• Remco H A Ebben, Lilian C M Vloet, Donna M J Schalk, Joke A J Mintjes-de Groot, and Theo van Achterberg.
• Nijmegen, the Netherlands. Electronic address: remco.ebben@han.nl.
• J Emerg Nurs. 2014 Mar 1;40(2):124-30.

IntroductionAdherence 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.MethodsSemi-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.ResultsThe 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.DiscussionFactors 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.Copyright © 2014 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.

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