Identifying Barriers and Enablers for Nurse-Initiated Care for Designing Implementation at Scale in Australian Emergency Departments: A Mixed Methods Study

Abstract

Aim: The aim of this study was to (i) identify barriers and enablers and (ii) inform mitigating or strengthening strategies for implementing nurse-initiated care protocols at scale in emergency departments (EDs).

Design: Embedded mixed methods.

Methods: The study included four clusters with a total 29 EDs in NSW, Australia. Concurrent quantitative and qualitative data were collected via electronic nursing and medical staff surveys and analysed. Barriers and enablers to implementation were identified and mapped to the domains of the Theoretical Domains Framework (TDF). Selection of intervention functions and behaviour change techniques (BCTs) enabled development of implementation strategies.

Results: In total, 847 responses from nursing and medical staff (43%) reported four enablers for use and implementation: (i) knowing or being able to learn to use simple nurse-initiated care; (ii) protocols help staff remember care; (iii) carefully considered education programme with protected time to attend training; and (iv) benefits of nurse-initiated care. Nine barriers were identified: (i) lack of knowledge; (ii) lack of skills to initiate complex care (paediatric patients, high-risk medications and imaging); (iii) risk for inappropriate care from influence of cognitive bias on decision-making; (iv) punitive re-enforcement; (v) protocols that are too limited, complex or lack clarity; (vi) perceived lack of support from medical or management; (vii) perception that tasks are outside nursing role; (viii) concern nurse-initiated care may increase the already high workload of medical and nursing staff; and (ix) context. The barriers and enablers were mapped to nine TDF domains, five intervention functions and 18 BCTs informing implementation using strategies, including an education programme, pre-existing videos, audit and feedback, clinical champions and an implementation plan.

Conclusion: A rigorous, systematic process generated a multifaceted implementation strategy for optimising nurse-initiated care in rural, regional and metropolitan EDs.

Implications: Staff wanted safe interventions that did not lead to increased workload. Staff also wanted support from management and medical teams. Common barriers included a lack of knowledge and skill in advanced practice. Clinicians and policymakers can consider these barriers and enablers globally when implementing in the ED and other high-acuity areas. Successful strategies targeting barriers to advanced practice by emergency nurses can be addressed at the local, state and national levels.

Impact: Implementation of new clinical practices in the ED is complex and presents challenges. Key barriers and enablers, including those related to initiating care and workloads in the ED were identified in this study. This research broadly impacts ED staff and policymakers globally.

Reporting method: Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS).

Patient or public contribution: Site senior nurse researchers for each cluster worked closely with site stakeholders, including local consumer groups. Consumer councils were engaged at all the sites. Site visits by the research nurses have been an important strategy for discussing the study with key stakeholders.

Trial registration: Australian and New Zealand Clinical Trial: ACTRN12622001480774p.

Keywords: Implementation science; barriers; enablers; implementation strategies.

FIGURE 1

EPIC‐START model of care compared with standard emergency care. This figure demonstrates the difference in the usual pathway of care compared with the EPIC_START model of care. With the new model of care, patients receive nurse‐initiated investigations, diagnostics and treatments, and bed requests are made earlier, resulting in earlier disposition times. ECAT, Emergency Care Assessment and Treatment; EPIC, Emergency Protocols Initiating Care; START, The Sydney Triage to Admission Risk Tool. [Colour figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Flowchart summary of methods and results for identification of barriers and enablers and strategies. This figure demonstrates the three phases of the study and the associated findings at each phase leading to the key findings. *APEASE assessment, Affordability, Practicality, Effectiveness and cost‐effectiveness, Acceptability, Side‐effects/safety, and Equity; ECAT, Emergency Care Assessment and Treatment; ED, Emergency Department; e.g., example, eMR, Electronic Medical Records; TDF. Theoretical Domains Framework. [Colour figure can be viewed at wileyonlinelibrary.com]