2 43 Implementation strategies used to implement nursing guidelines in daily practice post-implementation measurement, with a median duration of 6 months (IQR 3.8-12.8). One study performed a third post-implementation measurement lasting 16 months. Discussion To our knowledge, this is the first systematic review on the effects of implementation of nursing guidelines in all fields of practice and the used implementation strategies. The broad view across the field of implementation science regarding nursing guidelines identified a diverse range of implementation strategies, combinations of different strategies, guidelines, outcome measures and settings. These findings provide a good reflection of current practices and considerations. We presented the findings as a descriptive and narrative synthesis because a meta-analysis was not possible in view of the heterogeneity of guidelines, implementation and clinical outcomes, the variety of used (combinations of) strategies and the varying timing in follow-up measurements among the included studies. More than half of the studies showed a significant positive effect of the implementation of nursing guidelines on patient-related nursing outcomes and/or adherence to the guideline(s). There was no association between relative change on patient-related nursing outcomes and the number of implementation strategies in total or the use of combined strategies from the different EPOC categories. There was a significant difference in the relative change in favour of the before-after studies, however this seems to be related to the study design. There is not one strategy, or combination of strategies, which can be linked directly to successful implementation. We could not assess whether implementation success was related to the use of a theory, model or framework, performing a barrier assessment or using tailored strategies, due to the small number of studies describing this. In line with findings from previous reviews [12, 79], we found that education was the most used strategy to implement evidence-based nursing, and noted that education is less to moderate effective on its own [80, 81]. However, somewhat less than half of the studies that performed a barrier assessment found a lack of knowledge as a barrier. In contrast to other medical professions, nurses are not always –differs per country– required to take continuing education courses to keep their licensing [82]. Taken that into account, it makes sense to apply at least an educational strategy for the implementation of nursing guidelines.
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