A cluster randomised controlled trial, the T3 trial, was undertaken in emergency departments (EDs) Australia (Middleton et al., 2016). The aim of the T3 trial was to evaluate the effectiveness of a nurse-initiated evidence-based clinical protocols, to improve the management of the triage, treatment and transfer of patients with acute stroke. Process evaluations of trials are increasingly being used in trials of evidence implementation strategies to examine intervention reach and fidelity and to investigate the influential contextual factors needed to produce change (Grant, Treweek, Dreischulte, Foy, & Guthrie, 2013; Ibrahim & Sidani, 2016; Moore et al., 2015). Contextual factors might include those related to the workplace such as leadership, staffing levels, research culture and resources (Squires et al., 2015). Generally, process evaluation is conducted from the viewpoint of key stakeholders such as health care staff who are tasked with driving practice change. Findings from process evaluations are needed to unpack and understand the critical factors that may have influenced uptake of an evidence-based intervention in order to improve the design of future implementation interventions. As there are few trials of nurse-initiated interventions in the ED for stroke patients, a process evaluation was conducted to understand the critical factors for integrating the clinical protocols in practice and for the sustainability of practice change in the study sites that were in the intervention arm of the T3 trial.
Aim
To understand, from the viewpoint of ED staff, the extent to which intervention sites that were part of the T3 trial, integrated the T3 clinical protocols into practice and to identify the contextual factors that may have influenced the uptake and adoption of the intervention.
Methods
A descriptive qualitative study design using face-to-face semi-structured interviews was used. Purposive sampling was used to select two high and two low performing intervention sites from which to sample participants who were involved in implementing the T3 protocols and embedding them in practice. Eligible participants were from the emergency departments and included: Medical Directors, Nurse Unit Mangers, bedside nurses and T3 trial clinical champions (local ED and stroke unit staff). Consenting participants were interviewed and covered the following areas related to processes of implementation and sustainability and also barriers and facilitators related to implementation. Data were anonymised and analysed thematically. Emergent themes were coded, refined and grouped into a final set of themes.
Results
Twenty-five interviews were completed that represented all groups sampled. Three major themes represented the data relating to the dynamics of change, protocol fidelity and care trajectory. Dynamics of change represents the challenges of achieving multidisciplinary education for a multidisciplinary intervention and staff turnover. Fidelity to the protocol represented the impact of organisational factors on fidelity to the intervention. These factors included local models of care, clinical capacity, rotation of staff and the importance of teamwork for implementation. Care Trajectory represents the movement of the patient through the care pathway for stroke and the availability of resources along the pathway that may impact on whether elements of the protocols are delivered.
Implications
When implementing an intervention in the complex and busy setting of the emergency department, in which staff are constantly changing and where stroke competes with what ED staff deem as urgent, the delivery of evidence-based care can be compromised, despite best intentions. Knowledge of these factors will assist with improving the design of future interventions in the ED, which in turn will have greater potential to increase uptake of evidence based guidelines.