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To understand how reductions in resource allocation affect food safety services in England.
This longitudinal ecological study analysed secondary observational data.
England, data at the local authority level.
Ecological study, without human participants.
The primary outcome measures were the number of staff, represented by the number of full-time equivalents per capita, number of interventions per establishment, and proportion of hygiene-compliant establishments.
A £1 decrease in food safety expenditure per capita was associated with a 2% (–3.3 to –0.7) decrease in staffing levels and a 1.6% (–3.2 to –0.1) decrease in the number of interventions achieved per establishment. A one-unit reduction in staff was associated with a 42.2% (–80.5 to –11.9) decrease in the number of interventions achieved. No evidence of an association was found between expenditure or staff levels and the proportion of compliant establishments.
Spending reductions negatively affected the capacity of food safety teams to provide key services. Reductions in food safety expenditure significantly affected food hygiene staff levels and service provision. This finding raises concerns about the capacity of food safety teams to operate and the potential for increased public risk of gastrointestinal infections.
To determine characteristics, variability and enablers/barriers to evidence-based care and generate recommendations with implementation strategies to improve the management of early pregnancy bleeding in the emergency department (ED).
Multi-method study.
This paper reports the integration phase of a multi-method study conducted in a regional health service with five sites. Quantitative results (characteristics, variabilities in care and barriers/enablers to evidence-based care) and qualitative findings (ED clinicians' perspectives and experiences) were integrated to generate new findings and recommendations, mapped to the Theoretical Domains Framework (TDF) and corresponding intervention strategies using the Behaviour Change Wheel.
This study integrated findings from two cohort studies of 9859 women over 10 years and a mixed-method study of 104 ED clinicians from five sites. The four key findings were (i) ED remains a critical source of assessment, (ii) Improved access to resources is needed to provide evidence-based care, (iii) Gaps in ED clinician knowledge, skill and confidence have potential patient and health service consequences and (iv) A practice guideline is available; however, it needs refinement. These were mapped to five TDF domains: beliefs about capabilities and consequences, environmental context and resources, knowledge and skills and seven intervention functions. Recommended implementation strategies included multimodal education, clinical champions and an updated practice guideline.
Recommendations to improve delivery of care to women with early pregnancy bleeding in the ED focus on clinical skills and resources. An implementation strategy, considering resource availability, clinician knowledge, skills and confidence, was developed using behaviour change theory.
Integration of characteristics, variability of, and influences on evidence-based care generated recommendations that could contribute to more consistent and effective care, improving patient and health service outcomes.
No patient or public involvement.
Commentary on: Zhao et al. The impact of education/training on nurses caring for patients with stroke: a scoping review. BMC Nurs 23:90
Implications for practice and research Nurses working in clinical stroke care could benefit from leadership and management strategies that encourage empowerment and time and space to reflect on current evidence, training and practice. Comprehensive evaluation strategies are needed to assess the impact and effectiveness of empowerment-based stroke education and training on patient outcomes.
Stroke nursing is widely recognised for its significant role across the whole multidisciplinary stroke care pathway.
Emergency Departments face increasing pressure due to rising patient demand, complex presentations, and resource constraints, resulting in long waits and extended stays. Nurse-initiated protocols enable nurses to commence investigations and treatments based on clinical guidelines, improving care and efficiency. Despite evidence supporting their effectiveness, few nurse-initiated protocol implementation strategies are grounded in behaviour change theory. This gap may contribute to limited uptake, as many initiatives fail to address the complex factors influencing clinician behaviour.
To develop a behaviour change theory-informed implementation strategy to enhance the uptake of nurse-initiated protocols in the emergency department.
A framework-based intervention design was used.
The Behaviour Change Wheel and Theoretical Domains Framework guided the development of the implementation strategy. Barriers and enablers identified through prior research in 2023 using surveys and focus groups were mapped to relevant intervention functions. Behaviour change techniques were selected based on their potential to address barriers or strengthen enablers. The APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects, and Equity) were applied to optimise feasibility.
Nine barriers and ten enablers to nurse-initiated protocols use were identified and categorised using the COM-B (Capability, Opportunity and Motivation) framework and mapped to the Theoretical Domains Framework. Eight intervention functions were selected and mapped to 24 behaviour change techniques and 23 delivery modes. The key implementation strategies are education, clinical champions, documentation changes, audit and feedback, and leadership engagement. Stakeholders confirmed the feasibility of the selected strategies.
Theory-informed, context-specific strategies are essential for implementing nurse-initiated protocols in emergency departments. This approach enables the design of targeted, feasible interventions that directly respond to identified barriers and enablers. Future research should test context-specific implementation strategies, assess their long-term impact on healthcare outcomes, and evaluate their scalability across diverse healthcare settings.
By targeting the behavioural determinants of clinician practice, this study fills a critical gap in implementation science within emergency nursing. This study identified 24 behaviour change techniques across eight intervention functions to support nurse-initiated protocol uptake. Strategies such as education, clinical champions, and audit provide a practical, replicable framework to overcome barriers, enhance autonomy, and reduce care delays. Findings support sustainable implementation in emergency settings, with future research needed on long-term impact and scalability.
There is no EQUATOR guideline available for this study.
This study did not include patient or public involvement in its design, conduct, or reporting.
To identify the barriers and enablers to implementing nurse-initiated protocols in an emergency department.
Nurse-initiated protocols empower emergency nurses to autonomously initiate interventions, investigations and treatments based on predefined clinical guidelines. These protocols reduce waiting times and enhance staff and patient satisfaction. However, their uptake remains inconsistent, and the reasons for this variability are not well understood.
Focus groups were conducted with emergency nurses using an interview guide informed by the theoretical domains framework to explore perceived barriers and enablers to protocol implementation. Audio recordings were transcribed and analysed using inductive content analysis.
Six focus groups with 34 participants identified seven categories influencing protocol implementation. Barriers were: (i) nurses' workload and psychological stress, (ii) lack of competence, confidence and experience, and (iii) documentation burden and limited access to resources. Enablers were: (i) education and clinical support, (ii) improved clinical practice, and (iii) positive healthcare outcomes. The nurses and doctor relationship was identified as both a barrier and an enabler.
Effective implementation of nurse-initiated protocols requires systemic changes that empower nurses within a well-supported, adequately resourced environment. Addressing structural and professional development challenges is crucial to ensuring these protocols are consistently integrated into emergency departments.
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