title: An exploration of factors influencing ambulance and emergency nurses' protocol adherence in the Netherlands.
abstract: BACKGROUND
  Adherence to ambulance and ED protocols is often suboptimal. Insight into factors influencing adherence is a requisite for improvement of adherence. This study aims to gain an in-depth understanding of factors that influence ambulance and emergency nurses' adherence to protocols.
  
  
  METHODS
  Semi-structured interviews were held with ambulance nurses, emergency nurses, and physicians (N = 20) with medical end responsibility in the Netherlands to explore influencing factors. Content analysis was used to identify influencing factors.
  
  
  RESULTS
  The main influencing factors for adherence were individual factors, including individual (clinical) experience, awareness, and the preference of following local protocols instead of national protocols. Organizational or external factors were involvement in protocol development, training and education, control mechanisms for adherence, and physicians' interest. Also of influence were protocol characteristics including integration of the advanced trauma life support approach, being in accordance with daily practice, and the generality of the content. Influencing factors could be a barrier as well as a facilitator for adherence.
  
  
  CONCLUSIONS
  Factors influencing ambulance and emergency nurses' protocol adherence could be assigned to individual, organizational, and external categories, as well as to protocol characteristics. To improve adherence, implementation strategies should be tailored to identified factors. Multifaceted implementation strategies will be needed to improve adherence.
authors.affiliation: Nijmegen, the Netherlands. Electronic address: remco.ebben@han.nl.
authors.forename: Remco H A
authors.initials: RH
authors.lastname: Ebben
authors.affiliation: Nijmegen, the Netherlands.
authors.forename: Lilian C M
authors.initials: LC
authors.lastname: Vloet
authors.affiliation: Nijmegen, the Netherlands.
authors.forename: Donna M J
authors.initials: DM
authors.lastname: Schalk
authors.affiliation: Nijmegen, the Netherlands.
authors.forename: Joke A J
authors.initials: JA
authors.lastname: Mintjes-de Groot
authors.affiliation: Nijmegen, the Netherlands.
authors.forename: Theo
authors.initials: T
authors.lastname: van Achterberg
mesh_terms: D000552:Ambulances; D001291:Attitude of Health Personnel; D004632:Emergency Medical Services / Q000592:standards*; D016529:Emergency Nursing / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009426:Netherlands; D009937:Organizational Objectives; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D012307:Risk Factors
keywords: Emergency medical services; Emergency nursing; Guideline adherence