Implementation Fidelity Research Articles

Implementing a Digital Platform for Recurrent Urinary Tract Infections.

A patient-centered care model is needed for recurrent urinary tract infection (UTI) management. The aim of this study was to develop a conceptual model for a digital platform to implement evidence-based guidelines for recurrent UTI management. This was a qualitative, 3-stage mixed methods study that included (1) developing an evidence-based prototype texting platform; (2) qualitative feedback from recurrent UTI patients using the platform; and (3) quantitative data on acceptability (proportion of patients engaging with the platform), accuracy (proportion of patient messages interpreted accurately by the platform), and usability (score 0-100). Thirty-one women with recurrent UTI (median age, 71 years; range, 60-74 years) participated in testing over 4 months. The prototype platform was modified through iterative rounds of qualitative and quantitative analysis until engagement ≥85%, accuracy ≥90%, and usability score of ≥80 were achieved in 10 patients. Qualitative feedback indicated that patients valued rapid access to treatment through fewest possible health encounters during an acute episode, evidence-based education about prevention, and ability to participate in self-management with support from health care providers. Based on this feedback, a conceptual model consisting of 3 main components was developed: (1) an algorithm to triage acute symptoms, (2) educational videos emphasizing prevention strategies, and (3) supportive messages. Patient feedback identified 4 key implementation outcomes-usability, acceptability (engagement), fidelity (accuracy), and cost-and 3 clinical outcomes-self-efficacy, health care utilization, and rate of unnecessary antibiotics for testing the model. The proposed model can be used to implement and test a patient-centered evidence-based digital platform for the management of recurrent UTI.

A retrospective analysis of a clinician-initiated high-intensity locomotor training implementation project in an inpatient rehabilitation facility.

The Academy of Neurologic Physical Therapy's Intensity Matters campaign recommends the implementation of high-intensity locomotor training for all patients with neurologic dysfunction with goals to improve walking. Retrospectively determine the effectiveness of a clinician-initiated implementation project on the adoption, reach, and fidelity of high-intensity locomotor training for patients with stroke during inpatient rehabilitation and, determine whether the project led to changes in patient outcomes. Retrospective analysis of electronic medical records from 1 year before and after the project. Patients admitted with a stroke diagnosis were included. Demographic information, the number of high-intensity sessions, the percentage of time spent in the target heart rate zone, standardized assessment scores for motor function, functional mobility, balance, gait speed and endurance, and discharge destination were extracted for descriptive and linear mixed model analysis. Clinician reach was 75%, and adoption of high-intensity training varied between clinicians from 47.1% and 83.3%. Of eligible patients, 55% received the target intervention at least once, reflecting the patient reach. Implementation fidelity was 18.84%. Linear mixed effects modeling revealed a statistically significant effect of time (p < .001) but not group allocation or group × time interaction. Although statistically significant differences in patient outcomes compared to pre-implementation were not found, results highlight the limitations associated with adopting high-intensity locomotor training for patients post-stroke in this setting .It remains unclear whether the implementation fidelity achieved was sufficient to impact patient outcomes. Further research is needed to establish fidelity targets and identify barriers to successful implementation projects by clinicians.

Effectiveness of Supporting lifestyle change in pregnant mothers with obesity through the wearable internet-of-things (SLIM) -intervention on self-efficacy in weight management in pregnant women: a quasi-experimental trial

BackgroundHalf of women with overweight gain excessive weight during pregnancy. Perceived self-efficacy plays a significant role in adherence to healthy behaviours, especially in turning points of life, such as a pregnancy. ObjectivesTo assess the effectiveness of the Supporting lifestyle change in pregnant mothers with obesity through the wearable internet-of-things (SLIM)-intervention in terms of improving self-efficacy in eating and physical activity and preventing excessive weight gain of pregnant women with overweight. The second aim was to evaluate the fidelity of the intervention implementation. MethodsPregnant women with overweight (N=54) attending maternity clinics in Southwest Finland between 2021 and 2023, were recruited using convenience sampling. The SLIM-intervention included: health technology, motivational interviewing, feedback, and goal setting. The intervention was implemented in prenatal visits in maternity clinics continuing to 12 weeks postpartum. The change in self-efficacy was measured with Weight Efficacy Life-Style Questionnaire (score 0–180) and Self-Efficacy for Physical Activity Scale (score 5–25) with repeated measures in three timepoints. Data on weight were collected from patient records. ResultsThe levels of self-efficacy were high throughout the study period and there were no significant changes in self-efficacy in eating (p=0.650) or physical activity (p=0.936). Most of the women (N=9/10), whose gestational weight gain was within recommendations or less, managed to lose weight during the postpartum period (p<0.001). ConclusionsAlthough the intervention was not effective in improving self-efficacy, the importance of recommended gestational weight gain on better postpartum weight management was highlighted. A long follow-up time was valuable for examination of changes over time and understanding trends, patterns, and outcomes of the study. RegistrationThe trial was registered at the Clinicaltrials.gov register platform (ID NCT04826861) on March 17th, 2021.

Replication in educational interventions: developing a tool to measure and promote fidelity

ABSTRACT The impact of many interventions weakens during the scaling up process and low fidelity of implementation (i.e. delivering an intervention but not as it was intended) may explain why. In this paper we introduce, discuss, and exemplify the use of a framework for developing fidelity tools that aim to measure and promote fidelity of implementation. The framework includes four steps that are typical of the development of new psychological and educational measures: conception, piloting and revision, implementation, and evaluation. We exemplify the use of the framework by describing the activities we carried out and the reasons for the choices we made in each stage to develop a tool to assess and promote fidelity in the scaling up of the Improving Working Memory Plus Arithmetic (IWM+A) intervention in a randomized controlled trial, involving 201 schools. In the scaling up process we used the train-the-trainer model. Twelve teacher leaders, who were trained by the programme developers, trained teaching assistants (the end users) who then delivered the intervention to children in the intervention schools (N = 100). We describe the intervention, the training model, and the process of developing, piloting, implementing, and evaluating the tool.

Data based individualization in early writing: the importance and measurement of implementation fidelity

In this paper we describe the process of monitoring fidelity of implementation for a teacher-implemented early writing intervention. As part of a large, federally funded project, teachers who worked with students in grades 1 through 3 in schools across two states in the US were recruited and then randomly assigned to implementation and control conditions. Using Data-Based Individualization (DBI) as a framework for best practice in assessment and intervention, teachers in the implementation group received professional development on early writing intervention and assessment and then implemented these practices with their students who had significant writing challenges. Coaches, who were part of the research project, supported teachers and also observed teachers in both the implementation and control conditions at least twice during the course of the 20-week study. This paper focuses on the results of the fidelity measures that were administered throughout the project. An overview of the importance of fidelity checks is followed by a description of the fidelity tools used, as well as data from those tools. Areas of strength and challenge for teachers when implementing early writing assessment and intervention and engaging in data-based decision making with fidelity are discussed, along with recommendations regarding the practical and research importance of fidelity checks.

Empirically Deriving Cut Scores in the Positive Behavioral Interventions and Supports (PBIS) Tiered Fidelity Inventory (TFI) Through a Bookmarking Process

We aimed to identify empirically valid cut scores on the positive behavioral interventions and supports (PBIS) Tiered Fidelity Inventory (TFI) through an expert panel process known as bookmarking. The TFI is a measurement tool to evaluate the fidelity of implementation of PBIS. In the bookmark method, experts reviewed all TFI items and item scores by difficulty in order estimated by an item response theory (IRT) model of TFI data. Over two sessions involving data review and discussion, panelists individually identified which corresponding cut scores in each TFI tier scale indicated minimally adequate fidelity in the TFI, leading to corresponding scores of 83.3% for TFI Tier 1, 84.6% for TFI Tier 2, and 82.4% for TFI Tier 3. Then, the proposed cut scores were compared with the original cut scores of 70% for percentage of schools meeting fidelity and the association between the cut scores and school discipline outcomes using an extant sample. The results of descriptive statistics and multiple t-tests suggested that the bookmark cut score in TFI Tier 1 was reachable and more strongly associated with improved school discipline outcomes. Findings for TFI Tier 2 and Tier 3 were less conclusive.

Assessing the implementation of suicide-focused treatments delivered in hybrid telemental health format in a real-world setting

Objective The purpose of this study was to assess the implementation of suicide-focused treatments delivered via a hybrid telemental health (TMH) and in-person format. Method This study was conducted at four university counseling centers (UCCs) across the United States. Treatment-seeking clients were recruited from their local UCCs and participated in adaptive treatment strategies (ATSs) involving Treatment as Usual (TAU), Collaborative Assessment and Management of Suicidality (CAMS), and Dialectical Behavior Therapy (DBT). Implementation outcomes, including appropriateness, acceptability, feasibility, fidelity, safety, and client satisfaction, were assessed. UCC clinicians participated in qualitative interviews focused on implementation of TMH for clients presenting with suicidal ideation (SI). Results Overall, treatments delivered via hybrid format were reported to be appropriate, acceptable, feasible, and satisfactory by clinicians and clients. Implementation of TMH was reported to be equivalent to in-person treatment across multiple measurement methods. Conclusion Results from this study demonstrate that TMH is an implementable treatment modality for addressing suicidality, particularly for college students presenting to UCCs with SI. This study has implications for real-world clinical settings planning to offer hybrid treatment modalities to address SI. Trial registration: ClinicalTrials.gov identifier: NCT04728815.

Strengthening implementation of integrated care for small and nutritionally at-risk infants under six months and their mothers: Pre-trial feasibility study.

An integrated care pathway to manage small and nutritionally at-risk infants under 6 months (u6m) and their mothers (MAMI Care Pathway) is consistent with 2023 WHO malnutrition guidelines and is being tested in a randomised controlled trial (RCT) in Ethiopia. To optimise trial implementation, we investigated contextual fit with key local stakeholders. We used scenario-based interviews with 17 health workers and four district managers to explore perceived feasibility. Eighteen policymakers were also surveyed to explore policy coherence, demand, acceptability, evidence needs, opportunities and risks. The Bowen feasibility framework and an access to health care framework were adapted and applied. Health workers perceived the MAMI Care Pathway as feasible to implement with support to access services and provide care. The approach is acceptable, given consistency with national policies, local protocols and potential to improve routine care quality. Demand for more comprehensive, preventive and person-centred outpatient care was driven by concerns about unmet, hidden and costly care burden for health services and families. Inpatient care only for severe wasting treatment is inaccessible and unacceptable. Support for routine and expanded components, especially maternal mental health, is needed for successful implementation. Wider contextual factors may affect implementation fidelity and strength. Policymakers cautiously welcomed the approach, which resonates with national commitments, policies and plans but need evidence on how it can work within varied, complex contexts without further system overstretch. A responsive, pragmatic randomised controlled trial will generate the most useful evidence for policymakers. Findings have informed trial preparation and implementation, including a realist evaluation to contextualise outcomes.

Conducting Assessments of Community-Based Programs for Individuals with Dementia and their Family Caregivers.

While the gold standard for intervention science is the randomized controlled trial (RCT), there is growing emphasis on the practical implementation and evaluation of evidence-based programs into community agencies. Assessment of program efficacy by community-based organizations can confirm planned delivery of services, implementation fidelity, and demonstrate positive outcomes, which can provide justification for funding. Methods and measures used in an RCT, however, often cannot be implemented in non-research settings and different approaches are needed. This manuscript reviews the emerging literature on program evaluation work and draws upon the authors' experiences conducting evaluations with three community-based organizations funded by Administration for Community Living to implement programs for individuals with dementia and their family care partners. This manuscript argues for an examination of the expectations of evaluation efforts for translation of research-based trials to practice and emphasizes three main strategies for assessment: (1) Development of brief tailored assessments; (2) Measuring fidelity of implementation of the program; and (3) Measuring acceptability of the program to clients.

The RETurn to work After stroKE (RETAKE) trial: Findings from a mixed-methods process evaluation of the Early Stroke Specialist Vocational Rehabilitation (ESSVR) intervention.

A key goal for working age stroke survivors is to return to work, yet only around 50% achieve this at 12 months. Currently, there is limited evidence of effectiveness of early stroke-specialist vocational rehabilitation (ESSVR) interventions from randomised controlled trials. This study examined fidelity to ESSVR and explored social and structural factors which may have influenced implementation in the RETurn to work After stroKE (RETAKE) randomised controlled trial. Mixed-methods process evaluation assessing intervention fidelity and incorporating longitudinal case-studies exploring stroke survivors' experiences of support to return to work. Normalisation Process Theory, and the Conceptual Model for Implementation Fidelity, informed data collection and analysis. Sixteen sites across England and Wales participated in RETAKE. Forty-eight occupational therapists (OTs), supported by 6 mentors experienced in vocational rehabilitation (VR), delivered the intervention (duration 12 months) between February 2018 and April 2022. Twenty-six participants (15 ESSVR, 11 usual care (UC)) were included in longitudinal case-studies. An additional 18 participants (8 ESSVR and 10 UC) were interviewed once. Nineteen OTs, 6 mentors and 19 service managers were interviewed. Fidelity was measured for 39 ESSVR participants; mean fidelity score was 78.8% (SD:19.2%, range 31-100%). Comparison of the experiences of ESSVR and UC participants indicated duration and type of support to return to work were perceived to be better for ESSVR participants. They received early, co-ordinated support including employer liaison and workplace adjustments where appropriate. In contrast, UC participants reported limited or no VR or return to work support from health professionals. Typically, UC support lasted 2-8 weeks, with poor communication and co-ordination between rehabilitation providers. Mentor support for OTs appeared to increase fidelity. Service managers indicated ESSVR would enhance post-stroke services. ESSVR was valued by participants and was delivered with fidelity; implementation appeared to be facilitated by mentor support for OTs.

Consensus-Building Processes for Implementing Perioperative Care Pathways in Common Elective Surgeries: A Systematic Review.

To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries. Systematic review. Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023. Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions. The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full-text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions. Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented. Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals. These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. No patient or public contribution. CRD42023413817.

Randomized Clinical Trial to Increase Self-Monitoring of Physical Activity and Eating Behaviors in Youth: A Feasibility Study

ABSTRACT Introduction Mobile health (mHealth) has the potential to reduce reliance on in-person healthcare visits, making monitoring of health, eating, and physical activity less burdensome. There is a great need to develop and test mHealth tools for pediatric weight loss programs to enhance clinical practice. This study aimed to test the feasibility of utilizing a tailored suite of mHealth components to augment an existing evidence-based in-person pediatric weight management program. Method Using a two-group randomized superiority trial design, participants who completed baseline measurement were randomized to Brenner Families in Training (Brenner FIT) or Brenner FIT + mHealth (Brenner mFIT), and follow-up measures were completed at 3 and 6 months. Feasibility was assessed in terms of screening, recruitment, randomization, retention, and the assessment process. Acceptability was assessed in terms of program completion, and implementation fidelity was assessed in terms of logging activity, frequency of self-monitoring, goal setting, and retention rate. Results Overall, 173 dyads were eligible for enrollment based on inclusion criteria. Twenty-five dyads consented to participate. Sixteen dyads completed baseline psychosocial questionnaires, eight dyads completed at least two 24-h dietary recalls, and 20 (youth) participants returned accelerometers. Of the 14 dyads who completed enrollment, seven dyads were each randomized into the intervention and control groups, with ten and five dyads retained at three and six months, respectively. A total of four caregivers and two youth who utilized the website for goal setting set at least one goal, all seven youth linked their activity tracker, and most downloaded at least one video (two youth) or podcast (six caregivers). Conclusions Our results suggest that the assessment protocol was overly burdensome, the intervention had low acceptability, and the study as designed was not feasible to complete. Future studies should evaluate barriers and facilitators to the uptake of mHealth.

Integrating Heart Rate Monitoring Into a Camp for Children With Neuromotor Disorders: A Case Series.

This case series investigated the implementation fidelity, feasibility, and effectiveness of integrating continuous heart rate monitoring with visual feedback into an established, intensive physical therapy camp for children with neuromotor disorders. The provision of continuous visual feedback through color-coded, individually calculated heart rate zones was a feasible and effective intervention, encouraging pediatric gait camp participants to exercise at intensities that produced aerobic and functional gains. The use of technology facilitated participation with peers, an outcome equally as important as their endurance and functional improvements. Pediatric physical therapists play a crucial role in enhancing the well-being and physical fitness of children with disabilities. Encouraging regular exercise in a social environment fosters enjoyable, inclusive experiences while promoting overall health. It is important for clinicians in various pediatric rehabilitation settings to establish programs that offer such opportunities for children with neuromotor disorders.

Teachers' Perceptions of the Impact of the COVID-19 Pandemic and Their Implementation of an Evidence-based HIV Prevention Program in the Bahamas.

Information on how school-based programs is implemented and sustained during crises is limited. In this study, we assessed the impact of the COVID-19 pandemic on the implementation of a HIV prevention intervention in The Bahamas. Data were collected from 139 Grade 6 teachers in 2021-2022. Teachers attended virtual training and received implementation monitoring from coordinators. On average, teachers taught 26.4 (SD = 9.2) of the 35 core activities, and 7.4 (SD = 2.4) out of 9 sessions. More than half (58.3%) of teachers completed 28 or more core activities; 69.1% covered eight or all nine sessions, which is equivalent to 80% of the HIV intervention curriculum. Almost half of the teachers (43%) reported that the pandemic negatively impacted their ability to teach the program; 72% of teachers maintained that the program remained "very important" during times of crisis. Greater self-efficacy and supports increased implementation fidelity.

Leveraging implementation science for secondary prevention of cervical cancer in South Africa

Aim Cervical cancer is the second most common cancer and the top cause of cancer deaths amongst women in South Africa. Evidence-based interventions for secondary prevention of cervical cancer (cervical screening followed by treatment of identified pre-cancerous lesions) are available in South Africa’s health system, yet cervical cancer incidence remains high. This paper argues that this is partly due to implementation failure, i.e., deploying a good intervention ineffectively. Interventions found efficacious in controlled research settings may not achieve desired health outcomes when deployed in the real world due to implementation failure. Methods The field of implementation science offers frameworks for enhancing effective implementation. These frameworks guide the identification of implementation barriers and selection of context-relevant strategies for addressing them. This paper applies implementation science frameworks to secondary prevention in South Africa and promotes using such frameworks in cervical cancer prevention programming. Findings The problem of secondary prevention of cervical cancer in South Africa is contextualised. The paper conceptualises effective implementation as the attainment of implementation outcomes including acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, reach, and sustainability of evidence-based interventions. Drawing from the South African literature, examples of ineffective and failed implementation of secondary prevention interventions are presented including: low acceptability of screening by users and providers, sub-optimal adoption of screening provision by providers, low feasibility of hospital-centred pre-cancer treatment provision, low implementation fidelity, and limited reach of screening and pre-cancer treatment. Finally, using two examples, the paper provides practical guidance on how implementation science frameworks could be leveraged in South Africa to mitigate implementation failure. Conclusions Greater application of and capacity building in implementation science are recommended to contribute towards strengthening cervical cancer secondary prevention in South Africa.

Feasibility of a theory-based intervention towards benzodiazepine deprescribing in Belgian nursing homes: protocol of the END-IT NH cluster-randomised controlled trial

IntroductionDespite several calls to deprescribe benzodiazepine receptor agonists (BZRA) in older adults, their use among nursing home residents (NHRs) remains high. Therefore, we developed an intervention targeting general practitioners’ and...

Implementation Fidelity of Materiovigilance Program in a Tertiary Care Hospital

Implementation Fidelity of Materiovigilance Program in a Tertiary Care Hospital

Strengthening China’s National Essential Public Health Services Package for hypertension and diabetes care: protocol for an interrupted time series study with mixed-methods process evaluation and health economic evaluation

BackgroundDespite major primary health care (PHC) reforms in China with the 2009 launch of the National Essential Public Health Service Package, the country experiences many challenges in improving the management of non-communicable diseases in PHC facilities. “EMERALD” is a multifaceted implementation strategy to strengthen the management of hypertension and type-2 diabetes mellitus (T2DM) in PHC facilities. The study aims to: (1) examine the effectiveness of EMERALD in improving hypertension and T2DM management; (2) evaluate the implementation of the interventions; and (3) use the study findings to model the long-term health economic impact of the interventions.MethodsThe EMERALD intervention components include: (1) empowerment for PHC providers through training and capacity building; (2) empowerment for patient communities through multi-media health education; and (3) empowerment for local health administrators through health data monitoring and strengthening governance of local PHC programs. An interrupted time series design will be used to determine the effectiveness of the interventions based on routinely collected health data extracted from local health information systems. The primary effectiveness outcome is the guideline-recommended treatment rates for people with hypertension and T2DM. Secondary effectiveness outcomes include hypertension and T2DM diagnosis and control rates, and enrolment and adherence rates to the recommended care processes in the National Essential Public Health Service Package. A mixed-methods process evaluation will be conducted to evaluate the implementation of the interventions, including the reach of the target population, adequacy of adoption, level of implementation fidelity, and maintenance. Qualitative interviews with policy makers, health administrators, PHC providers, and patients with hypertension and/or T2DM will be conducted to further identify factors influencing the implementation. In addition, health economic modelling will be performed to explore the long-term incremental costs and benefits of the interventions.DiscussionThis study is expected to generate important evidence on the effectiveness, implementation, and health economic impact of complex PHC interventions to strengthen the primary care sector’s contribution to addressing the growing burden of non-communicable diseases in China.Trial registrationThe study has been registered on Chinese Clinical Trial Registry at https://www.chictr.org.cn/ (Registration number ChiCTR2400082036, on March 19th 2024).

The Challenges and Opportunities of Implementing Montessori Education in the Public Sector

Over the past two decades, Montessori education in the United States has rapidly expanded from the private to the public sector. This expansion has created important questions about whether or not the Montessori approach can thrive alongside the education standards and accountability movement in the public sector. Questions also exist as to precisely who is benefiting from this expansion of and investment in public Montessori. To examine these topics, this study focused on South Carolina, the state with the highest number of public programs in the United States. We used implementation surveys, classroom observations, and teacher interview data collected by the research team and student record data collected by the state of South Carolina to conduct the analysis, which consisted of three parts. First, we investigated to what extent public programs in South Carolina are able to implement Montessori education with fidelity to the model. Second, we considered what program characteristics were related to higher levels of Montessori implementation fidelity. Third, we analyzed which children had access to higher-fidelity Montessori programs. Generally, findings indicated that, despite challenges created by the education standards and accountability movement and concerns expressed by educators about authenticity, most programs in South Carolina were implementing Montessori with fidelity. Several characteristics were associated with higher levels of fidelity, including the age of the program. Findings also indicated that Black, Hispanic, and students from low-income families were disproportionately participating in lower fidelity programs. Our study provides an in-depth analysis of the challenges and opportunities associated with government trying to implement successful private-sector education models in the public sector.

Data-Driven Implementation Strategy to Optimise Clinician Behaviour Change at Scale in Complex Clinical Environments: A Multicentre Emergency Care Study.

To develop an evidence-driven, behaviour change focused strategy to maximise implementation and uptake of HIRAID (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) in 30 Australian rural, regional and metropolitan emergency departments. An embedded, mixed-methods study. This study is the first phase of a step-wedge cluster randomised control trial of HIRAID involving over 1300 emergency nurses. Concurrent quantitative and qualitative data were collected via an electronic survey sent to all nurses to identify preliminary barriers and enablers to HIRAID implementation. The survey was informed by the Theoretical Domains Framework, which is a synthesis of behavioural change theories that applies the science of intervention implementation in health care to effect change. Quantitative data were analysed using descriptive statistics and qualitative data with inductive content analysis. Data were then integrated to generate barriers and enablers to HIRAID implementation which were mapped to the Theoretical Domains Framework. Corresponding intervention functions and Behaviour Change techniques were selected and an overarching implementation strategy was developed through stakeholder consultation and application of the APEASE criteria (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety and Equity). Six barriers to HIRAID implementation were identified by 670 respondents (response rate ~58%) representing all 30 sites: (i) lack of knowledge about HIRAID; (ii) high workload, (iii) lack of belief anything would change; (iv) not suitable for workplace; (v), uncertainty about what to do and (vi) lack of support or time for education. The three enablers were as follows: (i) willingness to learn and adopt something new; (ii) recognition of the need for something new and (iii) wanting to do what is best for patient care. The 10 corresponding domains were mapped to seven intervention functions, 21 behaviour change techniques and 45 mechanisms. The major components of the implementation strategy were a scaffolded education programme, clinical support and environmental modifications. A systematic process guided by the behaviour change wheel resulted in the generation of a multifaceted implementation strategy to implement HIRAID across rural, regional and metropolitan emergency departments. Implementation fidelity, reach and impact now require evaluation. HIRAID emergency nursing assessment framework reduced clinical deterioration relating to emergency care and improved self-confidence and documentation in emergency departments in pilot studies. Successful implementation of any intervention in the emergency department is notoriously difficult due to workload unpredictability, the undifferentiated nature of patients and high staff turnover. Key barriers and enablers were identified, and a successful implementation strategy was developed. This study uses theoretical frameworks to identify barriers and enablers to develop a data-driven, behavioural-focused implementation strategy to optimise the uptake of HIRAID in geographically diverse emergency departments which can be used to inform future implementation efforts involving emergency nurses. The CROSS reporting method (Supporting Information S3) was used to adhere to EQUATOR guidelines. No Patient or Public Contribution. Australian New Zealand; Clinical Trials Registry (ANZCTR) number: ACTRN12621001456842, registered 25/10/2021.