Commentary On “Successful and sustained implementation of a behaviour-change informed strategy for emergency nurses: a multicentre implementation evaluation”

Implementing and sustaining interventions in fast-paced healthcare environments is complex due to evolving practices, high workloads, unpredictable conditions, and reimbursement policies. Curtis et al. provide valuable insights into overcoming these challenges through behavior-change strategies, demonstrating their effectiveness in achieving long-term adoption and sustainability. Their multicenter study, involving 29 emergency departments (EDs), evaluated the implementation of HIRAID (History including Infection Risk, Red Flags, Assessment, Interventions, Diagnostics, Communication, and Reassessment), an evidence-based framework designed to reduce clinical variation and enhance emergency nursing care. The authors addressed implementation barriers using 21 behavior change techniques (BCTs) and conducted a type II effectiveness-implementation hybrid design. They assessed the intervention’s reach, effectiveness, adoption, dose, and sustainability using the RE-AIM framework, supported by data from surveys and documentation audits.

The results were impressive: HIRAID was adopted across all 29 EDs with high fidelity and 82% of nurses completed training within 12 weeks. The framework demonstrated significant sustainability, with consistent use at six months and full maintenance three years post-implementation, despite disruptions such as the COVID-19 pandemic and natural disasters. This underscores the adaptability and effectiveness of the behavior-change strategy under challenging conditions.

While HIRAID’s success in Australian EDs is promising, it raises questions about how similar frameworks might perform in other healthcare systems, including those in the U.S. or resource-limited countries. Adapting behavior-change strategies to fit specific regulatory, cultural, and operational contexts will be crucial for enhancing their global applicability.

The authors identified “Optimism,” which encourages staff to adopt and sustain new practices, and “Social Professional Role and Identity,” reflecting how individuals align their roles with the intervention’s goals, as key mechanisms behind HIRAID’s success. We see an opportunity to further explore how these mechanisms interact with contextual factors. For instance, understanding how leadership styles, organizational culture, and staff engagement influence these factors could offer deeper insights into successful implementation.

Although the study is robust, incorporating objective measures such as direct observations or external performance audits could provide a more comprehensive view of intervention fidelity. These methods can offer detailed insights into how the intervention is implemented and identify gaps between intended and actual practices. However, there is a tradeoff: these methods are resource-intensive and may introduce other biases, as the presence of external evaluators or the act of being observed could alter staff behavior.

Overall, this study advances implementation science by showing how behavior-change strategies can drive the successful adoption and long-term sustainability of interventions in complex healthcare settings. The approach, utilizing 21 behavior change techniques, serves as a practical model for overcoming implementation barriers while maintaining high fidelity. Beyond the authors’ suggested implications, this approach could help standardize care in other specialties with variability, such as outpatient care and chronic disease management. The success of HIRAID during the COVID-19 pandemic also suggests its potential for disaster preparedness and response, offering a resilient foundation for healthcare systems during global crises. Extending this approach to emergency protocols could strengthen healthcare systems’ capacity to handle future public health emergencies, highlighting a critical area for further research and application.

References:

Curtis, K., Kennedy, B., Considine, J. et al. Successful and sustained implementation of a behaviour-change informed strategy for emergency nurses: a multicentre implementation evaluation. Implementation Sci 19, 54 (2024). https://doi.org/10.1186/s13012-024-01383-7

Authorship:

On behalf of the INTERACT team

• Carolina Mejia, PhD – IS Technical Advisor, Duke Department of Population Health Sciences, INTERACT
• Megan Oakes, MS – Senior Research Program Leader, Duke Department of Population Health Sciences, INTERACT
• Leah Zullig, PhD – Professor, Duke Department of Population Health Sciences; Director, INTERACT