title: A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study.
abstract: BACKGROUND
  Best practice guidelines are a tool for narrowing research-to-practice gaps and improving care outcomes. There is some empirical understanding of guideline implementation in nursing settings, yet there has been almost no consideration of the longer-term sustainability of guideline-based practice improvements. Many healthcare innovations are not sustained, underscoring the need for knowledge about how to promote their survival.
  
  
  OBJECTIVE
  To understand how a nursing best practice guidelines program was sustained on acute healthcare center nursing units.
  
  
  METHODS
  We undertook a qualitative descriptive case study of an organization-wide nursing best practice guidelines program with four embedded nursing unit subcases. The setting was a large, tertiary/quaternary urban health center in Canada. The nursing department initiated a program to enhance patient safety through the implementation of three guidelines: falls prevention, pressure ulcer prevention, and pain management. We selected four inpatient unit subcases that had differing levels of program sustainability at an average of almost seven years post initial program implementation. Data sources included 39 key informant interviews with nursing leaders/administrators and frontline nurses; site visits; and program-related documents. Data collection and content analysis were guided by a framework for the sustainability of healthcare innovations.
  
  
  RESULTS
  Program sustainability was characterized by three elements: benefits, routinization, and development. Seven key factors most accounted for the differences in the level of program sustainability between subcases. These factors were: perceptions of advantages, collaboration, accountability, staffing, linked levels of leadership, attributes of formal unit leadership, and leaders' use of sustainability activities. Some prominent relationships between characteristics and factors explained long-term program sustainability. Of primary importance was the extent to which unit leaders used sustainability-oriented activities in both regular and responsive ways to attend to the relationships between sustainability characteristics and factors.
  
  
  CONCLUSIONS
  Continued efforts are required to ensure long-term program sustainability on nursing units. Persistent and adaptive orchestration of sustainability-oriented activities by formal unit leadership teams is necessary for maintaining best practice guidelines over the long term. Leaders should consider a broad conceptualization of sustainability, beyond guideline-based benefits and routinization, because the development of unit capacity in response to changing circumstances appears essential.
authors.affiliation: Ingram School of Nursing, McGill University, Wilson Hall, 3506 University Street, Montreal, Quebec H3A 2A7, Canada. Electronic address: andrea.fleiszer@mail.mcgill.ca.
authors.forename: Andrea R
authors.initials: AR
authors.lastname: Fleiszer
authors.affiliation: Ingram School of Nursing, McGill University, Wilson Hall, 3506 University Street, Montreal, Quebec H3A 2A7, Canada; McGill University Health Centre (MUHC), 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada. Electronic address: sonia.semenic@mcgill.ca.
authors.forename: Sonia E
authors.initials: SE
authors.lastname: Semenic
authors.affiliation: Ingram School of Nursing, McGill University, Wilson Hall, 3506 University Street, Montreal, Quebec H3A 2A7, Canada. Electronic address: judith.ritchie@mcgill.ca.
authors.forename: Judith A
authors.initials: JA
authors.lastname: Ritchie
authors.affiliation: Ingram School of Nursing, McGill University, Wilson Hall, 3506 University Street, Montreal, Quebec H3A 2A7, Canada; McGill University Health Centre (MUHC), 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada. Electronic address: marie-claire.richer@mcgill.ca.
authors.forename: Marie-Claire
authors.initials: MC
authors.lastname: Richer
authors.affiliation: École nationale d'administration publique (ENAP), 4750 Avenue Henri Julien, Montreal, Quebec H2T 2C8, Canada. Electronic address: jean-louis.denis@enap.ca.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Denis
mesh_terms: D002170:Canada; D004059:Diffusion of Innovation; D007857:Leadership; D009729:Nursing / Q000592:standards*; D019982:Organizational Case Studies; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D058996:Quality Improvement; D012449:Safety
keywords: Case studies; Change management; Diffusion of innovation; Leadership; Nursing; Practice guidelines; Program implementation; Quality improvement; Routinization; Sustainability