CHAPTER 10
Enduring Professional Practice Models: Sustainment
KEY WORDS
Sustainability, organizational memory
OBJECTIVES
By the end of this chapter, readers will be able to:
1. Define the nurse leader’s role in the long-term sustainment of a professional practice model (PPM)
2. Evaluate various sustainability frameworks and assessment tools
3. Analyze the term organizational memory
4. State at least four leadership strategies used to enhance sustainability of PPMs
THE NATURE OF SUSTAINABILITY
Although a PPM may become internalized such that professional nurses reinterpret the nature of nursing practice according to its components, embed it in daily workflow, and assume accountability for its appropriate delivery, its long-term survival in a health system is not ensured.
In fact, in the face of adjustments (in this case, behavior changes), many individuals are prone to returning to older, more familiar behaviors and, as the initial enthusiasm wanes and competing demands begin to dominate leaders’ time, many often fail to recognize their important role in this phase of integration. In fact, without active engagement, continued support, and dedicated attention, sustaining a professional practice model (PPM) over the long term often lapses after implementation is completed. Upholding a PPM over time, however, is necessary to positively impact health outcomes and demonstrate value for a health system. Furthermore, it represents an organization’s investment in the PPM and as such, warrants ongoing upkeep.
Sustainability refers to the continual presence of all or most of an innovation’s (e.g., PPM) components so that delivery of its intended benefits over an extended period of time can be realized after implementation support has been terminated (Blasinsky, Goldman, & Untzer, 2006; Shediac-Rizkallah & Bone, 1998). The importance of sustaining a PPM so that its usefulness and value can be demonstrated is crucial. Too many health care innovations are left inadequately integrated and, despite major investments of time and resources, their intended results often remain unknown to clinicians, health systems, or worse, to patients and families.
Some studies have illustrated the difficulties of sustaining new programs but few have systematically investigated the concept. However, in one systematic review, partial sustainability was reported to be more common than full sustainability, an increase in the number of recipient-level benefits was reported, and fidelity to the original innovation was incomplete (Stirman et al., 2012). Additionally, the evidence for sustainability was reported to be immature and fragmented, limiting knowledge advancement. In spite of this, understanding the challenges related to sustainability of innovations and testing various strategies for long-term sustainment could never be more necessary. Some authors have provided frameworks concerning sustainability that may help foster research and more effective integration.
SUSTAINABILITY FRAMEWORKS
The public health discipline has provided several frameworks for considering the concept of sustainability. For example, Schell and colleagues (2013) referred to specific factors that influence sustainability, particularly related to chronic disease innovations for community application. Using a comprehensive literature review, input from an expert panel, and the results of concept mapping, a number of selected factors were identified that represent the core domains of capacity for public health program sustainability. They include environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, communications, and strategic planning. The authors suggest that these factors may be related to a program’s ability to sustain its activities and benefits over time and may be useful for decision makers, program managers, program evaluators, and implementation researchers.
Another contribution from the public health literature is the sustainability planning model (Johnson, Hays, Hayden, & Daley, 2004), also known as intervention theory. This model is a comprehensive, prescriptive, capacity-building approach that denotes a group of factors (e.g., type of structure and formal linkages, presence of champions for an innovation, effective leadership, resources, administrative policies and procedures, and expertise), innovation attributes (e.g., alignment with needs, positive relationships among key implementers, successful implementation and effectiveness in the target system, and ownership by system stakeholders), and actions that need to be addressed to explain sustainability readiness and ultimately sustainability outcomes (e.g., integration of an innovation into normal operations at the organizational, community, state, or federal levels and key stakeholders’ benefits received as a result of the innovation). The relationship between innovation integration into a system and stakeholder benefits is considered reciprocal in this framework, with each outcome influencing the other.
From a broader organizational view, Yin’s routinization framework (1979, 1981) was developed after examining how technical innovations became standard practice. Yin refers to sustainability as the institutionalization or routinization of programs into ongoing organizational core services. Yin suggested that full routinization depends on processes or cycles and distinguishes among three degrees of routinization: marginal, moderate, and high, reflecting the number of cycles that had been encountered. Some examples of routinization cycles (Yin, 1979, 1981) are as follows:
• The new program survives annual budget cycles.
• Program activities become part of job descriptions/hiring practices.
• The program survives turnover of personnel/leadership.
• Key program staff members are promoted within the agency.
• Supply and maintenance are provided by the agency.
• It is spread throughout the system (or niche saturation).
• Many training cycles are observed.
• Competencies become part of professional standards.
• The use of the program is recognized in manuals, procedures, meeting minutes, and regulations.
• The innovation is recognized as permanent within the agency.
In this way, the new program becomes unidentifiable as it is blended into the institutional infrastructure.
In another framework, Racine (2006) names three sets of factors—innovation legitimacies, contextual conditions (organizationally and locally), and functional attributes such as technical competence and communication influencing sustainment of innovations. The usefulness, relevance, acceptability, and, most important, the value of an innovation, which consistently delivers on these factors, demonstrate an innovation’s legitimacy. The local and organizational fit with the innovation and employee functional attributes also play important roles in sustained effectiveness of innovations.
Although these frameworks help to better understand the complex nature of sustaining new programs, they have several limitations. For example, there is little discussion of costs or contexts, and they refer to sustainment in a linear fashion (which is often not the case in the complex world of health care).
The challenge of implementing multicomponent innovations, such as a PPM in complex, dynamic health systems, presumes that a well-developed implementation plan followed by evaluation and ongoing leadership support will ensure successful and lasting integration. Yet, the ever changing health care context often limits such sustainability. The Dynamic Sustainability Framework (DSF), however, acknowledges that change is constant and sustainability of an innovation over time requires ongoing development and refinement that is never complete (Chambers, Glasgow, & Stange, 2013).
In this way of imagining sustainability, the PPM, already enculturated within a health system, benefits from continued improvement that allows potential enhancements to be made and shared, offering better information on which to make decisions to cease old ways of delivering care. The intention is to recognize and support rapid learning, real-time problem solving, and generation of knowledge, through a shared process of continual experimentation and analysis, not just routine application of a static PPM.
The DSF is intended to suggest a new longer term paradigm with ongoing improvement of the PPM (even pooling of data from multiple sites), allowing continuous exposure of the innovation to new populations and new contexts. Indeed, the DSF posits that ongoing improvement is the ultimate aim, with optimization of the fit between the model and the dynamic delivery context essential to achieving sustainment. Although this framework is more dynamic, the question of sustainability of a PPM in health systems may also be understood through more practical behaviors observed in most organizations.
Organizational Memory
As suggested by several sustainability frameworks, shared knowledge, actions, or practices (organizational routines) play a key role in innovation continuance. One of those shared traditions, namely, organizational memory, is defined as shared interpretations of past experiences that are brought to bear on present activities (Stein, 1995). Furthermore, Walsh and Ungson (1991) asserted that organizational memory is not stored centrally but is distributed across different retention facilities. It refers to the collective ability to acquire, store, and retrieve knowledge and information. This persistence of organizational traits over time suggests that retention and transmission of information (or knowledge) from past generations to future members of a system is intact. This is important for organizations because it represents the “personality” of the system (Weick, 1979) and preserves its autonomy (Deutsch, 1966). In essence, the memories maintained by an organization plot a map of the past that contains information crucial to organizational effectiveness (Stein, 1995).
In terms of significant experiences, organizations “remember” lessons from the past in a variety of ways. An organization’s memory resides in the minds of individual employees, in their many relationships with each other, in repositories, such as computer databases and file cabinets, and can also be embedded in work processes that have evolved over time. For example, in nursing, the routine of admitting a new patient into a hospital may be “remembered” as a unique series of tasks that involves specific individuals and reflects lessons learned about admission over time. This collective knowledge is then transmitted to each new generation of nurses in such a way that allows for little deviation from those past experiences.
Thus, organizational memory is neither good nor bad, but it sets the tone for a system, affecting employee attitudes and behaviors, and ultimately its success.
Stein (1995) proposed that organizational memory is associated with organizational effectiveness, and the processes of acquisition, retention, maintenance, and retrieval are necessary for organizational memory to operate. Because they vary from one system to the next, higher or lower levels of organizational memory are created. For example, memories are acquired through learning over time, recorded events, and are retained within individuals or groups of people who work together for a long time, and through certain rituals or ceremonies. They are maintained through specific norms and artifacts, including logos, symbols, or designs, and are retrievable through individuals, written documents, and observations of specific routines. Such memories can enhance or thwart long-term sustainability of innovations.
Organizational memory as it relates to a PPM refers to what organizations learn, reminisce about, and recollect as they experience it. If organizational memory about professional practice is congruent with organizational values and mission, this can lead to long-lasting performance that may advantage the system over its competitors. Contrarily, if it evokes negative memories, it can threaten the practice, leading to fragmentation or inappropriate behaviors, and its chances for extended survival are less likely because employees’ “remembered” routines may undermine the new innovation, damaging the system’s ability to deliver long term. Thus, the long-term sustainability of a PPM may be dependent on organizational memories about what nursing means in the model and how it was applied. Nevertheless, because organizational memory resides in individuals and groups of individuals, it can easily fall apart.
For example, as systems lose employees, restructure, realign purposes, or add innovations to meet new demands, the shared knowledge and routines accumulated over time begin to collapse. For leaders, organizational memory is a system characteristic that must be respected and, in the case of a PPM, leveraged for future decision making. For instance, identifying ahead of time which experiences vis-à-vis the PPM hold important lessons for future nurses helps direct efforts to preserve such knowledge. For example, important learning events that are critical, one-of-a-kind opportunities, such as inaugural presentations, inspirational messages, or significant consulting engagements during which unique approaches were discussed, should be preserved through archived means. Assigning appropriate champions and role models who will facilitate integration in a relationship-friendly manner gradually helps nurses develop new skills and embeds these new behaviors into routine practices. Noticing, naming, and documenting relevant practices in which the PPM is entrenched ensure that the lessons of experience influence how nursing work is remembered for future generations. The main leadership challenge consists of establishing what needs to be preserved and how that preservation will drive nursing work in the future, ultimately creating long-lasting value for the health system. In doing so, the benefits of good organizational memory may be realized:
• It can help leaders and leaders of the future uphold intentional direction over time.
• It can facilitate access to the choice, design, implementation, and evaluation of the model as it was first encountered, providing meaning to the work of individual nurses.
• It can strengthen the identity of the health system.
• It can enable health systems to avoid past mistakes.
• It can enable use of best practices.
• It can provide newcomers with access to the expertise of those who preceded them.
In essence, nurse leaders can continue to influence future nurse work by deliberately developing good organizational memories and using those pockets of knowledge to guide organizational activities and decision making over time.
A health system’s capacity for sustainment, however, might be assessed through specific tracking and sustainability measures.
MEASURING SUSTAINABILITY
Although individual health systems and researchers create unique approaches for evaluating sustainability of new programs, services, and innovations, many are not routinely applied, validity and reliability are often not reported, and many are inaccurately administered. Because some theoretical work has already been conducted on sustainability (see sustainability frameworks, described previously), acceptable precision is available to guide the evaluation of sustainability, albeit it tends to be very specific to a population. For example, the Program Sustainability Assessment Tool (PSAT; Luke, Calhoun, Robichaux, Elliott, & Moreland-Russell, 2014) derived from the program sustainability framework (Schell, 2013) has been reported (N = 592). This instrument contains 40 items, has eight domains, with five items per domain. Confirmatory factor analysis shows good fit of the data and the subscales have excellent internal consistency, ranging from .79 to .92 with the overall Cronbach’s α = .88. Although seemingly easy to use, validation is ongoing.
Similarly, Goodman, McLeroy, Steckler, and Hoyle (1993) used Yin’s (1979) routinization framework to develop the Level of Institutionalization Scales (LoIn) of health-promotion programs. The LoIn instrument is a beginning effort to measure the extent of program integration in organizations. A questionnaire designed to test this construct was mailed to 453 administrators in 141 organizations that operate health-promotion programs in North Carolina. Based on a 71% response rate, a confirmatory factor analysis supported an eight-factor structure: four factors concerned how routinized the program was in each subsystem and four factors concerned the degree of program saturation within each subsystem. Correlations of the eight factors with the number of years the programs had been in operation, and managers’ perceptions of program permanency, indicated that the four routinization factors were more highly correlated with program longevity than the four niche saturation factors, and the niche saturation factors were more highly correlated with managers’ perceptions of program permanence than the routinization factors. The instrument, which has 15 items, is a beginning effort to operationalize the degree of routinization and warrants further research and validation in other contexts.
Mancini and Marek (2004) developed a 29-item Program Sustainability Index (PSI) to assess six factors related to the sustainability of community-based programs. They are leadership competence, effective collaboration, demonstrating program results, strategic funding, staff involvement and integration, and program responsivity. Internal consistency among the factors was acceptable: leadership competence (α = .81, 5 items), effective collaboration (α = .88, 10 items), staff involvement and integration (α = .76, 4 items), demonstrating program results (α = .85, 4 items), strategic funding (α = .76, 3 items), and program responsivity (α = .67, 3 items). The researchers used a fairly homogeneous group (N = 242) to test the PIS with 242 respondents yielding a promising measure. However, further research is needed with a larger and more diversified population to refine the instrument.
According to Stirman et al. (2012), qualitative and mixed methodologies that assess potential influences across multiple levels of sustainability will continue to be necessary to better understand the relationships between sustainability drivers, and facilitate the development of interventions to promote sustainability. In their review, they suggested that certain qualitative studies yielded a wider variety of findings and highlighted processes and constructs that warrant further study. However, most did not provide interview guides, limiting interpretability and replicability. Thus, although several sustainability measures exist, the development and improvement of the measures will promote better understanding and more effective evaluation.
ENHANCING SUSTAINABILITY
Sustainability cannot be easily addressed after it is finished; rather, it is important to make it a priority from the very beginning of PPM integration.
