Table 3 Summary of quotes for sustainability phenomena and themes

Sustainment of core elements

1

“There are still three of [5 of] those team members who are working on SCOPE. They're still using some of the…measurement tools that they developed. They're still focusing on disruptive behaviors.” [Team Sponsor, CH4]

Sustainability of key benefits

2

“She is looking for opportunities to improve. She's giving suggestions, what approach will work and does not work for this particular special-needs unit, and the team listens to her suggestions, and we trial it, and if it will work, then we put it into place.” [Senior Sponsor, CH3]

3

“We just have gone through … an inter-RAI [Resident Assessment Instrument] quality of life residents survey, their satisfaction survey for this year… and actually some of what we see in there, we actually believe that the work that the SCOPE team did back in 2016–2017 might be utilized to address some of the areas where we see room for improvement based on those results… my vision is to bring healthcare aides back into that process of revisioning how we implement that on the floor… you would hope that you implement your new initiative using the tools that our healthcare aides developed.” [Senior Sponsor, CH6]

Intra-organizational spread

4

“It almost has become second nature for people… The walk that we've been doing and the cards [indicating residents’ mobility level] that they [care aides] rolled out are on all the floors.” [Senior Sponsor, CH1]

Theme 1: Adaptive capacity of care aides and adaptability of the intervention facilitate sustainment

5

“If they [care aides] have hurdles, at the end of shift, they sit and say like, ‘This one [resident] we have this problem and we tried a few things, but it still doesn't work.’ Then they're trying different people, not from one group only… And then they're getting a better understanding of what can be changed. It's an ongoing process.” [Senior Sponsor, CH3]

Theme 2: Facilitative formal leadership of Sponsors is important to sustainment and sustainability

6

“It's not like, ‘I don't think [it] is a good idea … it will be too expensive. Bye, see you later.’ Even if I [am] afraid that this is not going to work, still, I'll give her the opportunity to try… it's not coming from me prescribing what to do, it's actually coming from her, and she has some control [over] it.” [Senior Sponsor, CH3]

7

“The good thing …is, it makes the healthcare aides be the leader, and I'll be the follower…I think those are the strengths that I think I can offer to them. It's just like, ‘You guys, you started this. You can see some improvements. We can do this…’” [Team Sponsor, CH4]

Theme 3: Social dynamics among Sponsors and care aides are important to sustainment

8

“If somebody [care aides] needs something, they will come to her [a particular care aide] and say like, ‘You know how to talk to these people in the office.’ … because she developed some communication with us, the trust …” [Senior Sponsor, CH3]

9

“We do tours of newcomers [older adults and/or family members] coming in and when they see the mobility sign, they make comments on it. We need to pass those compliments on to the SCOPE team themselves.” [Senior Sponsor, CH1]

Theme 4: Culture of innovation and change is associated with sustainment

10

“I had been in the recreation department beforehand, and there [are] always days where everyone's trying to think, ‘What can we do differently? How can we improve the process and basically helping the residents?’ We're very resident focused here, so it's just the natural [way].” [Team Sponsor, CH1]

Theme 5: Structural mechanisms are associated with sustainment and sustainability

11

“I think talking about it, about their work at all of our different meetings and making sure that they receive the emails talking about how great their work is. These sort of piquing other people's curiosity to know what it's all about and making that seem to feel special, like appreciating their work.” [Senior Sponsor, CH1]

Theme 6: Institutionalized practice changes contribute to sustainment and spread

12

“The walk that we've been doing and the cards that they rolled out [during SCOPE] are [still used] on all the floors and it's just a little prompt as you enter their room, [about] what kind of mobility is required and … a reminder for the staff to do that.” [Senior Sponsor, CH1]

Theme 7: Workforce stability influences sustainment

No quotes cited in the text

Theme 8: Competing internal demands detract from sustainment

13

“In everyday work, there's always something that comes in that you’ve got to do. As a leader, that [SCOPE project] was one of the things that just fell off.” [Senior Sponsor, CH2]

14

“You have to pick a few things and say this is what we're going to work on … If we could say, have the healthcare aide teams working on initiative X because that's part of our larger quality operational plan for the year … I think there could be a good synergy there … We're not there yet … we're still entrenched in all places doing things”. [Senior Sponsor, CH6]

Theme 9: Observable benefits are associated with sustainment, sustainability, and spread

15

“In order for us to roll it out to others, we had had to show that, yes, if we continue to keep these folks mobile, it's going to make all these other benefits with our residents, and that's when it makes our life here as caregivers [better]. That was the buy-in right there.” [Team Sponsor, CH1]

16

“If they don't see an improvement, they don't want to [be] involved [in] it. … if they see some changes in staff they get more interested, they ask more questions. That's how we do spreading the change which is we do some posters, storyboards, and memos.” [Team Sponsor, CH4]

Theme 10: Alignment with system imperatives affects sustainment and sustainability

17

“… The fact that … we've been closing out the emergency [departments in hospitals, in their jurisdiction] and everything, and cutting off funding, so we don't have enough staff sometimes. For that reason, you can't really give quality care if you don't have enough resources.” [Team Sponsor, CH4]

18

“Yes, this is important. We got it, we need to work on this. But my operational priorities, I also have to look at what the long-term care program and [the overseer] is identifying as their priorities for the program. Because I, as an organization, need to support the larger system and how I fit with that.” [Senior Sponsor, CH6]