Table 4 What works, for whom, how, and in what circumstances.

New roles: standardised care approaches that enabled the extension of nursing roles tended to be used.

Location and visibility: standardised care approaches that are readily available and are highly visible are more likely to be used.

Incentives: standardised care approaches linked to financial rewards were consistently used.

Buy-in: generally when the whole team (multi/uni-disciplinary) has been actively involved in the development of a standardised care approach it tends to be used.

Making a difference: standardised care approaches that practitioners perceived as making difference to their practice and patients were used.

For whom

Mainly nurses, midwives, and health visitors: despite existence of multi-disciplinary standardised care approaches, medical staff rarely used them (for exceptions see below).

Medical staff: some junior doctors found standardised care approaches useful. General Practitioners consistently used Quality Outcomes Framework related protocols.

Students, newly qualified, temporary, and new staff: standardised care approaches were perceived to be a useful heuristics to organising care for those who do not have experience (usually nurses but also medics and Allied Health Professionals).

Nurses taking on new roles: standardised care approaches gave nurses confidence for delivering care autonomously (e.g., nurse/midwife-led clinics and services).

How

Explicit use: some standardised care approaches were being used on-screen and shared with the patient -- usually as checklists or prompts. Additionally they could be useful sources of information for some staff.

Implicit use: some standardised care approaches were not explicitly referred to, but their principles may guide care.

Embedded in documentation: some standardised care approaches were embedded in routine documentation, sometimes replacing or complementing patient's notes.

Embedded in IT systems: some standardised care approaches were part of routine systems and worked effectively as a prompt.

In what circumstances

Nurse/midwife-led services: standardised care approaches supporting the running of nurse and midwife-led services and clinics were more likely to be used.

Protection from litigation: when nurses were practising outside their traditional scope of practice standardised care approaches were consistently used because they provided a safety net.

Mandatory: when the use of standardised care approaches was compulsory they were consistently used, and supported with regular audits and training.

Financial reward: for outcomes of use, encouraged commitment to and use of linked protocols.

Ongoing project lead: the existence of such a role seemed to facilitate active involvement of the multi-disciplinary team. The lead also enabled on-going monitoring of use.

Strategic support: for the development and sustained implementation of standardised care approaches.