title: Sustaining guideline implementation: A multisite perspective on activities, challenges and supports.
abstract: OBJECTIVE
  To examine activities conducted, challenges encountered and supports used when sustaining nursing practice guideline implementation in multiple healthcare organisations over 3 years.
  
  
  BACKGROUND
  Numerous models and frameworks exist to guide the implementation of guidelines, yet very few focus on sustaining improved practice changes. It is not known if one intervention or multiple interventions are required, nor the long-term activities, challenges and supports for sustaining improved practices.
  
  
  METHODS
  Qualitative descriptive study.
  
  
  METHODS
  We conducted focus group interviews with steering committee members and individual interviews with leaders and direct care providers at the end of a 3-year guideline implementation study. The National Health Service Sustainability Model was used to guide data collection and analysis.
  
  
  RESULTS
  The eight sites included three teaching hospitals, a community hospital, a long-term care facility, two community health agencies and a community health centre. Individual interviews were conducted with 36 leaders and 26 direct care providers. Focus group interviews were conducted with steering committee members (n = 70) at each site. Guideline implementation activities (n = 45) included developing new outcome monitoring systems, conducting chart audits, communicating progress to internal stakeholders, appointing interprofessional staff to steering committees, developing educational sessions and resources for staff and patients, revising policies and procedures, and developing partnerships with external organisations. Supports included lessons learned from previous and concurrent change initiatives, and commitment, involvement and positive attitudes of staff and leaders.
  
  
  CONCLUSIONS
  Activities identified by the participants addressed all 10 factors in the Sustainability Model in the three areas of process, staff and organisation. The challenges and supports encountered provide insights into the process of guideline implementation and sustainability.
  
  
  CONCLUSIONS
  A multilevel action plan for staff, leaders and the organisation is recommended when introducing and sustaining practice changes.
authors.affiliation: Faculty of Health Sciences, School of Nursing, Nursing Best Practice Research Centre, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Kathryn S
authors.identifier: http://orcid.org/0000-0001-9813-4696
authors.initials: KS
authors.lastname: Higuchi
authors.affiliation: Faculty of Health Sciences, School of Nursing, Nursing Best Practice Research Centre, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Barbara
authors.initials: B
authors.lastname: Davies
authors.affiliation: Faculty of Health Sciences, Aging, Community Health Research Unit, School of Nursing, McMaster University, Hamilton, ON, Canada.
authors.forename: Jenny
authors.initials: J
authors.lastname: Ploeg
mesh_terms: D003695:Delivery of Health Care / Q000592:standards; D017144:Focus Groups; D006801:Humans; D007857:Leadership; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D058996:Quality Improvement / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*
keywords: evidence-based practice; guideline implementation; nursing guidelines; sustainability