Translation and cross-cultural adaptation of the National Health Service Sustainability Model to the Chinese healthcare context

Evidence-based healthcare has been widely recognised as improving healthcare delivery quality and patient experience [1]. Increasingly, evidence-based practice (EBP) or evidence implementation is also being introduced into clinical practice by healthcare organisations [2]. A scoping review published in 2015 showed that the number of EBP projects in nursing practice in China has gradually grown from zero to 28 [3]. As expected, these projects have increased patient satisfaction with care and improved patient clinical outcomes [4‐6].

It is recognised that the design of EBP requires a high level of time commitment from staff participants. This is often not built into the clinical practice workload, and as a result, EBPs are not adopted and sustained over time [7]. A previous study identified that quality improvement projects in the UK did perform well during the project's active timescale but were not sustained over time, resulting in wasted upfront investment [8]. A systematic review which included 125 healthcare improvement projects, found that even when full implementation was achieved, most programs did not achieve sustainability of all aspects of the project as initially designed or achieved [9]. Another systematic review focusing on implementing clinical practice guidelines found that about half of the 14 studies reported a decline in compliance with clinical practice guidelines by medical staff, returning to the previous routine [10].

The failure to maintain EBP can result in reduced interest and confidence of medical staff in investing time to introduce evidence into clinical practice. [2]. In a community context, none sustainability of improvements in care pathways may result in a lower level of community support and trust in healthcare organisations [11]. Therefore, it is necessary to identify how to influence the sustainability of implemented initiatives to maintain staff confidence to test and implement improvements and achieve long-term impact through the best use of financial investments [9, 12].

In recent years, a growing body of research has considered the challenges of sustaining evidence-based practice projects [13‐15], and many scholars have developed models or frameworks to promote and monitor the sustainability of evidence implementation in healthcare settings [16, 17]. A systematic review identified that despite no clear consensus on how to define or influence sustainability, 62 approaches to assessing healthcare sustainability, including theories, frameworks and models, have been proposed within the literature up to 2017, with an average of two assessment methods created every two years since 1980 [2]. A scoping review of sustainability assessment tools for clinical practice programs published in China in 2021 also noted that China needs a culturally appropriate sustainability assessment tool [18]. Currently, most published sustainability tools are from developed countries [2]. As China is located in East Asia, one of the largest developing countries in the world, its clinical leadership hierarchy is different from that of many developed Western countries. The dominant culture of nursing leadership in Chinese clinics is centralised with the role of the Head Nurse, and most clinical nurses in China have less theoretical knowledge and experience in EBP [19]. A scoping review published in China showed that as of 17 January 2020, there were 152 articles published in Chinese on evidence implementation projects in nursing. Only 7.2% of the articles suggested that evidence should be consistently applied in clinics, and 3.3% indicated specific strategies to maintain sustainability in the clinical setting [20]. This suggests that although evidence implementation projects in nursing have gradually increased over the past 20 years in China, there needs to be more research on evidence translation and sustainability in nursing practice in China [20]. Therefore, to better facilitate the implementation and maintenance of evidence, there is an urgent need to develop or translate a culturally appropriate tool for assessing the sustainability of evidence implementation projects in China [18].

To date, the sustainability approaches often explicitly stated to be applied in clinical practice are the Normalisation Process Theory, the Normalisation Process Model, the Programme Sustainability Assessment Tool and the National Health Service (NHS) Sustainability Model (SM) [21]. The NHS SM is a diagnostic tool developed to help predict the sustainability of organisational change and provide strategies for sustaining change outcomes [22]. The model was developed through a rigorous process, initially incorporating 100 factors that influence sustainability through an extensive collection of literature on sustainability in management and interviews with project leaders, managers, clinical staff, quality control experts, global health experts, and others. The 100 factors were then weighted on a scale of 1 to 10 through focus interviews with 250 internal NHS staff and health management experts who identified from their perspective which of the factors was most relevant and essential. Ten factors emerged through this process and were included in the NHS Sustainability Model [23]. One study notes that it is one of the most comprehensive of the existing sustainability development frameworks and is organised in a checklist format that facilitates knowledge translation [24]. This study aimed to translate the NHS SM into Chinese and to verify that the Chinese version of NHS SM can be adapted to the Chinese healthcare context.

Six respondents completed the model in 10–15 min, with an average of 13 min and 33 s. All indicated that the result of completing the NHS SM sustainability rating aligned with their assessment. Two respondents thought item six: "Staff behaviours toward sustaining the change", where respondents were asked to rate the level at which staff were able to share their ideas, was inappropriate in Chinese culture and clinical settings. One respondent said that nurses in China could express their ideas but were unwilling to do so. Given the heavy clinical workload, putting forward ideas may mean the nurse needs to sacrifice personal time to improve the clinical work. Another respondent stated that employees are not encouraged to express their ideas in the clinical context in China.

Of the ten items in the Chinese version of NHS SM, more than half of the respondents found only items 4 and 9 challenging to understand, with the remaining items being found easy to understand by more than half. The terms/points which respondents identified as challenging to understand were: "monitoring system", "small-scale testing", "staff have been involved from the beginning of the change process", and "senior leadership". The results of the cognitive interviewing for each item are shown below.

For item one (Does the change have any other benefits besides helping the patient), one (1/6) respondent had a problem with their understanding of the factor descriptions, which affected their judgement. When recalling the benefits of their project, the respondent did not exclude the description about benefits to the patient.

For item two (Credible benefits of the change), only one (1/6) respondent expressed difficulty understanding it because she was unsure about the difference in the range of detail within the level descriptors. The understanding of the dissemination was probed according to the established script, and no understanding bias occurred.

For item three (Adaptability of improved processes), only one (1/6) respondent expressed difficulty understanding because she felt unsure what the elements in the entry referred to, and further probing by the respondent revealed that the respondent did not have a misunderstanding.

For item four (Is the system for monitoring progress effective), five (5/6) respondents expressed difficulty understanding it because they were unsure what monitoring systems meant. Further probing revealed that some respondents understood it to include some intelligent computer systems, but this did not affect their responses.

For item five (Staff are engaged and trained to sustain change), no interviewees expressed difficulty understanding, but the interviewer detected issues that were not previously anticipated. Some respondents interpreted "the involvement of staff from the beginning of change" as "being implemented from the beginning of the evidence transformation project".

For item six (Staff actions to sustain change), one (1/6) respondent expressed difficulty in understanding it, and a respondent interpreted the “small-scale test” as a “small-scale examinations after training”.

For item seven (Involvement and support of senior leadership), two (2/6) respondents said they had difficulty understanding who the senior leaders were. For item eight (Involvement and support of clinical leadership), no interviewees said they had difficulty understanding. Probing the terms of senior leadership and clinical leadership according to the script probe revealed that two respondents (2/6) had a bias in their understanding of senior leadership, as they perceived both senior and clinical leadership as the department's leader in the hospital.

For item nine (Alignment of change with the strategic objectives and culture of the organisation), three (3/6) respondents indicated it was difficult to understand. Further probing by the interviewer revealed that although they found the term "culture" more challenging to understand, it did not affect their responses. A previously unanticipated understanding issue was identified here, with one interviewee interpreting the "organisation has demonstrated successful sustainability of improvements before", meaning that their change project had been successfully sustained within the organisation.

For item ten (Infrastructure), one (1/6) respondent found it difficult to understand, and the interviewer probed the respondent's understanding of infrastructure and procedures according to the predicted script. Most respondents indicated that their understanding of infrastructure was biased towards hardware facilities. One (1/6) respondent said that in addition to representing the flow, the procedure in Chinese could be understood as software, such as electronic work systems in hospitals. However, these did not influence the respondents' responses.

The setting of the organisational context influenced the respondents' use of the model. Although all respondents came from a hospital, there was a misunderstanding in the respondents' understanding of the organisation, with half of the respondents understanding it as the ‘hospital’ and half of the respondents understanding it as the ‘department’ in the hospital where their project was implemented.

“For item Nine (Fit with the organisation’s strategic aims and culture), can you describe your understanding of the topic in your words? (Interviewer)

The changes are the same as some of the goals of improving the quality of care you want to achieve in this area (pause and think) and the cultural climate of this improvement project in your department. (F2)

I noticed you said department, so how do you understand the word organisation? (Interviewer) It's a small part of the environment where I work. (F2)

Just this tiny part of it, is it? (Interviewer)

Well, yes. (F2) This is a difficult question for you to understand. Why? (Interviewer) Because it feels like an extensive term, with the strategic objectives of the organisation and the culture of the organisation. This is something that is not mentioned much in China. Well, so it's going to be a conversion. I understand the organisation as the department that I work in. (F2).”

“You think that item Nine (Fit with the organisation’s strategic aims and culture) is challenging to understand. Why? (Interviewer)

It's the word of organisation; it's the idea that it can have more than one meaning. I think it's important to clarify this; otherwise, I don't know what this organisation exactly means. (F3)

So, what did you think about this entry when you answered it? (Interviewer)

When I started looking at the item, I wondered whether it was a department or a hospital. Because the head doctor and head nurse of different departments think differently, some department heads, for example, don't think evidence-based practice is useful, but some department heads will think it's useful. So, you're still supporting it in terms of the wider hospital environment. (F3)

So, you're just defining it as a hospital. (Interviewer) Yes, it is. (F3)”

Differences in specific scenario settings will further influence their responses. This is because even within the same hospital, different department heads may have different styles, which can influence respondents' perceptions when implementing their projects and then affect their judgement when evaluating NHS SM.

“In fact, according to the title and options of this item, I feel that it mainly wants to express whether there are channels for employees to share their ideas in the process of achieving this change and then whether they can be recognised for sharing them and whether they will be empowered to implement them. First of all, no matter the hospital construction or discipline development, the leadership, such as the director of the nursing department and the head nurse, are very encouraging for people to conduct evidence implementation projects. Hence, staff might be allowed to share, but there is a situation where no one will share their opinion since the staff do not want to do these things because of the heavy workload. You might need to spend extra time in China to do these things (EBP). So, the staff just do not want to share their opinion about it even if their ideas will be accepted and can be implemented in the clinic. However, the item does not have this option. (F1)”

“For item six, in the department where I work, everyone is just doing these things (EBP) more passively. ah… (F4)

Is it relative to the general environment in China? (Interviewer)

The whole environment, the encouragement of expression (thinking). Just the expression of this question is not in line with the clinical scenario in China, that is, in the general environment. I do not think Chinese (leaders) are too keen on (staff) expressing themselves, well, encouraging (staff) to express this thing. I think, um, it does not quite fit (the Chinese clinical scenario). (F4).”

Based on the results of the expert review and cognitive interviews, items one, three, four, five, seven, nine, and ten (items 1,3, 4, 5, 7, 9 and 10) were revised through group discussions, and the original NHS SM developers examined the final Chinese version of the revision. The seven items changed in the process are shown in Table 4.

There has been an increase in the number of EBPs in China in recent years, but few of these EBPs mention the sustainability of the project [20], and there is no tool to evaluate the sustainability of EBPs or continuous quality improvement projects in China [18].

As such, this study describes the process of translation and cross-cultural adaptation of the NHS SM for use in China by following rigorous translation and linguistic validation guidelines, including cognitive interviews [25, 33]. The main objectives of this study were to develop a Chinese version of the NHS SM and to validate the NHS SM's conceptual equivalence and linguistic validity in a Chinese healthcare scenario.

Meetings with the translation committee on the forward and reverse translation process helped to identify any differences and improve the quality of the translation [25]. Although most of the NHS SM items were relatively easy to translate in forwarding translation, the committee found some differences between the first and second forward translations. After refining each stage of the translation process, the committee identified some inconsistencies between the English and Chinese versions. All discrepancies were resolved by group discussions until every member of the group reached a consensus. For example, the communication (沟通) terminology in the original NHS SM item two was challenging to match in Chinese in that context because, according to the Xinhua dictionary, "communicate" in Chinese means to make both parties understand each other, such as ideas, culture [37], yet “communication” in NHS SM means much more than just two parties. It took four rounds of group discussion and confirmation with the author of NHS SM before we finally settled on translating it into “dissemination” (传播), which is the process of transmitting information, intelligence, opinions, feelings and directly or indirectly between people or groups of people with the help of verbal and non-verbal symbols in Chinese [38].

Content equivalence between the pre-final translation and the original version can be further improved through expert review, and the composition of the expert committee needs to be carefully considered because it is essential for achieving cross-cultural equivalence, such as the expert's knowledge of the study area and the expert's familiarity with the target subjects of the study [25]. This criterion was met in this study by inviting eight Chinese EBP experts who had the experience of studying abroad and proficiency in English to assess the equivalence and content validity of the pre-translated NHS SM. The experts rated the pre-translated NHS SM as good overall but identified minor issues, such as the ordering of statements and the use of pronouns, which were revised by the translation team.

The primary purpose of the cognitive interview was to test whether the developed Chinese version of the NHS SM was understood following our measurement intentions by understanding the respondents' cognitive processes towards the NHS SM. Some predicted questions were given more detailed information through the cognitive interviews, while some unpredicted understanding issues were also identified. These issues were addressed through group discussion, interviewee, and expert suggestions, and the content equivalence between the Chinese and the original versions was verified together with the NHS SM. This study used a cognitive debriefing technique to conduct the cognitive interview [35, 39], which enabled some quantitative data to be collected before the formal interviews began. For example, how long it took respondents to complete the model, how well the total item persistence scores matched their ratings, and which items were difficult or easy to understand. These quantitative results can be used not only as a basis to help interviewers conduct interviews but also as an aid in determining whether the NHS SM can initially test the sustainability of the evidence translation project and whether the respondents easily understand it.

Of six respondents from the same hospital, half understood the ‘organisation’ as ‘department’ and half as ‘hospital’. This difference may be related to how EBP is implemented and the clinical culture in China. Currently, in China, EBPs are primarily carried out on a departmental basis rather than throughout the hospital. Therefore, the smooth implementation and maintenance of EBP mainly depend on departmental leaders' support [40]. In addition, due to the traditional Chinese culture, Chinese clinical departmental leaders present a centralised form of paternalism, which means that if the head nurse does not agree to conduct or continue to maintain the implementation of EBP, then EBP will not be introduced [41].

The level of understanding of the organisation influenced the respondent's answers to the models’ items. Two respondents in the cognitive interview felt that the description of NHS SM item six on whether employees could express their ideas and opinions needed to be more consistent with Chinese culture in healthcare. However, it is worth noting that there are also differences between the two interviewees' statements. One interviewee felt that the hospital and department heads allowed and encouraged staff to express their ideas, but that staff were reluctant to do so because they were already busy with their nursing routines, and giving their opinions would increase their workload and sacrifice their own personal time to do so. Another interviewee stated that staff in his department are only passive in implementing EBP and felt that, generally speaking, Chinese leaders need to encourage staff to express themselves. This difference may be related to the leadership style of the respondent's supervisors [42]. However, the management style of clinical scenarios in China is dominated by the traditional type of staff obedience [43, 44]. Some senior leaders are transitioning to transformational leadership by introducing the concept of transformational leadership [45, 46].

Given that the NHS SM measures the sustainability of the evidence translation project itself, the measurement of entry six needs to be more integrated with the leadership style of the specific scenario in which the project is implemented rather than judging the sustainability of the evidence translation project from the perspective of the leadership style of China as a whole. As such, the translation team did not make changes to item six.

In this study, the English version of the NHS SM was translated into Chinese, and language validation was completed in a Chinese healthcare setting according to rigorous and systematic guidelines. The reliability of the translation and linguistic validation was reinforced by the involvement of the original tool developers in the process [25]. This study provides insight into the use of the NHS SM in the local Chinese healthcare setting and highlights the importance of understanding the different contexts in which the tool was developed and used. Large-scale testing is needed further to evaluate the Chinese version of the NHS SM.