44 Chapter 2 In this review, it was identified that most strategies were quite traditional, such as using posters and written material, instead of apps, screensavers, or educational games. Several studies recommend investing in online and social media, which can substantially advance implementation science [83-85]. The scope of this review was to get a complete overview of strategies used to implement nursing guidelines, and subsequently get insights in the effects of implementation strategies across all settings and guideline topics. We were able to gain insight in the strategies used on a regular basis. Nevertheless, because of the varying strengths and limitations of the included studies, we could not identify a single or combination of implementation strategies that is most effective in getting nursing guidelines into practice. We think that narrowing the scope of settings and guideline topics will not result in better understanding of the effectiveness of implementation strategies. Only a comparison of studies with detailed descriptions of the delivered strategies and the same timeline might achieve this. Strength and Limitations This review has several strengths and limitations. First, we are confident that we present a complete overview of implementation studies regarding nursing guidelines. Most studies were found with the initial search strategy. Second, due to the collaboration in data extraction between TR, EI and DS we warranted that the collected data from the individual studies are reliable. Repeated discussion about several implementation strategies led to a better understanding of the individual data, and resulted in a consistent reliable assessment of each included study. Third, for the interpretation of the effectiveness of the implementation strategies the outcomes where dichotomized into effect or no effect for patient-related nursing outcomes or guideline adherence. Using these two primary outcomes to assess the impact of the implementation studies is consistent with Curran et al. [86]. These authors suggest that a dual focus in assessing clinical effectiveness and implementation could speed the translation of research findings in routine practice. A limitation is the quality of the before-after studies, which resulted in an overall low evidence base, precluding drawing conclusions. Which caused a high risk of bias across all studies, so caution is needed in drawing conclusions. A second limitation is the probable publication bias, in that studies achieving negative results tend to go unpublished. Still, nearly half of the published studies showed no change.
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