Introduction

Dyslipidemia is defined as “elevated total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), or triglycerides (TG); low high-density lipoprotein cholesterol (HDL-C); or a combination of these abnormalities” [1]. In 2019, WHO considered dyslipidemia a major risk factor for two causes of death in the world: ischemic heart disease (IHD) and stroke [2]. In 2017, the WHO estimated the worldwide deaths from IHD and ischemic stroke at 3.9 million (3.7–4.2 million) for one type of dyslipidemia (high non-HDL cholesterol) [3]. Each year, 4 million people in the United States and 1.5 million in the European Union die from cardiovascular disease (CVD), according to the European Society of Cardiology (ESC) [4].

In 2018, CVDs accounted for 37% of all deaths in Jordan [5]. A Jordanian cohort study identified hypertension, diabetes, hyperlipidemia, and coronary artery disease as the leading risk factors for ischemic stroke [6]. A national prevalence study conducted in 2017 on the lipid profile in Jordan reported that 44.3% had high TC, 41.9% had high TG, 75.9% had high LDL-C, and 59.5% had low HDL-C [7].

Physicians and nurses play a major role in the treatment and management of dyslipidemia [8]. Few studies have explored the implementation of dyslipidemia management guidelines among nurses and physicians in Jordan. Halawani et al. (2019) highlighted the importance of physicians’ knowledge of the latest guidelines in improving patient care quality, which leads to better lipid profile outcomes [9]. Another study in Jordan reported a low level of knowledge regarding the American College of Cardiology/American Heart Association (ACC/AHA) guidelines among Jordanian physicians [10]. Furthermore, a separate study conducted in Jordan showed awareness rates of dyslipidemia (9.3%), treatment (50.3%), and control (25.4%) among adults [11]. The most recent ACC/AHA and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for dyslipidemia management aim to control blood cholesterol and reduce cardiovascular risk [12,13].

To the best of our knowledge, no national guidelines for dyslipidemia management have been published in Jordan to date, posing a significant challenge for healthcare professionals. Consequently, healthcare providers primarily rely on international guidelines, particularly those from the ACC/AHA and ESC/EAS. Due to the lack of prior research on this topic, this study was conducted to explore the implementation of the updated ACC/AHA and ESC/EAS guidelines among nurses and physicians, assess the level of treatment control among patients with dyslipidemia, and identify barriers and suggestions for guideline implementation in Jordan.

Method

A qualitative descriptive design was used to explore the implementation of dyslipidemia treatment guidelines among nurses and physicians in Jordanian hospitals. This design was chosen because it is appropriate for gaining a detailed understanding of participants’ real-life experiences, perspectives, and the contextual challenges involved in implementing clinical guidelines. The study involved three semi-structured focus group interviews. Participants were recruited from two public Jordanian hospitals and one teaching hospital: King Abdullah University Hospital, Al Basheer Governmental Hospital, and Al Mafraq Governmental Hospital. These hospitals are located in two geographical regions in northern and central Jordan.

Results

As described in the methodology, focus group interviews were audio-recorded after forming the groups and obtaining written consent from participants. An interview guide with open-ended questions was used (File 1). The analysis resulted in three main themes (Table 1). Each theme is discussed in detail in this section and supported with direct participant quotations.

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Table 1. Themes and sub-themes emerging from the interview data.

https://doi.org/10.1371/journal.pone.0319126.t001

Discussion

The qualitative findings revealed that the majority of participants did not use any recommendations in their clinical practices, while some attempted to follow easier and more up-to-date rules. However, all participants stated that they manage patients with dyslipidemia based on their experience, and some nurses stated that the guidelines constitute medical management rather than nursing management. Previous findings suggested that the dyslipidemia care guidelines were not implemented and followed by all participants, and they relied on their clinical experience to handle patients with dyslipidemia.

This gap between knowledge and practice underscores a broader challenge within healthcare systems where clinical guidelines are not adequately translated into day-to-day workflows. While the presence of guidelines may suggest theoretical awareness, the lack of practical integration suggests insufficient institutional support, absence of accountability, and poor implementation infrastructure. These findings are consistent with research conducted in Saudi Arabia and Jordan, which revealed a low level of awareness and understanding of the 2013 ACC/AHA guidelines among physicians and clinical pharmacists [10,19]. In both contexts, knowledge gaps translated directly into weak adherence, highlighting a common pattern in the region.

Furthermore, the reported dependence on individual experience rather than standardized approaches may reflect a fragmented care culture where interdisciplinary collaboration is minimal and continuing education opportunities are scarce. This dynamic reinforces inequities in care delivery and increases the risk of inconsistency in managing dyslipidemia across settings.

The current study revealed several systemic and practical challenges that contribute to the low adoption of dyslipidemia guidelines in clinical practice. Participants described barriers such as limited resources, time constraints, insufficient training opportunities, and a lack of institutional support. These challenges are not only logistical but also reflect deeper organizational and structural issues that hinder the integration of evidence-based practices. Similar difficulties have been reported in previous studies, highlighting the complexity of applying clinical guidelines in everyday healthcare [20–23].

In addition to these systemic barriers, the study also highlighted the significant role of workplace culture and individual attitudes in influencing guideline adherence. Many healthcare providers tend to rely on their personal clinical experience and question the practical relevance of guidelines in their specific settings. This skepticism may undermine efforts to implement guidelines even when institutional support and resources are available. Therefore, addressing both structural challenges and individual perceptions is essential to enhance the implementation of dyslipidemia management guidelines and improve patient care outcomes.

The results of this study align with previous research indicating that patient noncompliance is a persistent barrier in managing chronic conditions such as dyslipidemia. Participants frequently reported that patients did not follow prescribed treatments or return for follow-up testing. This behavior was often accepted as a common reality of practice rather than actively addressed. From a reflective standpoint, such normalization of noncompliance may point to a deeper issue in the clinical culture where expectations for patient responsibility are low, and systematic efforts to address adherence are limited. While studies like Taniguchi et al. (2024) have documented the role of follow-up and medication adherence in treatment outcomes [24], the present findings offer contextual insight into how providers may internalize these barriers as unchangeable, which can further entrench the problem.

The current findings align with and extend prior research emphasizing the multifactorial nature of barriers to effective dyslipidemia management. As previously shown in a randomized intervention study, patients often fail to adopt dietary and physical activity changes despite targeted efforts [25], and similarly, participants in this study described persistent unhealthy lifestyle behaviors among patients. However, the present results add contextual insight by illustrating how such behaviors are often normalized within routine care. This suggests that providers may perceive nonadherence as expected rather than modifiable, potentially weakening the clinical emphasis on lifestyle counseling and leading to missed opportunities for meaningful patient engagement.

Psychological distress, such as depression and anxiety, also emerged as a critical but often overlooked factor undermining treatment adherence. Previous research has advocated for integrating behavioral health into chronic disease care as a way to reduce disparities and improve outcomes [26]. While systemic-level solutions have been proposed, the present study emphasizes the importance of embedding such integration at the provider–patient level, where lack of mental health support may directly disrupt adherence in daily clinical practice.

In addition, participants identified financial constraints as a significant barrier preventing access to medications, follow-up care, and specialized services. This reinforces evidence from earlier multi-institutional research that linked institutional and structural limitations, such as resource shortages and policy inefficiencies, to persistent gaps in guideline implementation [27]. However, our findings contribute further by illustrating how these barriers manifest specifically within the context of Jordanian hospitals, pointing to the need for locally informed policies and context-sensitive adaptations of clinical guidelines.

In addition to patient-related barriers, the findings revealed that healthcare professionals themselves face several challenges that hinder the effective implementation of dyslipidemia guidelines. Participants described a lack of proper and specialized training in dyslipidemia management, reflecting broader system-level gaps in clinical education and professional development. This observation is consistent with earlier research, which highlighted how insufficient provider training contributes to inconsistent application of evidence-based practices [27,28].

Limited familiarity with updated guidelines also appears to be a key concern. For instance, a cross-national study involving Jordanian and Egyptian educators emphasized that outdated knowledge among providers can limit the quality of care delivered [29]. In areas such as lipid management, where clinical recommendations evolve rapidly, this gap in up-to-date understanding may result in suboptimal decision-making. Furthermore, ineffective provider–patient communication was frequently mentioned as a barrier to treatment adherence. Supporting this, Tiwary and colleagues (2019) documented how breakdowns in clinical communication can lead to disengagement and negative health outcomes, particularly in chronic conditions requiring long-term management [30]. These findings suggest that strengthening provider training and improving communication practices are essential for achieving better adherence and more effective guideline implementation.

Consistent with previous findings from regional contexts, the current study identified multiple system-level barriers, including limited resources, insufficient institutional support, high workloads, and limited engagement from healthcare leadership, all of which hinder the implementation of dyslipidemia management guidelines. These findings align with those reported by Hamaideh (2017), who found that mental health nurses in Saudi Arabia encountered significant obstacles to evidence-based practice due to inadequate structural support and limited access to professional development opportunities [28]. While Hamaideh’s study focused on the mental health sector, our findings broaden this perspective by demonstrating that similar structural and institutional challenges are also prevalent in general medical practice in Jordan, particularly in the management of chronic conditions such as dyslipidemia. In the absence of sufficient infrastructure, clear institutional policies, and supportive leadership, healthcare professionals may lack both the capacity and incentive to adhere to clinical guidelines, which may contribute to inconsistencies in care delivery.

The absence of a structured follow-up system represents a significant barrier to effective dyslipidemia management because it disrupts continuity of care and reduces opportunities for timely therapeutic adjustments [31]. Additionally, the low rate of patient attendance at follow-up visits, with only 18% attending within six months after diagnosis, highlights systemic challenges related to patient engagement and healthcare coordination. These challenges undermine treatment effectiveness and limit the achievement of optimal clinical outcomes [24].

This issue is further complicated by the limited availability of essential diagnostic tools, medication shortages, and inadequate training among healthcare providers. Together, these factors contribute to inconsistent application of clinical guidelines in practice and reduce their impact on patient care [32]. Implementing integrated follow-up systems that combine technological solutions like electronic health records and automated reminders with improved resource allocation and workforce training is essential. Such measures are expected to improve patient adherence, enable early detection of treatment failures or adverse effects, and promote more consistent and effective management of dyslipidemia, leading to better health outcomes.

Heavy workload and lack of resources were consistently identified by participants as key barriers to the implementation of dyslipidemia guidelines. This finding is consistent with existing literature, which shows that healthcare providers working in high-pressure environments often do not have the time, support, or capacity to follow clinical guidelines thoroughly [33]. In such settings, immediate clinical demands tend to take priority over preventive and long-term care, which limits the attention given to chronic disease management. The current findings illustrate how time constraints, particularly among physicians, reduce opportunities for patient counseling, documentation, and critical decision-making, all of which are essential for effective guideline adherence [34]. These observations suggest that workload is not just an individual-level challenge but rather a structural issue that may require system-wide interventions. Recognizing and addressing this burden is essential for improving the practical application of evidence-based guidelines in routine care.

The lack of governmental support for healthcare institutions was identified as a critical barrier to the effective implementation of dyslipidemia guidelines. Participants described how insufficient funding, inadequate infrastructure, and limited political commitment directly affected the ability of institutions to secure essential resources, such as medications, diagnostic tools, and trained personnel. This aligns with previous research showing that health systems with weak institutional support often struggle to operationalize clinical recommendations in daily practice [32,33]. A scoping review emphasized that without adequate financial and structural backing, institutions are unlikely to sustain the processes required for guideline adherence, particularly in under-resourced settings [34]. Similarly, studies in other clinical contexts, including rare and acute care conditions, have also highlighted the role of system-level support as a key determinant of successful implementation [34,35]. The current findings reinforce the need for a supportive policy environment that ensures health institutions are equipped to integrate evidence-based guidelines into routine care.

Based on participants’ perspectives, several actionable strategies were identified to enhance the implementation of dyslipidemia management guidelines in Jordan. A major recommendation was the need for increased financial support and equitable distribution of resources. This aligns with previous research indicating that limited funding and infrastructural constraints, particularly in under-resourced systems, restrict the capacity to adopt and sustain evidence-based practices [36]. The establishment of specialized clinics and training programs targeting dyslipidemia management was also emphasized. This approach has been associated with improved cholesterol control and better adherence to clinical guidelines in similar healthcare settings [37]. Additionally, participants highlighted the importance of developing national guidelines that are adapted to the Jordanian context. Simplified content, better accessibility, and cultural relevance were viewed as essential components. These considerations are consistent with findings that stress the impact of guideline clarity, design, and contextual adaptation on successful implementation [33,34].

Enhancing patient engagement and increasing awareness were also viewed as crucial for improving guideline adherence. Suggestions included providing free lipid profile testing to support early detection and encouraging greater participation in follow-up care. Public health campaigns were viewed as essential tools to raise awareness of dyslipidemia and the importance of adhering to treatment guidelines. These insights align with evidence indicating that public education and clinician confidence are important facilitators of implementation [38,39]. In addition, a structured follow-up system was considered vital to ensure continuity of care, reinforce patient adherence, and support long-term monitoring. This corresponds with previous research highlighting the role of leadership, coordination, and organizational support in sustaining effective implementation [40]. Finally, ongoing professional development was frequently mentioned as necessary to ensure healthcare providers stay current with evolving clinical recommendations, which is consistent with reviews identifying training as a core facilitator of guideline use [38].

One of the most critical findings of this study is the perceived limited implementation of dyslipidemia management guidelines across healthcare institutions in Jordan. Although participants demonstrated awareness of these guidelines, most reported that they do not actively use them in clinical decision-making. In the absence of clear institutional direction, many professionals rely on their individual clinical experience rather than standardized protocols. This highlights a persistent gap between knowledge and practice, reflecting a broader challenge in translating evidence-based recommendations into routine care.

Such inconsistencies in guideline implementation have been previously documented and are often attributed to institutional, professional, and system-level barriers [32]. In the current study, limited implementation appeared to result from a combination of insufficient training, lack of coordination, and weak follow-up systems. Additionally, the findings revealed that nurses are often excluded from the decision-making process related to guideline use, which further limits interdisciplinary collaboration and consistent implementation. These dynamics suggest that awareness alone is not sufficient to drive practice change; rather, guideline implementation depends on system-wide support mechanisms that address both structural limitations and the distribution of clinical responsibilities within healthcare teams.

This study presents several strengths. It is among the first qualitative investigations in Jordan to examine how physicians and nurses implement the ACC/AHA and European guidelines for dyslipidemia management. By focusing on the practical implementation of these international guidelines within a local healthcare context, the study addresses a critical gap in the literature. The insights generated are especially relevant for informing the development of national, context-specific dyslipidemia guidelines that account for local barriers, resources, and clinical dynamics. Furthermore, by identifying key barriers and facilitators from the perspective of frontline healthcare providers, the study offers a foundational evidence base to support future interventions aimed at enhancing clinical implementation and improving patient outcomes.

While this study provides valuable insights into the implementation of dyslipidemia management guidelines, several limitations must be acknowledged. First, the sample size was relatively small; however, it was sufficient to achieve data saturation, which is a recognized standard in qualitative research. Second, the study was conducted in only three hospitals. Nonetheless, these included both governmental and educational institutions from two regions in Jordan, ensuring diversity in clinical settings and enhancing transferability. Third, while some clinical data, such as BMI and blood pressure, were briefly reviewed from patient medical records to provide general background context, these data were not analyzed or used in the thematic findings of the study. Fourth, the study focused on physicians and nurses, excluding other stakeholders such as pharmacists, dietitians, and patients. This was aligned with the study aim, which was to explore the perceptions and practices of direct care providers responsible for implementing the guidelines. Finally, although the interview guide was newly developed, it was informed by existing literature and expert input. Trustworthiness of the study was ensured through the use of member checking, audit trail documentation, and peer review of the analysis process. These limitations are typical in exploratory qualitative research and do not compromise the validity or credibility of the findings. Rather, they highlight directions for future, broader-scale investigations.

The findings of this study have significant implications for both policy and practice. To enhance the implementation of dyslipidemia management guidelines, healthcare policymakers in Jordan should prioritize training healthcare professionals, particularly in updated guideline content and effective patient communication. In parallel, healthcare institutions must be equipped with the necessary resources to support implementation. Investment in specialized clinics, public awareness campaigns, and the establishment of a national follow-up system are also essential to address existing barriers. Furthermore, the development of Jordan-specific guidelines that reflect local cultural and economic contexts would enable a more tailored and effective approach to dyslipidemia management. By addressing these barriers and adopting the proposed recommendations, there is considerable potential to improve the quality of care for patients with dyslipidemia in Jordan and comparable settings.

Conclusion

The results of the current study showed a low level of implementation of any dyslipidemia management guidelines among Jordanian nurses and physicians in their clinical practices. The nurses and physicians responded difficulties they face in implementation. Besides, they gave suggestions that may help them implement dyslipidemia management guidelines. Hence, future research should focus on the development and evaluation of context-specific guidelines, the impact of specialized clinics, the use of digital tools for follow-up, and the strengthening of healthcare infrastructure. Investigating cultural, socioeconomic, and behavioral factors that influence patient adherence, as well as examining effective public health campaigns, will also be critical in advancing dyslipidemia management in Jordan and other similar settings.

Supporting information

Acknowledgments

This manuscript is based on research conducted by the first author as part of her Master’s thesis at Al al-Bayt University. The study was subsequently expanded and revised for journal submission with the support of the co-authors. An abstract of this study was presented at the Association of Cardiovascular Nursing and Allied Professions (ACNAP) conference [41]. The current work was supported by Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2025R814), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.