HEALTH SERVICE RESEARCH CSIRO PUBLISHING
Australian Health Review, 2015, 39, 70–75 http://dx.doi.org/10.1071/AH14031
A theoretical framework to support research of health service innovation Amanda Fox1,2 RN, PhD candidate, Lecturer Glenn Gardner1 RN, PhD, Professor of Nursing Sonya Osborne1 RN, PhD, Senior Lecturer 1
Queensland University of Technology, School of Nursing, Victoria Park Road, Kelvin Grove, Qld 4059, Australia. Email: [email protected]; [email protected] 2 Corresponding author. Email: [email protected]
Abstract Objective. Health service managers and policy makers are increasingly concerned about the sustainability of innovations implemented in health care settings. The increasing demand on health services requires that innovations are both effective and sustainable; however, research in this field is limited, with multiple disciplines, approaches and paradigms influencing the field. These variations prevent a cohesive approach, and therefore the accumulation of research findings, in the development of a body of knowledge. The purpose of this paper is to provide a thorough examination of the research findings and provide an appropriate theoretical framework to examine sustainability of health service innovation. Methods. This paper presents an integrative review of the literature available in relation to sustainability of health service innovation and provides the development of a theoretical framework based on integration and synthesis of the literature. Results. A theoretical framework serves to guide research, determine variables, influence data analysis and is central to the quest for ongoing knowledge development. This research outlines the sustainability of innovation framework; a theoretical framework suitable for examining the sustainability of health service innovation. Conclusion. If left unaddressed, health services research will continue in an ad hoc manner, preventing full utilisation of outcomes, recommendations and knowledge for effective provision of health services. The sustainability of innovation theoretical framework provides an operational basis upon which reliable future research can be conducted. What is known about the topic? Providers of health services are rapidly implementing innovations in an effort to provide effective health care. Little research has been conducted to evaluate the sustainability of these health service innovations. What does this paper add? This paper aims presents an integration and synthesis of the current body of knowledge to provide a theoretical framework to evaluate the sustainability of health service innovation. What are the implications for the practitioner? An improved body of knowledge surrounding the sustainability of health service innovations generated from research will consequently result in more appropriate use of resources and improved provision of health services. Additional keywords: healthcare, sustainability, delivery models.
Received 4 February 2014, accepted 23 September 2014, published online 17 December 2014
Introduction Spiralling healthcare costs and increased consumer demand have seen a rapid introduction of many health service innovations. Despite great interest and a need to understand these innovations, research into sustainability is scant and fragmented. There is a need for research that is embedded in appropriate theoretical framework and presents a clear methodology for replication to extend the body of knowledge. Health services research typically spans multiple disciplines, many of which have conflicting or Journal compilation Ó AHHA 2015
varied preferences in relation to research concepts, approach and perspectives. Health services research is complex, partly due to the large number of occupational groups, disparity of influence between employee groups and changing patient acuity, which prevents standardising some processes.1 As such, health services research has many stakeholders and research in this field draws upon methods from several disciplines and paradigms.1 The challenge is to successfully synthesise the research findings from these varied sources to effectively meet the needs of health service www.publish.csiro.au/journals/ahr
Theoretical frameworks for health service research
managers and policy writers attempting to meet current service needs. The purpose of this paper is to present an integrative review of research into sustainability of health service innovation and to propose a theoretical framework to guide future research in this field. Methods A comprehensive search was undertaken to locate both published and grey literature in databases including Medline, CINAHL, PubMed and the Cochrane Library. Key subject words and terms used were combined, adapted and spelling altered to suit the needs of the database searched (Table 1). Synonyms of the key terms were identified using thesaurus options in each database to ensure all terms were broad enough to capture the research pertaining to the field of health service innovation and sustainability. A manual search was then conducted of articles in the reference lists of the articles identified to further identify relevant studies. The initial search returned 334 articles. Peer-reviewed articles that used or recommended a theoretical or conceptual framework to examine the sustainability of a health service innovation were included in the analysis. Articles were excluded based on duplication, if sustainability was referred to in the sense of environmental sustainability or sustainability of a patient outcome following an intervention. The review method consisted of perusal of the abstract of each article and, where eligibility could not be ascertained, the full text of the article. Studies were then examined in full text for quality and those based on poor methodological quality were excluded. Following this process, 29 studies were included in the analysis.2–30 Results Definitions lack clarity In the case of health service innovation sustainability, the literature review identified minimal empirical research. The research that has been completed is mostly lacking in rigor2 and a theoretical or conceptual framework. The definition of ‘sustainability’ is controversial and much debated, with many varied definitions throughout the literature.2,31 The same variability was found in the literature related to health service innovation. A systematic review by Greenhalgh et al.3 yielded a conceptual model of the determinants of diffusion, dissemination and implementation of innovations in service organisations. However, despite the original research question related to sustainability, the scarcity of research addressing sustainability prevented Greenhalgh et al. from including this concept in their work.3 Following this publication, further research has emerged. However, clarity of definition and research informed by and informing theory are still lacking.3 Predominantly, the research Table 1. Summary of the themes and keywords used in the literature review *Truncations were used in the terms as shown to ensure thorough capture of research pertaining to the field of health service innovation and sustainability Concept
Setting
Topic
Sustain* Institutional* Routini*
Health service* Health service research Health service innovation
Theoretical framework Conceptual framework Framework
Australian Health Review
71
consists of descriptive publications relating to rural health program implementation,4–9 sustainability of community-based programs,10–17 health systems in low-income countries18,19 and theories related to behaviour change and management.2,25,26 Variation between operational definitions of sustainability made comparison difficult and less than half the studies appeared to be guided by a conceptual model or framework.2,31 Use of theoretical underpinnings Application of a theoretical framework in research may prevent repetition of previously explored concepts, adding to, rather than replacing or repeating, previous research and can inform a thorough examination of the phenomena to be studied. A framework is necessary to bind together all aspects of the research and can be likened to a research compass that guides the research question, implementation strategies and evaluation process of any research.32 Systematic structure, rationale and justification for how and why research will be undertaken, and transferability of research processes across contexts and settings, is made possible by the use of theoretical frameworks.32 Research that is not embedded in theory results in questionable contribution to knowledge. Expansion of a solid research paradigm and body of knowledge is developed by replication, comparison and systematic reviews of health services research. However, this can only occur with clear articulation of theoretical frameworks and methodological approaches. A recent systematic review into the sustainability of new programs and innovations found few comprehensive or methodologically rigorous studies.2 Research into health services sustainability has previously presented a pragmatic rather than academic perspective and has often been presented as grey reports that lack guidance about theoretical frameworks or research processes taken.3 All research is guided, either explicitly or implicitly, by the existing body of knowledge in the field; however, when a field of research is in its infancy, the methods used to gain a body of evidence need to be formalised and justified to support the validity of concepts and development of the paradigm.33 To date, there has been limited research examining sustainability of innovative health service delivery models within acute healthcare settings. Theoretical frameworks for health service sustainability Initially, the sustainability of innovation concept can be traced back to Rogers’ diffusion of innovation theory.34 Rogers’ work has been highly influential across many domains and disciplines, including and leading to the work of Greenhalgh et al.3 in 2003 into service innovations, among others.20–22 The child survival sustainability assessment (CSSA) framework was specifically designed to examine programs in the context of developing countries23,24 and the Sustainability Analysis Methodology (SAP) was designed by Blanchet and Girois25 specifically for low-income countries implementing health programs. The normalisation process theory was presented by May et al. in 2009 as an effective method of implementing, embedding and integrating practices.26 In 2013, Chambers et al. challenged the concept that sustainability was an endpoint and introduced the dynamic sustainability framework (DSF), positing a framework that involves continual adaptation as a result of learning, problem
72
Australian Health Review
solving and evolution.29 This framework is yet to be operationalised, but this concept and others have been influential in the construction of the sustainability of innovation framework discussed below. Discussion Construction of a theoretical framework
A. Fox et al.
innovation sustainability.2,3,34 Chambers et al. argue that sustainability of innovation is enhanced when continual improvements are made to refine an innovation to suit the individual context.29 Agreed operational governance within an organisation26 and effective communication within and across departmental boundaries in an organisation will enhance sustainability.21 A lack of meetings and teamwork has led to a lack of support for innovation and poor sustainability.21 As a result, the organisational factors of the framework strongly focus on identifying existing communication and networking strategies.
Expert researchers working in established fields knowingly conduct research from a well-grounded theoretical base that has been established through years of research and knowledge development. For novice researchers and those working in emerging fields, it is essential that the use of theory is made explicit, not only for paradigm construction, but also to hone research skills and ingrain robust practice among inexperienced researchers. Selection or construction of a relevant theoretical framework is a process often found arduous by novice researchers. Learning how to identify or construct a suitable theoretical framework and how to use the framework to guide research is an essential component of the learning pathway of novice researchers. The process requires identification of key research concepts and clarification of these as they exist and inform the proposed research idea or question. Careful examination and analysis of existing theories and prominent authors in the field will allow the researcher to determine the appropriateness of a particular theory to the pending research. Synthesis of these ideas by the researcher will inform construction or selection of a theoretical framework most appropriate for the proposed research.
Financial factors influencing sustainability are the provision of funding and budgetary planning for ongoing resources, human and consumable, as well as a demonstrated cost-effectiveness of the innovation. Research that has been completed on programs and projects often found sustainability was impacted once external funding ceased. Innovations introduced as trials or projects often are not sustained long term due to the temporary funding associated with trials.30 An innovation that has a dedicated, ongoing and adequate budget sufficient to meet the needs is more likely to be routinised by the organisation.3 Lack of research evaluating the financial value and cost-effectiveness of innovations often leave innovations vulnerable.21 Therefore, the financial factors of the theoretical framework ascertain funding sources, planning and evaluation strategies of the innovation.
Development of the sustainability of innovation framework
Workforce factors
Completing this integrative review has informed the theoretical background to the development of the sustainability of innovation framework. The sustainability of innovation framework combines the concepts presented by Greenhalgh et al. in their systematic review of service innovation3 and the DSF of Chambers et al.29 to provide a theoretical framework suitable for the examination of sustainability of any health service innovation. The sustainability of innovation framework consists of five factors that have been constructed by synthesis of theoretical propositions of the above-cited prominent authors in the field and additional current literature. These factors are political, organisational, financial, workforce and innovation related; each is explained briefly below.
Research has found that minimal staff and role changes and staff training that is timely with the use of high-quality training resources support sustainability of an innovation.3 Innovations consistent with values and needs of staff are more readily adopted21 and employee perceptions of the value of an innovation strongly impact upon routinisation.21,30 Lack of continuity or not having adequate staff to implement an innovation are threats to sustainability.21 Single staff member service models found the ability to meet demands proved difficult and annual leave, parental leave and staff attrition made innovations vulnerable, particularly where succession planning had not been initiated.30 Having processes in place to monitor the quality and outcome of the innovation and regularly providing staff with feedback enhance routinisation.3 Staff attrition, continuity and employment models, along with staff attitudes and perceptions as to the quality of the innovation, are key to the workforce factors in the theoretical framework.
Political factors Research suggests that a political focus on one particular policy will strongly influence the sustainability of an innovation related to this policy, and innovations well linked to regional health planning and national policy directions are more likely to be routinised.3,21 These policies change with the change of government, as does funding provision surrounding these policies. Political sustainability is thought to be enhanced when upperlevel management staff and organisational culture support the innovation.2,21 Therefore, questions regarding alignment, links and staff involvement are the major focus of the political segment. Organisational factors Flexibility and adaptation of the innovation to suit the local context and organisation has been acknowledged as supporting
Financial factors
Innovation-specific factors The nature and type of innovation will play a role in sustainability.2 Important features of an innovation are fluidity and adaptability to respond to changes in funding and service requirements based on local decision making and need.3,21 Latest research suggests that innovations are constantly evolving to suit context needs, and this change is inevitable for sustainability.30 The acceptability, quality and safety of the innovation to the stakeholders can be linked directly to sustainability. Ongoing evaluation using measures relevant to stakeholders to evaluate the quality of an innovation is imperative.29 As a result, the
Theoretical frameworks for health service research
• • • •
Australian Health Review
Government and local policy alignment Links with regional health plans, goals and visions Local and national champion involvement Staff involvement in the implementation and decision making
• • •
Political factors
• •
Interdepartmental and intradepartmental communications Adaptation of the innovation to local context and perceived need Existence of networking opportunities with external organisations
Organisation factors
Financial factors
•
Workforce factors •
Funding sources identified and secure Budgetary planning for continuation of the innovation Evaluation strategies to examine cost effectiveness are in place
Innovation specific factors
• • •
• • •
73
Staff recruitment processes, succession and leave planning Education and training provisions and processes Staff perception of innovation need Staff per ception of innovation safety and quality
Support for the innovation Barriers to the innovation Safety and quality of innovation
Fig. 1. Sustainability of innovation theoretical framework.
innovation-specific factors focus on identifying support and barriers to the innovation and evaluation strategies of the innovation itself. The five factors can be operationalised and guide research to explore the dynamics influencing sustainability of health service innovation. The factors are not discrete areas, but rather a collection of characteristics that are dynamic and may interact with each other. The framework represents the dynamic nature of sustainability, as suggested by Chambers et al.,30 as the innovation is optimised within the relevant context to enable rather than prevent sustainability. The framework characteristics are conceptual and sufficiently robust to guide the research and to identify the variables and data collection and evaluation methods that should be used (see Fig. 1). Health service innovations exist in real-life, often complex environments and, as such, data collected relating to a factor from one area may provide insights into characteristics that impact on one or more of the other factors within the framework. Interactions between components of a framework may not be fully understood until after practical utilisation and evaluation of research results. Empirical research allows for collection and
examination of unforeseen additional information, inadequacies and complications that may only arise during implementation of the research. Recommendations This theoretical framework may be appropriate to examine sustainability across different research methodologies and various service innovations. Given the minimal amount of empirical research in this field, testing of the framework is recommended across a broad range of health service innovations. In addition, a specific theoretical framework, although based on highly regarded theoretical background information, is often only a starting point and may look considerably different following practical application, evaluation, revision and development. Limitations are recognised by the over-dependence on theoretical frameworks developed within the community health domain and international programs that dominate the existing small body of knowledge. Operationalising this proposed framework in several contexts will provide a broader understanding and development of these concepts. This leads to new knowledge development,
74
Australian Health Review
where theory informs research processes and, in turn, is informed by research findings. Conclusion Although health services research is an emergent field, strong theoretical links need to be made in an attempt to establish a sound knowledge base. The current paucity of research, and therefore evidence, on which to develop a paradigm for health service research is recognised. This article has explored the rationale for using theoretical frameworks and their importance for novice researchers and emerging research fields, and has presented the developmental process to construct a framework to explore health service innovation sustainability. Testing of frameworks with research using appropriate methodology is required across many health services to identify inadequacies and refine theory. If future research in this field is to effectively inform health services, policy and implementation of innovations, theoretical frameworks must be used and tested. Researchers are urged to scaffold their work in strong, evidence-based theoretical frameworks to ensure synthesis of findings and development in the health services research paradigm. Competing interests None declared. References 1
Black N. Health services research: saviour or chimera? Lancet 1997; 349: 1834–6. doi:10.1016/S0140-6736(96)12164-4 2 Stirman SW, Kimberley J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future use. Implement Sci 2012; 7: 17. doi:10.1186/1748-5908-7-17 3 Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004; 82: 581–629. doi:10.1111/j.0887-378X. 2004.00325.x 4 Tham R, Humphreys J, Kinsman L, Buykx P, Sasid A, Tuohey K, Riley K. Evaluating the impact of sustainable comprehensive primary health care on rural health. Aust J Rural Health 2010; 18: 166–72. doi:10.1111/ j.1440-1584.2010.01145.x 5 Taylor J, Blue I, Misan G. Approach to sustainable primary health care service delivery for rural and remote South Australia. Aust J Rural Health 2001; 9: 304–10. doi:10.1046/j.1038-5282.2001.00387.x 6 Gruen R, Weeramanthri T, Bailie R. Outreach and improved access to specialist services for Indigenous people in remote Australia: the requirements for sustainability. J Epidemiol Community Health. 2002; 56: 517–21. doi:10.1136/jech.56.7.517 7 Swayne A, Eley D. Synergy and sustainability in rural procedural medicine: views from the coalface. Aust J Rural Health 2010; 18: 38–42. doi:10.1111/j.1440-1584.2009.01104.x 8 Fuller J, Harvey P, Misan G. Is client-centred care planning for chronic disease sustainable? Experience from rural South Australia. Health Soc Care Community 2004; 12: 318–26. doi:10.1111/j.1365-2524.2004. 00501.x 9 Buykx R, Humphreys J, Tham R, Kinsman L, Wakerman J, Asaid A, Tuohey K. How do small rural primary health care services sustain themselves in a constantly changing health system environment? BMC Health Serv Res 2012; 12: 81–7. doi:10.1186/1472-6963-12-81 10 Scheirer MA, Dearing JW. An agenda for research on sustainability of public health programs. Am J Public Health 2011; 101: 2059–67. doi:10.2105/AJPH.2011.300193
A. Fox et al.
11 Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res 1998; 13: 87–108. doi:10.1093/her/13.1.87 12 Willis K, Small R, Brown S. Using documents to investigate links between implementation and sustainability in a complex community intervention: the PRISM study. Soc Sci Med 2012; 75: 1222–9. doi:10.1016/j.socscimed.2012.05.025 13 Nordqvist C, Timpka T, Lindqvist K. What promotes sustainability in safe community programmes? BMC Health Serv Res 2009; 9: 4–12. doi:10.1186/1472-6963-9-4 14 Pluye P, Potvin L, Denis J, Pelletier J, Mannoni C. Program sustainability begins with the first events. Eval Program Plann 2005; 28: 123–37. doi:10.1016/j.evalprogplan.2004.10.003 15 Pluye P, Potvin L, Denis J, Pelletier J. Program sustainability: focus on organisational routines. Health Promot Int 2004; 19: 489–500. doi:10.1093/heapro/dah411 16 Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health 2003; 26: 177–93. doi:10.1097/00003727-200307000-00003 17 Barnett L, Van Beurden E, Eakin E, Beard J, Dietrich U, Newman B. Program sustainability of a community-based intervention to prevent falls among older Australians. Health Promot Int 2004; 19: 281–8. doi:10.1093/heapro/dah302 18 Olsen I. Sustainability of health care: a framework for analysis. Health Policy Plan 1998; 13: 287–95. doi:10.1093/heapol/13.3.287 19 Gruen R, Elliott J, Nolan M, Lawton P, Parkhill A, McLaren C, Navis J. Sustainability science: an integrated approach for health-programme planning. Lancet 2008; 372: 1579–89. doi:10.1016/S0140-6736(08) 61659-1 20 Homa K. Evaluating the sustainability of a quality improvement initiative. Doctor of Philosophy Thesis, Dartmouth College, New Hampshire; 2006. 21 Sibthorpe B, Glascow N, Wells R. Emergent themes in the sustainability of primary health care innovation. Med J Aust 2005; 183: 77–80. 22 Raffel K, Yee Lee M, Dougherty C, Green G. Making it work: administrator views on sustaining evidence-based mental health interventions. Adm Soc Work 2013; 37: 494–510. doi:10.1080/03643107. 2013.828003 23 Sarriot E, Winch PJ, Ryan LJ, Bowie J, Kouletio M, Swedberg E, LeBan K, Edison J, Welch R, Pacqué MC. A methodological approach and framework for sustain assessment in NGO-implemented primary health care programs. Int J Health Plann Manage 2004; 19: 23–41. doi:10.1002/ hpm.744 24 Sarriot E, Winch PJ, Ryan LJ, Edison J, Bowie J, Swedberg E, Welch R. Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organisations. Int J Health Plann Manage 2004; 19: 3–22. doi:10.1002/ hpm.743 25 Blanchet K, Girois S. Selection of sustainability indicators for health services in challenging environments: Balancing scientific approach with political engagement. Eval Program Plan 2013; 38: 28–32. 26 May C, Finch T. Implementing, embedding and integrating practices: an outline of normalization process theory. Sociology 2009; 43: 535–54. doi:10.1177/0038038509103208 27 May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res 2006; 6: 86–94. doi:10.1186/1472-6963-6-86 28 Forster D, Newton M, McLachlan H, Willis K. Exploring implementation and sustainability of models of care: can theory help? BMC Public Health 2011; 11: S8. doi:10.1186/1471-2458-11-S5-S8 29 Chambers D, Glasgow R, Strange K. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci 2013; 8: 117. doi:10.1186/1748-5908-8-117
Theoretical frameworks for health service research
Australian Health Review
30 Considine J, Fielding K. Sustainable workforce reform: case study of Victorian nurse practitioner roles. Aust Health Rev 2010; 34: 297–303. doi:10.1071/AH08727 31 Hanson H, Salmoni A, Volpe R. Defining program sustainability: differing views of stakeholders. Can Public Health Assoc 2009; 100: 304–9. 32 Ringsted C, Hodges B, Scherpbier A. ‘The research compass’: an introduction to research in medical education: AMEE Guide No. 56. Med Teach 2011; 33: 695–709.
75
33 Bowling A. Research methods in health investigating health & health services, 3rd edn. New York: Open University Press; 2009. 34 Rogers E. A prospective and retrospective look at the diffusion model. J Health Commun 2004; 9: 13–9. doi:10.1080/10810730490271449
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 70–75 http://dx.doi.org/10.1071/AH14031
A theoretical framework to support research of health service innovation Amanda Fox1,2 RN, PhD candidate, Lecturer Glenn Gardner1 RN, PhD, Professor of Nursing Sonya Osborne1 RN, PhD, Senior Lecturer 1
Queensland University of Technology, School of Nursing, Victoria Park Road, Kelvin Grove, Qld 4059, Australia. Email: [email protected]; [email protected] 2 Corresponding author. Email: [email protected]
Abstract Objective. Health service managers and policy makers are increasingly concerned about the sustainability of innovations implemented in health care settings. The increasing demand on health services requires that innovations are both effective and sustainable; however, research in this field is limited, with multiple disciplines, approaches and paradigms influencing the field. These variations prevent a cohesive approach, and therefore the accumulation of research findings, in the development of a body of knowledge. The purpose of this paper is to provide a thorough examination of the research findings and provide an appropriate theoretical framework to examine sustainability of health service innovation. Methods. This paper presents an integrative review of the literature available in relation to sustainability of health service innovation and provides the development of a theoretical framework based on integration and synthesis of the literature. Results. A theoretical framework serves to guide research, determine variables, influence data analysis and is central to the quest for ongoing knowledge development. This research outlines the sustainability of innovation framework; a theoretical framework suitable for examining the sustainability of health service innovation. Conclusion. If left unaddressed, health services research will continue in an ad hoc manner, preventing full utilisation of outcomes, recommendations and knowledge for effective provision of health services. The sustainability of innovation theoretical framework provides an operational basis upon which reliable future research can be conducted. What is known about the topic? Providers of health services are rapidly implementing innovations in an effort to provide effective health care. Little research has been conducted to evaluate the sustainability of these health service innovations. What does this paper add? This paper aims presents an integration and synthesis of the current body of knowledge to provide a theoretical framework to evaluate the sustainability of health service innovation. What are the implications for the practitioner? An improved body of knowledge surrounding the sustainability of health service innovations generated from research will consequently result in more appropriate use of resources and improved provision of health services. Additional keywords: healthcare, sustainability, delivery models.
Received 4 February 2014, accepted 23 September 2014, published online 17 December 2014
Introduction Spiralling healthcare costs and increased consumer demand have seen a rapid introduction of many health service innovations. Despite great interest and a need to understand these innovations, research into sustainability is scant and fragmented. There is a need for research that is embedded in appropriate theoretical framework and presents a clear methodology for replication to extend the body of knowledge. Health services research typically spans multiple disciplines, many of which have conflicting or Journal compilation Ó AHHA 2015
varied preferences in relation to research concepts, approach and perspectives. Health services research is complex, partly due to the large number of occupational groups, disparity of influence between employee groups and changing patient acuity, which prevents standardising some processes.1 As such, health services research has many stakeholders and research in this field draws upon methods from several disciplines and paradigms.1 The challenge is to successfully synthesise the research findings from these varied sources to effectively meet the needs of health service www.publish.csiro.au/journals/ahr
Theoretical frameworks for health service research
managers and policy writers attempting to meet current service needs. The purpose of this paper is to present an integrative review of research into sustainability of health service innovation and to propose a theoretical framework to guide future research in this field. Methods A comprehensive search was undertaken to locate both published and grey literature in databases including Medline, CINAHL, PubMed and the Cochrane Library. Key subject words and terms used were combined, adapted and spelling altered to suit the needs of the database searched (Table 1). Synonyms of the key terms were identified using thesaurus options in each database to ensure all terms were broad enough to capture the research pertaining to the field of health service innovation and sustainability. A manual search was then conducted of articles in the reference lists of the articles identified to further identify relevant studies. The initial search returned 334 articles. Peer-reviewed articles that used or recommended a theoretical or conceptual framework to examine the sustainability of a health service innovation were included in the analysis. Articles were excluded based on duplication, if sustainability was referred to in the sense of environmental sustainability or sustainability of a patient outcome following an intervention. The review method consisted of perusal of the abstract of each article and, where eligibility could not be ascertained, the full text of the article. Studies were then examined in full text for quality and those based on poor methodological quality were excluded. Following this process, 29 studies were included in the analysis.2–30 Results Definitions lack clarity In the case of health service innovation sustainability, the literature review identified minimal empirical research. The research that has been completed is mostly lacking in rigor2 and a theoretical or conceptual framework. The definition of ‘sustainability’ is controversial and much debated, with many varied definitions throughout the literature.2,31 The same variability was found in the literature related to health service innovation. A systematic review by Greenhalgh et al.3 yielded a conceptual model of the determinants of diffusion, dissemination and implementation of innovations in service organisations. However, despite the original research question related to sustainability, the scarcity of research addressing sustainability prevented Greenhalgh et al. from including this concept in their work.3 Following this publication, further research has emerged. However, clarity of definition and research informed by and informing theory are still lacking.3 Predominantly, the research Table 1. Summary of the themes and keywords used in the literature review *Truncations were used in the terms as shown to ensure thorough capture of research pertaining to the field of health service innovation and sustainability Concept
Setting
Topic
Sustain* Institutional* Routini*
Health service* Health service research Health service innovation
Theoretical framework Conceptual framework Framework
Australian Health Review
71
consists of descriptive publications relating to rural health program implementation,4–9 sustainability of community-based programs,10–17 health systems in low-income countries18,19 and theories related to behaviour change and management.2,25,26 Variation between operational definitions of sustainability made comparison difficult and less than half the studies appeared to be guided by a conceptual model or framework.2,31 Use of theoretical underpinnings Application of a theoretical framework in research may prevent repetition of previously explored concepts, adding to, rather than replacing or repeating, previous research and can inform a thorough examination of the phenomena to be studied. A framework is necessary to bind together all aspects of the research and can be likened to a research compass that guides the research question, implementation strategies and evaluation process of any research.32 Systematic structure, rationale and justification for how and why research will be undertaken, and transferability of research processes across contexts and settings, is made possible by the use of theoretical frameworks.32 Research that is not embedded in theory results in questionable contribution to knowledge. Expansion of a solid research paradigm and body of knowledge is developed by replication, comparison and systematic reviews of health services research. However, this can only occur with clear articulation of theoretical frameworks and methodological approaches. A recent systematic review into the sustainability of new programs and innovations found few comprehensive or methodologically rigorous studies.2 Research into health services sustainability has previously presented a pragmatic rather than academic perspective and has often been presented as grey reports that lack guidance about theoretical frameworks or research processes taken.3 All research is guided, either explicitly or implicitly, by the existing body of knowledge in the field; however, when a field of research is in its infancy, the methods used to gain a body of evidence need to be formalised and justified to support the validity of concepts and development of the paradigm.33 To date, there has been limited research examining sustainability of innovative health service delivery models within acute healthcare settings. Theoretical frameworks for health service sustainability Initially, the sustainability of innovation concept can be traced back to Rogers’ diffusion of innovation theory.34 Rogers’ work has been highly influential across many domains and disciplines, including and leading to the work of Greenhalgh et al.3 in 2003 into service innovations, among others.20–22 The child survival sustainability assessment (CSSA) framework was specifically designed to examine programs in the context of developing countries23,24 and the Sustainability Analysis Methodology (SAP) was designed by Blanchet and Girois25 specifically for low-income countries implementing health programs. The normalisation process theory was presented by May et al. in 2009 as an effective method of implementing, embedding and integrating practices.26 In 2013, Chambers et al. challenged the concept that sustainability was an endpoint and introduced the dynamic sustainability framework (DSF), positing a framework that involves continual adaptation as a result of learning, problem
72
Australian Health Review
solving and evolution.29 This framework is yet to be operationalised, but this concept and others have been influential in the construction of the sustainability of innovation framework discussed below. Discussion Construction of a theoretical framework
A. Fox et al.
innovation sustainability.2,3,34 Chambers et al. argue that sustainability of innovation is enhanced when continual improvements are made to refine an innovation to suit the individual context.29 Agreed operational governance within an organisation26 and effective communication within and across departmental boundaries in an organisation will enhance sustainability.21 A lack of meetings and teamwork has led to a lack of support for innovation and poor sustainability.21 As a result, the organisational factors of the framework strongly focus on identifying existing communication and networking strategies.
Expert researchers working in established fields knowingly conduct research from a well-grounded theoretical base that has been established through years of research and knowledge development. For novice researchers and those working in emerging fields, it is essential that the use of theory is made explicit, not only for paradigm construction, but also to hone research skills and ingrain robust practice among inexperienced researchers. Selection or construction of a relevant theoretical framework is a process often found arduous by novice researchers. Learning how to identify or construct a suitable theoretical framework and how to use the framework to guide research is an essential component of the learning pathway of novice researchers. The process requires identification of key research concepts and clarification of these as they exist and inform the proposed research idea or question. Careful examination and analysis of existing theories and prominent authors in the field will allow the researcher to determine the appropriateness of a particular theory to the pending research. Synthesis of these ideas by the researcher will inform construction or selection of a theoretical framework most appropriate for the proposed research.
Financial factors influencing sustainability are the provision of funding and budgetary planning for ongoing resources, human and consumable, as well as a demonstrated cost-effectiveness of the innovation. Research that has been completed on programs and projects often found sustainability was impacted once external funding ceased. Innovations introduced as trials or projects often are not sustained long term due to the temporary funding associated with trials.30 An innovation that has a dedicated, ongoing and adequate budget sufficient to meet the needs is more likely to be routinised by the organisation.3 Lack of research evaluating the financial value and cost-effectiveness of innovations often leave innovations vulnerable.21 Therefore, the financial factors of the theoretical framework ascertain funding sources, planning and evaluation strategies of the innovation.
Development of the sustainability of innovation framework
Workforce factors
Completing this integrative review has informed the theoretical background to the development of the sustainability of innovation framework. The sustainability of innovation framework combines the concepts presented by Greenhalgh et al. in their systematic review of service innovation3 and the DSF of Chambers et al.29 to provide a theoretical framework suitable for the examination of sustainability of any health service innovation. The sustainability of innovation framework consists of five factors that have been constructed by synthesis of theoretical propositions of the above-cited prominent authors in the field and additional current literature. These factors are political, organisational, financial, workforce and innovation related; each is explained briefly below.
Research has found that minimal staff and role changes and staff training that is timely with the use of high-quality training resources support sustainability of an innovation.3 Innovations consistent with values and needs of staff are more readily adopted21 and employee perceptions of the value of an innovation strongly impact upon routinisation.21,30 Lack of continuity or not having adequate staff to implement an innovation are threats to sustainability.21 Single staff member service models found the ability to meet demands proved difficult and annual leave, parental leave and staff attrition made innovations vulnerable, particularly where succession planning had not been initiated.30 Having processes in place to monitor the quality and outcome of the innovation and regularly providing staff with feedback enhance routinisation.3 Staff attrition, continuity and employment models, along with staff attitudes and perceptions as to the quality of the innovation, are key to the workforce factors in the theoretical framework.
Political factors Research suggests that a political focus on one particular policy will strongly influence the sustainability of an innovation related to this policy, and innovations well linked to regional health planning and national policy directions are more likely to be routinised.3,21 These policies change with the change of government, as does funding provision surrounding these policies. Political sustainability is thought to be enhanced when upperlevel management staff and organisational culture support the innovation.2,21 Therefore, questions regarding alignment, links and staff involvement are the major focus of the political segment. Organisational factors Flexibility and adaptation of the innovation to suit the local context and organisation has been acknowledged as supporting
Financial factors
Innovation-specific factors The nature and type of innovation will play a role in sustainability.2 Important features of an innovation are fluidity and adaptability to respond to changes in funding and service requirements based on local decision making and need.3,21 Latest research suggests that innovations are constantly evolving to suit context needs, and this change is inevitable for sustainability.30 The acceptability, quality and safety of the innovation to the stakeholders can be linked directly to sustainability. Ongoing evaluation using measures relevant to stakeholders to evaluate the quality of an innovation is imperative.29 As a result, the
Theoretical frameworks for health service research
• • • •
Australian Health Review
Government and local policy alignment Links with regional health plans, goals and visions Local and national champion involvement Staff involvement in the implementation and decision making
• • •
Political factors
• •
Interdepartmental and intradepartmental communications Adaptation of the innovation to local context and perceived need Existence of networking opportunities with external organisations
Organisation factors
Financial factors
•
Workforce factors •
Funding sources identified and secure Budgetary planning for continuation of the innovation Evaluation strategies to examine cost effectiveness are in place
Innovation specific factors
• • •
• • •
73
Staff recruitment processes, succession and leave planning Education and training provisions and processes Staff perception of innovation need Staff per ception of innovation safety and quality
Support for the innovation Barriers to the innovation Safety and quality of innovation
Fig. 1. Sustainability of innovation theoretical framework.
innovation-specific factors focus on identifying support and barriers to the innovation and evaluation strategies of the innovation itself. The five factors can be operationalised and guide research to explore the dynamics influencing sustainability of health service innovation. The factors are not discrete areas, but rather a collection of characteristics that are dynamic and may interact with each other. The framework represents the dynamic nature of sustainability, as suggested by Chambers et al.,30 as the innovation is optimised within the relevant context to enable rather than prevent sustainability. The framework characteristics are conceptual and sufficiently robust to guide the research and to identify the variables and data collection and evaluation methods that should be used (see Fig. 1). Health service innovations exist in real-life, often complex environments and, as such, data collected relating to a factor from one area may provide insights into characteristics that impact on one or more of the other factors within the framework. Interactions between components of a framework may not be fully understood until after practical utilisation and evaluation of research results. Empirical research allows for collection and
examination of unforeseen additional information, inadequacies and complications that may only arise during implementation of the research. Recommendations This theoretical framework may be appropriate to examine sustainability across different research methodologies and various service innovations. Given the minimal amount of empirical research in this field, testing of the framework is recommended across a broad range of health service innovations. In addition, a specific theoretical framework, although based on highly regarded theoretical background information, is often only a starting point and may look considerably different following practical application, evaluation, revision and development. Limitations are recognised by the over-dependence on theoretical frameworks developed within the community health domain and international programs that dominate the existing small body of knowledge. Operationalising this proposed framework in several contexts will provide a broader understanding and development of these concepts. This leads to new knowledge development,
74
Australian Health Review
where theory informs research processes and, in turn, is informed by research findings. Conclusion Although health services research is an emergent field, strong theoretical links need to be made in an attempt to establish a sound knowledge base. The current paucity of research, and therefore evidence, on which to develop a paradigm for health service research is recognised. This article has explored the rationale for using theoretical frameworks and their importance for novice researchers and emerging research fields, and has presented the developmental process to construct a framework to explore health service innovation sustainability. Testing of frameworks with research using appropriate methodology is required across many health services to identify inadequacies and refine theory. If future research in this field is to effectively inform health services, policy and implementation of innovations, theoretical frameworks must be used and tested. Researchers are urged to scaffold their work in strong, evidence-based theoretical frameworks to ensure synthesis of findings and development in the health services research paradigm. Competing interests None declared. References 1
Black N. Health services research: saviour or chimera? Lancet 1997; 349: 1834–6. doi:10.1016/S0140-6736(96)12164-4 2 Stirman SW, Kimberley J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future use. Implement Sci 2012; 7: 17. doi:10.1186/1748-5908-7-17 3 Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004; 82: 581–629. doi:10.1111/j.0887-378X. 2004.00325.x 4 Tham R, Humphreys J, Kinsman L, Buykx P, Sasid A, Tuohey K, Riley K. Evaluating the impact of sustainable comprehensive primary health care on rural health. Aust J Rural Health 2010; 18: 166–72. doi:10.1111/ j.1440-1584.2010.01145.x 5 Taylor J, Blue I, Misan G. Approach to sustainable primary health care service delivery for rural and remote South Australia. Aust J Rural Health 2001; 9: 304–10. doi:10.1046/j.1038-5282.2001.00387.x 6 Gruen R, Weeramanthri T, Bailie R. Outreach and improved access to specialist services for Indigenous people in remote Australia: the requirements for sustainability. J Epidemiol Community Health. 2002; 56: 517–21. doi:10.1136/jech.56.7.517 7 Swayne A, Eley D. Synergy and sustainability in rural procedural medicine: views from the coalface. Aust J Rural Health 2010; 18: 38–42. doi:10.1111/j.1440-1584.2009.01104.x 8 Fuller J, Harvey P, Misan G. Is client-centred care planning for chronic disease sustainable? Experience from rural South Australia. Health Soc Care Community 2004; 12: 318–26. doi:10.1111/j.1365-2524.2004. 00501.x 9 Buykx R, Humphreys J, Tham R, Kinsman L, Wakerman J, Asaid A, Tuohey K. How do small rural primary health care services sustain themselves in a constantly changing health system environment? BMC Health Serv Res 2012; 12: 81–7. doi:10.1186/1472-6963-12-81 10 Scheirer MA, Dearing JW. An agenda for research on sustainability of public health programs. Am J Public Health 2011; 101: 2059–67. doi:10.2105/AJPH.2011.300193
A. Fox et al.
11 Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res 1998; 13: 87–108. doi:10.1093/her/13.1.87 12 Willis K, Small R, Brown S. Using documents to investigate links between implementation and sustainability in a complex community intervention: the PRISM study. Soc Sci Med 2012; 75: 1222–9. doi:10.1016/j.socscimed.2012.05.025 13 Nordqvist C, Timpka T, Lindqvist K. What promotes sustainability in safe community programmes? BMC Health Serv Res 2009; 9: 4–12. doi:10.1186/1472-6963-9-4 14 Pluye P, Potvin L, Denis J, Pelletier J, Mannoni C. Program sustainability begins with the first events. Eval Program Plann 2005; 28: 123–37. doi:10.1016/j.evalprogplan.2004.10.003 15 Pluye P, Potvin L, Denis J, Pelletier J. Program sustainability: focus on organisational routines. Health Promot Int 2004; 19: 489–500. doi:10.1093/heapro/dah411 16 Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health 2003; 26: 177–93. doi:10.1097/00003727-200307000-00003 17 Barnett L, Van Beurden E, Eakin E, Beard J, Dietrich U, Newman B. Program sustainability of a community-based intervention to prevent falls among older Australians. Health Promot Int 2004; 19: 281–8. doi:10.1093/heapro/dah302 18 Olsen I. Sustainability of health care: a framework for analysis. Health Policy Plan 1998; 13: 287–95. doi:10.1093/heapol/13.3.287 19 Gruen R, Elliott J, Nolan M, Lawton P, Parkhill A, McLaren C, Navis J. Sustainability science: an integrated approach for health-programme planning. Lancet 2008; 372: 1579–89. doi:10.1016/S0140-6736(08) 61659-1 20 Homa K. Evaluating the sustainability of a quality improvement initiative. Doctor of Philosophy Thesis, Dartmouth College, New Hampshire; 2006. 21 Sibthorpe B, Glascow N, Wells R. Emergent themes in the sustainability of primary health care innovation. Med J Aust 2005; 183: 77–80. 22 Raffel K, Yee Lee M, Dougherty C, Green G. Making it work: administrator views on sustaining evidence-based mental health interventions. Adm Soc Work 2013; 37: 494–510. doi:10.1080/03643107. 2013.828003 23 Sarriot E, Winch PJ, Ryan LJ, Bowie J, Kouletio M, Swedberg E, LeBan K, Edison J, Welch R, Pacqué MC. A methodological approach and framework for sustain assessment in NGO-implemented primary health care programs. Int J Health Plann Manage 2004; 19: 23–41. doi:10.1002/ hpm.744 24 Sarriot E, Winch PJ, Ryan LJ, Edison J, Bowie J, Swedberg E, Welch R. Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organisations. Int J Health Plann Manage 2004; 19: 3–22. doi:10.1002/ hpm.743 25 Blanchet K, Girois S. Selection of sustainability indicators for health services in challenging environments: Balancing scientific approach with political engagement. Eval Program Plan 2013; 38: 28–32. 26 May C, Finch T. Implementing, embedding and integrating practices: an outline of normalization process theory. Sociology 2009; 43: 535–54. doi:10.1177/0038038509103208 27 May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res 2006; 6: 86–94. doi:10.1186/1472-6963-6-86 28 Forster D, Newton M, McLachlan H, Willis K. Exploring implementation and sustainability of models of care: can theory help? BMC Public Health 2011; 11: S8. doi:10.1186/1471-2458-11-S5-S8 29 Chambers D, Glasgow R, Strange K. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci 2013; 8: 117. doi:10.1186/1748-5908-8-117
Theoretical frameworks for health service research
Australian Health Review
30 Considine J, Fielding K. Sustainable workforce reform: case study of Victorian nurse practitioner roles. Aust Health Rev 2010; 34: 297–303. doi:10.1071/AH08727 31 Hanson H, Salmoni A, Volpe R. Defining program sustainability: differing views of stakeholders. Can Public Health Assoc 2009; 100: 304–9. 32 Ringsted C, Hodges B, Scherpbier A. ‘The research compass’: an introduction to research in medical education: AMEE Guide No. 56. Med Teach 2011; 33: 695–709.
75
33 Bowling A. Research methods in health investigating health & health services, 3rd edn. New York: Open University Press; 2009. 34 Rogers E. A prospective and retrospective look at the diffusion model. J Health Commun 2004; 9: 13–9. doi:10.1080/10810730490271449
www.publish.csiro.au/journals/ahr
![[Partnership-based research as a space to support innovation].](/assets/img/hold.png)
