Emergency departments (ED) bear the burden of increased health service demands [1], in an environment exacerbated by nursing shortages [2,3]. In rural Australia, EDs are spread across large geographic distances, with reduced service availability [4]. In some instances, facilities are staffed by emergency nurses with medical services provided through on-call general practitioners or telehealth arrangements [5]. Emergency nurses are responsible for the initial and ongoing assessment and management of patients presenting to the ED and may be the only clinician patients will see [5]. Historically, there was no standardised nursing framework to guide and support nurses in the delivery of emergency nursing care. The HIRAID® emergency nursing framework addressed this gap [6].

Use of HIRAID® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, assessment and communication) has demonstrated a positive impact on nurses, patients and health service outcomes [[6], [7], [8], [9], [10]] (Fig. 1). HIRAID® development was informed by an integrative review of the literature and expert consensus [11]. Testing in the simulated environment resulted in improved nursing assessment, and recognition and escalation of deterioration triggers [10]. Feasibility studies conducted in a small regional health district in Australia found HIRAID® was acceptable to emergency nurses [6], and improved the quality of nursing assessment documentation and reduced clinical deterioration events related to emergency nursing care [8,9].

In the current study, HIRAID® was implemented in February 2021 across a large, predominantly rural local health district (LHD) in Australia. Implementation was guided by a behaviour change-informed implementation strategy that included multiple components, e.g. executive support, education and environmental changes, and is detailed elsewhere [12]. The strategy incorporated a train-the-trainer model, using HIRAID® Instructors who received training, to deliver education to nurses and provide clinical support across the large geographic area during the initial implementation. Additionally, preformatted documentation templates were used to support recall of HIRAID® and provide a structure to guide documentation of relevant details in clinical records that would support and justify clinical decision-making and care delivery.

No previous studies have explored nurses’ perspectives of HIRAID® implementation. Clinical outcomes, as a measure of success, are often the focus in evaluation of implementation efforts. However, evaluation of implementation processes is also important to promote ongoing uptake and sustainability of interventions [13,14]. Understanding participant experiences aids evaluation and can inform modifications to improve uptake of interventions and/or strengthen sustainability of implementation efforts [13]. The aim of this study was to firstly understand emergency nurses’ experience of implementation, in particular the strategies employed, and secondly whether the HIRAID® emergency nursing framework impacted nursing practice.