Limited attention to implementation process

A striking finding is the lack of attention to the Implementation Process. Across studies, there was limited detail about how IPC guidelines or interventions were implemented in practice. Subdomains such as planning, assessing context, executing, tailoring strategies, and reflecting and evaluating were rarely mentioned. Only few studies referenced training activities or IPC champions, but these elements were presented as isolated features rather than part of a structured implementation approach. No study described a comprehensive implementation strategy or roadmap, nor did they report how healthcare organizations prepared for, monitored, or adjusted the rollout of IPC measures over time. This implementation process gap is critical. Without attention to how interventions are introduced and sustained, it becomes difficult to assess what works, for whom, and under what conditions. The lack of implementation strategy also suggests that IPC is often treated as a set of rules or policies to follow, rather than as a change process requiring adaptation, buy-in, and continuous support. This may help explain why certain IPC practices, such as hand hygiene or PPE use, remain inconsistently adopted despite widespread awareness.

Similar observations have been reported in previous reviews. ^{Reference Low, Fletcher and Goodenough51,Reference Spoon, Rietbergen and Huis49} For example, one review noted that only three studies explicitly described their program logic or explained how the intervention was intended to achieve its impact. ^{Reference Low, Fletcher and Goodenough51} Another review found considerable variation in the reporting of implementation strategies: although a small number of studies provided a detailed description of the implementation process, most merely mentioned the type of strategy used (eg, audit and feedback), without further elaboration. ^{Reference Spoon, Rietbergen and Huis49} Moreover, multiple reviews emphasize that no single implementation strategy, or fixed combination of strategies, can be directly linked to successful implementation. ^{Reference Lee, Lee, Lee and Park16,Reference Low, Fletcher and Goodenough51,Reference Spoon, Rietbergen and Huis49} Instead, strategies need to be tailored to the specific context. By systematically applying the full CFIR framework, this review highlights a persistent gap in the literature: IPC implementation is frequently reduced to behavior change, although implementation processes and contextual mechanisms remain underexplored. Evidence from other healthcare settings indicates that structured attention to implementation is crucial for achieving effective and sustainable outcomes. In hospital settings, AMS programs supported by pragmatic, step-by-step implementation guides, have been associated with improved implementation outcomes. ^{Reference Mendelson, Morris, Thursky and Pulcini52} Translating such approaches to long-term care remains challenging, as implementation in dementia care and other LTC settings has been shown to be less successful than in acute clinical settings.Reference Low, Fletcher and Goodenough ⁵¹ Nevertheless, research demonstrates that the use of explicit implementation strategies can improve the adoption and effectiveness of nursing guidelines. ^{Reference Spoon, Rietbergen and Huis49} Implementation mapping provides a systematic process for developing strategies to improve the adoption, implementation, and maintenance of evidence-based interventions in real-world settings. ^{Reference Fernandez, Ten Hoor and Van Lieshout53} Importantly, dedicating structured attention to the implementation process, particularly through tailoring to the local context, has been shown to enhance outcomes without increasing overall implementation time. ^{Reference Vis, Schuurmans and Aouizerate54}

Overemphasis on individual responsibilities hampers acknowledgement of wider context

Most reported factors concentrated within the Inner Setting and Characteristics of Individuals domains, in particular structural constraints (eg, staffing, supplies), leadership engagement, and staff-level knowledge and attitudes. Most studies focused on perspectives from nursing staff, and the perspectives from managers, policymakers, residents, and their families received limited attention so far. This is consistent with earlier reviews in other settings, such as hospitals and residential care. Here, also individual compliance and organizational culture received more attention than implementation processes and outer setting influences on implementation. These findings align with prior literature emphasizing individual and organizational determinants of IPC behavior. ^{Reference Gastaldi, Festa and Nieddu17,Reference Fujimoto, Utsumi and Swa18,Reference Low, Fletcher and Goodenough51,Reference Spoon, Rietbergen and Huis49}

This focus on individual and organizational factors appears to overshadow consideration of broader contextual influences. Several Outer Setting subdomains were underrepresented. The role of external systems, policy incentives, or inter-organizational collaboration, in line with research in hospitals and nursing homes. ^{Reference Spoon, Rietbergen and Huis49} There was limited attention to external pressures (eg, regulations, funding, benchmarking) and patient or family engagement, despite their potential influence on implementation success. Most studies studied nursing staff perspectives, with little involvement of other stakeholders such as managers, policymakers, or residents, further narrowing the scope of insight.

Within the Intervention Characteristics domain, emphasis was primarily on complexity and burden (eg, confusing protocols, demanding procedures). There was no exploration of whether staff or other end-users were involved in shaping guidelines or planning their introduction, an important omission, given the need to build ownership and contextual fit. It is important to involve the end users, staff, with the development of guidelines and implementation. Altogether these findings indicate that although individual and environmental barriers are well-documented, the process of implementing IPC in LTCFs remains poorly understood and under-researched. Most studies examine perceptions of IPC once it is already in place, rather than investigating how new policies are introduced, scaled, or maintained. This represents a major knowledge gap with direct implications for improving practice.

Strengths and limitations

A strength of this scoping review is the application of the CFIR to synthesize barriers and facilitators to IPC implementation. Applying the CFIR enabled systematic comparison across studies and facilitated the identification of gaps, particularly in process- and outer-setting determinants. In addition, the inclusion of qualitative and mixed-methods studies across different long-term care settings allowed for a broad mapping of implementation determinants from diverse contexts.

This review also has two limitations. Several included studies were conducted during the COVID-19 pandemic, ^{Reference Samdal, Alpers and Sekse28,Reference Cheng, Ali and Chen Collet31,Reference Lohiniva, Toura, Arifulla, Ollgren and Lyytikäinen33} which may limit the generalizability of findings to routine IPC practices in non-crisis contexts. As this was a scoping review, no formal quality appraisal of included studies was conducted. The findings should therefore be interpreted as a broad map of existing evidence rather than an assessment of evidence quality.

Implications for future research and practice

This review points to two directions for future work. First, implementation science and practice benefits from attention to implementation processes that plan and monitor how IPC interventions are introduced, adapted, and sustained in LTCFs. Mixed-method process evaluations, guided by frameworks such as CFIR, can provide insight into what strategies work, for whom, and under what conditions. At the facility level, managers should develop clear implementation plans that define leadership roles, outline staff engagement strategies, and establish monitoring and feedback mechanisms. Simple measures such as regular audit-and-feedback cycles, the appointment of IPC champions, and the integration of tailored training modules can help sustain adherence over time. IPC should be embedded into broader quality and safety management systems rather than treated as an isolated policy requirement. This includes ensuring consistent access to hygiene resources, supporting staff through protected time and training, and balancing IPC measures with the goal of maintaining a home-like environment for residents. At the system level, policy-makers and regulators have an important role in creating external incentives for IPC. Structured external audits, regulatory standards, and dedicated funding streams could strengthen accountability and ensure that LTCFs are not left behind compared to acute care settings. Moreover, involving a broader set of stakeholders such as residents, families, and advocates can help align IPC practices with resident needs and values, increasing both feasibility and acceptance. Second, and following, a broader scope of stakeholders need to be involved throughout the implementation process and need to move beyond a focus on nursing staff alone. Implementation success also depends on the roles of managers, policymakers, infection control specialists, residents, and families, particularly for leadership engagement, policy alignment, and resident-cantered care. Third, IPC research and practice need to tailored to the unique challenges of LTCFs, tested in small-scale pilots before full rollout, and evaluated in terms of sustainability and resource use. Understanding these factors is crucial for ensuring that interventions are both feasible and durable in resource-constrained environments such as LTCFs. Finally, strategies for fostering cultural and behavioral change within care teams remain needed. Beyond providing knowledge and resources, effective IPC implementation requires building ownership, accountability, and collective responsibility across staff. Monitoring and evaluations can track how such cultural shifts can be achieved and maintained would provide valuable evidence for practice.

Conclusions

In conclusion, the review points to the need for multilevel, context-sensitive strategies that acknowledge the realities of LTC. Without structured planning, leadership support, and external reinforcement, even well-designed IPC guidelines are unlikely to translate into consistent and sustainable practice. Although barriers related to staffing, resources, and knowledge are well-described in the literature, this review reveals a significant blind spot: how IPC interventions are implemented in long-term care settings. Sustainable implementation of IPC within LTCFs requires moving beyond compliance-based approaches toward structured and strategic implementation.