From city evidence to country practice: making change stick
If you work in a rural emergency department, you’ve probably said it before. A new model of care, a clever protocol, or a shiny new guideline arrives from a big teaching hospital, and the reaction is almost automatic: “Great idea — but it won’t work here.”
And often, you’re right.
Why? Because the realities of care in Albury or Albany are different from those in the big tertiary hospitals where most research is done. Our patients are different, our resources are different, and our capacity to implement change is different. Staffing is thin; one registrar calling in sick can upend the roster. We don’t have project officers or change managers to shepherd things through. In rural hospitals, change usually has to be carried by the clinicians themselves, layered on top of the day job. And of course, reforms often need to roll out across a network of small hospitals, each with its own quirks.
That’s where implementation research comes in. Unlike traditional clinical research, which asks “does this intervention work?”, implementation research asks “how do we get this intervention used effectively in everyday settings?” And unlike a simple quality audit, it doesn’t just tell you whether your service meets a standard. Done well, it generates knowledge about how to make an intervention stick across different contexts and how to adapt it without losing its value.
Implementation science is really just the study of how good ideas get off the page and into practice. It asks whether people actually take up a new approach, whether it fits the setting, and whether it lasts once the spotlight fades. It looks at the nuts and bolts — who needs to be convinced, what support or training is required, and what barriers stand in the way. If you want to dig deeper, the BMJ article Implementation research: what it is and how to do it is a good place to start.
Implementation research can and does work in rural emergency departments. A great example is the HIRAID Nursing Effectiveness Study — which tested the rollout of HIRAID, a structured framework for nursing assessment (History, Infection risk, Red flags, Assessment, Interventions, Diagnostics).
Researchers ran what, in the BMJ framework, would be called an effectiveness–implementation trial. In other words, they looked at whether HIRAID improved care and how well it could be put into practice. Patient records showed nurses using HIRAID completed more thorough assessments, picked up deteriorating patients earlier, and communicated concerns more clearly. Nurses themselves reported it made their work easier to organise. And the framework stuck: within six months more than 95% were using it, and three years later, participating EDs, rural and metropolitan alike, were still using it.
For rural emergency departments, that’s the real value of implementation science. It doesn’t assume what works in a tertiary hospital will work the same way in a small rural service. It gives us tools to adapt, adopt, and sustain innovations in the real world. And the best part is that we improve care as we study it, learning what helps or hinders and making the next change easier.
Because in the end, it’s not about whether a new idea is good. It’s about whether it works here.
How to get started with implementation research
Start small. Pick a clear, practical problem that could make a real difference in your setting.
Align with priorities. Link your project to goals your hospital or service already cares about — it makes leadership buy-in much easier.
Find a mentor. Work with someone experienced in implementation science to help with design, ethics, and writing it up.
Use a framework. Don’t invent your own — tools like RE-AIM or CFIR give you a ready-made structure.
Document the “how.” Record barriers, adaptations, and lessons learned — not just whether it worked.
First published in the RRECN Newsletter (September 2025).
Working in rural emergency care? Join the RRECN network