Contents lists available at ScienceDirect
International
Journal
of
Nursing
Studies
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / i j n s
Implementation
strategies
used
to
implement
nursing
guidelines
in
daily
practice:
A
systematic
review
Denise
Spoon
a ,∗,
Tessa
Rietbergen
b,
Anita
Huis
c,
Maud
Heinen
c,
Monique
van
Dijk
a ,d,
Leti
van
Bodegom-Vos
b,
Erwin
Ista
a ,daDepartmentofInternalMedicine,SectionNursingScience,ErasmusMCUniversityMedicalCentre,RoomRg-532,P.O.Box2040,Rotterdam,CA3000,The
Netherlands
b DepartmentofBiomedicalDataSciences,sectionMedicalDecisionMaking,LeidenUniversityMedicalCentre,Leiden,TheNetherlands
c Radbouduniversitymedicalcentre,RadboudInstituteforHealthSciences,ScientificInstituteforQualityofHealthcare,Nijmegen,TheNetherlands
d DepartmentofPaediatricSurgeryandIntensiveCare,ErasmusMCUniversityMedicalCentre,Rotterdam,TheNetherlands
article info
Articlehistory:
Received5February2020
Receivedinrevisedform29July2020 Accepted10August2020
Keywords:
Systematicreview[MeSH] Nursing[MeSH]
Guidelineadherence[MeSH] Implementationscience[MeSH] Nursingguidelines
Implementationstrategies
abstract
Objectives:Researchspecificallyaddressingimplementationstrategiesregardingnursingguidelinesis lim-ited.Theobjectiveofthisreviewwas toprovideanoverviewofstrategiesused toimplementnursing guidelinesinallnursingfields,aswellastheeffectsofthesestrategiesonpatient-relatednursing out-comesandguidelineadherence.Ideally,thefindingswouldhelpguidelinedevelopers,healthcare profes-sionalsandorganizationstoimplementnursingguidelinesinpractice.
Design:Systematicreview.PROSPEROregistrationnumber:CRD42018104615.
Datasources:WesearchedtheEmbase,Medline,PsycINFO,WebofScience,Cochrane,CINAHLandGoogle ScholardatabasesuntilAugust2019aswellasthereferencelistsofrelevantarticles.
Reviewmethods:Studies wereincluded that describedquantitative dataonthe effectof implementa-tionstrategiesandimplementationoutcomesofanytypeofanursingguidelineinanysetting.No lan-guageordateofpublicationrestriction wasused.The CochraneEffective Practiceand Organisationof Caretaxonomywasusedtocategorizetheimplementationstrategies.Studieswereclassifiedaseffective ifasignificantchangeineitherpatient-relatednursingoutcomesorguidelineadherencewasdescribed. Strengthoftheevidencewasevaluatedusingthe‘Cochraneriskofbiastool’forcontrolledstudies,and the‘Newcastle-OttawaQualityAssessmentform’forcohortstudies.
Results:Atotalof54articlesregarding53differentguidelineimplementationstudieswereincluded. Fif-teenwere(cluster)RandomizedControlledTrialsorcontrolledbefore-afterstudiesand38studieshada before-afterdesign.Thetopicsoftheimplementedguidelineswerediverse,mostlyconcerningskincare (n = 9)andinfectionprevention(n = 7).Studieswerepredominantlyperformedinhospitals(n = 34) andnursinghomes(n = 11).Thirtystudiesshowedapositivesignificanteffectineitherpatient-related nursingoutcomesorguidelineadherence(68%,n = 36).Themediannumberofimplementation strate-giesusedwas6(IQR4–8)perstudy.Educationalstrategieswereusedinnearlyallstudies(98.1%,n= 52), followedbydeploymentoflocalopinionleaders(54.7%,n = 29)andauditandfeedback(41.5%,n = 22). Twenty-three(43.4%)studiesperformedabarrierassessment,nineteenusedtailoredstrategies.
Conclusions:Awidevarietyofimplementationstrategiesareusedtoimplementnursingguidelines.Not one single strategy,orcombination ofstrategies, can be linkeddirectly tosuccessful implementation ofnursingguidelines.Overall,thirty-six studies (68%) reportedapositivesignificant effectofthe im-plementationofguidelinesonpatient-relatednursingoutcomes orguideline adherence.Future studies shoulduseastandardizedreportingchecklisttoensureadetaileddescriptionoftheused implementa-tionstrategiestoincreasereproducibilityandunderstandingofoutcomes.
© 2020TheAuthor(s).PublishedbyElsevierLtd. ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/)
∗ Correspondingauthor.
E-mailaddress:[email protected](D.Spoon).
https://doi.org/10.1016/j.ijnurstu.2020.103748
Whatisalreadyknownaboutthetopic?
• Effectiveimplementationstrategiesarerequiredtosuccessfully introduce the increasing number of available (inter)national nursingguidelines.
• Publishingordisseminatinganursingguidelinedoesnotensure itseffectiveuseinpractice.
Whatthispaperadds
• Besides education, a wide range ofimplementation strategies areusedtoimplementnursingguidelinesintodailypractice. • The level of evidence for strategies directed atimplementing
nursing guidelines is limited dueto a lack ofwell-conducted studies.
• Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategiestoincreasereproducibilityandunderstandingof out-comes.
1. Introduction
Nurses are increasingly expected to provide evidence-based careintendedtoenhancequalityofcare(Herron and Strunk, 2019 ). Therefore, an increasing number of nursing guidelines are being published. A guideline in general contains evidence-based rec-ommendations for health care providers, policy makers, and pa-tients about health interventions intended to optimize patient care. Guidelines are published with the aim of reducing unwar-ranted variation in healthcare delivery (Grimshaw et al., 1993 ; Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, 2011 ; World Health Or- ganization, 2012 ).Still, healthcareproviders’adherence to guide-line recommendations has proven suboptimal (Arts et al., 2016 ; Grimshaw et al., 2006 ; Grimshaw et al., 2004 ; Lugtenberg et al., 2009 ).Publishing ordisseminatingaguideline alone willnot en-sureadequate useof aguideline in practice.An essential second stepis to apply strategies to effectively implementthe guideline (Grol et al., 2001 ). Using a theory, model or framework, is ex-pectedtoincreasetheprobabilityofsuccessoftheimplementation (Nilsen et al., 2015 ).Thisalsoholdsforperformingabarrier assess-mentandtailoringstrategies(Geerligs et al., 2018 ),whichareoften elementsintheories,modelsorframeworks.
As nursing andmedical care,aswell as theassociated guide-lines,differ in nature, other strategies may be neededto anchor nursing guidelines in practice. Previous reviews about nursing guideline implementation considered studies addressing a single implementationstrategy,suchaseducation(Häggman-Laitila et al., 2017 ) or facilitation (Dogherty et al., 2014 ), or a specific setting, such as nursing homes (Diehl et al., 2016 ). More and more im-plementation studies inthe field of nursingare being conducted (Sales et al., 2019 ). However, to the best of our knowledge, the implementation strategies of nursing guidelines, independent of typeorsetting,havenotbeensystematicallyreviewedtothisdate. Asystematic review could provide insights useful in all areas of nursing.
The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields,aswell astheeffects ofthesestrategieson patient-related nursing outcomes and guideline adherence. Ideally, the findings wouldhelpguideline developers,healthcareprofessionals and or-ganizationsinimplementingnursingguidelinesinpractice.
2. Methods 2.1. Design
This systematic review was conducted according to the Pre-ferred Reporting Itemsfor SystematicReviewsand Meta-Analysis (PRISMA)guidelines(Moher et al., 2010 );theresearchprotocolwas registeredonPROSPERO(registrationnumber:CRD42018104615). 2.2. Search
Relevant studies were searched in the Embase, Medline, PsycINFO, Web of Science,Cochrane, CINAHL andGoogle Scholar databasesuntil August2019. Varioussearch termswere purpose-fullyselectedto coverallnursing fieldsandimplementation syn-onyms. Abiomedicalinformationspecialist ofthemedicallibrary oftheErasmusMC– UniversityMedicalCentreRotterdamguided the search. The full search strategy ispresented in Supplement 1. Search strategy. The titlesandabstracts ofall search results were screened on relevance by DS and EI independently, according to specifiedeligibility criteria, usingEndnoteR (Bramer et al., 2017 ). Next,the full textsof possibly relevantarticles were checkedfor inclusionbyDS.Consensusonfinalinclusionwasachievedby dis-cussion (DS, EI). After the initial search, a referenceand citation checkwasperformedforallrelevantstudies(byDS,EI).Toensure havingacompleteoverviewofallpublishedstudies,several previ-ouslypublishedsystematicreviewswerescreenedforrelevant in-cludedstudies(Diehl et al., 2016 ; Dogherty et al., 2014 ; Häggman- Laitila et al., 2017 ; Thomas et al., 1999 ).
2.3. Eligibilitycriteria
The scope of the review was limited to studies that consid-eredtheimplementationofanursingguideline,definedas recom-mendationsabouthealthinterventionsmainlyprovidedby nurses (>50%), intended to optimize patient care and based on either national or international guidelines. The following inclusion cri-teria were applied: 1) studies had to describe the implementa-tionstrategiesandoutcomesoftheimplementationofthenursing guideline;2)studies hadto measureeithertheeffectsofthe im-plemented nursingguideline onpatient-relatednursingoutcomes (e.g.pain,falls, pressureulcers),oradherence totheguideline by thehealthcareprofessionalsmeasuredbyobservationor documen-tation;3)studies hadtoincludeareferencegroup(e.g.,withand withoutguideline).Casestudiesofindividual patients,lettersand editorialswere not eligible.Tooptimize theobjectivity ofthe in-cluded study results, we excluded studies with only survey out-comes. We excluded bundle implementation studies because of their protocol-like characteristics.No search limitationswere im-posedonlanguage.
2.4. Outcomemeasures
Theprimaryoutcomeswere;1)impactonpatient-related nurs-ing outcomes, and 2) adherence to the guideline. Studies were classifiedwithapositiveeffectwhenastatisticallysignificant im-provement inpatient-related nursingoutcomes and/or adherence wasreported.
Thesecondaryoutcomeswerethenumberandtypesof imple-mentationstrategies perstudy.Thedifferentstrategiesused were categorized according to the Cochrane Effective Practice and Or-ganisation of Care taxonomy (Effective Practice and Organisation of Care, 2016 ).TheEffectivePracticeandOrganisationofCare tax-onomy includes four domains of interventions: Implementation strategies,Deliveryarrangements,Financialarrangementsand Gov-ernancearrangements.
2.5. Dataextraction
Relevant information fromthe includedarticles wasextracted inadataabstractionform.Thisformwaspilotedforthefirstfive studies and finalizedafter discussion (DS, TR, EI). Data included country of origin, setting, type of guideline, participants, imple-mentation strategies, barrier assessment, use of implementation theory orframework, andoutcomes. Depending on the measure-mentsperformedintheincludedstudies,bothoreitherofthe pri-maryoutcomes(i.e.patient-relatednursingoutcomesoradherence to the guideline) were collected. All data abstractionforms were initially completed by DS andcheckedby either TRor EI. Differ-enceswerediscussedwhennecessary.
2.6. Riskofbiasassessment
The risk of bias of the included studies was assessed with two tools.The Cochrane risk of bias tool wasused forthe con-trolled studies (Cochrane and Effective Practice and Organisation of Care, 2017 ). This tool consists ofnine items, ofwhich each is scored high, low or unclear risk of bias. The ‘Newcastle-Ottawa Quality Assessmentform forCohort studies’ wasused forcohort before-after studies (Wells et al., 20 0 0 ). The Newcastle-Ottawa Quality Assessmentconsists ofthree parts; selection,comparison andoutcome.Foreachpartanumberofstarscanbeassigned, re-sulting in an overall score (good, fair orpoor). Both risk of bias tools were included in the data abstraction form, initially com-pletedby DS andcheckedby eitherTR orEI. Discrepancieswere resolvedbydiscussion.
The Newcastle-Ottawa Quality Assessment form for Cohort Studies contains a question on whether the follow-up was long enough for the outcome to appear (Wells et al., 20 0 0 ). In line with recommendations of the World Health Organisation (WHO) on implementation research, we took itthat a periodof atleast of 3 months, forbaseline andafter measurement each, was suf-ficient(World Health Organization, 2014 ).Afterdiscussion DS,TR, andEIjointlydecidedthatathree-monthperiodwassufficient. Re-gardingthebefore-afterstudies,afollow-upperiodlessthanthree months thereforeresultedin poorscores ontheoutcome partof theNewcastle-OttawaQualityAssessmentformforCohortStudies. TheCochranetooldoesnotcontainsuchaparameter.
2.7. Analysisandsynthesis
Meta-analysiswasprecludedduetoheterogeneityacross stud-ies. This heterogeneity concerned differences in guidelines, im-plementation strategies, outcome measures, timing of follow-up measurements, and the level of detail of the used strategies. In-stead we provided a descriptive and narrative synthesis of the primary outcomes guideline adherence andpatient-related nurs-ing outcomesof the individual implementation studies. We pro-videdasummarytablewithallcrucialelementsofthe implemen-tationprocesses(duration,usedimplementationstrategies,barrier assessment,useofimplementationframework, used implementa-tionoutcomesSupplement2.
Descriptionof includedstudies). Thenumberofimplementation strategies were categorizedinto the four EPOC categories (Deliv-ery,Financial,GovernmentandImplementationstrategies).The to-talnumberofimplementationstrategiesthatwereusedinthe im-plementation studies were summarized asmedianwith IQR. The median number ofused implementationstrategies was provided forallstudies,perEPOCcategory(Delivery,Financial,Government and Implementation strategies), for the studies that presented a positive significant change on one ormore oftheir primary out-comes,andforthestudieswhoreportednosignificantchange.
Further, the relative change percentage was calculated for the studies providing patient-related nursing outcomes. Cal-culating a relative change of guideline adherence before the (re)implementationofaguideline isexpectedto be oflowvalue, because the adherence rate to a not yet implemented guideline willalwaysbelowatbaseline.Moreover,notallstudiesmeasured adherenceatbaseline.Therefore,wechosenottocalculatethe rel-ative change of our other primary outcome ‘adherence’. For the before-afterstudies, the relative change wascomputed by divid-ingtheabsoluteoutcome bythebaseline level,preferablyforthe primaryoutcomeofthatindividual study.However,insome stud-iesthepatient-relatednursingoutcomewasasecondaryoutcome. Forcontrolled studies,wefirstcomputedtherelativechange sep-arately forthe intervention group and the control group. Subse-quently,thecalculatedrelativechangepercentageinthe interven-tion group was divided by the calculated relative change in the controlgroup(Mölenberg et al., 2019 ).Supplement3providean ex-ampleofhowtherelativechangeswerecalculatedforbothstudy groups.Ofnoteisthattherelativechangeforthebefore-after stud-ies could have been overestimated due to the lack of a control group.
Theassociationbetweentherelativechangeandthetotal num-ber of EPOC strategies used in the included studies was visual-ized in a scatterplot, for the controlled studies and the before-afterstudies separately.The difference betweenthe median rela-tive changeforstudies usingonly strategiesfromthe EPOC cate-goryImplementation strategies orusing a combinationof strate-giesfromdifferentEPOCcategorieswasassessedusingthe Mann-WhitneyUtest.Forcomparablegroupsofsimilarguidelineswith similar outcomes(at least3 studies), the medianrelative change wasassessed andrelatedtotheuse ofEPOCcategory implemen-tationstrategiesaloneortotheuseofacombinationofstrategies fromdifferentEPOCcategories.
3. Results 3.1. Studyselection
Theinitialsearchstrategyandthecross-referencecheckyielded atotalof17,058records.After8539duplicateswereremoved,8519 abstracts were assessed foreligibility. Two-hundred-and-five full-textrecordsremainedandwereassessedforeligibility,afterwhich eventually54records,regarding53uniquestudies,were included forthesynthesis’(Fig. 1 Flowdiagramforidentification,screening andeligibility accordingtothePreferred ReportingItemsfor Sys-tematicReviewsandMeta-Analysesprotocol).
3.2.Studycharacteristics
3.2.1. Studydesign,settingandguidelinetopic
The54papersdescribed53uniqueimplementationstudies on 21guidelinetopics.Fifteenhadacontrolled before-after, random-izedcontrolledtrialorclusterrandomizedcontrolled trialdesign; 38 studies (71.7%) had a before-after design. Most studies were conductedinwestern countries(USA n= 10,Netherlands n= 9, Australian = 8). Halfof the studies were performedin a single centre(n = 27,50.9%). Mostofthe guidelinesregarded skincare (n = 9) andinfection prevention(n= 7). Twostudies addressed theimplementationofacombinationofseveralguidelines, respec-tivelysix(Edwards et al., 2007 )andthree(van Gaal et al. (a), 2011 ; van Gaal et al. (b), 2011 ).The moststudiedsettingwasa hospital (n=34,64.2%),followedbyanursinghome(n=11),general prac-tice(n=5), home care(n= 2), andinpatient rehabilitation cen-tre (n = 1). Table 1 Study characteristicsbroken down by guide-linetopicshowsthe studycharacteristicsoftheincluded studies,
Fig.1. Flowdiagramforidentification,screeningandeligibilityaccordingtothePreferredReportingItemsforSystematicReviewsandMeta-Analysesprotocol(Moheretal., 2010).(Forinterpretationofthereferencestocolourinthisfigurelegend,thereaderisreferredtothewebversionofthisarticle.)
Supplement2providesamoredetaileddescriptionoftheincluded studies.
3.2.2. Participants
Twenty-seven studies provided no description of the targeted professionalsotherthan‘nurses’.Insome studies,nurseaids, stu-dentnursesornursepractitioners were(partof)thetargetgroup, few studies targeted multiple professionals (physicians, physical therapists, etc.). The median number of involved caregivers per study(n=27)was118(IQR34– 238);twenty-sixstudiesdidnot providethenumberofinvolvedcaregivers.
Sixteenstudiesdidnotdescribeanydetailsofthetargeted pa-tients;the other studies described basic characteristics regarding ageandgender. Several studies describedbaseline characteristics relatedto the guideline of interest. Regarding 35 of all included studies,themediansamplesizeofincludedpatientswas373(IQR 140– 1577);seventeenstudiesdidnotreportthesamplesize.Also showninSupplement2.
3.2.3. Riskofbiasassessment
Nine controlled studies scoredlow risk of biason mostitems (sevenormoreoutofthe nineitems), asshowninSupplement 4 Cochraneriskofbias forcontrolledstudies.The remainingsix stud-ies scored unclear or high risk of bias on three or more out of nineitems. Thirty-two ofthe38 before-afterstudiesscored poor,
assessed withtheNewcastle-OttawaQuality Assessmentformfor CohortStudies(Supplement).Thirtyofthese32studiesscoredpoor on the comparability part. These studies didnot control forage, sex,orotherfactors,ordidnotcorrectforconfoundingwhen com-paringthebeforeandaftergroups.Fourbefore-afterstudies were assessedasgood;twoasfair.
3.3. Implementationoutcomes
All studiesused a variety ofimplementation strategies,which wererarelycomparableandwithvariableoutcomes.The duration of the measurements, the intensity and the degree of details of theusedstrategiesvariedacrossstudies.Twenty-onestudies mea-suredbothpatient-relatednursingoutcomesandguideline adher-ence. Elevenof thesestudies found asignificant improvementon both outcomes. Overall, thirty-six studies (68%) measured a sig-nificantpositivechangeoneitherpatient-relatednursingoutcome measure(s)orguidelineadherence.
3.3.1. Patient-relatednursingoutcomes
Patient-relatednursingoutcomesweremeasuredin30studies. Twenty-one (70%) measured a significant positive change, seven measured no change, and two studies did not perform statisti-caltests.Allstudiesreportedfindingsindicatingapositivechange or no change. However, one study (Törma et al. 2014) reported
Table1
Studycharacteristicsbrokendownbyguidelinetopic.
Author,Year Country Design Setting,Single/Multicentre Guidelinetopic
vandenBoogaard etal.,2009
Netherlands Before-After Hospital-IntensiveCareUnit(PICUandIntensive CareUnit)inatertiaryhospital,Singlecentre
Agitation-Delirium
Trogrlicetal.,2019 Netherlands Before-After Hospital-IntensiveCareUnitsin1UniversityMedical Centreandfivecommunityhospitals,Multicentre
Agitation-Delirium
Punetal.,2005 USA Before-After Hospital-IntensiveCareUnitwardsoftheVander BiltUniversityMedicalCentreinNashvilleandthe VeteransAdministrationTennesseeValley HealthcareSystem-YorkCampus,Multicentre
Agitation - Delirium and sedation
Edwardsetal., 2007
Canada Before-After Hospitalandnursinghomes-7hospitals + 2home visitingnursingserviceorganisationsandone publichealthunit,Multicentre
Combinationofmultipleguidelines-Asthma, breastfeeding,
delirium-dementia-depression,smoking cessation,venouslegulcers,diabetes
vanGaal(aetal., 2011;vanGaal (b)etal.,2011)
Netherlands Cluster Randomized ControlledTrial
Hospitalandnursinghomes-1universityhospital.2 largeteachinghospitals,onesmallhospitaland6 nursinghomes.10hospitalwards+ 10Nursing homewards,Multicentre
Combinationofmultipleguidelines-Pressure ulcer,urinarytractinfectionandfalls
Setoetal.,1991 China Before-After Hospital-6wards,3male,3female,Singlecentre Infectionprevention-Catheterassociated urinarytractinfections
Huisetal.,2013 Netherlands Cluster Randomized ControlledTrial
Hospital-3hospitalsintheNetherlands,Multicentre Infection prevention-handhygiene
GopalRaoetal., 2009 United Kingdom Cluster Randomized ControlledTrial
Nursinghome-12nursinghomesinandsurrounding southLondon,Multicentre
Infectionprevention-Handhygiene, environmentalanddisposalhygiene.
Zhuetal.,2018 China Before-After Hospital-ShanghaiPublicHealthClinicalCentre, Singlecentre
Infectionprevention-Non-pharmacological fevermanagementinHIVpatients
Cabilanetal.,2014 Australia Before-After Hospital,Singlecentre Infectionprevention-Peripheralcannula infections
Frigerioetal.,2012 Italy Before-After Hospital-6OrthopaedicSurgery,2Traumatology,1 Neurosurgery,1Neurology,1GeneralSurgery,2 GeneralMedicine,Singlecentre
Infectionprevention-Peripheralvenous cathetermanagement Gomarverdietal., 2019 Iran Cluster Randomized ControlledTrial
Hospital-IntensiveCareUnitwardsintwodifferent hospitals,Multicentre
Infectionprevention-Standardprecautionsin IntensiveCareUnits
Abrahametal., 2019
Germany Cluster Randomized ControlledTrial
Nursinghome-120nursinghomes,Multicentre Mobility-physicalrestraintuse
Wardetal.,2010 Australia Cluster Randomized ControlledTrial
Nursinghome-residentialagedcarefacilitieswithat least20beds,88facilitiesincluded,Multicentre
Mobility-Preventingfalls
Köpkeetal.,2012 Germany Cluster Randomized ControlledTrial
Nursinghomes,36intotal,Multicentre Mobility-Useofphysicalrestraints
Lockwoodand Hunter,2018
Australia Before-After Hospital-Twoprivatehospitalsinaregionalarea, Multicentre
Mobility-Venous-thromboembolism preventionprogramme
Törmä et al., 2014 Sweden ControlledBefore-After Nursinghomes-4,Multicentre Nutritional
Cahilletal.,2014 Canada/USA Before-After Hospital-5participatingIntensiveCareUnit’s(one dividedin3units)inCanadaandtheUSA.In non-andteachinghospitals,Multicentre
Nutritional-EnteralnutritionintheIntensive CareUnit
Johnsonetal., 2017
United Kingdom
Before-After Hospital-tertiaryneonatalintensivecareunit,Single centre
Nutritional-improvenutritionandgrowthof preterminfantsinneonatalintensivecare.
Giuglianietal., 2010
Angola Before-After Hospital-Therapeuticfeedingcentre,consistsofa separatewardforseverelymalnourishedchildren only,Singlecentre
Nutritional-MalnutritioncareinruralAfrica
Lopezetal.,2004 China Before-After Hospital-Tertiarycareteachinghospital,Single centre
Nutritional-nutritionsupportin mechanicallyventilated,criticallyilladult patients.
Amesetal.,2011 USA Before-After Hospital-4differentcriticalcareunits,Multicentre OralCare-PreventionofVAP
DeVisschere,2012 Belgium Cluster Randomized ControlledTrial
Nursinghomes-InFlandersBelgium,Multicentre Oralcare
Vander Putten,2013
Netherlands Cluster Randomized ControlledTrial
Nursinghomes-Within100kmradiusofthecentre oftheNetherlands,Multicentre
Oralcare
Lozanoetal.,2004 USA Cluster Randomized ControlledTrial
Primarycarepaediatricpractices,Multicentre Other-Asthmatreatment
Clarkand Rawlinson,2001
United Kingdom
Before-After Hospital-alargeteachinghospital,Singlecentre Other-Bloodtransfusion
Tianetal.,2017 Belgium Before-After Hospital,Singlecentre Other-Cancerrelatedfatigue
vanLieshoutetal., 2016
Netherlands Cluster Randomized ControlledTrial
GeneralPractices,Multicentre Other-Cardiovascularriskmanagementin generalpractices
Table1(Continued).
Author,Year Country Design Setting,Single/Multicentre Guidelinetopic
Downeyand Kirsa,2015
Australia Before-After Hospital-A18bedHead,neckandlungmedical oncologyward,Singlecentre
Other-CrushingmedicationincaseofTube feedingonly
Sipilaetal.,2008 Finland Before-After Generalpractices-31intotal,Multicentre Other-Earlydetection,preventionand treatmentofCVD(Cardiovasculardisease)
Snelgrove-Clarkeetal., 2015
Canada RCT Hospital-Universityaffiliatedteachinghospitalin Atlantic,Singlecentre
Other-FoetalHealthSurveillance
Featherstonand Gilder,2018
USA Before-After Communitymentalhealthcentre,Singlecentre Other-Paediatricmentalhealthcare
Jagt-vanKampen etal.,2015
Netherlands Before-After Hospital-Academicchildren’shospital,Singlecentre Other-Paediatricpalliativecare
Duff etal.,2013 Australia Before-After Hospital-a250-bedmagnetdesignatedprivate hospital,Singlecentre
Other-Preventionofvenous thromboembolism
VanderWegetal., 2017
USA Before-After Hospital-GeneralmedicalunitsoffourUS DepartmentofVeteransAffairshospitals,Multi centre
Other-Smokingcessation
Reynoldsetal., 2016
USA Before-After Hospital-Neurocriticalcareunit,Singlecentre Other-Strokecare
Cheateretal.,2006 United Kingdom
Cluster Randomized ControlledTrial
Familypractice,Multicentre Other-Urinaryincontinence
Savvasetal.,2014 Australia Before-After Nursinghome-Residentialagedcarefacilitiesacross threeAustralianstates,Multicentre
Pain-AustralianPainSociety
Dulkoetal.,2010 USA Before-After Hospital,Singlecentre Pain-Cancerrelated
Choietal.,2014 South-Korea Before-After Hospital-Auniversityaffiliatedtertiaryhospital, Singlecentre
Pain-Cancerrelated
Kingsnorthetal., 2015
Canada Before-After Hospital-alargeacademicpaediatricrehabilitation hospital,Singlecentre
Pain-Paediatricpain
Habichetal.,2012 USA Before-After Hospital-PaediatricIntensiveCareUnitata communityhospitallocatedinasuburbofChicago, IL,Singlecentre
Pain-Paediatricpainassessmentand managementguidelines
Baleetal.,2004 USA Before-After Nursinghomes-6,Multicentre Skincare
Harrisonetal., 2005
Canada Before-After Homecare-TheOttawaCommunityCareAccess Centre,aneasternOntariohomecare-authority, Multicentre
Skincare-Legulcers
DeLaat,2006 Netherlands Before-After Universityhospital,Singlecentre Skincare-pressureulcer
Paquayetal.,2010 Belgium Before-After Homecare-5participatinghomenursingagencies, Multicentre
Skincare-pressureulcer
DeLaat,2007 Netherlands Before-After Hospital-Criticalcareunitinanacademichospital, Singlecentre
Skincare-pressureulcer
Beeckmanetal., 2013
Belgium Cluster Randomized ControlledTrial
Nursinghome-11wards,Multicentre Skincare-pressureulcercare
Kohetal.,2018 Singapore Before-After Hospital-Twoorthopaedicwards,Singlecentre Skincare-pressureulcerprevention
Rosenetal.,2006 USA Before-After Nursinghome,Singlecentre Skincare-pressureulcerprevention
Lopezetal.,2011 Australia Before-After Hospital-AustralianCapitalTerritoryhospitals, Singlecentre
Skincare-Skintears
Jolliffeetal.,2019 Australia Before-After Other-InpatientRehabilitationsetting,Singlecentre Strokecare
Bjartmarzetal., 2017
Iceland Before-After Hospital-Neurologyandrehabilitationwardin universityhospital,Singlecentre
Strokecare
a significant negative effect on one of the patient-related nurs-ing outcome measures that were addressed. Törmä et al. (2014) comparedtwo implementationstrategies(externalfacilitationand educationoutreach visits)inordertointroduce nutritional guide-lines. Besides no differences in nutritional parameters after 18 months, they found significant deteriorations for functional and cognitive status, as well as for the EQ-5D index (quality of life questionnaire), (p<0.05) in the intervention group that received educationaloutreach visits.
Ten of the controlled studies (n = 15) measured patient-related nursing outcomes. Six found a significant positive ef-fect; four found no effect. Twenty-two of the before-after stud-ies (n = 37) measured patient-related nursing outcomes. Thir-teen found a significant positive effect, seven found no signif-icant effect (n = 7), and two performed no statistical tests (n = 2). When comparing the controlled and before-after stud-ies, we found no significant difference between these groupson reported significant change in patient-related nursing outcomes (p≥0.05).
3.3.1.1. Relativechangepercentageonthepatient-relatednursing out-comes. All relative change are shown in Supplement 6 and Sup-plement 7. The median relative change measuring patient-related nursingoutcomeswas2.7%(IQR1.0– 40.6)forthecontrolled stud-ies(n=10), and22.1%(IQR8.7– 81.4)forthebefore-after stud-ies(n=19).Thisdifferedsignificantlybetweenthecontrolledand before-aftergroups(p=0.009).
The scatterplots for the controlled (Fig. 2 ) and before-after (Fig. 3 ) studies show that there wasno association between the total number of used strategies and the relative change on the patient-related nursing outcomes. For the controlled studies the slope suggests that using more strategies, will result in a lower relativechange.However,thesampleistoosmalltoconcludethis (n=10).
Themedianrelativechangeforstudiesthatusedstrategiesfrom theEPOCcategoryimplementationstrategiesalonewas13.8%(IQR 3.6–81.9). For the studies that used a combination of strategies from the EPOC categories the median was 20.1% (IQR 3.2–67.3), howeverthiswasnotstatisticallydifferent(p=0.95).
Fig.2. ScatterplotrelatingthetotalnumberofEPOCimplementationstrategiesusedtotherelativechangepercentageinpatient-relatednursingoutcomesforthecontrolled studies.
Fig.3. ScatterplotrelatingthetotalnumberofEPOCimplementationstrategiesusedtotherelativechangepercentageinpatient-relatednursingoutcomesforthe before-afterstudies.
We created three groups of studies with comparable patient-related nursing outcomes regarding comparable nursing guide-lines. Onegroup consistedoffive studies(Beeckman et al., 2013 ; De Laat et al. 2006 ; De Laat et al. 2007 ; Rosen et al., 2006 ; Koh et al., 2018 ) regarding pressure ulcers. The median relative change percentage for these studies was 27.8 (IQR 11.1 – 58.3). The outcomes were comparable between these studies, but not exactly derived in the same way. For example, Koh et al., 2018
reportedthat they measured the incidenceof pressure ulcers on the heel only. The other four studies provided no details about the location of pressure ulcers. The second group consisted of four studies (Törma et al. 2014, Giugliani et al., 2010 , Johnson etal.2015,Cahiletal.2014)regardingnutritionalintake.The me-dian relative change percentage for these studies was 3.3 (IQR 0.9 – 11.0). The third group consistedof three studies (De Viss- chere et al. 2012 ; van der Putten et al. 2013 , Ames et al. 2011)
regarding oral care, with a median relative change percentage of3.3.
3.3.2. Guidelineadherence
Guideline adherence was measured in 44 studies, of which 26 (59,1%) showed a significant improvement, fourteen mea-sured no change, and four did not perform statistical tests. Due to the heterogeneity in measuring adherence across all studies, we cannot draw an overall conclusion on the change in ad-herence rates. For example, several studies measured adherence ratesregarding pain management (assessment and/or treatment). Kingsnorth et al. (2015) founda significantandclinically relevant improvement in the documentation of pain scores, from 9% ad-herencerate at baseline to 100% adherence rate two years later. Dulko et al. (2010) showedanincreaseinadherencerateforinitial comprehensivepainassessmentfrom1%to43%(p=0.008).
Twelveofthecontrolledstudies(n=15)measured adherence. Insixstudiesasignificantpositiveeffectonadherencewasfound (n=6);sixfoundnoeffect(n=6).Thirty-twoofthebefore-after studies(n=32)measuredadherence.Twentystudiesfounda sig-nificantpositiveeffectonadherence(n=20),eightfoundnoeffect (n=8),andfourperformednostatisticaltests(n=4).When com-paringthe controlled and before-after studies, we found no sig-nificant difference between thesegroups on effect on adherence (PearsonChi-Square0.564,p>0.05).
3.3.3. Implementationstrategies
Description ofthedetailsoftheimplementationstrategies var-iedwidelybetweenstudies.Someprovidedadetailedprocess de-scription, others just mentioned the type of strategy (e.g., audit andfeedback).
Table 2 provides an overviewofappliedstrategies categorized accordingto the Cochrane Effective Practice and Organisation of Caretaxonomy andSupplement2provides adetaileddescription ofthe implementationstrategies.Eachstudyused morethanone strategy, with a median of 6 (IQR 4–8). Apart from one study (Dulko et al., 2010 ),studiesappliedatleastoneeducational strat-egy; e.g., educational material (n = 38, 71.7%),meeting (n = 43, 81.1%), outreach (n = 10, 18.9%) or inter-professional education (n=14,26.4%).Nexttoeducationalstrategies,theuseoflocal opin-ionleaders(n=29,54.7%),andauditandfeedback(n=22,41.5%) were regularly applied. Only one study, Rosen et al. (2006) de-scribedagovernancearrangement,inthiscase;formalreprimands andsubjecttoterminationincaseoffailingtocompletetraining.
For all studies, the median number of used strategies was 6 (IQR 4 – 8), with a median of 0 forthe EPOC category delivery (IQR 0 – 1), and 0 for the EPOC category financial (IQR 0 – 0), and0fortheEPOCcategorygovernmentarrangements(IQR0– 0), andamedianof6(IQR4– 7)fortheEPOCcategory implementa-tionstrategies. The mediannumberof strategies instudies mea-suringpatient-relatednursingoutcomeswas7.0(IQR5–8,n=21) forstudieswhichreportedasignificantimprovement,andwas6.0 (IQR4.5–8.5,n=9)forstudieswhichreportednochange.The me-diannumberofstrategiesinstudiesmeasuringadherencewas6.0 (IQR4.8–8,n=26)forstudiesthatreportedasignificant improve-ment,andwas6.0(IQR4–7, n=18) forstudiesthat reportedno change.
Most studies did not apply strategies in the control group, or did not provide a description of usual care. Eight studies (Abraham et al., 2019 ; Beeckman et al., 2013 ; Cheateret al., 2006 ; Köpke et al., 2012 ; Lockwoodet al., 2018 ; Lozano et al., 2004 ; van der Puttenet al., 2013 ; Ward et al., 2010 ) appliedstrategiesin thecontrol group, in mostcases printedstudy material or avail-abilityofproductse.g.providingpH-strips.
3.3.4. Effectsofimplementationstrategies
Fifteen cluster randomized controlled trials studied the ef-fects of specific implementation strategies. The individual strate-giesandthecombinationsofstrategiesappliedinthesetrials var-ied (Abraham et al., 2019 ; Beeckman et al., 2013 ; Cheater et al., 2006 ; De Visschere et al. 2012 , Gomarverdi et al. 2019, Huis etal.2013, Kopke et al. 2012 , Lazano et al. 2004 ,Raoetal.2009, Snelgrove-Clarke et al. 2015 Torma et al. 2014, Van der Putten et al. 2013 , Van Gaal(a,b) et al. 2011 ,VanLieshoutetal.2016, Ward et al., 2010 ).
For example, two cluster randomized controlled trials, by De Visschere et al. (2012) , and van der Putten et al. (2010) , de-scribed asupervised implementationstrategy foran oral hygiene guideline.Bothfoundadecreaseofdentureplaqueaftera6-month follow-up(respectively;p<0.01andp<0.0001).Other randomized controlledtrialsdidnotuseasupervisedimplementationstrategy, whichlimitedtheabilitytoconcludeeffectivenessofthisspecific implementationstrategy.
Lozano et al. (2004) created three groups to implement an asthma treatment guideline. One group received a peer leader intervention, one received a planned care intervention, and one servedasacontrolgroup,receivingcareasusual.Theyonlyfound aneffectonpatient-relatednursingoutcomesintheplannedcare intervention group; i.e., a decrease in asthma symptom days per year compared to usual care (p = 0.02). We could not compare these outcomes with those of another cluster randomized con-trolled trial, because no similar implementation strategies were usedinotherrandomizedcontrolledtrials.
3.3.5. Barrierassessment
A barrier assessment was performed in twenty-three (43%) studies.’Nineteenstudies explicitlyusedtheoutcomesofthe bar-rierassessment to selecttailored implementationstrategies.Lack ofknowledge was themost commonfound barrier,described by eleven studies (48%). Other barriers were accessibility of prod-ucts (n = 6%), time limitations (n = 4%), and lack of leader-ship/motivation(n=4%).Therewasnodifferenceinstudies who described a positive significant effect on patient-related nursing outcomesorguidelineadherence betweenstudies thatdidordid not perform a barrier assessment. From the studies which mea-suredpatient-relatednursingoutcomes, elevenstudiesperformed abarrierassessment,ofwhichsevenreportedapositivesignificant effect on patient-related nursing outcomes, and four did not re-portachange(PearsonChi-Square0.335,df1,p=0.56).Fromthe studieswhich measuredadherence, nineteenstudies performeda barrierassessment,ofwhichtwelve showedapositive significant effectonadherence(PearsonChi-Square0.229,df1,p=0.63).
3.3.6. Useofimplementationtheory,modelsorframeworks
Seventeen (31%) studies used a theory, model or framework. TheJohannaBriggsInstituteGettingResearchintoPracticemodel was used in six studies, the Implementation Model of Change by Grol and Wensing in four, and the Promoting Action on Re-search Implementationin HealthServicesintwo. The Normalisa-tionProcessTheory,Knowledgetoactionmodel,TheoryofChange, AIM model, and Awareness Desire Knowledge Ability Reinforce-ment (ADKAR)Change management modelwere used once.Nine of the studies which measured patient-related nursing outcomes useda theory,modelorframework,ofwhich sixreporteda pos-itive significant effecton patient-relatednursing outcomes (Pear-sonChi-Square0.68,p=0.79).Sixteenofthestudieswhich mea-sured adherence used a theory, model or framework, of which eight reporteda positive significanteffect onadherence (Pearson Chi-Square0.860,p=0.35).
D. Spoon, T. Rie tbergen and A. Huis et al. / Int ernational Journal of Nu rs in g St u d ie s 111 (2020) 103 748 9
Author Year Implementationstrategies1 Effect
Or g a nisational Chang e A udit and Fe e d b a ck Clinical incident re p o rt in g Monit o ring Communities of pr actice Educational mat erials Educational mee tings Educational outr eac h Int e r-pr of essional Education Local Consensus Pr ocess Local Opinion leaders Manag erial supervision Pa ti e n t me diat e d int erv ention R e minders Ro u ti n e PR OMS Ta ilor e d Deli v e ry Arr a ng ements Financial Arr a ng ements Go v ernance Arr a ng ements To ta l numb er of EPOC im plementation st ra te g ie s Ad h e re n ce P a tient-r e lat e d nursing outcomes
(Cluster)RandomizedControlledTrials
Abraham 2019
Updatedversion 1 1 1 1 1 1 1 1α 9 NC NC
Conciseversion 1 1 1 1 1 1α 7 NC NC
Control 1 1 NC NC
Beeckman 2013
Intervention(Intrinsic-motivationorientated strategies)
1 1 1 1 1 1 1 1 2¥,α 11 P P
Control 1 1 2 NC NC
Cheater 2006
Auditandfeedback(AF) 1 1 2 NC NC
Educationaloutreach(EO) 1 1 1 1 1 6 NC NC
AF+EO 1 1 1 1 1 5 NC NC
Control 1 1 NC NC
DeVisschere 2012
Intervention(supervisedimplementation) 1 1 1 1 1 1 1α 8 – P
Control 0 – NC
Gomarverdi 2019
Intervention(multi-componenteducatio-l) 1 1 1 1α 5 P –
Control 0 NC –
Huis 2013
Teamandleaders-directed 1 1 1 1 1 1 1 1 1 1 1α 11 P NC
Stateoftheart 1 1 1 1 1 1α 6 P NC
Köpke 2012
Intervention(guideline-andtheory-based multicomponentintervention)
1 1 1 1 1 1 1 1 1 1 11 P P
Control 1 1 2 NC NC
Lazano 2004
Peerleaderintervention 1 1 1 1 1 1 1α 9 NC
Plannedcareintervention 1 1 1 1 5 P
Control 1 2 NC
Rao 2009
Intervention(infectioncontrolteam) 1 1 1 1 1α 6 NC –
Control 0 NC –
Snelgrove-Clarke 2015
Intervention(Actionlearning) 1 1 1€ 4 NC –
Control 0 NC –
Törmä 2014
ExternalFacilitatorStrategy 1 1 1 4 – NC
EducationalOutreachVisits 1 1 – NC
VanderPutten 2013
Intervention(supervisedimplementation) 1 1 1 1 1 1α 7 – P
Control 1α 1 – NC
VanGaal(a)&VanGaal(b) 2011
Intervention(education,patientinvolvement, feedback)
1 1 1 1 1 1 1 8 NC P
Control 0 NC NC
VanLieshout 2016
Intervention(tailoredimprovementprogramme) 1 1 1 1 1 1β 7 NC P
Control 0 NC NC
D. Spoon, T. Rie tbergen and A. Huis et al. / Int ernational Journal of Nu rs in g St u d ie s 111 (2020) 103 748 Table2(Continued).
Author Year Implementationstrategies1 Effect
Or g a nisational Chang e A udit and Fe e d b a ck Clinical incident re p o rt in g Monit o ring Communities of pr actice Educational mat erials Educational mee tings Educational outr eac h Int e r-pr of essional Education Local Consensus Pr ocess Local Opinion leaders Manag erial supervision Pa ti e n t me diat e d int erv ention R e minders Ro u ti n e PR OMS Ta ilor e d Deli v e ry Arr a ng ements Fi n a n ci a l Arr a ng ements Go v ernance Arr a ng ements To ta l numb er of EPOC im plementation st ra te g ie s A d her e nce P atient-r e lat e d nursing outcomes Ward 2010
Intervention(full-timeprojectnurse) 1 1 3 NC NC
Control 1 1 NC NC
Beforeafter
Seto 1991
Opinionleader 1 1 1 4 P –
Lecture(control) 1 1 NC –
Opinionleader&Lecture 1 1 1 3 P –
Ames 2011 1 1 1 1α 5 – P Bale 2004 1 1 1 1 1 6 – P Bjartmaz 2017 1 1 1 1 5 P – Cabilan 2014 1 1 1 1 1 1 7 NC – Cahill 2014 1 1 1 1 5 NC NC Choi 2014 1 1 1 1 1 1 1¥ 8 P – Clark 2001 1 1 1 1 5 P – DeLaat 2006 1 1 1α 7 P P DeLaat 2007 1 1 1 1 1 3 P P Downey 2015 1 1 1 1 1 6 NC – Duff 2013 1 1 1 1 5 – NC Dulko 2010 1 1 3 P P Edwards 2007 1 1 1 3 NC – Featherston 2018 1 1 1 1δ 5 P – Frigerio 2012 1 1 1 4 P – Giugliani 2010 1 1 3 – P Habich 2012 1 1¥ 3 P – Harrison 2005 1 1 1 1 3 – P Jagt-vanKampen 2015 1 1 3 NC – Johnson 2017 1 1 1 1 1 1α 7 P P Joliffe 2019 1 1 1 1 1α 6 P P Kingsnorth 2015 1 1 1 1 1 1 1 8 P P Koh 2018 1 1 1 1 1 1 1 8 P NC Lockwood 2018 1 1 1 1δ 5 P NC Lopez 2004 1 1 1 7 – NC Lopez 2011 1 1 1 1 1 1 1α 5 P P Paquay 2010 1 1 1 1 1 6 P P Pun 2005 1 1 1 4 NC NC Reynolds 2016 1 1 1 4 NC – Rosen 2006 1 1 1 1 1 1$ 1! 8 – P Sawas 2014 1 1 3 NC – Sipila 2008 1 1 1 1 1 1 1 1₤ 9 NC – Tian 2017 1 1 1 1 1 6 NC – Troglic 2019 1 1 1 1 1 1 1 1 1 1 1 1 13 P P
VandenBoogaard 2009 1 1 1 1 1 1 1γ 8 P P
VanderWeg 2017 1 1 1 1 1 1 1 1 2∗,γ 1₿ 12 – NC
Zhu 2018 1 1 1 1 1 1α 7 P –
Implementationstrategies:1AllCochraneEffectivePracticeandOrganisationofCaretaxonomyimplementationstrategiesexcept:clinicalpracticeguideline(appliedinallstudies),educationalgamesandcontinuousquality improvement(appliedinnoneofthestudies).DeliveryArrangements:∗Self-managementsupport.¥ -Healthinformationsystems.α-Procurementanddistributionofsupplies.βDiseasemanagement.γ-Theuseofinformation andcommunicationtechnology.δ-Carepathway.FinancialArrangements:€Nursesreceived$50,-permeetingtoacknowledgetheireffortinoff-dutymeeting.$$75,-foreachstaff memberifthedesiredreductioninPressure Ulcerincidencewasachieved.$10forattendingtrainingsession.₤Facilitatorspersiteweremotivatedbyasmallfinancialincrementontheirmonthlysalary.₿Forthepatients,first$10,-then$20,-.Governancearrangements: ᵎProfessionalcompetence.NANotapplicable;NCnochange;Ppositive.
3.3.7. Studyduration
Thedurationoftheimplementationstudiesvariedwidely,from a few weeksup toseveralyears.Some studies usedpoint preva-lence measures, others used continuousdata. Severalstudies did notdescribethedurationand/orintervalofthemeasurements per-formed. Seventeen studies did not mention the duration of the baseline measurements, twenty-four the implementation phase, andeleventhepost-implementationphase.
Overall,amongst thestudies providingtherespective informa-tion,baseline measurementswere collectedovera medianperiod of threemonths (IQR 1–6),andthe implementation phaselasted a median of three months (IQR 2–9.5). The post-implementation phase hadamedianduration of3.5months(IQR 1.75–6.0). Four-teen studies performed a second post-implementation measure-ment, with a median duration of 6 months (IQR 3.8–12.8). One studyperformedathirdpost-implementationmeasurementlasting 16months.
4. Discussion
Toourknowledge,thisisthefirstsystematicreviewonthe ef-fectsofimplementationofnursingguidelinesinallfieldsof prac-ticeandtheusedimplementationstrategies.Thebroadviewacross the field of implementation science regarding nursing guidelines identified a diverserangeof implementationstrategies, combina-tionsofdifferentstrategies,guidelines,outcomemeasuresand set-tings.Thesefindings provideagoodreflectionofcurrentpractices andconsiderations.Wepresentedthefindingsasadescriptiveand narrative synthesis because a meta-analysis was not possible in viewoftheheterogeneityofguidelines,implementationand clini-cal outcomes,thevarietyofused(combinations of)strategiesand the varying timing in follow-up measurements amongst the in-cludedstudies.
Morethan halfofthestudiesshowedasignificant positive ef-fectoftheimplementationofnursingguidelinesonpatient-related nursingoutcomesand/oradherencetotheguideline(s).Therewas noassociationbetweenrelativechangeonpatient-relatednursing outcomesandthenumberofimplementationstrategiesintotalor theuseofcombinedstrategiesfromthedifferentEPOCcategories. There wasasignificant differenceintherelativechangeinfavour ofthebefore-afterstudies,howeverthisseemstoberelatedtothe studydesign.There isnot one strategy, orcombinationof strate-gies, which can be linked directly to successful implementation. Wecould notassesswhetherimplementationsuccesswasrelated to theuseofatheory,modelorframework,performing abarrier assessment orusing tailoredstrategies,due tothe smallnumber ofstudiesdescribingthis.
In line with findings from previous reviews (Häggman- Laitila et al., 2017 ; Thompson et al., 2007 ),wefoundthateducation wasthemostusedstrategytoimplementevidence-basednursing, andnotedthateducationislesstomoderateeffectiveonitsown (Forsetlund et al., 2009 ; Giuere et al., 2012 ). However, somewhat lessthan halfofthe studies thatperformeda barrierassessment found alackofknowledge asa barrier.Incontrasttoother med-ical professions, nurses are not always –differs per country– re-quired totake continuingeducation coursesto keeptheir licens-ing (World Health Organisation, 2019 ). Takenthat intoaccount,it makes sense toapply atleastaneducational strategy forthe im-plementationofnursingguidelines.
Inthisreview,itwasidentifiedthatmoststrategieswerequite traditional, such as using posters and written material, instead of apps, screensavers, or educational games. Several studies rec-ommend investing in online and social media, which can sub-stantiallyadvanceimplementationscience(Gatewood et al., 2019 ; Glasgow et al., 2012 ; Graham et al., 2019 ).
The scope of this review was to get a complete overview of strategiesusedtoimplementnursingguidelines,andsubsequently getinsights in the effects ofimplementation strategiesacross all settingsandguidelinetopics.Wewere abletogain insightinthe strategies used on a regular basis. Nevertheless, because of the varyingstrengthsandlimitationsoftheincludedstudies,wecould notidentify asingleorcombinationofimplementation strategies that is most effective ingetting nursing guidelines into practice. Wethinkthat narrowingthe scopeofsettingsandguideline top-icswill not resultinbetter understanding of theeffectiveness of implementationstrategies.Onlyacomparisonofstudies with de-taileddescriptions ofthedelivered strategiesandthesame time-linemightachievethis.
4.1. Strengthandlimitations
Thisreviewhasseveralstrengthsandlimitations.First,weare confident that we present a complete overview of implementa-tionstudiesregardingnursingguidelines.Moststudieswerefound withthe initial search strategy. Second, due to the collaboration indata extractionbetween TR,EI andDS we warranted that the collected data from the individual studies are reliable. Repeated discussion about several implementation strategies led to a bet-ter understanding of the individual data, and resulted in a con-sistent reliable assessment of each included study. Third, for the interpretation of the effectiveness of the implementation strate-gies the outcomes where dichotomized into effect or no effect forpatient-related nursing outcomesor guideline adherence. Us-ing thesetwo primary outcomesto assessthe impactof the im-plementationstudiesisconsistentwith Curran et al. (2012) .These authorssuggestthatadualfocusinassessingclinicaleffectiveness andimplementationcould speedthe translationofresearch find-ingsinroutinepractice.
Alimitationisthequalityofthebefore-afterstudies,which re-sultedinanoveralllowevidencebase,precludingdrawing conclu-sions.Whichcauseda highriskofbiasacross allstudies, so cau-tionisneededindrawingconclusions.
A second limitation is the probable publication bias, in that studies achieving negative results tend to go unpublished. Still, nearlyhalfofthepublishedstudiesshowednochange.
A third limitation regards the wide variety in degree of de-tails of the used strategies. All describedimplementation strate-gies classified accordingthe EPOC taxonomy independent to the provided description and operationalisation of the strategy were considered equally in this study. It can be questioned, however, whetherthedescribedimplementationstrategieswerecomparable forallstudiesthat usedthesametypeofstrategies.Thepotential lackof comparability mayhaveaffected the interpretationof the effectsoftheimplementationstrategies.Strategieswerepoorly de-scribedandoperationalized;forexample,onlythetypeofstrategy wasprovided,suchasauditandfeedback.Weproposethat strate-giesmust be precise enough to enablemeasurement and repro-ducibility,followingtherecommendationof Proctor et al. (2013) or usingTheStandards forReportingImplementation Studies(StaRI) Statement(Pinnock et al., 2017 ).Thesechecklistscouldhelp stan-dardize theway thesestudies are described. Tofully understand theeffectofastrategysuchasauditandfeedback,informationon the extent,the number ofaudits andthe fraction ofthe partici-pantsinthetargetgroupmustbeavailable.
Fourth, calculating the relative change for controlled studies andbefore-after studies separately might lead to an overestima-tion forthe before-afterstudies, and an underestimation for the controlledstudies. Insome controlledstudies therewere signsof contaminationbetweengroups, whatcould havecausedan effect inthecontrolgroup,thusleadingtoanunderestimationofthe rel-ativechange.
Lastly,we foundawide varietyinthedurationandinterval of measurements,andmanystudiesdidnotprovideanindicationof theirbaseline,implementationand/orpost-implementationphase, orprovided a‘short’ follow-up. Anadequate follow-up time pro-videsinformationaboutthesustainability;i.e.,whetherthe guide-lineismaintainedorinstitutionalizedwithinaservicesetting’s on-going, stable operations (Proctor et al., 2011). The problem is of course that research projects are sponsored for a limited period andevaluatingthelong-termeffectsareoftennotfeasible.
4.2.Recommendations
We recommend well-designedstudiesto testtheeffectiveness of implementation strategies. In future research the implemen-tation details should ideally be reported according to standard-izedformats,forexampleassuggestedby Proctor et al. (2013) or Pinnock et al. (2017) .Amoredetaileddescriptionofthe implemen-tationprocess makes it easier to understand the change mecha-nism. Abraham et al. (2019) providedadetailedsupplementalfile containingthe components,descriptionandactualdosedelivered oftheir interventioncomponents.Thisinventoryishelpfulfor fu-tureresearch,butalsoforclinicalpractice.
We recommend guideline developers to think about audit criteria while developing a nursing guideline. Most studies de-scribed developing an audit criteria checklist as one of their preparations. A predefined audit criteria checklist could help healthcareprofessionals andorganizationsinthe execution, goal-setting and evaluation of the implementation of nursing guide-lines.We noteda lack ofgoal-setting inmoststudies. The study of Jolliffe et al. (2019) wasoneoftheexceptions:thegoalwasfor staff toadheretominimally75%ofapplicableguidelineindicators perpatientpriortocommencingthestudy.Whenpre-defined au-ditcriteriaareavailableitmightbepossibletosetgoalsand eval-uatetheimplementationofguidelineswithoutextensive prepara-tions.
Lessthanhalfofthestudiesincludedinthisreviewperformed abarrierassessment,andmostwerepoorlydescribed.Further,we couldnot relateperforming abarrierassessmenttoa positive ef-fectontheprimary outcomes.Fourstudiesthatperformeda bar-rierassessmentdidnotstatethattheidentifiedbarrierswereused toselecttheimplementationstrategies.Inlinewithotherreviews, we think that tailoring strategies based on a barrier assessment isimportant (Baker et al., 2010 ; Diehl et al., 2016 ). A barrier as-sessmentscanprovidecrucialinformationaboutthecontextwhere theimplementationwilltakeplace.Findinganddescribingbarriers andfacilitatorsindetailcanhelpinchoosingadequate implemen-tationstrategies,thismayincreasetheeffectivenessofthe imple-mentationofnursingguidelines.
5. Conclusion
This systematic review provides an extensive, up-to-date re-view of the implementation of nursing guidelines and the used implementationstrategies. More thanhalf of the studies showed apositivesignificanteffectoftheimplementationofguidelineson patient-relatednursing outcomesor guideline adherence.A wide varietyofimplementationstrategieswereidentifiedin implement-ingnursingguidelines.Educationisthemostfrequentlyused strat-egy to implement nursing guidelines in practice. Not one single strategy,orcombinationofstrategies,canbelinkeddirectlyto suc-cessful implementation of nursing guidelines. Consistency in re-portingoftheusedimplementationstrategiesandthedurationof measurementoftheimpactofthestrategyshouldbeimprovedin futurestudies.
ConflictofInterest Nonedeclared. Funding
TheNetherlandsOrganizationforHealthResearchand Develop-ment(ZonMw) fundedthisstudy;withthe GrantNo. 516004017 . The sponsorhadno role incollection,analysisandinterpretation ofdata,andhadnoroleinwritingthereport,andinthedecision tosubmitthisarticleforpublication.
EthicalApproval Nonedeclared. Supplementarymaterials
Supplementary material associated with this article can be found,intheonlineversion,atdoi:10.1016/j.ijnurstu.2020.103748 . References
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