Does this scenario sound familiar?
Your team worked diligently to provide an evidence-based quality improvement project in your NICU to incorporate a developmental care change. Hours were spent creating education, providing resources, and attempting creative and motivational implementation strategies. The project seemed to proceed without a hitch until… a year later. During an annual assessment of the project, you discover the process has not been sustained, leaving you frustrated, helpless and realizing your efforts and resources were inefficient. If this resonates with you, rest assured you are not alone. In fact, the National Health Service (NHS) found that 33% of quality improvement projects are not sustained 1 year after completion.(1) Other reports suggest up to 70% of organizational change is not sustained.(2) For anyone involved in creating change in your hospital environment, sustainability is the most important outcome.
What are sustainable interventions and what is the importance?
A general definition of sustainability in interventions is the ‘enduring implementation of an intervention after its initial roll-out in practice.’(3) While there is a great deal in the research about creating change and innovation implementation, there has been less attention focused historically on what happens after these early stages of change. Sustaining change is just as important as creating change. It is essential to improve health outcomes, reduce research waste, and build practitioners’ confidence in the value of adopting new interventions.(3)Sustainability is so essential that it has been pegged to be ‘one of the most significant translational research problems of our time’ in healthcare articles.(4)
Barriers and Facilitators to Sustainability:
Even when interventions are successfully implemented, sustaining change is not automatic. There are common themes in the literature to barriers and the facilitators that support.
Indequate staff resourcing
Inadequate staff resources and/or a high turnover of staff is a strong barrier. Units need to ensure there are standard policies to continue updated education including changed policies and procedures for all new staff. In a study documenting specific nursing sustainability, staff departures lead to evaporation of knowledge and practice. Higher sustainable units incorporate permanent programs or guidelines, rather than knowledge embedded in staff.(5) An example of this would be a formal education program or integrating a formal policy, vs. staff informally relaying information.
Also included in staff barriers is a lack of awareness of the problem and/or staff unaware of the impact or effectiveness of the intervention.(3)Facilitators to address these barriers include establishing credibility of the intervention and a strong evidence base. Are your quality improvement projects conducted by educating your staff on the benefits of change for both patients and staff?
Lack of leadership or support by champions (3,5)
Lack of a strong leadership team or champions to regularly enforce implementation change is a strong barrier. Supportive leadership is the most frequently reported facilitator.(3) During the planning phase, securing strong leadership as well as establishing a team of champions that take ownership of the program is essential. This champion team works to embed the change into the daily routines of the unit. Organizational support is also key. The unit does not exist in isolation. Fleiszer described an organization-wide nursing best practice guideline where the high sustainability units experienced a shared, consistent perspective between executive, clinical program, and unit management leaders. Practically, this looked like visible presence of leaders and their attentiveness to daily unit function. Higher sustainability units had leaders who used activities such as continual education and training, reminders, discussions, evaluating performance, and integrating changes into other initiatives.
Resources
Resources were cited as an obstacle to the sustainability of hospital-based interventions. Resources can include staff (turnover), time(staff struggling to find time to implement the intervention), or lack of long-term funding. In addition, components of the intervention may be threatened if general resources are unavailable. One example that may resonate in developmental care is when a QI project is adopted to improve feeding methods in the NICU that includes embracing a new reusable bottle system. The education and implementation may be difficult to sustain if bottle systems cannot continue to be purchased or there is not a solid cleaning policy/plan.
To support resources, having an infrastructure in place to support change is one of the most reported facilitators.(3) Examples may include adequate documentation plans, necessary supplies, adequate funding to continue the change, and dedicated, protected time.(3)
Change is challenging. Sustaining change can be even harder. While more research is needed in this area, it appears that from day one when planning a project, it is essential to plan for sustainability. Change must be sustained, for your team and for the babies and families in your care.
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