Evid Based Nurs doi:10.1136/eb-2013-101457
  • Nursing issues
  • Grounded theory

Use of multifaceted strategies and processes at multiple levels, and passionate frontline leaders are associated with uptake of best practice guidelines on breastfeeding

  1. Amanda Henderson
  1. Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
  1. Correspondence to: Professor Amanda Henderson, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia; Amanda_Henderson{at}

Commentary on: [CrossRef][Medline][Web of Science]Google Scholar.

Implications for practice and research

  • The organisational context can be instrumental in enabling and supporting facilitative processes.

  • Effective facilitative processes communicate clear messages and provide direct assistance to individuals.

  • An active role by leaders and facilitators can overcome resistance to change associated with organisational inertia.

  • Further research should explore the value of facilitative processes specifically variations and degrees of impact.


Research evidence should inform health practices and, arguably, improve healthcare outcomes. Research findings and systematic reviews that can reliably advise about good practices abound in the scientific literature. Unfortunately, this literature often fails to make an impact on how healthcare is delivered. The use of evidence in practice is not an automatic process. Three key factors, namely evidence, context and facilitation, have been proposed as essential elements if research is to be translated into practice.1 These three factors are largely accepted as being representative of the considerations for health leaders and managers seeking to translate knowledge into routine healthcare delivery. Despite their importance, there is still a lack of understanding of the social and contextual elements and the relationship to facilitation processes. Facilitation processes, depending on contextual nuances, can either impede or advance the uptake of evidence; therefore, investigation in the interplay of these factors is warranted.2


This study explored the processes and impact of the implementation and uptake of one specific set of best practice guidelines (breastfeeding) across three different sites. The purpose of the exploration was to identify the best course of action for individual staff and the broader organisational culture to address the multifaceted contingencies in implementing best practice guidelines. The exploration was undertaken using constructivist grounded theory. It involved purposeful sampling of the broad range of stakeholders in knowledge translation. The sample of stakeholders participated in multiple data collection methods including interview, questionnaires and field notes. Data collection and analysis occurred concurrently. While the data collection method did not include direct observation, there was a sufficient spread and diversity of stakeholders that should have reliably provided information offering evidence of the adoption of the breastfeeding guidelines.


This analysis distinguishes the significance of individual behaviours, the importance of supportive leadership and the contextual initiatives of the organisation that culminate to facilitate changed practice. The findings provide clarity in the ‘black box of processes’ necessary for effective and sustainable evidence implementation. A particular significant element was trust. Trust was essential for staff to have confidence in making behavioural changes. Trust was achieved through nurses and others observing successes from use of best practice guidelines and also being actively supported and guided in changing processes. Overall, helpful facilitation and individual determinants were of greater significance in change than context.


This study supports that the strength of evidence, receptiveness of context and effectiveness of facilitation are still relevant for the successful implementation of best practice guidelines. The specific contribution of this study is around illuminating the salient aspects of effective facilitation. Processes of facilitation are frequently presented and discussed in relation to behavioural change and routinely include activities such as bedside teaching episodes, interactive sessions, case study analyses and reminder mechanisms such as newsletters and notices. Research findings verifying the specific value of particular facilitation processes is not as common. This analysis supports the importance of the contribution of engagement by the leader with the facilitation processes. Leadership is recognised as important, and the findings presented by Matthew-Maich and colleagues support the emerging evidence of the value of positive engagement by leaders where they reinforce behavioural shifts associated with guideline implementation.3 This exploration also identified other important activities namely, the building of relationships and feedback to nurses in the form of recognition. These behaviours are often given little credence as their contribution is difficult to ascertain; however, this work supports other contemporary work to the importance of reinforcing outcomes that are powerful in sustaining and embedding desired behaviours.4 These are often invisible aspects of successful facilitation and, therefore, their significance is hard to independently demonstrate.


  • Competing interests None.


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