233 General discussion 8 be incorporated into BN2040 to strengthen the value of implementation science in nursing. Additionally, preparing more implementation support practitioners [44] as highlighted by Brownson, Cabassa [45] and Wensing and Wilson [46] can support researchers and practitioners. These efforts should ultimately improve patient outcomes and healthcare efficiency. Methodological considerations This thesis includes three systematic reviews. The value and limitations of systematic reviews in implementation science are important to consider. Unlike in traditional medical research, where systematic reviews with meta-analysis of randomized controlled trials top the hierarchy of evidence, comparison of methods from publications used in implementation science is less straightforward. First, randomization options are often limited, or rely on cluster randomization [47]. Second, the contexts are rarely completely comparable [48]. Third, implementation strategies often are adapted in the process, operationalized by different people, who may interpret the instructions on how to apply these strategies differently, and simply are different human beings taking their personality and personal beliefs with them [22]. Fourth, implementation science and nursing studies are often quality improvement studies with before-after designs or qualitative research, which limits the added value of performing meta-analysis. While we were able to perform a meta-analysis in Chapter 6, the reviews in chapters 2 and 3 did not include studies using comparable implementation strategies and outcomes. The inability of pooling limited the learning potential from systematic reviews in this field. Other review methods – such as a scoping or integrative review – might be more appropriate for assessing the literature in this field. Scoping reviews allow for assessing grey literature, revealing all existing knowledge on a specific topic. In this type of review the weight of the evidence is less important [49]. Integrative reviews go beyond the scoping review as they not only provide an overview of available knowledge but also establish connections and/or develop theories that are directly applicable to practice and policy [50]. The latter could especially be beneficial for identifying mechanisms of change. Confidence in implementation science Over the last years, I was often asked why nurses do not always provide evidence-based care or follow protocols. This question felt like an attack on the nursing profession, but this was completely unjustified considering that it is an equally big problem among other healthcare professional groups. For instance, Cabana, Rand [51] published a paper titled 'Why don't doctors follow the guidelines' in 1999. More recent publications among
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