Identifying relevant concepts and factors for the sustainability of evidence-based practices within acute care contexts: a systematic review and theory analysis of selected sustainability frameworks

Over a decade ago, the sustained use of evidence-based practices (EBPs) was identified as a gap in the literature. Evolving debate among experts suggest sustainability should be considered a distinct concept that occurs “(1) after a defined period of time, (2) the program, clinical intervention and/or implementation strategies (hereafter referred to as EBPs) continue to be delivered and/or, (3) individual behavior change (i.e. clinician, patient ) is maintained, (4) the program (EBP) and individual behavior change may evolve or adapt while (5) continuing to produce benefits for individuals/systems [1]”. Despite growing interest, the timing and understanding of how to sustain the use of EBPs remains a relatively unexplored field of research [2, 3] and least understood part of the translation research process [4] that has challenged practitioners and researchers alike. Evidence reveals the integration and sustainability of EBPs in clinical practice is “an iterative, dynamic” [5] and “complex process,” [6] which poses a significant challenge. Emerging discourse indicates efforts to sustain EBPs in healthcare should be guided by conceptual frameworks, models or theories (hereafter collectively referred to as F/M/Ts) [1, 7‐12] to better understand the factors that impact sustainability as a distinct concept [13, 14], over time, in a range of distinct healthcare settings [3, 10, 11]. Thus, a critical analysis of existing sustainability F/M/Ts relevant to acute care contexts was conducted as a way to understand the meaning of key concepts, factors, and their relationships to ultimately provide direction for practice and research.

Increasing demand on healthcare organizations to improve patient outcomes [10, 15, 16] in an efficient, cost-effective manner [17, 18]) has resulted in the growing expectation that EBPs be informed by research, be effective and sustainable to inform clinical decision making [19, 20]. In response, healthcare organizations have undertaken a number of quality improvement initiatives [10]. Despite efforts, variable rates of sustained use of EBPs exist ranging from none to full adherence [2], not only among various healthcare professionals but also within different settings [1, 9, 10, 17, 20‐24]. Researchers argue the decay of sustained EBPs [17, 23, 25, 26], also referred to as the “improvement evaporation effect” [25, 26] can be attributed to the limited use of theoretical F/M/Ts [27, 28]. To overcome these challenges and to advance knowledge, researchers [7, 11‐14] recommend the use of F/M/Ts to examine the factors that impact sustainability as a distinct concept, especially in complex acute care environments [11].

Recent reviews/syntheses reveal a lack of use/empirical testing of existing F/M/Ts [10, 19, 24], highlight several diverse perspectives, applications and constructs deemed useful for sustainability [10], and few F/M/Ts that focus solely on the sustainability of EBPs within acute settings [10, 24, 29]. Specifically, the majority of sustainability F/MTs and approaches are designed for use in non-specified healthcare settings (37% or 23/62) (e.g., healthcare organizations or systems), followed by 31% (19/62) specified for use in public health, 26% (16/62) in community settings, and only 3% (2/62) primarily focused within acute care [10]. To date, a review that examines how to improve the sustainability of EBPs in acute care settings has not been conducted [11]. Given healthcare expenditures are reported to be the largest in hospitals (36.9% in 2018) [30], exclusively identifying relevant concepts and factors related to sustainability in this challenging setting will likely be of considerable benefit to research and practice, potentially improving the quality of care and reducing costs. Clearly, a gap exists regarding which existing sustainability F/M/Ts are applicable and what factors are relevant when trying to sustain the use of EBPs primarily in acute care contexts [10, 13].

The aims of this study were to (i) identify existing healthcare F/M/Ts that explicitly address the process of sustained use of research (EBPs/guidelines/innovations/clinical protocols/programs/interventions) and are recommended for use within acute care contexts or unspecified healthcare organization/setting; (ii) compare F/M/Ts, using a theory analysis approach, to identify key concepts and factors that influence/predict the likelihood of successful sustainability of EBPs; and (iii) provide a list of relevant sustainability F/M/Ts, concepts, and core factors to act as a guide for practice and provide direction for future research within acute care contexts.

Of the 2967 citations identified, 8 met the inclusion criteria (e.g., four from Moore et al. [1], three from Lennox et al. [10], one from the new systematic review) and were eligible for theory analysis (Fig. 1). Rationale for excluded citations is documented in Additional file 3. Most F/M/Ts containing both implementation and sustainability phases did not explicitly provide a detailed breakdown of the sustainability concepts/factors and were excluded. Those that did were recommended for use in community and/or public health settings and were excluded.

This systematic review is the first to include a comprehensive analysis of healthcare sustainability F/M/Ts with a primary focus on identifying key concepts influencing the sustained use of EBPs in acute care contexts. Our search revealed the vast majority of F/M/Ts relating to sustainability were designed specifically for use in community and public health settings, which is congruent with the current literature [3, 10]. Notably, only three F/M/Ts were primarily focused on the sustainability of EBPs within acute care settings [13, 40, 41], and five were recommended for use in non-specified healthcare organizational/settings [25, 34, 39, 42, 43]. Recommended target domains for use across disciplines imply general learning can be gathered to inform sustainability for practice and research using an interdisciplinary approach. Addressing sustainability challenges from a variety of theoretical perspectives and disciplines is equally pivotal to understanding this concept in acute care as reported in other healthcare sectors [3].

The two most commonly described constructs cited in the F/M/Ts for sustainability were

“continued delivery or use” and “evolution or adaption” constructs. The prominence of these constructs emphasizes the continuous use and evolutionary nature of sustained EBPs in context over time and is congruent with Moore et al.’s [1] previous developed definition of sustainability. Furthermore, this analysis provides insight into sustainability as a “process” or “stage/phase” of ongoing/continuous use of EBPs post-implementation. This finding is congruent with researchers who argue sustainability is not an all or nothing “phase or endgame” [34] nor an “outcome” [52] but rather a “process of managing and supporting the evolving EBP” overtime [34]. Some contend it is a “matter of degree of sustained change” [18, 53] to be viewed as a “continuous phase” [54] or a “continuum” [14] or a “process” [10]. The importance of this construct is consistent with a recent review [10], ultimately adding new knowledge to the current definition [1]. The shift in perspective of sustainability as a “process or ongoing/continuous stage/phase” [3, 10], together with the EBPs’ evolutionary nature and dynamic interaction/influence among the factors overtime [3, 34], highlights the complexity of planning and measuring sustainability and the need to consider how strategies for sustainment overtime differ from implementation and/or potentially overlap.

Results provide a resource of eight F/M/Ts and hypothesized factors that can be used by acute care team members planning or currently implementing EBPs with the goal of improving patient outcomes. Our synthesis of the concepts/factors revealed 37 core factors which cluster around 7 themes specifically defined by the F/M/T originators to be relevant to acute care settings. Four F/M/Ts containing all [13, 25, 34] or most [42] of the themes provide a knowledge base for practitioners and researchers to evaluate the sustained use of EBPs within their acute care setting. Four themes align with those deemed useful in any setting by Lennox et al. [10] (e.g., (i) initiative design and delivery = inner processes, (ii) people involved = adopters, (iii) organizational setting = inner context, (iv) external environment = outer context), and three add to the current knowledge, namely, leadership and management, characteristics of the innovation, and outcomes. The equal distribution of core factors among six of the seven themes (excluding outcome) signifies the relative importance of each theme for the sustainability of EBPs in acute care. Notably, several factors support the conceptualization of sustainability as “a dynamic construct that allows for adaptation in response to new or changing populations, evidence, policies, or other contextual influences” [3]. The combined contextual factors (57% or 21/37) influencing sustainability related to acute care contexts include (i) the integration of four layers of context factors influencing the sustained use of complex organizational change practices (e.g., individual, interpersonal relationships, internal context, wider infrastructure system) [41]; (ii) attention to the complexity, multi-layered, ever-changing organizational setting [13, 25, 34]; (iii) the adaptability of the innovation/EBP to context [13, 34, 39], and (iv) the dynamic process of routinization of innovations/EBPs as a source of change [40]. Arguably, contextual factors impacting sustainability within and among departments or sites will likely provide insight into why the sustained use of EBPs may vary within the same acute care setting. In turn, this likely will affect the strategies needed for sustainment.

Differences amongst F/M/Ts lie in the overall structures, the degree of refinement, substantiation to date, and identified gaps. Each F/M/T reflects a different conceptualization of sustainability evident in the varied schematics. The use of vague/minimal terminology defining concepts/factors and their relationships increases the potential for multiple interpretations. Sustainability outcomes were depicted in three F/M/Ts as a range (e.g., decay to sustainability to development [25], a spectrum from high to nil [13] or as an ongoing stage/phase of implementation [41]). The Chambers DSF [34] defined outcomes as the “continuation of intended benefits.” The outcome theme is not explicitly defined in the remaining four F/M/Ts [39, 40, 42, 43]. Consistent with other researchers [3], we recommend future inquiry focus on articulating sustainability outcomes.

Identified gaps among the eight F/M/Ts were revealed by examining their concepts/factors and tools. Variation existed related to the inclusiveness of each factor and labeling of themes. For example, the absence of any type of ‘financial factor’ in the Racine MSI [42] to guide stakeholders offers little insight into how this factor influences sustainability. Additionally, Fleiszer SIHF [13] did not include a separate “adopter theme” but instead recognized the role of leadership and management as distinct. A lack of focus on facilitation as a factor either explicitly or implicitly or its inclusion and the perceived need for it is not evident in most F/M/Ts [25, 34, 39, 41, 42], except the Fleiszer SIHF [13]. Originators of the Chambers DSF [34] were distinct in their acknowledgement of the “dynamic relationship” between three “changing” concepts (innovation, practice setting, broader system), their focus on “benefits beyond helping patients” and the “fit of the innovation” with existing routines/processes. Despite this acknowledgement, the potential risk of overlooking the impact on patient outcomes has been recognized [21]. Slaghuis FMIS-WP [40] originators claim their framework is part of a larger unpublished framework. Lastly, only two of the F/M/Ts included tools to measure changed work practices [39 40]. To date, minimal evidence for instrument reliability and validity is available for these tools.

Sustainability is an emerging field of study. Given the ever-changing nature and complexity of acute healthcare settings and related costs, it is imperative practitioners and researchers consider the use of sustainability F/M/Ts to guide their practice and inquiry to ensure EBPs are sustained effectively, continue to inform clinical decisions and contribute to improved patient outcomes. Principally, selecting one of the eight sustainability F/M/Ts proactively to plan, evaluate and interpret findings is recommended. Then consider the context level for F/M/T use, specify the goals of sustainability, and determine if the concepts and factors listed apply [55]. We also recommend future inquiry adopt the use of mixed methodologies to explore the complex relationship between implementation factors and outcomes (including sustainability), and determine their level of influence using Proctor’s Framework [56]. Additionally, using a theory analysis approach to examine F/M/Ts containing both implementation and sustainability could provide new insight into the relationship of factors over time (e.g., early, mid-process, and long-term) and/or the potential impact of implementation on the sustainability phase.