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Background Despite increasing interest in research on how to translate knowledge into practice and improve healthcare, the accumulation of scientific knowledge in this field is slow. Few substantial new insights have become available in the last decade. Main body Various problems hinder development in this field. There is a frequent misfit between problems and approaches to implementation, resulting in the use of implementation strategies that do not match with the targeted problems. The proliferation of concepts, theories and frameworks for knowledge transfer – many of which are untested – has not advanced the field. Stakeholder involvement is regarded as crucial for successful knowledge implementation, but many approaches are poorly specified and unvalidated. Despite the apparent decreased appreciation of rigorous designs for effect evaluation, such as randomized trials, these should remain within the portfolio of implementation research. Outcome measures for knowledge implementation tend to be crude, but it is important to integrate patient preferences and the increased precision of knowledge. Conclusions We suggest that the research enterprise be redesigned in several ways to address these problems and enhance scientific progress in the interests of patients and populations. It is crucially important to establish substantial programmes of research on implementation and improvement in healthcare, and better recognize the societal and practical benefits of research.

The emergence of SARS-CoV-2/Covid-19 affects all of us and is associated with rapid and massive changes in healthcare and societies. As a response, a range of interventions for patients and populations have been implemented in health and preventive settings, or need to be implemented in the short and long term. Implementation science offers a multidisciplinary perspective and systematic approach for the design, evaluation and analysis of programmes and policies to enhance implementation. The emergence of Covid-19 provides an urgent need to develop new perspectives and approaches in implementation science, such as the addition of innovative and rigorous approaches to the collection, use and analysis of ‘real-world’ data. Above all, we hope that implementation scientists will focus on what they can contribute to manage Covid-19 and its consequences for people, healthcare and society.

Implementation researchers often find themselves as research partners in practice improvement projects, clinical trials or other applied health studies. The implementation science component in these projects can be described as supportive, descriptive or explanatory. This commentary reflects on the potential contributions of such projects to implementation science. They may provide evidence on implementation strategies, so it is essential to identify and evaluate these separately from the clinical and preventive interventions of interest. The use of theory on implementation processes and associated factors can contribute to knowledge accumulation, particularly if the focus is on what actually gets implemented when, why and how. The development and validation of relevant measures is a third potential contribution to implementation science. Although not all issues in implementation science can be addressed in this way, capitalization on the opportunities beyond the field can contribute to implementation science.

Process evaluation of implementation strategies is increasingly common, but a review by Bracci et al. showed that room for improvement exists. In this contribution, we complement their recommendations by ideas on the design of process evaluations. Process evaluations are meant to provide explanations for why implementation strategies were effective, or not effective. Therefore, they are best guided by theory or frameworks, but the frequent focus on intervention acceptability reflects a lack of imagination on moderators and mediators that influence outcomes. Intervention fidelity is relevant in all process evaluations. Meaningful synthesis of process evaluation studies requires a homogeneous outcome, such as uptake of practices.

In 2004, Germany introduced a program based on voluntary contracting to strengthen the role of general practice care in the healthcare system. Key components include structured management of chronic diseases, coordinated access to secondary care, data-driven quality improvement, computerized clinical decision-support, and capitation-based reimbursement. Our aim was to determine the long-term effects of this program on the risk of hospitalization of specific categories of high-risk patients. Based on insurance claims data, we conducted a longitudinal observational study from 2011 to 2018 in Baden-Wuerttemberg, Germany. Patients were assigned to one or more of four open cohorts (in 2011, elderly, n = 575,363; diabetes mellitus, n = 163,709; chronic heart failure, n = 82,513; coronary heart disease, n = 125,758). Adjusted for key patient characteristics, logistic regression models were used to compare the hospitalization risk of the enrolled patients (intervention group) with patients receiving usual primary care (control group). At the start of the study and throughout long-term follow-up, enrolled patients in the four cohorts had a lower risk of all-cause hospitalization and ambulatory, care-sensitive hospitalization. Among patients with chronic heart failure and coronary heart disease, the program was associated with significantly reduced risk of cardiovascular-related hospitalizations across the eight observed years. The effect of the program also increased over time. Over the longer term, the results indicate that strengthening primary care could be associated with a substantial reduction in hospital utilization among high-risk patients.

Background The shortage of qualified nurses is a problem of growing concern in many countries. Recruitment of internationally trained nurses has been used to address this shortage, but successful integration in the workplace is complex and resource intensive. For effective recruitment and retention, it is important to identify why nurses migrate and if their expectations are met to ensure their successful integration and promote a satisfying work climate for the entire nursing team. The aim of this study was to examine the perceptions of safety culture, work-life-balance, burnout and job demand of internationally trained nurses and associated host nurses in German hospitals. Methods A multicentric, cross-sectional study was conducted with internationally trained nurses ( n  = 64) and host nurses ( n  = 103) employed at two university hospitals in the state of Baden-Wuerttemberg, Germany. An anonymous paper-based survey was conducted between August 2019 and April 2020. The questionnaire included sociodemographic questions, questions regarding factors related to migration, and the German version of the Assessment of your work setting Safety, Communication, Operational Reliability, and Engagement (SCORE) questionnaire. SCORE is divided into three sections: Safety Culture Domains ( six subscales ), Work-Life-Balance ( one subscale ), and Engagement Assessment Tool ( four subscales ). Results Nurses who migrated to Germany were primarily seeking better working conditions, a higher standard of living, and professional development opportunities. Internationally trained nurses reported lower work-related burnout climate (Mean 55.4 (SD 22.5)) than host nurses (Mean 66.4 (SD 23.5)) but still at a moderately high degree (Safety Culture Domains). Host nurses indicated a higher workload (Mean 4.06 (SD 0.65)) ( Engagement Assessment Tool ) and a lower Work-Life-Balance (Mean 2.31 (SD 0.66)) (Work-Life-Balance) compared to nurses who trained abroad (Mean 3.67 (SD 0.81) and Mean 2.02 (SD 0.86), respectively). No differences were detected for the other subscales. The Safety Culture Domains and Engagement Assessment Tool showed room for improvement in both groups. Conclusion The study suggest that the expectations migrant nurses had prior to migration may not be met and that in turn could have a negative impact on the integration process and their retention. With increasing recruitment of internationally trained nurses from within Europe but also overseas, it is crucial to identify factors that retain migrant nurses and assist integration. Trial registration The study has been prospectively registered (27 June 2019) at the German Clinical Trial Register ( DRKS00017465 ).

Background The increasing nursing shortages worldwide has focused attention on the need to find more effective ways to recruit and retain nurses. The aim of this study was to gain understanding of factors that keep German nurses in nursing and explore their perceptions of factors that contribute to nurses leaving or staying in the profession. Methods An explorative qualitative study was undertaken at four different hospitals (two university hospitals and two public hospitals) in Baden-Wuerttemberg, a state in South Germany. Semi-structured face-to-face or telephone interviews were conducted with 21 state-qualified nurses who had graduated from a German nursing program. Each interview was pseudonymized and transcribed. Transcripts were coded according to Qualitative Content Analysis with data structured into themes and subthemes. The study was reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist for qualitative research. Results Two themes emerged from the analysis and each theme had several subthemes: a) PUSH FACTORS i.e. factors that may push nurses to consider leaving the profession included limited career prospects, generational barriers, poor public image of nursing, and workplace pressures; b) PULL FACTORS i.e. factors that nurses wished for and could keep them in the profession included professional pride, improved remuneration, recognition of nursing, professionalisation, and improving the image of nursing as a profession. Conclusion The decision to leave or stay in nursing is influenced by a complex range of dynamic push and pull factors. Nurse Managers responsible for stabilizing the workforce and maintaining their health system will continue to have to navigate challenges until working conditions, appropriate wages and career development opportunities are addressed. A key to tackling nursing shortages may be focusing on pull factors and nurse managers listening in particular to the perspectives of junior nurses directly involved in patient care, as giving them opportunity to further develop professionally, reinforcing a strong and supportive workplace relationships, paying an appropriate salary, and improving the public image of nursing profession. Registration number The study has been prospectively registered (27 June 2019) at the German Clinical Trial Register ( DRKS00017465 ).

Background Recruitment of participants for preventive health intervention studies remains a significant challenge: Approximately 19% of studies are discontinued due to insufficient participant numbers, and one in three extends its recruitment period. This study aimed to examine the impact of recruiting measures on the recruitment rate over time and to describe costs of these strategies to inform future study planning and optimize resource allocation. Methods A cluster-randomized controlled trial (“AOK-Family+” study) was conducted from April 2023 to June 2024 in southwestern Germany. The intervention focused on reducing lifestyle-related risk factors (LRRFs) among pregnant women and women planning a pregnancy. Analog recruitment strategies included e.g., printed magazines, flyers and digital recruitment strategies included e.g. social media ads, influencer marketing. For 255 interested women, contact details, recruitment source, and participation status were documented and analyzed. A segmented linear regression analysis was used to identify turning points in application trends. Direct costs were calculated based on internal project budget tracking. Results The targeted sample size was not reached despite substantial investment in recruitment measures. The highest number of applications resulted from analog strategies—especially printed AOK magazines (35.5%)—followed by influencer marketing (23.6%). The segmented linear regression analysis identified three significant increases in application rates, the first coinciding with the magazine distribution and the second with the influencer marketing on Instagram. Social media marketing showed a short-lived effect, with application rates dropping immediately after posts ended. Total costs amounted to 99.334 € equaling 389,54€ per application and 534,05€ per actually enrolled participant. Conclusion Health magazines proved to be the most cost-efficient and sustainable recruitment strategy. Influencer marketing led to high reach and initial spikes in engagement but had limited long-term impact. While digital measures generated many clicks, only a small fraction translated into study participation—indicating a pronounced intention–behavior gap and procedural barriers in the enrolment process. For future studies, a mixed-methods recruitment strategy is recommended combining wide digital outreach with personalized, trust-based communication, ideally through healthcare professionals such as gynecologists and midwives, to reach women in early pregnancy and reduce participation barriers. Trial registration The German Clinical Trials Register DRKS00027804. Registered on 2022/01/12.

Care engagement or active patient involvement in healthcare contributes to the quality of primary care, but organisational preconditions in routine practice need to be aligned. A Maturity Matrix for Care Engagement to assess and discuss these preconditions in the general practice team was developed and tested on feasibility and acceptability in general practice. A systematic user-centred approach was applied, starting with a scoping literature search to describe the domains on the horizontal axis of the maturity matrix. The domains and growing steps (vertical axis) were refined by patients (n = 16) and general practice staff (n = 11) in three focus group discussions and reviewed by six experts (local facilitators and scientists). Seven domains could be distinguished: Personalised Care, Shared Decision Making, Self-Management, Patient as Partner, Supportive Means, Patient Environment, and Teamwork among Healthcare Professionals. The growing steps described three to six activities per domain (n = 32 in total) that contribute to care engagement. Local facilitators implemented the tool in two general practice teams according to a user guide, starting with a two-hour kick-off meeting on care engagement. In the next step, practitioners, nurses and assistants in each practice indicated their score on the domains individually. The scores were discussed in the facilitated practice meeting which was aimed at SMART improvement plans. Feasibility and acceptability were assessed in interviews showing that the tool was well received by the pilot practices, although the practice assistants had difficulties scoring some of the activities as they did not always relate to their daily work. An assessment after three months showed changes in practice organisation towards increased care engagement. The maturity matrix on care engagement is a tool to identify the organisational practice maturity for care engagement. Suggested adaptations must be implemented before large-scale testing.

Background Chronic cardiovascular diseases demand continuous care from general practitioners and medical specialists. Especially in fragmented healthcare systems, such as in Germany, a large body of research is devoted to the improvement of care continuity. Meanwhile, measuring continuity of care itself has been a challenge due to the absence of validated instruments. In 2011, the Dutch Nijmegen Continuity Questionnaire (NCQ) was developed and validated to measure continuity of care across care settings from the patients’ perspectives in the Netherlands. Its applicability in other countries and health systems, however, has rarely been tested. We therefore aimed at assessing the applicability of the Nijmegen Continuity Questionnaire to the German health care context.  Methods We translated and applied the original NCQ to an ambulatory cardiovascular care setting in Germany. Qualitative interview data and quantitative survey data on our adaptation were collected from patients in 27 general practices within the German states of Baden-Wuerttemberg and Rhineland-Palatinate. Qualitative data on understandability and clearness of the questionnaire was obtained using semi-structured telephone interviews and think aloud-protocols. Quantitative data was obtained through an anonymous written questionnaire containing the translated NCQ items to assess applicability of our translation. We performed confirmatory and exploratory factor analyses based on the original NCQ-structure mapped to general practitioners and an aggregated analysis of general practitioners and cardiologists combined. Results A total of 6 patients participated in the interviews and a total of 435 patients participated in the written survey. The interviews showed that, overall, patients had little difficulties comprehending and answering to our translation of the NCQ. The confirmatory factor analyses then showed that the structure of the original NCQ with 12 items and 3 latent factors can also be found in the German context. However, a simpler 2-factor-structure would also fit well with the data. Conclusion A German translation of the NCQ yielded a factor structure comparable to the original version and proved to be understandable for patients. Trial registration The project underlying the study was registered on November 7, 2019 in the German Clinical Trials Register ( www.drks.de ) under ID: DRKS00019219.