*3.5. Sustainability*

Sustainability was examined in relation to organizational conditions of leadership, staff participation, resources, and communication.

**Leadership** was vital for the sustainability of participatory programs. Administrative and supervisor support for wellness towards PIP teams and employees were indicated in many forms within the qualitative data. It included financial support, enabling staff to take time off for meetings and activities, providing meeting space, and verbal encouragement.

Both management and supervisor support were cited in the qualitative data by many employees and managers to be important for program sustainability. The effects of administrator support (and turnover) were mentioned as important in encouraging or discouraging team meetings and activities. Support from management (administrators and nursing directors) and from supervisors (department heads and unit/office managers) were examined separately.

Overall, the NPHP centers demonstrated higher management support than the PIP centers. Administrators in PIP centers discussed HP as part of their everyday work and considered their wellness champions and teams as part of their organizational structure (except in I-2).

Supervisor support was perceived to be higher in two PIP centers, I-1 and I-3, and low at I-2. At the NPHP center C-2, many employees described their supervisors as being supportive to HP by allowing flexibility in their staff schedules and even covering for them while they participated in activities. Other supervisors within this center were described to be supportive by participating in activities themselves and motivating their staff to participate.

PIP teams were able to provide more activities for the staff members with the presence of leadership support. When leadership support was absent, management in these centers talked about being faced with other pressures, needing to make decisions in favor of other more urgent projects and programs.

Management changes in two PIP centers led to combining the existing PIP teams with other, previously inactive committees ("staff appreciation committee" in site I-1, and "fun committee" in I-3). In both cases, the non-supervisory PIP teams were converted to administrator-directed committees with different agendas and priorities.

**Sta**ff **participation** in programs and activities is obviously a key measure of program impact as well as likely sustainability. Perceived lack of staff participation in PIP teams and activities was evaluated from the PIP team member interviews and focus groups.

All PIP team members stated in the focus groups that clinical staff had difficulty in getting time to attend team meetings or activities. Staff participation in team-sponsored activities was poor within center I-2. Researcher experience and logs showed that participation in PIP teams had been quite high at the start of the project, yet involvement of clinical staff diminished due to frustrations with their decision-making process and clinical responsibilities.

Employee participation in all three PIP teams dropped to a low number of non-supervisory clinical staff at the end of year 3 of the intervention. Low participation of clinical staff in activities were attributed to staffing shortages, time constraints, and clinical care responsibilities.

**Resources** mentioned in the interviews and focus groups included financial support from the corporation, in-house/in-kind personal effort, and outside support. Although wellness was a stated goal for both the PIP and NPHP centers, no funds were allocated in any of the facilities' budgets for employee wellness except in the first year (2008), when the corporation provided \$700 per year for each facility. After this line item was dropped, most facilities engaged in regular fund-raising for their programs and many of the key informants expressed frustration at the lack of funds for their programs.

In the PIP centers, several projects and especially the higher cost projects simply could not be implemented without adequate resources. At one PIP site (I-2), much of their past activity had focused on fund-raising, which detracted from effort and time that could otherwise have been spent on health and wellness activities.

Using existing in-house resources was an opportunity for the PIP teams to benefit from the knowledge and skills of individual staff members. At Center I-1, one of the nurses offered yoga classes and another offered massages; at I-3, the dietitian offered many in-house programs and services including a weight loss program, potlucks, and healthy recipes.

Team members in the PIP centers identified researcher involvement and guidance as a key outside resource and a vital link to sustainability of the teams. At center I-2, most members believed that the PIP team would not continue without researcher support. The research team provided material support to all three PIP centers, including ergonomic training sessions to staff members, tools and seedlings for the garden, and an exercise class instructor.

Among NPHP centers, the primary forms of outside support cited were discounts for gym membership, health information, and free health screenings by group health insurance companies. In Center C-2, respondents also cited outside support from community programs along with insurance company services.

**Communication** was mentioned in the qualitative data as factors that are essential for sustaining a participatory health program.

Communication between the PIP teams or wellness champions with management as well as with the employees was uneven in both the PIP and NPHP centers. Employees in the PIP centers reported having good communication except at the I-2 center, where both the employees and managers expressed lack of communication as one of the largest stressors and most critical barriers to successful program implementation. The administrator at center I-2 concurred about the lack of communication between the PIP team and management. There appeared to be a trend towards better communication in centers where there was focused attention on work organization issues. In centers where closed-door management meetings were opened to staff or where the wellness champion utilized several methods of communication (e.g., memos, flyers, announcements during meetings, etc.), it was viewed as a smaller problem or not a problem at all.
