First-line managers' experience of guideline implementation in orthopaedic nursing and rehabilitation: a qualitative study.

BACKGROUND: First-line managers have a unique role and potential in encouraging the use of evidence-based clinical practice guidelines (CPGs) and thus serve the provision of safe patient care. In acute and planned hospital care, effective yet safeguarded nursing procedures are a necessity. Little is currently known about how first-line managers engage in supporting the adoption of evidence-based nursing care and about what barriers and enablers there are for implementation of CPGs in the orthopaedic care context. PURPOSE: To investigate first-line managers' experience of clinical practice guideline implementation in orthopaedic care. METHODS: This qualitative interview study included 30 first-line nursing and rehabilitation managers in 17 orthopaedic units in Sweden. A deductive content analysis, with the Ottawa Model of Implementation Leadership as a guide, was employed. RESULTS: To the first-line managers, any guideline implementation required them to balance contexts, including their outer context (signified by the upper-level management and decision-makers) and their inner context, including staff and patients in their unit(s). Acting in response to these contexts, the managers described navigating the organization and its terms and conditions; using relations-, change-, and task-oriented leadership, such as involving the staff; motivating the change by emphasizing the patient benefits; and procuring resources, such as time and training. Even though they knew from past experience what worked when implementing CPGs, the first-line managers often encountered barriers within the contexts that hampered successful implementation. CONCLUSIONS: Although first-line managers know how to effectively implement CPGs, an organization's terms and conditions can limit their opportunities to fully do so. Organizational awareness of what supports and hinders first-line managers to offer implementation leadership can enhance opportunities to alter behaviours and conditions for the benefit of CPG implementation. TRIAL REGISTRATION: The study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021.

Adherence to evidence-based guidelines for prevention of urinary retention in hip surgery patients: a multicentre observational study.

Urinary retention is a healthcare complication putting patients at risk of unnecessary suffering and harm. Orthopaedic patients are known to face an increased such risk, calling for evidence-based preoperative assessment and corresponding measures to prevent bladder problems. The aim of this study was to evaluate healthcare professionals' adherence to risk assessment guidelines for urinary retention in hip surgery patients. This was an observational study from January 2021 to April 2021 with a descriptive and comparative design, triangulating three data sources: (I) Medical records for 1382 hip surgery patients across 17 hospitals in Sweden were reviewed for preoperative risk assessments for urinary retention and voiding-related variables at discharge; (II) The patients completed a survey regarding postoperative lower urinary tract symptoms, and; (III) data were extracted from a national quality registry regarding type of surgery, preoperative physical status, and perioperative urinary complications. Group differences were analysed with Chi-square/Fisher's exact test, t-test, Wilcoxon rank-sum test, or Mann-Whitney U-test. Logistic regression was used to analyse variables associated with completed risk assessments for urinary retention. Of all study participants, 23.4% (n = 323) had a preoperative documented risk assessment of urinary retention. Whether a risk assessment was performed was significantly associated with acute surgery [odds ratio (OR) 3.56, 95% confidence interval (CI) 2.48-5.12] and undergoing surgery at an academic hospital (OR 4.59, 95% CI 2.68-7.85). Acute patients were more often affected by urinary retention and had bladder issues and/or an indwelling catheter at discharge. More than every tenth patient (11. 9%, n = 53) completing the survey experienced intensified bladder problems after their hip surgery. The study shows a lack of adherence to risk assessment for urinary retention according to evidence-based guidelines, which negatively affects quality of care and patient safety.

Effects of an interactive web-based support system via mobile phone on preference-based patient participation in patients living with hypertension - a randomized controlled trial in primary care.

OBJECTIVE: To estimate the effects of an interactive web-based support system via mobile phone on preference-based patient participation in patients with hypertension treated in primary care (compared with standard hypertensive care only). DESIGN: A parallel group, non-blinded, randomized controlled trial, conducted October 2018-February 2021. Besides standard hypertensive care, the intervention group received eight weeks of support via mobile phone to facilitate self-monitoring and self-management, tentatively providing for augmented patient engagement. SETTING: 31 primary healthcare centers in Sweden. SUBJECTS: 949 patients treated for hypertension. MAIN OUTCOME MEASURES: The effects on preference-based patient participation, that is, the match between a patient's preferences for and experiences of patient participation in their health and healthcare. This was measured with the 4Ps (Patient Preferences for Patient Participation) tool at baseline, after 8 weeks, and at 12 months. Data were registered electronically and analyzed with multilevel ordinal regression. RESULTS: At baseline, 43-51% had a complete match between their preferences for and experiences of patient participation. There was an indication of a positive effect by a higher match for 'managing treatment myself' at 8-weeks in the intervention group. Such preference-based participation in their health and healthcare was reversed at 12 months, and no further effects of the intervention on preference-based patient participation persisted after 12 months. CONCLUSION: The interactive web-based support system via mobile phone had a wavering effect on preference-based patient participation. There is a prevailing need to better understand how person-centered patient participation can be facilitated in primary care.

Although patient participation is essential when having a long-term condition, interventions optimizing individuals' engagement have not been fully identified.About half of the patients with hypertension in this study did not experience participation in the manner and extent they preferred.A web-based support system via mobile phone improved some aspects of patient participation in the short- but not long term.Strategies to better identify patients' preferences for patient participation are needed, to evaluate and improve the outcome of care.

First-line managers' experience of guideline implementation during the COVID-19 pandemic.

AIM(S): To explore first-line managers' experience of guideline implementation in orthopaedic care during the COVID-19 pandemic. DESIGN: A descriptive, qualitative study. METHODS: Semi-structured interviews with 30 first-line nursing and rehabilitation managers in orthopaedic healthcare at university, regional and local hospitals. The interviews were analysed by thematic analysis. RESULTS: First-line managers described the implementation of guidelines related to the pandemic as different from everyday knowledge translation, with a swifter uptake and time freed from routine meetings in order to support staff in adoption and adherence. The urgent need to address the crisis facilitated guideline implementation, even though there were specific pandemic-related barriers such as staffing and communication issues. An overarching theme, Hanging on to guidelines for dear life, is substantiated by three themes: Adapting to facilitate change, Anchoring safety through guidelines and Embracing COVID guidelines. CONCLUSION: A health crisis such as the COVID-19 pandemic can generate enabling elements for guideline implementation in healthcare, despite prevailing or new hindering components. The experience of guideline implementation during the COVID-19 pandemic can improve understanding of context aspects that can benefit organizations in everyday translation of evidence into practice. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Recognizing what enabled guideline implementation in a health crisis can help first-line managers to identify local enabling context elements and processes. This can facilitate future guideline implementation. IMPACT: During the COVID-19 pandemic, the healthcare context and staff's motivation for guideline recognition and adoption changed. Resources and ways to bridge barriers in guideline implementation emerged, although specific challenges arose. Nursing managers can draw on experiences from the COVID-19 pandemic to support implementation of new evidence-based practices in the future. REPORTING METHOD: This study adheres to the EQUATOR guidelines by using Standards for Reporting Qualitative Research (SRQR). No Patient or Public Contribution.

Patient participation in end-stage kidney disease care: variation over time and effects of staff-directed interventions - a quasi-experimental study.

BACKGROUND: Among those elements establishing decent quality of care from a patient perspective, opportunities to participate in accord with one's individual needs and preferences are central. To date, little is known the extent of preference-based patient participation in kidney care, and what facilitates optimal conditions. This study investigated i) preference-based patient participation in kidney care over time, and ii) the effects of interventions designed to enhance person-centred patient participation. METHODS: A quasi-experimental study was conducted across nine kidney care sites in southeast Sweden. A cohort of 358 patients with stage IV chronic kidney disease (eGRF 15-19 ml/min) or V (eGRF < 15 mL/min) entered the study. Of these, 245 patients (with kidney replacement therapy or intermittent outpatient visits only) completed a survey on patient participation at four time points: every six months from August 2019 to May 2021, patients reported their preferences for and experiences of participation using the validated Patient Preferences for Patient Participation tool, the 4Ps. Between the first and second data collection points, interventions were provided for designated staff to facilitate person-centred participation, using two strategies for two subgroups at three sites each: the managers receiving a bundle of information via e-mail on patient participation in a standard dissemination procedure (three sites), or an additional half-year support program for implementation offered to 1-2 staff per site (three sites), with no intervention for a control group (three sites). The differences in 4Ps data between groups were analysed using multilevel ordinal regression. RESULTS: Over time and across all sites, most patients' experiences of participation fully or almost fully matched their engagement preferences (57%-90%). Still, up to 12% of patient reports indicated that their preferences and experiences were insufficiently matched: in these cases, the patients had preferred to be more involved than they had experienced, for example, in making healthcare plans and setting health-related goals. The interventions did not affect the levels of preference-based participation, but patients in the control group sites had slightly more consistent matches. CONCLUSIONS: Living with kidney failure necessitates patient engagement, but opportunities to participate in accordance with one's preferences are not fully provided for all patients. Additional efforts to support a common understanding and to ensure person-centred patient participation is still needed.

Evaluation of patient participation in relation to the implementation of a person-centered nursing shift handover.

BACKGROUND: It has been suggested that nursing shift-to-shift handover should be a more team-based dialogue with and for the patient rather than about a patient. AIM: The aim of this study was to evaluate patient participation in relation to the implementation of the person-centered handover (PCH). METHOD: A pretest-posttest design was used without a comparison group, including patients from nine units in a university hospital at pretest (n = 228) and after implementing PCH (posttest, n = 253) per the framework integrated-Promoting Action on Research Implementation in Health Services. The PCH is inspired by an Australian bedside handover model. The Patient Preferences for the Patient Participation tool was used to rate the preference for and experience of participation on 12 items, combined into three levels of preference-based participation (insufficient-fair-sufficient). RESULTS: There were no differences regarding experience or preference-based participation between patients at pretest-posttest; however, posttest patients experienced participation in the item Reciprocal communication to a lesser extent than the pretest patients. Only 49% of the posttest group received PCH; of those not receiving PCH, some would have wanted PCH (27%), while some would have declined (24%). Patients receiving PCH had sufficient participation (82%), to a greater extent, regarding the item Sharing one's symptoms with staff than patients at pretest (72%). Patients receiving PCH also had sufficient participation, to a greater extent, than patients at posttest who did not receive, but would have wanted PCH, regarding four items: (1) sharing one's symptoms with staff, (2) reciprocal communication, (3) being told what was done, and (4) taking part in planning. LINKING EVIDENCE TO ACTION: Most patients want to be present at PCH. Therefore, nurses should ask for the patients' preferences regarding PCH and act accordingly. Not inviting patients who want PCH could contribute to insufficient patient participation. Further studies are needed to capture what assistance nurses would want in identifying and acting in alignment with patient preferences.

Patient preferences and experiences of participation in surgical cancer care.

BACKGROUND: Quality cancer care necessitates opportunities for patient participation, supposedly recognizing the individual's preferences and experiences for being involved in their health and healthcare issues. Previous research shows that surgical cancer patients wish to be more involved, requiring professionals to be sensitive of patients' needs. AIMS: To explore preference-based patient participation in surgical cancer care. METHODS: A cross-sectional study was conducted. The Patient Preferences for Patient Participation tool (4Ps) was used, which includes 12 attributes of preferences for and experiences of patient participation. Data were analyzed with descriptive and comparative statistical methods. RESULTS: The results are based on a total of 101 questionnaires. Having reciprocal communication and being listened to by healthcare staff were commonly deemed crucial for patient participation. While 60% of the patients suggested that taking part in planning was crucial for their participation, they had experienced this only to some extent. Learning to manage symptoms and phrasing personal goals were items most often representing insufficient conditions for preference-based patient participation. LINKING EVIDENCE TO ACTION: To support person-centered surgical care, further efforts to suffice preference-based participation are needed, including opportunities for patients to share their experiences and engage in the planning of healthcare activities.

Conceptualizing patient participation in psychiatry: A survey describing the voice of patients in outpatient care.

BACKGROUND: While increasingly discussed in somatic care, the concept of patient participation remains unsettled in psychiatric care, potentially impeding person-centred experiences. OBJECTIVE: To describe outpatient psychiatric care patients' conceptualization of patient participation. DESIGN: An exploratory survey. SETTING AND PARTICIPANTS: Patients in four psychiatric outpatient care units. VARIABLES: Patients conceptualized patient participation by completing a semi-structured questionnaire, including optional attributes and free text. Data were analysed using statistics for ordinal data and content analysis for free text. RESULTS: In total, 137 patients (69% of potential respondents) completed the questionnaire. The discrete items were favoured for conceptualizing patient participation, indicating a primary connotation that participation means being listened to, being in a reciprocal dialogue, learning about one's health care and managing one's symptoms. Additional free-text responses acknowledged the attributes previously recognized, and provided supplementary notions, including that patient participation is about mutual respect and shared trust. DISCUSSION: What patient participation is and how it can be facilitated needs to be agreed in order to enable preference-based patient participation. Patients in outpatient psychiatric care conceptualize participation in terms of both sharing of and sharing in, including taking part in joint and solo activities, such as a reciprocal dialogue and managing symptoms by yourself. CONCLUSION: While being a patient in psychiatric care has been associated with a lack of voice, an increased understanding of patient participation enables person-centred care, with the benefits of collaboration, co-production and enhanced quality of care. PATIENT CONTRIBUTION: Patients provided their conceptualization of patient participation in accordance with their lived experience.

Preference-based patient participation for most, if not all: A cross-sectional study of patient participation amongst persons with end-stage kidney disease.

BACKGROUND: Patient participation is considered central for good healthcare. Yet, the concept is not fully understood when it comes to patients' experiences of participation in conjunction with their preferences, particularly in long-term healthcare. The aim of this study was to investigate the extent and variation of preference-based patient participation in patients with end-stage kidney disease (ESKD). METHODS: A cross-sectional study was conducted with 346 patients in renal care. The main variables were patients' preferences for and experiences of patient participation, determined using the Patient Preferences for Patient Participation tool, the 4Ps. Analyses identified the degree of match between preferences and experiences, that is, the preference-based patient participation measure. RESULTS: Overall, 57%-84% of the patients reached a sufficient level of preference-based patient participation on the items, while 2%-12% reached an insufficient level. A mismatch indicated either less or more participation than preferred; for example, 40% had less experience than preferred for taking part in planning, and 40% had more than preferred for managing treatment. CONCLUSION: This study shows that, although many patients reach a sufficient level of preference-based patient participation, this is not the case for all patients and/or attributes. Further opportunities for a mutual understanding of patients' preferences are needed for healthcare professionals to support person-centred patient participation. PATIENT OR PUBLIC CONTRIBUTION: The 4Ps is manufactured in collaboration with people with experience of the patient role, and persons living with ESKD were engaged in identifying their preferences and experiences of participation in renal care.

A Human, Organization, and Technology Perspective on Patients' Experiences of a Chat-Based and Automated Medical History-Taking Service in Primary Health Care: Interview Study Among Primary Care Patients.

BACKGROUND: The use of e-visits in health care is progressing rapidly worldwide. To date, studies on the advantages and disadvantages of e-consultations in the form of chat services for all inquiries in primary care have focused on the perspective of health care professionals (HCPs) rather than those of end users (patients). OBJECTIVE: This study aims to explore patients' experiences using a chat-based and automated medical history-taking service in regular, tax-based, not-for-profit primary care in Sweden. METHODS: Overall, 25 individual interviews were conducted with patients in the catchment areas of 5 primary care centers (PCCs) in Sweden that tested a chat-based and automated medical history-taking service for all types of patient inquiries. The semistructured interviews were transcribed verbatim before content analysis using inductive and deductive strategies, the latter including an unconstrained matrix of human, organization, and technology perspectives. RESULTS: The service provided an easily managed way for patients to make written contact with HCPs, which was considered beneficial for some patients and issues but less suitable for others (acute or more complex cases). The automated medical history-taking service was perceived as having potential but still derived from what HCPs need to know and how they address and communicate health and health care issues. Technical skills were not considered as necessary for a mobile phone chat as for handling a computer; however, patients still expressed concern for people with less digital literacy. The opportunity to take one's time and reflect on one's situation before answering questions from the HCPs was found to reduce stress and prevent errors, and patients speculated that it might be the same for the HCPs on the other end of the system. Patients appreciated the ability to have a conversation from almost anywhere, even from places not suitable for telephone calls. The asynchronicity of the chat service allowed the patients to take more control of the conversation and initiate a chat at any time at their own convenience; however, it could also lead to lengthy conversations where a single issue in the worst cases could take days to close. The opportunity to upload photographs made some visits to the PCC redundant, which would otherwise have been necessary if the ordinary telephone service had been used, saving patients both time and money. CONCLUSIONS: Patients generally had a positive attitude toward e-visits in primary care and were generally pleased with the prospects of the digital tool tested, somewhat more with the actual chat than with the automated history-taking system preceding the chat. Although patients expect their PCC to offer a range of different means of communication, the human, organization, and technology analysis revealed a need for more extensive (end) user experience design in the further development of the chat service.

Assessing and reporting patient participation by means of patient preferences and experiences.

BACKGROUND: Although patient participation is strongly associated with high quality of healthcare, valid means to measure and report a comprehensive notion of patient participation are scarce. The Patient Preferences for Patient Participation (4Ps) is a new healthcare practice and research tool, comprising patients' preferences as well as experiences. The 4Ps employs 12 items for the patient to conceptualise patient participation. The aim of this paper is to describe how the two perspectives of patient participation, namely preferences and experiences, can be combined to visualise and report preference-based patient participation. METHODS: With four response alternatives in each section, the 4Ps offers sixteen possible combinations of degree of match per item. Theoretical and clinical principles fostered a tentative order of six ranks and three levels of preference-based patient participation. To test the standard, statistical analyses for ordinal data were performed, using data from a randomised controlled trial evaluating an intervention aiming to improve patient participation. Further, structures for visualising the preference-based patient participation of individuals and groups were suggested. RESULTS: Data from the 4Ps demonstrated the individuals' preference-based patient participation, indicating either a match or a mismatch for each item. Mismatches represented either the experience of participation surpassing the patient's preferences, or the patient's preferences for patient participation not being established. At group level, the suggested approach for visualising and reporting the 4Ps demonstrated that the intervention group had a significantly higher proportion of sufficient preference-based patient participation for certain items than the control group. These results had not been identified earlier, when using the preferences and experiences of patient participation as separate measures. CONCLUSIONS: Ways to easily acquaint stakeholders with patients' preferences for patient participation are needed, in order for healthcare staff to better use resources to match the basic requirements of individuals and groups. While the 4Ps can guide professionals to patient participation as framed in legislations, concept analyses and by patients, a visualisation of the results is needed to capture preference-based patient participation. The proposed route to representing degree of match in preferences and experiences may also be relevant to other dimensions of quality of healthcare.

Context Factors Facilitating and Hindering Patient Participation in Dialysis Care: A Focus Group Study With Patients and Staff.

BACKGROUND: Safe health care of good quality depends on structured and unceasing efforts to progress, promoting strategies tailored to the context, including elements such as patients' preferences. Although patient participation is a common concept in health care, there is yet limited understanding of the factors that facilitate and hinder it in a healthcare context. AIMS: This paper identifies what patients and health professionals depict in terms of enablers and barriers for patient participation in dialysis care. METHODS: An explorative qualitative design was applied with seven focus group discussions with patients, staff, and managers across different types of hospitals, with the texts analyzed with content analysis. RESULTS: The dialysis context represents three key elements-people, resources, and interactions-that can both enable and hinder patient participation. Both barriers and facilitators for patient participation were found to reside at individual, team, and organizational levels, with a greater number of enabling factors implied by both patients and staff. LINKING EVIDENCE TO ACTION: While the dialysis context comprises opportunities for progress in favor of patient participation, a shared understanding of the concept is needed, along with how contextual factors can facilitate conditions for participation by patient preferences. In addition, the most favorable strategy for implementing person-centered care is not yet known, but to facilitate patient participation from a patient perspective, creating opportunities to enable staff and patients to share a common understanding is needed, along with tools to facilitate a dialogue on patient participation.

Using Nonparticipant Observation as a Method to Understand Implementation Context in Evidence-Based Practice.

BACKGROUND: The uptake of evidence-based knowledge in practice is influenced by context. Observations are suggested as a valuable but under-used approach in implementation research for gaining a holistic understanding of contexts. AIM: The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research. METHODS: Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively). RESULTS: Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence-based practice, and the dynamic interaction between different aspects of context. LINKING EVIDENCE TO ACTION: Although qualitative observations are resource-intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge-sharing triad in implementation research.

Patient participation in dialysis care-A qualitative study of patients' and health professionals' perspectives.

BACKGROUND AND OBJECTIVE: End-stage renal disease (ESRD) affects a multitude of aspects in the patient's daily life, often entailing their own involvement in various aspects of the treatment. Although patient participation is a core health-care value, what the concept signifies is not yet fully known. The purpose of this paper is to conceptualize patient participation in dialysis care, depicting patients' and health-care professionals' perspectives. DESIGN: This explorative study employed qualitative interviews and content analysis. SETTING AND PARTICIPANTS: Seven focus group discussions engaging 42 key informants were performed, including patients, staff and managers with experience of dialysis care. RESULTS: In dialysis care, patient participation connotes a sharing of information and knowledge, the learning of and planning of care, including partaking in shared decisions with regards to treatment and management, and being involved in the management of one's own health-care treatment and/or self-care activities. Although these attributes were illustrated by all stakeholders, their significance varied: patients suggested that their preferences regarding primary aspects of participation vary, while staff considered patients' performance of dialysis to be the ultimate form of participation. Further, while patients considered multiple ways to execute participation, staff suggested that aspects such as sharing information were a route to, rather than actual, involvement. CONCLUSIONS: Without a common understanding to denote the idea of patient participation, staff and patients are exposed to a potential deficit in terms of facilitating patient participation in everyday encounters of dialysis treatment. Further studies and means to serve a mutual understanding are needed.

Nursing management matters for registered nurses with a PhD working in clinical practice.

AIM: To investigate what registered nurses (RNs) with a PhD working in clinical practice experience in terms of their role, function and work context. BACKGROUND: Previous studies have shown that RNs with a graduate degree contribute to better and safer care for patients. However, little is known about what further academic schooling of RNs, at PhD level, means for clinical practice. METHOD: Qualitative design, with semi-structured interviews and inductive content analysis. RESULTS: The main areas of responsibilities for RNs with a PhD working in clinical practice were related to practice development and implementation of research results. In their work, they experienced barriers to the full use of their competence; the expectations and prerequisites of the organisation were not clearly defined, and they often lacked a mandate to create conditions for quality improvement of nursing care. CONCLUSIONS: RNs with a PhD can contribute to evidence-based practice (EBP), clinical training, as well as the development of clinical research. Their roles and responsibilities need to be clarified, and for this, they need support from managers. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers have the opportunity to partner with RNs with a PhD to support the EBP process and help structure nursing practice in more efficient ways.

Clinical interventions, implementation interventions, and the potential greyness in between -a discussion paper.

BACKGROUND: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. DISCUSSION: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. CONCLUSION: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

Are data from national quality registries used in quality improvement at Swedish hospital clinics?

OBJECTIVE: To investigate the use of data from national quality registries (NQRs) in local quality improvement as well as purported key factors for effective clinical use in Sweden. DESIGN: Comparative descriptive: a web survey of all Swedish hospitals participating in three NQRs with different levels of development (certification level). SETTING AND PARTICIPANTS: Heads of the clinics and physician(s) at clinics participating in the Swedish Stroke Register (Riksstroke), the Swedish National Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) and the Swedish Lung Cancer Registry (NLCR). MAIN OUTCOME MEASURE(S): Individual and unit level use of NQRs in local quality improvement, and perceptions on data quality, organizational conditions and user motivation. RESULTS: Riksstroke data were reported as most extensively used at individual and unit levels (x̅ 17.97 of 24 and x̅ 27.06 of 35). Data quality and usefulness was considered high for the two most developed NQRs (x̅ 19.86 for Riksstroke and x̅ 19.89 for GallRiks of 25). Organizational conditions were estimated at the same level for Riksstroke and GallRiks (x̅ 12.90 and x̅ 13.28 of 20) while the least developed registry, the NLCR, had lower estimates (x̅ 10.32). In Riksstroke, the managers requested registry data more often (x̅ 15.17 of 20). CONCLUSIONS: While there were significant differences between registries in key factors such as management interest, use of NQR data in local quality improvement seems rather prevalent, at least for Riksstroke. The link between the registry's level of development and factors important for routinization of innovations such as NQRs needs investigation.

Urinary incontinence and its management in patients aged 65 and older in orthopaedic care - what nursing and rehabilitation staff know and do.

AIMS AND OBJECTIVES: To describe what nursing and rehabilitation staff know and do with regard to urinary incontinence and risk of urinary incontinence in patients 65 years or older undergoing hip surgery. BACKGROUND: Urinary incontinence is a common but often neglected issue for older people. Despite the existence of evidence-based guidelines on how to assess, manage and prevent urinary incontinence, there are indications that these guidelines are not applied in hospital care. DESIGN: A qualitative study with descriptive design was conducted in two orthopaedic units. METHODS: Forty-six interviews and 36 observations of care were conducted from January-October 2014 and analysed with qualitative content analysis. RESULTS: Enrolled nurses performed most of the care related to bladder function, with focus on urinary catheterisation and preventing urinary tract infection and urinary retention. Registered nurses' role in urinary matters mainly comprised documentation, while the rehabilitation staff focused on making it possible for the patient to be independent in toileting. The nursing staff considered urinary incontinence a common condition for older people and that it was convenient for the patients to have an indwelling catheter or incontinence pad/pant, although they acknowledged some of the risks associated with these procedures. CONCLUSIONS: Urinary incontinence is not a priority in orthopaedic care, and urinary incontinence guidelines are not applied. Further, attitudes and actions are mainly characterised by a lack of urinary incontinence knowledge and the nursing and rehabilitation staff do not take a team approach to preventing and managing urinary incontinence. RELEVANCE TO CLINICAL PRACTICE: An increased focus on knowledge on urinary incontinence and evidence-based guidelines is needed. To secure evidence-based practice, the team of nursing and rehabilitation staff and managers must be aligned and work actively together, also including the patient in the team.

'I have the world's best job' - staff experience of the advantages of caring for older people.

RATIONALE: Besides a growing demand for safe high-quality care for older people, long-term care (LTC) often struggles to recruit appropriately qualified nursing staff. Understanding what LTC staff value in their work may contribute to a more comprehensive understanding of what can attract staff and support person-centred care. AIM: To explore staff experience of the advantages of working in LTC settings for older people. METHODS: Narrative descriptions of 85 LTC staff in Ireland, the Netherlands and Sweden on what they value in their work were analysed with qualitative content analysis. ETHICS: Ethical approval was obtained according to the requirements of each country, and participants provided informed consent prior to the individual interviews. FINDINGS: Working in LTC signifies bonding with the older people residing there, their next of kin and the team members. It means autonomy in one's daily tasks amalgamated with being a part of an affirmative team. Participants reported a sense of accomplishment and fulfilment; caring meant consideration and recognition of the older people and the relationships formed, which provided for professional and personal growth. The sharing of compassion between staff and residents indicated reciprocity of the relationship with residents. STUDY LIMITATIONS: The findings may be transferable to LTC in general although they address only the positive aspects of caring for older people and only the experiences of those staff who had consented to take part in the study. CONCLUSIONS: The findings add to what underpins the quality of care in nursing homes: compassion in the nurse-resident relationship and person-centred care in LTC. They indicate reciprocity in the relations formed that may contribute to the empowerment of older people, but further studies are needed to explore this in more detail.

What Registered Nurses Do and Do Not in the Management of Pediatric Peripheral Venous Catheters and Guidelines: Unpacking the Outcomes of Computer Reminders.

BACKGROUND: Clinical practical guidelines (CPGs) may enhance evidence-based practice, but require implementation. Computer reminders have previously shown various effects in supporting implementation; in a concomitant study, we found no effect on complications in peripheral venous catheters (PVCs) or registered nurses' (RNs) adherence to a CPG in pediatric care. Yet, there is a need to determine how reminders operate in particular contexts. AIM: To depict if, in what context, and how computer reminders regarding evidence-based management of PVC in pediatric care are applied according to RNs' actions and experience. METHODS: Qualitative data from nonparticipant observations and interviews with 18 RNs in four intervention units at a pediatric hospital were analyzed with content analysis. FINDINGS: Attention given to the computer reminders varied; the RNs noticed them in units where there was an agreement about the management and recording of PVCs, but not elsewhere. Rather, computer reminders did not facilitate adherence to the PVC-CPG where the CPG was not acknowledged from the start. RNs who knew how to manage PVCs had peer support and received additional reminders, which suggested that the computer reminders added to the significance of PVCs in pediatric care. LINKING EVIDENCE TO ACTION: While the computer reminders alone did not support CPG implementation, they further increased the attention to PVCs in contexts where there was a readiness to change along with a supportive culture. We suggest further studies tailoring implementation strategies to include electronic means if there is a beneficial context.