2 33 Implementation strategies used to implement nursing guidelines in daily practice but not exactly derived in the same way. For example, Koh et al. [73] reported that they measured the incidence of pressure ulcers on the heel only. The other four studies provided no details about the location of pressure ulcers. The second group consisted of four studies [41-44] regarding nutritional intake. The median relative change percentage for these studies was 3.3 (IQR 0.9 – 11.0). The third group consisted of three studies [46-48] regarding oral care, with a median relative change percentage of 3.3. Guideline adherence Guideline adherence was measured in 44 studies, of which 26 (59,1%) showed a significant improvement, fourteen measured no change, and four did not perform statistical tests. Due to the heterogeneity in measuring adherence across all studies, we cannot draw an overall conclusion on the change in adherence rates. For example, several studies measured adherence rates regarding pain management (assessment and/or treatment). Kingsnorth et al. [65] found a significant and clinically relevant improvement in the documentation of pain scores, from 9% adherence rate at baseline to 100% adherence rate two years later. Dulko et al. [63] showed an increase in adherence rate for initial comprehensive pain assessment from 1% to 43% (p = 0.008). Twelve of the controlled studies (n=15) measured adherence. In six studies a significant positive effect on adherence was found (n=6); six found no effect (n=6). Thirty-two of the before-after studies (n=32) measured adherence. Twenty studies found a significant positive effect on adherence (n=20), eight found no effect (n=8), and four performed no statistical tests (n=4). When comparing the controlled and before-after studies, we found no significant difference between these groups on effect on adherence (Pearson Chi-Square 0.564, p>.05). Implementation strategies Description of the details of the implementation strategies varied widely between studies. Some provided a detailed process description, others just mentioned the type of strategy (e.g., audit and feedback). Table 2 provides an overview of applied strategies categorized according to the Cochrane Effective Practice and Organisation of Care taxonomy and Supplement 2 provides a detailed description of the implementation strategies. Each study used more than one strategy, with a median of 6 (IQR 4-8). Apart from one study [63], studies applied at least one educational strategy; e.g., educational material (n=38, 71.7%), meeting (n=43, 81.1%), outreach (n=10, 18.9%) or inter-professional education (n=14,26.4%). Next to educational strategies, the use of local opinion leaders (n=29, 54.7%), and audit and feedback (n=22, 41.5%) were regularly applied. Only one study, Rosen et al. [74]
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