231 General discussion 8 de-implementation from a nursing perspective, exemplified by the fact that an overview of systematic reviews on de-implementation effectiveness (Kien, Daxenbichler [35] included only one systematic review aiming to reduce low-value care in nursing. Implications Economic evaluations In chapter 4, we collected data on the resources used to execute implementation processes. Data included numbers of hours invested in these processes, numbers of participants, and the duration of the activities. However, in the systematic reviews (chapters 2, 3 and 6) we found that economic evaluations of implementation or de-implementation efforts were rarely reported. When costs were mentioned, they often focused on estimated healthcare savings rather than a comprehensive economic evaluation, which should include the costs of implementation or de-implementation strategies. While an implementation strategy and the innovation itself may impact the targeted outcome, they can also but could also have further impact on costs in other healthcare processes [36]. Economic evaluations help ensure that healthcare interventions are not only effective but also cost-efficient, supporting the long-term sustainability of healthcare systems. It is encouraging that the number of studies including economic evaluations is increasing in response to the growing societal relevance of sustainability and the shift towards appropriate care. For instance, the "Helping Hands" project by Anita Huis demonstrated the effectiveness of various strategies for promoting hospital nurses’ hand hygiene in, highlighting the importance of rigorous implementation and evaluation in achieving sustainable healthcare practices [37]. One critical aspect of sustainability in healthcare is addressing healthcare’s significant environmental impact by promoting the reuse of raw materials. Reducing plastic waste, as the sector is a major contributor to plastic pollution due to its reliance on single-use plastics for medication administration and personal protective equipment. At Erasmus MC, we are working to make intensive care units more sustainable and circular. [38]. These examples illustrate how implementation science can bridge the gap between technological advancements and their practical application in nursing, ensuring that innovations are both effective and sustainable. Education Fundamental care is an important part of nursing education. In the BN2030 profile [39], nurses’ roles have shifted from primarily curative tasks to clearly identifiable preventive responsibilities. Health promotion and prevention have gained prominence in education due to the introduction of concepts like 'positive health' [40] and 'healthy
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