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Cassidy CE, Flynn R, Campbell A, Dobson L, Langley J, McNeil D, Milne E, Zanoni P, Churchill M, Benzies KM. Knowledge translation strategies used for sustainability of an evidence-based intervention in child health: a multimethod qualitative study. BMC Nurs 2024; 23:125. [PMID: 38368328 PMCID: PMC10874067 DOI: 10.1186/s12912-024-01777-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/30/2024] [Indexed: 02/19/2024] Open
Abstract
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.
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Affiliation(s)
- Christine E Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, 5869 University Avenue, B3H 4R2, Halifax, NS, PO Box 15000, Canada.
| | - Rachel Flynn
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College of Cork, College Road, T12 AK54, Cork, Ireland
| | - Alyson Campbell
- Faculty of Nursing, University of Prince Edward Island, 550 University Avenue, HSB Room 116, C1A 4P3, Charlottetown, PE, Canada
| | - Lauren Dobson
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Level 3, 11405 87 Avenue, T6G 1C9, Edmonton, AB, Canada
| | - Jodi Langley
- Faculty of Health, Dalhousie University, 5790 University Avenue, B3H 1V7, Halifax, NS, Canada
| | - Deborah McNeil
- Strategic Clinical Networks, Alberta Health Services, 10101 Southport Road SW, T2W 3N2, Calgary, AB, Canada
- Faculty of Nursing, Departments of Pediatrics and Community Health Science, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, T2N 1N4, Calgary, AB, Canada
| | - Ella Milne
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Level 3, 11405 87 Avenue, T6G 1C9, Edmonton, AB, Canada
| | - Pilar Zanoni
- Faculty of Nursing , University of Calgary, 2500 University Drive NW, T2N 1N4, Calgary, AB, Canada
| | - Megan Churchill
- Department of Pediatrics, IWK Health, 5980 University Ave #5850, B3K 6R8, Halifax, NS, Canada
| | - Karen M Benzies
- Faculty of Nursing, Departments of Pediatrics and Community Health Science, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, T2N 1N4, Calgary, AB, Canada
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Rhoten B, Jones AC, Maxwell C, Stolldorf DP. Hospital Adaptions to Mitigate the COVID-19 Pandemic Effects on MARQUIS Toolkit Implementation and Sustainability. J Healthc Qual 2024; 46:1-11. [PMID: 37788425 PMCID: PMC10840884 DOI: 10.1097/jhq.0000000000000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To explore the perceived effects of COVID-19 on MARQUIS toolkit implementation and sustainability, challenges faced by hospitals in sustaining medication reconciliation efforts, and the strategies used to mitigate the negative effects of the pandemic. DATA SOURCES AND STUDY SETTINGS Primary qualitative data were extracted from a Web-based survey. Data were collected from hospitals that participated in MARQUIS2 ( n = 18) and the MARQUIS Collaborative ( n = 5). STUDY DESIGN A qualitative, cross-sectional study was conducted. DATA COLLECTION/DATA EXTRACTION Qualitative data were extracted from a Research Electronic Data Capture survey databased and uploaded into an Excel data analysis template. Two coders independently coded the data with a third coder resolving discrepancies. PRINCIPAL FINDINGS Thirty-one team members participated, including pharmacists ( n = 20; 65%), physicians ( n = 9; 29%), or quality-improvement (QI) specialists ( n = 2; 6%) with expertise in medication reconciliation (MedRec) (14; 45%) or QI (10; 32%). Organizational resources were limited, including funding, staffing, and access to pharmacy students. To support program continuation, hospitals reallocated staff and used new MedRec order sets. Telemedicine, workflow adaptations, leadership support, QI team involvement, and ongoing audits and feedback promoted toolkit sustainability. CONCLUSIONS COVID-19 affected the capacity of hospitals to sustain the MARQUIS toolkit. However, hospitals adapted various strategies to sustain the toolkit.
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Flynn R, Cassidy C, Dobson L, Al-Rassi J, Langley J, Swindle J, Graham ID, Scott SD. Knowledge translation strategies to support the sustainability of evidence-based interventions in healthcare: a scoping review. Implement Sci 2023; 18:69. [PMID: 38049900 PMCID: PMC10694920 DOI: 10.1186/s13012-023-01320-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/13/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Knowledge translation (KT) strategies are widely used to facilitate the implementation of EBIs into healthcare practices. However, it is unknown what and how KT strategies are used to facilitate the sustainability of EBIs in institutional healthcare settings. OBJECTIVES This scoping review aimed to consolidate the current evidence on (i) what and how KT strategies are being used for the sustainability of EBIs in institutional healthcare settings; (ii) the reported KT strategy outcomes (e.g., acceptability) for EBI sustainability, and (iii) the reported EBI sustainability outcomes (e.g., EBI activities or component of the intervention continue). METHODS We conducted a scoping review of five electronic databases. We included studies describing the use of specific KT strategies to facilitate the sustainability of EBIs (more than 1-year post-implementation). We coded KT strategies using the clustered ERIC taxonomy and AIMD framework, we coded KT strategy outcomes using Tierney et al.'s measures, and EBI sustainability outcomes using Scheirer and Dearing's and Lennox's taxonomy. We conducted descriptive numerical summaries and a narrative synthesis to analyze the results. RESULTS The search identified 3776 studies for review. Following the screening, 25 studies (reported in 27 papers due to two companion reports) met the final inclusion criteria. Most studies used multi-component KT strategies for EBI sustainability (n = 24). The most common ERIC KT strategy clusters were to train and educate stakeholders (n = 38) and develop stakeholder interrelationships (n = 34). Education was the most widely used KT strategy (n = 17). Many studies (n = 11) did not clearly report whether they used different or the same KT strategies between EBI implementation and sustainability. Seven studies adapted KT strategies from implementation to sustainability efforts. Only two studies reported using a new KT strategy for EBI sustainability. The most reported KT strategy outcomes were acceptability (n = 10), sustainability (n = 5); and adoption (n = 4). The most commonly measured EBI sustainability outcome was the continuation of EBI activities or components (n = 23), followed by continued benefits for patients, staff, and stakeholders (n = 22). CONCLUSIONS Our review provides insight into a conceptual problem where initial EBI implementation and sustainability are considered as two discrete time periods. Our findings show we need to consider EBI implementation and sustainability as a continuum and design and select KT strategies with this in mind. Our review has emphasized areas that require further research (e.g., KT strategy adaptation for EBI sustainability). To advance understanding of how to employ KT strategies for EBI sustainability, we recommend clearly reporting the dose, frequency, adaptations, fidelity, and cost of KT strategies. Advancing our understanding in this area would facilitate better design, selection, tailored, and adapted use of KT strategies for EBI sustainability, thereby contributing to improved patient, provider, and health system outcomes.
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Affiliation(s)
- Rachel Flynn
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College of Cork, College Road Cork, Cork, T12 AK54, Ireland.
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Christine Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada.
| | - Lauren Dobson
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Joyce Al-Rassi
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada
| | - Jodi Langley
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada
| | - Jennifer Swindle
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- The Centre for Implementation Research, Ottawa Hospital Research Institute, 501 Smyth Road, Box 241, Ottawa, Ontario, K1H 8L6, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Zurynski Y, Ludlow K, Testa L, Augustsson H, Herkes-Deane J, Hutchinson K, Lamprell G, McPherson E, Carrigan A, Ellis LA, Dharmayani PNA, Smith CL, Richardson L, Dammery G, Singh N, Braithwaite J. Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review. Implement Sci 2023; 18:62. [PMID: 37957669 PMCID: PMC10641997 DOI: 10.1186/s13012-023-01315-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/08/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. DATA SOURCES AND STUDY SETTING Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. STUDY DESIGN A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool. DATA COLLECTION/EXTRACTION METHODS A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. RESULTS Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. CONCLUSIONS This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area. TRIAL REGISTRATION https://bmjopen.bmj.com/content/7/11/e018568 .
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Affiliation(s)
- Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109.
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia.
| | - Kristiana Ludlow
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Luke Testa
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Hanna Augustsson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden
| | - Jessica Herkes-Deane
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Karen Hutchinson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Gina Lamprell
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Elise McPherson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Ann Carrigan
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Putu Novi Arfirsta Dharmayani
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Carolynn L Smith
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Lieke Richardson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Genevieve Dammery
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Nehal Singh
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
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Tomotaki A, Morioka N, Tsuda Y. Mapping of instruments in Japanese for measuring evidence-based practice among clinical nurses: A scoping review. Int J Nurs Pract 2023; 29:e13086. [PMID: 35903956 DOI: 10.1111/ijn.13086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 11/27/2022]
Abstract
AIMS This work aims to map instruments available in Japanese that have been assessed for reliability or validity for measuring evidence-based practice (EBP) among clinical nurses. BACKGROUND As EBP competencies comprise various domains, many EBP instruments have been developed. However, instruments available in Japanese for measuring EBP have not been reported systematically. DESIGN We conducted a scoping review. DATA SOURCES Two different bibliography databases were searched to identify EBP instruments published until 2019: ICHUSHI (for Japanese articles) and PubMed. REVIEW METHODS After relevant studies were screened and identified, study profile characteristics were extracted to identify EBP instruments in Japanese, and the quality of methodology for developing such instruments was evaluated. This information was recorded and the characteristics were descriptively summarized. RESULTS Ninety potentially relevant articles were identified, of which seven articles and nine instruments were included in this review. All instruments were based on self-reported self-efficacy and attitudes. Few Japanese instruments included all the steps required for EBP. The overall reporting quality of each instrument was low. CONCLUSIONS EBP instruments available in Japanese are extremely scarce. The study results show that it is difficult to measure the various aspects of EBP with the existing instruments.
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Affiliation(s)
- Ai Tomotaki
- Nursing Informatics, School of Nursing, National College of Nursing, Tokyo, Japan
| | - Noriko Morioka
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Messiha K, Chinapaw MJM, Ket HCFF, An Q, Anand-Kumar V, Longworth GR, Chastin S, Altenburg TM. Systematic Review of Contemporary Theories Used for Co-creation, Co-design and Co-production in Public Health. J Public Health (Oxf) 2023; 45:723-737. [PMID: 37147918 PMCID: PMC10470345 DOI: 10.1093/pubmed/fdad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/25/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND There is a need to systematically identify and summarize the contemporary theories and theoretical frameworks used for co-creation, co-design and co-production in public health research. METHODS The reporting of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Given substantial interest in and application of co-creation, co-design and co-production, we searched PubMed, CINAHL, Scopus and APA PsycINFO from 2012 to March-April 2022. A quality assessment and data extraction for theory content was performed. RESULTS Of the 3763 unique references identified through the comprehensive search strategy, 10 articles were included in the review: four articles named co-creation, two articles named co-creation and co-design, two articles named co-production and co-design, and two articles named co-design. Empowerment Theory was employed by two articles, whereas other theories (n = 5) or frameworks (n = 3) were employed by one article each. For the quality assessment, eight articles received a strong rating and two articles received a moderate rating. CONCLUSION There is little indication of theory applications for the approaches of co-creation, co-design and co-production in public health since 2012, given 10 articles were included in this review. Yet, the theories described in these 10 articles can be useful for developing such co-approaches in future public health research.
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Affiliation(s)
- Katrina Messiha
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mai J M Chinapaw
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Hans C F F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Qingfan An
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Vinayak Anand-Kumar
- Department of Psychology and Methods, Jacobs University Bremen, Bremen, Germany
| | - Giuliana R Longworth
- Faculty of Psychology, Education and Sport Sciences Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | - Sebastien Chastin
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
- Department of Movement and Sports Science, Ghent University, Ghent, Belgium
| | - Teatske M Altenburg
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Nadalin Penno L, Graham ID, Backman C, Davies B, Squires J. The SITS framework: sustaining innovations in tertiary settings. FRONTIERS IN HEALTH SERVICES 2023; 3:1102428. [PMID: 37363733 PMCID: PMC10287174 DOI: 10.3389/frhs.2023.1102428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/08/2023] [Indexed: 06/28/2023]
Abstract
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".
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Affiliation(s)
- Letitia Nadalin Penno
- Faculty of Environment and Health Sciences, Canadore College, North Bay, ON, Canada
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Ian D. Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Centre for Implementation Research, Ottawa Health Research Institute, Ottawa, ON, Canada
| | - Chantal Backman
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Barbara Davies
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Janet Squires
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
- Centre for Implementation Research, Ottawa Health Research Institute, Ottawa, ON, Canada
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Gil E, Zisberg A, Shadmi E, Gur-Yaish N, Shulyaev K, Chayat Y, Agmon M. Still WALKing-FOR: 2-year sustainability of the 'WALK FOR' intervention. Age Ageing 2023; 52:afad115. [PMID: 37390475 DOI: 10.1093/ageing/afad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND low mobility of hospitalised older adults is associated with adverse outcomes and imposes a significant burden on healthcare and welfare systems. Various interventions have been developed to reduce this problem; at present, however, their methodologies and outcomes vary and information is lacking about their long-term sustainability. This study aimed to evaluate the 2-year sustainability of the WALK-FOR (walking for better outcomes and recovery) intervention implemented by teams in acute care medical units. METHODS a quasi-experimental three-group comparative design (N = 366): pre-implementation, i.e. control group (n = 150), immediate post-implementation (n = 144) and 2-year post-implementation (n = 72). RESULTS mean participant age was 77.6 years (± 6 standard deviation [SD]) and 45.3% were females. We conducted an analysis of variance test to evaluate the differences in primary outcomes: number of daily steps and self-reported mobility. Levels of mobility improved significantly from the pre-implementation (control) group to the immediate and 2-year post-implementation groups. Daily step count: pre-implementation (median: 1,081, mean: 1,530 SD = 1,506), immediate post-implementation (median: 2,225, mean: 2,724. SD = 1,827) and 2-year post-implementation (median: 1,439, mean: 2,582, SD = 2,390) F = 15.778 P < 0.01. Self-reported mobility: pre-implementation (mean:10.9, SD = 3.5), immediate post-implementation (mean: 12.4, SD = 2.2), 2-year post-implementation (mean: 12.7, SD = 2.2), F = 16.250, P < 0.01. CONCLUSIONS the WALK-FOR intervention demonstrates 2-year sustainability. The theory-driven adaptation and reliance on local personnel produce an effective infrastructure for long-lasting intervention. Future studies should evaluate sustainability from a wider perspective to inform further in-hospital intervention development and implementation.
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Affiliation(s)
- Efrat Gil
- Haemek Medical Center, Afula, Israel
- Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Anna Zisberg
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa
| | - Efrat Shadmi
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa
| | - Nurit Gur-Yaish
- Faculty of Graduate Studies and Continuing Education , Oranim Academic College of Education, The Center for Research and Study of Aging, University of Haifa, Tivon, Israel
| | - Ksenya Shulyaev
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa
| | | | - Maayan Agmon
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa
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Johnson K, Collins D, Wandersman A. Developing a sustainability readiness strategy for health systems: Toolkit, interactive tools, and virtual support system. EVALUATION AND PROGRAM PLANNING 2023; 97:102241. [PMID: 36702007 DOI: 10.1016/j.evalprogplan.2023.102241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/08/2022] [Accepted: 01/19/2023] [Indexed: 06/17/2023]
Abstract
While the literature strongly supports the need for sustainability of evidence-based interventions (EBIs), we present a review of the literature that indicates only three articles discuss a health-focused sustainability strategy. The aims of our sustainability readiness strategy (SRS) are to increase infrastructure capacity and EBI advocacy to impact the level of sustainability readiness. In this article, we describe the development of an evidence-informed promising practice sustainability readiness strategy (SRS) with three evidence-based components. This strategy: 1) is based on an adaptation of the Getting To Outcomes® (GTO) evidence-based implementation process, 2) includes a logic model with documented evidence of the connection between targeted readiness factors and sustainability outcomes, and 3) describes resources considered necessary to support implementation of the readiness strategy, namely a step-by-step Toolkit, Excel™ Tools, webinar coaching and evaluation guides, and a coaching and evaluation training guide. The national SRS survey results are presented. Lessons learned and future dissemination and implementation plans are described.
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Affiliation(s)
- Knowlton Johnson
- Pacific Institute for Research and Evaluation Louisville Center, 401 West Main Street, Suite 2100, Louisville, KY 40202, USA.
| | - David Collins
- Pacific Institute for Research and Evaluation Louisville Center, 401 West Main Street, Suite 2100, Louisville, KY 40202, USA.
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Adjognon OL, Sullivan JL, Pendergast J, Wray LO, Curyto K. Identifying Factors Affecting the Sustainability of the STAR-VA Program in the Veterans Health Administration. THE GERONTOLOGIST 2023; 63:577-588. [PMID: 35772105 DOI: 10.1093/geront/gnac090] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Sustained implementation of new programs in complex care systems like nursing homes is challenging. This prospective qualitative evaluation examined factors affecting the sustainability of the Staff Training in Assisted Living Residences in Veterans Health Administration (STAR-VA) program in Veterans Health Administration (VA) Community Living Centers (CLC, i.e., nursing homes). STAR-VA is an evidence-based interdisciplinary, resident-centered, behavioral approach for managing distress behaviors in dementia. EVALUATION DESIGN AND METHODS In 2019, we conducted 39 semistructured phone interviews with STAR-VA key informants across 20 CLCs. We identified a priori themes based on the Organizational Memory Framework, which includes 7 Knowledge Reservoirs (KRs): people, routines, artifacts, relationships, organizational information space, culture, and structure. We conducted content-directed analysis of transcripts to identify factors to program sustainment. RESULTS We identified 9 sustainment facilitators across KRs: engaged site leaders and champions, regular meetings and trainings, written documentation and resources, regular and open communication, available educational tools (e.g., handouts and posters), adequate spaces, leadership support on many levels, staff buy-in across disciplines, and staff competencies and recognition. Ten barriers across KRs included: staffing concerns, inconsistent/inefficient routines, inconsistent documentation, lack of written policies, communication gaps, nonstandardized use of tools, constraints with meeting spaces and regulations on posting information, limited leadership support, division among staff, and missing performance expectations. DISCUSSION AND IMPLICATIONS Findings inform tailored strategies for optimizing STAR-VA program sustainment in CLCs, including the development of a sustained implementation guide, implementation resources, regional communities of practice, and STAR-VA integration into national CLC quality improvement routines for team communication and problem-solving.
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Affiliation(s)
- Omonyêlé L Adjognon
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jennifer L Sullivan
- Center of Innovation in Long-Term Services and Supports (LTSS COIN), VA Providence Healthcare System, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jacquelyn Pendergast
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Laura O Wray
- VA Center for Integrated Health (CIH), VA Western New York Healthcare System, Buffalo, New York, USA
| | - Kimberly Curyto
- VA Center for Integrated Health (CIH), VA Western New York Healthcare System, Batavia, New York, USA
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Ataman R, Ahmed S, Zidan A, Thomas A. Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review. Arch Phys Med Rehabil 2022; 103:2429-2443. [PMID: 35760107 DOI: 10.1016/j.apmr.2022.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/18/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome). DATA SOURCES MEDLINE, Embase, reference lists, and targeted websites. STUDY SELECTION Two independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice. DATA EXTRACTION Two reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text. DATA SYNTHESIS Using basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes. CONCLUSIONS Implementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.
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Affiliation(s)
- Rebecca Ataman
- School of Physical and Occupational Therapy, McGill University, Montréal, Quebec; Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Quebec, Canada
| | - Sara Ahmed
- School of Physical and Occupational Therapy, McGill University, Montréal, Quebec; Clinical Epidemiology, McGill University Health Center, Montréal, Quebec; Clinical Epidemiology, McGill University Health Center, Montréal, Quebec
| | - Ahlam Zidan
- School of Physical and Occupational Therapy, McGill University, Montréal, Quebec; Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Quebec, Canada
| | - Aliki Thomas
- School of Physical and Occupational Therapy, McGill University, Montréal, Quebec; Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Quebec, Canada; Institute of Health Sciences Education, McGill University, Montréal, Quebec, Canada.
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12
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Flynn N, Froude E, Cooke D, Dennis J, Kuys S. The sustainability of upper limb robotic therapy for stroke survivors in an inpatient rehabilitation setting. Disabil Rehabil 2022; 44:7522-7527. [PMID: 34904486 DOI: 10.1080/09638288.2021.1998664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE To investigate the sustainability of Robot-assisted upper limb therapy (RT-UL) as part of routine occupational therapy and physiotherapy clinical practice. METHODS Two separate audits, 12 months apart, of RT-UL computer data records were undertaken to determine sustainability in a subacute rehabilitation unit. Records of the two audits were compared in terms of the number of early subacute stroke survivors using RT-UL, the number of RT-UL sessions, duration of RT-UL sessions, and disciplines prescribing RT-UL. RESULTS During Audit 1 58% (n = 18) of stroke survivors received RT-UL compared to 50% (n = 7) in Audit 2. The total number of RT-UL sessions reduced between audits (148 vs. 36 sessions) reflecting the overall reduction in admission rates for stroke survivors. There was no significant difference between audits in the average number of RT-UL sessions per patient (p = 0.203) nor the length of sessions (p = 0.762). Patients engaged in active therapy more than three-quarters of the time when on the robotic device. Physiotherapists were the primary prescribers of RT-UL when compared to occupational therapists. CONCLUSIONS RT-UL was in continued and regular use with stroke survivors 2 years after initial implementation within an inpatient rehabilitation setting. RT-UL practice was intensive and used routinely with patients.IMPLICATIONS FOR REHABILITATIONRT-UL is a sustainable and intensive intervention for stroke survivors within an inpatient rehabilitative setting.The cost-benefits of RT-UL should be evaluated from the perspective of the whole rehabilitation service not just at an individual patient level.RT-UL may be considered a "bridging" form of UL practice for those with more limited active UL movement until there is sufficient UL movement and power for more complex real-world task-specific practice.
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Affiliation(s)
| | | | - Deirdre Cooke
- Mater Private Hospital Rehabilitation Unit, Australian Catholic University, Brisbane, Australia
| | - Jessica Dennis
- Brighton Rehabilitation Unit, Australian Catholic University, Brisbane, Australia
| | - Suzanne Kuys
- Australian Catholic University, Brisbane, Australia
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13
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Ramsden V, Middleton S, McInnes E, Babl FE, Tavender E. Review article: A primer for clinical researchers in the emergency department: Part XII. Sustainability of improvements in care: An introduction. Emerg Med Australas 2022; 34:670-674. [PMID: 35918063 DOI: 10.1111/1742-6723.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023]
Abstract
Despite an increased focus on ways to improve implementation of evidence and de-implementation of practices with no known benefit, there is limited guidance on how to sustain these improvements. This review provides an introduction to sustainability of improvements in care and sustainability research, discussing how to support sustainability in practice and detailing a sustainability research agenda for the emergency medicine setting.
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Affiliation(s)
- Victoria Ramsden
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Midwifery and Health Sciences, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Sandy Middleton
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, New South Wales, Australia
| | - Elizabeth McInnes
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Sydney, New South Wales, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
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14
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Petto PN, Tosh SL, Wentzel KR. Magnet® Empirical Outcomes: Key Strategies to Improve Sustainability. J Nurs Adm 2022; 52:505-506. [PMID: 36166627 DOI: 10.1097/nna.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Healthcare organizations are challenged to demonstrate sustainability of quality outcomes within an ever-changing healthcare environment. The Magnet® model and empirical outcomes component provides a framework for demonstrating improvements in quality outcomes and is a foundation for creating professional nursing care environments to support sustainability. Within this high-performing professional nursing care environment, nursing leaders are able to engage in key strategies to enhance sustainability of quality outcomes once achieved.
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Affiliation(s)
- Pamela N Petto
- Author Affiliation : Senior Magnet Program Analyst, Magnet Recognition Program , American Nurses Credentialing Center, Silver Spring, Maryland
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15
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Ramsden V, Babl FE, Dalziel SR, Middleton S, Oakley E, Haskell L, Lithgow A, Orsini F, Schembri R, Wallace A, Wilson CL, McInnes E, Wilson PH, Tavender E. Sustainability of evidence-based practices in the management of infants with bronchiolitis in hospital settings - a PREDICT study protocol. BMC Health Serv Res 2022; 22:1099. [PMID: 36038929 PMCID: PMC9423692 DOI: 10.1186/s12913-022-08450-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals. Methods A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome; composite score); and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework. Discussion This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care. Trial registration Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.
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Affiliation(s)
- Victoria Ramsden
- Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia.,Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,University of Notre Dame, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia.,St Vincent's Hospital, Level 5 DeLacy Building, Victoria Road, Darlinghurst, NSW, 2010, Australia
| | - Ed Oakley
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Libby Haskell
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Anna Lithgow
- Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Northern Territory, 0810, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Alexandra Wallace
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Department of Paediatrics, Waikato Hospital, Selwyn St, Hamilton Central, Hamilton, 3204, New Zealand
| | - Catherine L Wilson
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia
| | - Peter H Wilson
- Australian Catholic University, Building 460, Level 8, 250 Victoria Parade, East Melbourne, Victoria, 3002, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia.
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English M, Nzinga J, Oliwa J, Maina M, Oluoch D, Barasa E, Irimu G, Muinga N, Vincent C, McKnight J. Improving facility-based care: eliciting tacit knowledge to advance intervention design. BMJ Glob Health 2022; 7:e009410. [PMID: 35985694 PMCID: PMC9396143 DOI: 10.1136/bmjgh-2022-009410] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/16/2022] [Indexed: 12/23/2022] Open
Abstract
Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory-practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, Oxford, UK
| | - Jacinta Nzinga
- Health Economics Research Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Michuki Maina
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorothy Oluoch
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Naomi Muinga
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Health Systems Collaborative, Nuffield Department of Medicine, Oxford, UK
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Watson H. The Center for Nursing Inquiry: Developing Nurse-Led Inquiry. Qual Manag Health Care 2022; 31:149-150. [PMID: 35648592 DOI: 10.1097/qmh.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Heather Watson
- Department of Nursing, Johns Hopkins Health System, Baltimore, Maryland
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18
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Claessens F, Seys D, Brouwers J, Van Wilder A, Jans A, Castro EM, Bruyneel L, De Ridder D, Vanhaecht K. A co-creation roadmap towards sustainable quality of care: A multi-method study. PLoS One 2022; 17:e0269364. [PMID: 35771777 PMCID: PMC9246114 DOI: 10.1371/journal.pone.0269364] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Objective Hospitals demonstrated increased efforts into quality improvement over the past years. Their growing commitment to quality combined with a heterogeneity in perceptions among healthcare stakeholders cause concerns on the sustainable incorporation of quality into the daily workflow. Questions are raised on the drivers for a sustainable hospital quality policy. We aimed to identify drivers and incorporate them into a new, unique roadmap towards sustainable quality of care in hospitals. Design A multi-method design guided by an eight-phase approach to develop a conceptual framework consists of multiple, iterative phases of data collection, synthesis and validation. Starting with a narrative review followed by a qualitative in-depth analysis and including feedback of national and international healthcare stakeholders. Setting Hospitals. Results The narrative review included 59 relevant papers focusing on quality improvement and the sustainability of these improved quality results. By integrating, synthesising and resynthesizing concepts during thematic and content analysis, the narrative review evolved to an integrated, co-creation roadmap. The Flanders Quality Model (FlaQuM) is presented as a driver diagram that features six primary drivers for a sustainable quality policy: (1) Quality Design and Planning, (2) Quality Control, (3) Quality Improvement, (4) Quality Leadership, (5) Quality Culture and (6) Quality Context. Six primary drivers are described in 19 building blocks (secondary drivers) and 104 evidence-based action fields. Conclusions The framework suggests that a manageable number of drivers, building blocks and action fields may support the sustainable incorporation of quality into the daily workflow. Therefore, FlaQuM can serve as a useful roadmap for future sustainable quality policies in hospitals and for future empirical and theoretical work in sustainable quality management.
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Affiliation(s)
- Fien Claessens
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
- * E-mail:
| | - Deborah Seys
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
| | - Jonas Brouwers
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Astrid Van Wilder
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
| | - Anneke Jans
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
- Department of Quality Management, Sint-Trudo Ziekenhuis, Sint-Truiden, Flanders, Belgium
| | - Eva Marie Castro
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
- Department of Quality Management, Regionaal Ziekenhuis Heilig Hart Tienen, Tienen, Flanders, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
| | - Dirk De Ridder
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy–Department of Public Health, KU Leuven–University of Leuven, Leuven, Flanders, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Flanders, Belgium
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Song Y, MacEachern L, Doupe MB, Ginsburg L, Chamberlain SA, Cranley L, Easterbrook A, Hoben M, Knopp-Sihota J, Reid RC, Wagg A, Estabrooks CA, Keefe JM, Rappon T, Berta WB. Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions. BMC Health Serv Res 2022; 22:666. [PMID: 35581651 PMCID: PMC9116057 DOI: 10.1186/s12913-022-08026-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation. Methods Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis. Results Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system. Conclusions Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08026-x.
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Affiliation(s)
- Yuting Song
- School of Nursing, Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China. .,Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 5-305, 11405 87 Ave, AB, T6G 1C9, Edmonton, Canada.
| | - Lauren MacEachern
- Management & Evaluation, Institute for Health Policy, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 1P8, Canada
| | - Malcolm B Doupe
- Max Rady College of Medicine, University of Manitoba, 408-727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada
| | - Liane Ginsburg
- School of Health Policy & Management, York University, Stong College 353, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Stephanie A Chamberlain
- Department of Family Medicine, University of Alberta, 6-50 University Terrace, Edmonton, AB, T6G 2T4, Canada
| | - Lisa Cranley
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Adam Easterbrook
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588 - 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada
| | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 5-305, 11405 87 Ave, AB, T6G 1C9, Edmonton, Canada
| | - Jennifer Knopp-Sihota
- Faculty of Health Disciplines, Athabasca University, 1 University Drive, Athabasca, AB, T9S 3A3, Canada
| | - R Colin Reid
- School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia - Okanagan campus, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, 1-198 Clinical Sciences building, 11350 - 83Avenue, Edmonton, AB, T6G 2P4, Canada
| | - Carole A Estabrooks
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 5-305, 11405 87 Ave, AB, T6G 1C9, Edmonton, Canada
| | - Janice M Keefe
- Nova Scotia Centre On Aging, Mount Saint Vincent University, McCain 201F, 166 Bedford Hwy, Halifax, NS, B3M 2J6, Canada
| | - Tim Rappon
- Management & Evaluation, Institute for Health Policy, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 1P8, Canada
| | - Whitney B Berta
- Management & Evaluation, Institute for Health Policy, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 1P8, Canada
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McCabe LA, Ruberti MR, Endres T. Sustaining program implementation: A co-constructed technical assistance process to support continuous high-quality implementation of the Therapeutic Crisis Intervention program. EVALUATION AND PROGRAM PLANNING 2022; 91:102049. [PMID: 35217287 DOI: 10.1016/j.evalprogplan.2022.102049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/24/2021] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
Strategies for sustaining a program beyond initial implementation remain one of the most poorly understood aspects of high-quality program implementation. This paper describes the Quality Improvement and Fidelity Assessment Process (QIFAP), a program purveyor-agency partnership that uses a unique, multi-step method for supporting sustained implementation of the Therapeutic Crisis Intervention (TCI) system to manage crises in child serving organizations. It outlines the steps of the process and highlights how specific activities are linked to current knowledge and principles from implementation science. The QIFAP occurs over a period of about three months, during which time program developers and agency representatives conduct staff surveys, a two-day site visit, and fidelity assessments in order to gather information, discuss findings, and plan steps for improving the TCI system in the organization. The process is guided by principles that emphasize the importance of organization leadership, building relationships, co-learning, using an individualized approach, data informed decision making, acknowledging risk, and congruence. We describe ways in which the strategies and approaches within the QIFAP are rooted in implementation science literature. Thus, the model represents an illustration of how research-based knowledge can work in practice to support long-term, high-quality program implementation.
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Affiliation(s)
- Lisa A McCabe
- Bronfenbrenner Center for Translational Research, Cornell University, 1201 Martha Van Rensselaer Hall, Ithaca, NY 14853, USA.
| | - Mary R Ruberti
- Bronfenbrenner Center for Translational Research, Cornell University, 1201 Martha Van Rensselaer Hall, Ithaca, NY 14853, USA.
| | - Thomas Endres
- Bronfenbrenner Center for Translational Research, Cornell University, 1201 Martha Van Rensselaer Hall, Ithaca, NY 14853, USA
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Liu XL, Wang T, Tan JY, Stewart S, Chan RJ, Eliseeva S, Polotan MJ, Zhao I. Sustainability of healthcare professionals' adherence to clinical practice guidelines in primary care. BMC PRIMARY CARE 2022; 23:36. [PMID: 35232391 PMCID: PMC8889781 DOI: 10.1186/s12875-022-01641-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sustainability of adherence to clinical practice guidelines (CPGs) represents an important indicator of the successful implementation in the primary care setting. AIM To explore the sustainability of primary care providers' adherence to CPGs after receiving planned guideline implementation strategies, activities, or programmes. METHODS Cochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); EMBase; Joanna Briggs Institute; Journals@Ovid; Medline; PsycoINFO; PubMed, and Web of Science were searched from January 2000 through May 2021 to identify relevant studies. Studies evaluating the sustainability of primary care providers' (PCPs') adherence to CPGs in primary care after any planned guideline implementation strategies, activities, or programmes were included. Two reviewers extracted data from the included studies and assessed methodological quality independently. Narrative synthesis of the findings was conducted. RESULTS Eleven studies were included. These studies evaluated the sustainability of adherence to CPGs related to drug prescribing, disease management, cancer screening, and hand hygiene in primary care. Educational outreach visits, teaching sessions, reminders, audit and feedback, and printed materials were utilized in the included studies as guideline implementation strategies. None of the included studies utilized purpose-designed measurements to evaluate the extent of sustainability. Three studies showed positive sustainability results, three studies showed mixed sustainability results, and four studies reported no significant changes in the sustainability of adherence to CPGs. Overall, it was difficult to quantify the extent to which CPG-based healthcare behaviours were fully sustained based on the variety of results reported in the included studies. CONCLUSION Current guideline implementation strategies may potentially improve the sustainability of PCPs' adherence to CPGs. However, the literature reveals a limited body of evidence for any given guideline implementation strategy. Further research, including the development of a validated purpose-designed sustainability tool, is required to address this important clinical issue. TRIAL REGISTRATION The study protocol has been registered at PROSPERO (No. CRD42021259748 ).
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Affiliation(s)
- Xian-Liang Liu
- College of Nursing and Midwifery, Charles Darwin University, 410 Ann Street, Brisbane, QLD, 4000, Australia
| | - Tao Wang
- College of Nursing and Midwifery, Charles Darwin University, 410 Ann Street, Brisbane, QLD, 4000, Australia
| | - Jing-Yu Tan
- College of Nursing and Midwifery, Charles Darwin University, 410 Ann Street, Brisbane, QLD, 4000, Australia
| | - Simon Stewart
- Torrens University Australia, Wakefield Campus, Adelaide, SA, 5000, Australia
- University of Glasgow, Glasgow, Scotland, UK
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, 5042, Australia
| | - Sabina Eliseeva
- College of Nursing and Midwifery, Charles Darwin University, 410 Ann Street, Brisbane, QLD, 4000, Australia
- Thornlands General Practice, 51 Island Outlook Ave Thornlands, Redland, QLD, 4164, Australia
| | - Mary Janice Polotan
- College of Nursing and Midwifery, Charles Darwin University, 410 Ann Street, Brisbane, QLD, 4000, Australia
- Thornlands General Practice, 51 Island Outlook Ave Thornlands, Redland, QLD, 4164, Australia
| | - Isabella Zhao
- College of Nursing and Midwifery, Charles Darwin University, 410 Ann Street, Brisbane, QLD, 4000, Australia.
- Cancer & Palliative Care Outcomes Centre, Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD, 4059, Australia.
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22
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Simpson BE, Kara S, Wilson A, Wolf D, Bailey K, MacBriar J, Mayes T, Russell J, Chundi P, Sturm P. Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis. Hosp Pediatr 2022:e2021006196. [PMID: 35174385 DOI: 10.1542/hpeds.2021-006196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical correction remains the most effective treatment of patients with severe neuromuscular scoliosis (NMS). However, postoperative inpatient clinical care after spinal surgery for NMS patients is highly complex and variable, depending on the provider and/or institution. Our project used a quality improvement methodology to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery, with the global aim of decreasing postoperative hospitalized length of stay (LOS). METHODS A multidisciplinary team developed a postoperative pathway for nonambulatory patients with NMS after their primary, nonstaged corrective spinal surgery. The outcome measure was mean LOS, and the process measure was percentage compliance with the newly implemented NMS pathway. The team used statistical process control charts and measures were evaluated over 3 phases to assess the impact of the interventions over time: pretesting, testing, and sustain. RESULTS The mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases. CONCLUSIONS Using quality improvement methodology, we successfully standardized major components of clinical care for patients with NMS after spinal corrective surgery. Through enhanced care consistency, the mean postoperative LOS decreased by nearly 3 days and decreased LOS variability. Robust multidisciplinary involvement with key stakeholders ensured sustainability of these improvements.
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Affiliation(s)
- Blair E Simpson
- Divisions of Hospital Medicine
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Setenay Kara
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Debra Wolf
- Division of Pain Management, Departments of Anesthesia and
| | | | | | | | | | - Pavan Chundi
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Nunnery MA, Gilmartin H, McCarthy M, Motta LUD, Wills A, Kelley L, Jones CD, Leonard C. Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program. BMC Health Serv Res 2022; 22:119. [PMID: 35090448 PMCID: PMC8796421 DOI: 10.1186/s12913-021-07420-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Understanding how to successfully sustain evidence-based care coordination interventions across diverse settings is critical to ensure that patients continue to receive high quality care even after grant funding ends. The Transitions Nurse Program (TNP) is a national intervention in the Veterans Administration (VA) that coordinates care for high risk veterans transitioning from acute care VA medical centers (VAMCs) to home. As part of TNP, a VA facility receives funding for a full-time nurse to implement TNP, however, this funding ends after implementation. In this qualitative study we describe which elements of TNP sites planned to sustain as funding concluded, as well as perceived barriers to sustainment. Methods TNP was implemented between 2016 and 2020 at eleven VA medical centers. Three years of funding was provided to each site to support hiring of staff, implementation and evaluation of the program. At the conclusion of funding, each site determined if they would sustain components or the entirety of the program. Prior to the end of funding at each site, we conducted midline and exit interviews with Transitions nurses and site champions to assess plans for sustainment and perceived barriers to sustainment. Interviews were analyzed using iterative, team-based inductive deductive content analysis to identify themes related to planned sustainment and perceived barriers to sustainment. Results None of the 11 sites planned to sustain TNP in its original format, though many of the medical centers anticipated offering components of the program, such as follow up calls after discharge to rural areas, documented warm hand off to PACT team, and designating a team member as responsible for patient rural discharge follow up. We identified three themes related to perceived sustainability. These included: 1) Program outcomes that address leadership priorities are necessary for sustainment.; 2) Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability; and 3) Lack of leadership buy-in, changing leadership priorities, and leadership turnover are perceived barriers to sustainment. Conclusions Understanding perceived sustainability is critical to continuing high quality care coordination interventions after funding ends. Our findings suggest that sustainment of care coordination interventions requires an in-depth understanding of the facility needs and local leadership priorities, and that building adaptable programs that continually engage key stakeholders is essential. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07420-1.
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24
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Wong DR, Schaper H, Saldana L. Rates of sustainment in the Universal Stages of Implementation Completion. Implement Sci Commun 2022; 3:2. [PMID: 34983685 PMCID: PMC8727078 DOI: 10.1186/s43058-021-00250-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Sustainment is a desirable outcome of implementation, but its precise definition remains unclear, contributing to the difficulty of identifying a generalized rate of sustainment. Several studies and reviews on the topic differ on both definition and levels of analysis. Furthermore, methodological limitations might have influenced the results, including the unknown quality with which some interventions were delivered. The Universal Stages of Implementation Completion (UniSIC) is a standardized measurement tool that tracks the implementation process and milestone completion across a wide range of real-world implementations-this provides a unique opportunity to identify a generalized rate of sustainment. METHODS UniSIC data was captured from the SIC website on 27 September 2020 and included data from all sites (n = 1778) that had been tracked to date. Data were restricted to sites that achieved competency in program delivery, and thus had a newly adopted program worthy of sustainment. Dates and indicator variables of implementation activities were combined to form two alternate definitions of sustainment: sustained (start-up) was achieved if sites continued to deliver services 2 years past their program start-up date; sustained (competent) was achieved if sites continued to deliver services 2 years past their competence and/or certification date. Of sites eligible for inclusion based on these definitions (N = 208), descriptive analyses were conducted to determine a rate of sustainment for all programs that successfully started a program. These definitions were also applied to a combined sample for a general rate of sustainment among all sites. Rates of competency among both a sample of sites that started up and a combined sample were also identified. RESULTS The rate of competence was 58.5% and the rate of sustained (start-up) was 37.1%, while the rate of sustained (competent) was 25.1%. The rates of competence and sustainment among the combined samples were far lower: 15.6% for competence, 6.8% for sustained (start-up), and 4.4% for sustained (competent). CONCLUSIONS These identified rates of sustainment are accurate initial estimates of sustainment of community-based practices, or in general. Future research on rates of sustainment should carefully define measures of sustainment and be transparent about the real-world conditions on which analyses are centered.
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25
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Cullen L, Hanrahan K, Edmonds SW, Reisinger HS, Wagner M. Iowa Implementation for Sustainability Framework. Implement Sci 2022; 17:1. [PMID: 34983585 PMCID: PMC8725573 DOI: 10.1186/s13012-021-01157-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research. Methods A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework. Results Participants (n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master’s or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3–4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants (n = 51) identified implementation strategy timing within four phases (Cochran’s Q); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders (n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework. Conclusion The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01157-5.
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Affiliation(s)
- Laura Cullen
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA.
| | - Kirsten Hanrahan
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA
| | - Stephanie W Edmonds
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA.,Institute for Clinical and Translational Science, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA
| | - Michele Wagner
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA
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26
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Shrubsole K, Rogers K, Power E. Sustaining acute speech-language therapists' implementation of recommended aphasia practices: A mixed methods follow-up evaluation of a cluster RCT. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2022; 57:152-171. [PMID: 34882907 DOI: 10.1111/1460-6984.12684] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND While implementation studies in aphasia management have shown promising improvements to clinical practice, it is currently unknown if aphasia implementation outcomes are sustained and what factors may influence clinical sustainability. AIMS To evaluate the sustainment (i.e., sustained improvement of aphasia management practices and domains influencing clinicians' practice) and sustainability (i.e., factors influencing sustainability) outcomes of the Acute Aphasia IMplementation Study (AAIMS). METHODS & PROCEDURES A convergent interactive mixed-methods sustainability evaluation was conducted on two previously delivered implementation interventions (AAIMS). The AAIMS interventions were targeted at improving either written aphasia-friendly information provision (Intervention A) or collaborative goal-setting (Intervention B). Outcomes were collected 2 and 3 years post-implementation, addressing the research questions of sustainment (e.g., medical record audits and behavioural constructs questionnaires) and sustainability (e.g., post-study focus groups and organizational readiness surveys). Quantitative sustainability data were compared with post-implementation data, allowing for sustainment to be determined. Clinicians' perspectives on sustainability outcomes and challenges were analysed using framework analysis and integrated with the quantitative findings. OUTCOMES & RESULTS A total of 35 speech-language therapists (SLTs) from four hospitals participated. The medical records of 79 patients were audited in the sustainability period compared with the 107 medical records audited during AAIMS. Overall, there was variable sustainment of the target behaviours; implementation for Intervention A was not sustained at either sustainability time point (2018 = 47.8% decrease; 2019 = 22.78% decrease), but implementation for Intervention B was sustained at both time points (2018 = 7.78% increase; 2019 = 18.1% increase). There was a pattern of sustained change in the behaviour change domains targeted by the implementation interventions, where scores of the targeted domains increased over time (0.13, 95% confidence interval (CI) = -0.05 to 0.30) and scores of the non-targeted domains declined (-0.03, 95% CI = -0.11 to 0.04). Factors influencing sustainability were mainly related to 'processes', 'the inner context' and 'SLT characteristics', and these interacted dynamically to account for variation between teams. CONCLUSIONS & IMPLICATIONS Implementation outcomes (i.e., practice changes) were not sustained to the same level for three of the four participating SLT teams, with variable or partial sustainment most common. While the factors influencing sustainability differed depending on the context and individuals involved, the most important factor influencing outcomes seemed to be the level to which behaviour-change processes and strategies were embedded within the SLT department. Future implementation studies should incorporate sustainability measures from the onset and include follow-ups and monitoring systems to help support sustained change in the long term. WHAT THIS PAPER ADDS What is already known on the subject In post-stroke aphasia management, there are few examples of long-term sustainability of implementation outcomes. It is therefore unknown what factors are potentially important to sustain implementation of best-practice recommendations in aphasia services. What this paper adds to existing knowledge There is potential for implementation outcomes to be sustained long term, but sustainment is impacted by a range of factors. Ongoing facilitation or follow-up after initial implementation may to useful to promote sustainment, but is not essential if processes are sufficiently embedded. Gradual implementation into practice may lead to better sustainment than rapid change that is quickly forgotten. What are the potential or actual clinical implications of this work? Future implementation efforts should incorporate sustainability measures from the onset. Applying a sustainability framework was useful to guide evaluations and explore factors influencing the sustainment outcomes and is recommended for those interested in sustainability. Results from our evaluation can be used to guide refinement and support future development of sustainable implementation interventions.
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Affiliation(s)
- Kirstine Shrubsole
- Faculty of Health, Southern Cross University, Gold Coast, QLD, Australia
- The Queensland Aphasia Research Centre, The University of Queensland, Herston Health Precinct, Brisbane, QLD, Australia
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, Bundura, Australia
| | - Kris Rogers
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Emma Power
- Centre for Research Excellence in Aphasia Recovery and Rehabilitation, Bundura, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
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Nadalin Penno L, Graham ID, Backman C, Fuentes-Plough J, Davies B, Squires J. Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study. FRONTIERS IN HEALTH SERVICES 2022; 2:940936. [PMID: 36925887 PMCID: PMC10012662 DOI: 10.3389/frhs.2022.940936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022]
Abstract
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."
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Affiliation(s)
- Letitia Nadalin Penno
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Ian D Graham
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Chantal Backman
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Fuentes-Plough
- Business School and Leadership School, Anahuac-Mayab University, Mérida, Yucatan, Mexico
| | - Barbara Davies
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Janet Squires
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Flynn R, Mrklas K, Campbell A, Wasylak T, Scott SD. Contextual factors and mechanisms that influence sustainability: a realist evaluation of two scaled, multi-component interventions. BMC Health Serv Res 2021; 21:1194. [PMID: 34736470 PMCID: PMC8570000 DOI: 10.1186/s12913-021-07214-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 10/21/2021] [Indexed: 12/04/2022] Open
Abstract
Background In 2012, Alberta Health Services created Strategic Clinical NetworksTM (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.
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Affiliation(s)
- Rachel Flynn
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Alberta, T6G 1C9, Edmonton, Canada.
| | - Kelly Mrklas
- Strategic Clinical Networks™, Provincial Clinical Excellence, Alberta Health Services, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, T2N 4N1, Calgary, Canada
| | - Alyson Campbell
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Alberta, T6G 1C9, Edmonton, Canada
| | - Tracy Wasylak
- Strategic Clinical Networks™, Provincial Clinical Excellence, Alberta Health Services, Calgary, Canada.,Faculty of Nursing, University of Calgary, T2N 4V8, Alberta, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Alberta, T6G 1C9, Edmonton, Canada
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Okere NE, Lennox L, Urlings L, Ford N, Naniche D, Rinke de Wit TF, Hermans S, Gomez GB. Exploring Sustainability in the Era of Differentiated HIV Service Delivery in Sub-Saharan Africa: A Systematic Review. J Acquir Immune Defic Syndr 2021; 87:1055-1071. [PMID: 33770063 PMCID: PMC8219088 DOI: 10.1097/qai.0000000000002688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The World Health Organization recommends differentiated service delivery (DSD) to support resource-limited health systems in providing patient-centered HIV care. DSD offers alternative care models to clinic-based care for people living with HIV who are stable on antiretroviral therapy (ART). Despite good patient-related outcomes, there is limited evidence of their sustainability. Our review evaluated the reporting of sustainability indicators of DSD interventions conducted in sub-Saharan Africa (SSA). METHODS We searched PubMed and EMBASE for studies conducted between 2000 and 2019 assessing DSD interventions targeting HIV-positive individuals who are established in ART in sub-Saharan Africa. We evaluated them through a comprehensive sustainability framework of constructs categorized into 6 domains (intervention design, process, external environment, resources, organizational setting, and people involvement). We scored each construct 1, 2, or 3 for no, partial, or sufficient level of evidence, respectively. Interventions with a calculated sustainability score (overall and domain-specific) of >90% or domain-specific median score >2.7 were considered likely to be sustainable. RESULTS Overall scores ranged from 69% to 98%. Top scoring intervention types included adherence clubs (98%) and community ART groups (95%) which comprised more than half of interventions. The highest scoring domains were design (2.9) and organizational setting (2.8). The domains of resources (2.4) and people involvement (2.3) scored lowest revealing potential areas for improvement to support DSD sustainability. CONCLUSIONS With the right investment in stakeholder involvement and domestic funding, DSD models generally show potential for sustainability. Our results could guide informed decisions on which DSD intervention is likely to be sustainable per setting and highlight areas that could motivate further research.
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Affiliation(s)
- Nwanneka E. Okere
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Laura Lennox
- Department of Primary Care and Public health, Imperial College, National Institute for Health Research, Applied Research Collaboration, North West London, London, United Kingdom
| | - Lisa Urlings
- Department of Medicine, Amsterdam UMC University of Amsterdam, Amsterdam, Netherlands
| | - Nathan Ford
- Department HIV, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Denise Naniche
- ISGlobal, Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Tobias F. Rinke de Wit
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sabine Hermans
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Health and Tropical Medicine, London, United Kingdom; and
- Department of Modelling, Epidemiology and Data Science, Currently, Sanofi Pasteur, Lyon,France
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O'Malley G, Beima-Sofie KM, Roche SD, Rousseau E, Travill D, Omollo V, Delany-Moretlwe S, Bekker LG, Bukusi EA, Kinuthia J, Barnabee G, Dettinger JC, Wagner AD, Pintye J, Morton JF, Johnson RE, Baeten JM, John-Stewart G, Celum CL. Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:668672. [PMID: 36303982 PMCID: PMC9580786 DOI: 10.3389/frph.2021.668672] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/22/2021] [Indexed: 10/07/2023] Open
Abstract
Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.
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Affiliation(s)
- Gabrielle O'Malley
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Stephanie D. Roche
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Elzette Rousseau
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Danielle Travill
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Victor Omollo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, WA, United States
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Julie C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Rachel E. Johnson
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
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31
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Keen A, Thoele K, Oruche U, Newhouse R. Perceptions of the barriers, facilitators, outcomes, and helpfulness of strategies to implement screening, brief intervention, and referral to treatment in acute care. Implement Sci 2021; 16:44. [PMID: 33892758 PMCID: PMC8063328 DOI: 10.1186/s13012-021-01116-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 04/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a clinical intervention used to address alcohol and illicit drug use. SBIRT use has resulted in positive health and social outcomes; however, SBIRT implementation remains low. Research on implementing interventions, such as SBIRT, lacks information about challenges and successes related to implementation. The Expert Recommendations for Implementing Change (ERIC) provides a framework to guide comprehension, clarity, and relevance of strategies available for implementation research. This framework was applied to qualitative feedback gathered from site coordinators (SCs) leading SBIRT implementation. The purpose of this study was to describe the SCs’ experiences pertaining to SBIRT implementation across a health system. Methods Within the context of a larger parent study, a semi-structured interview guide was used to capture 14 SCs’ perceptions of the barriers, facilitators, and outcomes pertaining to SBIRT implementation. Qualitative data were analyzed using standard content analytic procedures. A follow-up survey was developed based on 14 strategies identified from qualitative data and was administered electronically to determine the SC’s perceptions of the most helpful implementation strategies on a scale of 1 (least helpful) to 5 (most helpful). Results All 14 invited SCs participated in the SBIRT implementation interview, and 11 of 14 (79%) responded to the follow-up survey. Within the categories of barriers, facilitators, and outcomes, 25 subthemes emerged. The most helpful implementation strategies were reexamining the implementation (M = 4.38; n = 8), providing ongoing consultation (M = 4.13; n = 8), auditing and providing feedback (M = 4.1; n = 10), developing education materials (M = 4.1; n = 10), identifying and preparing champions (M = 4; n = 7), and tailoring strategies (M = 4; n = 7). Conclusion SCs who led implementation efforts within a large healthcare system identified several barriers and facilitators to the implementation of SBIRT. Additionally, they identified clinician-related outcomes associated with SBIRT implementation into practice as well as strategies that were helpful in the implementation process. This information can inform the implementation of SBIRT and other interventions in acute care settings.
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Affiliation(s)
- Alyson Keen
- Indiana University School of Nursing, 600 Barnhill Dr., Indianapolis, IN, 46202, USA. .,Indiana University Health Adult Academic Health Center, 1701 N. Senate Ave, Indianapolis, IN, 46202, USA.
| | - Kelli Thoele
- Indiana University School of Nursing, 600 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Ukamaka Oruche
- Indiana University School of Nursing, 600 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Robin Newhouse
- Indiana University School of Nursing, 600 Barnhill Dr., Indianapolis, IN, 46202, USA
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Sullivan JL, Kim B, Miller CJ, Elwy AR, Drummond KL, Connolly SL, Riendeau RP, Bauer MS. Collaborative chronic care model implementation within outpatient behavioral health care teams: qualitative results from a multisite trial using implementation facilitation. Implement Sci Commun 2021; 2:33. [PMID: 33762023 PMCID: PMC7992349 DOI: 10.1186/s43058-021-00133-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background This paper reports on a qualitative evaluation of a hybrid type II stepped-wedge, cluster randomized trial using implementation facilitation to implement team-based care in the form of the collaborative chronic care model (CCM) in interdisciplinary outpatient mental health teams. The objective of this analysis is to compare the alignment of sites’ clinical processes with the CCM elements at baseline (time 1) and after 12 months of implementation facilitation (time 2) from the perspective of providers. Methods We conducted semi-structured interviews to assess the extent to which six CCM elements were in place: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. Interviews were transcribed and a priori CCM elements were coded using a directed content analysis approach at times 1 and 2. We sought consensus on, and compared, the extent to which each CCM element was in place at times 1 and 2. Results We conducted 27 and 31 telephone interviews at times 1 and 2, respectively, with outpatient mental health providers at nine participating sites. At time 1 and time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from time 1 to time 2 were work role redesign, patient self-management support, and clinical information systems. For two CCM elements, linkages to community resources and organizational/leadership support, some sites had increased implementation at time 2 compared to time 1, while others had reductions. For the provider decision support element, we saw little change in the extent of its implementation. Conclusions Sites increased the extent of implementation on several CCM elements. The most progress was made in the CCM elements where sites had CCM-aligned processes in place at time 1. Teams made progress on elements they could more easily control, such as work role redesign. Our results suggest that maximizing the benefits of CCM-based outpatient mental health care may require targeting resources and training toward specific CCM elements—especially in the use of clinical information systems and linking with community resources. Trial registration Clinical Trials NCT02543840. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00133-w.
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Affiliation(s)
- Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA. .,Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Talbot Building, Boston, MA, USA.
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, USA.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Karen L Drummond
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, USA
| | - Samantha L Connolly
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rachel P Riendeau
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
| | - Mark S Bauer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Birken SA, Haines ER, Hwang S, Chambers DA, Bunger AC, Nilsen P. Advancing understanding and identifying strategies for sustaining evidence-based practices: a review of reviews. Implement Sci 2020; 15:88. [PMID: 33036653 PMCID: PMC7545853 DOI: 10.1186/s13012-020-01040-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation science has focused mainly on the initial uptake and use of evidence-based practices (EBPs), with less attention to sustainment-i.e., continuous use of these practices, as intended, over time in ongoing operations, often involving adaptation to dynamic contexts. Declining EBP use following implementation is well-documented yet poorly understood. Using theories, models, and frameworks (TMFs) to conceptualize sustainment could advance understanding. We consolidated knowledge from published reviews of sustainment studies to identify TMFs with the potential to conceptualize sustainment, evaluate past uses of TMFs in sustainment studies, and assess the TMFs' potential contribution to developing sustainment strategies. METHODS We drew upon reviews of sustainment studies published within the past 10 years, evaluated the frequency with which included articles used a TMF for conceptualizing sustainment, and evaluated the relevance of TMFs to sustainment research using the Theory, Model, and Framework Comparison and Selection Tool (T-CaST). Specifically, we examined whether the TMFs were familiar to researchers, hypothesized relationships among constructs, provided a face-valid explanation of relationships, and included sustainment as an outcome. FINDINGS Nine sustainment reviews referenced 648 studies; these studies cited 76 unique TMFs. Only 28 TMFs were used in more than one study. Of the 19 TMFs that met the criteria for T-CaST analysis, six TMFs explicitly included sustainment as the outcome of interest, 12 offered face-valid explanations of proposed conceptual relationships, and six identified mechanisms underlying relationships between included constructs and sustainment. Only 11 TMFs performed adequately with respect to all these criteria. CONCLUSIONS We identified 76 TMFs that have been used in sustainment studies. Of these, most were only used once, contributing to a fractured understanding of sustainment. Improved reporting and use of TMFs may improve understanding of this critical topic. Of the more consistently used TMFs, few proposed face-valid relationships between included constructs and sustainment, limiting their ability to advance our understanding and identify potential sustainment strategies. Future research is needed to explore the TMFs that we identified as potentially relevant, as well as TMFs not identified in our study that nonetheless have the potential to advance our understanding of sustainment and identification of strategies for sustaining EBP use.
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Affiliation(s)
- Sarah A. Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, 135 Dauer Drive, Campus Box 7411, Chapel Hill, NC 27599-7411 USA
| | - Emily R. Haines
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, 1101B McGavran - Greenberg Hall, CB# 7411, Chapel Hill, NC 27599-7411 USA
| | - Soohyun Hwang
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, 1101B McGavran - Greenberg Hall, CB# 7411, Chapel Hill, NC 27599-7411 USA
| | - David A. Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 3E414, Rockville, MD 20850 USA
| | - Alicia C. Bunger
- College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH 43210 USA
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83 Linköping, Sweden
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Moullin JC, Sklar M, Green A, Dickson KS, Stadnick NA, Reeder K, Aarons GA. Advancing the pragmatic measurement of sustainment: a narrative review of measures. Implement Sci Commun 2020; 1:76. [PMID: 32964208 PMCID: PMC7499830 DOI: 10.1186/s43058-020-00068-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/24/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Sustainment, an outcome indicating an intervention continues to be implemented over time, has been comparatively less studied than other phases of the implementation process. This may be because of methodological difficulties, funding cycles, and minimal attention to theories and measurement of sustainment. This review synthesizes the literature on sustainment measures, evaluates the qualities of each measure, and highlights the strengths and gaps in existing sustainment measures. Results of the review will inform recommendations for the development of a pragmatic, valid, and reliable measure of sustainment. METHODS A narrative review of published sustainment outcome and sustainability measures (i.e., factors that influence sustainment) was conducted, including appraising measures in the Society of Implementation Research Collaboration (SIRC) instrument review project (IRP) and the Dissemination and Implementation Grid-Enabled Measures database initiative (GEM-D&I). The narrative review used a snowballing strategy by searching the reference sections of literature reviews and definitions of sustainability and sustainment. Measures used frequently and judged to be comprehensive and/or validated by a team of implementation scientists were extracted for analysis. RESULTS Eleven measures were evaluated. Three of the included measures were found in the SIRC-IRP, three in the GEM-D&I database, (one measure was in both databases) and six were identified in our additional searches. Thirteen constructs relating to sustainment were coded from selected measures. Measures covered a range of determinants for sustainment (i.e., construct of sustainability) as well as constructs of sustainment as an outcome. Strengths of the measures included, development by expert panels knowledgeable about particular interventions, fields or contexts, and utility in specific scenarios. A number of limitations were found in the measures analyzed including inadequate assessment of psychometric characteristics, being overly intervention or context specific, being lengthy and/or complex, and focusing on outer context factors. CONCLUSION There is a lack of pragmatic and psychometrically sound measures of sustainment that can be completed by implementation stakeholders within inner context settings (e.g., frontline providers, supervisors).
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Affiliation(s)
- Joanna C. Moullin
- Faculty of Health Sciences, School of Pharmacy and Biomedical Sciences, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102 Australia
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
| | - Marisa Sklar
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego DISC), Altman Clinical and Translational Research Institute, 9500 Gilman Drive (0990), La Jolla, CA 92093-0990 USA
| | - Amy Green
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
- The Trevor Project, PO Box 69232, West Hollywood, CA 90069 USA
| | - Kelsey S. Dickson
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
- San Diego State University, 5500 Campanile Drive, San Diego, CA 92182 USA
| | - Nicole A. Stadnick
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego DISC), Altman Clinical and Translational Research Institute, 9500 Gilman Drive (0990), La Jolla, CA 92093-0990 USA
| | - Kendal Reeder
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
| | - Gregory A. Aarons
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego DISC), Altman Clinical and Translational Research Institute, 9500 Gilman Drive (0990), La Jolla, CA 92093-0990 USA
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Cowie J, Nicoll A, Dimova ED, Campbell P, Duncan EA. The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review. BMC Health Serv Res 2020; 20:588. [PMID: 32594912 PMCID: PMC7321537 DOI: 10.1186/s12913-020-05434-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 06/15/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Identifying factors that influence sustained implementation of hospital-based interventions is key to ensuring evidence-based best practice is maintained across the NHS. This study aimed to identify, appraise and synthesise the barriers and facilitators that influenced the delivery of sustained healthcare interventions in a hospital-based setting. METHODS A systematic review reported in accordance with PRISMA. Eight electronic databases were reviewed in addition to a hand search of Implementation Science journal and reference lists of included articles. Two reviewers were used to screen potential abstracts and full text papers against a selection criteria. Study quality was also independently assessed by two reviewers. Barriers and facilitators were extracted and mapped to a consolidated sustainability framework. RESULTS Our searching identified 154,757 records. We screened 14,626 abstracts and retrieved 431 full text papers, of which 32 studies met the selection criteria. The majority of studies employed a qualitative design (23/32) and were conducted in the UK (8/32) and the USA (8/32). Interventions or programmes were all multicomponent, with the majority aimed at improving the quality of patient care and/ or safety (22/32). Sustainability was inconsistently reported across 30 studies. Barriers and facilitators were reported in all studies. The key facilitators included a clear accountability of roles and responsibilities (23/32); ensuring the availability of strong leadership and champions advocating the use of the intervention (22/32), and provision of adequate support available at an organisational level (21/32). The most frequently reported barrier to sustainability was inadequate staff resourcing (15/32). Our review also identified the importance of inwards spread and development of the initiative over time, as well as the unpredictability of sustainability and the need for multifaceted approaches. CONCLUSIONS This review has important implications for practice and research as it increases understanding of the factors that faciliate and hinder intervention sustainability. It also highlights the need for more consistent and complete reporting of sustainability to ensure that lessons learned can be of direct benefit to future implementation of interventions. TRIAL REGISTRATION The review is registered on PROSPERO ( CRD42017081992 ).
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Affiliation(s)
- Julie Cowie
- Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU), Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, Glasgow, G4 0BX, Scotland.
| | - Avril Nicoll
- Health Services Research Unit, University of Aberdeen, 2nd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Elena D Dimova
- Department of Nursing and Health, School of Life Sciences, Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, Glasgow, G4 0BX, Scotland
| | - Pauline Campbell
- Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU), Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, Glasgow, G4 0BX, Scotland
| | - Edward A Duncan
- Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU), Unit 13 Scion House, University of Stirling Innovation Park, Stirling, FK9 4NF, Scotland
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