2 45 Implementation strategies used to implement nursing guidelines in daily practice A third limitation regards the wide variety in degree of details of the used strategies. All described implementation strategies classified according the EPOC taxonomy independent to the provided description and operationalisation of the strategy were considered equally in this study. It can be questioned, however, whether the described implementation strategies were comparable for all studies that used the same type of strategies. The potential lack of comparability may have affected the interpretation of the effects of the implementation strategies. Strategies were poorly described and operationalized; for example, only the type of strategy was provided, such as audit and feedback. We propose that strategies must be precise enough to enable measurement and reproducibility, following the recommendation of Proctor et al. [87] or using The Standards for Reporting Implementation Studies (StaRI) Statement [88]. These checklists could help standardize the way these studies are described. To fully understand the effect of a strategy such as audit and feedback, information on the extent, the number of audits and the fraction of the participants in the target group must be available. Fourth, calculating the relative change for controlled studies and before-after studies separately might lead to an overestimation for the before-after studies, and an underestimation for the controlled studies. In some controlled studies there were signs of contamination between groups, what could have caused an effect in the control group, thus leading to an underestimation of the relative change. Lastly, we found a wide variety in the duration and interval of measurements, and many studies did not provide an indication of their baseline, implementation and/ or post-implementation phase, or provided a ‘short’ follow-up. An adequate followup time provides information about the sustainability; i.e., whether the guideline is maintained or institutionalized within a service setting’s ongoing, stable operations [87]. The problem is of course that research projects are sponsored for a limited period and evaluating the long-term effects are often not feasible. Recommendations We recommend well-designed studies to test the effectiveness of implementation strategies. In future research the implementation details should ideally be reported according to standardized formats, for example as suggested by Proctor et al. [87] or Pinnock et al. [88]. A more detailed description of the implementation process makes it easier to understand the change mechanism. Abraham et al. [37] provided a detailed supplemental file containing the components, description and actual dose delivered of their intervention components. This inventory is helpful for future research, but also for clinical practice.
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