188 Chapter 6 review of Colla et al. [7], because the quality of the uncontrolled studies could be poor as shown in our study. Another strength is that that the number of ‘missed’ studies is limited because our search strategy was based on the 43 unique terms referring to the process of de-implementation found by Niven et al. [20] and these terms are also used in implementation studies such as ‘reduce, stop and avoid’. Implementation studies may have the same purpose as de-implementation studies. An example of this, is an implementation study that aims to implement a guideline recommendation that states ‘not to use of bandages for wounds closed by primary intention’. In future research, the search strategy may be further improved by adding nursing procedures that are marked as low-value nursing procedures in guidelines [1, 4, 11, 12]. A limitation of this review is the quality of the included studies. The uncontrolled studies had a poor quality, which resulted in an overall low evidence based, precluding drawing conclusions. In addition, the included studies lacked measurements of patient reported outcomes. As a result, it was not possible to determine whether the reduction of low-value nursing procedures have adverse effects on patient outcomes. Furthermore, the included studies did not report on the adherence to the intended deimplementation strategy. As a consequence, it was not possible to determine whether the de-implementation strategy has been executed as planned and the effect can be attributed to the de-implementation strategy. Therefore, further research should not only focus on developing and evaluating the effectiveness of de-implementation strategies, but also to evaluate the process of the de-implementation including the identification of changes in multi-level barriers and facilitators that should be the target of the strategies [17, 53, 54]. Finally, not all controlled studies could be included in the meta-analysis due to missing data. Although we contacted the authors of the two papers with missing data on the change in volume of low-value in nursing, we were not able to obtain the data of two studies due to non-response of the authors.
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