Factors influencing the continuity of evidence-based practice in perioperative airway management for elderly patients with fractures: A qualitative study

Abstract

BACKGROUND

More and more evidence-based practices are emerging, but researchers mostly focus on short-term effects, resulting in evidence-based practices not being applied in the clinic in the long term. In this study, we took the evidence-based practice of perioperative airway management in elderly fracture patients as an example and adopted a descriptive phenomenological approach to understand the influencing factors of its sustainability to provide a reference basis for promoting the continuity of evidence-based practice in the clinic.

AIM

To explore factors influencing the persistence of evidence-based practice in perioperative airway management in elderly patients with fractures.

METHODS

This study was qualitative research. Nine nurses who implemented evidence-based practice in the orthopedic ward of a tertiary comprehensive hospital in Shanghai from September 2023 to October 2023 were selected using purposive sampling as research subjects. Semi-structured interviews were conducted with them, and the data were analyzed using the Colaizzi phenomenological analysis method based on the three dimensions and ten factors of the NHS sustainability model.

RESULTS

Three main themes and ten subthemes were identified: Process aspects (benefits to patients, benefits to nurses, lack of follow-up, complex processes); staff aspects (insufficient human resources, inadequate training and education, lack of leadership support); and organizational environment aspects (inadequate infrastructure, poor patient compliance, poor doctor cooperation).

CONCLUSION

Human resources, training and education, leadership support, infrastructure, and patient-physician collaboration are important factors influencing the sustainability of evidence-based practice for perioperative airway management in older patients with fractures.

Key Words: Elderly, Fracture, Airway management, Evidence-based practice, Sustainability, Sustainability model

Core Tip: This study used a descriptive phenomenological approach to investigate the factors influencing the persistence of evidence-based practice of perioperative airway management in elderly patients with fractures. It also explored the influencing factors that promoted and impeded the persistence of evidence-based practice of perioperative airway management in elderly patients with fractures to provide a basis for the development of appropriate maintenance strategies and the promotion of their continued application.

INTRODUCTION

Elderly people have a high prevalence of fractures. As the global aging population increases, the number of fractures in the elderly population aged 80 years or older is expected to grow to 44 million by 2040[1]. The decline of all physiological functions and balance function in the elderly makes them prone to falls, which together with the severe osteoporosis in the elderly leads to a high incidence of fractures. Surgery is an important treatment modality for fractures in the elderly[2].

However, due to the deterioration of the body and the functioning of the organs in the elderly, there are multiple comorbidities, including cardiovascular and respiratory diseases[3]. In addition, the poor resistance of the elderly, long bedrest duration after fracture, and general anesthesia for surgery make their respiratory function seriously reduced. Therefore, elderly fracture patients are very prone to postoperative lung infection, pulmonary atelectasis, and other airway complications.

Perioperative airway complications not only affect the rehabilitation process and postoperative quality of life of elderly fracture patients[4] but also prolong hospitalization time, increase the economic burden of patients, and in severe cases cause patient death[5,6]. Perioperative airway management is an important component of accelerated surgical recovery, which can effectively reduce complications, shorten hospitalization time, decrease readmission rates and risk of death, improve prognosis, and reduce healthcare costs. Therefore, the group conducted a best-evidence-based practice of perioperative airway management for elderly fracture patients in a tertiary general hospital in Shanghai in 2023, which achieved good results, but the research found that the continuity of the evidence-based practice gradually decreased after 1 year.

The NHS sustainability model applied in healthcare is a tool for assessing sustainability developed by Maher et al[7] in 2010. It is mainly used to identify and understand the main barriers to sustainability, to plan for improvements in the sustainability of work, and consequently to provide higher quality healthcare services. The NHS continuity model consists of three dimensions (process, employee, and organization) and ten factors related to them. This study interviewed nurses based on the NHS continuity model and categorized and analyzed the results of the interviews in order to explore the factors affecting the continuity of this evidence-based practice and to provide a basis for the development of appropriate maintenance strategies to promote the continuity of evidence-based practice.

MATERIALS AND METHODS

Design

According to the purpose of the study, review of relevant literature at home and abroad, and discussion among the members of the group, the interview outline was initially formulated. Before the formal interview, two nurses who met the inclusion criteria were pre-interviewed (the results of the pre-interviews were not included in the study analysis). Based on the results of the pre-interviews, the interview outline was adjusted and revised to form the formal interview outline. The outline of the interview was as follows: (1) Ongoing status of evidence-based practice of perioperative airway management in elderly fracture patients; (2) Impact assessment of evidence-based practice of perioperative airway management in elderly fracture patients; (3) Difficulties faced in the application of evidence-based practice of perioperative airway management in elderly fracture patients; and (4) Exploration of the factors influencing the persistence of evidence-based practice of perioperative airway management in elderly fracture patients. The interview outline is used as a reference, and the interview process adjusts the interview questions according to the actual situation to ensure an in-depth understanding of the feelings of the nurses involved in the evidence-based practice of perioperative airway management in elderly fracture patients.

Data collection and ethical considerations

Using purposive sampling method, nine nurses implementing evidence-based practice in the orthopedic ward of a tertiary general hospital in Shanghai, China were selected from September 2023to October 2023 for the study. Inclusion criteria: (1) Nurses with professional qualifications; (2) Work experience of at least 1 year; and (3) Nurses who participated in the “Evidence-based practice of perioperative airway management in elderly patients with fractures.” Exclusion criteria: Student nurses; assistant nurses; rotating nurses; and advanced practice nurses. Data were collected using face-to-face, one-to-one, semi-structured interviews, and the interview venue was the orthopedic department conference room with no other personnel on site to ensure a quiet and private interview environment. All interviews were conducted by the researcher herself, introducing the researcher to the interviewees before the interview, explaining in detail the purpose and significance of the study and obtaining the interviewees’ informed consent to carry out the interview, and making synchronized audio recordings of the interview process.

During the interview process, we communicated with the interviewees in a sincere tone, listened patiently, encouraged the interviewees to express their true thoughts, responded positively to the interviewees’ expressions, clarified the contents of the record in a timely manner, observed the interviewees’ expressions, tone of voice, and other changes, and asked additional questions when necessary. Each interview was limited to 15-30 min. The sample size was determined on the basis of the principle of saturation of information, i.e. sampling was discontinued when the information was repetitive, and no new themes were presented. The study was reviewed and approved by the Ethics Committee of Shanghai Tongren Hospital (approval number: Tongren Lun Audit 2022-075-01). All study subjects volunteered to participate in this study and signed an informed consent form.

Data analysis

After each interview, the audio-recorded content was converted to text by the researcher within 24 h, and non-verbal information was marked or annotated. Specific themes and codes were categorized according to the three dimensions and ten factors of the NHS continuity model, and the text was analyzed for generalized, deductive content. The information was independently transcribed, coded, categorized, distilled into themes, and analyzed by two members of the group. Any disagreements were discussed and determined by the members of the group to ensure the completeness of the information and the accuracy of the analysis. The Colaizzi 7-step analysis method[8] was used to refine the themes: (1) Repeatedly and carefully read the collected and organized data; (2) Analyze the data word by word and sentence by sentence to analyze the statements that are relevant, important, and meaningful to the research question; (3) Construct/code meanings for recurring and meaningful ideas; (4) Gather the coded ideas, finding meaningful common concepts, and forming theme prototypes; (5) Define and describe in detail each of the resulting themes; (6) Repeatedly compare similar themes, identify and extract similar ideas, and construct phrases, i.e. themes; and (7) Return the results to the respondents for verification and make modifications and additions based on the respondents’ feedback.

RESULTS

A total of nine orthopedic nurses, all females, aged 25-46 (35.56 ± 7.10) years, with 6-26 (13.67 ± 7.62) years of experience, participated in this study. The main sociodemographic information of the interviewees is presented in Table 1. Data collected through collation and analysis, three themes and ten sub-themes were identified, indicating facilitators and barriers to the sustainability of evidence-based perioperative airway management practice in elderly fracture patients. Table 2 lists the three themes and ten subthemes of this study.

Table 1 Sociodemographic data of respondents, n = 9.

Serial number	Sex	Age in yr	Educational attainment	Experience in yr	Title
N1	Female	35	Undergraduate degree	12	Nurse practitioner
N2	Female	42	Master’s degree	23	Nurse practitioner-in-charge
N3	Female	36	Undergraduate degree	10	Nurse practitioner-in-charge
N4	Female	46	Undergraduate degree	26	Nurse practitioner
N5	Female	29	Undergraduate degree	8	Nurse practitioner
N6	Female	25	College degree	4	Nurse
N7	Female	28	College degree	6	Nurse practitioner
N8	Female	38	Undergraduate degree	16	Nurse practitioner
N9	Female	41	Undergraduate degree	18	Nurse practitioner-in-charge

Table 2 Themes and subthemes of the study.

Themes	Subthemes
Process aspects	Patient benefit
	Nurse benefit
	Lack of follow-up
	Complicated process
Staff aspects	Inadequate human resources
	Inadequate training and education
	Insufficient leadership support
Organizational environment aspects	Inadequate infrastructure
	Poor patient cooperation
	Poor physician collaboration

Theme 1: Process aspects

Patient benefit: The benefits to patients indicate the need for continued clinical implementation of this evidence-based practice. Elderly people have degenerative body and organ functions and a variety of comorbidities. Without timely and standardized management during the perioperative period, patients are susceptible to postoperative airway complications such as lung infections and pulmonary atelectasis, which can even be life-threatening in severe cases. This evidence-based practice has driven nurses to carry out perioperative airway management through the ability of standardized interventions in the patient’s perioperative period to reduce the incidence of lethal complications and improve the patient’s quality of life, which in turn has driven practice to continue.

“The patients themselves know that doing this prevents lung infections (N01). It can, and doing it consistently is definitely effective (N02). If it is effective in avoiding his asphyxia, it will definitely shorten his hospitalization time, and if there is no attention to it and it causes asphyxia and lung infection, it will definitely increase his financial burden (N04). It still has a role to play, especially for the elderly, to enable them to recover faster (N06). Like someone with a more severe choking cough, this knowledge is still useful if you tell her family (N09).”

Nurse benefit: Nurse benefit is one of the core elements of the clinical sustainability of this evidence-based practice. Although this evidence-based practice was not the focus of nursing work in the department, this evidence-based practice promoted the scientific and standardization of clinical nursing services by summarizing the best evidence of airway management during peripheral surgery in China and forming a protocol to be applied in the clinic, which makes nurses pay more attention to the airway problems of the elderly patients with fractures and unconsciously forms conscious behaviors, which somehow promotes the continuation of the practice.

“Nurses knew about the use of respiratory function devices, recognized the importance of back patting, and paid more attention to such patients (N02). We nurses are a little more familiar with the assessment of the puddle drinking test, pre-operative, intra-operative, post-operative and discharge processes, etc. (N03). We will now pay attention to choking in the elderly and if they are at risk we will label the case as well as remind the physician not to allow liquid diet or water to be given to patients with severe choking (N04). We’ll have a better understanding of this knowledge of airway evidence-based, and we’ll use this knowledge when we come across patients with choking problems and coughs that don’t come out (N07). We used to encounter elderly patients with choking and suffocation and aspiration in our work, and through this evidence-based practice we will pay more attention to the problems of choking and aspiration of food in the elderly due to choking and coughing, so that we can avoid them (N08). People who are assessed at level 3 or 4 by the Kubota Drinking Water Test we will tell the doctor in time, and if the doctor pays attention to it he will get a rehabilitation doctor to assess it with him, which is also useful (N09).”

Lack of follow-up: The hospitalization cycle of elderly fracture patients is short, and the evidence-based practice of perioperative airway management for elderly fracture patients lacks follow-up of discharged patients. Clinical nurses do not see the long-term effects, which leads to a gradual decrease in their motivation and makes it difficult to promote the practice to be sustained.

“The cycle is relatively short, and most of the patients are discharged within a week, and the subsequent results we do not follow up on them, so the change whether it is obvious cannot be seen (N01). The changes are there, but honestly it’s important to look at the long term, and we don’t know what happens to patients after they are discharged (N03). Too busy to track the patient’s follow-up (N07). There’s no way to be able to know if it’s all done down or not, and while some patients have the whole process all done down, there’s no time to see if it’s working very well for the patient or not (N08). Patients are not hospitalized for a long time, it is the time at home that is critical, not knowing if the patient is sticking to what they are doing at home, and it is more difficult to follow up and monitor, not being able to see the long term effects (N09).”

Complicated process: The evidence-based practice of perioperative airway management in elderly patients with fractures is cumbersome, time-consuming, and heavy, taking up a lot of the nurses’ working time, while the elderly patients’ difficulty in adhering to it hinders the continuity of the practice.

“The workload is a little bit heavy and it takes up a lot of my working time because when the patient comes in the list has to be written in many sheets (N01). It’s really hard to get the patient to cough as well as blow up the balloon 30 times or 10 times, and I can’t do it as a normal person to blow, cough, or pat the back to follow that process (N02). There are a lot of sheets to be filled out and a lot of results to be checked at the end of the process, which increases the workload (N03). Patients complete a set of processes to do down quite tired, some older people cannot hold out, the nurse is next to the patient may do a do, the nurse a go may not do (N05). There are too many forms to fill out, resulting in being too late or forgetting to fill out the forms (N06). A set of processes takes too long, if the patient comes back after surgery they have to pat the patient’s back, have the patient blow up a balloon or something, it takes too long to get the whole process down (N08). The best thing is to blow up the balloon, respiratory function training, effective coughing this kind of training do not do it separately, you can do a process together, such as blowing a few times, coughing a few times so that the patient is more acceptable a little bit, not so boring etc. (N07).”

Theme 2 Staff aspects

Inadequate human resources: Clinical nurses are busy, and the implementation of this evidence-based practice increased the workload of nurses. The severe lack of human resources in the department led to complaints or refusal to implement the new practice. It was difficult to take the initiative to incorporate the new work content into their work routines, which blocked the continuation of the practice.

“Staffing problem, right, staff is relatively small, if there are enough staff this evidence-based practice can be sustained (N01). Less human resources, it is difficult to go to work itself, so it is interrupted (N02). Increasing human and material resources will facilitate completion (N03). Insufficient human resources, it is better to have a specialized person to manage this airway evidence-based better (N06). The main thing is that there is no manpower, if there is enough manpower, it would be fine to take off one person specifically to do this (N07). Fewer people, a bit more clinical pressure, only enough people to do anything without fear (N08). The main thing is that there are too few nurses, clinical work is very busy so we don’t have time to do it one by one (N09).“

Inadequate training and education: Before the development of this evidence-based practice, nursing staff lacked evidence-based awareness and airway management-related knowledge and skills. At the same time they had not carried out relevant airway management work. Before the implementation of the practice, all nursing staff of the orthopedics department were organized to carry out the special training on evidence-based knowledge, airway management knowledge, and airway management program (a total of 4 times). Nurses were organized to practice on-site, and irregular operation was corrected. This laid a good foundation for the implementation of evidence-based practice. However, after the practice was carried out, there was almost no training, which led to the relevant knowledge and skills being easily forgotten and hindered the continuous development of the practice.

“Although the training has been given in the pre-training, how long it is not mentioned, some knowledge and operation are not sure (N01). It’s familiar after the pre-training, though it’s forgotten again after a long time (N03). At the same time the evidence-based practice takes the form of teaching for the responsible nurse oral health promotion and TV video teaching, the main body relies on the responsible nurse oral teaching, this way has little effect, and increases the workload of nurses, reduces their motivation to work, and unconsciously reduces the probability of the evidence-based practice to continue to develop. If the patient does not cooperate, then it is necessary to keep going deeper into the clinic to go and explain to the patients (N01). Clinical work is busy, it is too late to go one by one to preach so comprehensively (N05). Clinical work is quite busy, and the things in the education include several items, sometimes it is good to explain to the patients, but when they are busy, they don’t necessarily have time to supervise the patients (N06). If there are uncooperative patients, then we have to keep preaching to the patients, which will take us nurses a lot of energy (N09).”

Insufficient leadership support: The evidence-based practice was a full-time postgraduate project. During the period when the evidence-based practice was underway, it was supported by the nursing department and ward managers, who regularly supervised progress. When the postgraduate project was over, the managers’ supervision gradually weakened, and the clinical nurses’ initiative and motivation consequently declined, impeding the continued development of the evidence-based practice.

“The research stopped when it was done, like completing the task (N03). Before it was a certain number of case numbers to be collected, and it slowly stopped after the number of cases was collected without repeated emphasis from the leader (N04). The leader told us to do it and we did it, and it stopped after it was done without re-emphasizing (N06). It was a graduate student who asked us to help so we did, and when she finished later we finished too (N09).”

Theme 3 Organizational environment aspects

Inadequate infrastructure: Infrastructure provides the material foundation and environmental preparation for evidence-based practice. A good material foundation and adequate environmental preparation can better promote the continuous development of evidence-based practice.

“The balloons and respiratory function trainers and stuff provided are free (N04). You can also do something with brochures that patients can read, patients have very detailed brochures for them to read, nurses can do other things, and when the patient understands it, the nurse can explain it, it can be better communication (N06). That respiratory function trainer can get a counter on the side, such as the patient coughs twice and presses twice, it can be remembered, otherwise sometimes elderly patients can’t remember; or provide a timer, put it on the side of the patient and set the time, when the time is up ring the bell, and the patient will know that it’s done (N07). Incorporating patients can be arranged in the same ward, where one patient is willing to cooperate and the others are willing to cooperate (N03).”

Poor patient cooperation: Patients are the recipients of evidence implementation. Patients’ active participation in cooperating can increase nurses’ motivation to take the initiative to implement evidence-based practice, which can promote evidence-based practice to be sustained.

“Some patients’ compliance is not that strong (N01). Patients will say I’m doing this as a trial and create resistance, first of all patients have to cooperate, if there are patients who don't cooperate, then we nurses have to keep on educating the patients (N04). Some patients don’t want to cooperate, so they say he doesn’t want to do this stuff, why do I want to do this stuff, etc, so they don’t want to do it (N05). Some patients find it troublesome and don’t want to do it (N06). Family members don’t understand, patient feels it’s too complicated and doesn’t want to do it, and doesn’t want to do it even though it’s been explained (N07). I don’t want to do it even if the patient doesn’t cooperate (N08). The clinic itself is quite busy, and some patients don’t cooperate, so I don’t have the motivation anymore (N09).”

Poor physician collaboration: Evidence-based practice of perioperative airway management in elderly fracture patients is not purely a nursing topic; it requires nurse-led multidisciplinary cooperation.

“Those who are assessed by the Puddlefield Drinking Water Test at level 3 or 4 we will tell the doctor in time, and if the doctor pays attention to it, he will get the rehabilitation doctor to assess it with him (N09). However, some doctors only care about their own medical aspects. Multidisciplinary cooperation is needed, some postoperative labs and tests are controlled by the doctor, and it is difficult for nurses to ask the doctor to prescribe relevant tests (N02). Doctors rarely prescribe relevant tests before the patient is discharged, unless the patient’s symptoms are obvious and the nurses do not see the effect, resulting in low motivation (N03). Having to do this and that for patients, doctors also think why are you so troublesome (N04). Some doctors don’t listen to the nurses when they feel that the patient has met the criteria for discharge (N07).”

DISCUSSION

Elements of sustainability of this evidence-based practice

This study found that the evidence-based practice of perioperative airway management in elderly patients with fractures was beneficial to patients, i.e. the practice was based on urgent clinical care issues with the goal of promoting improved patient safety and health outcomes. Relevant studies[9] have confirmed that the evidence-based practice of reducing the rate of perioperative lung infections in elderly patients has been shown to reduce the rate of postoperative lung infections and the incidence of aspiration and shorten the time to extubation for tracheal intubation in elderly patients. At the same time, the department lacked a complete process of scientific and standardized airway management before the development of this evidence-based practice. This evidence-based practice has largely improved the knowledge of clinical nurses in perioperative airway management, standardized the behavior of clinical nurses, and improved the quality of nursing services. If the practice does not solve the clinical nursing problems and bring benefits to patients and units, nurses will be skeptical of the new content, which in turn will hinder the continuation of the practice. This is similar to the findings of Fleiszer et al[10] and Fleiszer et al[11] that benefits are one of the elements of practice sustainability.

Improve this evidence-based practice for sustainability

This study found that although the evidence-based practice of perioperative airway management for elderly patients with fractures provides a complete guideline for airway assessment, health education, and rehabilitation exercises, the short hospitalization period and the lack of follow-up content have led to a gradual stagnation of the evidence-based practice because clinical nurses are not able to see the long-term effects and have gradually lost their motivation. Some studies have suggested that evidence-based practice should be “developed,” and its continuous improvement should be promoted[11]. This study also found that the process of evidence-based practice is complex and increases the workload of clinical nurses. Interventions are more sustainable when they reduce the complexity of existing tasks by simplifying and streamlining processes. A mixed study Ugandan health facility repeatedly modified the ART intervention to improve adaptability to its resource-limited environment, thus contributing to long-term sustainability[12]. The Oliveira et al[13] study also highlighted that continuous monitoring and adaptation of the Family Health Program to respond to critical events was identified as a strategic enabler of the program’s sustainability over 12 years. Therefore, there is a need to continuously improve this evidence-based practice at a later stage to promote its long-term sustainability.

Emphasis on human resources, training, education, and leadership support for the sustainability of the evidence-based practice

The results of this study found that insufficient human resources, training and education, and leadership support were important factors affecting the sustainability of this evidence-based practice.

Clinical nurses are the main implementers of evidence-based practice. Once an evidence-based practice is implemented, it is a process from scratch for the department concerned. Clinical nurses need to learn new theoretical knowledge, carry out new related operations, and fill out a large number of new nursing forms, etc., which greatly increases the workload and makes it worse for the department that already has a shortage of staff. Geerligs et al[14] found that personnel is one of the main areas of implementation of evidence-based practice. In a systematic review by Cowie et al[15], it was found that the most commonly reported barrier to sustainability was insufficient staff resources, usually due to staff shortages and/or high staff turnover. If human resources are consistently understaffed and/or constantly fluctuating, shortages of staff to implement the practice or the need to retrain new staff will largely impact the sustainability of evidence-based practice. Continued shortage of staff in the department results in nurses not having the time and energy to develop practice in depth, hindering the sustainability of evidence-based practice. This is consistent with the findings of Hamaideh[16] that nurses lack sufficient time to implement evidence-based practice. Nurses’ training and active participation is the basis for the continued good implementation of evidence-based practice.

More studies have shown that factors hindering the development of evidence-based practice include nurses’ lack of knowledge and skills, difficulty in understanding research reports, and inadequate training[16-18]. Before the start of this evidence-based practice, the nurses in the relevant departments had not conducted systematic studies on perioperative airway management, and their theoretical knowledge and operational skills were weak. Through theoretical training and operational assessment, the level of nurses’ knowledge of perioperative airway management was strengthened, and nurses’ attention to the risk of patients’ airway difficulties was enhanced. Therefore, the connotation and significance of the practice could be understood in depth. At the same time, responsible nurses play a role in reminding and educating both themselves and their patients through verbal health promotion and TV video promotion, which improves nurses’ ability to practice as well as their motivation, and can promote the continuation of evidence-based practice. Relevant studies have shown that regular training, mentoring, and supervising for staff is a facilitator of sustainability[19,20], while lack of training has been identified as a barrier to sustainability[21-23]. Patient evangelization is a must for the sustainability of evidence-based practice. The purpose of conducting various forms of patient education and emphasizing the importance of practice is to focus on patients’ health, deepen patients’ understanding of the purpose and significance of the practice, and facilitate communication between patients and nurses, thus improving patients’ adherence and cooperation.

Leadership support plays a crucial role in the sustained implementation of evidence-based practice. This is because leadership support implies effective resource allocation of resources, shaping a relevant organizational culture, developing guidelines, regulations, and processes, creating incentives, and promoting teamwork, etc., thus promoting the sustained application of evidence-based practice. Also, if leaders have a thorough understanding of evidence-based care, evidence-based practice is more likely to advance smoothly. If leaders do not mandate and make evidence-based practice routine, the departmental staff will not pay attention to it, and the related evidence-based practice may be slowly terminated.

Therefore, it is recommended that units implementing evidence-based practice should have timely manpower, regular training for nurses, multiple forms of education, and regular supervision by relevant leaders to maintain the implementation of evidence-based practice.

Providing a good organizational environment to facilitate the continuation of this evidence-based practice

This study found that insufficient infrastructure and poor patient cooperation and physician collaboration affected the continuation of evidence-based practice to some extent.

Infrastructure is a must to support the continuation of evidence-based practice. This evidence-based practice required the use of measuring cups for the Kubota drinking test, a large number of balloons, and a respiratory function trainer to drive practice implementation. Lack of resources such as mission manuals, timers, and respiratory function trainers were mentioned by nurses in the interviews, which somehow hindered the efficient implementation of the practice. Shoesmith et al[24], in a systematic review of findings, showed that among the barriers and facilitators affecting the maintenance of health behavior interventions in schools and childcare services was the availability of facilities or equipment that had an impact on the maintenance of the interventions. Findings from other more scholarly studies have also shown that weak infrastructure has a negative impact on the ability to sustain interventions[25-27].

More patients are reluctant to cooperate, while patients are the main body of evidence-based practice. Their active participation and cooperation is the key to the success of evidence-based practice. Therefore, the implementation of evidence-based practice should be patient-centered and patient-need oriented, valuing patients’ values and wishes and striving to actively involve patients in the practice. Failure to engage patients or consider their perspectives can negatively impact the sustainability of an intervention, especially when patients give positive feedback on the intervention. Jangland et al[28] mentioned patient engagement as one of the cornerstones of person-centered care in a 2-year evaluation study of an implementation program. A study by Wiltsey Stirman et al[29] noted that active participation of recipients can facilitate new, sustained programs.

Good collaboration between healthcare professionals is an important factor in the continued effective rollout of the evidence-based practice, which is a nurse-led multidisciplinary co-collaboration that includes nurses, physicians, and rehabilitation therapists as members. Mazzocato et al[30] showed that collaboration between healthcare professionals is crucial. The results of a systematic evaluation by Radhakrishnan et al[31] indicated that communication between patients, nurses, and other health care workers was an important factor influencing persistence.

CONCLUSION

Based on the NHS sustainability model, this study used qualitative research to explore the factors affecting the sustainability of evidence-based practice in perioperative airway management in elderly patients with fractures. The results showed that evidence-based practice processes, human resources, training and education, leadership support, infrastructure, and physician and patient cooperation are important factors affecting the sustainability of evidence-based practice in perioperative airway management in elderly patients with fractures. Therefore, it is recommended that researchers or administrators should regularly assess the sustainability of evidence-based practice and reassess the clinical situation if poor sustainability occurs to adjust interventions in a timely manner.

ACKNOWLEDGEMENTS

We thank all the participants and all the researchers and collaborators who participated in this study.