FormalPara Learning Outcomes

By the end of this chapter, you will be able to:

  • Understand the key elements of sustainability and differentiate between spread and scale.

  • Formulate strategies to include sustainability from the beginning of nutrition care improvements.

  • Justify elements integral to building, sustaining, and spreading nutrition care improvements.

  • Recognize common barriers and enablers to sustaining and spreading nutrition care improvements.

  • Know some tools to use to help support sustainability planning.

  • Recognize the importance of equity considerations in planning for sustainability and spread.

1 Getting Started

When you make a change that improves practice, you want to make sure that it continues to have the desired benefit. This is why it is important to think about sustainability of interventions or programs from the beginning of your work. There are ways to integrate sustainability plans from the beginning and strategies to use once the initiative is working to help make sure that the processes and benefits continue. Another way to have a longer-term impact is to have your work used in other locations by spreading the program or improvement. This chapter will go through definitions, strategies, barriers, and enablers to sustainability and spread, drawing on case examples from Canada and Australia.

1.1 Definitions

A major challenge when talking about sustainability is that there is no consistent definition or length of time used to determine if a program was “sustained” [1,2,3,4,5]. There are also many terms used to describe this concept, such as maintenance, normalization, institutionalization, and routinization [3, 6]. Moore et al.’s (2017) definition of sustainability is commonly used as it breaks sustainability into five main components regarding time, continued delivery of the intervention and/or behavior change, and recognition that the program may continue to adapt in order to produce benefits for individual/systems [3] (p. 6). As put by Scheirer and Dearing, sustainability is the “continued use of program components and activities for the continued achievement of desirable program and population outcomes” [7].

When planning for the use of a program or improvement in another setting, two common ways to explain this process are spread and scale. As with sustainability, there are no consistent definitions for spread and scale. This chapter focuses on spread, but it is important to understand the difference since these concepts are often used interchangeably. Differentiating between these concepts allows for more targeted strategies. Greenhalgh et al. (2019) define spread as “Replicating an initiative somewhere else (i.e. one site to another)” and scale as “Tackling the infrastructure problems that arise during full scale implementation (i.e. implementing provincial policy)” [8, 9]. Shaw et al. [10] further indicate that spread is for “complex” problems where following a specific formula may not work and you may need to extensively adapt the program to fix the context. Scale is for “complicated” problems where formulas are critical and a high level of expertise is needed, yet solutions do not need to be adapted [10, 11]. As an example, if a nutrition care program that was working well in one long-term facility was taken up in another and adapted to that setting, it would be called spread, while if a specific change were made across all facilities, this would be scale.

2 Case Example: Improving Nutrition Care in Hospital

To further understand the concepts of sustainability and spread, this case example, led by Prof Heather Keller from the University of Waterloo, demonstrates how hospitals across Canada were able to implement nutrition care activities including nutrition screening and assessment [12, 13], sustain those changes for several years [14], and spread to new hospitals with minimal researcher involvement [14]. This grassroot, or “bottom-up,” approach focused on implementation, sustainability, and spread, while complemented by “top-down” effort from the Canadian Malnutrition Task Force, the Canadian Nutrition Society, and the Health Standards Organization to develop malnutrition standards which could be scaled across Canada.

2.1 Initial Implementation and Considering Sustainability from the Beginning

Five hospitals across Canada were tasked with implementing the Integrated Nutrition Pathway for Acute Care (INPAC), a consensus-based pathway for the prevention, detection, and treatment of hospital malnutrition [15, 16]. After 1 year, a multidisciplinary team of hospital staff and management had implemented nutrition screening and a standardized assessment [12], decreased barriers to food intake (i.e., when the meal tray is too far from the patient), and increased food intake monitoring [12, 17]. Another year later, those changes continued [14], and six new hospitals that had started INPAC implementation were able to reach similar levels with less support from a research team [14].

A summary of strategies for initial implementation of INPAC is provided in Fig. 11.1, and strategies for sustainability and spread are in Fig. 11.2. These figures are based on interviews and focus groups with those involved in the original five hospitals [13, 18]. An INPAC implementation toolkit has also been developed which walks through steps for implementation and sustainability (

Fig. 11.1
figure 1

A visual summary of how hospitals implemented nutrition care improvements and built the foundation for sustainable change [18]. (The figure is used with permission)

Fig. 11.2
figure 2

The sustain and spread framework. This summary of strategies to support sustainability and spread begins once there is some initial implementation success.

To implement INPAC, a multidisciplinary implementation team worked together to build a reason to change practice. These reasons varied slightly depending on the audience (management, nurses, and others), typically demonstrating the national and local prevalence (i.e., one in three patients are malnourished at admission) [18,19,20,22], the impact on length of stay (i.e., malnourished patients stay 2–3 days longer) [23], and the cost (i.e., approximately $2 billion CAN per year) [24]. These reasons for change were coupled with potential solutions, including ways that everyone can be involved in improving nutrition care.

This multidisciplinary approach led to the next main factor for change which was about involving the right people in the change process, including those most impacted (i.e., admission nurses who conduct nutrition screening). To be sustained, all changes had to be embedded into current practice, such as by adapting existing workflows and working with those impacted to see what made the most sense in that unit/hospital.

Context was key, so considering the external factors, such as hospital structure and overall climate, was needed. Climate focuses on the values of the organization, including the means, motivation, and opportunities for innovation [25]. For example, changes need to be within the regulations of the health region (context), while aligning with the hospital priorities (climate). Finally, strong relationships within the hospital teams were required throughout the change process, a factor that continues to apply through sustainability and spread.

2.2 Strategies for Sustainability and Spread

Nutrition care improvements, specifically nutrition screening and assessment, were sustained and spread [14]. Strategies for how these changes were sustained were explored with the original hospitals 1 year after initial implementation [13] and again 2 years later with six new hospitals [26]. A summary of these strategies is provided in Fig. 11.2.

Figure 11.1 could be placed in the “implementation” oval of Fig. 11.2. Strategies to encourage changes to be sustained or spread are included within each large circle, with the two overlapping strategies in the middle relevant to sustaining and spreading success. To spread to a new setting, it goes back to initial implementation (arrows from the spread circle back to implementation) in the new context. Working through several rounds of sustaining and spreading may potentially lead to culture change. The figure is used with permission [13].

To achieve sustainability, the multidisciplinary teams focused on maintaining the routine, building intrinsic motivation, continuing to measure and report, as well as engaging new staff and management. High staff turnover was common, making orientation sessions and quick introduction chats with new management key for continued success. Regular audits were also important, allowing teams to see their progress and to know when “booster” activities, such as reminders, were needed to maintain the momentum. Audits were less frequent than during initial implementation.

For spread, the teams mentioned the importance of being responsive to opportunities such as interest from other locations and finding ways to make it easier by learning from previous implementation experience. As with initial implementation, the new context needed to be considered, as well as how ready the new location was to start implementation. In the new location, the change needed to start again, thinking through each factor of implementation, ideally learning from what has come before.

Strategies important for both sustaining and spreading changes were about being and staying visible, such as having a member of the team regularly present where the change was taking place. Champions, those that bring the implementation efforts forward, were key to success. Champions for specific tasks or new locations were needed in order to decrease the burden on the original champion and facilitate sustainability. Attributes for effective champions have been suggested, such as influence, ownership, physical presence at the point of change, persuasiveness, grit, and a participative leadership style [27].

This case example was conducted in Canada, and the frameworks have not been validated in other settings. However, the Systematized, Interdisciplinary Malnutrition Pathway for impLementation and Evaluation (SIMPLE) in hospitals is based on INPAC and has used these strategies for improving nutrition care in Australia [28, 29].

3 Tools for Sustainability and Spread

There are many theories, models, frameworks, and tools that can be used as guides for implementation, sustainability, and spread [30, 31]. Although some tools may be more directed toward initial implementation and others toward sustainability, the most important factor is choosing what works for you and your team, and ideally, validated. A more detailed tool may provide useful ideas about factors to consider yet may not be practical for everyday use. Others may be too simplistic, focusing on key questions without providing direction on what to do with the information. Training courses have been developed, such as those from the Center for Implementation (, which can introduce you to several options and help you decide what makes sense for your work.

3.1 Sustainability Tools

While implementation tools can be used to plan for implementation and sustainability, it is recommended that sustainability be considered from the beginning, rather than only at the end, where it is typically placed. There are also tools focused on sustainability:

  • Program Sustainability Assessment Tool (PSAT): This is designed to support the implementation of an evidence-based program, typically in the community. The tool has several resources that help you understand, assess, review, and plan for sustainability [32]. The Clinical Sustainability Assessment Tool is also available (

  • The NHS Sustainability Model and Guide: This model focuses on staff, process, and organization and is designed to be used at several points throughout your implementation. This model allows you to work through a checklist and provides a quantitative score to inform your next steps [33].

4 Monitoring and Evaluation

It is difficult to know if the intended benefit or process is continuing without measuring it. Monitoring and evaluation are essential factors for initial implementation, and continued monitoring will allow you to know if your processes and outcomes are sustained [34]. The frequency of this monitoring may not need to be the same as during the earlier stages of implementation; however, an occasional check on progress will let you know if further effort or “boosters” are needed.

5 Barriers and Facilitators

There are many barriers and facilitators to implementation, sustainability, and spread [35,36,37,38]. Examples of facilitators include the continued role of the champion, ongoing organizational leadership and support, adequate funding and resources, continued effectiveness of the program, setting characteristics and policies, and fit of the program/intervention within the context. Examples of barriers include lack of funding, high staff turnover, or changes in policy. Using pre-established lists of barriers and facilitators [35,36,37] can help you think through possible factors; however, it is important to understand which factors are impacting your specific work before trying to overcome barriers that may not exist in your setting. Monitoring and evaluation, including discussions with those involved, can facilitate this understanding.

6 Considering Equity

When planning for a nutrition improvement to be sustained, spread, or scaled, it is important to take an equity lens to ensure the improvement is equitable, and not perpetuating or exacerbating existing inequities. Improvements also need to acknowledge the diverse experiences that impact implementation efforts and account for social influence, such as sociopolitical forces, physical structures, and economics [39]. A key goal in this work is to improve the quality and outcomes of services and make treatments and services available to multiple communities and settings [40, 41]. To achieve this goal, Baumann and Cabassa (2020) have listed five strategies [41]:

  1. 1.

    Focus on reach from the very beginning.

  2. 2.

    Design and select interventions for vulnerable populations and low-resource communities with implementation in mind.

  3. 3.

    Implement what works and develop implementation strategies that can help reduce inequities in care.

  4. 4.

    Develop the science of adaptations.

  5. 5.

    Use an equity lens for implementation outcomes.

7 Summary

When making nutrition care improvements in any setting, changes should be planned with the potential for sustainability and spread considered from the beginning. Focusing on improvements that are unlikely to be sustained can lead to wasted time and resources, which can be discouraging when trying to involve and motivate others for the next change. Not everything needs to be sustained and spread; evaluation and equity are key to this decision. Healthcare is constantly changing, making adaptability and flexibility key, and considering how to sustain or spread your improvement from the beginning will be beneficial for success.

Take-Home Points

  • Sustainability and spread should be considered and planned for, if relevant, from the beginning of any change process.

  • Sustainability is difficult to define; definitions typically focus on the continuation of program components which lead to the continuation of the desired outcomes.

  • Distinguishing between spread and scale allows for more strategic approaches to have your nutrition care improvement used in other settings.

  • Regular monitoring and evaluation allow for understanding of how a change is progressing and if “boosters” or reminders are needed.

  • An equity lens is needed so that by sustaining and spreading nutrition care improvements you are not also sustaining and spreading inequities.