Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review

We conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome).

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Two independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice.

Two reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text.

Using basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes.

Implementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.