¹ School of Public Health ,, Walter Sisulu University Faculty of Health Sciences, Mthatha, Eastern Cape, South Africa
² Walter Sisulu University Institute for Clinical Governance and Healthcare Administration, Walter Sisulu University Faculty of Health Sciences, Mthatha, Eastern Cape, South Africa
³ Biostatistics and Analytics training unit, Walter Sisulu University, Faculty of Health SCIENCES, Eastern Cape, 5200, South Africa

Bomkazi Majeke
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Linda Sobekwa
Roles: Methodology, Writing – Review & Editing

Thokoe Vincent Makola
Roles: Methodology, Writing – Review & Editing

Siyonela Mlonyeni
Roles: Conceptualization, Methodology, Writing – Review & Editing

Ntandazo Dlatu
Roles: Methodology, Writing – Review & Editing

G.A. Pulido Estrada
Roles: Data Curation, Formal Analysis, Methodology, Validation, Writing – Review & Editing

Mirabel Nanjoh
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Writing – Review & Editing

A facility-based quantitative cross-sectional survey was conducted to assess healthcare professionals' perceptions of the availability, accessibility, implementation, and perceived effectiveness of Clinical Practice Guidelines (CPGs) at a single point in time¹³ between 9 and 30 May 2026. The study was undertaken at two district teaching hospitals in the Eastern Cape Province, South Africa: Oliver and Adelaide Tambo Regional Hospital in Bizana, Alfred Nzo District (290-bed capacity), and Dr Malizo Mpehle Memorial Hospital in Tsolo, OR Tambo District (155-bed capacity). Both hospitals provide comprehensive district-level healthcare services to predominantly rural populations and serve as accredited decentralized clinical training platforms for undergraduate and postgraduate health sciences students of the Walter Sisulu University Faculty of Medicine and Health Sciences. These facilities offer a broad range of medical, surgical, obstetric, paediatric, emergency, and outpatient services, making them appropriate settings for evaluating the availability and implementation of clinical practice guidelines within routine healthcare delivery.

The study population comprised healthcare professionals employed at the two participating district teaching hospitals who were directly involved in patient care and clinical decision-making. A census sampling approach was adopted, whereby all eligible healthcare professionals working at the study sites during the data collection period were invited to participate. Of the 229 eligible healthcare professionals, 169 completed the survey, yielding a response rate of 73.8%. Non-participation was primarily due to annual leave, sick leave, or declining to participate.

Inclusion criteria: Healthcare professionals who were involved in direct patient care, clinical supervision, or clinical decision-making, had been employed at the study facility for at least six months, and were able and willing to provide written informed consent were eligible for inclusion.

Exclusion criteria: Non-clinical personnel, non-resident medical officers, agency or temporary nursing staff, allied health professionals, and undergraduate health sciences students were excluded from the study because they were either not routinely involved in clinical decision-making within the participating hospitals or were not permanent members of the clinical workforce.

Data were collected using a self-administered, structured questionnaire developed specifically for this study, as no validated instrument was identified that comprehensively assessed the availability, accessibility, implementation, perceived effectiveness, and barriers to the use of Clinical Practice Guidelines (CPGs) in the study context. The questionnaire comprised both closed-ended questions and five-point Likert-scale items ranging from 1 (Strongly disagree) to 5 (Strongly agree). It consisted of six sections covering participants' demographic and professional characteristics, availability of CPGs (five items), methods of accessing CPGs, implementation of CPGs (five items), perceived effectiveness of CPGs (five items), implementation barriers (five items), and an open-ended question inviting participants to suggest strategies for improving CPG implementation. The questionnaire was developed following a review of the literature on clinical practice guideline implementation and was conceptually informed by the study objectives and the clinical governance framework. Face and content validity were evaluated by an expert in clinical governance and health services research to ensure that the questionnaire adequately measured the intended constructs. Following expert review, the instrument was pilot tested with 23 healthcare professionals (10% of the eligible study population) from a comparable district hospital not included in the main study. The pilot study assessed the clarity, relevance, comprehensiveness, and feasibility of the questionnaire, and no substantive revisions were required before implementation in the main study. Internal consistency reliability was assessed using Cronbach's alpha, with a coefficient≥0.70 considered indicative of acceptable reliability.¹⁴ In the main study, the questionnaire demonstrated excellent internal consistency for the availability domain (α = 0.915), good internal consistency for the implementation (α = 0.837) and perceived effectiveness (α = 0.814) domains. The barriers domain yielded a lower reliability coefficient (α = 0.657), reflecting the multidimensional nature of implementation barriers rather than poor measurement consistency. Consequently, barrier items were analysed individually rather than as a composite scale.

Data collection was conducted over a two-week period at each participating hospital following the receipt of ethical approval, institutional permission, and gatekeeper approval from the relevant district health authorities. Hospital managers facilitated access for eligible participants and coordinated data collection within their respective facilities. Healthcare professionals who met the eligibility criteria received an information sheet outlining the study objectives, procedures, potential risks and benefits, and their rights as research participants. Participation was entirely voluntary, and written informed consent was obtained from all participants before enrolment from 9-30 May 2026. Participants completed a self-administered questionnaire that took approximately 15–20 minutes. To maximize participation and accommodate participant preferences, the questionnaire was administered either in paper-based format or electronically using a secure Google Forms platform. Completed paper questionnaires were collected immediately after completion, while electronic responses were securely stored in the password-protected online platform.

Data were entered, cleaned, and verified in Microsoft Excel before being imported into IBM SPSS Statistics version 30 (IBM Corp., Armonk, NY, USA) for statistical analysis. Data cleaning included checking for completeness, consistency, coding errors, duplicate entries, and missing values before analysis. Descriptive statistics were used to summarise participant characteristics and questionnaire responses. Categorical variables were presented as frequencies and percentages, whereas Likert-scale responses were summarised using frequencies, percentages, mean scores, and standard deviations for each questionnaire domain, with higher scores indicating stronger agreement. Differences in composite domain scores according to participants' demographic and professional characteristics were assessed using independent-samples t-tests for dichotomous variables (gender, professional role, and district) and one-way analysis of variance (ANOVA) for variables with more than two categories (age group and years of professional experience). Where statistically significant differences were identified, post hoc multiple comparison tests were performed to determine which groups differed. All statistical tests were two-tailed, and a p-value of <0.05 was considered statistically significant.

A total of 169 healthcare professionals participated in the study, representing a response rate of 73.8% (169/229). Most participants were female (76.3%), nearly one-third (31.4%) were aged 45–54 years, and the majority (79.9%) were professional nurses. Almost half (45.6%) had 11–20 years of experience in the public health sector. Participants were predominantly recruited from Oliver and Adelaide Tambo Regional Hospital (59.2%), reflecting its larger clinical workforce ( Table 1).

Participants generally reported favourable perceptions regarding the availability of Clinical Practice Guidelines (CPGs). Approximately 7 in 10 participants indicated that CPGs were available within their facilities (71.0%) and relevant to the clinical conditions they managed (72.2%). Most respondents also reported that guidelines were available in multiple formats (67.5%) and were readily accessible during routine clinical practice (63.3%). In contrast, fewer than half (44.3%) agreed that CPGs were reviewed and updated regularly ( Table 2). The distribution of responses is also illustrated in Figure 1.

Participants identified CPGs covering a broad spectrum of clinical areas, including communicable and non-communicable diseases, maternal and obstetric care, neonatal and paediatric care, trauma, emergency medicine, anaesthesia, nutrition, and infection prevention and control.

Among the 86 participants who responded to questions on accessibility, printed guidelines were the most reported means of accessing CPGs (30.2%), followed by multiple complementary access methods (26.7%). Posters accounted for 18.6% of responses, whereas mobile applications (9.3%) and digital platforms (8.1%) were used less frequently. Notably, 7.0% of respondents reported having no access to CPGs within their workplace ( Table 3).

Participants generally reported high levels of CPG implementation in routine clinical practice. Most respondents reported frequently using CPGs to inform clinical decision-making (80.5%) and expressed confidence in applying guideline recommendations in patient care (88.8%). Over three-quarters (77.0%) considered the guidelines to be clear, practical, and easy to understand, while 71.0% perceived organisational support for CPG implementation. However, only 53.9% reported receiving sufficient training on the use of CPGs ( Table 4). These implementation findings are illustrated in Figure 2.

Healthcare professionals reported highly favourable perceptions regarding the effectiveness of CPGs. Nearly all participants agreed that CPGs improve patient health outcomes (98.8%), reduce clinical errors (97.0%), and enhance the quality of healthcare (95.3%). Perceptions were comparatively less positive regarding the role of CPGs in standardising clinical practice across healthcare providers (62.7%) and improving direct patient benefit (61.5%), with approximately one-third of participants selecting neutral responses ( Table 5). These perceptions are illustrated in Figure 3.

The most frequently reported barriers to CPG implementation were inadequate resources (85.8%), staff shortages (76.9%), and insufficient training (72.2%). Fewer participants identified outdated or unavailable guidelines (51.5%) and limited consultation time (46.1%) as barriers ( Table 6). The reported barriers are summarised graphically in Figure 4.

Eighty participants provided open-ended recommendations to improve the availability and implementation of CPGs. The most frequently proposed strategy was the regular review and updating of guidelines (26.3%), followed by increased training and continuing professional development (22.5%) and improved availability and accessibility of CPGs (20.0%). Other recommendations included increasing staffing levels (10.0%), strengthening digital access and information technology infrastructure (8.8%), enhancing organisational and management support (6.3%), improving the availability of clinical resources and equipment (3.8%), and simplifying or standardising guideline formats (2.5%). These recommendations closely reflected the barriers identified in the quantitative findings ( Table 7).

Significant differences in CPG availability scores were observed according to gender, professional role, age group, and years of professional experience. Female participants reported significantly higher availability scores than males (3.79 ± 0.97 vs. 3.22 ± 1.06; p = 0.002), while nurses reported higher scores than medical doctors (3.84 ± 0.96 vs. 2.92 ± 0.94; p < 0.001). Availability scores also increased significantly with age and years of professional experience, whereas no significant difference was observed between the two study hospitals (p = 0.082). Implementation scores did not differ significantly across any demographic or professional characteristic (all p > 0.05). Perceived effectiveness scores differed significantly by professional role (p = 0.049) and years of professional experience (p = 0.038), with healthcare professionals with 6–10 years of experience reporting the highest perceived effectiveness. The complete comparative analyses are presented in Table 8.

This study has several strengths. It employed a census sampling approach that included all eligible healthcare professionals across two district teaching hospitals and achieved a satisfactory response rate. The study was guided by a locally relevant clinical governance framework¹² and used a comprehensive questionnaire to assess multiple dimensions of CPG implementation, including availability, accessibility, implementation, perceived effectiveness, and barriers.

Several limitations should also be acknowledged. First, the cross-sectional design precludes causal inference and does not permit assessment of changes in CPG implementation over time. Second, the reliance on self-reported data may have introduced recall and social desirability bias. The absence of objective measures of guideline adherence, such as clinical audits or medical record reviews, means that reported implementation may overestimate actual clinical practice, particularly given the discrepancy observed between confidence and formal training. Third, although the questionnaire demonstrated acceptable face validity, content validity, and internal consistency for most domains, it has not been externally validated in other healthcare settings. The lower internal consistency observed for the barriers domain likely reflects the multidimensional nature of implementation barriers rather than poor instrument performance. Finally, the study was conducted in only two district teaching hospitals within one province over a relatively short data collection period, which may limit the generalisability of the findings to non-teaching hospitals, primary healthcare facilities, or other provinces.

Clinical Practice Guidelines were generally available, accessible, well implemented, and perceived to be highly effective among healthcare professionals working in two district teaching hospitals in the Eastern Cape Province. However, important gaps remain in the regular updating of guidelines, equitable digital access, and the provision of structured training for healthcare professionals. Significant differences in perceived guideline availability according to professional role, gender, and years of experience suggest that organisational factors influence access to evidence-based resources. Healthcare organisations should strengthen local guideline governance by establishing routine review and updating processes, expanding digital and mobile access while maintaining printed resources, and investing in continuous professional development focused on guideline implementation. Addressing workforce shortages and resource constraints will also be essential to support sustained implementation. Future research should incorporate qualitative methods to explore organisational and professional factors influencing CPG implementation, alongside objective audit-based assessments of guideline adherence. Multicentre studies involving different levels of healthcare and multiple provinces would further improve understanding of CPG implementation across the South African health system.

The authors sincerely thank the Eastern Cape Department of Health for granting permission to conduct this study. They also express their appreciation to the Chief Executive Officers, hospital management teams, and healthcare professionals of Dr Malizo Mpehle Memorial Hospital and Oliver and Adelaide Tambo Regional Hospital for their support, cooperation, and participation. Special thanks are extended to Ms. Palesa Njube for her valuable assistance with data collection.

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