To Örebro University

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: Postoperative urine retention can lead to permanent bladder dysfunction. This occurs even though healthcare personnel can access evidence-based guidelines on avoiding urine bladder injuries related to care. AIM: This study aimed to describe healthcare professionals' experiences with, and strategies to avoid post-operative urinary retention among hip surgery patients.

METHOD: A descriptive qualitative study using telephone interviews, were conducted in April to June 2021, with 22 healthcare professionals (13 nurses, 7 nursing assistants and 2 occupational therapists) in 17 orthopaedic wards in Sweden. Qualitative content analysis of interview data was performed.

RESULTS: Five categories were identified: "Knowledge about guidelines regarding bladder monitoring", "Understanding of patients' prehospital bladder function influences healthcare professionals' reasoning and actions", "Strategies are applied to make it easier for the patients to empty their bladder", "Indwelling catheter is used routinely" and "Short length of stay creates stress".

CONCLUSION: To optimise safe patient bladder monitoring after hip surgery, health care professionals need to be more aware of the availability of guidelines about bladder monitoring to adopt consistent monitoring practices, and to have enough time to care for patients.

Nilsen et al.'s (Implement Sci Commun 6:90, 2025) proposal to distinguish between implementation efficacy and effectiveness, and to situate implementation studies along a continuum from ideal to real-world conditions, offers a valuable conceptual advance. In this commentary, we acknowledge the contribution of their debate while highlighting potential limitations of applying a single-axis continuum to a field heavily characterized by contextual complexity. Drawing from decades of healthcare quality improvement, we argue that implementation interventions often blend efficacy-like and effectiveness-like elements, making neat classification difficult. We further suggest that oversimplification risks obscuring the realities of organizational change. Instead, we propose a double-axis model that considers both the implementation intervention and the context in which it unfolds. Economic evaluation likewise requires nuanced approaches that go beyond their proposed continuum indicator tool ("Implementation PRECIS"). To constructively extend Nilsen et al.'s contribution, we advocate for integration of the tool with existing approaches to evaluation, co-production with stakeholders, and empirical validation across diverse settings. While no implementation endeavor is ideal, advancing discourse around how efficacy and effectiveness are conceptualized can support more pragmatic, context-responsive, and sustainable improvements in healthcare.

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.

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: 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.

Aim: Dignity in older persons is a goal of palliative care. This study aimed to perform a process evaluation of the Swedish Dignity Care Intervention (DCI-SWE) in municipal palliative care in Sweden, focusing on implementation, context, and mechanism of impact.

Methods: This study had a process evaluation design. The Knowledge to Action framework supported the implementation of the DCI-SWE. The intervention was used by community nurses with older persons (n = 18) in home healthcare and nursing homes. Data were collected by focus groups- and individual interviews with community nurses (n = 11), health care professionals (n = 5) and managers (n = 5), reflective diaries, and field notes.

Results: Grasping the DCI-SWE was challenging for some community nurses. Enhanced communication training and increased engagement from managers were requested. However, the DCI-SWE was perceived to enhance professional pride in nursing. In terms of fidelity, dose and reach the project was not fully achieved. Regarding mechanism of impact the DCI-SWE contributes to address older persons' loneliness and existential life issues, as it put conversations with older persons on community nurses' agenda.

Conclusions: The DCI-SWE provided opportunities to maintain older persons' dignity and quality of life. However, with refinements of design and the DCI-SWE, the sustainability in the context may increase.

BACKGROUND: Cervical cancer is a global disease and it is well established that cervical cancer is caused by human papillomavirus (HPV). In Sweden self-sampling for HPV is now used as a complement to sampling performed by a midwife. However, there is a lack of knowledge on how older women perceive the self-sampling compared to the sampling performed by a midwife. Therefore, the aim of the study was to describe how women, aged 64 years and older, perceived the process of self-sampling and sampling performed by a midwife for HPV-testing.

METHODS: Eighteen women were included in a qualitative interview study, and a phenomenographic approach was used for the analysis of the interviews.

RESULTS: Three descriptive categories emerged: Confidence in sampling, Facilitating participation and Being informed. Within the categories, eight conceptions emerged describing the variation relating to how the women perceived the process of self-sampling and sampling performed by a midwife.

CONCLUSIONS: Women in this study describe confidence in self-sampling for HPV-testing and that the self-sampling was saving time and money, both for themselves and for society. Information in relation to an HPV-positive test result is of importance and it must be kept in mind that women affected by HPV may feel guilt and shame, which health care professionals should pay attention to. This knowledge can be used in education of health care staff.