Implementing Best Practice Guidelines under the Best Practice Spotlight Organisation: Facilitators and Barriers for Nurses: A Delphi Study
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
I am grateful for the opportunity to review this manuscript, focusing on a topic that is particularly close to my heart. Without detracting from the merit of the authors and the work deposited here, the manuscript shows, through omission or insufficiency, a lack of methodological clarity (a fundamental aspect in a study that uses the Delphi technique), which is why it should be subjected to extensive revision prior to acceptance.
Introduction
The framework of Best Practice Spotlight Organisations needs to be further developed from a theoretical point of view because the Delphi study was carried out using this model as a basis.
Material and methods
The Delphi technique consists of obtaining consensus on a given topic from a group of experts who anonymously give their opinions.
The eligibility criteria for admitting the experts need to be explained. The procedures for identifying and accessing experts must be described in detail (by the research team, snowballing, external recommendation, etc.).
Regarding the preliminary identification of facilitators and barriers. Was the PubMed and Cochrane Library search a genuine literature review or a convenience search? If it was a literature review, it needs to be more detailed; if it wasn't, how can the authors be sure that no facilitators and barriers were left unidentified in the literature?
Regarding the instrument, there is a lack of detail regarding the structure and sections of the questionnaire. Were there open questions or fields where the experts consulted could give an opinion, a suggestion or justify their position in addition to the Likert-type scale?
The cutoff for the consensus value needs to be clearly defined before the study begins.
Finally, concerning the number of rounds, it is strange that this number was defined in the material and methods as if it was already understood that there would only be two rounds. Was this the case?
Discussion
At the moment, the discussion seems to be a more detailed narrative of the results chapter. The authors should review this chapter and compare the results with the extensive literature.
Does this study have any limitations? Does it have any implications for professional nursing practice? No recommendations for nursing research?
Conclusion
Revise and present a proper conclusion.
Comments on the Quality of English Language
It is clear from some parts of the manuscript that English is not the authors' mother tongue, so the document should be professionally revised. For example, table 1 reads ‘Specialism’ when it should read ‘specialisation’.
Author Response
Introduction
Comment 1: The framework of Best Practice Spotlight Organisations needs to be further developed from a theoretical point of view because the Delphi study was carried out using this model as a basis.
Response 1: Thank you for pointing this out. We have added lines 45–63, providing further information on the BPSO framework as a long-term institutional process focused on the implementation and sustainability of best practices by champion nurses who actively participate within the BPSO programme. This is addressed in the final paragraph of the introduction, where the study is justified:
“At the time of writing, June 2024, the hospital is in the sustainability phase of three of the BPGs, and the implementation phase of a fourth, boasting 50 active champions spread across the various hospital departments. This study aims to identify the facilitators and barriers identified by this cohort of 50 best practice champion nurses, all actively involved in the implementation of the BPGs of the RNAO®, within the framework of the BPSO® strategy, in a hospital setting”.
Two words have been highlighted in red to emphasise that the goal is to reach a consensus among this cohort of champion nurses regarding the barriers and facilitators they identify for implementing best practices within the BPSO framework.
Material and methods
Comment 2: The eligibility criteria for admitting the experts need to be explained. The procedures for identifying and accessing experts must be described in detail (by the research team, snowballing, external recommendation, etc.).
Response 2: Thank you for your comment. The research team leads the implementation of the BPSO programme at our institution, providing training to the champions and overseeing the entire process. Close collaboration is maintained with the 50 facilitators, making it a priority to understand their perceptions regarding the barriers and facilitators to the implementation of best practices within the BPSO framework. These findings will help design strategies to further streamline the process. The study population was accessed during working group meetings. This has been reflected in lines 103-112 of the text.
Comment 3: Regarding the preliminary identification of facilitators and barriers. Was the PubMed and Cochrane Library search a genuine literature review or a convenience search? If it was a literature review, it needs to be more detailed; if it wasn't, how can the authors be sure that no facilitators and barriers were left unidentified in the literature?
Response 3: We agree with this comment. We have expanded the details of the integrative review conducted, providing more information in the text between lines 116, 117, and 122-129.
Comment 4: The cutoff for the consensus value needs to be clearly defined before the study begins.
Response 4: Thank you for your comment. We have added the following clarification in lines 149 and 150: “The consensus threshold was set at a mean value of ≥ 3.50 for both barriers and facilitators.”
Comment 5: Finally, concerning the number of rounds, it is strange that this number was defined in the material and methods as if it was already understood that there would only be two rounds. Was this the case?
Response 5: In response to your comment, we would like to clarify that the type of Delphi method used was the “Modified Delphi” method, which is characterised by using only two rounds to reach consensus. This information has been included in the Methods section.
Discussion
Comment 6: At the moment, the discussion seems to be a more detailed narrative of the results chapter. The authors should review this chapter and compare the results with the extensive literature.
Response 6: Thank you for the suggestion. We have added several comments comparing our findings with other publications in the Discussion. These additions are highlighted in red in the text and can be found in lines 231, 132; 240-242; 265-275; and 279-281.
Comment 7: Does this study have any limitations? Does it have any implications for professional nursing practice? No recommendations for nursing research?
Response 7: Thank you for pointing this out. We have added the limitations inherent to the study design between lines 263-265. Implications for nursing practice and further research have been included in lines 256-259.
Conclusion
Comment 8: Revise and present a proper conclusión
Response 8: Thank you very much for your comment. We have added a proper conclusion in lines 285-290.
Comments on the Quality of English Language
It is clear from some parts of the manuscript that English is not the authors' mother tongue, so the document should be professionally revised. For example, table 1 reads ‘Specialism’ when it should read ‘specialisation’.
Response to Quality of English Language: Thank you for your suggestions. We have reviewed the text and the specific terms mentioned. The manuscript has been professionally translated and reviewed by experts. A certificate has been attached.
Thank you for your kind attention
Reviewer 2 Report
Comments and Suggestions for Authors
This is a well-written and potentially important study that can continue to build on the knowledge base of evidence-based practice guidelines. The research design using Delphi is a reasonable approach for data analysis.
Abstract: while well-written, does not include the BPGs in question: ostomies, injury from falls, adults with suicidal ideation, and vascular access.
Introduction: for those readers unfamiliar with the BPG program and the extensive efforts by the RNAO to advance EBP guidelines, it would be helpful to include some historical background and a basic explanation of this program.
When were the studies done in Australia and Spain?
Identify the city and country (Spain) as the location of this study, after mentioning the institution.
Section 2.1: Materials and Methods:
Why were the four specific BPGs chosen? How are they to be incorporated into the data collection and analysis? Is this to be a study that focuses on the general aspects of EBP or is it focusing on these 4 specific clinical practices. If it is the latter, that was not represented in any of the references, and in the instruments used.
For the instrument used, was it created by the authors? Was it piloted? More information on instrument source/design can be included. The process of use of the instruments and the statistical analysis was explained well.
3. Results
The results were presented clearly, the tables are easy to follow and interpret. Once again however, there is no mention of the 4 BPGs indicated in the Methods section. It seems like a disconnect to have mentioned them at all, and instead this can be a study on the general aspects of EBP in clinical practice. If that is the case however, then there are many other studies already in the literature with similar foci.
4. Discussion
The discussion is clear and provides results, both facilitators and barriers, for EBP. This does add to the knowledge of EBP, however again, where are the 4 BPGS? How do the results relate to these specific practices? That tie-in should be established earlier in the manuscript and then pulled together here.
5. Conclusion
The brief conclusion synthesized the results and discussion, only for the general advancement of EBP, and unrelated to the BPGs identified.
In summary, this is a worthy manuscript for advancement of the knowledge of EBP. My suggestion is to either delete the BPGs completely, or incorporate them in the discussion. The data does not relate to them specifically in any way that has been brought forth to the reader.
Author Response
Response to reviewer 3
Thank you very much for your suggestions and comments to improve our work, all of which have been taken into account and are reflected in red in the text. The explanations to your comments can be found below.
Comment 1: Abstract: while well-written, does not include the BPGs in question: ostomies, injury from falls, adults with suicidal ideation, and vascular access.
Response to comment 1: Thank you very much for your comment. We agree that mentioning the specific guidelines could confuse the reader, as this is not the focus of the study. The BPSO programme follows a methodology that applies equally to any clinical guidelines being implemented, so we have removed the references to these guidelines throughout the text.
Comment 2: Introduction: for those readers unfamiliar with the BPG program and the extensive efforts by the RNAO to advance EBP guidelines, it would be helpful to include some historical background and a basic explanation of this program.
When were the studies done in Australia and Spain?
Identify the city and country (Spain) as the location of this study, after mentioning the institution.
Response to comment 2: Thank you very much for your comment. We have included more information about the BPSO programme and its implementation methodology in the introduction (lines 45-64).
We have also added the city and country where the study was conducted in line 114.
Section 2.1: Materials and Methods:
Comment 3: Why were the four specific BPGs chosen? How are they to be incorporated into the data collection and analysis? Is this to be a study that focuses on the general aspects of EBP or is it focusing on these 4 specific clinical practices. If it is the latter, that was not represented in any of the references, and in the instruments used.
For the instrument used, was it created by the authors? Was it piloted? More information on instrument source/design can be included. The process of use of the instruments and the statistical analysis was explained well.
Response to comment 3: Thank you for highlighting this point. As explained at the beginning, the names of the four BPGs have been removed from the text, as they are not the focus of the study; they were only mentioned to identify the champions (lines 103-106).
Regarding the instrument, thank you for your suggestion. We have added more information on this topic in lines 131-135.
- Results
Comment 4: The results were presented clearly, the tables are easy to follow and interpret. Once again however, there is no mention of the 4 BPGs indicated in the Methods section. It seems like a disconnect to have mentioned them at all, and instead this can be a study on the general aspects of EBP in clinical practice. If that is the case however, then there are many other studies already in the literature with similar foci.
Response to comment 4: Thank you very much for your perspective. This study aims to address the proposed objective, which is to investigate the challenges that champions face when implementing the programme in our institution. This is particularly relevant for our Autonomous Community, as we are the first tertiary healthcare facility to be designated as a BPSO®, and it could have significant implications for practice. This information has been added to the text (lines 266-276).
- Discussion
Comment 5- The discussion is clear and provides results, both facilitators and barriers, for EBP. This does add to the knowledge of EBP, however again, where are the 4 BPGS? How do the results relate to these specific practices? That tie-in should be established earlier in the manuscript and then pulled together here.
Response to comment 5: Thank you for your comment. This issue has been addressed by removing the references to the four BPGs, as explained above.
- Conclusion
The brief conclusion synthesized the results and discussion, only for the general advancement of EBP, and unrelated to the BPGs identified.
In summary, this is a worthy manuscript for advancement of the knowledge of EBP. My suggestion is to either delete the BPGs completely, or incorporate them in the discussion. The data does not relate to them specifically in any way that has been brought forth to the reader.
As you suggested, your feedback has helped us to remove the references to the four BPGs, as they could potentially confuse the reader and detract from the study’s main objective.
thank you for your kind attention
Round 2
Reviewer 1 Report
Comments and Suggestions for Authors
I acknowledge the authors' efforts to incorporate the suggestions made during the first revision. The manuscript is now suitable for acceptance, albeit with minor changes to the limitations section. The limitations mentioned by the authors are not genuine limitations but rather characteristics of the method. Therefore, they should be reviewed and reformulated before final acceptance.
Author Response
Comment 1: The manuscript is now suitable for acceptance, albeit with minor changes to the limitations section. The limitations mentioned by the authors are not genuine limitations but rather characteristics of the method. Therefore, they should be reviewed and reformulated before final acceptance.
Response to comment 1: Tnakyou for your comment we have added a limitation which is ‘Moreover, the study was conducted in a very specific setting and in a single hospital, which may make it difficult to generalise the results’, in lines 279-280 of the manuscript.
we hope that you will now consider this to be correct
thank you for reviewing our work so promptly.
Reviewer 2 Report
Comments and Suggestions for Authors
The comments indicate that the feedback was indeed incorporated into several section of the study report. I have reviewed all of the changes made in the revised manuscript and it has improved it considerably. The deletion of the four BPGs was a significant improvement.
I would now recommend publication, and with enthusiasm!
Author Response
Response to reviewer 2: Thank you very much for your comments on our work, which have helped us to improve it and encourage us to continue working along the same lines.
