Facilitators and barriers to guide implementation strategy design for a blunt chest injury care bundle: A multisite mixed-method survey

Ms Sarah Kourouche1, Dr Belinda Munroe1,2, Associate Professor Tom Buckley1, Dr Connie Van1, Professor Kate Curtis1,2

1University Of Sydney, Susan Wakil School of Nursing and Midwifery, Camperdown, Australia, 2Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital,  Wollongong, Australia

Background: To address the evidence-practice gap, implementing evidence needs planning and strategy that addresses the complexity of multidisciplinary emergency department systems by identifying and addressing facilitators and barriers to change.

Aim: To identify the facilitators and barriers to the implementation of a blunt chest injury care bundle and identify implementation strategies informed by the behaviour change wheel (BCW).

Methods: An electronic survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the future activation of or response to a blunt chest injury care bundle was distributed to 441 staff from 12 departments across two hospitals.

Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using inductive content analysis.  Quantitative and qualitative results were then integrated by mapping to the TDF. When a positively geared item had a mean greater or equal to four on a 5-point scale, then it was considered as a facilitator.

The facilitators and barriers were then evaluated using the BCW to extract specific intervention functions, policies, behaviour change techniques and intervention strategies. Each phase was assessed against the APEASE criteria.

Results: 198 staff (45%) completed the survey. Eight facilitators and seven barriers were identified. The factors facilitating implementation were: understanding patient care; patient assessment skills; blunt chest injury management skills, professional role identity, belief of consequences, provision of training, social supports and the protocol design. The barriers were the not understanding the term ‘care bundle’, lacking regional analgesia skills, not remembering to use protocol, belief of consequences, emotions, equipment and protocol access. Seven intervention functions were selected to address target behaviours: modelling, training, education, incentivisation, environmental restructuring, enablement, and persuasion.

Conclusions: Targeted implementation strategies can be developed using theoretical frameworks to consider facilitators and barriers to behaviour change and guide implementation strategy.


Sarah has worked in the emergency department and as a trauma case manager for over 10 years at St George Hospital in Sydney. She is currently working towards a PhD through the University of Sydney investigating the implementation of a care bundle for patients with blunt chest injury. She also teaches at the Sydney Nursing School, teaching undergraduate nursing students.