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BACKGROUND: Appropriately and comprehensive applying implementation frameworks is one of the key challenges in implementation science resulting in increased use of multiple implementation frameworks within projects. This is particularly true for frameworks such as PARIHS/i-PARIHS. Therefore, this systematic review aimed to examine if and why the PARIHS/i-PARIHS framework has been applied in research with other implementation frameworks.

METHODS: We searched six databases from 2016 (the year following i-PARIHS' publication) to April 2024 and supplemented this with a citation search of the seminal i-PARIHS paper. We included studies that 1) were peer-reviewed with a protocol or empirical study design, 2) have applied the PARIHS or i-PARIHS framework for implementation planning, delivery, analysis, or evaluation and 3) also used at least one other implementation framework. Descriptive statistics were conducted to report on study characteristics and frequency for each implementation framework used with PARIHS/i-PARIHS. A qualitative, content analysis was used to analyse the answers to open-ended extraction questions.

RESULTS: Thirty-six articles met criteria for inclusion and included 16 protocols and 20 empirical articles (twelve intervention and eight cross-sectional studies). Thirty-four of the studies used one additional implementation framework and two studies used two additional implementation frameworks. In total, nine implementation frameworks were applied with PARIHS/i-PARIHS, including: 1) RE-AIM, 2) CFIR, 3) NPT, 4) REP, 5) TDF, 6), DSF, 7) KTA, 8) Stetler's Model, and 9) SIF. Thirty-four reported a rationale for using PARIHS/i-PARIHS and 34 reported a rationale for using the other implementation framework. Only eleven reported a rationale for using more than one implementation framework. Only three reported strengths of combining implementation frameworks.

CONCLUSIONS: Overall, this review identified that implementation researchers are using PARIHS/i-PARIHS in combination with other implementation frameworks and providing little to no rationale for why. Use of multiple implementation frameworks without detailed rationales compromises our ability to evaluate mechanisms of effectiveness. Implementation researchers and practitioners need to be more explicit about their framework selection, detailing the complementary strengths of the frameworks that are being used in combination, including why using one is not sufficient.

TRIAL REGISTRATION: This systematic review was registered with PROSPERO: ID: 392147.

BACKGROUND: The COVID-19 pandemic exacerbated distressing situations among healthcare professionals, due to resource limitations and complex patient care challenges.

RESEARCH OBJECTIVES: The research aims to explore the frequency of RNs' exposure to distressing situations across various care settings during the pandemic and assess the association between this exposure and: (1) stress of conscience, (2) intentions to leave the profession, (3) job satisfaction, and (4) self-rated health in the late phase of the pandemic. In addition, the aim was to describe other common situations they encountered during the pandemic.

RESEARCH DESIGN: A cross-sectional multi-method study was conducted with participants recruited from a national cohort of Registered Nurses (RNs) between October 2021 and January 2022. In total, 3,958 individuals met the eligibility criteria, with 2,237 participants (56.5%) responding to the survey. Among these respondents, 1,881 answered questions about distressing situations, and 239 shared open-ended responses about their experiences.

RESULTS: The results showed that during the peak of the COVID-19 pandemic, between 24% and 70% of RNs encountered distressing situations on a weekly basis or more often. Over 70% reported difficulties in communication due to personal protective equipment. Additionally, just over 40% of RNs reported working in situations lacking clear guidelines and facing prioritization challenges. RNs exposed to these distressing situations were frequently nearly twice as likely to experience stress of conscience (44% vs. 21%, [OR] = 2.87) and showed a stronger intention to leave the profession (25% vs. 14%, [OR] = 1.98). Moreover, they reported lower job satisfaction (85% vs. 92%, [OR] = 0.50) and poorer self-rated health (34% vs. 50%, [OR] = 0.52) compared to their counterparts with less exposure. In addition, RNs experienced a lack of support, understaffing, and working beyond their expertise, leading to emotional and physical exhaustion. They felt inadequate due to overwhelming workloads and limited recovery time.

CONCLUSION: The COVID-19 pandemic has significantly impacted RNs, underscoring the need for strong organizational support and leadership. Nurses require guidance from leaders and institutions to manage distress and ethical challenges effectively. Future strategies should prioritize adequate staffing, skill development, teamwork, mental health resources, and transparent communication to support nurses' wellbeing and recovery, ensuring the delivery of high-quality care.

Background: During the COVID-19 pandemic, many registered nurses (RNs) worked on the frontline caring for severely ill patients. They did so with limited knowledge of how to treat and prevent the disease. This extreme situation puts pressure on RNs to find evidence on which to base the care of their patients. Aims: To examine: (1) the extent to which evidence-based practice (EBP) process was applied by Swedish RN cohorts 15–19 years after graduation during the pandemic, (2) whether there was any change to their EBP process from pre-pandemic to late pandemic, (3) the relationship between RNs' use of the EBP process and the duration of exposure to work situations severely affected by the COVID-19 pandemic, and (4) whether level of education, position and care setting were associated with the extent of RNs' EBP process. Methods: In 2021, the level of EBP activities was investigated among 2237 RNs 15–19 years after graduation. The scale used to measure EBP consisted of six items of the EBP process. Unpaired t-tests or one-way analysis of variance (ANOVA) were used in the analysis. Results: RNs used the EBP process to a moderate extent to inform and transform their clinical practice. There was a minor but significant decrease in practicing the EBP process from pre-pandemic to late in the pandemic. RNs who were most affected by the pandemic scored higher on the scale than less-affected colleagues. RNs in nonclinical positions reported more EBP activities, as did RNs in management positions. RNs working in outpatient settings reported more EBP activities than their colleagues in hospitals. Linking Evidence to Action: It is imperative that RNs hone their skills in EBP if they are to be prepared for future healthcare crises. Healthcare providers have a duty to facilitate the development of EBP and, in this regard, RNs in clinical positions in hospitals need particular support. © 2023 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.

BACKGROUND: With the increased demand for health care services and with simultaneous staff shortages, new work models are needed in primary health care. In November 2015, a Swedish primary health care centre introduced a work model consisting of a structured patient sorting system with triage and Nurse on Call. The aim of this study was to describe the staff's experiences of introducing the triage and Nurse on Call model at the primary health care centre.

METHODS: Five focus group discussions with staff (n = 39) were conducted 4 years after the introduction of the work model. Groups were divided by profession: medical secretaries, nursing assistants, physicians, primary health care nurses, and registered nurses. The transcribed text from the discussions was analysed using qualitative inductive content analysis.

RESULTS: The analysis generated one overarching theme: The introduction of triage and Nurse on Call addresses changed preconditions in primary health care, but the work culture, organization, and acquisition of new knowledge are lagging behind. The overarching theme had five categories: (1) Changed preconditions in primary health care motivate new work models; (2) The triage and Nurse on Call model improves teamwork and may increase the quality of care; (3) Unclear purpose and vague leadership make introducing the work model difficult; (4) Difficulties to adopt the work model as it challenges professional autonomy; and (5) The triage and Nurse on Call model requires more knowledge and competence from nurses in primary health care.

CONCLUSIONS: This study contributes with knowledge about implications of a new work model in primary health care from the perspective of health care staff. The work model using triage and Nurse on Call in primary health care was perceived by participants to increase availability and optimize the use of resources. However, before introduction of new work models, it is important to identify barriers to and facilitators for successful improvements in the local health care context. Additional education for the health care staff is important if the transition is to be successful. Complementary skills and teamwork, supported by a facilitator seems important to ensure a well-prepared workforce.

BACKGROUND: Internationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited.

AIM: To describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs.

METHODS: The study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes.

RESULTS: A total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care.

CONCLUSION: Our study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.

Objectives: Limited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. Methods: This is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. Results: Medium (IRR 0.77; 95% CI 0.59–0.99) and high (IRR 0.77; 95% CI 0.56–0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. Conclusions: ED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults. © 2023