Applying Behaviour Change Theory to Develop an Implementation Strategy for Nurse‐Initiated Protocols in the Emergency Department

ABSTRACT

Background

Emergency Departments face increasing pressure due to rising patient demand, complex presentations, and resource constraints, resulting in long waits and extended stays. Nurse‐initiated protocols enable nurses to commence investigations and treatments based on clinical guidelines, improving care and efficiency. Despite evidence supporting their effectiveness, few nurse‐initiated protocol implementation strategies are grounded in behaviour change theory. This gap may contribute to limited uptake, as many initiatives fail to address the complex factors influencing clinician behaviour.

Aim

To develop a behaviour change theory‐informed implementation strategy to enhance the uptake of nurse‐initiated protocols in the emergency department.

Design

A framework‐based intervention design was used.

Methods

The Behaviour Change Wheel and Theoretical Domains Framework guided the development of the implementation strategy. Barriers and enablers identified through prior research in 2023 using surveys and focus groups were mapped to relevant intervention functions. Behaviour change techniques were selected based on their potential to address barriers or strengthen enablers. The APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects, and Equity) were applied to optimise feasibility.

Results

Nine barriers and ten enablers to nurse‐initiated protocols use were identified and categorised using the COM‐B (Capability, Opportunity and Motivation) framework and mapped to the Theoretical Domains Framework. Eight intervention functions were selected and mapped to 24 behaviour change techniques and 23 delivery modes. The key implementation strategies are education, clinical champions, documentation changes, audit and feedback, and leadership engagement. Stakeholders confirmed the feasibility of the selected strategies.

Conclusion

Theory‐informed, context‐specific strategies are essential for implementing nurse‐initiated protocols in emergency departments. This approach enables the design of targeted, feasible interventions that directly respond to identified barriers and enablers. Future research should test context‐specific implementation strategies, assess their long‐term impact on healthcare outcomes, and evaluate their scalability across diverse healthcare settings.

Impact

• By targeting the behavioural determinants of clinician practice, this study fills a critical gap in implementation science within emergency nursing.

• This study identified 24 behaviour change techniques across eight intervention functions to support nurse‐initiated protocol uptake. Strategies such as education, clinical champions, and audit provide a practical, replicable framework to overcome barriers, enhance autonomy, and reduce care delays. Findings support sustainable implementation in emergency settings, with future research needed on long‐term impact and scalability.

Reporting Method

There is no EQUATOR guideline available for this study.

Patient or Public Contribution

This study did not include patient or public involvement in its design, conduct, or reporting.

1. Introduction

Emergency Departments (EDs) worldwide are high‐pressure environments where clinicians must manage undifferentiated patients with varying acuity levels simultaneously. Increasing patient demand, greater clinical complexity, and persistent resource constraints have exacerbated these pressures, resulting in prolonged waiting times, extended lengths of stay, and overcrowding (Forero et al. 2019; Pearce et al. 2023). In Australia, for example, in 2024, only 67% of ED patients were seen within the recommended timeframe (AIHW 2025). Similar trends have been observed internationally; in England, ED attendance increased by 27% per capita between 2002/03 and 2022/23, contributing to mounting pressure on frontline services (Jacob et al. 2024).

One strategy to enhance patient care and efficiency in the ED is the implementation of Nurse‐Initiated Protocols (NIPs). In this context, “nurses” refers to Registered Nurses (RNs) who, following appropriate training and within their scope of practice, are authorised to initiate specific investigations, treatments, and interventions based on predefined clinical guidelines. Similar practices exist internationally under various terms such as “standing orders,” or “nurse‐initiated orders,” reflecting differences in regulatory frameworks and clinical governance structures (Burgess et al. 2021).

Evidence from diverse healthcare systems supports the effectiveness of NIPs, which can significantly reduce patient wait times, expedite treatment, and enhance patient satisfaction by enabling faster symptom relief (Burgess et al. 2021; Cabilan and Boyde 2017; Calder et al. 2024; Considine et al. 2019; Garrouste et al. 2025; Victoria et al. 2020). A systematic review of nurse‐initiated X‐rays in EDs demonstrated reductions in imaging delays without compromising patient safety (Burgess et al. 2021). Multiple studies on nurse‐initiated analgesia show improved timeliness of pain management without an increase in adverse events (Cabilan and Boyde 2017; Calder et al. 2024; Varndell et al. 2018; Victoria et al. 2020). By expediting early clinical decision‐making and intervention, NIPs have the potential to improve patient outcomes, optimise resource use, and enhance patient satisfaction.

In Australia, to standardise NIPs in the state of New South Wales (NSW) the Ministry of Health, Agency for Clinical Innovation (ACI) developed 73 Emergency Care and Treatment (ECAT) protocols for implementation across the more than 170 NSW EDs. The protocols were designed through a multidisciplinary expert consensus of frontline nursing, medical, and allied health clinicians, nurse managers, health executives, and consumer representatives, as well as being informed by peer‐reviewed literature and existing local guidelines (Agency for Clinical Innovation 2023).

The mere existence of protocols does not ensure their use; rather, uptake of protocols is contingent on a complex interplay of behavioural, organisational, and systemic factors (Cassidy et al. 2021; Spoon et al. 2020). Consistent with international literature, the use of NIPs in practice highlights the need for targeted, evidence‐based strategies that address specific barriers and enablers influencing clinician behaviour (Atkins et al. 2017). In the initial phase of our mixed methods study in 2023, we examined the barriers and enablers affecting NIP uptake through a survey of emergency nurses and physicians supplemented by focus groups with emergency nurses (Gawthorne et al. 2025; Gawthorne, Curtis, and McCloughen 2025). Findings identified eight barriers such as limited confidence, competence, and experience among nurses, exacerbated by high workload demands, psychological stress, inadequate staffing, and apprehension about making errors. Conversely, enablers were targeted education, real‐time clinical support, and recognition of the positive impact of NIPs on patient outcomes and ED efficiency (Gawthorne et al. 2025; Gawthorne, Curtis, and McCloughen 2025).

While the initial phase of our study identified the barriers and enablers influencing NIP adoption, a structured, theory‐informed approach was needed to translate these findings into an effective implementation strategy. Behaviour change frameworks offer a valuable tool to design interventions that promote the sustained and effective use of NIPs (Skivington et al. 2021). The aim of this integration phase of the study was to develop an evidence‐based implementation strategy to enhance the uptake and sustained use of NIPs in EDs by addressing barriers and leveraging enablers to their uptake using behaviour change theory.

2. Aim

To develop a behaviour change theory‐informed implementation strategy to enhance the uptake of NIPs in EDs.

3. Methods

3.1. Study Design

A framework‐based intervention design (French et al. 2012) was used to guide this secondary analysis. This study represents the second phase of a larger mixed methods project. The aim of the original study was to identify behavioural, organisational, and contextual barriers and enablers influencing the uptake of nurse‐initiated protocols (NIPs) in the emergency department, using survey and focus group data from nursing and medical staff (Gawthorne, Curtis, Fry, et al. 2025; Gawthorne, Curtis, and McCloughen 2025). Building on those findings, the current study undertakes a secondary analysis to develop a theory‐informed implementation strategy for NIPs in the ED.

A framework‐based intervention design refers to the structured development of implementation strategies guided by theoretical models to ensure interventions are targeted, systematic, and evidence‐informed (French et al. 2012; Michie et al. 2014). This approach enhances intervention fidelity and replicability, increasing the likelihood of sustained behavioural change and improved protocol uptake (Spoon et al. 2020). The Behaviour Change Wheel (BCW), Theoretical Domains Framework (TDF), and COM‐B (Capability, Opportunity and Motivation) model were applied to guide this process, providing a structured pathway for linking identified barriers and enablers to appropriate intervention functions and behaviour change techniques.

3.2. Context and Setting

The study was conducted in a tertiary referral hospital in an inner‐city hospital in Sydney, Australia, which manages approximately 60,000 adult ED presentations annually. The ED nursing workforce included registered nurses, nurse practitioners, Clinical Nurse Educators (CNEs), Clinical Nurse Consultants (CNCs) and nurse managers. Nurses not permanently employed at the study site, such as agency nurses, were excluded, as they did not routinely engage with NIPs. Emergency physician trainees and consultants were included in the study to capture multidisciplinary perspectives on protocol implementation. Junior physicians were excluded due to their short‐term rotations in the ED and limited exposure to emergency nursing workflows and protocol implementation.

3.3. Data Sources

This study builds on previously collected qualitative and quantitative data that identified key barriers and enablers influencing the uptake of NIPs in ED (Gawthorne et al. 2025; Gawthorne, Curtis, and McCloughen 2025). In August 2023, a survey was conducted with a convenience sample of 76 nursing staff (82% response rate) and 34 emergency physician trainees and consultants (72% response rate) (Gawthorne, Curtis, Fry, et al. 2025). To further explore nursing perspectives on NIP implementation, focus groups were conducted with 34 nurses recruited via a convenience sample.

These findings informed the systematic application of the BCW and TDF to develop a theoretically grounded implementation strategy. By directly mapping intervention components to identified behavioural determinants, this approach ensures alignment with established implementation science methodologies (Michie et al. 2011). No new primary data were collected. All previously collected data were obtained under prior approval from the hospital's Human Research Ethics Committee.

3.4. Theoretical Framework Underpinning the Intervention Design

This study was informed by three established frameworks in implementation science, BCW, TDF, and the COM‐B model (Capability, Opportunity, Motivation, Behaviour). Together, these frameworks provided a systematic and theory‐driven approach to developing an evidence‐informed implementation strategy for embedding nurse‐initiated protocols (NIPs) in the ED.

The BCW provides a comprehensive and structured approach to designing behaviour change interventions focusing on the COM‐B model. This model theorises that behaviour change occurs when individuals have the capability (physical and psychological), opportunity (social and environmental), and motivation (automatic and reflective) required to perform the desired behaviour (Michie et al. 2014). The COM‐B model was used as the foundational lens to identify what needs to change to support the routine use of NIPs by emergency nurses.

To strengthen behavioural diagnosis, the TDF was used to complement the COM‐B model. The TDF breaks down behavioural influences into 14 domains, such as knowledge, skills, and beliefs about capabilities (Michie et al. 2014) offering a more detailed understanding of the barriers and enablers affecting nurses' use of NIPs. This integration enabled a systematic mapping of qualitative and quantitative findings to targeted interventions, ensuring the strategy was theory‐informed and contextually relevant.

In the third stage of the BCW process, selected intervention functions were linked to the Behaviour Change Technique (BCT) Taxonomy, a comprehensive classification of 93 evidence‐based techniques across 16 categories (French et al. 2012; Michie et al. 2014). The BCT taxonomy identifies the “active ingredients” of behaviour change interventions, enhancing fidelity, replicability, and evaluation (Michie et al. 2014). In this study, it was used to inform the selection of strategies to support the uptake of NIPs by emergency nurses.

To guide decisions across all three stages, the APEASE criteria, Acceptability, Practicability, Effectiveness, Affordability, Side‐effects and Equity, were applied. These criteria assess whether interventions are acceptable to stakeholders, feasible to implement, effective and cost‐efficient, safe, and equitable in their impact (Michie et al. 2014). The use of APEASE supported pragmatic decision making by balancing the strength of the evidence with real world implementation considerations.

3.5. Implementation Strategy Development

A structured, theory‐driven process was undertaken to develop an implementation strategy for NIPs in the ED. This involved four sequential stages (Figure 1): (1) understanding the behaviour, (2) identifying intervention options, (3) selecting behaviour change techniques (BCTs) (4) assessing feasibility and stakeholder validation (Michie et al. 2014). Each stage was systematically applied to ensure the strategy was theoretically grounded and feasible within the ED setting. Data from the staff survey and focus groups were primarily used in Stage 1 to identify behavioural barriers and enablers and were subsequently integrated across all stages to inform the selection of relevant intervention functions and BCTs. This ensured that the strategy reflected the real‐world experiences, needs, and priorities of frontline emergency nurses.

FIGURE 1.

Process for developing the NIP implementation strategy using the BCW framework.

3.6. Stage 1: Understanding the Behaviour

To support NIP implementation, Stage 1 focused on identifying key behavioural factors influencing protocol uptake in the ED. This stage drew on findings from our previous studies (Gawthorne et al. 2025; Gawthorne, Curtis, and McCloughen 2025) which involved surveys and focus groups with emergency nurses and physicians. These data were analysed using the BCW and TDF.

A total of nine barriers and 10 enablers were mapped to the COM‐B model to determine how capability, opportunity, and motivation influence NIP uptake. Capability‐related barriers were limited knowledge and confidence using protocols, while opportunity‐related challenges encompassed staffing constraints, workload pressures, and interprofessional dynamics. Motivation‐related factors were perceived professional autonomy and the preceived positive impact of NIPs on patient outcomes.

3.7. Stage 2: Identify Intervention Options

The second stage focused on selecting intervention functions to address the behavioural determinants identified in Stage 1. The nine BCW intervention functions, education, training, enablement, persuasion, modelling, environmental restructuring, incentivisation, coercion, and restriction—were reviewed for their relevance to the COM‐B model. Functions were selected based on how effectively they addressed the barriers and enablers identified in our previous studies and their feasibility within the ED context.

3.8. Stage 3: Identification of Behaviour Change Techniques

In stage three, BCTs were mapped to the selected intervention functions using the Behaviour Change Techniques Taxonomy (BCTTv2) to ensure precise alignment with the barriers and enablers. To ensure feasibility and acceptability of the proposed interventions before implementing, all selected BCTs were evaluated using the APEASE criteria. Potential modes of delivery were also assessed through APEASE, considering strategies such as face‐to‐face training, opinion leaders, audit and feedback mechanisms, and environmental modifications. In this context, affordability and practicability were prioritised due to resource limitations in the current healthcare setting.

3.9. Stage 4: Feasibility and Stakeholder Validation

The final stage involved structured co‐design with three senior emergency nurses, a Nurse Unit Manager (NUM), Clinical Nurse Educator (CNE), and Transitional Nurse Practitioner (TNP), purposefully selected for their leadership roles and expertise in NIPs. Using the APEASE criteria, they systematically assessed each proposed BCT and delivery method. Guided by a preformatted table, the group rated each strategy and reached consensus on whether to retain, modify, or exclude it. This co‐process ensured the final implementation strategy was co‐designed, contextually relevant, and practically feasible for the ED setting.

3.10. Ethics Approval

Ethics approval for the study was obtained from the St Vincent's Hospital, Sydney Human Research Ethics Committee (HREC), Reference number—2023/ETH01182, for the entire program of research. The use of survey and focus group data to develop the implementation strategy was included in the original ethics application and approved by the HREC. This study was conducted under the original ethics approval and involved no new data collection. The study complies with the National Health and Medical Research Council of Australia National Statement on Ethical Conduct in Human Research (2023) (National Health and Medical Research Council & Australia 2023).

4. Results

4.1. Barriers and Enablers to NIPs Uptake

The nine barriers and ten enablers influencing the implementation of NIPs in ED were categorised using the COM‐B framework (Table 1). Each barrier and enabler was further mapped to the domains of the TDF to better understand the behaviours affecting NIP use. Based on this analysis, nine potential intervention functions from the BCW were identified as appropriate. These functions were then assessed using the APEASE criteria to determine their relevance and feasibility within the ED setting. As a result, eight intervention functions were selected: education, persuasion, incentivisation, training, restriction, environmental restructuring, modelling, and enablement. Coercion was excluded due to concerns regarding acceptability and equity.

TABLE 1.

Mapping of barriers and enablers to the COM‐B model components.

COM B	Barriers	Enablers
Capability
Psychological capability	Lack of knowledge about NIPs and their application	Education to develop nursing practice
Physical capability	Lack of competence and experience using NIPs	Education to develop nursing practice
Opportunity
Physical opportunity	High workload and psychological stress Insufficient physical and human resources Documentation burden	Support in the clinical environment
Social opportunity	Uneven distribution of workload between physicians and nurses Nurses and physicians' professional relationship	Support from management and physician A supportive work environment
Motivation
Reflective motivation	Fear of using the wrong protocol and initiating incorrect care	Recognition of expedited treatment leading to improved patient outcomes Organisational benefits in meeting hospital targets Feedback regarding the impact of NIPs on healthcare outcomes
Automatic motivation	Lack of confidence using NIPs	Enhanced nursing autonomy, career progression, and job satisfaction Nurses' motivation to use NIPs NIPs improve clinical practice and patient safety

The eight intervention functions were then mapped to 24 BCTs (with some addressing multiple barriers and enablers). These BCTs were operationalised through 23 distinct delivery modes. These interventions represent a proposed theory and stakeholder‐informed implementation strategy that has not yet been implemented or evaluated. A detailed summary of the full implementation strategy is available in the Table S1.

4.2. Implementation Strategies

Building on the selected intervention functions and mapped behaviour change techniques, a set of tailored implementation strategies was developed to address barriers and leverage enablers to support the uptake of NIPs in the ED. These proposed strategies are education, training, clinical support, environmental restructuring, audit and feedback, and policy development (Table 2).

TABLE 2.

Implementation strategies.

Implementation strategy	Intervention description	Rationale	Delivery
Education and training program	Two‐day interactive workshop incorporating skills stations and clinical simulations to practice NIPs delivered using a staged, scaffolded approach Inservice education Insitu education in the clinical setting	To enhance nurses' knowledge, skill and clinical application of NIPs Builds knowledge, skills, and confidence to apply NIPs safely and effectively in practice	Delivered by ED CNC, CNEs, experienced nurses, and champions Bimonthly courses and weekly (minimum) in‐service Daily insitu education
Clinical support: Clinical champions and precepting model	4Preceptor program 5Clinical champions 6Train‐the‐trainer program for clinical champions	To enhance nurses' familiarity, confidence and competence in applying NIPs Provide support and real time feedback in the clinical setting To ensure consistent education and clinical support	Preceptor program—CNC/CNEs, and clinical champions CNC to deliver the train the trainer program to CNEs and clinical champions
Resources and workflow integration	7Dedicated time allocated for education and training 8Changes to documentation templates and modifications to the initial documentation requirements 9More Workstation on Wheels (WOWs) in the clinical setting 10Develop ‘quick list’ pathology panels	To facilitate learning, provide visual prompts and reminders, consistency, easy access to protocols Reduce time taken to order pathology and ensure nurses adhere to NIPs	Nurse managers approve protected teaching time. CNE allocated teaching time on nursing roster monthly CNC to lead documentation changes in consultation with emergency nurses IT and finance services Pathology and ED Director, Clinical Information System team
Audit and feedback	11Audit patient outcomes, organisational performance targets and incidents 12Feedback via multiple sources; email, staff huddles, meetings, high traffic areas 13Maintain issues log for staff to provide feedback/identify issues 14Monitor NIP related incidences via the incident reporting system	To promote awareness and transparency of protocol adherence and provide ongoing motivation to use protocols Enable real time feedback and reflective practice to support continuous learning, identify implementation challenges early, and ensure nurse perspectives inform the ongoing refinement of NIPs	CNC and analytics team to build ED nursing dashboard that will hold real time NIP associated data Audit results collated weekly by the ED CNC and clinical champions Move to monthly/quarterly reports when protocol uptake is sustained Real time monitoring of incident reports related to NIPs. Monthly incident report presented at monthly meetings
Policy development	15Local policy defining roles, responsibilities, and protocol initiation and incident management	To ensure clarity, consistency, and accountability in NIP implementation	ED leadership team with endorsement from relevant hospital committees Accessible digitally and in print
Leadership and organisational support	16Personalised messages, videos, interdisciplinary meetings 17Revise local career progression framework 18Regular group feedback session	To emphasise organisational commitment to NIP implementation To ensure the revised framework incorporates NIPs and supports an expanded scope of practice A space for nurses to reflect on challenges, share successful strategies, and receive constructive feedback	Delivered by hospital executives and ED managers, CNEs and clinical champions prior to and during implementation A safe space for nurses to reflect on challenges, share strategies, and give and receive feedback
Nurse‐physician relationship and workload distribution	19Multidisciplinary meeting with emergency nurses and physicians 20Incorporate NIP education into ED orientation for physicians at the change of each term	To ensure collaborative relationships and even workload distribution between nurses and physicians	Monthly multidisciplinary ED meeting, added as standing agenda item CNC/CNE included in the quarterly ED orientation program for physicians
Recognition program	21Team acknowledgments across hospital intranet, the bi‐monthly nursing newsletter, emails, and approved hospital social media platforms 22Peer recognition program 23Team celebrations with a special event, for example lunch/afternoon tea	To motivate protocol uptake and adherence and celebrate success	Recognition promoted across hospital intranet, the bi‐monthly nursing newsletter, emails, and approved hospital social media platforms

4.3. Education and Training Program

A comprehensive education and training program will be central to supporting nurses in implementing NIPs. This program will use a multifaceted approach incorporating a face‐to‐face workshop featuring interactive teaching methods, skills stations, and simulation scenarios. These components are designed to enhance nurses' clinical application of NIPs, deepen their understanding of protocols, and promote skill acquisition in a safe, controlled environment. Verbal and written instructions on protocol application, including medication, pathology, and X‐ray ordering systems, will be provided throughout the education programmes to enhance familiarity prior to clinical use.

The education program will be delivered by a multidisciplinary team of ED CNCs, CNEs, and experienced emergency nurses, who will take on the role of clinical champions. Leveraging the expertise of these respected clinicians will enhance the credibility of the training, boost motivation, and foster peer‐led learning. To promote continuous learning and skill refinement, structured feedback mechanisms will be embedded throughout the education program. Immediate, constructive feedback during simulations and practical exercises will support nurses in identifying areas for improvement and consolidating strengths. Mentorship from clinical champions will further facilitate knowledge transfer and skill acquisition.

Recognising the demands of a busy ED environment, protected education time will be prioritised to allow nurses to fully engage with the programme without competing clinical pressures. By minimising interruptions and ensuring dedicated learning opportunities, this approach aims to enhance protocol uptake, adherence, and sustainability.

4.4. Clinical Support: Clinical Champions

A structured precepting model will be implemented, involving emergency CNCs, CNEs, and clinical champions to provide individualised, on‐the‐floor mentorship to nurses transitioning to NIPs. Clinical champions will work alongside nurses new to NIPs, delivering real‐time support, guidance, and feedback to enhance confidence, competence, and consistency in applying NIPs. Champions will lead structured end‐of‐shift debriefs with preceptees to facilitate reflection, knowledge consolidation, and feedback.

CNEs and clinical champions will participate in a comprehensive ‘train‐the‐trainer’ program led by the ED CNC, ensuring consistency in teaching and mentorship across clinical settings. This program will focus on developing skills in effective feedback delivery, mentorship techniques, reflective practice, role modelling, and debriefing to enhance fidelity.

4.5. Resources and Workflow Integration

Adequate resources and workflow integration will be essential for supporting NIP implementation. To facilitate this, protected time will be allocated to nurses for study days, in‐services, and completion of eLearning modules related to NIPs. To streamline protocol use and encourage consistent application, nursing documentation templates will be revised to include dedicated fields for recording the name of the initiated protocol. This modification will serve as a visual prompt, encouraging protocol initiation during the initial patient assessment and ensuring accurate documentation.

Additional workstations on wheels (WOWs) will be provided to facilitate immediate access to electronic protocols, diagnostic tools, and medication ordering systems at the point of care. Hard copies of NIP policies will be maintained throughout the ED to support protocol application during system downtimes or technical disruptions.

4.6. Audit and Feedback

A comprehensive audit and feedback strategy will be implemented to support NIP uptake and ensure adherence to clinical protocols. Regular audits will be conducted to evaluate the uptake of protocols focusing on patient clinical indicators and organisational performance targets. Metrics will report the number of patients with a protocol initiated, types of protocols applied, time to symptom relief (e.g., analgesia), and hospital performance targets such as time to treatment and length of stay (LOS) in the ED.

Audit findings will be disseminated through staff newsletters, emails, team huddles, clinical governance meetings, and visual displays in high‐traffic ED areas. This approach will ensure transparency and promote awareness of protocol adherence and outcomes.

4.7. Policy Development

A comprehensive local policy outlining roles and responsibilities related to NIP activation will be developed. This policy will provide explicit guidance on protocol initiation, detailing authorised personnel, mandatory training requirements, documentation standards, and procedures for managing incidents and network downtimes.

The policy will be made available in both digital and printed formats. Digital versions will be accessible through the intranet, ensuring ease of access for all staff. Printed copies will be placed at all nursing stations within the ED to support consistent adherence during clinical practice.

4.8. Leadership and Organisational Support

Regular, monthly, interdisciplinary meetings will be held to assess implementation readiness, address challenges, and develop targeted solutions, ensuring implementation is optimised. Executive support will be communicated through personalised messages, memos, and videos from hospital executives and ED managers endorsing NIP implementation. These communications will demonstrate organisational commitment and emphasise the importance of NIPs in enhancing patient care.

4.9. Nurse‐Physician Relationship and Workload Distribution

Effective implementation of NIPs requires fostering a strong nurse‐physician relationship and ensuring equitable workload distribution. A major barrier to protocol uptake is physicians' deferring patient assessments, assuming nurses will complete the initial workup, which leads to uneven workload distribution. To address this, the role of NIPs will be integrated into the physician orientation programme, with sessions led by the ED CNC to ensure a common understanding of each professional's role in patient care and protocol application.

Regular ED interdisciplinary meetings will be scheduled to review and refine workflows, clarify responsibilities, and encourage shared accountability between nurses and physicians. In addition, nurse feedback sessions during regular unit meetings will provide an opportunity to communicate concerns regarding workload distribution. A formal feedback mechanism will ensure that concerns are shared with physicians and addressed collaboratively.

To monitor and maintain equitable workload distribution, regular audits will assess the timeliness of medical reviews following NIP initiation. The results of these audits will be shared and discussed during multidisciplinary ED meetings.

4.10. Recognition and Motivation

To sustain the uptake of NIPs, recognition programs will be established to acknowledge and reward effective protocol implementation and motivate continuous engagement, with a focus on peer recognition and team‐based achievements. Public acknowledgment of team successes will be shared through various internal communication channels such as the hospital intranet, the bi‐monthly nursing newsletter, emails, and approved hospital social media platforms.

4.11. Feasibility and Stakeholder Validation

To ensure the practical applicability of the proposed interventions, key ED stakeholders consisting of emergency nurses, clinical educators, and departmental managers evaluated their feasibility using the APEASE criteria. This assessment led to refinements in the strategies, emphasising cost‐effectiveness, practicality, and sustainability in resource‐constrained settings.

Despite the lack of an integrated electronic medical record (eMR) being identified as a major barrier to the uptake of NIPs, the introduction of an eMR did not meet the APEASE criteria for affordability. Implementing an eMR would require considerable financial investment, extensive resources, and significant time. Such a large‐scale implementation was deemed unaffordable and impractical by stakeholders as an immediate implementation strategy and was not included as an implementation strategy.

5. Discussion

This study describes the development of a behaviour change‐informed implementation strategy to improve the uptake of NIPS in the ED. Through the BCW framework, eight intervention functions were identified and mapped to 24 BCTs, resulting in 23 delivery modes. By systematically translating known barriers and enablers into targeted intervention components, this work contributes to the emerging but limited body of literature applying behavioural theory to complex implementation challenges in healthcare settings.

Our findings demonstrate the value of using an implementation science lens to design strategies that enhance the uptake of evidence‐based practice. While the benefits of NIPs, such as reduced time to treatment and improved patient outcomes, are well documented (Burgess et al. 2021; Cabilan and Boyde 2017; Considine et al. 2019; Forero et al. 2019; Varndell et al. 2018), their inconsistent uptake reflects a persistent implementation gap in emergency care (Spoon et al. 2020). To address this, we aligned our intervention strategies with the COM‐B model, which offers a comprehensive framework for understanding and influencing behaviour change in healthcare settings (Michie et al. 2011). This model enabled us to move beyond simple knowledge dissemination to target key behavioural determinants identified in our study, including perceived knowledge and confidence gaps, workload pressures, psychological stress, role ambiguity, and environmental barriers. Our interventions addressed all three COM‐B components: capability (through a structured education program), opportunity (via integration into existing workflows and clinical mentorship), and motivation (using peer modelling and performance feedback).

The use of the TDF added conceptual rigour by systematically identifying behavioural determinants influencing the uptake of NIPs. Widely used in implementation research, the TDF maps psychological, social, and contextual factors that inform the selection of evidence‐based BCTs (Geerligs et al. 2018). Grounding our intervention in this framework ensured it was both theory driven and tailored to the realities of emergency nursing. The resulting strategy comprising structured education, clinical champions, audit and feedback, executive support, professional identity reinforcement, and environmental restructuring was directly aligned with identified barriers and enablers. This approach reflects growing evidence that contextually adapted strategies are essential in complex clinical environments, where generic models often fail. A recent systematic review provides strong support for this view, showing that tailored strategies are significantly more effective than standardised approaches in overcoming real world implementation challenges (Geerligs et al. 2018).

The APEASE criteria provided a pragmatic framework to refine strategies that were not only theoretically robust but also feasible, acceptable, and contextually appropriate within the ED setting. For example, while the lack of an integrated eMR was identified as a significant barrier to protocol uptake, its high cost and limited feasibility placed it beyond the scope of this study. The remaining strategies were validated through stakeholder consultation and co‐design processes, which confirmed their relevance and acceptability within the local context. This method aligns with best practice in implementation science, which emphasises the importance of evidence‐informed, context‐sensitive prioritisation. Recent systematic reviews reinforce this approach, demonstrating that strategies tailored to local barriers and enablers are more effective and sustainable than standardised, generic solutions (Cassidy et al. 2021; Geerligs et al. 2018).

The implementation strategy in this study incorporated multiple evidence‐informed components: structured education, clinical champions, executive engagement, role clarity, and audit and feedback. Structured education was selected to address specific barriers identified through the TDF, particularly lack of confidence and unfamiliarity with protocols. The education program goes beyond knowledge transmission by emphasising practical application in real‐world scenarios, building competence and confidence in a supportive environment. A 2024 systematic review found that both individual and group education significantly enhanced nursing practice, improving knowledge, attitudes, skills, perceived behavioural control, and social norms (Fontaine et al. 2024), all of which map to the COM B components of capability, motivation, and opportunity.

To further reinforce capability, simulation‐based training was included as a complementary method to offer hands‐on learning aligned with the high acuity nature of emergency nursing. Simulation enables repeated, reflective practice in a controlled environment and has been shown to improve clinical performance, decision‐making, and adherence to evidence‐based protocols (Hegland et al. 2017, Moslehi et al. 2022). This approach ensures that the education strategy does not merely inform practice but actively supports behaviour change through mechanisms that are theoretically grounded and contextually relevant to the ED.

While education forms a critical foundation for implementation, it is rarely sufficient on its own. Systematic reviews consistently show that education alone yields only modest and short‐term improvements in clinical practice (Cassidy et al. 2021; Fontaine et al. 2024). The effectiveness of education is significantly enhanced when it is combined with complementary strategies that reinforce learning and support sustained behaviour change (Fontaine et al. 2024; Spoon et al. 2020). In this study, clinical champions were identified as key to supporting NIP uptake by complementing education with peer leadership, role modelling, and mentorship that facilitated their routine use of NIPs. Champions have consistently been shown to support the uptake and sustained use of evidence‐based practices by influencing peer behaviours and reinforcing change within local contexts (Miech et al. 2018; Morena et al. 2022; Santos et al. 2022).

To optimise their impact, champions will complete a purpose‐designed ‘train‐the‐trainer’ program grounded in adult learning principles and aligned with the goals of the implementation strategy. This addresses evidence that unprepared or unsupported champions are less effective at sustaining change (Miech et al. 2018, Morena et al. 2022). By combining clinical credibility with structured training and ongoing support, this approach enhances champions' ability to lead practice change and embed new behaviours in routine emergency nursing care.

Audit and feedback were selected as key implementation strategies to support behaviour change, reinforce protocol adherence, and promote sustained improvements in practice. This approach is strongly supported by implementation science literature. A Cochrane review found that audit and feedback can improve professional practice by 0.5% to 16%, with the greatest effects observed when feedback is timely, specific, and delivered by a peer or supervisor (Grimshaw et al. 2019). To maximise effectiveness, this study incorporated the 15 evidence‐based principles of effective feedback, ensuring feedback is relevant, actionable, and aligned with clinicians' needs (“Practice Feedback Interventions: 15 Suggestions for Optimizing Effectiveness,” Brehaut et al. 2016). When designed well, feedback mechanisms enhance accountability and foster ongoing engagement with protocols. In contrast, poorly executed feedback can undermine motivation and limit impact (Grimshaw et al. 2019). By embedding structured, meaningful feedback into routine ED workflows, this strategy aims to support consistent practice change and long‐term sustainability.

5.1. Limitations

This study has several limitations. First, it was conducted within a single metropolitan tertiary ED, which may limit the generalisability of findings across diverse healthcare settings. However, the use of well‐established implementation frameworks, stakeholder co‐design, and context‐specific tailoring strengthens the internal validity and provides a replicable model.

While the intervention strategy was rigorously developed and validated, it has not yet been implemented or evaluated in practice. Future research should focus on piloting the approach across multiple sites to assess its impact on clinician behaviour, protocol adherence, and patient outcomes. Quantitative data, for example, adherence rates, time to treatment, and safety indicators, should be complemented by qualitative data from staff focus groups to assess feasibility, acceptability, and contextual factors. These findings will inform refinement and optimisation of the strategy.

Patient perspectives should also be incorporated. Future evaluations should integrate patient‐reported measures (Patient Reported Health Outcomes Measures (PROMs) and Patient Reported Experience Measures (PREMs)), using interviews or surveys to explore patients understanding and satisfaction with nurse‐initiated care. Including the patient voice will support a more comprehensive assessment and ensure the strategy aligns with patient needs and expectations (Amat‐Fernandez et al. 2025).

6. Conclusion

This study presents a theory‐informed, co‐designed strategy to embed NIPs in emergency care by addressing the behavioural, social, and structural barriers that influence clinical practice. It moves beyond education alone to deliver a context‐sensitive, scalable approach to implementation. As EDs face rising acuity and demand, enabling nurses to work to their full scope is critical. Future research should focus on refining and testing context‐specific implementation strategies, exploring the long‐term impact on patient outcomes, and evaluating the scalability of such models across diverse healthcare settings.

Ethics Statement

Ethics approval was obtained from St Vincents Hospital Sydney Human Research Ethics Committee. Reference number—2023/ETH01182. The study complies with the National Health and Medical Research Council of Australia National Statement on Ethical Conduct in Human Research (2023).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: jan70169‐sup‐0001‐Supinfo.docx.

Data S2: jan70169‐sup‐0002‐Supinfo.docx.

Gawthorne, J. , McCloughen A., Branch J., McPhillips O., Scott D., and Curtis K.. 2026. “Applying Behaviour Change Theory to Develop an Implementation Strategy for Nurse‐Initiated Protocols in the Emergency Department.” Journal of Advanced Nursing 82, no. 5: 5194–5205. 10.1111/jan.70169.

Data Availability Statement

No new datasets were generated for this study. Data from previous studies was used and is available from the corresponding author upon reasonable request.