171 Effects of de-implementation strategies aimed at reducing low-value nursing procedures 6 value nursing care till 61.9% [33]. Four of the positive significant studies had a single de-implementation strategy [31, 33, 35, 37], which means that the strategies consisted of only one strategy component (table 3a). Five of the six studies used an educational component (meetings and/or materials) as an intervention strategy [31-34, 37]. However, none of the studies with a positive significant effect on the primary outcome based their de-implementation strategy on a barrier assessment. Only one uncontrolled study without a positive significant effect performed a barrier assessment [9]. None of the uncontrolled studies reported about adherence to the de-implementation strategy, changes in patient satisfaction with care, changes in costs made by the deimplementation strategy, and changes in costs of the delivery of care. Controlled studies The de-implementation strategies of eight of the fifteen controlled studies resulted in a positive significant effect on volume of low-value nursing procedures (table 2b). The reduction in volume of low-value nursing procedure in the controlled studies with a Positive significant effect who measured patient outcomes (n=7) ranged from 6.5% [47] till 28.7% [39]. Seven of the eight positive significant studies had a multifaceted de-implementation strategy (table 3b) and all eight studies focused their strategy at reducing the use of restraints [39, 41-43, 47, 50-52]. Besides, the eight studies with a positive significant effect had an educational component (educational meetings, educational materials, educational outreach visits, and educational games) in their de-implementation strategy. However, none of the studies with a positive significant effect on the primary outcome based their de-implementation strategy on a barrier assessment. Only one controlled study without a positive significant effect performed a barrier assessment [38]. None of the studies reported about adherence to the de-implementation strategy, changes in patient satisfaction with care, changes in costs made by the deimplementation strategy, and changes in costs of the delivery of care. Five studies aiming to reduce restraint use, reported about falls [39, 46-49]. However, different outcome measurements (e.g. risk of falls, total number of falls, fall related injuries, the proportion of those who suffered from one or more falls, and the percentages of falls) have been used for these studies.
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