Healthcare organisations monitor patient experiences in order to evaluate and improve the quality of care. Because nurses spend a lot of time with patients, they have a major impact on patient experiences. To improve patient experiences of the quality of care, nurses need to know what factors within the nursing work environment are of influence. The main focus of this research was to comprehend the views of Dutch nurses on how their work and their work environment contribute to positive patient experiences.
The nurses mentioned essential elements that they believe would improve patient experiences of the quality of nursing care: clinically competent nurses, collaborative working relationships, autonomous nursing practice, adequate staffing, control over nursing practice, managerial support and patient-centred culture. They also mentioned several inhibiting factors, such as cost-effectiveness policy and transparency goals for external accountability. Nurses feel pressured to increase productivity and report a high administrative workload. They stated that these factors will not improve patient experiences of the quality of nursing care.
Participants formulated several facilitating elements that they consider fundamental to improving patient experiences of the quality of care. They also mentioned such inhibiting factors as cost-effectiveness and transparency and accountability goals. These factors prevent them from improving patient experiences (Table 3).
In addition to substantive expertise, participants stated that nursing experience is also of influence. According to them, a junior nurse has too little experience to respond creatively to sometimes complex care situations. However, according to participants, junior and senior nurses can learn from each other: they should work as a team and collectively pursue their common objectives. In their view, experience is gained through practice. According to participants, this can be characterised as 'expertise'.
According to participants, it is important to develop and maintain collaborative working relationships with professionals, including those in their own field. In the view of participants, collaborative working relationships exist when all the involved professionals interact and operate in a complementary manner, and show mutual respect that is based on knowledge and expertise. Participants stated that all professionals need to discuss and influence patient care on the basis of their own expertise. Participants believe that problems will be solved sooner when ideas and thoughts are exchanged. In their view, it is about sharing information and communication. As stated by participants, communication and aligning with each other is needed so that no conflicting information is given and uniformity in care or treatment is provided. This generates, according to the participants, composure and clarity towards patients.
Participants in all four focus groups stated that the scope of practice for which they are accountable influences patient experiences. The scope of practice, according to them, means that nurses can control their own work related to patient care and can make independent decisions about patient outcomes based on clinical judgements. Participants therefore believe it is essential to monitor and measure outcomes, as long as the monitoring is directly related to patient care. However, participants indicated that they did not have insight into care results obtained from assessments.
Participants stated that the number of nurses available influences how patients experience the quality of care. Although they could not indicate what number they consider sufficient, they think that a sufficient nurse staffing level is linked to team composition or staff mix. For instance, participants indicated the proportion of registered nurses to student nurses, or the number of different nurse qualification levels in one team. Participants stated that several tasks and assignments have been transferred to nurses with a lower qualification in order to work as efficiently as possible and to achieve higher productivity. As a result, participants believe that nursing care is, in general, increasingly developing in the direction of task-centred care in which different working methods are applied. According to them, this affects patient experiences of the quality and effectiveness of nursing care.
The participants stated that if nurses were more involved in the development of nursing policies, this would have a positive influence on patient care. According to them, they would be able to reflect upon and discuss nursing issues related to the quality of patient care, which would improve the quality of care.
It could be argued that the dominance of cost-effective policy and transparency determines the manner in which nurses can practise their profession and that this influences patient experiences of care. Ancarani  showed that patient satisfaction was negatively associated with management-controlled wards that are under pressure to produce. Open, collaborative, innovative wards and wards that are focused on the welfare and involvement of nurses and that provide supervisory support and training were positively associated with patient satisfaction. This confirms that the environment in which nurses operate influences patient experiences of the quality of care. This corresponds with the findings of our research, in which participants stated that the dominance of policies focussed on cost-effectiveness and transparency lead to more pressure to produce and a high administrative workload. The participants feel that they have insufficient autonomy to influence this policy.
This research revealed several factors that nurses find inhibiting when it comes to improving patient experiences of the quality of nursing care. Current nursing policy is heavily focussed on cost-effectiveness and transparency for external accountability, which creates a high administrative workload and pressure to increase productivity. However, despite all the registrations that take place for external accountability, the participating nurses stated that they do not monitor care results to improve their own practice. They felt they insufficient autonomy to influence this. They believe it is important to reflect upon and discuss nursing issues related to the quality of patient care, including patient experiences.
Technology is used extensively to provide and deliver health care worldwide [1, 2]. e-Health (the application of information, computer or communication technology to some aspects of health or health care) is viewed as essential for solving problems facing healthcare systems of increasing demand, due to an ageing population and improved treatments, and limited resources . However, although there is widespread agreement about the importance and potential benefits of e-health, realisation of these benefits has often been slower than anticipated, often because of difficulties with implementation . For example, in the UK, the National Health Service (NHS) Five Year Forward View  states the need to make better use of available health technologies and acknowledges that the NHS has previously failed to make best use of these because of difficulties in understanding how best to adopt and implement them. High-profile implementation failures continue to be reported, such as the failure of implementation of an e-health system in a major UK teaching hospital, leading to reduced performance, demoralised staff, costs of 200 million and the trust being put into special measures . This highlights the strong need for those undertaking the implementation of e-health to understand factors that influence implementation and be well equipped to devise strategies and interventions to improve the widespread effective use of e-health and address blockages to implementation.
The aim of this systematic review of reviews was to provide a synthesis of the implementation of e-heath literature that both acknowledges the multi-level complexity of implementation and also provides a framework for thinking about implementation in a way that is accessible and useful for those planning implementation such as health service managers, healthcare professionals and researchers. Specific objectives were to (i) identify published reviews pertaining to implementation of e-health systems; (ii) summarise the data contained in these reviews; (iii) synthesise these data according to the Consolidated Framework for Implementation Research (CFIR) ; and (iv) provide recommendations for future implementations of e-health systems. The CFIR provides a systematic way of identifying the factors that are important for implementation, and its use also allows identification of areas where there is insufficient evidence and further research is required.
The original review had used a thematic approach to analysing and synthesising the data, together with an analysis based on normalization process theory, which focusses on the work of implementation. In view of the large amount of new data, and the subsequent development of the CFIR , which pays more detailed attention to aspects such as legislative or financial frameworks, we decided to update the analytic approach to use an approach which drew on the principles of meta-ethnography for data synthesis, with the CFIR as an organising framework. The use of a framework like the CFIR aids the transferability and comparability of findings from this review to other implementation studies and allows those undertaking implementation to access the parts of this review that are of most interest to them. The CFIR , consolidates implementation factors from a broad array of implementation theories and is composed of five major constructs made up of components that influence the implementation of innovations into practice (see Table 2).
A data extraction form was developed to extract key information and concepts from the included studies and to ease comparison between them. Data were firstly extracted to describe the type of study including publication date, e-health domain, healthcare setting, inclusion and exclusion criteria and methods used. Secondly, the main themes from each review relating to factors that influence implementation of e-health were extracted from both results and discussion sections of the included papers. Data from discussions were included as they often contained further interpretations from the authors, which offered important insights and enhanced the richness of the findings. A summary table created from this matrix with key study details, and summaries of main findings are presented in Additional file 2.