The intent is good but… Exploring barriers and enablers to clinical pathway use in regional Australian Emergency Departments.

BACKGROUND: Clinical pathways can improve the quality, safety, and efficiency of care, but their integration into routine emergency department (ED) practice remains challenging. Factors influencing pathway use, particularly organisational and contextual determinants, are often overlooked, despite their importance for successful implementation and sustainability. These challenges may be amplified in regional EDs facing workforce and resource constraints. This study examined the barriers and enablers influencing the use of fractured neck of femur (NOF) and suspected stroke pathways in regional Australian EDs to inform service improvement and pathway redesign. METHODS: A qualitative exploratory study was conducted across regional EDs in Tasmania. The study utilised big picture mapping workshops and semi‑structured interviews to examine pathway use in real‑world clinical settings. 25 clinicians participated in three multidisciplinary mapping workshops, and 14 clinicians took part in in‑depth interviews. Mapping identified key steps and decision points within fractured NOF and stroke pathways, while interviews explored clinicians' experiences and perceptions. Data were deductively analysed using the updated Consolidated Framework for Implementation Research (CFIR). RESULTS: Mapping revealed common care processes but significant site-level differences, including inconsistent pathway initiation. Interviews revealed that pathway use was influenced by factors across CFIR domains: complexity and workflow misalignment were barriers, with digital integration a valued enabler (Innovation). Time pressures and resource limitation affected pathway use (Outer Setting). Leadership buy‑in and champions enabled use (Inner Setting). Clinicians expressed concern about diminishing clinical judgment (Individuals domain), while Implementation Process domain barriers included limited collaboration. CONCLUSION: Pathway use in Tasmanian EDs is influenced by barriers and enablers across CFIR domains. Simplifying pathways and ensuring adaptability were perceived to improve usability, while misaligned workflows and paper-based processes hinder uptake. Addressing resource constraints, fostering leadership engagement, and strengthening education are essential. Embedding planning, collaboration, and feedback will ensure pathways remain practical, evidence-based, and deliver timely, standardised care.