Implementation Evaluation of 41 Nurse-Initiated Care Protocols in an Emergency Department: A Mixed Methods Study

To evaluate the implementation outcomes of nurse-initiated care protocols (NICP) in an emergency department (ED) using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

Convergent mixed-methods implementation evaluation.

The study was conducted between April 2025 and April 2026. Data were collected via electronic medical records, nursing and medical staff surveys, implementation records and patient and health service data. Descriptive statistics were used to summarise quantitative data and inductive content analysis was performed on qualitative data. Quantitative and qualitative results were analysed separately, and subsequently integrated and mapped to the RE-AIM framework to evaluate implementation outcomes of reach, effectiveness, adoption, implementation and maintenance.

A total of 9049 NICPs were initiated. Reach increased from 5.98% pre-implementation to 15.55% post-implementation, representing a 164% relative increase. A greater proportion of NICP patients were treated within recommended triage timeframes compared with non-NICP patients (76% compared to 68%). Adoption was high, with 95% of nurses using protocols in clinical practice, evidenced by 19,356 nurse-initiated interventions. Implementation fidelity was high, with 23 of 24 implementation strategies delivered as intended and 100% of eligible nurses completing Emergency Care Assessment and Treatment (ECAT) protocol education. Maintenance was demonstrated through sustained routine ECAT use and continued integration of ECAT protocol education into orientation and professional development pathways 12 months post-implementation. Barriers to protocol uptake included workload pressures, limited patient eligibility, diagnostic restrictions and early medical review.

Nurse-initiated care protocols were successfully embedded into routine emergency nursing practice, demonstrating high adoption and strong implementation fidelity. Nurse-initiated care can be effectively operationalised in complex ED settings when supported by structured education, engaged leadership and governance and workflow integration. However, sustained implementation requires ongoing attention to workload pressures, protocol scope and continuing education to ensure nurses have the opportunity to use NICPs in routine practice.

Inconsistent implementation of NICPs in EDs remains a challenge, where environmental constraints limit protocol use despite clinician capability and motivation. A theory-informed, multi-component implementation strategy achieved strong effectiveness, adoption, implementation fidelity and early maintenance of nurse-initiated care protocols, although reach was constrained by emergency department overcrowding, workload pressures and competing clinical priorities. Sustainable implementation of NICPs is contingent on embedding them within emergency department systems and processes that reliably enable their use in everyday clinical practice.

No patient or public contribution.