To Örebro University

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.