A Sequential Explanatory Mixed Methods Evaluation of a Clinical Nursing Practice Guideline for Intracranial Pressure Management

Rungnapha Khiewchaum (Phrapokklao Nursing College, Chanthaburi, Faculty of Nursing, Praboromarajchanok Institute)
Pimwalunn Aryuwat (Boromarajonani College of Nursing Udonthani, Faculty of Nursing, Praboromarajchanok Institute)
Pawena Narasri (Ramathibodi School of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University)
Mahka Kittitornkul (Phrapokklao Hospital Chanthaburi)
Wanchananan Kuhasak (Phrapokklao Hospital Chanthaburi)

Nurse Media Journal of Nursing
Vol 16, No 2 (2026): (August 2026) [In Progress]

Background: Increased intracranial pressure (IICP) is a life-threatening complication of traumatic brain injury (TBI). Previous studies in Thailand have not evaluated the effectiveness of a structured clinical nursing practice guideline (CNPG) in improving nurses’ knowledge, skills, and confidence, highlighting the urgent need for a rigorously developed and evaluated CNPG.Purpose: This study evaluated the effectiveness of a CNPG in improving nurses’ knowledge, skills, and confidence in managing IICP among patients with TBI, and explored nurses’ perceptions of its feasibility, optimality, and benefits.Methods: A sequential explanatory mixed methods design was employed. A quantitative pretest–posttest design was conducted from February to September 2024. The intervention involved implementing an IICP CNPG among 45 registered nurses in two neurological wards at a tertiary hospital in eastern Thailand. Data were collected using four validated instruments: the Nurses’ Knowledge on IICP Questionnaire, Clinical Skills Observation Checklist, Self-Confidence Scale for IICP Care, and Nurses’ Perception of CNPG Questionnaire. In the qualitative phase, 20 nurses participated in two focus group discussions, which were analyzed using conventional content analysis.Results: Nurses showed statistically significant improvements in knowledge, clinical skills, and self-confidence following CNPG implementation (all p < .001). Perceptions of the CNPG in terms of feasibility, optimality, and benefits all significantly exceeded the standard benchmark (all p < .001). Eight qualitative themes were identified, highlighting the roles of evidence-based knowledge, repeated training, structured protocols, interprofessional collaboration, and refresher training in improving consistency, confidence, and quality of IICP care.Conclusion: The CNPG was feasible, effective, and well-accepted among nurses, leading to significant improvements in knowledge, clinical skills, and self-confidence in IICP management. Future research should examine its long-term impact and effectiveness across diverse clinical settings.