Impact of context on nurse-led implementation of evidence-based pain management practices in the Sumamos Excelencia project: a qualitative study

Background Context analysis is a key element in the implementation of evidence-based practice for understanding why certain interventions succeed in some settings and fail in others, but also for tailoring implementation strategies to different populations and settings. This task becomes especially challenging when implementing complex interventions that involve multidisciplinary teams operating across multiple organisations. Current literature highlights the need for innovative methodological approaches capable of capturing complexity across settings and examining the interactions between contextual factors and the various levels of the healthcare system. The aim of this study is to understand how context influenced the implementation of evidence-based recommendations on pain assessment and management in adult hospital units participating in the Sumamos Excelencia implementation project. Methods This study is a qualitative process evaluation. Eleven team leaders and ten nurses from local implementation teams participating in the Sumamos Excelencia project were selected based on their audit implementation results, and unit and hospital characteristics. Semi-structured interviews with local implementation leaders and one focus group with non-leader members were conducted between February and June 2023. Thematic saturation was achieved. Data were analyzed using content analysis, guided by a coding frame. Barriers, facilitators, and strategies were identified and categorized. Heatmaps and social network analysis visualized contextual interactions and influencing factors. Results Contextual factors were categorized into four levels: individual characteristics, internal context, external context, and project-related factors. Key barriers included time constraints, resistance to change, high workload, and record system limitations. Facilitators included coherence with care objectives, positive outcomes, leader commitment, teamwork, and alignment with institutional goals. Heatmaps and social network analysis emphasized motivation as central to implementation success. Conclusion Successful implementation depends on motivation, organizational support, staff stability, and registration systems. Context analysis is essential for tailored strategies. Innovative methods are needed to holistically identify barriers and facilitators. Effective evidence-based practice implementation requires addressing interconnected factors like motivation, support, resources, and knowledge. Complexity science and visualization tools enhance context analysis. The Sumamos Excelencia strategy is effective but requires usability and feedback improvements.