Integrating implementation science to explore barriers and facilitators influencing nurses’ bioterrorism preparedness: a mixed-methods systematic review protocol

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Background: Bioterrorism involves the intentional release of biological agents capable of causing mass casualties, public health emergencies, and societal disruption. As frontline healthcare providers, nurses play a critical role in early detection, isolation, emergency care, and surveillance. However, substantial gaps exist in nursing bioterrorism preparedness across healthcare settings, and implementation determinants influencing preparedness remain insufficiently synthesised. Objective: To systematically synthesise quantitative and qualitative evidence on barriers and facilitators influencing nurses' bioterrorism preparedness using the Consolidated Framework for Implementation Research (CFIR 2.0). Methods: This mixed-methods systematic review will follow the Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews and adhere to PRISMA-P guidelines, with CFIR 2.0 serving as the guiding analytical framework. A comprehensive literature search will be performed across CINAHL, PubMed, Embase, Scopus, Web of Science, ProQuest, Cochrane Library, and Medline electronic databases from their inception until March 2026, including English and Chinese publications. Two independent reviewers will screen identified records against predefined eligibility criteria and appraise the methodological quality of included studies using the Mixed Methods Appraisal Tool (MMAT). Data synthesis will be thematically mapped to CFIR 2.0 constructs and integrated using a convergent integrated approach. Anticipated contributions: This review is expected to provide the first synthesis informed by implementation science of determinants influencing nurses' bioterrorism preparedness. By integrating evidence across methodological traditions, the review will generate a comprehensive understanding of individual, organisational, and contextual factors shaping preparedness implementation. Discussion: This protocol describes a mixed-methods systematic review informed by implementation science and guided by the Consolidated Framework for Implementation Research (CFIR 2.0) to examine barriers and facilitators influencing nurses' bioterrorism preparedness. The findings are expected to support a more comprehensive understanding of factors shaping preparedness in healthcare settings and to inform evidence-informed preparedness planning, nursing education, and organisational support strategies aimed at strengthening healthcare system resilience to biological threats. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251273403, Identifier CRD420251273403.

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