'There was a pivotal moment'. The dynamics, transitions, adaptations and trajectories of nursing at the front-line in the UK during the COVID-19 pandemic.

Using qualitative interview data (n = 142 interviews) generated with 50 nurses, over the course of the COVID-19 pandemic, this paper traces the trajectories of nurses in the UK and attempts to unpick the interplay between structure and agency in their narratives. Interviews were inductively analysed for themes and an additional narrative analysis was undertaken to preserve the form of each participant's narrative. We argue that nurses' pandemic trajectories occurred within the 'psychological vulnerability-stigma nexus' which operates within health and social care providers in the UK and whilst constraining nurses' agency at times it could also provide an impetus to act agentically. We found that the nurses' COVID-19 trajectories were characterised by: getting by, getting out (job-hopping) getting needs met and getting organised. We call for more considered systemic support to be generated and consistently provided to nurses to ensure retention of nurses and the security of society to avoid exacerbating existing workforce shortages.

Non-allergist healthcare workers views on delivering a penicillin allergy de-labelling inpatient pathway: identifying the barriers and enablers.

Background: Non-allergist delivered PADL is supported by UK and World Health Organization guidelines but is not yet routine in UK hospitals. Understanding the views of healthcare workers (HCWs) on managing patients with penA records and exploring perspectives on delivering a PADL inpatient pathway are required to inform the development of non-allergist delivered PADL pathways. Objective: To explore the perspectives of non-allergist HCWs working in medical specialties on managing patients with penA records, and to explore the enablers and barriers to embedding PADL as a standard of care for inpatients. Methods: Semi-structured interviews with doctors, nurses, pharmacists and medicines optimization pharmacy technicians working in a district general hospital in the UK. Thematic analysis was used to analyse the data. Results: The PADL pathway was considered a shared responsibility of the multidisciplinary team, which needed to be structured and supported by a framework. PADL aligns with HCW roles but time to deliver PADL was a barrier. Training for HCWs on the benefits of PADL and delivering PADL for those patients where a penicillin might be beneficial during the current episode of care would both motivate HCWs to deliver PADL. Discussion and conclusion: The PADL pathway was acceptable to HCWs and aligned with their roles and current healthcare processes but their capacity to deliver PADL in a time pressured environment was a significant barrier.

Experiences of an inpatient penicillin allergy de-labelling pathway: capturing the patient voice.

Background: Non-allergist-delivered penicillin allergy de-labelling (PADL) is supported by UK and other national guidelines but is not yet routine practice in UK hospitals. Those who have undergone PADL report high rates of acceptance, but it is unknown why some continue to avoid penicillin, and why some decline testing. Objectives: To explore the experiences of patients recently approached for penicillin allergy (penA) assessment and de-label by non-allergists in a UK hospital to determine the barriers and enablers to patient acceptance of PADL. Methods: Qualitative study using semi-structured interviews with patients who were penA assessed and de-labelled during an inpatient stay between November 2022 and January 2023. Thematic analysis was used to analyse the data. Results: Nineteen patients were interviewed. Patients were largely unaware of the negative impact of penA on their healthcare. Patients had differing views on challenging their penA status while they were acutely unwell, some agreeing that it is the right time to test and others not. Patients declined testing because they felt they were at higher potential risk because they were older or had multiple comorbidities. Some patients who declined testing felt they would have been persuaded if they had received a better explanation of the risks and benefits of PADL. Conclusions: Patients who were successfully de-labelled were positive about the experience. Those who declined testing did so for a variety of reasons including frailty/comorbidities or a fear of testing whilst unwell. Patients highlighted the importance of good communication about the personalized risks and benefits of testing.

The Experience of Physical Recovery and Physical Rehabilitation Following Hospital Discharge for Intensive Care Survivors-A Qualitative Systematic Review.

BACKGROUND: Over 120,000 people in the UK survive critical illness each year, with over 60% of these experiencing mobility issues and reduced health-related quality of life after discharge home. This qualitative systematic review aimed to explore critical care survivors' perceptions, opinions, and experiences of physical recovery and physical rehabilitation following hospital discharge. METHODS: This review followed the Joanna Briggs Institute (JBI) methodology with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was conducted between January 2020 and June 2022. The search was conducted using the following databases: Embase, CINAHL, Medline Ovid, Cochrane, and the Joanna Briggs Institute, and sources of grey literature were searched for eligible studies. Qualitative studies focused on physical rehabilitation or recovery, involving adult survivors of critical illness who had been discharged from hospital. RESULTS: A total of 7 of 548 identified studies published in 2007-2019 were eligible for inclusion. The findings indicate that qualitative evidence around the experiences of physical recovery and rehabilitation interventions following discharge home after critical illness is limited. Three synthesised findings were identified: 'Positivity, motivation and hope'; 'Recovery is hard and patients need support'; and 'Patients experience challenges in momentum of physical recovery'. CONCLUSIONS: Survivors struggle to access healthcare professionals and services following discharge home, which influences the momentum of physical recovery. Supervised exercise programmes had a positive impact on the perception of recovery and motivation. However, 'simple' structured exercise provision will not address the range of challenges experienced by ICU survivors. Whilst some factors influencing physical recovery are similar to other groups, there are unique issues experienced by those returning home after critical illness. Further research is needed to identify the support or interventions survivors feel would meet their needs and assist their physical recovery. This study was prospectively registered with Prospero on 3/2/2020 with registration number CRD42020165290.

The South West Clinical School model: an initiative to transform clinical academic career pathways.

Background: The Clinical School Model connects professorial staff from the university directly to practitioners in the National Health Service to promote evidence informed practice and develop clinical academic careers. These are promoted widely, but strategic adoption into organisational culture and workforce plans are challenging to overcome. Aims: To describe the development of the Clinical School Model in Cornwall and explore how it generates impact through staff engagement activities to support clinical academic career pathways. Structure, process and outcomes developments over the last 3-years are reported. Methods: Donabedian's framework (structure, process and outcome) was used to report on the development and impact of the Clinical School Model. Results: Structural and process activities are reported, illustrating strong foundations to embed clinical academic career pathway opportunities. In the absence of empirical reporting standards for such developments, quantitative and qualitative outcomes are reported against the Clinical School's 5-year strategic plan. Conclusions: This paper responds to the lack of reported evidence on developing organisational infrastructure to address the clinical academics aspirations of nurses and their employers. This important contribution leads a call for more organisations to report to the evidence base, enabling shared learning and shaping future research.

'Pretty cathartic actually': Reflections on the attempt to reduce re-traumatization of researchers and nurses taking part in a longitudinal interview study.

AIM: To critically evaluate the concepts of harm and re-traumatization in the research process and to explore the ethical implications of conducting research on distressing topics using our research on the experiences of nurses working during the COVID-19 pandemic as an exemplar. DESIGN: Longitudinal qualitative interview study. METHODS: Using qualitative narrative interviews, we explored the impacts of the COVID-19 pandemic on nurses' psychological well-being in the UK. RESULTS: To reduce the potential for harm to both research participants and researchers, the members of the research team were keen to establish ways to reduce the power differential between the researcher and participants. We found that our collaborative and team-based approach, with participant autonomy and researcher reflexivity embedded into the research framework, enabled the sensitive generation of data. CONCLUSION: Reduction of potential harm for both participants and researchers in the generation of at times highly distressing data with a traumatized population was achieved through a respectful, honest and empathetic approach within a team that met frequently for reflection. IMPACT: The research participants were not harmed by our research, instead they expressed gratitude at being given space and time to tell their stories in a supportive environment. Our work advances nursing knowledge through accentuating the value of giving autonomy to research participants to control their stories whilst working within a supportive research team with emphasis placed on reflexivity and debriefing. PATIENT AND PUBLIC CONTRIBUTION: Nurses working clinically during COVID-19 were involved in the development of this study. Nurse participants were given autonomy over how and when they participated in the research process.

A nurse-led comprehensive geriatric assessment intervention in primary care: A feasibility cluster randomized controlled trial.

AIM: To determine the feasibility of a nurse-led, primary care-based comprehensive geriatric assessment (CGA) intervention. DESIGN: A feasibility cluster randomized controlled trial. METHODS: The trial was conducted in six general practices in the United Kingdom from May 2018 to April 2020. Participants were moderately/severely frail people aged 65 years and older living at home. Clusters were randomly assigned to the intervention arm control arms. A CGA was delivered to the intervention participants, with control participants receiving usual care. Study outcomes related to feasibility of the intervention and of conducting the trial including recruitment and retention. A range of outcome measures of quality of life, function, loneliness, self-determination, mortality, hospital admission/readmission and number of prescribed medications were evaluated. RESULTS: All pre-specified feasibility criteria relating to recruitment and retention were met with 56 participants recruited in total (30 intervention and 26 control). Retention was high with 94.6% of participants completing 13-week follow-up and 87.5% (n = 49) completing 26-week follow-up. All outcome measures instruments met feasibility criteria relating to completeness and responsiveness over time. Quality of life was recommended as the primary outcome for a definitive trial with numbers of prescribed medications as a secondary outcome measure. CONCLUSION: It is feasible to implement and conduct a randomized controlled trial of a nurse-led, primary care-based CGA intervention. IMPACT: The study provided evidence on the feasibility of a CGA intervention for older people delivered in primary care. It provides information to maximize the success of a definitive trial of the clinical effectiveness of the intervention. PATIENT OR PUBLIC CONTRIBUTION: Patient and public representatives were involved in the study design including intervention development and production of participant-facing documentation. Representatives served on the trial management and steering committees and, as part of this role, interpreted feasibility data. ISRCTN Number: 74345449.

Exploring incidence and risk factors for persistent postoperative opioid use in adult surgical patients: a systematic review protocol.

OBJECTIVE: The objective of this review is to determine the incidence of persistent postsurgical use of opioids in adult patients and the associated risk factors. INTRODUCTION: Surgery has been identified as an independent risk factor for unwarranted chronic opioid use, contributing to opioid-related harm in the community. Persistent opioid use after surgery is associated with morbidity and mortality from opioid-related adverse events, indicating a significant yet mitigable public health concern. There is substantial variation in the reported incidence and risk factors for postoperative opioid use, which require evaluation for future evidence-based risk-reduction strategies. INCLUSION CRITERIA: This review will include studies investigating the persistent use of opioids after 90 postoperative days in adult (≥18 y) patients undergoing surgery of any type, including patients with cancer pain. Selected evidence must report on opioid use prior to surgery. Analytical and descriptive observational studies, and experimental and quasi-experimental studies, published in the previous decade will be eligible for inclusion. METHODS: The proposed study methods follow the JBI methodology for systematic reviews of prevalence and incidence. A systematic search will be conducted in PubMed, Embase, CINAHL, Cochrane Central, and Web of Science, and a search of gray literature will include Google Scholar and ClinicalTrials.gov. Study selection, critical appraisal, and data extraction will be performed by 2 independent reviewers aided by the relevant JBI systematic review tools. We aim to produce a narrative synthesis of results and conduct a meta-analysis where feasible, in addition to subgroup analyses of suitable populations. The results are intended to promote safe, evidence-based postoperative opioid prescribing when considering risk factors for persistent postoperative opioid use. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42022320691.

Speaking up during the COVID-19 pandemic: Nurses' experiences of organizational disregard and silence.

AIM: To critically examine nurses' experiences of speaking up during COVID-19 and the consequences of doing so. DESIGN: Longitudinal qualitative study. METHODS: Participants were purposively sampled to represent differing geographical locations, specialities, settings and redeployment experiences. They were interviewed (remotely) between July 2020 and April 2022 using a semi-structured interview topic guide. RESULTS: Three key themes were identified inductively from our analysis including: (1) Under threat: The ability to speak up or not; (2) Risk tolerance and avoidance: Consequences of speaking up; and (3) Deafness and hostility: Responses to speaking up. Nurses reported that their attempts to speak up typically focused on PPE, patient safety and redeployment. Findings indicate that when NHS Trusts and community services initiated their pandemic response policies, nurses' opportunities to speak up were frequently thwarted. CONCLUSION: Accounts presented in this article include nurses' feeling a sense of futility or of suffering in silence in relation to speaking up. Nurses also fear the consequences of speaking up. Those who did speak up encountered a 'deaf' or hostile response, leaving nurses feeling disregarded by their organization. This points to missed opportunities to learn from those on the front line. IMPACT: Speaking up interventions need to focus on enhancing the skills to both speak up, and respond appropriately, particularly when power, hierarchy, fear and threat might be concerned. PATIENT OR PUBLIC CONTRIBUTION: Nurses working clinically during COVID-19 were involved in the development of this study. Participants were also involved in the development of our interview topic guide and comments obtained from the initial survey helped to shape the study design.

Telerehabilitation for people with physical disabilities and movement impairment: development and evaluation of an online toolkit for practitioners and patients.

PURPOSE: Telerehabilitation has increasingly been used since the COVID-19 pandemic but with limited guidance available on undertaking physical assessments using remote methods. We aimed to provide such guidance by developing a Telerehab Toolkit, an online information and training resource for practitioners, patients, and carers on telerehabilitation for people with physical disabilities and movement impairment. MATERIALS AND METHODS: Development and evaluation of the toolkit were informed by the Knowledge to Action framework and took place iteratively in two phases-knowledge creation and action. Information was collated from various sources including literature review, online survey, service evaluation, and focus group discussions. The toolkit has been evaluated using think-aloud interviews, e-mail and social media feedback from users, and analytics data on user engagement with the website. RESULTS: The Telerehab Toolkit focuses on remote physical assessments, and contains information on technology, digital skills, remote assessment tools, information governance, and safety for telerehabilitation. Resources include top tips from practitioners and patients, how-to guides, checklists, videos, and links to evidence. CONCLUSIONS: The Telerehab Toolkit has been well-received by practitioners, healthcare students, patients, and carers, is being disseminated widely, and is freely available (www.plymouth.ac.uk/research/telerehab). IMPLICATIONS FOR REHABILITATIONTelerehabilitation has been increasingly used since the COVID-19 pandemic, but with limited guidance and training for practitioners on undertaking safe and effective remote physical assessments.The Telerehab Toolkit has been developed iteratively using the Knowledge to Action framework; it is a free online resource for practitioners and patients with specific guidance on telerehabilitation for physical disabilities and movement impairment.It is anticipated that the resource will help to improve the knowledge, skills, and confidence of the current and future rehabilitation workforce.

Experiences of health professionals towards using mobile electrocardiogram (ECG) technology: A qualitative systematic review.

OBJECTIVES: To identify and explore the experiences of health professionals towards using mobile electrocardiogram (ECG) technology. INTRODUCTION: Mobile technology is increasingly being incorporated into healthcare systems, and when implemented well, has the potential to revolutionise the way in which care is delivered. The uptake of mobile ECG technology enables health professionals to record and transmit ECGs electronically, at the point of care. It is important to explore both the impact of this technology and staff experiences to help understand how readily it is accepted and how effectively it is used in practice. There is a paucity of knowledge and understanding from primary healthcare providers and a lack of qualitative evidence offering insight into the monitoring and use of mobile ECG technology. Therefore, this review adds to the available body of knowledge by giving insight from the perspectives of health professionals on its use. METHODS: TRIP, CINAHL, MEDLINE, Scopus and sources of grey literature were searched for eligible studies. Databases were searched from their inception dates, with a restriction on studies written in English. The results of the search are presented in a PRISMA flow diagram. Two reviewers independently screened studies and assessed methodological quality in accordance with JBI methodology for systematic reviews of qualitative evidence. Data were extracted from the included studies and meta-aggregation methodology adopted to identify categories and create synthesised findings related to the healthcare professionals' experiences. RESULTS: A total of six studies were included, which resulted in 18 findings and five categories. Three synthesised findings were generated: Quick, easy and feasible in both urban and remote settings; Increased accessibility of AF screening opportunities for all; Enhanced support in staff resources, time and technology are required. The level of confidence of synthesised findings varied from low to moderate according to ConQual. CONCLUSIONS: This systematic review synthesised the experiences of healthcare professionals using mobile ECG technology. The methodological quality of the included studies was high, and findings indicated healthcare professionals (HCPs) generally found mobile ECG technology simple, quick, easy to use and non-invasive. Enablers regarding mobile ECG technology were time, workload, and remuneration for improved interoperability with current systems and sustainability for screening long term. Data on the experiences of HCPs came from studies capturing mainly proactive, lower-risk patients; therefore, this review was unable to demonstrate if there are any differences between the experiences of HCPs working in primary care settings, such as GP practices/pharmacies, and those working remotely in the community. This highlights a gap in provision for those patients requiring HCPs to record an ECG in their own home. RELEVANCE TO CLINICAL PRACTICE: The experiences of HCPs towards using Mobile ECG technology in practice is quick, easy and feasible in both urban and remote settings. HCPs and organisations should consider identifying key staff as "change champions" and use change/leadership models to support the integration (with current workflows), transformation, and evaluation of mobile ECG technology in their practice setting. HCPs and providers using mobile ECG technology should ensure it prioritises at-risk individuals and includes the "housebound" population.

The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis.

OBJECTIVES: Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling. METHODS: We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models. RESULTS: Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%). CONCLUSION: Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.

Ideal models of good inpatient care for adults with intellectual disability: Lessons from England.

BACKGROUND: In recent years, a significant proportion of inpatient facilities for people with intellectual disabilities and/or autism has been de-commissioned in England, This has resulted in individuals with intellectual disabilities being sent to distant hospitals far away from their families and carers leading to challenges in follow-up, community care and interventions. The impact of de-institutionalisation, has often caused patient trauma, family distress and subsequent discharge difficulties. Not every individual with intellectual disabilities and/or autism requires inpatient care but inpatient care when needed has to be local, adequate and appropriate. AIMS: To evaluate current evidence of utility of inpatient models for people with intellectual disabilities and outline best clinical practice. METHOD: PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, Web of Science were searched with key search terms. The search was conducted by the information specialist and identified abstracts screened further for inclusion criteria, methodological issues, and other appropriate characteristics. Twenty-three papers were included in the rapid review. Papers shortlisted had the inclusion criteria applied against the full text version independently by two reviewers. Disagreements regarding eligibility of studies was resolved by discussion and consensus within the project team. Key data related to in-patient models of care was extracted from the included papers, which included year of study, design, study objectives, target population, method/s tested, outcomes reported, country of study/studies, and results. Data extraction was performed by two reviewers and reviewed by the project team. RESULTS: From the review of services for people with intellectual disabilities, we came across four broad models/frameworks/approaches. Evidence on what worked for inpatient service provision tended to be based on models developed and implemented locally. CONCLUSIONS: We make recommendations for the best clinical practice and standards. Both clinical service providers and policymakers need to be aware of specific needs of individuals with intellectual disability and/or autism.

Prevalence and incidence of mental health issues amongst adults with diabetes at risk of foot complications in the European Union: a systematic review protocol.

OBJECTIVE: The objective of this systematic review is to evaluate and synthesize the evidence to establish the prevalence and incidence of mental health issues in people at risk of diabetic foot ulceration living within the European Union. INTRODUCTION: Due to the large health and financial burden of diabetic foot ulceration, prevention is a key focus for clinicians and researchers. Current foot ulcer prevention strategies are directed at the assessment and management of physical pathologies and risk factors for diabetic foot ulceration. Psychological burden and risk factors are often overlooked. This review will determine the prevalence and incidence of mental health issues among adults with diabetes mellitus who are at risk of foot ulceration. The review will focus on European Union countries. INCLUSION CRITERIA: Studies considered for inclusion will report on adults with a formal diagnosis of either type 1 or type 2 diabetes mellitus, who are at risk of foot ulceration and mental health issues. Studies will have been completed in the European Union. METHODS: A search of MEDLINE, CINAHL, AMED, Embase, Cochrane CENTRAL, and PsycINFO will be conducted for studies published in or translatable into English. Unpublished and gray literature will be searched. Studies will be selected against the review inclusion/exclusion criteria, and selected studies will be critically appraised, with data extraction and synthesis completed using the relevant JBI systematic review tools. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021260815.

Labouring Together: Women's experiences of "Getting the care that I want and need" in maternity care.

OBJECTIVE: Poor interprofessional collaboration and lack of decision-making with women have been identified as being detrimental to the quality, safety, and experience of maternity care. The aim of the Labouring Together study was to explore childbearing women's preferences for and experiences of collaboration and control over decision-making in maternity care. DESIGN: A sequential, mixed-method, multi-site case study approach was used to explore the perceptions and experiences of childbearing women regarding collaboration and decision-making. Women's preferred role for decision-making compared to the actual experiences, and the influences upon their preferences and experiences of collaboration were explored using semi-structured interviews. An inductive approach was used for qualitative analysis of interviews, and cross-case analyses were conducted using replication logic. SETTING: Postnatal wards of 1 private and 3 public maternity services in both metropolitan and regional Victoria, Australia. PARTICIPANTS: Postnatal women, over the age of 18 years (n=182). FINDINGS: Half (48.3%) of the participants indicated a preference for a shared decision-making role and 35% preferred an active role. Only 16.7% participants indicated a preference for a passive role, however 24.4% of women reported experiencing a passive decision-making role during their maternity care. Statistically significant differences were also identified between preferences for and experiences of decision-making among women who chose the private obstetrician model of maternity care compared to the public maternity care system. Negative impacts upon women's autonomy over decision-making included: poor access to midwifery models of care; poor access to relational continuity of care; poor understanding of the rights of the woman; inadequate information for women about the risks and benefits of all proposed interventions; and a bureaucratic style of decision-making based upon a dominant discourse of risk avoidance that could ultimately veto the woman's choice. KEY CONCLUSIONS: Despite evidence of the benefits for women of having autonomy over decision-making in their own care, fundamental barriers were identified that hindered women's participation in collaboration in maternity care. Shared decision-making with childbearing women is not routine practice in maternity care in Victoria, Australia. IMPLICATIONS FOR PRACTICE: Relational continuity of care is imperative to promote the autonomy of childbearing women and an environment conducive to women's active engagement in maternity care and participation in shared decision-making.

"What Is the Matter With Me?" or a "Badge of Honor": Nurses' Constructions of Resilience During Covid-19.

It has long been known that nursing work is challenging and has the potential for negative impacts. During the COVID-19 pandemic most nurses' working landscapes altered dramatically and many faced unprecedented challenges. Resilience is a contested term that has been used with increasing prevalence in healthcare with health professionals encouraging a "tool-box" of stress management techniques and resilience-building skills. Drawing on narrative interview data (n = 27) from the Impact of Covid on Nurses (ICON) qualitative study we examine how nurses conceptualized resilience during COVID-19 and the impacts this had on their mental wellbeing. We argue here that it is paramount that nurses are not blamed for experiencing workplace stress when perceived not to be resilient "enough," particularly when expressing what may be deemed to be normal and appropriate reactions given the extreme circumstances and context of the COVID-19 pandemic.

JBI series paper 3: The importance of people, process, evidence, and technology in pragmatic, healthcare provider-led evidence implementation.

In this paper, we describe and discuss evidence implementation as a venture in global human collaboration within the framework of "people, process, evidence, and technology" as a roadmap for navigating implementation. At its core implementation is not a technological, or theoretical process, it is a human process. That health professionals central to implementation activities may not have had formal training in implementation, highlights the need for processes and programs that can be integrated within healthcare organization structures. Audit with feedback is an accessible implementation approach that includes the capacity to embed theory, frameworks, and bottom-up change processes to improve the quality of care. In this third paper in the JBI series, we discuss how four overarching principals necessary for sustainability (Culture, Capacity, Communication, and Collaboration) are combined with evidence, technology, and resources for evidence-based practice change. This approach has been successfully used across hundreds of evidence implementation projects around the globe for over 15 years. We present healthcare practitioner-led evidence-based practice improvement as sustainable and achievable in collaborative environments such as the global JBI network as a primary interest of the practicing professions and provide an overview of the JBI approach to evidence implementation.