225 General discussion 8 Implementation in nursing care The aging population and increasing prevalence of chronic diseases are driving a higher demand for care in both home and hospital settings [1]. Nurses, comprising 59% of the global healthcare workforce, play a pivotal role in providing this care [2]. However, the growing shortage of nurses underscores the urgent need for effective implementation of evidence-based care to ensure nurses are supported in delivering the best possible care [3]. This thesis includes two systematic reviews (chapters 2 and 3) to identify effective implementation strategies. However, no single strategy or combination of strategies proved universally effective. Contributing factors included a lack of studies identifying determinants, as well as inconsistencies in the specification and reporting of implementation strategies. Identifying determinants Less than half of the studies included in our systematic reviews (Chapters 2 and 3) assessed implementation determinants. This gap is surprising given the abundance of descriptive studies exploring barriers and facilitators [4]. One possible explanation is that these studies often identify determinants within a specific context, making them less transferable to other settings. Only a few included studies used a determinant framework, such as the Theoretical Domains Framework [5] or the Consolidated Framework for Implementation Research (CFIR) [6], to structure their determinant analysis. However, even when studies conducted a determinants analysis, they rarely specified how these informed the selection of tailored implementation strategies. Without this alignment, the value of performing a determinants analysis is significantly diminished. In chapters 4 and 5, I learned about the value of identifying determinants before starting an implementation process, utilizing these to select implementation strategies. A process evaluation one and four years after the implementation of smart functions in medical beds (chapter 4) revealed the absence of a prior determinant assessment. I found that the available smart functions, such as weighing and exit alarm, were rarely used, even one and four years after the introduction. In a comprehensive determinants analysis using the Tailored Implementation for Chronic Diseases [7], many stakeholders seemed to underestimate the added value of the smart beds, dismissing it as ‘It’s just a bed’. In the pilot study of the risk prediction model for pressure ulcer risk, DRAAI (chapter 5), we identified determinants prior to the implementation, notably those considered transferable from the TIMBER study, along with determinants from the literature [8, 9]. These determinants formed the basis for the implementation strategies, likely contributing to the high acceptance of DRAAI in practice. For example, trust and credibility were identified as key barriers, which we addressed through strategies such
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