time. You try to
fit it in’ (P004). For many nurses, practice change is added onto
their workload, while nothing is taken away, heightening a sense
of feeling undervalued. One participant eloquently stated this: ‘…I
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1423
think we change too much … They really forget, they forget to assess
our workload…you're adding onto the workload…like a balloon, just
adding…it's going to explode…so, we are kind of sick of it’. (P003).
4.2.3 | It has to make sense
Considering how much work and effort is required to change
practice, it has to make sense; meaning fitting in with the context
in which it is being implemented. Participants described this as
affecting the extent to which the practice change is adopted.
One individual who worked in an intensive care unit described
how intentional rounding, which required patient rounding every
hour, did not make sense in that unit. ‘So, one [practice change] in
particular didn't work and still isn't working…intentional rounding…
we're in their rooms constantly…it doesn't make sense’ (P009). When
the practice change does not align with the clinical environment of
the nurse, the organisation loses credibility with nurses. Further,
nurses' negative experience with practice change becomes part of
their historical perspective influencing how they respond to future
requests to implement new changes.
When a practice change does not align with the nurses' work-
flow or make sense, it is more difficult to adopt and integrate the
new way of providing care. Conversely, a few participants described
practice changes that aligned with their workflow and made sense.
When this occurred, new practices were described as being adopted
more readily. One participant described a new practice of giving
every dose of subcutaneous heparin, even before a patient goes to
the operating room. ‘…the chances of that surgery getting bumped…
or whatever, so then you're holding a dose …it totally makes sense
especially when you see how many cases get delayed and how many
doses of heparin probably get missed, it makes complete sense to
me’ (P006).
Having appropriate education and resources available to the nurses
helped the change make sense and implementing the change easier.
Resources ranged from knowledge and skills to complete a practice
change, applicable technology, accessible policies and written sources
to refer to when questions about the practice arose. Multiple partici-
pants indicated one particular practice change, nurse-­to-­nurse change
of shift handoff at the bedside, being more difficult to implement
without access to the required resource. Computers hold information
needed to complete a handoff, but often were not available in every
patient room. ‘…we don't have a computer in the room. So, we can't
really see everything…So they're not really making sense. … there's a
conflict in that it's not really thoroughly planned’. (P003).
4.3 | It happens to nurses
Participants described practice change as something that happens
to them, rather than something that they are actively involved in.
Participants predominantly described not being engaged in the
decisions about whether a new practice change should occur. This
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1424
category consisted of three subcategories: being told; no why; and no
voice and no choice.
4.3.1 | Being told
Participants consistently referenced ‘they’ as a faceless group within
the organisation that are initiating practice changes. ‘They’ is allud-
ing to administrators or people outside of the nursing unit. When
‘they’ make a decision that a practice should be changed, participants
consistently describe being told about the new practice rather than
being engaged in a discussion about the change; ‘told, we just get
told’ (P005). Across participants, the unit Manager or Clinical Nurse
Specialist (CNS) deliver the practice change message primarily during
staff meetings or unit council meetings. ‘…a lot of times we'll have
these things brought up during our staff meetings…and [they] intro-
duce these things’ (P004). In addition to information being told ver-
bally from unit leadership, practice changes were also shared via fliers
posted on the unit and newsletters shared through employee email.
Even though the unit leadership (manager or CNS) delivered the
message, many participants were not able to articulate where the
change started or came from. Some assumed that a committee or
workgroup identified the need for a change. Others described an as-
sumption that changes are related to fiscal requirements. Some par-
ticipants assumed decisions were made with nurses' and patients'
best interest in mind. Other participants were uncertain about who
was making decisions, their background or nursing experience, and
how practice changes were determined. These assumptions influ-
enced how positively or negatively participants perceived the prac-
tice change.
4.3.2 | No why
Participants reported being frustrated when the reason for the
new practice change was not shared with them. Lack of hearing the
‘why’ of the practice change negatively influenced their perception
of the need for a new change. One nurse stated ‘…you always have
questions of why or how; it's seldom really explained. …somebody
says ‘well we're doing it like this’ and nobody really knows why and
I never think it's implemented well…’ (P005). Another participant
indicated ‘but they don't tell you the evidence behind it. That's a
huge thing…so, of course, you're going to have some resistance’.
(P002). Not knowing why practice changes were being implemented
made it harder for nurses to adopt the practice.
Conversely, participants described positive experiences with
implementing a practice change when they were provided rationale
for why a new practice is being initiated. Knowing the ‘why’ allowed
nurses to be engaged in practice change, increasing adoption and
promoting the change with other staff on the unit. One nurse de-
scribed a practice change to judicious use of head scans, rather than
routine ones: ‘We changed it for a reason…she's not doing it because
it's what she wants, it's because it's what the evidence says. The
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ARSENAULT KNUDSEN et al.
likelihood of having a head bleed is very low unless they actually
have symptoms, so then why are we scanning?’ (P011).
4.3.3 | No voice, no choice
When participants were notified about a practice change without re-
ceiving an explanation, they described not having a voice or a choice
about implementing the new change. Furthermore, participants
were told that the practice change must begin immediately. One par-
ticipant stated: ‘Well, I just take it as oh, here you go. New thing. No
place to complain. It's gonna happen, it doesn't matter what you say’
(P003). Another commented: ‘So, they kind of sprung [it] on all of us,
…it's top-­down… So, our manager came to us and said we're doing
this …you have to do it’ (P002). This lack of voice and input into the
change further exacerbated the feelings of having practice change
happen to them, rather than being an active participant.
4.4 | Doing right for the patient
Despite the challenges participants described with changing their
practice, they maintained an overall positive attitude towards
practice change. All participants consistently described wanting
to provide excellent patient care while maintaining patient safety,
which is central to their role as a nurse. Thus, when practice changes
were rolled out by the organisation, participants wanted to do the
right thing and align their nursing practice accordingly. Doing right
for the patient positively influenced participants' adoption of new
practices. This category consists of three subcategories: providing
the best possible care; monitoring helps; and ask for nurses' input.
4.4.1 | Providing the best possible care
Participants typically assume that the reason for a practice change
was to improve patient outcomes. ‘You can make any change if you
know it's gonna make your patient better. I think a nurse will change
anything if they know that it's gonna have a better patient outcome’
(P007). Many participants indicated that in order to continue to pro-
vide excellent nursing care, practice has to change. One stated, ‘I
think [practice change is] the ever-­evolving quest to deliver excel-
lence to our patients in every situation. The best care they could
possibly have…’ (P001).
The desire to provide the best patient care acts as a facilitator
to adopting the change, even if it added to the participants work-
load. Conversely, if the practice change is only intended to improve
nurses' outcomes (e.g. reduce their risk of injury), participants were
not as likely to adopt the change. ‘I get that it's saving my back but
let's just boost them up and get it done with… But that's not hurting
the patient, that's hurting me…’ (P006).
Sometimes, due to nursing or patient circumstances, the ideal
practice may not be possible or may not be appropriate for particular

ARSENAULT KNUDSEN et al.
patients. One participant described wanting to complete a cen-
tral line dressing change according to the new dressing protocol.
However, the patient's condition introduced multiple barriers pre-
cluding them from using the new practice, ‘it was impossible, you
couldn't do it’ (P001). Nurses often described being aware of what
the hospital expectations were and having to simultaneously use
their expertise to optimise care in instances when modifications are
needed. ‘…sometimes I think that maybe the change can't be the
total perfect thing that is ideal, maybe the best practice has to de-
cide there are sometimes that you have to modify it.’ (P005).
Participants readily recognise the seriousness of providing the
best possible care. In fact, when a change does not happen, some de-
scribed experiencing feelings of guilt and personalised their actions
as doing something wrong. ‘I know that personal guilt thing if I did
something wrong I'm going to dwell on it and I'm gonna think about
it and I'm gonna be upset about it and I'm gonna take that home and
why did I forget? It's going to affect me that I did that wrong.’ (P006).
4.4.2 | Monitoring helps
Monitoring occurred using various methods, such as reports and
audits, observations of practices by peer nurses, and conversations
with a nurse manager or CNS. Monitoring signalled to nurses that
the organisation prioritised the practice change, communicating to
them that they must integrate it into their practice. Conversely, if
monitoring was absent, the change was questioned, and participants
wondered if anyone cared if they changed their practice or not. ‘Not
once has somebody said so, how's that blood [transfusion] thing
going? We give the most blood. Does anybody care?’ (P009).
Monitoring also helps because it kept the new practice on the
forefront of nurses' minds and aids in remembering to do the practice
while enhancing the sense of accountability. One nurse described it
this way: ‘… I think people do a better job when there's somebody
watching. They just try harder…I just think people extend to do a
better job when someone's accountable’ (P004). Monitoring and
sense of accountability helped nurses to know that their efforts are
important and hopefully making a difference in patient outcomes.
To connect the practice change with the impact, patient out-
comes should be visible and shared with nurses. This awareness and
visibility of outcomes links the work of making the practice change
with the reason for the new practice. Linking makes it easier for
nurses to adopt the new change into their practice. ‘If nurses can
see the outcome…it's much easier to continue that change but some
things you can't see and so being told it is helpful, hey guys we did
this…our patient satisfaction scores are better’ (P011).
4.4.3 | Ask for nurses' input
In order to achieve the goal of providing the best care and doing right
for the patient, participants articulate the desire to be more involved
in providing input into practice change. Across all interviews,
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1425
participants described being very familiar with practice change,
experienced it frequently, and had insights into what helps practice
change to be successful. While participants recognised that they
cannot be part of every practice change decision, they identified
opportunities to be consulted to offer insight for successful practice
change initiatives.
When input from participants was omitted, it negatively im-
pacted the adoption of new practices on the unit. One individual
described it this way: ‘…but it's when the people that don't do the job
are making the decisions, if you were at bedside, you'd know that's
not gonna work…a bedside nurse that provides the patient care can
give a pretty good insight on what works and what really wouldn't
work…there's struggles if our input isn't taken’ (P010). Participants
wanted their nursing experience to be recognised and the work that
is required to initiate a practice change. Further, participants wanted
to meaningfully contribute to conversations about practice change
that would impact patient outcomes.
5 | DISCUSSION
This study sought to explore nurses' perceptions of practice change
and to develop a better understanding of the factors that influence
the adoption of practice changes. Our findings indicate that practice
changes have a variety of types, come in different sizes and occur
frequently, and often concurrently. Participants described multiple
factors that influence the uptake of new practices, including the
history of the change, the reality that it is a lot of work, and the
perception that practice change happens to them, rather than
being active participants. Despite all of this, nurses remain firmly
rooted in the ultimate goal of their job –­ to do right for the patient.
This study contributes new knowledge on nurses' perceptions of
practice change, providing valuable insights and guidance for how to
approach practice change differently.
A novel finding of this study is that nurses' experience multi-
ple practice changes simultaneously. These multiple co-­occurring
changes negatively influence the rate of adoption. This finding was
threaded throughout multiple categories, explicitly in ‘There is A
History’ and ‘It's A Lot of Work.’ Our findings differ from the cur-
rent literature where the implementation of a new practice is de-
scribed in isolation from any other practice changes occurring at the
organisation; the context of the practice change is rarely mentioned.
However, a recent study by Parker et al. (2020) identified that the
‘simultaneous implementation of multiple projects’ (p. 3052) was a
barrier to nurses implementing practices aimed to decrease the risk
of catheter-­associate urinary tract infections.
Implementation science focuses on exploring which strategies are
effective for whom, within different contexts, and optimising factors
for successful practice change (Mitchell & Chambers, 2017; Titler,
2008, 2010) and offers multiple models and frameworks that outline
determinants of implementation (Nilsen, 2015). These frameworks
are important to use for designing implementation studies or select-
ing implementation strategies for the adoption of practice changes.
 |
1426
However, findings from our study offer a new perspective suggesting
a need to expand these models to account for the frequency and mul-
tiplicity of practice changes happening within hospitals. Future studies
could aid in expanding these frameworks if data were collected and re-
ported to describe the co-­occurring practices during implementation.
Cullen and Adams (2012) offer the Implementation Strategies
for Evidence-­Based Practice guide, which was developed by nurses
for nurses, as ‘an application-­oriented approach to organize, plan,
and select strategies for implementation of EBP changes’ (p. 222).
The guide outlines multiple strategies to be used, and sometimes
repeated, across four phases of implementation that address both
individual nurses and the organisation as a whole. Intentionally plan-
ning for and applying strategies to promote practice change using
these strategies may help nurses overcome challenges of trying to fit
it all in and juggling their work. When change is thoughtfully planned,
rather than retrofitted, the disruption to workflow and workload
may be limited. While Cullen and Adams' (2012) model is specifi-
cally designed for planning the implementation of evidence-­based
practices, our findings indicate that a variety of types of changes
are perceived as practice change; therefore, this model may have a
broader applicability.
Furthermore, participants in this study described practice
change as a lot of work and indicated it is often under recognised.
This aligns with descriptions of efforts to improve patient outcomes,
which was likened to articulation work –­the important yet invisible
work that is taken for granted and undervalued (Fulton et al., 2019).
This sense of feeling undervalued is compounded when nurses
do not sense efforts for planned ways to minimise the impact of
changes on nurses' workflow and assuring adequate resources, such
as reminders and monitoring. When these factors are not consid-
ered, participants indicated that the new practice is harder to adopt
and can lead to unintentional non-­adherence to the new practice, a
finding which was echoed by Parker et al. (2020). To counterbalance
these challenges, hospitals should be thoughtful and explicit in plan-
ning practice changes, including taking into account the complexity
of the healthcare environment.
Piloting a practice change is a key strategy indicated in multiple
implementation models (Buckwalter et al., 2017; Cullen & Adams,
2012; Damschroder et al., 2009; Greenhalgh et al., 2004). However,
due to the amount of work needed to make a new practice change
happen, this strategy may need to be re-­evaluated. While the bene-
fits of piloting, or testing a change, are numerous (Institute for Health
Care Improvement, 2020), our findings indicate that the pilot itself
is experienced as no less work than a full-­fledged practice change.
This must be recognised and acknowledged; and the burden of the
workload should be considered before initiating a pilot to ‘just try’.
Communication is another key element of practice change.
Titler's (2010) Translational Research Model highlights the impor-
tance of communication with the users of EBPs; having conversa-
tions about barriers to the practice change or engaging champions in
discussions about the change influences the rate of adopting EBPs.
Our findings indicate that not only communication should occur, but
it should also include details of the rationale or the evidence for the
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ARSENAULT KNUDSEN et al.
change. Furthermore, communication should include recognition
of past experiences of change, the expertise that nurses possess,
and that nurses are steadfast in their intention to do the right thing
for patients. Outcomes of practice change should also be communi-
cated back to nurses to reinforce and continue their adoption.
5.1 | Limitations
This study's sample was comprised of 11 nurses from two hospitals
within one healthcare system. However, participants represented a
breadth of hospital nurses with a range of experience (3 years to
greater than 15), types of units and patient populations (adult and
paediatric; medical and surgical; ICUs, IMCs and general care units).
Additionally, these 11 nurses described 63 experiences with practice
change, which was the unit of analysis. Therefore, the researchers
were able to sample multiple events and occurrences of practice
change that nurses experienced. Thus, adding to the richness of the
data and capturing a wealth of experiences and various examples of
influential factors for adopting practice changes. Future work should
continue to explore this phenomenon with nurses from across
multiple healthcare systems.
6 | CO N C LU S I O N
This study articulates the realities of practice change for hospi-
tal nurses and highlights nurses' desire to be active partners in
practice change. Our findings indicate that nurses are hopeful that
practice change can be improved through tangible and practical
ways. By engaging nurses, using pilots judiciously and communi-
cating the rationale for and the outcomes of the change, practices
may be more readily adopted. Resistance to practice change may
not be a product of nurses' intention, which is positive, but rather
due to the amount of work that it takes to undertake the change
and the lack of thoughtful planning to minimise the workload and
recognise the context of nursing work. Nurse leaders should con-
sider ways to recognise nurses' history with practice changes and
their nursing experience and integrating their input to promote
successful change. Implementation scientists should explore ways
to account for the frequency and multiple co-­occurring practice
changes in determinant models. Future work should explore ways
to integrate these elements to accelerate practice change, so that
patients can reap the benefits of receiving high-­quality evidence-­
based nursing care.
7 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
Involving nurses in the practice change could help alleviate some
inhibiting factors for adopting new practices. Our participants iden-
tified that nurses would like to be asked if the new practice and
the accompanying process makes sense. The disconnect between

ARSENAULT KNUDSEN et al.
organisations expecting nurses to be passive recipients of change
and the reality that adopting new practices inherently requires ac-
tive participation by nurses should be recognised. Engaging workers
in the steps of changing their practice has been underscored as a
strategy to ensure that integration and sustained change is achieved
(Needleman & Hassmiller, 2009; Needleman et al., 2016). Yet, ac-
tualising the engagement of front-­line nurses is challenging. Even
when nurses were afforded the opportunity to attend a programme
to learn and lead EBP projects, time to complete the project was a
recurring challenge (Balakas et al., 2013; Fridman & Frederickson,
2014; Irwin et al., 2013). Local hospital and national policies should
explore creative and practical ways to balance the competing needs
of nurses providing direct care at the bedside and dedicated time to
be engaged in practice change initiatives. Investing time for nurses
to be involved with practice changes could lead to broader adoption,
less resistance and nurses advocating for practice change among
their peers and for their patients.
Nurses recognise that practice change is necessary to assure
best patient outcomes and often start with the assumption of that
goal. Nursing leaders communicating practice change should capital-
ise on this assumption and align messaging with nurses' intention of
doing right by the patient and providing excellent patient care. With
the ongoing focus on improving patient care and optimising patient
safety, nurses should be viewed as highly valued members of the
team when designing and implementing practice changes.
AC K N OW L E D G E M E N T S
The primary author would like to acknowledge Anne Ersig, PhD, RN;
Marlon Mundt, PhD, MS, MA; Sarah Brzozowski, PhD(c), MBA, BSN,
RN, NEA-­B.
C O N FL I C T O F I N T E R E S T
None of the authors have financial or personal relationship with
persons or organisations that might inappropriately influence our
work presented therein. The authors have no conflicts of interest
to declare.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
Élise N. Arsenault Knudsen https://orcid.
org/0000-0001-6048-3460
Linsey M. Steege https://orcid.org/0000-0002-8508-7787
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S U P P O R T I N G I N FO R M AT I O N
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Supporting Information section.
How to cite this article: Arsenault Knudsen ÉN, King BJ,
Steege LM. The realities of practice change: Nurses'
perceptions. J Clin Nurs. 2021;30:1417–1428. https://doi.
org/10.1111/jocn.15693