HEALTH SERVICE RESEARCH

CSIRO PUBLISHING
Australian Health Review, 2015, 39, 70–75
http://dx.doi.org/10.1071/AH14031

A theoretical framework to support research of health

service innovation

Amanda Fox1,2 RN, PhD candidate, Lecturer

Glenn Gardner1 RN, PhD, Professor of Nursing
Sonya Osborne1 RN, PhD, Senior Lecturer
1
Queensland University of Technology, School of Nursing, Victoria Park Road, Kelvin Grove,
Qld 4059, Australia. Email: ge.gardner@qut.edu.au; s.osborne@qut.edu.au
2
Corresponding author. Email: a.fox@qut.edu.au

Abstract
Objective. Health service managers and policy makers are increasingly concerned about the sustainability of
innovations implemented in health care settings. The increasing demand on health services requires that innovations are
both effective and sustainable; however, research in this field is limited, with multiple disciplines, approaches and paradigms
influencing the field. These variations prevent a cohesive approach, and therefore the accumulation of research findings, in the
development of a body of knowledge. The purpose of this paper is to provide a thorough examination of the research findings
and provide an appropriate theoretical framework to examine sustainability of health service innovation.
Methods. This paper presents an integrative review of the literature available in relation to sustainability of health
service innovation and provides the development of a theoretical framework based on integration and synthesis of the
literature.
Results. A theoretical framework serves to guide research, determine variables, influence data analysis and is central
to the quest for ongoing knowledge development. This research outlines the sustainability of innovation framework;
a theoretical framework suitable for examining the sustainability of health service innovation.
Conclusion. If left unaddressed, health services research will continue in an ad hoc manner, preventing full utilisation
of outcomes, recommendations and knowledge for effective provision of health services. The sustainability of innovation
theoretical framework provides an operational basis upon which reliable future research can be conducted.

What is known about the topic? Providers of health services are rapidly implementing innovations in an effort to provide
effective health care. Little research has been conducted to evaluate the sustainability of these health service innovations.
What does this paper add? This paper aims presents an integration and synthesis of the current body of knowledge to
provide a theoretical framework to evaluate the sustainability of health service innovation.
What are the implications for the practitioner? An improved body of knowledge surrounding the sustainability of
health service innovations generated from research will consequently result in more appropriate use of resources and
improved provision of health services.

Additional keywords: healthcare, sustainability, delivery models.

Received 4 February 2014, accepted 23 September 2014, published online 17 December 2014

Introduction varied preferences in relation to research concepts, approach and

Spiralling healthcare costs and increased consumer demand have
seen a rapid introduction of many health service innovations.
Despite great interest and a need to understand these innovations,
research into sustainability is scant and fragmented. There is a
need for research that is embedded in appropriate theoretical
framework and presents a clear methodology for replication to
extend the body of knowledge. Health services research typically
spans multiple disciplines, many of which have conflicting or
perspectives. Health services research is complex, partly due to
the large number of occupational groups, disparity of influence
between employee groups and changing patient acuity, which
prevents standardising some processes.1 As such, health services
research has many stakeholders and research in this field draws
upon methods from several disciplines and paradigms.1 The
challenge is to successfully synthesise the research findings from
these varied sources to effectively meet the needs of health service

Journal compilation Ó AHHA 2015 www.publish.csiro.au/journals/ahr

Theoretical frameworks for health service research
managers and policy writers attempting to meet current service
needs. The purpose of this paper is to present an integrative review
of research into sustainability of health service innovation and to
propose a theoretical framework to guide future research in this
field.
Methods
A comprehensive search was undertaken to locate both published
and grey literature in databases including Medline, CINAHL,
PubMed and the Cochrane Library. Key subject words and terms
used were combined, adapted and spelling altered to suit the needs
of the database searched (Table 1). Synonyms of the key terms
were identified using thesaurus options in each database to ensure
all terms were broad enough to capture the research pertaining to
the field of health service innovation and sustainability. A manual
search was then conducted of articles in the reference lists of the
articles identified to further identify relevant studies.
The initial search returned 334 articles. Peer-reviewed articles
that used or recommended a theoretical or conceptual framework
to examine the sustainability of a health service innovation
were included in the analysis. Articles were excluded based
on duplication, if sustainability was referred to in the sense of
environmental sustainability or sustainability of a patient out-
come following an intervention. The review method consisted of
perusal of the abstract of each article and, where eligibility could
not be ascertained, the full text of the article. Studies were then
examined in full text for quality and those based on poor
methodological quality were excluded. Following this process,
29 studies were included in the analysis.2–30
Results
Definitions lack clarity
In the case of health service innovation sustainability, the liter-
ature review identified minimal empirical research. The research
that has been completed is mostly lacking in rigor2 and a
theoretical or conceptual framework. The definition of
‘sustainability’ is controversial and much debated, with many
varied definitions throughout the literature.2,31 The same vari-
ability was found in the literature related to health service
innovation. A systematic review by Greenhalgh et al.3 yielded
a conceptual model of the determinants of diffusion, dissemina-
tion and implementation of innovations in service organisations.
However, despite the original research question related to sus-
tainability, the scarcity of research addressing sustainability
prevented Greenhalgh et al. from including this concept in their
work.3 Following this publication, further research has emerged.
However, clarity of definition and research informed by and
informing theory are still lacking.3 Predominantly, the research
Table 1. Summary of the themes and keywords used in the literature
review
*Truncations were used in the terms as shown to ensure thorough capture of
research pertaining to the field of health service innovation and sustainability
Concept Setting Topic
Sustain* Health service* Theoretical framework
Institutional* Health service research Conceptual framework
Routini* Health service innovation Framework
Australian Health Review 71
consists of descriptive publications relating to rural health pro-
gram implementation,4–9 sustainability of community-based pro-
grams,10–17 health systems in low-income countries18,19 and
theories related to behaviour change and management.2,25,26
Variation between operational definitions of sustainability made
comparison difficult and less than half the studies appeared to be
guided by a conceptual model or framework.2,31
Use of theoretical underpinnings
Application of a theoretical framework in research may prevent
repetition of previously explored concepts, adding to, rather than
replacing or repeating, previous research and can inform a
thorough examination of the phenomena to be studied. A frame-
work is necessary to bind together all aspects of the research and
can be likened to a research compass that guides the research
question, implementation strategies and evaluation process of
any research.32 Systematic structure, rationale and justification
for how and why research will be undertaken, and transferability
of research processes across contexts and settings, is made
possible by the use of theoretical frameworks.32 Research that
is not embedded in theory results in questionable contribution to
knowledge. Expansion of a solid research paradigm and body of
knowledge is developed by replication, comparison and system-
atic reviews of health services research. However, this can only
occur with clear articulation of theoretical frameworks and
methodological approaches.
A recent systematic review into the sustainability of new
programs and innovations found few comprehensive or method-
ologically rigorous studies.2 Research into health services sus-
tainability has previously presented a pragmatic rather than
academic perspective and has often been presented as grey reports
that lack guidance about theoretical frameworks or research
processes taken.3 All research is guided, either explicitly or
implicitly, by the existing body of knowledge in the field;
however, when a field of research is in its infancy, the methods
used to gain a body of evidence need to be formalised and justified
to support the validity of concepts and development of the
paradigm.33 To date, there has been limited research examining
sustainability of innovative health service delivery models within
acute healthcare settings.
Theoretical frameworks for health service sustainability
Initially, the sustainability of innovation concept can be traced
back to Rogers’ diffusion of innovation theory.34 Rogers’ work
has been highly influential across many domains and disciplines,
including and leading to the work of Greenhalgh et al.3 in 2003
into service innovations, among others.20–22 The child survival
sustainability assessment (CSSA) framework was specifically
designed to examine programs in the context of developing
countries23,24 and the Sustainability Analysis Methodology
(SAP) was designed by Blanchet and Girois25 specifically for
low-income countries implementing health programs. The nor-
malisation process theory was presented by May et al. in 2009 as
an effective method of implementing, embedding and integrating
practices.26 In 2013, Chambers et al. challenged the concept that
sustainability was an endpoint and introduced the dynamic
sustainability framework (DSF), positing a framework that
involves continual adaptation as a result of learning, problem
72 Australian Health Review
solving and evolution.29 This framework is yet to be operation-
alised, but this concept and others have been influential in the
construction of the sustainability of innovation framework dis-
cussed below.
Discussion
Construction of a theoretical framework
Expert researchers working in established fields knowingly con-
duct research from a well-grounded theoretical base that has
been established through years of research and knowledge de-
velopment. For novice researchers and those working in emerg-
ing fields, it is essential that the use of theory is made explicit, not
only for paradigm construction, but also to hone research skills
and ingrain robust practice among inexperienced researchers.
Selection or construction of a relevant theoretical framework is
a process often found arduous by novice researchers. Learning
how to identify or construct a suitable theoretical framework
and how to use the framework to guide research is an essential
component of the learning pathway of novice researchers. The
process requires identification of key research concepts and
clarification of these as they exist and inform the proposed
research idea or question. Careful examination and analysis of
existing theories and prominent authors in the field will allow the
researcher to determine the appropriateness of a particular theory
to the pending research. Synthesis of these ideas by the researcher
will inform construction or selection of a theoretical framework
most appropriate for the proposed research.
Development of the sustainability of innovation framework
Completing this integrative review has informed the theoretical
background to the development of the sustainability of innovation
framework. The sustainability of innovation framework com-
bines the concepts presented by Greenhalgh et al. in their
systematic review of service innovation3 and the DSF of Cham-
bers et al.29 to provide a theoretical framework suitable for the
examination of sustainability of any health service innovation.
The sustainability of innovation framework consists of five
factors that have been constructed by synthesis of theoretical
propositions of the above-cited prominent authors in the field
and additional current literature. These factors are political,
organisational, financial, workforce and innovation related; each
is explained briefly below.
Political factors
Research suggests that a political focus on one particular policy
will strongly influence the sustainability of an innovation related
to this policy, and innovations well linked to regional health
planning and national policy directions are more likely to be
routinised.3,21 These policies change with the change of govern-
ment, as does funding provision surrounding these policies.
Political sustainability is thought to be enhanced when upper-
level management staff and organisational culture support the
innovation.2,21 Therefore, questions regarding alignment, links
and staff involvement are the major focus of the political segment.
Organisational factors
Flexibility and adaptation of the innovation to suit the local
context and organisation has been acknowledged as supporting
A. Fox et al.
innovation sustainability.2,3,34 Chambers et al. argue that sus-
tainability of innovation is enhanced when continual improve-
ments are made to refine an innovation to suit the individual
context.29 Agreed operational governance within an organisa-
tion26 and effective communication within and across departmen-
tal boundaries in an organisation will enhance sustainability.21
A lack of meetings and teamwork has led to a lack of support
for innovation and poor sustainability.21 As a result, the organisa-
tional factors of the framework strongly focus on identifying
existing communication and networking strategies.
Financial factors
Financial factors influencing sustainability are the provision of
funding and budgetary planning for ongoing resources, human
and consumable, as well as a demonstrated cost-effectiveness of
the innovation. Research that has been completed on programs
and projects often found sustainability was impacted once
external funding ceased. Innovations introduced as trials or
projects often are not sustained long term due to the temporary
funding associated with trials.30 An innovation that has a dedi-
cated, ongoing and adequate budget sufficient to meet the needs
is more likely to be routinised by the organisation.3 Lack of
research evaluating the financial value and cost-effectiveness
of innovations often leave innovations vulnerable.21 Therefore,
the financial factors of the theoretical framework ascertain
funding sources, planning and evaluation strategies of the
innovation.
Workforce factors
Research has found that minimal staff and role changes and staff
training that is timely with the use of high-quality training
resources support sustainability of an innovation.3 Innovations
consistent with values and needs of staff are more readily
adopted21 and employee perceptions of the value of an innovation
strongly impact upon routinisation.21,30 Lack of continuity or not
having adequate staff to implement an innovation are threats to
sustainability.21 Single staff member service models found the
ability to meet demands proved difficult and annual leave,
parental leave and staff attrition made innovations vulnerable,
particularly where succession planning had not been initiated.30
Having processes in place to monitor the quality and outcome of
the innovation and regularly providing staff with feedback en-
hance routinisation.3 Staff attrition, continuity and employment
models, along with staff attitudes and perceptions as to the quality
of the innovation, are key to the workforce factors in the theo-
retical framework.
Innovation-specific factors
The nature and type of innovation will play a role in sustainabil-
ity.2 Important features of an innovation are fluidity and adapt-
ability to respond to changes in funding and service requirements
based on local decision making and need.3,21 Latest research
suggests that innovations are constantly evolving to suit context
needs, and this change is inevitable for sustainability.30 The
acceptability, quality and safety of the innovation to the stake-
holders can be linked directly to sustainability. Ongoing evalu-
ation using measures relevant to stakeholders to evaluate
the quality of an innovation is imperative.29 As a result, the
Theoretical frameworks for health service research Australian Health Review 73

• Government and local policy

• Interdepartmental and
alignment intradepartmental
• Links with regional health plans, communications
goals and visions • Adaptation of the innovation to
• Local and national champion local context and perceived need
involvement • Existence of networking
• Staff involvement in the opportunities with external
organisations
implementation and decision making

Political Organisation
factors factors

Financial Workforce
factors factors

• Funding sources identified • Staff recruitment

and secure processes, succession
• Budgetary planning for Innovation and leave planning
continuation of the specific factors • Education and training
innovation provisions and processes
• Evaluation strategies to • Staff perception of
examine cost effectiveness innovation need
are in place • Staff per ception of
innovation safety and
quality

• Support for the innovation

• Barriers to the innovation
• Safety and quality of innovation

Fig. 1. Sustainability of innovation theoretical framework.

innovation-specific factors focus on identifying support and
barriers to the innovation and evaluation strategies of the inno-
vation itself.
The five factors can be operationalised and guide research to
explore the dynamics influencing sustainability of health service
innovation. The factors are not discrete areas, but rather a
collection of characteristics that are dynamic and may interact
with each other. The framework represents the dynamic nature of
sustainability, as suggested by Chambers et al.,30 as the innova-
tion is optimised within the relevant context to enable rather than
prevent sustainability. The framework characteristics are con-
ceptual and sufficiently robust to guide the research and to identify
the variables and data collection and evaluation methods that
should be used (see Fig. 1).
Health service innovations exist in real-life, often complex
environments and, as such, data collected relating to a factor from
one area may provide insights into characteristics that impact on
one or more of the other factors within the framework. Interac-
tions between components of a framework may not be fully
understood until after practical utilisation and evaluation of
research results. Empirical research allows for collection and
examination of unforeseen additional information, inadequacies
and complications that may only arise during implementation of
the research.
Recommendations
This theoretical framework may be appropriate to examine
sustainability across different research methodologies and vari-
ous service innovations. Given the minimal amount of empirical
research in this field, testing of the framework is recommended
across a broad range of health service innovations. In addition, a
specific theoretical framework, although based on highly
regarded theoretical background information, is often only a
starting point and may look considerably different following
practical application, evaluation, revision and development.
Limitations are recognised by the over-dependence on theoretical
frameworks developed within the community health domain and
international programs that dominate the existing small body of
knowledge. Operationalising this proposed framework in several
contexts will provide a broader understanding and development
of these concepts. This leads to new knowledge development,
74 Australian Health Review
where theory informs research processes and, in turn, is informed
by research findings.
Conclusion
Although health services research is an emergent field, strong
theoretical links need to be made in an attempt to establish a sound
knowledge base. The current paucity of research, and therefore
evidence, on which to develop a paradigm for health service
research is recognised. This article has explored the rationale
for using theoretical frameworks and their importance for novice
researchers and emerging research fields, and has presented the
developmental process to construct a framework to explore health
service innovation sustainability. Testing of frameworks with
research using appropriate methodology is required across many
health services to identify inadequacies and refine theory. If future
research in this field is to effectively inform health services, policy
and implementation of innovations, theoretical frameworks must
be used and tested. Researchers are urged to scaffold their work in
strong, evidence-based theoretical frameworks to ensure synthe-
sis of findings and development in the health services research
paradigm.
Competing interests
None declared.
References
1 Black N. Health services research: saviour or chimera? Lancet 1997; 349:
1834–6. doi:10.1016/S0140-6736(96)12164-4
2 Stirman SW, Kimberley J, Cook N, Calloway A, Castro F, Charns M.
The sustainability of new programs and innovations: a review of the
empirical literature and recommendations for future use. Implement Sci
2012; 7: 17. doi:10.1186/1748-5908-7-17
3 Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion
of innovations in service organizations: systematic review and recom-
mendations. Milbank Q 2004; 82: 581–629. doi:10.1111/j.0887-378X.
2004.00325.x
4 Tham R, Humphreys J, Kinsman L, Buykx P, Sasid A, Tuohey K, Riley
K. Evaluating the impact of sustainable comprehensive primary health
care on rural health. Aust J Rural Health 2010; 18: 166–72. doi:10.1111/
j.1440-1584.2010.01145.x
5 Taylor J, Blue I, Misan G. Approach to sustainable primary health care
service delivery for rural and remote South Australia. Aust J Rural Health
2001; 9: 304–10. doi:10.1046/j.1038-5282.2001.00387.x
6 Gruen R, Weeramanthri T, Bailie R. Outreach and improved access
to specialist services for Indigenous people in remote Australia: the
requirements for sustainability. J Epidemiol Community Health. 2002;
56: 517–21. doi:10.1136/jech.56.7.517
7 Swayne A, Eley D. Synergy and sustainability in rural procedural
medicine: views from the coalface. Aust J Rural Health 2010; 18:
38–42. doi:10.1111/j.1440-1584.2009.01104.x
8 Fuller J, Harvey P, Misan G. Is client-centred care planning for chronic
disease sustainable? Experience from rural South Australia. Health Soc
Care Community 2004; 12: 318–26. doi:10.1111/j.1365-2524.2004.
00501.x
9 Buykx R, Humphreys J, Tham R, Kinsman L, Wakerman J, Asaid A,
Tuohey K. How do small rural primary health care services sustain
themselves in a constantly changing health system environment? BMC
Health Serv Res 2012; 12: 81–7. doi:10.1186/1472-6963-12-81
10 Scheirer MA, Dearing JW. An agenda for research on sustainability of
public health programs. Am J Public Health 2011; 101: 2059–67.
doi:10.2105/AJPH.2011.300193
A. Fox et al.
11 Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of
community-based health programs: conceptual frameworks and future
directions for research, practice and policy. Health Educ Res 1998; 13:
87–108. doi:10.1093/her/13.1.87
12 Willis K, Small R, Brown S. Using documents to investigate links
between implementation and sustainability in a complex community
intervention: the PRISM study. Soc Sci Med 2012; 75: 1222–9.
doi:10.1016/j.socscimed.2012.05.025
13 Nordqvist C, Timpka T, Lindqvist K. What promotes sustainability in
safe community programmes? BMC Health Serv Res 2009; 9: 4–12.
doi:10.1186/1472-6963-9-4
14 Pluye P, Potvin L, Denis J, Pelletier J, Mannoni C. Program sustainability
begins with the first events. Eval Program Plann 2005; 28: 123–37.
doi:10.1016/j.evalprogplan.2004.10.003
15 Pluye P, Potvin L, Denis J, Pelletier J. Program sustainability: focus
on organisational routines. Health Promot Int 2004; 19: 489–500.
doi:10.1093/heapro/dah411
16 Evashwick C, Ory M. Organizational characteristics of successful
innovative health care programs sustained over time. Fam Community
Health 2003; 26: 177–93. doi:10.1097/00003727-200307000-00003
17 Barnett L, Van Beurden E, Eakin E, Beard J, Dietrich U, Newman B.
Program sustainability of a community-based intervention to prevent
falls among older Australians. Health Promot Int 2004; 19: 281–8.
doi:10.1093/heapro/dah302
18 Olsen I. Sustainability of health care: a framework for analysis. Health
Policy Plan 1998; 13: 287–95. doi:10.1093/heapol/13.3.287
19 Gruen R, Elliott J, Nolan M, Lawton P, Parkhill A, McLaren C, Navis J.
Sustainability science: an integrated approach for health-programme
planning. Lancet 2008; 372: 1579–89. doi:10.1016/S0140-6736(08)
61659-1
20 Homa K. Evaluating the sustainability of a quality improvement
initiative. Doctor of Philosophy Thesis, Dartmouth College, New
Hampshire; 2006.
21 Sibthorpe B, Glascow N, Wells R. Emergent themes in the sustainability
of primary health care innovation. Med J Aust 2005; 183: 77–80.
22 Raffel K, Yee Lee M, Dougherty C, Green G. Making it work:
administrator views on sustaining evidence-based mental health inter-
ventions. Adm Soc Work 2013; 37: 494–510. doi:10.1080/03643107.
2013.828003
23 Sarriot E, Winch PJ, Ryan LJ, Bowie J, Kouletio M, Swedberg E, LeBan
K, Edison J, Welch R, Pacqué MC. A methodological approach and
framework for sustain assessment in NGO-implemented primary health
care programs. Int J Health Plann Manage 2004; 19: 23–41. doi:10.1002/
hpm.744
24 Sarriot E, Winch PJ, Ryan LJ, Edison J, Bowie J, Swedberg E, Welch R.
Qualitative research to make practical sense of sustainability in
primary health care projects implemented by non-governmental organi-
sations. Int J Health Plann Manage 2004; 19: 3–22. doi:10.1002/
hpm.743
25 Blanchet K, Girois S. Selection of sustainability indicators for health
services in challenging environments: Balancing scientific approach
with political engagement. Eval Program Plan 2013; 38: 28–32.
26 May C, Finch T. Implementing, embedding and integrating practices:
an outline of normalization process theory. Sociology 2009; 43: 535–54.
doi:10.1177/0038038509103208
27 May C. A rational model for assessing and evaluating complex inter-
ventions in health care. BMC Health Serv Res 2006; 6: 86–94.
doi:10.1186/1472-6963-6-86
28 Forster D, Newton M, McLachlan H, Willis K. Exploring implementation
and sustainability of models of care: can theory help? BMC Public Health
2011; 11: S8. doi:10.1186/1471-2458-11-S5-S8
29 Chambers D, Glasgow R, Strange K. The dynamic sustainability
framework: addressing the paradox of sustainment amid ongoing
change. Implement Sci 2013; 8: 117. doi:10.1186/1748-5908-8-117
Theoretical frameworks for health service research Australian Health Review 75

30 Considine J, Fielding K. Sustainable workforce reform: case study of 33 Bowling A. Research methods in health investigating health & health
Victorian nurse practitioner roles. Aust Health Rev 2010; 34: 297–303. services, 3rd edn. New York: Open University Press; 2009.
doi:10.1071/AH08727 34 Rogers E. A prospective and retrospective look at the diffusion model.
31 Hanson H, Salmoni A, Volpe R. Defining program sustainability: J Health Commun 2004; 9: 13–9. doi:10.1080/10810730490271449
differing views of stakeholders. Can Public Health Assoc 2009; 100:
304–9.
32 Ringsted C, Hodges B, Scherpbier A. ‘The research compass’: an
introduction to research in medical education: AMEE Guide No. 56.
Med Teach 2011; 33: 695–709.

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