To Örebro University

BACKGROUND: The number of frail individuals is increasing, and the proportion of frail patients in hospital settings is high. Assessing patient frailty as a part of hospital care can guide clinicians in determining which interventions are needed and what to prioritise. Orthopaedic in-patients often experience both pain and mobility limitations, which, in combination with frailty, make these patients particularly vulnerable. There is limited knowledge regarding how staff working in orthopaedic acute care units understand frailty and how they adjust their clinical practices in response. The aim is to understand how healthcare professionals in an orthopaedic acute care unit perceive frailty and possibly adapt their clinical practices in response to it.

METHODS: The study adopted a qualitative design and included 16 healthcare professionals from two hospitals. Semi-structured individual face-to-face interviews were conducted, digitally recorded, transcribed verbatim, and subsequently analysed using thematic analysis with an inductive approach.

RESULTS: Two themes were developed during the analysis mirroring the healthcare professionals’ perceptions. The first is “Considering an individual frail” supported by the subthemes ”Describing frailty in different ways”, “Recognising vulnerability”, “Identifying the need for support”, and “Acknowledging frailty in different contexts”. The second is “Caring for the frail”, supported by the subthemes “Understanding the concept of frailty”, “Assessing frailty”, “Taking frailty into account”, “Being one step ahead”, and “Having resource awareness”.

CONCLUSIONS: This study revealed that healthcare professionals perceive frailty as a broad and multidimensional concept that requires clearer specification to guide appropriate interventions. Participants emphasised that care is shaped primarily by individual needs rather than by frailty assessment, reflecting a person-centred approach. They also expressed a strong sense of responsibility toward frail patients and viewed hospital admission as an opportunity to identify and address unmet needs at home. While tools such as the Clinical Frailty Scale were viewed as limited in terms of capturing the full complexity of frailty, they were described as helpful for drawing attention to frailty and prompting deeper reflection.

TRAIL REGISTRATION: https://researchweb.org/is/fourol/project/281574 Reg. no 28 15 74. 

Aim: To better understand what enables evidence-based practice, this study investigated contextual factors influencing evidence-based practice in general, and in relation to the implementation of bladder-monitoring guidelines in orthopaedic care.

Design: Convergent parallel mixed method.

Methods: This study was part of a hybrid research project across 17 Swedish orthopaedic sites. The data collection (2021-2023) included interviews with orthopaedic staff and patients post-hip surgery, patient survey free-text responses, and a staff survey on organisational context. Data were analysed with deductive content analysis and descriptive statistics, later integrated using a mixed methods approach.

Results: Evidence-based practice was supported by context factors such as staff collaboration and multiprofessional engagement. Staff addressed patient safety and equality by using evidence-based guidelines, but rarely involved the patients. Orthopaedic fast-track procedures positioned patients as passive recipients, while staff voiced a call for a more person-centred context. Positive attitudes, leadership engagement, use of champions, and adequate staffing enabled evidence-based practice, though a shortage in evaluation and high staff turnover hindered its implementation.

Conclusion: Orthopaedic context is characterised by several enabling organisational context factors for evidence-based practice, although patients lacking recognition of their needs and queries justify greater focus on person-centredness and mutual information exchange. Audit and feedback are crucial for improvements, but were lacking in the orthopaedic care context.

Implications for the Profession and/or Patient Care: Assessments of efforts made to implement evidence-based practice and its outcomes should incorporate nursing care. Slimmed care processes require attention to ensure patient participation.

Impact: The orthopaedic care context is enabling for evidence-based practice, although staff are challenged by fast-track procedures with extensive information exchange and insufficient person-centredness.

Reporting Method: The Mixed Methods Reporting in Rehabilitation & Health Sciences checklist.

Patient or Public Involvement: No patient or public contribution.

Trial Registration: Identifier: NCT 04700969

Background: In the "One fracture is enough!” project, we want to reduce recurrent fractures by implementing a tailored care process for elderly people with hip fractures. We will study both the implementation process and the effect of the clinical intervention (the care process). The overall project aim is to evaluate the uptake and effects of an implementation strategy for the introduction of a tailored care process based on the degree of frailty for older adults with fragility fractures. The specific aim of this study is to describe the internal facilitators’ experiences of taking part in the implementation strategy.

Methods: This study was performed in the orthopaedic units at one university hospital and one local hospital in one Swedish county. Both units are providing care for older adults with hip fractures. Each included unit appointed a multi-professional internal facilitator team to lead the implementation. The teams received a 1-year support programme including five workshops on frailty, osteoporosis and implementation, followed by monthly support from external facilitators. A qualitative descriptive approach was chosen, and data were collected by means of focus group discussions with the internal facilitator teams at the two units, internal facilitator logbooks and notes made by the researchers during the study period. Data will be analysed with qualitative content analysis.

Results: The implementation support programme, as well as the internal facilitator role, was experienced as complex by some internal facilitators. Other internal facilitators understood their role and mission and wanted to know even more about implementation. They used the achieved knowledge to implement the new care process and could also see that they could also use this knowledge in other implementation projects. When the internal facilitator teams shifted focus from being task-oriented to becoming process-oriented, the implementation moved forward. Also, the first-line managers seem to play a central role in implementation.

Discussion and conclusion: Both the internal facilitator role and the implementation support programme were experienced as complex. Still, focus on the implementation process and managerial support are beneficial for successful implementation.

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.

Background Annually, many persons undergo hip surgery, where urinary retention (UR) is a common complication. A gap exists between clinical practice guidelines (CPGs) and performed care regarding the prevention of UR, highlighting the need for implementation interventions to support uptake of the CPGs. As implementation leaders, first-line managers (FLMs) are key to bridging the knowledge-practice gap and could be included in implementation strategies.

Aim To explore guideline implementation in orthopaedic healthcare with a focus on first-line managers’ implementation leadership.

Method A cluster-randomised hybrid effectiveness/implementation study involving 17 orthopaedic units performing hip surgery at hospitals located in Sweden. Intervention units formed multi-professional internal facilitating (IF) teams (each including at least one FLM) for a 12-month education and support programme to implement bladder monitoring CPGs. Data was collected via interviews (study I, II, IV), medical record reviews (study III), patient surveys (study III), and registry data (study III), and it was analysed using qualitative content analysis (study I) and thematic analysis (study II), statistical analysis (study III), and realist evaluation (study IV).

Results FLMs viewed guideline implementation as a balancing act between organisational structures and unit-level realities (study I). They adapted leadership strategies based on context, often translating guidelines to fit local conditions (study I,II). During COVID-19, implementation was smoother due to unified goals, but it faced barriers such as unclear evidence and rapid changes (study II). The intervention deepened participants’ understanding of both clinical guidelines and implementation science (study IV), though without any statistically significant differences in adherence to bladder monitoring CPGs between intervention and control (study III). Managers played a crucial role in anchoring decisions but stepped back to empower teams (study IV).

Conclusion Although FLMs have a clear vision of beneficial leadership in relation to change and use implementation leadership behaviours in CPG implementation, a support and education programme regarding implementation processes could build on their prior knowledge. Still, leadership actions can be influenced by contextual factors, and the FLMs sometimes have to adjust accordingly. Health organisations could support first-line managers in their important role in reinforcing an evidence-based practice by scrutinising the organisational context and creating processes that support implementation leadership.

BACKGROUND: 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.

METHODS: This was an observational study from January 2021 to April 2021 with a descriptive and comparative design, triangulating three data sources. 1) 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. 2) The patients completed a survey regarding postoperative lower urinary tract symptoms, and 3) data was 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.

RESULTS: 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 (OR 3.56, 95% 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.

CONCLUSION: 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.

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.