The Sustain and Spread Framework: strategies for sustaining and spreading nutrition care improvements in acute care based on thematic analysis from the More-2-Eat study

Celia Laur, Jack Bell, Renata Valaitis, Sumantra Ray, Heather Keller, Celia Laur, Jack Bell, Renata Valaitis, Sumantra Ray, Heather Keller

Abstract

Background: Successful improvements in health care practice need to be sustained and spread to have maximum benefit. The rationale for embedding sustainability from the beginning of implementation is well recognized; however, strategies to sustain and spread successful initiatives are less clearly described. The aim of this study is to identify strategies used by hospital staff and management to sustain and spread successful nutrition care improvements in Canadian hospitals.

Methods: The More-2-Eat project used participatory action research to improve nutrition care practices. Five hospital units in four Canadian provinces had one year to improve the detection, treatment, and monitoring of malnourished patients. Each hospital had a champion and interdisciplinary site implementation team to drive changes. After the year (2016) of implementing new practices, site visits were completed at each hospital to conduct key informant interviews (n = 45), small group discussions (4 groups; n = 10), and focus groups (FG) (11 FG; n = 71) (total n = 126) with staff and management to identify enablers and barriers to implementing and sustaining the initiative. A year after project completion (early 2018) another round of interviews (n = 12) were conducted to further understand sustaining and spreading the initiative to other units or hospitals. Verbatim transcription was completed for interviews. Thematic analysis of interview transcripts, FG notes, and context memos was completed.

Results: After implementation, sites described a culture change with respect to nutrition care, where new activities were viewed as the expected norm and best practice. Strategies to sustain changes included: maintaining the new routine; building intrinsic motivation; continuing to collect and report data; and engaging new staff and management. Strategies to spread included: being responsive to opportunities; considering local context and readiness; and making it easy to spread. Strategies that supported both sustaining and spreading included: being and staying visible; and maintaining roles and supporting new champions.

Conclusions: The More-2-Eat project led to a culture of nutrition care that encouraged lasting positive impact on patient care. Strategies to spread and sustain these improvements are summarized in the Sustain and Spread Framework, which has potential for use in other settings and implementation initiatives.

Trial registration: Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.

Keywords: Acute care; Hospital; Implementation; Knowledge translation; Nutrition; Participatory research; Spread; Sustainability.

Conflict of interest statement

Ethics approval and consent to participate

Ethical approval for the More-2-Eat project was obtained from the University of Waterloo Research Ethics Board (ORE #20590) and from the ethics committees at each of the five participating hospitals. For the sustainability interviews, all sites agreed to be covered by the University of Waterloo ethics. Written consent was obtained from each participant prior to their interview or focus group.

Consent for publication

Not Applicable.

Competing interests

At the time of the study, H.K. was co-chair of the Canadian Malnutrition Task Force, which receives unrestricted grants from the Canadian Nutrition Society. H.K. and C.L. have received honoraria for speakers’ bureaus with Abbott Nutrition, Nestlé Health Sciences, Fresenius Kabi and/or Baxter in the past three years. The other authors have no conflicts of interest to disclose.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
The Sustain and Spread Framework: Once there is initial implementation success, strategies are used to sustain and spread the successful change. Strategies to encourage changes to be sustained or spread are included within each circle, with the two strategies in the middle applying to both sustaining and spreading success. To fully spread into a new setting or unit, a new change goes back to implementation (arrows from the Spread circle back to Implementation) in the new context. Working through several rounds of sustaining and spreading may lead to an overall culture change

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