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J Nurs Scholarsh. 2019 Nov 8. doi: 10.1111/jnu.12527. [Epub ahead of print]

Understanding Determinants of Sustainability Through a Realist Investigation of a Large-Scale Quality Improvement Initiative (Lean): A Refined Program Theory.

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Postdoctoral research fellow, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
Professor, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.



Implementation science research seeks to understand ways to best ensure uptake of research-based initiatives to health care; however, there is little research done on how to sustain such efforts. Sustainability is the degree to which an initiative continues to be used in practice after efforts of implementation have ended. Sustainability research is a growing field of implementation science that needs further research to understand how to predict and measure the long-term use of effective initiatives to improve health care. The question of what influences the sustainability of research-based initiatives to improve health care remains unknown.


The purpose of this article was to present a refined program theory on the contextual factors and mechanisms that influence the sustainability of one large-scale quality management initiative (Lean) in pediatric health care.


We conducted a multiphase realist investigation to explain under what contexts, for whom, how, and why Lean efforts are sustained or not sustained in pediatric health care through the generation of an explanatory program theory.


This article presents the theoretical triangulation of our multiphase realist investigation, resulting in a refined program theory. We integrated the initial program theories (IPTs) from each research phase to form a refined program theory. It involved going back and forth from the initial IPT to the findings from each phase and our middle-range theories and examining the most substantiated IPTs on the contextual factors and mechanisms that influenced the sustainability of Lean efforts.


The refined program theory depicts the complex nature to sustaining Lean efforts and that sustainability as a small, often unrepresentative portion of something much larger or more complex that cannot yet be seen or understood. The approach and nature of implementation is critical to shaping contexts for sustainability. Outcomes from implementation become facilitating or hindering contexts for sustainability. Customization to context is an important contextual factor for sustainability. Sense making, value congruency, and staff engagement are critical aspects from early implementation that enable or hinder processes of sustainment. Such mechanisms can trigger staff empowerment that can lead to a greater likelihood of sustainability.


These findings have important implications for sustainability research, in understanding the determinants of sustainability of research-based initiatives in health care.


It is important to understand and explain determinants of sustainability through theory-driven evaluative research in order to assist key stakeholders in sustaining the effective research-based initiatives made to improve healthcare services, patient care, and outcomes.


Implementation science; Lean; pediatrics; quality improvement; realist; sustainability


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