Innovation adoption, use and implementation in emergency departments during the COVID-19 pandemic

Abstract

Introduction:

During a public health emergency like the COVID-19 pandemic, emergency department (ED) clinicians may be able to save more lives if they rapidly identify and implement innovations that are safe and effective. However, there is little research examining clinician decision-making around innovation implementation during public health emergencies and when evidence-based information is limited.

Objective:

The goals of this study were to understand how ED clinicians decided to implement innovations and to describe the facilitators and challenges they faced during implementation.

Methods:

We conducted 3 pilot interviews and 13 focus group discussions with clinicians from eight hospital-based EDs across the USA. Seventeen physicians, seven advanced practice providers, 18 nurses and seven respiratory therapists participated. We used inductive and deductive techniques to perform content and thematic analysis of focus group transcripts.

Results:

Participants cited social media, clinician autonomy, limited resources, organisational culture, supportive leadership and outside experiences as facilitators of trying innovations. Challenges in trying new innovations included limited evidence-based information, evolving guidelines, fear, moral distress and clinician pushback. Facilitators of using innovations in practice included leadership advocating for continued use, signs of patient improvement, ease of adoption and adequate resources. Challenges were the lack of familiarity, no established protocol and limited information dissemination about best practices.

Conclusion:

Our study highlights factors that influenced innovation adoption and implementation in EDs during the COVID-19 pandemic, including how fear and moral distress affected decision-making. Organisations can support the implementation of promising innovations by selecting strong leaders, ensuring clinician psychological safety, providing protocols and resources and highlighting successes.

Introduction

During a public health emergency such as the COVID-19 pandemic, emergency department (ED) clinicians can save lives by implementing healthcare innovations, previously defined by the World Health Organization as ‘new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health’.¹ Traditionally, the pace of innovation adoption in healthcare has been slow: a commonly cited study suggests that evidence-based medical practices can take as long as 17 years to be incorporated.² However, during the COVID-19 pandemic, ED clinicians adopted innovations quickly, even with limited supporting evidence (eg, for prone positioning).³

Limited research has been done to understand the implementation of innovations during public health emergencies. However, there are three relevant frameworks describing implementation practices during routine conditions: the Greenhalgh framework,⁴ which is used to study dissemination and implementation of innovations while appreciating complexity and interplay of factors affecting implementation; the Consolidated Framework for Implementation Research (CFIR),⁵ which is designed to guide implementation processes and identify barriers to and facilitators of implementation; and the technology acceptance model (TAM),⁶ which focuses more narrowly on acceptance and adoption of technology at the individual level. We adapted Greenhalgh et al’s⁴ framework to understand the dissemination and implementation of innovations in health services and related processes and how they interconnect to affect the spread and use of novel care practices.⁴ Our objectives were to describe how ED clinicians adopted various innovative COVID-19 innovations and identify the barriers and facilitators they faced in trying and in using these innovations.

Methods

Study Design and Setting

We conducted semistructured focus groups of self-described ED clinician practices related to the implementation of COVID-19 care innovations in ED settings. The focus group discussion guide was informed by a framework adapted from Greenhalgh et al⁴ and modified after piloting with one physician, one nurse and one nurse practitioner. After the initial pilot interviews, no changes were made to the content discussed or focus group guides. Thus, findings from the three pilot interviews were included in our overall analysis.

Because we believed that responses would differ by provider type and that professional hierarchy power dynamics could impact participant responses and comfort level,⁷ we had separate groups for ED prescribers (ie, physicians and nurse practitioners) and for other ED clinicians (ie, registered nurses (RNs) and respiratory therapists (RTs)) at each hospital to facilitate deeper conversation and limit concerns with non-participation.⁷

Patient and public involvement

No patients were involved in this study.

Focus Group Recruitment

We used maximum diversity sampling to recruit hospital-based EDs to participate in focus groups. Hospitals were diverse by US Census Bureau region (n=4),⁸ academic hospital (binary), rurality (binary) and safety net status.⁹ A site-specific champion was recruited by email who assisted in identifying dates and times likely to be well attended by participants at their site.

Participant Recruitment and Data Collection

Focus group participants were then recruited by email for either a physician/advanced practice provider (APP) focus group or for RN/RT focus group. Participants were eligible if they had experience providing care in a participating hospital’s ED during the COVID-19 pandemic. Each participant provided verbal consent at the start of the focus group. After receiving participant consent, we audio-recorded discussions on Zoom.gov for transcription.

Focus groups lasted approximately 60–90 min and included at least one moderator and one notetaker. Three researchers (SF, CB and CC) with previous experience as clinicians and facilitating focus groups led the discussions, and two assistant researchers (SH and NQ) served as notetakers. Before each focus group, the moderator introduced themselves and provided a brief description of the research project. Focus group topics included the following: gaining knowledge about COVID-19 innovations, facilitators of and barriers to adopting innovations, processes for confirming and sustaining promising innovations, processes for deimplementing innovations and how contextual factors impacted innovation adoption (see table 1). Participants were compensated with a $150 gift card for their time and participation.

Table 1:

Sample Focus Group Questions by Topic

Topics	Sample Questions
Gaining Knowledge	● What factors did you and other clinicians in the ED perceive were challenges in gaining knowledge or awareness about innovations in the care of COVID-19? Why were these challenges?   ● What were the factors that facilitated gaining awareness and knowledge about innovations?   ● Where do you get your information about innovations in care related to COVID-19?
Innovation Adoption*	● Can you provide an example of one innovation you or your institution adopted and describe how the decision was made to try it.    ○ How did you personally decide whether to try it?    ○ How did your department or ED decide whether to try it?    ○ How did the institution as a whole decide to try it?    ○ To what extent was there monitoring of patients’ health outcomes when you tried the intervention?   ● Who learned about the innovation? Where did they learn about it? How did it get introduced? How did it get shared to start using in practice?   ● What makes it easier to try new things in care delivery in your ED?    ○ How did practices spread in your ED?    ○ What makes it harder? Barriers?    ○ What is practice variation like? How does what your colleagues do affect your behavior?
Innovations – Confirming	● What factors affected whether ED clinicians and teams use of an already-implemented innovation was continued and why?   ● How do things become routine, i.e.: what is the process of something going from being a test to being standard use? Who decides? How many times do you try something before it becomes the way you do it?
Innovations – Disconfirming/De-implementing	● Tell me about a time you tried something and immediately said, I’m not doing that again? What was that like? What made you decide not to try it again?   ● Here are some examples of things you might have stopped using:   ● Were any of these things you were doing and then stopped? Tell us about it? What made you make that decision?     ○ Can you give an example of one innovation you or your institution adopted and later rejected? Please describe how the decision was made to reject it. [Reject is defined as to stop using after having tried it.]   ● How did you personally decide whether to reject it?   ● How did your department or ED decide whether to reject it?   ● How did the institution as a whole decide to reject it?
Outer Context	● How did the clinician implementation behaviors differ based on contextual factors related to the pandemic (i.e., early vs. late in pandemic; degree of community spread; hospital capacity)?
ED Structure and Processes	● What was the role of physicians in care for patients with COVID in the ED? Decision-making roles? (for physician group)   ● What was the role of non-physicians in care for patients with COVID in the ED? Decision-making roles? (for non-physician group)   ● Were there policies implemented during the COVID-19 emergency that were difficult to comply with? Which ones?

^*Topics covered in this paper

Data Analysis

We used both deductive and inductive analysis techniques to thematically code focus group data.¹⁰ We started by creating a preliminary codebook defined by topics included in the focus group discussion guide, based on the Greenhalgh⁴ framework (table 1).

After the first focus group was completed, two assistant researchers with expertise in health services and qualitative methodology (SH and NQ) independently reviewed a single transcript and applied codes to assess the quality of the codebook. The codebook was updated and finalised based on this coding. The two coders performed an inter-rater reliability test and calculated a kappa score of 0.72, indicating good agreement among coders on the transcript.¹¹ As new themes and insights emerged during focus group discussions, coders updated and added new codes to the codebook. Additions to the codebook were shared via regular meetings among the project team.¹²

The remaining transcripts were then divided in half and each coded by a single coder (SH and NQ). The two coders met regularly to review coding and address any questions that emerged to ensure consistent coding practice. After coding was completed, the coders discussed coded excerpts holistically to identify general themes and subthemes that differed across groups. To ensure accuracy, one coder reviewed a transcript coded by another coder at the beginning and end of the coding process. All qualitative analysis was conducted in Dedoose.¹³ We followed the Consolidated Criteria for Reporting Qualitative Research as a framework for data reporting.¹⁴

Results

Hospital and Participant Characteristics:

In addition to three pilot interviews, we conducted 13 semistructured focus group discussions. In total, 49 clinicians from eight hospitals participated: 24 ‘prescribers’, composed of 17 ED physicians and seven APPs (total of seven focus groups, ranged 3–6 participants per site focus group), and 25 ‘other clinicians’, composed of 18 RNs and seven RTs (total of six focus groups, ranged 3–6 participants per site focus group) (table 2).

Table 2:

Hospital and Participant Characteristics

		Focus Group Type: Physicians (MDs) and Advanced Practice Providers (APPs)		Focus Group Type: Registered Nurses (RNs) and Respiratory Therapists (RTs)
Hospital ID	Region	MDs	APPs	RNs	RTs	Total
Hospital 1	Midwest	6	0	5	0	11
Hospital 2	West	4	0	2	1	7
Hospital 3 (including 1 APP pilot)	West	3	1	5	2	11
Hospital 4	Northeast	2	1	1	4	8
Hospital 5	South	1	2	4	0	7
Hospital 6	South	0	3	0	0	3
Hospital 7 (pilot)	West	0	0	1	0	1
Hospital 8 (pilot)	West	1	0	0	0	1
All	National	17	7	18	7	49

Overall, clinicians averaged 11.2 years of experience in their profession as ED clinicians (9.4 for MDs/DOs, 11 for APPs, 12 for RNs, 14 for RTs). Sixty-seven percent identified as female, 71% identified as White, and 6% as Hispanic.

Four EDs were in the West (three Pacific and one Mountain), two EDs were in the South (one South Atlantic and one East South Central), one ED was in the Midwest (West North Central) and one ED was in the Northeast (Middle Atlantic). Some hospitals had two focus groups within their EDs, while others only had one.

We present qualitative findings grouped into two major topics: innovation adoption and use. Our subtopics include facilitators and challenges to trying new innovations (adoption) and facilitators and challenges to using new innovations in practice (use). Table 4 highlights key quotations from themes.

Table 4.

Key Quotations

Theme or subtheme	Innovation Adoption and Use
Facilitators to trying new innovations
Social Media	“…like REBEL EM, and EMCrit and EMRAP…. If I noticed a theme or a common theme amongst like all three of those then I would say maybe this is something that should be tried...”
Individual Autonomy	“I feel like we had quite a bit of individual leeway to make treatment decisions, particularly earlier on in the pandemic. As things got more established, there was institutional guidance, mostly around medications...”
Limited Resources	“Well, [there were] a lot of things that we had to make our own decision [on] because at that time, because we had so many COVID patients. And so we got pulled from all directions…But you know, the decision we make wasn’t anything on to the patient but just how we could get by.”
Organisational culture and supportive leadership*	‘[The medical director] made it known to the entire group that they wanted ideas about how to do things differently and there was a lot of communication that sort of early on recognised this is unprecedented circumstances and times and asking for ideas about ways to do things differently, more safely, and so the culture was one in which it felt like ideas and innovations are welcomed and desired’.
Outside Experiences	“We were very fortunate that we did not have a lot of permanent staff positions, we have a lot of locums. And whenever they would come from all over pretty much the United States, we would pick their brains on what was going on at their area of the world and we could incorporate it into our neck of the woods.”
Challenges to trying new innovations
Limited Evidence-Based Information Available*	“I think a lot of it was just there were so many things floating around, ‘Oh, this looks promising,’ ‘Oh, this was tried experimentally and had some success or didn’t have some success,’ and so you didn’t want to be the doctor who was not doing the experimental things because maybe in two months that was going to be the new standard of care. But you also didn’t want to be the person who was trying ivermectin on a patient and then clearly that was not a great idea.”
Constantly Changing Guidelines*	“You didn’t want to hurt your patient. You certainly didn’t want to make it worse. And every time you turned around, it was like somebody was telling you to do something different… And I think that was the hardest thing I had to do was, who do you listen to, who do you trust? You don’t want to harm your patient, but you’re getting all these conflicting recommendations for treatment and nobody knew anything.”
Fear and Moral Distress	“I feel like I didn’t have to do [prone] very often. I somehow kept dodging that bullet. But I think the resistance of the...what I would attach to that was the sense of moral distress of I don’t really know what I’m doing and I don’t feel like I’m providing the best care. Which is part of I guess crisis management but definitely a sense of I’m not really sure what I’m doing, I’m not really sure what protocols are supposed to go along with that which was really distressing.”
Individual Hesitancy	“I remember, there was a lot of resistance from providers who were not willing to try…high-flow,… as opposed to just straight intubating people. …there was a lot of hesitancy initially ‘cause they were like “Is it really going to help?” …we just had a lot of trial and error. So there would be some providers who would be more willing to take that risk and then other providers who would just kind of watch and wait.”
Facilitators to using new innovations
Organisational culture and supportive leadership*	‘We had calls with our service line to say from the leadership standpoint, what have we seen when we implemented this? What did the staff give us as feedback? So there was a lot of back-and-forth communication which I think was vital in all this’.
Patient Improvement	“I think watching patients not get sicker with your intervention was kind of reassuring. You know, once you’d seen your thousandth ICU patient get blasted with dexamethasone and either temporize them a little bit and helped them or didn’t really seem to make them sicker, I think you got a lot more comfortable starting those medications in the ER for patients you knew you were going to admit.”
Ease of Adoption	“Yeah, I think that was really one of the important steps is that we got a set of protocols from another country or other countries but we knew that not everything was applicable here, right? Or even reasonable. We’re talking about two different healthcare systems. And so, that really led the conversation with our leaders, ICU, infectious disease, hospital administration, and frontline staff. And they were basically releasing in a Teams chat the literature that corresponds to the most current practices, what we were following, and then a protocol that was fairly easy to follow. If patient comes in with this saturation, this is what you do.”
Adequate Resources and Support	“But our ICUs did do a lot of proning and they actually had proning teams, so teams of people who had been more educated about this process that would go to each patient’s bedside—it was like a whole team and they had a whole process.”
Challenges to using new innovations
Limited Evidence-Based Information Available*	“And so then, it’s like trying to—from what everyone else has said, like, we’re not very well-educated on this aspect. And then to be thrown into it, expected to do it, and then you have all these other comorbidities and things that we’re trying to factor in and make sure that they still potentially can get the best outcome.”
Constantly Changing Guidelines*	“Those little fine-tune changes [from swabbing protocols], it was just hard to keep up with because they could change so rapidly. And then, supply constraints. So, you might have rapid swabs today and you might not have them in a week. And then, you might get them in for a few days and then they would go out. So, it was really hard just to keep up.”
Inconsistent Rate of Information Dissemination	“I wonder if it has to do with—because at each hospital, from what I have been experiencing, it’s not like a one-size-fits-all, and if you are trying to prescribe or like trying to suggest a certain way to address a situation, certain hospitals or certain institutions may not have the materials or the support staff of the channels available to kind of carry out what you think is the best way to face or treat a certain situation…So maybe the different hospital practice settings can pose a challenge, the rate of information dissemination also is very difficult—it’s slower I think in public health emergencies because it—slower but fast at the same time because it changes so much on a day-to-day basis that people, when they get the information, may be not as updated as before is what I’m thinking.”

^*Denotes themes in one or more categories

Innovation Adoption:

Facilitators to trying new innovations:

Clinicians shared that social media facilitated trying new innovations. For example, a participant shared that an attending learned how to build an intubation box, using templates from the EM Docs Twitter group. Another clinician added that if there was a common theme or innovation mentioned among podcasts such as REBEL EM,¹⁵ EMCrit, ¹⁶ and EM:RAP, ¹⁷ then they were more willing to try it. A respiratory therapist also mentioned utilizing YouTube: “…I [watched] to learn how to connect one ventilator and put two patients together. I watched that YouTube [video] over and over again. I mimicked it…[until] I was like, yes, I finally got it.”

Participants also highlighted that hospital administration gave them more freedom to choose their treatments, especially early in the pandemic. Individual autonomy made it easier to try new innovations: one participant described that many decisions around oxygenation and respiratory management early in the pandemic were made by individuals and attendings assessing the best-case scenario. Others felt as though they had no choice but to innovate—and that limited staff and resources facilitated trying new innovations: “We were at a point that let’s try anything to help the care for the patient, because we were running low on other types of devices, other types of supplies, that anything that was provided to us.” The low supply of masks engendered the need to try reusing PPE. As one RN stated, “We would try anything that was recommended to us if it helped.”

Participants who worked at multiple hospitals indicated that outside experiences were helpful while trying new innovations: seeing an innovation tried out in one hospital environment would “make it easier” to learn and try at another. Clinicians at teaching hospitals noted that having residents that rotated through different settings exposed them to differing standards of care. Additionally, hospitals with more temporary staff from all over the United States, “picked their brains” on best practices and incorporated it into their settings.

Participants also noted the importance of supportive leadership and an organizational culture that prioritizes innovation and collaboration among ED colleagues: “[the new president] had no medical background and he [said], ‘I trust you as the frontline providers to do what’s right for our patients and yourselves and I will let you make those decisions.’” Participants highlighted that a culture of frequent communication encouraged greater willingness to try new things. Clinicians mentioned working together and deliberating with their ED colleagues as a facilitator – multiple participants spoke about “bouncing ideas off of each other”, and that talking to trusted colleagues was a way to achieve consensus and ensure they “were on the right track” moving forward. A respiratory therapist elaborated: “Even though I was researching everything online and [colleague] was texting me, I went back to my staff, and I was like, ‘Okay, guys, we’re going to try this. Do you think it’s going to work out?’”

Challenges to trying new innovations:

We identified several challenges to trying new innovations. Insufficient information describing how to implement innovations was a barrier. Clinicians noted that early in the pandemic, limited evidence-based information was available, making it difficult to decide whether to try an innovation. One clinician spoke about balancing the evidence at the time and lack of set rules or protocols. Similarly, other clinicians noted that constantly evolving guidelines posed a challenge for trying new innovations, such as those around PPE reuse— it was confusing to not know which one would persist. Implementation practices also evolved, so it was difficult for some clinicians to understand where they were with the process of utilizing the innovation. As one nurse from an academic medical center stated, “…mentally working in a pandemic was already exhausting. And so, trying to adapt and try new things every single day was equally, if not more, exhausting.” Educating staff on the innovation and proper guidelines was a burden, especially with limited resources. Difficulty with educating staff was greater given high staff turnover rates and traveling clinicians.

Additionally, clinicians spoke about fear and the moral distress¹⁸ of trying new innovations, and having to implement them without training and with limited guidance. Proning (placing patients face-down to improve oxygenation) was an example of this: one clinician stated that they did not feel like they were adequately prepared to prone patients because they were unsure of what protocols they were supposed to use and follow: “I definitely [had] a sense of ‘I’m not really sure what I’m doing, I’m not really sure what protocols are supposed to go along with that’, which was really distressing.” While trying innovations, clinicians shared they were afraid of doing the wrong thing, or accidentally jeopardizing patient safety by inadvertently causing harm. This sense of fear was heightened amidst all the uncertainty of the pandemic. Participants also shared that experiencing patient fear affected their decision-making and added to their own fear of doing something incorrectly. One participant shared that certain primary care providers refused to see patients with any infectious disease symptoms, which “…added a level of fear because, well, if other healthcare providers don’t want to see them, then I don’t want to see them, but I have to.”

Relatedly, individual hesitancy was as a barrier to trying new innovations. Some clinicians initially were reluctant to utilize certain innovations, like high flow oxygen, because they were unsure if it would help improve patient outcomes. One RN participant noted that staff had a “hard time accepting new things” and it was difficult to get agreement to do so, except when leadership expressed buy-in, or when there was a reoccurring problem. A nurse from a safety net hospital explained, “…it takes multiple problems or multiple maybe situations that could have been prevented in order for us to implement something to prevent it.”

Facilitators of using innovations in practice:

We identified several facilitators to using and to adopting innovations in practice. Like innovation adoption, attending physicians and leadership that advocated for innovations were key reasons innovations were used in ED settings. A clinician mentioned that leveraging expert teams for proning facilitated the use of it in practice; Innovations that felt protective against COVID-19 risks were more likely to be utilized. Many participants noted that observing improved patient outcomes, and absence of harm (e.g., watching patients not get sicker after using the innovations), was an important facilitator to using the innovation. For example, a participant mentioned: “We did see some…positive results with the proning in younger people. But that was something that came about that I think really turned a corner for us.” Finally, if innovations (e.g., medications) were relatively easy to incorporate and learn, participants were more likely to adopt the innovation in the long term.

Challenges of using innovations in practice:

Like innovation adoption, the lack of knowledge around the innovation and changing guidelines were barriers for innovation use. Limited resources, in addition to time consuming staff training, hindered innovation implementation. Training staff and frequently communicating with them proved to be difficult with many other competing priorities, especially given uncertainty that staff faced both on and off the job during the pandemic. Relatedly, participants also mentioned that it was difficult to establish consistency with shifting protocols: “What is the standard or what we thought was the standard didn’t necessarily work in every scenario.” Some clinicians described the need to see instant results from an innovation to justify continued use.

Finally, different hospital settings had inconsistent results at least in part due to the varying rate of information dissemination around innovations. If the rate of dissemination was slower in certain hospital settings, it was more difficult to adopt the innovation and use it in practice. Information about innovations could change so much on a day-to-day basis that once the information was received, it might no longer be useful or relevant.

Discussion

This study describes the barriers and facilitators ED clinicians faced while implementing innovations during the COVID-19 pandemic. Facilitators to trying new innovations in the ED included social media, individual autonomy, outside experience, supportive leadership and organizational culture, and resource availability. Challenges to trying new innovations included limited evidence-based information, evolving guidelines, fear, moral distress, and individual hesitancy. Facilitators to using innovations in practice included leadership that advocated for continued use, signs of patient improvement, and adequate information about the innovation. However, challenges remained for using the innovations in practice, such as the lack of familiarity with the innovation and established protocol and difficulty with best practice information dissemination. At the time of writing this article, COVID-19 care innovations first implemented in the early stages of the pandemic now have more evidence to support their benefit or lack thereof.

The role of fear is missing from prominent implementation frameworks. In addition to Greenhalgh,⁴ we examined other implementation frameworks such as the Technology Acceptance Model (TAM) ⁶ and the Consolidated Framework of Implementation Research (CFIR), neither of which include fear as a component.⁵ Greenhalgh’s framework emphasizes innovation implementation and dissemination and implementation processes, such as organizational readiness and the “knowledge purveyors” who spread the information on innovations to staff. ⁴ Our results demonstrated the importance of supportive leadership and organizational culture. TAM underscores perceived usefulness of innovations: participants stated they were more likely to use innovations if there were signs of patient improvement.⁶ CFIR considers factors that influence implementation outcomes like innovation type, hospital setting, individuals, and processes.⁵ Participants mentioned constructs within CFIR domains as facilitators and barriers for innovation adoption and use.

By exploring clinician practices related to innovation implementation during the COVID-19 pandemic, we highlight new insights into the barriers and facilitators to implementation during a large-scale public health emergency. Our results are similar to existing literature. However, limited literature about innovation adoption in public health emergencies exists. Other studies have demonstrated that hospital support and leadership buy-in for innovations^19,20 are essential for success in implementation adoption during typical working conditions²¹ and also more specifically during the COVID-19 pandemic. Lack of resources is a common reason for failure of innovation implementation, since any added financial expense or human capital needed to support implementation may detract from other pre-existing practices.²² A systematic review from Braithwaite et al.²³ found that eight key factors influenced success in implementation practices aimed at improving quality and safety: preparing for change, capacity for implementation, setting, types of implementation, resources, leverage, desirable implementation enabling features, and sustainability.²³ A recent publication evaluating technology adoption during the pandemic found that perceived usefulness and perceived ease of use were key factors positively influencing adoption during the pandemic, which is similar to our findings that positive outside experiences and ease of incorporating innovations were important facilitators.^23,24 Our results confirm these studies with regards to factors influencing innovation adoption and we add evidence about factors related to fear and moral distress.

Most implementation science inquiry into innovation adoption has been performed during routine conditions, whereas our study examined behavior during a worldwide pandemic that disrupted usual-care practices. We provide unique insights into how fear and moral distress influenced clinician decisions to adopt innovations when evidence was limited. Fear among health professionals and patients has been cited as a substantial barrier to deimplementation of low-value care.²⁵ However, the above frameworks should take into consideration the roles of fear and moral distress and revising existing conceptual frameworks could be appropriate to guide future work: although CFIR includes unanticipated events that disrupt implementation, experiencing fear and uncertainty within the workplace influences clinician willingness to try and adopt new innovations. Prior work has indicated that clinician moral distress may be used to identify opportunities for system improvement – ensuring psychological safety for clinicians to voice their concerns and attentive leadership may address these concerns and reduce stress.^26–28 Similarly, our findings indicate that psychological safety may facilitate innovation implementation by addressing clinician fear and moral distress in times of uncertainty.^29–31

Limitations

Because our study was conducted two to three years after the pandemic began, recall bias may have influenced participants’ self-reported experiences. Additionally, although we recruited a diverse set of EDs, the sample is not large enough to be considered nationally representative. Finally, our sample set is not demographically representative, so future larger-scale work should be undertaken with a broader sample that is demographically diverse.

Conclusion

ED clinicians are critical to the response to disease outbreaks and public health emergencies. During uncertain times, clinicians must rapidly implement new protocols and practices and assess these changes in real time under uncertain conditions. Our study identifies factors that affected innovation adoption and use in ED settings during the COVID-19 pandemic. It highlights many previous results on facilitators of and barriers to trying and using innovations, such as supportive leadership, organisational culture, lack of resources and guidelines, and difficulty with information dissemination. It also provides new evidence on how clinician fear and moral distress affected innovation adoption and use. During future public health emergencies, organisations can intentionally support the implementation of promising innovations by selecting strong leaders, providing protocols and resources, ensuring clinician psychological safety and highlighting successes.^29–31

Table 3:

Participant Demographic Characteristics

Respondent Type	Number of Respondents	Average Years of Experience
APP	7	11
Female	5	11.8
Male	2	9
ED Physician	17	9.4
Female	6	6.8
Male	11	10.8
Nurse	18	12
Female	16	11.4
Male	2	16.5
Respiratory therapist	7	14
Female	6	12.8
Male	1	21
Grand Total	49	11.2

What is already known on this topic

While there are existing frameworks describing implementation practices during routine conditions, limited research has been done to understand the implementation of innovations during public health emergencies. We adapted Greenhalgh et al’s framework to understand the use, adoption and implementation of innovations in health services.

What this study adds

The goals of this study were to understand how ED clinicians decided to implement COVID-19 care innovations and describe the barriers and facilitators they faced in adopting and using the innovations.

How this study might affect research, practice or policy

Our work offers important lessons that can inform policy and organisational decisions for the next pandemic, such as selecting strong leaders, providing protocols and resources, ensuring clinician psychological safety and emphasising successes. It also highlights the fear and moral distress clinicians felt during the pandemic, especially around patient safety, and how that may affect the ability to adopt and use innovations.

Data availability statement:

No data are available.