How is sustainability defined within the context of implementation science? As we prepared for the National Implementation Research Network (NIRN) team's June meeting, we found ourselves pondering this question―but with no definitive answer available on NIRN's Active Implementation Hub. Although this initially surprised us, through research we learned that the absence of a standard definition of sustainability is a frequent occurrence in implementation research and practice. To address this issue at NIRN, our team decided to begin the process of defining sustainability. We started by reading books, journal and website articles, and blog posts to understand how research defines sustainability and how other implementation practitioners define sustainability. We then took this information and centered our team discussion on how we think about sustainability, including what factors influence it and how it is addressed in the Active Implementation Frameworks.
What is sustainability?
The Handbook on Implementation Science (Lennox, 2020) defines sustainability in several ways, including one definition that says sustainability is a continuation of health benefits, initiative activities, workplace capacity, and financial viability. Other resources suggest that sustainability is an outcome, a final implementation stage, a specific period, or fidelity/integrity of the use of an innovation.
Over the course of our exploration, one concept remained constant—before we could define sustainability, first we would need to consider our perspective on the subject. One chapter in the Handbook (Lennox, 2020) outlined some differences in sustainability's linear and dynamic perspectives. With the linear perspective, sustainability is considered more of an outcome or reaching a final stage. This perspective receives the most attention in sustainability research, and the Handbook (Lennox, 2020) text notes that its primary support is to justify continued investment from funders. The linear perspective is not without limitations, however. One primary issue is that it may limit the results of a project because this perspective does not focus on how and why outcomes are reached (e.g., needed adaptations and adjustments).
The dynamic perspective views sustainability as a process that considers adaptations or modifications in the implementation process, as well as the context and system interventions. It supports building adaptive capacity for the implementing bodies to make changes based on need. As mentioned in the Handbook (Lennox, 2020), this perspective is supported by some theoretical perspectives (ecological, general, and complexity science). But there are limitations with this perspective as well―without outcome variables, it is difficult to determine when a project is considered sustained, and without that criterion, some studies may not last long enough to assess the continued benefits of the innovation.
These two perspectives are in ever present in our minds as we work toward creating NIRN’s definition of sustainability.
Why define sustainability?
Having a standard definition for sustainability is not a goal of NIRN simply because we found it absent from our website. The NIRN team also recognizes the importance of sustainability in implementation research and practice. It is one of the biggest challenges in implementation work, no matter the industry or the setting. For researchers, having a standard definition provides a focus for their research. It creates a path for developing measures that can support implementation practice. Practitioners would benefit from a clear definition because it would allow them to tailor their support to implement sustainable practices as they align with the organization’s view of sustainability.
Discussions focused on the organization’s view on sustainability need to take place throughout the implementation process. If sustainability is not kept at the forefront, we can end up in the “implement and forget” mindset. Many of us have experienced “implement and forget”―when all the time and effort is spent launching an innovation and then, over time, it fails and is forgotten. This is frustrating to all those involved in the process and a waste of time and resources. Constantly introducing new initiatives without working to sustain them can also damage future partnerships and relationships between individuals, organizations, communities, and funders or investors that have a stake in the implementation process.
The argument for dynamic sustainability
So what happens when an organization “reaches” sustainability as defined in the linear perspective? Let’s look at a juvenile justice center and its implementation of a new mental health program.
Over the last three years, the Lighthouse Juvenile Justice Center has focused on implementing Transforming Research into Action to Improve the Lives of Students (TRAILS), a mental health program. The center partnered with the school side of the facility, the Department of Health and Human Services, and Community Mental Health to ensure the involvement of various critical perspectives and ongoing support. The implementation team addressed barriers and examined their capacity and fidelity data. At their final meeting, the team celebrated that their trending implementation data showed positive growth and did not identify any specific barriers to address. They had “reached” sustainability, so they planned only to meet every three months to examine any data collected.
However, were this team considering sustainability as a dynamic approach, they might have celebrated the data but also discussed potential gaps or policy changes that would keep the program implemented at its expected level. Let’s take a look at what happened.
Two months after the last implementation meeting, the facility director and champion of the TRAILS program moved on to another career opportunity. Within three months, the center had yet to fill the director’s position, and the assistant director had not held an implementation meeting as he was not part of the implementation team and had not been part of any communications regarding the program. Five months passed before an implementation team member approached the facility's assistant director and new director regarding the program with some concerns. The team reconvened and discovered that since the director’s departure, no fidelity data was collected, two staff members had stopped using the program, and leadership was unclear on the program's core components.
Turnover, as illustrated here, is just one of several challenges to defining sustainability from a linear perspective. The Lighthouse Juvenile Justice Center learned that addressing sustainability through team membership, communication, and returning to the installation stage to address barriers allowed for a dynamic process for them.
Next steps for NIRN
As NIRN contemplates what sustainability means for us―and within the Active Implementation Frameworks, we want to share some initial thoughts with you on how to avoid a linear approach and create a more dynamic process for sustainabilty. Consider the following:
- Usable Innovations: When thinking about the concept of sustainability at your organization, define what it means within your context or the program you are implementing. Are you trying to define full implementation of a usable innovation with the term sustainability, or are you approaching it as a process?
- Stages of Implementation: Consider sustainability at all stages of implementation. What policies and procedures can you develop during exploration?
- Implementation Teams: Ensure that implementation does not fall on one person; instead, take a team approach.
- Implementation Drivers: Address sustainability as you develop selection criteria or a coaching system. Think about your DSDS and ensure everyone has access to data that will be needed moving forward for improvement purposes.
- Improvement Cycles: Conduct a small improvement cycle on your current infrastructure or implementation supports. What data can you collect to ensure a system is in place at all levels to ensure sustainability? What can you improve?
Lennox, L. (2020). Sustainability. In P. Nilsen & S.A. Birken (Eds.), Handbook of implementation science (pp. 333-366). Edward Elgar Publishing Limited.
Moore, J.E., Mascarenhas, A., Bain, J., & Strauss, S.E. (2017). Developing a comprehensive definition of sustainability. Implementation Science, 12(110). https://doi.org/10.1186/s13012-017-0637-1