Nursing unit leaders' influence on the long-term sustainability of evidence-based practice improvements

Effect of evidence-based nursing practices training programme on the competency of nurses caring for mechanically ventilated patients: a randomised controlled trial

BACKGROUND

Evidence-Based Practice (EBP) has been recognised worldwide as a standardised approach for enhancing the quality of healthcare and patient outcomes. Nurses play a significant role in integrating EBP, especially in Intensive Care Unit (ICU). Consequently, this study aims to examine the effect of an adapted evidence-based nursing practices training programme on the competency level of nurses caring for mechanically ventilated patients.

METHODS

A prospective open-label parallel 1:1 randomised controlled trial was conducted on 80 nurses caring for ICU patients at the National Hepatology and Tropical Medicine Research Institute, Egypt. The trial was carried out between November 2022 and February 2023 under the registration number NCT05721664. The enrolled nurses were randomly divided into intervention and control groups. The intervention group received the evidence-based nursing practice training programme (EBNPTP) in accordance with the Johns Hopkins EBP conceptional model, whereas the control group received traditional in-service education. Four assessments (one pre- and three post-assessments) were conducted to evaluate nurses' competency level over time using the adapted evidence-based nursing competency assessment checklist. The primary endpoint was an increase the competency levels among nurses caring for mechanically ventilated patients.

RESULTS

The current study results revealed statistically significant differences between intervention and control groups in relation to their level of competency across the three post-assessments, with (p <.001). The study also demonstrated that the nurses' competency level continued to decline significantly over time, with (p <.001). Additionally, a significant correlation was found between the nurses' pre-assessment and educational level, acting as independent variables (predictors), and the third endpoint assessment (p <.01), indicated by multiple linear regression.

CONCLUSION

The EBP training programme demonstrated a significant increase in the nurses' level of competency compared with traditional in-service education. This suggests that by training the nurses in various settings with the essential skills and knowledge for EBP, their competency level can be enhanced, leading to the delivery of effective care and improving patient outcomes. However, the long-term sustainability of the EBP adoptions was insufficient; further studies are needed to investigate the factors that affect the durability of EBP adoption.

TRIAL REGISTRATION

The study was registered with Clinical Trials.gov (Registration # NCT05721664) on 10/02/2023.

Frontline nurse leaders' competences in evidence-based healthcare: A scoping review

AIM

To identify evidence on frontline nurse leaders' competences in evidence-based healthcare (EBHC) and the instruments measuring these competences.

DESIGN

A scoping review.

DATA SOURCES

The search was conducted in June 2021 and complemented in June 2022. The CINAHL, ProQuest, Medline (Ovid), Scopus, Web of Science databases and MedNar along with the Finnish database Medic were searched.

REVIEW METHOD

The scoping review was conducted in accordance with the Joanna Briggs institute methodology for scoping reviews. Titles, abstracts and full-text versions were screened independently by two reviewers according to the inclusion criteria. Deductive-inductive content analysis was used to synthesize data.

RESULTS

A total of 3211 articles published between 1997 and 2022 were screened, which resulted in the inclusion of 16 articles. Although frontline nurse leaders had a positive attitude towards EBHC, they had a lack of implementing EBHC competence into practice. Part of the instruments were used in the studies, and only one focused especially on leaders. None of instruments systematically covered all segments of EBHC.

CONCLUSION

There is a limited understanding of frontline nurse leaders' competence in EBHC. It is important to understand the importance of EBHC in healthcare and invest in the development of its competence at all levels of leaders. Frontline nurse leaders' support is essential for direct care nurses to use EBHC to ensure the quality of care and benefits to patients. Leaders must enhance their own EBHC competence to become role models for direct care nurses. It is also essential to develop valid and reliable instruments to measure leaders' competence covering all EBHC segments. The results can be utilized in the assessment and development of frontline nurse leaders' EBHC competence by planning and producing education and other competence development methods.

Facilitating Evidence-Based Practice among Nurses in a Tertiary General Hospital: A Six-Year Practice of an Implementation Strategy Informed by the i-PARIHS Framework

Aims

To develop an evidence-based practice (EBP) facilitating strategy informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and evaluates the strategy's effectiveness on promoting EBP.

Background

Nurses are increasingly expected to use research evidence in practice to improve patients' outcomes, but the application of such evidence is still unsatisfactory. The facilitation of EBP in nursing needs the organization and the individual levels.

Methods

Based on an analysis of EBP-promoting strategies and expert consultation, the core team of the nursing department developed an EBP group-based and project-oriented strategy under the guidance of the i-PARIHS framework. The strategy was implemented for six years and evaluated by a longitudinal design. The validated Chinese version of the self-reported Evidence Based Practice Questionnaire (EBPQ) was used to assess the attitudes, knowledge, and practice of the nurses.

Results

The mean score of the total EBPQ was 4.46 (SD = 0.92) after one year of the EBP strategy, and the scores for knowledge, attitudes, and practice of EBP members were higher than those of general nurses (p < 0.05). After four years, EBP members' scores continued to increase. EBP groups conducted 51 EBP projects in the areas of emergency nursing, surgical and medical nursing, critical care, and so forth. Of these, 33 projects improved nursing practice by changing nursing procedures, upgrading nursing tools, and developing nursing standards, resulting in improved patient outcomes.

Conclusion

The EBP group-based and project-oriented strategy can promote EBP. The composition of the EBP group, the annual audit of EBP projects, and the roles of internal and external facilitators were key components of this EBP-facilitating strategy. Implications for Nursing Management. The strategy is an organizational-level EBP-facilitation approach which can improve nurses' academic preparation for EBP through ongoing training and sustained EBP behavior that involves annual projects.

Formative Evaluation of CLABSI Adoption and Sustainment Interventions in a Pediatric Intensive Care Unit

Background

Pediatric patients require central venous catheters to maintain adequate hydration, nutritional status, and delivery of life-saving medications in the pediatric intensive care unit. Although central venous catheters provide critical medical therapies, their use increases the risk of severe infection, morbidity, and mortality. Adopting an evidence-based central line-associated bloodstream infection (CLABSI) bundle to guide nursing practice can decrease and sustain low CLABSI rates, but reliable and consistent implementation is challenging. This study aimed to conduct a mixed-methods formative evaluation to explore CLABSI bundle implementation strategies in a PICU.

Methods

The team used The Consolidated Framework for Implementation Research to develop the interview guide and data analysis plan.

Results

Facilitators and barriers for the CLABSI bundle occurred in four domains: inner setting, process, characteristics of individuals, and innovation characteristics in each cycle that led to recommended implementation strategy opportunities. The champion role was a major implementation strategy that facilitated the adoption and sustainment of the CLABSI bundle.

Conclusions

Implementation Science Frameworks, such as Consolidated Framework for Implementation Research (CFIR), can be a beneficial framework to guide quality improvement efforts for evidence-based practices such as the CLABSI bundle. Using a champion role in the critical care setting may be an important implementation strategy for CLABSI bundle adoption and sustainment efforts.

Exploring Shared Implementation Leadership of Point of Care Nursing Leadership Teams on Inpatient Hospital Units: Protocol for a Collective Case Study

BACKGROUND

Nursing leadership teams at the point of care (POC), consisting of both formal and informal leaders, are regularly called upon to support the implementation of evidence-based practices (EBPs) in hospital units. However, current conceptualizations of effective leadership for successful implementation typically focus on the behaviors of individual leaders in managerial roles. Little is known about how multiple nursing leaders in formal and informal roles share implementation leadership (IL), representing an important knowledge gap.

OBJECTIVE

This study aims to explore shared IL among formal and informal nursing leaders in inpatient hospital units. The central research question is as follows: How is IL shared among members of POC nursing leadership teams on inpatient hospital units? The subquestions are as follows: (1) What IL behaviors are enacted and shared by formal and informal leaders? (2) What social processes enable shared IL by formal and informal leaders? and (3) What factors influence shared IL in nursing leadership teams?

METHODS

We will use a collective case study approach to describe and generate an in-depth understanding of shared IL in nursing. We will select nursing leadership teams on 2 inpatient hospital units that have successfully implemented an EBP as instrumental cases. We will construct data through focus groups and individual interviews with key informants (leaders, unit staff, and senior nurse leaders), review of organizational documents, and researcher-generated field notes. We have developed a conceptual framework of shared IL to guide data analysis, which describes effective IL behaviors, formal and informal nursing leaders' roles at the POC, and social processes generating shared leadership and influencing contextual factors. We will use the Framework Method to systematically generate data matrices from deductive and inductive thematic analysis of each case. We will then generate assertions about shared IL following a cross-case analysis.

RESULTS

The study protocol received research ethics approval (2022-8408) on February 24, 2022. Data collection began in June 2022, and we have recruited 2 inpatient hospital units and 25 participants. Data collection was completed in December 2023, and data analysis is ongoing. We anticipate findings to be published in a peer-reviewed journal by late 2024.

CONCLUSIONS

The anticipated results will shed light on how multiple and diverse members of the POC nursing leadership team enact and share IL. This study addresses calls to advance knowledge in promoting effective implementation of EBPs to ensure high-quality health care delivery by further developing the concept of shared IL in a nursing context. We will identify strategies to strengthen shared IL in nursing leadership teams at the POC, informing future intervention studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54681.

Knowledge translation strategies used for sustainability of an evidence-based intervention in child health: a multimethod qualitative study

BACKGROUND

Sustainability of evidence-based interventions (EBIs) is suboptimal in healthcare. Evidence on how knowledge translation (KT) strategies are used for the sustainability of EBIs in practice is lacking. This study examined what and how KT strategies were used to facilitate the sustainability of Alberta Family Integrated Care (FICare)™, a psychoeducational model of care scaled and spread across 14 neonatal intensive care units, in Alberta, Canada.

METHODS

First, we conducted an environmental scan of relevant documents to determine the use of KT strategies to support the sustainability of Alberta FICare™. Second, we conducted semi-structured interviews with decision makers and operational leaders to explore what and how KT strategies were used for the sustainability of Alberta FICare™, as well as barriers and facilitators to using the KT strategies for sustainability. We used the Expert Recommendations for Implementation Change (ERIC) taxonomy to code the strategies. Lastly, we facilitated consultation meetings with the Alberta FICare™ leads to share and gain insights and clarification on our findings.

RESULTS

We identified nine KT strategies to facilitate the sustainability of Alberta FICare™: Conduct ongoing training; Identify and prepare local champions; Research co-production; Remind clinicians; Audit and provide feedback; Change record systems; Promote adaptability; Access new funding; and Involve patients/consumers and family members. A significant barrier to the sustainability of Alberta FICare™ was a lack of clarity on who was responsible for the ongoing maintenance of the intervention. A key facilitator to sustainability of Alberta FICare was its alignment with the Maternal, Newborn, Child & Youth Strategic Clinical Network (MNCY SCN) priorities. Co-production between researchers and health system partners in the design, implementation, and scale and spread of Alberta FICare™ was critical to sustainability.

CONCLUSION

This research highlights the importance of clearly articulating who is responsible for continued championing for the sustainability of EBIs. Additionally, our research demonstrates that the adaptation of interventions must be considered from the onset of implementation so interventions can be tailored to align with contextual barriers for sustainability. Clear guidance is needed to continually support researchers and health system leaders in co-producing strategies that facilitate the long-term sustainability of effective EBIs in practice.

Facilitators and barriers for implementation of a novel resuscitation quality improvement package in public referral hospitals of Nepal

BACKGROUND

Improving the healthcare providers (HCP) basic resuscitation skills can reduce intrapartum related mortality in low- and middle-income countries. However, the resuscitation intervention's successful implementation is largely dependent on proper facilitation and context. This study aims to identify the facilitators and barriers for the implementation of a novel resuscitation package as part of the quality improvement project in Nepal.

METHODS

The study used a qualitative descriptive design. The study sites included four purposively chosen public hospitals in Nepal, where the resuscitation package (Helping Babies Breathe [HBB] training, resuscitation equipment and NeoBeat) had been implemented as part of the quality improvement project. Twenty members of the HCP, who were trained and exposed to the package, were selected through convenience sampling to participate in the study interviews. Data were collected through semi-structured interviews conducted via telephone and video calls. Twenty interview data were analyzed with a deductive qualitative content analysis based on the core components of the i-PARiHS framework.

RESULTS

The findings suggest that there was a move to more systematic resuscitation practices among the staff after the quality improvement project's implementation. This positive change was supported by a neonatal heart rate monitor (NeoBeat), which guided resuscitation and made it easier. In addition, seeing the positive outcomes of successful resuscitation motivated the HCPs to keep practicing and developing their resuscitation skills. Facilitation by the project staff enabled the change. At the same time, facilitators provided extra support to maintain the equipment, which can be a challenge in terms of sustainability, after the project. Furthermore, a lack of additional resources, an unclear leadership role, and a lack of coordination between nurses and medical doctors were barriers to the implementation of the resuscitation package.

CONCLUSION

The introduction of the resuscitation package, as well as the continuous capacity building of local multidisciplinary healthcare staff, is important to continue the accelerated efforts of improving newborn care. To secure sustainable change, facilitation during implementation should focus on exploring local resources to implement the resuscitation package sustainably.

TRIAL REGISTRATION

Not applicable.

The SITS framework: sustaining innovations in tertiary settings

Background

To date, little attention has focused on what the determinants are and how evidence-based practices (EBPs) are sustained in tertiary settings (i.e., acute care hospitals). Current literature reveals several frameworks designed for implementation of EBPs (0-2 years), yet fewer exist for the sustainment of EBPs (>2 years) in clinical practice. Frameworks containing both phases generally list few determinants for the sustained use phase, but rather state ongoing monitoring or evaluation is necessary. Notably, a recent review identified six constructs and related strategies that facilitate sustainment, however, the pairing of determinants and how best to sustain EBPs in tertiary settings over time remains unclear. The aim of this paper is to present an evidence-informed framework, which incorporates constructs, determinants, and knowledge translation interventions (KTIs) to guide implementation practitioners and researchers in the ongoing use of EBPs over time.

Methods

We combined the results of a systematic review and theory analysis of known sustainability frameworks/models/theories (F/M/Ts) with those from a case study using mixed methods that examined the ongoing use of an organization-wide pain EBP in a tertiary care center (hospital) in Canada. Data sources included peer-reviewed sustainability frameworks (n = 8) related to acute care, semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level, chart audits (n = 200), and document review (n = 29). We then compared unique framework components to the evolving literature and present main observations.

Results

We present the Sustaining Innovations in Tertiary Settings (SITS) framework which consists of 7 unique constructs, 49 determinants, and 29 related KTIs that influence the sustainability of EBPs in tertiary settings. Three determinants and 8 KTIs had a continuous influence during implementation and sustained use phases. Attention to the level of application and changing conditions over time affecting determinants is required for sustainment. Use of a participatory approach to engage users in designing remedial plans and linking KTIs to target behaviors that incrementally address low adherence rates promotes sustainability.

Conclusions

The SITS framework provides a novel resource to support future practice and research aimed at sustaining EBPs in tertiary settings and improving patient outcomes. Findings confirm the concept of sustainability is a "dynamic ongoing phase".

Implementation Science for the Practice-Oriented Nurse Leader

Senior nurse leaders are accountable for improving patient outcomes efficiently and cost-effectively. Nurse leaders often find heterogeneous patient outcomes across comparable nursing units in the same enterprise, presenting a challenge for nurse leaders tasked with making system-wide quality improvements. Implementation science (IS) offers a promising new approach to guide nurse leaders in understanding why certain implementation efforts meet with success or failure and the barriers faced in making practice changes. Knowledge of IS builds upon evidenced-based practice and quality improvement knowledge, adding to the armamentarium of tools at nurse leaders' disposal for improving nursing and patient outcomes. In this article, we demystify IS, differentiate it from evidence-based practice and quality improvement, describe IS concepts every nurse leader should be familiar with, and outline nurse leaders' role in building IS in their organizations.

The Implementation of Evidence-Informed Family Nursing Practices: A Scoping Review of Strategies, Contextual Determinants, and Outcomes

There is a lack of knowledge about the successful implementation of family nursing practices. This scoping review maps current knowledge about the implementation of evidence-informed family nursing practices across settings and populations. A systematic search (CINAHL, PubMed, Medline) identified 24 publications, published between 2010 and 2020. We found nurses' implementation experience to be one of disruption, learning, and moving to new ways of practicing. The implementation resulted in benefits to families and self but was marked by fluctuation and partial integration of evidence-informed family nursing practices into care delivery. Uptake was shaped by various contextual determinants, with barriers mainly at the team and organizational levels. We identified low-quality, tentative evidence that capacity-building strategies coupled with dissemination-educational strategies may enable family nursing practice skills and increase the quality of family care. More rigorous research is needed to build further knowledge about effective implementation. Future implementation endeavors should utilize the evolving knowledge base in family nursing and tailor implementation strategies to contextual barriers.

Organizational Factors Associated with Evidence-Based Practice Knowledge, Attitudes, and Implementation among Nurses in Saudi Arabia

Evidence-based practice (EBP) is crucial in keeping nurses aware of the current knowledge and improving clinical decision-making. The integration of nurses’ EBP competencies and organizational support has been suggested to create an effective arena in implementing EBP. The purpose of the study was to examine organizational factors influencing nurses’ EBP knowledge, attitudes, and implementation and identify staff nurses’ perceptions of EBP nursing leadership and hospital supports in Saudi Arabia. Data were collected from a convenience sample of staff nurses (N = 227) working in four hospitals using a cross-sectional, correlational descriptive design. Level of education (p < 0.05), EBP training (p < 0.05), unit type (ICU (p < 0.001) and ER (p < 0.01)), perceived nursing leadership (p < 0.001), and work environment (p < 0.05) supports were found significantly associated with nurses’ knowledge. Magnet recognition (p < 0.01) and knowledge (p < 0.001) had significant influence on nurses’ attitudes. Unit type (ER) (p < 0.05), knowledge (p < 0.001), and attitudes (p < 0.001) were associated with implementation. Encouragement to attend EBP trainings from nursing leadership was perceived by most nurses (51.1%). Nurses reported their hospitals support EBP through training (68.2%). Findings support the need for healthcare systems to create a culture that facilitates EBP implementation to enhance nurses’ EBP competencies and improve patients’ outcomes. Nursing managers may consider preparing nurses through education.

Using qualitative comparative analysis to uncover multiple pathways to program sustainment: implications for community-based youth substance misuse prevention

Background

In order to achieve wide-scale impact in community settings, programs must be sustained. Theory and empirical evidence suggest that intervention characteristics, organizational context, capacity for program implementation, and processes related to implementation are associated with continued program delivery. However, few studies examine how combinations of these factors work together in different settings to influence program sustainment.

Methods

Using scales specified in the Program Sustainability Assessment Tool (PSAT), the current cross-sectional study aims to identify the necessary and sufficient conditions for the sustainment of the Strengthening Families Program for Parents and Youth 10-14 (SFP 10-14). Staff (n = 59) at SFP 10-14 implementation sites across Washington State completed an online survey reporting on their current level of SFP 10-14 sustainment. They also completed PSAT, with eight scales designed to assess conditions that consistently produce sustainment. Data were analyzed using qualitative comparative analysis.

Results

Environmental support was the only necessary condition for sustainment success. Four solutions sufficient to achieve sustainment were also identified. These included the combined presence of (1) environmental support, organizational capacity, and funding stability; (2) environmental support, organizational capacity, communication, and program evaluation, in the absence of strategic planning; (3) environmental support, organizational capacity, program evaluation, and partnerships, in the absence of strategic planning; and (4) environmental support, communication, partnerships, and funding stability, in the absence of program evaluation.

Conclusions

Environmental support in combination with organizational capacity appeared to most consistently produce sustainment of SFP 10-14 programs in Washington State. Program providers will benefit from a focusing on enhancing those conditions to increase program sustainment.

The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis

Background

Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influence their KB efforts.

Methods

We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

Results

We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Conclusion

Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organizations. Future studies are required to refine and strengthen this framework.

Trial registration

A protocol for this review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07387-z.

Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study

Background

To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting.

Methods

We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review (n = 29), chart audits (n = 200), and semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level.

Results

We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0-2 yrs), sustained phase (>2-10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment.

Conclusion

This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic "ongoing process."

Contextual factors and mechanisms that influence sustainability: a realist evaluation of two scaled, multi-component interventions

Background

In 2012, Alberta Health Services created Strategic Clinical Networks^TM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these evidence-based implementation efforts.

Methods

We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN evidence-based interventions, a delirium intervention for Critical Care and an Appropriate Use of Antipsychotics (AUA) intervention for Senior’s Health. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research.

Results

We conducted thirty realist interviews in two cases and found four important strategies that facilitated sustainability: Learning collaboratives, audit & feedback, the informal leadership role, and patient stories. These strategies triggered certain mechanisms such as sense-making, understanding value and impact of the intervention, empowerment, and motivation that increased the likelihood of sustainability. For example, informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the intervention. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of sustainability of the two multi-component interventions. Patient stories demonstrated the interventions’ impact on patient outcomes, motivating staff to want to continue doing the intervention, and increasing the likelihood of its sustainability.

Conclusions

This research contributes to the field of implementation science, providing evidence on key strategies for sustainability and the underlying causal mechanisms of these strategies that increases the likelihood of sustainability. Identifying causal mechanisms provides evidence on the processes by which implementation strategies operate and lead to sustainability. Future work is needed to evaluate the impact of informal leadership, learning collaboratives, audit-feedback, and patient stories as strategies for sustainability, to generate better guidance on planning sustainable improvements with long term impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07214-5.

Alignment in implementation of evidence-based interventions: a scoping review

BACKGROUND

Alignment (i.e., the process of creating fit between elements of the inner and outer context of an organization or system) in conjunction with implementation of an evidence-based intervention (EBI) has been identified as important for implementation outcomes. However, research evidence has so far not been systematically summarized. The aim of this scoping review is therefore to create an overview of how the concept of alignment has been applied in the EBI implementation literature to provide a starting point for future implementation efforts in health care.

METHODS

We searched for peer-reviewed English language articles in four databases (MEDLINE, Cinahl, Embase, and Web of Science) published between 2003 and 2019. Extracted data were analyzed to address the study aims. A qualitative content analysis was carried out for items with more extensive information. The review was reported according to the preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) guidelines.

RESULTS

The database searches yielded 3629 publications, of which 235 were considered potentially relevant based on the predetermined eligibility criteria, and retrieved in full text. In this review, the results of 53 studies are presented. Different definitions and conceptualizations of alignment were found, which in general could be categorized as structural, as well as social, types of alignments. Whereas the majority of studies viewed alignment as important to understand the implementation process, only a few studies actually assessed alignment. Outcomes of alignment were focused on either EBI implementation, EBI sustainment, or healthcare procedures. Different actors were identified as important for creating alignment and five overall strategies were found for achieving alignment.

CONCLUSIONS

Although investigating alignment has not been the primary focus of studies focusing on EBI implementation, it has still been identified as an important factor for the implementation success. Based on the findings from this review, future research should incorporate alignment and put a stronger emphasize on testing the effectiveness of alignment related to implementation outcomes.

Enhancing the verbal handover process for nurses in inpatient orthopedic wards: a best practice implementation project

OBJECTIVES

This evidence-based quality improvement project aimed to evaluate the effectiveness of a handover guide in improving handovers from registered nurses to enrolled nurses.

INTRODUCTION

Nursing handover involves the transfer of the responsibility of care for a patient from one nurse to another. Handover techniques vary in different healthcare organizations. Non-standardized, incomplete handovers can lead to delays or errors in treatment, increased lengths of stay, and poor health outcomes.

METHODS

This project was conducted in two orthopedic wards of a tertiary hospital, and occurred in four phases over 12 months. The project utilized the JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) tools.

RESULTS

The baseline audit in March 2017 revealed a poor compliance in handover of essential patient information. The post-intervention audit showed a significant increase (P < 0.001) in the compliance of handover of essential patient information. Registered nurses' handovers of patient information to enrolled nurses improved from 11% to 27% (P < 0.000). Verbal face-to-face handovers occurred throughout the implementation. Eighty-two per cent of the nurses felt that the handover guide had reduced the number of monitoring errors and delays in treatment.

CONCLUSION

The project has successfully improved nurses' clinical handovers and contributed to safe patient care. Further audits are required to sustain the evidence-based practice change. Nursing leaders play a significant role in supporting the project and building a positive evidence-based practice environment.

Clinical nurse managers' leadership practices in Saudi Arabian hospitals: A descriptive cross-sectional study

AIM

To understand the situational profiles of clinical nurse managers' transformational leadership practices in Saudi hospitals.

BACKGROUND

Clinical nurse managers' effective leadership may enable registered nurses to provide safe patient care.

METHODS

This included 29 clinical nurse managers and 318 registered nurses from three Saudi hospitals. Data were collected using the leadership practice inventory-self and the leadership practice inventory-observer.

RESULTS

A significant difference between self- and observer-assessed transformational leadership practices of clinical nurse managers was found. There was also a significant difference in transformational leadership practice between Saudi and non-Saudi clinical nurse managers. Ward experience of clinical nurse managers was statistically positively associated with higher ratings of "enabling others to act". Length of clinical nurse managers' experience was associated with "enabling others to act" and "encouraging the heart" practices.

CONCLUSION

Clinical nurse managers rated their transformational leadership performance higher than that reported by registered nurses. Further, non-Saudi clinical nurse managers working in Saudi hospitals overestimated the extent of their transformational leadership practices.

IMPLICATIONS FOR NURSING MANAGEMENT

Clinical nurse managers should gather feedback about their leadership performance regularly and implement required changes. Hospital administrations should provide additional support to clinical nurse managers through effective leadership programmes, enculturation and team-building strategies, to create a shared vision regarding the execution of optimal leadership.

Influence of participation in a quality improvement collaborative on staff perceptions of organizational sustainability

BACKGROUND

Sustainability capacity (SC), which is an organization's ability to implement and maintain change, is influenced by internal attributes, environmental contextual influencers, and intervention attributes. Temporal changes in staff SC perceptions, as well as the influence of quality improvement collaborative (QIC) participation, has generally not been explored. This project addresses this gap, measuring staff SC perceptions at four time points (baseline and every 9 months) for clinics participating in an intervention - the Network for the Improvement of Addiction Treatment QIC initiative (called NIATx200).

METHODS

A mixed linear model repeated measures analysis was applied to matched staff members (n = 908, representing 2329 total cases) across the evaluation timeframe. Three separate statistical models assessed potential predictors of SC perceptions: Time (Models I-III); NIATx200 intervention, staff job function, and tenure (Models II &III); and NIATx200 participation hours and four organizational variables (Model III).

RESULTS

For Model I, staff perceptions of total SC increased throughout most of the study (t1,4 = - 6.74, p < .0001; t2,4 = - 3.100, p < .036; t3,4 = - 0.23, p = ns). Model II did not change Model I's overall Time effect, but combined NIATx200 services (t = - 2.23, p = .026), staff job function (t = - 3.27, p = .001), and organizational administrators (t = - 3.50, p = .001) were also significantly associated with greater perceptions of total SC. Inclusion of additional variables in Model III demonstrated the importance of a higher participation level (t = - 3.09, p < .002) and being in a free-standing clinic (t = - 2.06, p < .04) on staff perceptions of total SC.

CONCLUSION

Although staff exposure to sustainability principals was minimal in NIATx200, staff perceptions about their organization's SC significantly differed over time. However, an organization's participation level in a QIC became the principal predictor of staff SC perceptions, regardless of other factors' influence. Given these findings, it is possible to develop and introduce specific sustainability content within the structure of a QIC to assess the impact on staff SC perceptions over time and the sustainment of organizational change.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT00934141 . Registered July 6, 2009. Retrospectively registered.

Development, implementation and evaluation of an evidence-based practice model in a new hospital in Chile

AIMS

To describe an implementation programme for an evidence-based practice (EBP) model in a new Chilean hospital and to analyse the programme evaluation results.

BACKGROUND

Evidence-based practice is key to professional nursing for improving health care safety and quality.

METHODS

First, a literature review was performed to develop an institutional EBP model. Second, internal and external analyses contributed to assessing facilitators for and barriers to implementation. Third, a multi-stage implementation plan was conducted. Fourth, process and outcome indicators were evaluated.

RESULTS

The model considered the basic elements of EBP and outlined different decision-making levels in clinical practice. Several facilitators for implementation were identified. Each implementation stage included activities addressing EBP knowledge, attitude and skills. Outcome indicators showed significant improvement regarding knowledge (p = .038). Providers with formal EBP training, compared with providers without training, showed a significant difference of 8.6% (0.6 points) in the average CPBE-19 score in knowledge, attitude and application in the last evaluation (p < .01).

CONCLUSION

Having an EBP programme with ongoing implementation strategies improves knowledge over time, and formal training enhances positive results.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers can build an institutional research culture to improve the quality of care using an EBP programme that fits organisational needs.

Components of impactful dementia training for general hospital staff: a collective case study

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation.Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping.Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators.Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered.

First line nurse managers' experiences of opportunities and obstacles to support evidence-based nursing

AIM

The aim was to explore first line nurse managers' experiences of opportunities and obstacles to support evidence-based nursing.

DESIGN

A qualitative study with a phenomenographical approach.

METHOD

Data were collected through focus group interviews with 15 first line nurse managers' in four settings.

RESULTS

The results are presented in four categories of description headed: Manage the everyday work vs. evidence-based nursing; Uncertainties about evidence-based nursing and nursing research; Time as a reality, as an approach; and Shaping awareness-towards an active approach to evidence-based nursing. The overarching category of description has been formulated as follows: The internal relation-how active leadership influences evidence-based nursing. The outcome space is presented as: The individual path-how to make vision and reality become a working entity around evidence-based nursing.

Managerial leadership for research use in nursing and allied health care professions: a systematic review

Background

Leadership by point-of-care and senior managers is increasingly recognized as critical to the acceptance and use of research evidence in practice. The purpose of this systematic review was to identify the leadership behaviours of managers that are associated with research use by clinical staff in nursing and allied health professionals.

Methods

A mixed methods systematic review was performed. Eight electronic bibliographic databases were searched. Studies examining the association between leadership behaviours and nurses and allied health professionals’ use of research were eligible for inclusion. Studies were excluded if leadership could not be clearly attributed to someone in a management position. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. Narrative synthesis was conducted.

Results

The search yielded 7019 unique titles and abstracts after duplicates were removed. Three hundred five full-text articles were reviewed, and 31 studies reported in 34 articles were included. Methods used were qualitative (n = 19), cross-sectional survey (n = 9), and mixed methods (n = 3). All studies included nurses, and six also included allied health professionals. Twelve leadership behaviours were extracted from the data for point-of-care managers and ten for senior managers. Findings indicated that managers performed a diverse range of leadership behaviours that encompassed change-oriented, relation-oriented and task-oriented behaviours. The most commonly described behavior was support for the change, which involved demonstrating conceptual and operational commitment to research-based practices.

Conclusions

This systematic review adds to the growing body of evidence that indicates that manager-staff dyads are influential in translating research evidence into action. Findings also reveal that leadership for research use involves change and task-oriented behaviours that influence the environmental milieu and the organisational infrastructure that supports clinical care. While findings explain how managers enact leadership for research use, we now require robust methodological studies to determine which behaviours are effective in enabling research use with nurses and allied health professionals for high-quality evidence-based care.

Trial registration

PROSPERO CRD42014007660

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0817-7) contains supplementary material, which is available to authorized users.

Assessing long-term sustainment of clinic participation in NIATx200: Results and a new methodological approach

BACKGROUND

Sustainability frameworks differentiate between sustainability capacity and sustainment of organizational change. Multiple studies have examined sustainability capacity. Methodological approaches to assess long-term sustainment have not been explored. This study addresses this gap by describing the development of a long-term sustainment methodology and evaluating its application utilizing data from substance abuse clinics participating in a quality improvement collaborative.

METHODS

The study involved clinics (n = 121) in three states (MI, NY and WA) participating in the 2007-2009 NIATx200 quality improvement (QI) intervention. It extended the primary analysis to focus on clinics' long-term sustainment of wait time, retention and admission improvements. Long-term sustainment was defined as two years post end of the active implementation period (Calendar Years 2010 and 2011). The analysis defined case exclusion criteria and spline "knot" time intervals; allowed for C_p statistic use to address clinic data volatility; established the structure of sustainment plots and explored differences between NIATx implementation strategies.

RESULTS

Example spline and sustain plots highlight the application of the long-term sustainment methodology for NIATx200 clinics. In clinics with available longitudinal outcome data, 40.8% (n = 31 of 76 clinics) sustained improvements in wait time, 26.7% (n = 20 of 75 clinics) in retention, and 28.1% (n = 32 of 114 clinics) for admissions. Clinic assignment to a NIATx200 implementation strategy did not significantly influence a clinics' long-term sustainment except for lower wait time changes in the interest circle interventions. Thirty clinics (24.8%) sustained improvements for two outcomes and six clinics (5.0%) did so for all three outcomes. The clinics that sustained multiple outcome improvements were assigned to the interest circle (n = 12), learning session (n = 10), combination (n = 8), and coaching (n = 6) implementation strategies. Guidance for applying the long-term sustainment methodology in other quality improvement settings is described.

CONCLUSIONS

Research about sustainability capacity and sustainment of change has become increasingly important in dissemination and implementation research. Assessment of long-term sustainment in a multi-organizational quality improvement collaborative (QIC) is needed to identify when program drift and intervention decay occurs. If "cut-points" indicate when effects diminish, specific sustainability modules could be developed and introduced within the structure of a QIC to improve organizational long-term sustainment. Coaches and change teams could be trained to focus on organizational change sustainment and strengthen the likelihood of institutionalization. ClinicalTrials.gov Identifier: NCT00934141 Registered July 6, 2009. Retrospectively registered.

The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care

There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research.

Factors influencing the long-term sustainment of quality improvements made in addiction treatment facilities: a qualitative study

BACKGROUND

A greater understanding of the factors that influence long-term sustainment of quality improvement (QI) initiatives is needed to promote organizational ability to sustain QI practices over time, help improve future interventions, and increase the value of QI investments.

METHODS

We approached 83 of 201 executive sponsors or change leaders at addiction treatment organizations that participated in the 2007-2009 NIATx200 QI intervention. We completed semi-structured interviews with 33 individuals between November 2015 and April 2016. NIATx200 goals were to decrease wait time, increase admissions and improve retention in treatment. Interviews sought to understand factors that either facilitated or impeded long-term sustainment of organizational QI practices made during the intervention. We used thematic analysis to organize the data and group patterns of responses. We assessed available quantitative outcome data and intervention engagement data to corroborate qualitative results.

RESULTS

We used narrative analysis to group four important themes related to long-term sustainment of QI practices: (1) finding alignment between business- and client-centered practices; (2) staff engagement early in QI process added legitimacy which facilitated sustainment; (3) commitment to integrating data into monitoring practices and the identification of a data champion; and (4) adequate organizational human resources devoted to sustainment. We found four corollary factors among agencies which did not sustain practices: (1) lack of evidence of impact on business practices led to discontinuation; (2) disengaged staff and lack of organizational capacity during implementation period led to lack of sustainment; (3) no data integration into overall business practices and no identified data champion; and (4) high staff turnover. In addition, we found that many agencies' current use of NIATx methods and tools suggested a legacy effect that might improve quality elsewhere, even absent overall sustainment of original study outcome goals. Available quantitative data on wait-time reduction demonstrated general concordance between agency perceptions of, and evidence for, sustainment 2 years following the end of the intervention. Additional quantitative data suggested that greater engagement during the intervention period showed some association with sustainment.

CONCLUSIONS

Factors identified in QI frameworks as important for short-term sustainment-organizational capacity (e.g. staffing and leadership) and intervention characteristics (e.g. flexibility and fit)-are also important to long-term sustainment.

Translating Knowledge From a Family Systems Approach to Clinical Practice: Insights From Knowledge Translation Research Experiences

While there has been continued growth in family nursing knowledge, the complex process of implementing and sustaining family nursing in health care settings continues to be a challenge for family nursing researchers and clinicians alike. Developing knowledge and skills about how to translate family nursing theory to practice settings is a global priority to make family nursing more visible. There is a critical need for more research methods and research evidence about how to best move family nursing knowledge into action. Enhancing health care practice is a multifactorial process that calls for a systemic perspective to ensure its efficacy and sustainability. This article presents insights derived from lessons learned through recent research experiences of using a knowledge translation model to promote practice changes in health care settings. These insights aim to optimize (a) knowledge translation of a Family Systems Approach (FSA) in practice settings; (b) knowledge translation research processes; and

Sustaining guideline implementation: A multisite perspective on activities, challenges and supports

AIMS AND OBJECTIVES

To examine activities conducted, challenges encountered and supports used when sustaining nursing practice guideline implementation in multiple healthcare organisations over 3 years.

BACKGROUND

Numerous models and frameworks exist to guide the implementation of guidelines, yet very few focus on sustaining improved practice changes. It is not known if one intervention or multiple interventions are required, nor the long-term activities, challenges and supports for sustaining improved practices.

DESIGN

Qualitative descriptive study.

METHODS

We conducted focus group interviews with steering committee members and individual interviews with leaders and direct care providers at the end of a 3-year guideline implementation study. The National Health Service Sustainability Model was used to guide data collection and analysis.

RESULTS

The eight sites included three teaching hospitals, a community hospital, a long-term care facility, two community health agencies and a community health centre. Individual interviews were conducted with 36 leaders and 26 direct care providers. Focus group interviews were conducted with steering committee members (n = 70) at each site. Guideline implementation activities (n = 45) included developing new outcome monitoring systems, conducting chart audits, communicating progress to internal stakeholders, appointing interprofessional staff to steering committees, developing educational sessions and resources for staff and patients, revising policies and procedures, and developing partnerships with external organisations. Supports included lessons learned from previous and concurrent change initiatives, and commitment, involvement and positive attitudes of staff and leaders.

CONCLUSION

Activities identified by the participants addressed all 10 factors in the Sustainability Model in the three areas of process, staff and organisation. The challenges and supports encountered provide insights into the process of guideline implementation and sustainability.

RELEVANCE TO CLINICAL PRACTICE

A multilevel action plan for staff, leaders and the organisation is recommended when introducing and sustaining practice changes.

Six-Month Follow-up of a Regional Evidence-based Practice Fellowship Program

OBJECTIVE

This study examined a 6-month follow-up of a regional evidence-based practice (EBP) fellowship program and the predictors of EBP adoption at hospital units.

BACKGROUND

The immediate beneficial effects of a regional EBP program are known, but the medium-term effects are not certain.

METHODS

A matched pretest/posttest study was conducted using a mailed questionnaire 6 months after the completion of a 9-month regional EBP fellowship program among 3 annual cohorts of participants.

RESULTS

Statistically significant improvements in the mean scores of EBP beliefs, EBP implementation, and group cohesion were found (P < .05). Of the 47 participants who completed their EBP projects, more than three-quarters reported EBP adoption at their own hospital units, and EBP beliefs were a positive predictor of EBP adoption (odds ratio, 1.12; 95% confidence interval, 1.02-1.22; P = .017).

CONCLUSIONS

The outcome improvements continued 6 months after the fellowship program, and strong EBP beliefs predicted EBP adoption in the participants' units.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa

BACKGROUND

The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care.

METHODS

A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test.

RESULTS

Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps.

CONCLUSIONS

Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.

An organizational perspective on the long-term sustainability of a nursing best practice guidelines program: a case study

BACKGROUND

Many healthcare innovations are not sustained over the long term, wasting costly implementation efforts and often desperately-needed initial improvements. Although there have been advances in knowledge about innovation implementation, there has been considerably less attention focused on understanding what happens following the early stages of change. Research is needed to determine how to improve the 'staying power' of healthcare innovations. As almost no empirical knowledge exists about innovation sustainability in nursing, the purpose of our study was to understand how a nursing best practice guidelines (BPG) program was sustained over a long-term period in an acute healthcare centre.

METHODS

We conducted a qualitative descriptive case study to examine the program's sustainability at the nursing department level of the organization. The organization was a large, urban, multi-site acute care centre in Canada. The patient safety-oriented BPG program, initiated in 2004, consisted of an organization-wide implementation of three BPGs: falls prevention, pressure ulcer prevention, and pain management. Data were collected eight years following program initiation through 14 key informant interviews, document reviews, and observations. We developed a framework for the sustainability of healthcare innovations to guide data collection and content analysis.

RESULTS

Program sustainability entailed a combination of three essential characteristics: benefits, institutionalization, and development. A constellation of 11 factors most influenced the long-term sustainability of the program. These factors were innovation-, context-, leadership-, and process-related. Three key interactions between factors influencing program sustainability and characteristics of program sustainability accounted for how the program had been sustained. These interactions were between: leadership commitment and benefits; complementarity of leadership actions and both institutionalization and development; and a reflection-and-course-correction strategy and development.

CONCLUSIONS

Study findings indicate that the successful initial implementation of an organizational program does not automatically lead to longer-term program sustainability. The persistent, complementary, and aligned actions of committed leaders, in a variety of roles across a health centre department, seem necessary. Organizational leaders should consider a broad conceptualization of sustainability that extends beyond program institutionalization and/or program benefits. The development of an organizational program may be necessary for its long-term survival.