Exploring the long-term sustainability of a nursing best practice guidelines program
Bibliographic record
Abstract
BACKGROUNDDespite advances in knowledge about the implementation of healthcare innovations, little attention has been focused on what happens following the early stages of change. Yet many innovations are not sustained, wasting valuable initial investments and gains. Knowledge gaps related to the sustainability of healthcare innovations are pronounced in nursing, where there is a need to determine how to heighten the "staying power" of practice improvement initiatives.PURPOSEThe purpose of this study was to understand how a nursing best practice guidelines (BPG) program was sustained over a long-term period in an acute healthcare centre.METHODOLOGYI began by conducting a concept analysis of healthcare innovation sustainability. This concept analysis provided a framework to guide a qualitative descriptive case study of an organization-wide nursing BPG program eight years following initial implementation. The case study setting was a tertiary / quaternary urban healthcare centre in Canada. The BPG program was established to improve nursing care practices related to the patient safety challenges of falls, pressure ulcers, and pain. I investigated program sustainability at the organization (nursing department) level, and then across two pairs of embedded, contrasting subcases on inpatient units in the organization. Data sources included 39 key informant interviews (14 organizational, 25 subcase), site visits, and program-related documents. FINDINGSOrganization-level and unit-level findings supported the proposed framework by providing evidence for three characteristics of sustainability (benefits, routinization / institutionalization, and development) and four categories of influencing factors (innovation, context, leadership, and process). At both levels, the combination of the three characteristics was essential; and development of the program and / or its context was increasingly important for program survival over time. Key factors influencing sustainability at the organization level were: commitment of several nursing leaders, complementarity of leadership actions, and leaders’ use of a reflection-and-course-correction strategy. Key influencing factors at the unit level were: perceptions of advantages of BPGs, collaboration, accountability, stability of staffing, linked levels of leadership, attributes of unit leadership teams, and leaders’ strategic use of activities. At both levels, the relationships between characteristics and factors accounted for how the program was sustained.CONCLUSIONSThe persistent, responsive, and complementary efforts of formal leaders, from executive to frontline roles, seem necessary for program longevity. These include strategically-aligned leadership actions focused on the dynamics between teamwork, evaluation, and learning. Such sustainability work appears to be most successful if undertaken as part of managing overall performance. Leaders should consider a broad conceptualization of sustainability that extends beyond program-related benefits and routinization / institutionalization, because development could ensure endurance. Building on the initial framework, theoretical representations of key relationships between sustainability characteristics and factors are provided. These representations can serve to guide research about and to plan for the longer-term sustainability of practice improvement initiatives.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.033 | 0.086 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.005 | 0.004 |
| Scholarly communication | 0.005 | 0.003 |
| Open science | 0.002 | 0.006 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".