Chronic kidney disease (CKD) is a global health concern characterised by progressive and irreversible loss of kidney function (Vaidya & Aeddula 2024). It is classified into five stages based on estimated glomerular filtration rate (eGFR), with early stages (stages 1–4) often asymptomatic and stage 5 indicating end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT) (Levey et al. 2020). Chronic kidney disease disproportionately affects low- and middle-income countries (LMICs) due to limited diagnostic capacity, workforce shortages, and medication stockouts (Bello et al. 2019b). Limited availability and affordability of kidney health laboratory tests, together with shortages of nephrology services, and inconsistent access to treatment, continue to hinder effective CKD management in these settings (Okpechi et al. 2021). In sub-Saharan Africa, including Eswatini, major drivers include hypertension, diabetes, HIV-associated kidney disease, infections, nephrotoxic drugs, and delayed health-seeking (George et al. 2022; Stanifer et al. 2019). These factors are compounded by the broader challenges faced in many LMICs. According to the World Health Organization (WHO), CKD is a major non-communicable disease (NCD) and a chronic health condition that progresses gradually over time and is often irreversible (WHO 2025). In Eswatini, dialysis services reflect a growing CKD burden, emphasising the importance of early detection and prevention; however, access to RRT, including dialysis and transplantation, remains limited by high treatment costs, inadequate infrastructure, and shortages of specialised healthcare personnel (Nkunu et al. 2024; Yeung et al. 2024). Strengthening early detection and management of CKD at the primary healthcare level is essential to slow disease progression, prevent complications, and reduce reliance on costly RRT (George et al. 2022; Vaidya & Aeddula 2024).

This acknowledgement highlights the essential role of nurses in applying clinical practice guidelines to deliver standardised, evidence-based care for CKD patients in primary health care (PHC) facilities (Raphael et al. 2023b). Clinical practice guidelines offer structured recommendations to guide clinical decision-making and promote patient care, particularly for NCDs such as CKD (Raphael et al. 2023a). The effective implementation of clinical practice guidelines in PHC facilities is crucial to improving CKD management by ensuring early detection, appropriate interventions, and consistent care delivery, ultimately enhancing patient outcomes in the renal population (Schwabenbauer et al. 2020).

In Eswatini’s PHC facility, nurses serve as the main providers of chronic disease care, placing them at the frontline of CKD management. They have a pivotal role in implementing clinical practice guidelines in the early detection and management of CKD. They are responsible for identifying early indicators of CKD through routine patient assessments and performing basic diagnostic tests, as well as educating patients about major risk factors such as hypertension and diabetes, as both conditions are the leading causes of CKD and can significantly accelerate kidney damage if poorly controlled. Hypertension increases pressure within the blood vessels of the kidney, gradually damaging their filtering function, while diabetes causes persistent high blood glucose levels that injure kidney tissue over time, leading to faster CKD progression, severe complications, and kidney failure requiring dialysis or kidney transplantation (Weldegiorgis et al. 2020). Additionally, they actively promote preventive strategies to reduce disease progression (Thwala, Zwane & Magagula 2023). If detected early at the PHC facility, CKD progression can be significantly slowed, leading to improved patient outcomes, reduced mortality, and decreased reliance on high-cost tertiary services such as dialysis (Mthethwa, Dlamini & Thwala 2023).

In Eswatini, PHC nurses obtain their clinical practice guidelines mainly from the Ministry of Health through National Standard Treatment Guidelines (STGs), Essential Medicines Lists (EMLs), and disease-specific guidelines and clinic-level guides for hypertension, diabetes, and kidney disease management. The application of clinical practice guidelines has been shown to improve healthcare quality by encouraging evidence-based practice, minimising inconsistencies in treatment approaches, and ensuring timely intervention for patients (Mlambo, Shabangu & Dlamini 2021). In low-resource environments like Eswatini, specialist care is often limited due to broader challenges faced by LMICs, including inadequate healthcare funding, constrained government health budgets, and competing public health priorities that reduce investment in specialised services. In this context, enabling nurses to utilise clinical practice guidelines effectively help to address critical gaps in service delivery.

This approach supports early diagnosis and management of CKD at the primary care level, which is essential for early recognition of and prevention of disease progression (Theilmann et al., 2023). Nurses facilitate prompt referrals to specialists and follow clinical practice guidelines to improve the quality of care and patient outcomes (Nozu et al. 2024). Little is known in Eswatini about PHC nurses’ experiences in implementing clinical practice guidelines for the detection and management of CKD.

The availability of clinical practice guidelines in PHC facilities across Eswatini varies considerably. While general NCD guidelines, the Package of Essential Non-communicable Disease Interventions (WHO-PEN) protocol, and the Eswatini STGs (Ministry of Health Eswatini 2022; WHO 2020) are present in many clinics, their distribution is often inconsistent (Hlophe et al. 2023b).

Furthermore, the early stages of CKD are typically asymptomatic, necessitating proactive, and protocol-driven screening and evidence-based decision-making, an approach that remains inconsistently applied across PHC facilities (Magagula & Mndzebele 2022). This gap is further compounded by insufficient training for most PHC nurses, who are often not adequately prepared to detect or manage CKD in their clinical practice (Hlophe et al. 2023a). Some nurses face challenges accessing printed copies of the guidelines, while others lack functional electronic systems to support the implementation of clinical practice guidelines (Nkambule, Mthethwa & Hlophe 2020a).

In Eswatini, nurses face high patient loads and understaffing, which limit their ability to consistently apply the basic elements of available clinical practice guidelines (Mndzebele, Khumalo & Mabuza 2022). Health system resource constraints and patient-related factors, such as geographic and economic challenges, can hamper the effective implementation of clinical practice guidelines.

There is a growing recognition of the need to adapt proven implementation frameworks, such as the Consolidated Framework for Implementation Research (CFIR), to Eswatini’s PHC context (Turner et al. 2020). Emerging evidence also emphasises the need for CKD-specific tools, structured nurse-led training programs, and digital decision support systems to facilitate timely diagnosis and management (Mthethwa et al. 2023). The study explored the experiences of PHC nurses in implementing clinical practice guidelines to identify context-specific barriers and develop practical, locally appropriate evidence-based solutions for early detection and management of CKD in Eswatini. Chronic kidney disease is a growing global public health concern marked by progressive and irreversible loss of kidney function (Vaidya & Aeddula 2024). Chronic kidney disease is classified into five stages based on eGFR. Chronic kidney disease often remains asymptomatic in its early stages (1–4), with stage 5 representing ESKD requiring RRT (Levey et al. 2020). This silent progression contributes to late diagnosis, particularly in resource-limited settings.

Chronic kidney disease disproportionately affects LMICs, where limited diagnostic capacity, workforce shortages, and medication stockouts hinder early detection and management (Bello et al. 2019a). In sub-Saharan Africa, including Eswatini, major drivers include hypertension, diabetes mellitus, HIV-associated kidney disease, recurrent infections, nephrotoxic medication use, and delayed health-seeking behaviour, resulting in advanced disease at presentation (George et al. 2022; Stanifer et al. 2019). Data services in Eswatini have revealed a growing disease burden, yet access to RRT remains limited due to high costs and infrastructure demands (Bello et al. 2019a).

Strengthening early detection and management of CKD at the PHC level is therefore essential. Preventive strategies targeting high-risk populations are more sustainable than managing advanced CKD and can slow disease progression, reduce complications, and limit dependence on costly tertiary services (George et al. 2022; Vaidya & Aeddula 2024). Nurses play a critical role in applying clinical practice guidelines to deliver standardised, evidence-based care, particularly for NCDs such as CKD (Raphael et al. 2023b; Schwabenbauer et al. 2020).

In Eswatini, nurses are the main providers of chronic disease care in PHC facilities and are central to early CKD detection, patient education, preventive care, and referral (Mthethwa et al. 2023; Thwala et al. 2023). However, inconsistent availability of clinical practice guidelines, limited training, high patient loads, and weak digital support systems constrain effective implementation (Hlophe et al. 2023a; Mndzebele et al. 2022; Nkambule et al. 2020). Emerging evidence highlights the need for CKD-specific tools, nurse-led training, and context-adapted implementation frameworks, such as the CFIR, to improve CKD care in Eswatini’s PHC context (Theilmann et al., 2023; Nozu et al. 2024; Turner et al. 2020).

Table 1 presents demographic data and professional background information of the 25 study participants, including their age, gender, and years of experience. Of the 25 participants, 14 were female, and 11 were male, aged 25–45 years (mean age 33.9 years), with 2–21 years (average 10 years) of experience. All 25 participants were full-time employed professional nurses at the PHC facilities.

The analysis identified three themes and 12 sub-themes related to the experiences of professional nurses in implementing clinical practice guidelines for CKD in the PHC facilities, as shown in Table 2.

This qualitative study explored the experiences of nurses in implementing clinical practice guidelines for CKD detection and management in PHC facilities in Eswatini. The analysis of participant narratives generated three main themes and 12 sub-themes, reflecting the multifaceted experiences of nurses in implementing clinical practice guidelines for CKD in PHC facilities.

The results of this study highlighted nurses’ experience in implementing clinical practice guidelines in PHC facilities. Nurses working in these environments reported that, while clinical practice guidelines offer valuable frameworks for guiding care, several barriers hinder their full integration into everyday practice. Factors such as staff shortages, heavy workloads, inadequate resources, and limited training reduce adherence to guideline recommendations. Strengthening resource availability, ongoing professional training, and institutional support is necessary to improve compliance with clinical practice guidelines. These findings are consistent with current literature and underscore the systemic, structural, and human resource challenges present in low-resource healthcare environments (Olowu et al. 2020).

Participants frequently reported time constraints as a major barrier to clinical practice guideline implementation, citing overcrowding and limited consultation durations. These challenges are representative of time constraints, which limit nurses’ ability to apply comprehensive guidelines implementation during brief consultations (Munyewende, Rispel & Chirwa 2020). Furthermore, a lack of resources was evident, with participants highlighting staff shortages, inadequate training opportunities, and limited access to necessary technologies. This aligns with findings by Grimmer et al. (2019), who argue that without sufficient human and infrastructural resources, the uptake and consistent application of guidelines remain suboptimal. Together, these findings reinforce the factors that influence clinical practice guideline implementation, particularly in under-resourced primary healthcare settings.

This difficulty is further exacerbated by limited access to the guidelines themselves. Many nurses reported having few or no physical copies, especially CKD-specific materials. These concerns are echoed in global research, which indicates that dissemination of disease-specific guidelines is often poor in rural and low-income settings (Chansa, Chitah & Kachimba 2022). Evidence-based practices are consistent with findings from Raphael et al. (2023c), who describe how institutional inertia and fear of change can obstruct progress in clinical settings. In their study, they found that healthcare professionals often resist new guidelines due to established routines, perceived increases in workload, and uncertainty about the outcomes of implementation. This reluctance is not solely individual but often stems from broader organisational cultures that favour the status quo over innovation.

Greenhalgh et al. (2022) highlighted that even when evidence-based interventions are well-supported and accessible, uptake remains low in facilities where change is perceived as risky or disruptive. This is further echoed by Whitehead, Taket and Smith (2021), who found that healthcare workers often feel overwhelmed by the constant evolution of clinical guidelines, especially when adequate training and leadership support are lacking. They emphasised that without a supportive infrastructure, efforts to implement evidence-based practice may encounter passive or active resistance.

Training emerged as a vital but under-resourced component of successful clinical practice guideline implementation. Participants highlighted the need for structured training on guideline content and practical application. Abimbola et al. (2020) found that consistent education, mentorship, and leadership are crucial for health workers to adopt new guidelines. Those who had received mentorship or facilitated training felt empowered, suggesting that leadership development and peer mentorship are effective strategies. This finding highlights that mentorship and task-shifting are effective strategies for enhancing nurses’ ability to implement clinical practice guidelines for CKD in primary healthcare, including in Eswatini. The need for training and mentorship among participants aligns with the WHO’s (2021) recommendation to enhance guideline uptake in PHC through mentorship and task redistribution. This approach is particularly vital in the study setting, given the relatively young age and diverse clinical experience of the participants, ensuring they receive the support necessary to confidently apply clinical guidelines in practice.

Implementing clinical practice guidelines in PHC by nurses offers several important benefits; it helps standardise care, ensuring that all patients receive evidence-based, high-quality treatment regardless of where they are seen. This consistency improves patient safety and reduces variations in practice (Kitson et al. 2019). Clinical practice guidelines support early detection and better management of chronic diseases, such as diabetes and hypertension, and CKD, which are common in PHC facilities. By following clear clinical practice guidelines, nurses can intervene sooner, preventing complications and improving long-term health outcomes (Marais, Ntshoe & Moolla 2023). Using clinical practice guidelines strengthens nurses’ confidence and clinical decision-making skills. Having clear guidance empowers them to act decisively, reduces uncertainty, and enhances professional development (Camargo et al. 2022). CPG implementation promotes more efficient use of resources. It helps avoid unnecessary tests or treatments, improving cost-effectiveness and ensuring that limited supplies are used appropriately (Brouwers et al. 2019). The implementation of clinical practice guidelines often facilitates the integration of technology, such as electronic health records, clinical decision support systems, and mobile health tools, which further standardise care and enhance transparency (Sutton et al. 2020). Several studies have shown that integrating technology alongside clinical practice guidelines improves adherence, supports real-time guideline updates, and strengthens patient-provider communication, all of which contribute to building trust and improving outcomes (Khalifa 2014).

Adherence to clinical practice guidelines fosters patient trust. Patients are more likely to follow care plans and remain engaged when they see that care is systematic and based on the latest evidence, ultimately leading to better patient satisfaction and stronger nurse–patient relationships (Stacey et al. 2021).

Nurses in Eswatini’s PHC settings play a central role in implementing clinical practice guidelines for the early detection and management of CKD. Their experiences reflect the strengths and challenges of translating evidence-based recommendations into routine practice. Many nurses indicate that clinical practice guidelines provide structure, clarity, and improved consistency in the screening and management of CKD and other chronic diseases.

However, implementation is not without its challenges, including limited resources, high patient loads, staff shortages, and time constraints. Chronic kidney disease guidelines at the PHC level are often brief, lack sufficient detail, and are not easily accessible, making them challenging to apply in complex cases. To overcome these issues, it is recommended to develop comprehensive, context-specific guidelines designed specifically for PHC facilities, complemented by practical tools such as simplified algorithms and decision aids to better support nurses. Ensuring these guidelines are readily available in both print and digital formats can further promote their consistent use in everyday practice.