Sustaining Practice Change in Canadian Nursing Homes

By Whitney Berta

Making changes to any established work practice, process or routine is challenging. We have all tried to break work habits of our own, to change our own or others’ behaviours…and have all likely had mixed success doing so.

The challenges associated with changing work practices are present in practically every work setting, including health care.  Health Systems Researchers who are focused on knowledge translation, implementation science, and dissemination science – all informed by work in the fields of psychology, sociology, and communications – have invested considerable efforts in studying how best to introduce new research knowledge into care practices and to influence the “uptake”, “utilization” or “adoption” of it in the interests of improving patient care.  But, even after the new knowledge seems firmly in place, a whole host of new factors can still displace it once the supportive implementation approaches – like incentives, or a particularly compelling “change champion” – are removed.

Very often, we see people reverting to their “old ways of doing”.  We are, after all, creatures of habit.  This is particularly concerning in healthcare when we want to exchange older less effective knowledge for new knowledge that can change care processes and improve patients’ care.

So, how do we make new knowledge “stick”?  We don’t yet understand how to ensure that new knowledge is sustained in practice, over time.  In fact, we don’t really understand sustainability in most work settings.  Nor do we know whether and how that new knowledge is spread in an organization, once it is firmly stuck, beyond the unit or department in which it is originally introduced.

A newly funded pan-Canadian study, led by researchers from the Institute of Health Policy, Management & Evaluation (IHPME) at the University of Toronto, and the University of Alberta, will examine the long-term sustainability of a quality improvement intervention implemented in Canadian nursing homes in B.C. Alberta, and Manitoba.

Known as “SSaSSY”, the Sustainability, Sustainment, and Spread Study will track the sustainment and spread of new work processes on the part of Health Care Aides, and the benefits associated with these new processes, including health outcomes like improved mobility and reduced pain, and staff work engagement and job satisfaction.  The vehicle by which these new work processes are introduced is an evidence-based practice intervention called SCOPE, Safer Care for Older Persons in (residential) Environments.

SCOPE is itself unique, as it capitalizes on the underutilized capacity of health care aides to implement research evidence in care. SCOPE’s implementation in B.C. and Alberta nursing homes is currently being co-led by Dr. Adrian Wagg and Dr. Carole Estabrooks at the University of Alberta. SSaSSy, which focuses on SCOPE’s sustainability, will be co-led by Dr. Whitney Berta at the University of Toronto’s Institute for Health Policy, Management & Evaluation and Drs. Estabrooks and Wagg.

“The significance of the SSaSSy study is threefold”, says Whitney Berta, a professor at IHPME.  “First, the SCOPE intervention on which SSaSSy focuses is led by Health Care Aides in nursing homes.  While these workers provide 80% or more of direct care to residents in nursing homes across the country, they are not often given opportunities to lead changes in the way they work. SCOPE enables and empowers them to improve the care of nursing home residents.  Second, SSaSSy is a study of sustainability that starts while implementation is still going on, so that we can make clear connections between what happens during the time that new knowledge is introduced into a work setting, and what happens post-implementation once the additional resources and supports for putting the knowledge into place are withdrawn.  Finally, this study takes place in long term care which is historically understudied and I think that it is great that we have the potential to contribute so significantly to solving post-implementation challenges that are pervasive in every sector of health care and other work settings.  It is expensive to generate new scientific knowledge, and expensive to implement it, and we need to understand how to capitalize on these investments and realize the longer-term benefits.”

SSaSSy has received three years of funding support from the Canadian Institutes of Health Research (CIHR).