The intent is good but… exploring barriers and enablers to clinical pathway use in regional Australian Emergency Departments

Abstract

Background

Clinical pathways can improve the quality, safety, and efficiency of care, but their integration into routine emergency department (ED) practice remains challenging. Factors influencing pathway use, particularly organizational and contextual determinants, are often overlooked, despite their importance for successful implementation and sustainability. These challenges may be amplified in regional EDs facing workforce and resource constraints. This study examined the barriers and enablers influencing the use of fractured neck of femur (NOF) and suspected stroke pathways in regional Australian EDs to inform service improvement and pathway redesign.

Methods

A qualitative exploratory study was conducted across regional EDs in Tasmania. The study utilized big picture mapping workshops and semistructured interviews to examine pathway use in real‑world clinical settings. Twenty-five clinicians participated in three multidisciplinary mapping workshops, and 14 clinicians took part in in‑depth interviews. Mapping identified key steps and decision points within fractured NOF and stroke pathways, while interviews explored clinicians’ experiences and perceptions. Data were deductively analysed using the updated Consolidated Framework for Implementation Research (CFIR).

Results

Mapping revealed common care processes but significant site-level differences, including inconsistent pathway initiation. Interviews revealed that pathway use was influenced by factors across CFIR domains: complexity and workflow misalignment were barriers, with digital integration a valued enabler (Innovation). Time pressures and resource limitations affected pathway use (Outer setting). Leadership buy‑in and champions enabled use (Inner setting). Clinicians expressed concern about diminishing clinical judgement (Individuals domain), while Implementation process domain barriers included limited collaboration.

Conclusion

Pathway use in Tasmanian EDs is influenced by barriers and enablers across CFIR domains. Simplifying pathways and ensuring adaptability were perceived to improve usability, while misaligned workflows and paper-based processes hinder uptake. Addressing resource constraints, fostering leadership engagement, and strengthening education are essential. Embedding planning, collaboration, and feedback will ensure pathways remain practical, evidence-based, and deliver timely, standardized care.

Introduction

Clinical pathways (pathways) are structured, evidence-based tools designed to standardize care, improve patient outcomes, and enhance efficiency for defined clinical conditions [1]. Since their introduction in the UK in the 1990s, they have been increasingly adopted internationally and associated with improved care quality, organizational efficiency, and adherence to recommended practice [1, 2]. However, pathway use in high-pressure emergency department (ED) settings remains challenging due to time and workload pressures, and evidence of effectiveness is mixed [3]. Sustained pathway use requires attention to intervention characteristics, organizational context, implementation processes, and evaluation, with targeted strategies shown to improve adoption and sustainability [4, 5].

Despite evidence of a wide range of strategies used to improve uptake, gaps persist between evidence and sustainable pathway use, particularly in EDs [6]. Embedding pathway use into routine practice is complex and context-dependent, requiring attention to local barriers and enablers [7]. Research often prioritizes clinical outcomes over organizational and contextual factors, with few studies examining how pathway use context drives long-term success [8]. Limited evidence exists on organizational dynamics that potentially influence pathway use and sustainability [6].

Fractured neck of femur (NOF) and suspected stroke were selected as exemplar pathways within a broader statewide pathways program that also included chest pain and sepsis. Both pathways were implemented across all Tasmanian EDs, enabling comparison of pathway use across sites and exploration of factors influencing their use in different emergency care settings. Fractured NOF and suspected stroke are commonly managed using ED pathways and carry substantial clinical and organizational consequences [9, 10]. Fractured NOF is a leading cause of ED admission in Australia, with 12‑month mortality rates approaching 30% [11]. Cognitive impairment and delirium affect up to one‑third of patients, while inadequate pain management contributes to poorer outcomes [12]. Stroke remains a leading cause of death and disability, with timely pathway‑driven care critical to improving outcomes and patient satisfaction [13].

These challenges are particularly pronounced in regional, rural, and remote EDs facing workforce and resource constraints. Variation in fractured NOF pathway use across regional EDs has been reported, with underlying causes unclear [9]. This study aimed to explore barriers and enablers to fractured NOF (Supplementary File S1) and suspected stroke (Supplementary File S2) pathway use across publicly funded Tasmanian EDs by examining current practice, site‑level variation, and influencing factors.

Materials and methods

Study design

As part of a broader healthcare redesign project, this qualitative exploratory study examined barriers and enablers to pathway use in Tasmanian EDs [14]. This approach was selected because limited evidence exists on the organizational and contextual factors influencing pathway use in regional ED settings. A sequential multimethod design was employed, combining big picture mapping workshops and semistructured interviews. Mapping workshops were conducted first to identify patient journey variations, delays, and gaps in pathway use, which informed the development of the interview guide. Subsequent interviews explored clinicians’ perspectives on the barriers and enablers underlying these findings. Together, the methods provided complementary service-level and clinician-level insights to inform service redesign.

Study setting

Tasmania, an island state of Australia classified as regional under the Australian Standard Geographic Classification [15], introduced statewide paper-based pathways for fractured NOF and suspected stroke in 2019–2020 to improve care quality and safety. Tasmania’s healthcare network spans three regions with a major hospital in each: Hospital 1 (H1) in the south, a principal referral hospital with highly specialised services; Hospital 2 (H2) in the North, a public acute hospital offering 24-h emergency care, ICU, and oncology but with less breadth than H1; and lastly, Hospital 3 (H3) and Hospital 4 (H4) in the North West region, both smaller acute hospitals serving rural and remote communities with limited specialist capacity [15]. This study has been reported according to the COREQ checklist (Supplementary File S3), ensuring transparency, rigour in design, and reflexivity.

Recruitment and consent

Purposive sampling was used to recruit ED clinicians with direct experience in the use, management, or evaluation of the fractured NOF or suspected stroke pathways, ensuring representation across disciplines and seniority levels relevant to the research aims [16]. Recruitment occurred via email and feedback sessions, with expressions of interest submitted through a QR code. Sampling continued until adequate thematic depth was achieved and no new substantive themes emerged. Participation was voluntary. Informed consent, confidentiality, and withdrawal rights were assured throughout the study. Ethical approval was granted by the University of Tasmania Human Research Ethics Committee.

Data collection

Participant demographic and professional characteristics were collected at the commencement of the mapping workshops and semistructured interviews using a brief information form. Data included professional role, years of experience, and hospital site to describe the sample and ensure representation across participating EDs. No identifiable or sensitive personal information was collected.

Big picture mapping workshops

To understand pathway use, this study employed big-picture mapping, adapted from Lean and the Toyota Production System, to map patient journeys through EDs and identify workflow variations, delays, and quality improvement opportunities [14, 17]. Facilitated by experienced researchers (S.J.P., P.G., I.T.M.), workshops used the prompts ‘What happens?’, ‘What happens next?’, and ‘Are there any issues?’ to explore current processes and challenges.

Three multidisciplinary mapping workshops were conducted at Tasmanian Health Service EDs (H1–H3) between August and September 2025, lasting ∼60 min each. Although no workshop was conducted at H4, many H3 participants also worked at H4, ensuring representation of all four hospitals.

Semistructured interviews

Findings from the mapping workshops informed development of the interview guide. Semistructured interviews were conducted by one researcher (I.T.M.) using a piloted guide exploring participants’ roles, experiences with pathway use, and perceived barriers and enablers. Interviews were conducted online via Microsoft Teams between September and November 2025, lasted ∼60 min, and were audio-recorded and transcribed. Transcripts were anonymized and securely stored. To enhance data quality and minimize bias, the interviewer used open-ended questions and maintained a neutral, non-judgemental approach throughout the interviews.

Data analysis

Mapping workshop data generated visual representations of fractured NOF and suspected stroke pathways, capturing clinician insights and site-level variation. Conventional content analysis was used to analyse these data [18]. Consistent with the structured nature of the pathways, findings were organized by pathway stage (prenotification, triage, investigations, treatment/management, discharge, and transfer) and examined for barriers, enablers, process variations, and delays. Findings from the mapping workshops informed the development of the interview guide (Table 1).

Table 1.

Mapping issues informing questions asked at interview.

Key issues (from mapping)	Stage	Semistructured interview guide topic/question
Inconsistent prenotification	Arrival	Let’s focus on the early stages of a patient’s journey, registration, triage and waiting time to see Doctor. How do you see clinical pathways influencing this stage? What helps or hinders their use here?
No code stroke after hours Staffing issues	Triage—identification and pathway initiation	What challenges have you encountered? What improvements would you suggest?
CT not available 24/7	Investigations	When it comes to investigations, ordering, initiating, and executing, how do pathways support or complicate this process? What’s working well? What’s not working?
Inexperienced doctors for nerve blocks Reluctance to activate code	Management	Clinical pathways often include time-sensitive treatments. How do you experience this aspect in practice? What enables timely care? What gets in the way?
Bed delays Incomplete documentation	Transfer/discharge	Thinking about discharge from the ED, how do pathways shape this process? What’s effective? What’s problematic? Are there any tasks or elements within the pathway that you feel don’t belong in the ED setting?
Staff role clarity (e.g. who activates code stroke, who performs nerve blocks)	Throughout	How clear do you think staff roles are when following a clinical pathway? Where do you see clarity? Where do you see confusion or overlap? Looking at the pathway document itself, how would you describe its usability and relevance?
	Additional questions	Thinking about your experience with clinical pathways: What aspects have worked well for you or your team? What challenges have you encountered? If you could change anything, what would it be and why?

Interview data were analysed using deductive thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR) 2.0 [19] and Braun and Clarke’s six-phase approach [20]. Transcripts were reviewed for familiarisation and coded against relevant CFIR domains and constructs. Initial coding was undertaken by the lead researcher (I.T.M.) and reviewed by the research team to enhance consistency and rigour. Codes were grouped into themes and subthemes representing barriers and enablers to pathway use and were iteratively refined through team discussion. Thematic saturation was reached when no new substantive themes emerged across interviews.

The two datasets were analysed separately and integrated during interpretation. Mapping workshop findings informed the development and focus of the clinician interviews, facilitating deeper investigation of process variations, delays, and gaps in pathway use identified during the workshops. The interviews subsequently explored the barriers and enablers contributing to these issues. Integrating the findings enabled triangulation of system-level processes and clinician perspectives, providing a comprehensive understanding of the factors influencing pathway use [20].

Bias Mitigation

Member checking embedded within workshops enabled participants to confirm and refine representations, enhancing accuracy, limiting misinterpretation, and fostering trust. Participants were invited to review interview transcripts. This collaborative approach strengthened validity and anchored findings in real clinical practice. Multidisciplinary research team expertise supported robust interpretation (I.T.M., S.J.P., P.G.) and kept reflective notes, verified coding, and themes.

Results

Big picture mapping workshop participant characteristics

A total of 25 clinicians participated in three mapping workshops across the EDs. Participants represented a range of professional roles, providing diverse and experienced perspectives on ED workflows. Medical staff comprised most participants (n = 16), including ED registrars and Fellows of the Australasian College for Emergency Medicine. Nursing staff (n = 7) included clinical nurses, nurse educators, and clinical coaches. Two participants held senior leadership positions, specifically a Nurse Unit Manager and a Director of ED.

Big picture mapping workshop findings

Mapping workshops identified broadly similar processes for managing fractured NOF and suspected stroke presentations; however, notable variation existed in how pathways were operationalized. Findings were organized according to the key stages of care: arrival and prenotification, triage and pathway initiation, investigations, management, and transfer/referral.

Arrival and prenotification

Both pathways typically commenced with ambulance arrival and handover. For fractured NOF presentations, ambulance prealerts often enabled staff to prepare equipment and resources before patient arrival. For suspected stroke, prenotification facilitated early recognition and timely Code Stroke activation. However, practices varied across sites, and inconsistent use of prenotification limited opportunities for early patient identification and pathway commencement.

Triage and pathway initiation

Fractured NOF presentations were generally triaged as Category 3, while suspected stroke presentations were commonly assigned Category 2 status and managed through Code Stroke activation. Participants reported considerable variation in pathway initiation processes across sites, which they perceived to be influenced by clinician experience, staff awareness, and local workflow practices. Nurses frequently assumed responsibilities traditionally undertaken by medical staff, including initiating investigations. Participants reported that reluctance to activate Code Stroke contributed to delays, particularly among junior medical staff who expressed concerns about potential criticism if the final diagnosis was not confirmed as stroke. This issue was subsequently explored during the interviews.

Investigations

Investigation processes emerged as the most significant source of delay because they directly influenced treatment decisions and patient progression through the pathway. For fractured NOF, investigations typically included imaging and blood tests, while suspected stroke required urgent imaging and pathology testing to determine eligibility for time-critical treatments. Access to imaging varied considerably between sites, particularly after hours, with reliance on on-call services and limited overnight availability contributing to delays.

Management

Management generally aligned with pathway recommendations. Fractured NOF care included analgesia, intravenous fluids, nerve blocks, Mini-Cog assessments, goals-of-care discussions, and orthopaedic review. Stroke management involved thrombolysis and clot retrieval where indicated. Challenges included limited clinician confidence in performing nerve blocks, low completion of Mini-Cog assessments, and restricted access to resuscitation spaces required for thrombolysis administration.

Transfer and referral

Referral pathways involved orthopaedic registrars for fractured NOF and specialist stroke services for suspected stroke. Transfer processes varied according to local service capability and were often affected by inter-hospital retrieval requirements. Delays were particularly evident when transfers depended on weather-sensitive helicopter services.

Overall, the workshops demonstrated that while pathway stages were largely consistent across sites, pathway use was shaped by a combination of factors.

Characteristics of interview participants

A total of 14 clinicians participated in the semistructured interviews. Participants comprised 10 females and 4 males. Two participants elected to be interviewed together due to a shared role and time constraints. The average ED experience was 13 years, ranging from 3 to over 20 years. Participants represented a range of roles, including clinical nurses, nurse educators, clinical nurse consultants, ED specialists, and senior ED leaders.

Summary of interview findings: pathway use

Analysis of interview data mapped to CFIR constructs revealed key barriers and enablers to use of pathways across five domains, summarized in Table 2.

Table 2.

Interview summary of barriers and enablers mapped to CFIR 2.0 constructs.

CFIR domain	Construct	Key barriers and enablers
I. Innovation	Complexity	Barriers: Pathways sometimes perceived as extra paperwork or redundant. Mini-Cog and goals of care often neglected due to time pressures. ‘Anything that goes beyond one page of paper… things are gonna fall apart’. Long pathways (e.g. four pages for stroke) are seen as impractical in a busy ED. Multiple documents used in tandem for stroke (e.g. thrombolysis, VST protocol). Stroke pathway documents hard to locate (H1) Staff perceive pathways as ‘tick-box’ tasks without understanding their purpose. ‘Often staff won’t understand why we are doing it… they just feel it’s another tick box’. Dysphagia screening delays linked to lack of awareness of national timeframes. ‘I didn’t know about the four-hour timeline… nurses are not gonna know that on the floor’.
I. Innovation	Adaptability	Barriers: Flexibility needed in completing elements (e.g. IDC, swallow assessment) depending on ED capacity. Pathways can be ceased if diagnosis changes—this flexibility should be emphasized. ‘Pathways should fit in with existing business processes’. Misalignment with usual workflows (e.g. EMR vs paper) is a barrier. Enablers : Nurses frequently initiate pathways, especially in locum-heavy environments. Pathways used to guide junior or unfamiliar staff. Pathways useful for junior staff and onboarding: ‘…very useful resource for junior doctors and people who are new to a system’. Also valued for collaboration and governance ‘…useful tool for collaboration between different teams… and for governance’.
I. Innovation	Design quality	Barriers: Positive view on short documents but strong dislike for overly long forms. ‘If it’s 30 pages, no ED staff member will fill that out’. Role-specific sections (doctor vs. nurse) not always clearly distinguished. Suggestion for pop-up reminders and mandatory fields in EMR. ‘There should be triggers and reminders… and some elements mandatory before next step’. Suggestions include color-coded highlights, visual role indicators (e.g. triangles/squares), and embedded prompts. Poor physical organization of pathway storage (e.g. flight deck clutter). ‘Some of these pathways are a little bit different from our usual business practices’. Paper-based pathways conflict with electronic documentation (TrackED). Paper pathways seen as necessary due to tech limitations: ‘…there is a benefit… to having a piece of paper in front of you. It’s transportable… not my ideal situation but required in the situation we live’. New nuance: ideal is integrated digital system, but warns against complexity creep: ‘…digitised pathways have the tendency to expand out past what is helpful’. Enablers: The stroke and NOF pathways are clearer and less cluttered. ‘If somebody picks up a pathway and it’s more than just simple… that clearly is going to be a hindrance’. Simplicity and easy accessibility (e.g. link on the hub) are enablers.
II. Outer setting	Patient or population needs and resources	Barriers: ‘Busy clinicians… don’t want to tick a bunch of boxes unless they feel it adds value’. Time pressure and staffing turnover hinder consistent use. Bed block and delays in ward admission hinder discharge. Swallow assessments and nerve blocks may be delayed due to competing priorities. Lack of stroke unit and ICU bed availability delays postlysis transfers. Ramping Lack of privacy (H3) Family refusal of transfer (H2) Resource constraints and ramping hinder pathway execution: ‘…absence of resources, may that be clinician space or physical equipment… allow you to undertake the things we would like in those pathways’. Prioritization pressures: ‘…we triage the resources of our department… opportunity cost if we activate code stroke incorrectly’. Enablers: Pathways help maintain quality for inexperienced staff and diverse workforce. ‘Having a standard pathway definitely is useful for junior staff… and prompts best evidence care’.
II. Outer setting	External policies and incentives	Barriers: Paramedics use defined criteria for prenotification; triage nurse confirms via flowchart. Stroke team availability varies; confusion around changing hours affects activation. ‘Who takes ownership of initiating the pathway…? Is it medical or nursing?’ Interim management plans underutilized despite potential to expedite transfers. VST neurologists coordinate with Hobart interventional radiologists for thrombectomy Clot retrieval only available in H1/Melbourne (None at H2 and H3)
III. Inner setting	Context—inner setting	Barriers: High staff turnover and reliance on agency staff limits pathway consistency. Orientation includes pathway education for nurses, less clear for doctors. ED layout issues Enablers: Champions for specific pathways (e.g. stroke CNC, NOF advocates) improve uptake. Clinical facilitators available 24/7 in some EDs to support new staff.
III. Inner setting	Organizational culture and resources	Barriers: Role modelling by senior staff critical to pathway uptake. Hesitancy to refer to stroke team due to fear of misdiagnosis or past negative experiences. ‘Some registrars… reluctant to call out a code stroke because that requires a lot of resources… and they worry if the diagnosis is wrong’ New insight: risk of over-prescription vs. flexibility: ‘…risk that pathways become too prescriptive rather than used as a guideline’. Highlights tension between clarity and adaptability: ‘…trying to pigeonhole people into their role only… erodes what makes emergency medicine function’. Enablers : Pathways seen as helpful tools, especially for guiding unfamiliar staff. Emphasis on clinical champions and peer-driven advocacy. ‘If you can get some people passionate about this, that really helps… peer encouragement works better than top-down’.
III. Inner setting	Readiness for implementation	Barriers: Fractured NOF pathway more consistently used than suspected stroke. Staff attitudes and past experiences influence pathway engagement. Executive support exists but should focus on resourcing, not micromanaging pathway use. ‘Buy-in from lead clinicians… if people from the top are not using the pathway…’ Lack of leadership endorsement reduces uptake. Buy-in and collaboration critical: ‘…pathway needs to be a collaboration between us and the teams these patients go through’. Stroke pathway underused because care happens without documentation. ‘Things happen without the pathway actually being written on’. Enablers : Strong advocacy for electronic integration.
IV. Individuals domain	Adopter/implementer/decision‑maker characteristics Acceptability/feasibility (perceived by individuals)	Barriers: Staff generally aware of pathways but may not use them. ‘The intent is good… but how to create one that people are going to use is the elephant in the room’. Positive attitude toward concept, scepticism about practicality. Concern about over-reliance on pathways at the expense of clinical judgement Junior doctors unaware of pathways (H3) Agency staff unfamiliar with pathway processes (H2, H3) Concern about pathways replacing clinical judgment: ‘…guidelines are important, but they shouldn’t replace good clinician decision making’. Lack of clarity on rationale for tasks (Mini-Cog, dysphagia screening). ‘People don’t understand why we want a Mini-Cog done’. Education gap highlighted: ‘We don’t explain the why… orientation is overwhelming, so it gets lost’. Enablers : Pathways valued for governance and standardization: ‘…important not only to do the right thing, but to be able to show we are doing the right thing’. Pathways valued for reducing cognitive load and standardizing care.
IV. Individuals domain	Champions or field agents	Barriers: Nurses confident in initiating and using pathways; limited by scope (e.g. group and hold, X-rays). ‘We certainly start things like our sepsis pathways prior to patients being picked up by doctors. It’s very clear that from point of triage… if you suspect sepsis, you start the pathway’. Swallow screening training available online but underutilized. ‘When we looked at dysphagia screening… staff don’t actually realise we need to meet the four-hour timeline… I didn’t know that before I met with the speech pathologist’. Some reluctance to pursue extra training due to lack of incentives Nurse-led initiation varies. Experienced clinicians rely on gestalt (They use their clinical intuition or big-picture judgment based on experience, rather than strictly following a detailed checklist or pathway); juniors depend on pathways. ‘Guidelines are important, but they shouldn’t replace good clinician decision-making’ Enablers : ‘Pathways are a very useful resource for junior doctors and people who are new to a system… to understand the medicine and exactly how that system functions’.
V. Implementation process domain	Planning	Barriers: Suggestions to improve visibility of stroke team hours and flowcharts. ‘Usually, you’ll have a team… emergency doctors, cardiologists… come up with a pathway’. Multidisciplinary development is common, but embedding in workflow is weak.
V. Implementation process domain	Engaging	Barriers: Coaches and team leaders play a key role in reinforcing pathway use. ‘peer‑to‑peer encourage it… rather than top‑down’ Orientation includes pathway walkthroughs for nurses. Champions and portfolios help embed pathway use. Multidisciplinary development essential but hard to achieve: ‘…over 50 subspecialty teams… many do not have time to collaborate’. New emphasis: collaboration beyond ED is a major barrier.
V. Implementation process domain	Executing	Barriers: ‘Having to find the piece of paper… is a barrier’. Poor execution due to physical accessibility issues. ‘You have to go and find the form. It’s not there and ready to go’ Pathways facilitate early imaging and treatment; hindered by bed block and cultural hesitancy. Completion often partial; better when initiated early and reinforced during handover. Delays in clerking, imaging, and bloods due to staffing and environment (all sites) ‘but staff are dealing with multiple demands’ Enablers : Pathways used to guide locum doctors and ensure care standards.
V. Implementation process domain	Reflecting and evaluating	Barriers: Staff feedback encouraged; lack of feedback assumed as acceptance. ‘I think it’s probably something we haven’t had a drive around for a while… when you haven’t had a drive around pathways and decent education… it falls off the wagon here because there are so many things that our staff need to do’. Electronic pathways preferred; hybrid systems seen as inefficient. ‘In an ideal world… paperless… but we have multiple computer systems that don’t talk… insufficient numbers of computers… there is a benefit to having a piece of paper’. Enablers: Completion rates better in EDs with nurse empowerment and workflow integration. ‘Anything like this always helps when you’ve got clinical champions… helps drive it on the floor’

Domain 1: Innovation

Pathway complexity emerged as a significant barrier to use, with lengthy, multipage documents perceived as impractical in the fast-paced ED environment: ‘Anything that goes beyond one page of paper… things are going to fall apart’ [P13, P14]. Pathways were also frequently viewed as compliance-driven ‘tick-box’ activities, with limited understanding of their purpose, reducing engagement and perceived value: ‘Often staff won’t understand why we are doing it’ [P11].

Conversely, pathway adaptability was identified as a key enabler. Participants valued pathways as decision-support tools, particularly for junior, locum, and newly oriented clinicians, providing structure and confidence in care delivery: ‘…very useful resource for junior doctors and people who are new to a system’ [P10]. However, misalignment between paper-based pathways and electronic workflows created inefficiencies and disrupted integration into routine practice. Participants emphasized the importance of simple, clear, and user-friendly pathway design, suggesting features such as colour coding, embedded prompts, and integration with electronic medical records (EMRs), while cautioning against excessive digital complexity that could compromise usability.

Domain 2: Outer setting

The Outer Setting comprises external influences on service delivery, including healthcare systems, resources, partnerships, and policy factors. Participants described external pressures, particularly workforce, resource, and capacity constraints, as significant barriers to pathway use: ‘…absence of resources, may that be clinician space or physical equipment…’ [P10]. System-level challenges such as bed block, ambulance ramping, and patient or family refusal of inter-hospital transfer further affected pathway implementation. As one participant noted, ‘Patients are not able to move because there’s no beds… it’s not the pathway… it’s access to beds’ [P04], while another described a situation where ‘The person was ramped in an ambulance. There was nowhere to put them. We already had a full department’ [P06].

External policies and service arrangements also influenced pathway activation and delivery. Participants highlighted the importance of paramedic prenotification and noted that variations in specialist service availability, particularly after hours, affected pathway execution. Reduced staffing levels and changing responsibilities outside business hours often created additional challenges: ‘After hours we have decreased staff compared to in hours… roles change and who does what depends on the time of day’ [P06].

Domain 3: Inner setting

High staff turnover and reliance on agency staff reduced consistency. Champions and peer advocacy were strong enablers: ‘If you can get some people passionate about this, that really helps… peer encouragement works better than top-down’ [P09]. Cultural preferences favoured flexibility over rigid adherence: ‘…risk that pathways become too prescriptive rather than used as a guideline’ [P11]. Leadership endorsement was essential for pathway use: ‘Buy-in from lead clinicians… if people from the top are not using the pathway’ [P13, P14].

Domain 4: Individuals domain

Clinicians valued pathways for promoting standardization but expressed concern about erosion of clinical judgement: ‘…guidelines are important, but they shouldn’t replace good clinician decision making’ [P11]. Education gaps were evident: ‘In an ideal world, it would all be included in each new staff member’s orientation. However, the orientation is already very long… they’re often not dwelt on during the orientation, and I think that’s something that we could probably improve on’ [P02]. ‘We don’t explain the why… orientation is overwhelming’ [P12]. Self‑efficacy varied by role; nurses reported high confidence and empowerment to initiate pathways, junior clinicians relied on pathways for guidance, and experienced staff often drew on gestalt to complement structured protocols: ‘Every triage nurse knows about the stroke pathway… there’s a bias to enacting the stroke pathway… it usually works best when the nurses start it… nurses are very empowered to start pathways’ [P01].

Domain 5: Implementation process domain

Planning and engagement required multidisciplinary collaboration, though time constraints hindered this: ‘…over 50 subspecialty teams… many do not have time to collaborate’ [P10]. Execution was hampered by poor accessibility: ‘Having to find the piece of paper… is a barrier’ [P09].

Discussion

Statement of principal findings

This study provides context-specific insights into factors influencing pathway use across Tasmanian EDs. Statewide pathways were introduced in 2019 to improve the quality and safety of acute care; however, internal audits identified low adherence despite implementation across all EDs. Inclusion of sites with different staffing models and operational practices enabled exploration of diverse experiences and workflows. Consistent with existing literature, delays in acute stroke and fractured NOF care were multifactorial [10, 11], but several challenges characteristic of regional EDs were identified, including documentation burden within hybrid paper–electronic systems, workforce instability, limited after-hours services, and transfer constraints. Mapping workshops revealed variation in pathway initiation, resource availability, and care processes across sites. Interviews highlighted pathway complexity, workflow misalignment, and paper-based systems as barriers, while simplicity, adaptability, education, clinical champions, leadership support, and digital integration were identified as key enablers of sustained pathway use and timely, evidence-based care.

Strengths and limitations

This study identified key enablers of pathway use, including clinical champions, simplified pathway design, and addressing process-related barriers, consistent with evidence that targeted strategies improve adoption and integration into clinical workflows [8]. Limitations include reliance on self-reported data, which may be subject to recall and social desirability bias [20, 21], and the focus on Tasmanian EDs, which may limit transferability. Registrars were not represented in the interview sample, potentially limiting insights into registrar-specific decision-making. Voluntary participation may have introduced selection bias, patient perspectives were not included, and the qualitative design precludes causal inference despite the analytical strengths of CFIR.

Interpretation within the context of the wider literature

Our findings align with international ED pathway literature. Variation in nursing capability, inconsistent guideline awareness, and variable application of protocols are well-established barriers to pathway use in emergency care [21]. Early identification and pathway activation are critical determinants of door-to- Computed Tomography (CT) and door-to-needle times in stroke care. Studies from Iran and Finland demonstrated that prehospital notification systems improve stroke workflows and reduce treatment delays [22, 23]. Similarly, investigation delays emerged as a major barrier in this study, exacerbated by limited after-hours imaging access. Continuous imaging availability has been associated with improved patient outcomes and more timely care [24, 25]. Delays in pathway initiation were further influenced by reluc­tance to activate Code Stroke, particularly among junior clinicians. Previous studies have shown that fear of criticism and diagnostic uncertainty can contribute to delayed escalation and stroke pathway activation [26, 27]. Investigation delays are also recognized barriers to effective stroke care, often driven by resource constraints, workflow inefficiencies, and poor coordi­nation [10].

Beyond operational challenges, our findings are consistent with evidence from the UK and US demonstrating that organizational culture, stakeholder characteristics, and workflow integration strongly influence pathway adoption [26]. Training, clear communication of pathway benefits, leadership support, and feedback mechanisms were identified as important enablers of sustained use. Compared with other CFIR-based studies [27], our findings highlight additional challenges relevant to regional settings, including hybrid paper–electronic documentation systems and workforce instability associated with agency staff and locum doctors, underscoring the need for targeted orientation and context-specific implementation strategies.

Cultural resistance, documentation burden, and role variability also influenced pathway use, supporting evidence that organizational culture and leadership behaviours shape clinical practice [28]. The importance of nursing autonomy and clinical champions aligns with research linking staff empowerment to improved care quality and innovation [29]. Likewise, nurse-led pathway initiation reflects broader trends supporting expanded advanced nursing roles in acute care settings [30]. Sustaining pathway use will require addressing workforce instability, improving digital integration, and leveraging nursing leadership and autonomy [29].

Implications for policy, practice, and research

Pathway use may be improved through digital integration, simplified pathway design, leadership engagement, and ongoing education for all staff, including agency and locum clinicians. Cultural change should be supported through clinical champions, feedback mechanisms, and appropriate expansion of nursing roles. Future research should use mixed-methods approaches, incorporate patient perspectives, and examine pathway use across additional settings and clinical conditions to enhance transferability. Observational studies may help validate self-reported practices, while further investigation of digital solutions and workforce stability could inform sustainable implementation strategies. Study findings were disseminated to participating EDs and presented at statewide forums to support service improvement and targeted quality improvement initiatives. The findings have also provided foundational evidence for the integration of stroke pathways into the statewide EMR and have informed quality improvement workshops delivered by the Stroke Foundation, Australia’s peak independent organization for stroke, supporting broader system-level improvements in stroke care.

Conclusion

Pathway use in Tasmanian EDs is influenced by barriers and enablers across CFIR domains. Simplifying pathways and ensuring adaptability were perceived to improve usability, while misaligned workflows and paper-based processes hinder uptake. Addressing resource constraints, fostering leadership engagement, and strengthening education are essential. Embedding planning, collaboration, and feedback will ensure pathways remain practical, evidence-based, and deliver timely, standardized care.

Author contributions

The authors confirm contribution to the paper as follows: Innocent Tawanda Mudzingwa (Conceptualisation, Methodology, Investigation, Data Curation, Formal Analysis, Writing Original Draft, Review and Editing, Project Administration), Sarah Jane Prior (Conceptualisation, Methodology, Investigation, Formal Analysis, Review and Editing), Phoebe Griffin (Conceptualisation, Methodology, Investigation, Formal Analysis, Review and Editing), Emma Tavender (Conceptualisation, Methodology, Formal Analysis, Review and Editing), Viet Tran (Conceptualisation, Methodology, Formal Analysis, Review and Editing), and Giles Barrington (Conceptualisation, Methodology, Review and Editing)

Supplementary material

Supplementary material is available at IJQHC online.

Conflicts of interest

None declared.

Funding

This work was supported by the Medical Research Future Fund (MRFF), grant number MRF2018041.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethics and dissemination

The study received Ethics approval from the University of Tasmania Human Research Ethics Committee (HREC) and site-specific approvals from the three regions.