A concurrent mixed methods approach was used for the study. Quantitative data identified patterns across large numbers of study participants and sites while qualitative data were used to examine the underlying reasons for these patterns by understanding clinic personnel’s perspectives on the perceived permanence of the DA [24]. Each data strand was collected and analyzed independently, followed by integration through triangulation to develop a comprehensive picture of DA sustainment. The study was part of a larger evaluation of the effectiveness of different implementation strategies for helping 15 clinics throughout the United States implement and sustain the use of a culturally competent, electronic DA designed to educate patients with lupus about their treatment options and help them engage in more shared decision-making with their clinical care team. The detailed description of the DA for patients with lupus is described elsewhere [25].

The study was approved by the Institutional Review Board (IRB) at the University of Alabama at Birmingham (UAB, 300002272; UAB Coordinating Center 200002554). Each study site’s IRB (15 sites including UAB) also reviewed and approved the study. The IRB approved the use of verbal informed consent given that the interviews were conducted via Zoom. During the consent process, clinical personnel were informed that participation was voluntary, and they could withdraw from the study at any time. All investigations were conducted in conformity with ethical principles of research. All study procedures adhered to the ethical principles outlined in the Belmont Report and complied with the Health Insurance Portability and Accountability Act (HIPAA). All study data were deidentified and stored securely on IRB-approved services, accessible only to authorized personnel. Each study participant was paid US $50 for completing the baseline survey assessment and US $10 for follow-up assessments.

The multivariate results are reported in Table 5. The internal learning climate was negatively associated with perceived permanence of the DA (β=−1.39; P<.05), as was external learning climate (β=−2.11; P<.01). Thus, we did not find support for hypotheses 1a and 1b.

The relationship between the change commitment climate and perceived DA permanence was negative and not statistically significant. However, findings indicated that the change efficacy climate, on average, was positively associated with perceived permanence of the DA (β=4.00; P<.001), supporting hypothesis 3.

The strongest and most robust results for control variables were observed for the years of clinic experience, ownership, size, and culture (Table 5). Specifically, the number of years of experience was negatively associated with the perceived permanence of the DA (β=−0.23; P<.01). This result suggests that those who have more clinical experience are less likely to continue using the DA. Respondents from nonuniversity clinics reported more positive perceptions of DA permanence than respondents from university-owned clinics (β=1.06; P<.01). Finally, relative to members of clinics with no dominant culture, members of clinics with a team culture reported more positive perceptions of DA permanence (β=0.65; P<.01).

Another consistent pattern was that, although the DA was regarded by clinic staff as a valuable tool for learning about lupus in general, many felt it would be particularly beneficial for patients who are newly diagnosed. According to several clinic members, patients who had been recently diagnosed with lupus reportedly expressed that they had learned something new from the DA. Given that clinic visits are typically brief, with an average of 15 (SD 5) minutes for return patients and 30 (SD 10) minutes for new patients, physicians feel compelled to be as efficient as possible when conveying information to patients. Therefore, the DA could serve as a valuable source of additional information or a reminder of topics that may have been missed or forgotten during appointments. However, several clinic members noted that, during the study period, the DA was primarily viewed by patients who have had lupus for a long time and did not require medication changes, making it difficult to gage its value. Moreover, because the participating clinics were outpatient, clinic staff believed most patients were not making an active treatment decision. As a result, clinic members observed that many patients, particularly those with longstanding lupus and stable treatment plans, did not perceive the DA as significantly enhancing their knowledge of lupus. However, clinic members suggested that the DA may be more beneficial for patients experiencing disease flares, those undergoing medication changes, or individuals receiving care in inpatient settings where active decision-making is more common.

Clinic members from 5 sites noted that the medication choices presented in the DA did not reflect those used by their clinics for treating lupus. It was recommended to include more scenarios in the DA, as the current version covered either more intense immunosuppressive drugs or those not prescribed by the clinics. Given that the DA often was not applicable to their clinical situations, providers who used different medications inconsistent with the treatment options presented in the DA were unlikely to use it in the future.

Almost all clinic members from all 15 sites noted that the DA was seen exclusively as a research tool, with the research coordinator responsible for recruiting and obtaining patient consent, as well as distributing the DA to patients. However, participating in the study imposed certain limitations, as clinics were required to adhere to institutional rules and the DA was not fully integrated into their daily workflow. Most of the time was devoted to research-related tasks, such as identifying eligible patients, obtaining consent, and ensuring that surveys were completed. As a result, the DA was viewed as an “add-on” rather than a clinical tool, making it challenging to garner buy-in from all members of the clinic. Some clinic members noted that if it had been introduced as a clinical tool, it could have been reinforced during weekly physician meetings and better integrated into the clinical workflow.

The DA being viewed only as a research tool had the consequence of limiting involvement from clinic personnel. In many clinics, nurses, medical assistants, and front desk staff were not heavily involved in the study. While they were aware of the study taking place, they did not play a substantial role in distributing the DA. This approach had both advantages and disadvantages. One advantage was that the research coordinator remained the same throughout the study in some clinics, which helped maintain consistency when clinic staff had to leave for various reasons. However, it also limited the potential sustainability of the DA as it was not perceived as a clinical tool that would continue to be used after the study was over.

Several clinics did not have a dedicated clinic for lupus, so a study coordinator would screen patients beforehand and identify those with lupus based on their ICD (International Classification of Diseases) code. The coordinator would then seek approval from the physician to include a patient in the study and hand the DA. In other clinics, the physician or principal investigator would identify eligible patients. Regardless of the approach, all clinic members acknowledged the need to identify patients who may be experiencing a flare-up or have recently been diagnosed with lupus in a proactive manner. Ideally, during an office visit, a physician would assess a patient’s eligibility for the DA and inform them that a link would be sent. In addition, the physician should schedule a follow-up visit to answer any questions. However, participants noted that manually prescreening and identifying which patients should view the DA would be a barrier to long-term sustainability.

This study examined the relationship between learning climate, change readiness climate, and the perceived permanence of a lupus DA for patients in 15 geographically diverse rheumatology clinics across the United States. We found that a positive change efficacy climate was significantly associated with the greater perceived permanence of the lupus DA, while change commitment was not significantly associated. Interestingly, both internal and external learning climates were negatively associated with DA permanence. Qualitative findings highlighted challenges to sustainment, including poor workflow integration, lack of physician buy-in, and perceptions of limited applicability of the DA to certain patient populations. Our findings underscore the importance of organizational context for the successful implementation and sustainment of evidence-based interventions, echoing prior theoretical and empirical work [33,34]. Respondents from clinics with a more positive change efficacy climate were more likely to have positive perceptions of DA permanence. This aligns with organizational readiness theory, which posits that efficacy, the belief in collective capability, is a critical driver of change implementation [17].

In contrast, change commitment was not significantly associated with DA permanence. This may be due to the setting of many participating clinics in academic environments with ongoing research and quality improvement projects. Interviews revealed that staff often viewed the DA as a temporary research tool, not a sustained clinical practice. This perception likely undermined broader organizational commitment, despite early engagement. However, the DA being viewed only as a research tool had the consequence of limiting clinic-wide commitment. Most of the clinics had only a handful of isolated research teams designated to implement the study. Thus, the DA did not have a pervasive presence and was rarely articulated as an ongoing explicit priority.

Unexpectedly, more favorable internal and external learning climates were negatively associated with perceived permanence. While this may seem counterintuitive, our qualitative data suggest that supportive learning environments facilitated critical reflection, leading clinic staff to identify limitations of the DA in their specific settings. For example, some physicians realized during implementation that the DA was less applicable to patients with stable disease or those not facing medication changes. Others noted the absence of a reliable method to identify eligible patients, further complicating routine integration. This suggests that learning environments, while essential for innovation adoption, may also lead to early discontinuation if an intervention is perceived as misaligned with clinical needs.

Among the organizational factors, years of experience, culture, and ownership were associated with the perceived permanence of the DA. Interestingly, the results indicated that more experienced members were less optimistic about the likelihood of continuing to use the DA, which is in line with the literature on organizational tenure and its weak positive effect on employee innovative behavior [35]. The interviews shed light on why this might be the case. In most of the clinics, physicians have been with the clinic for 5 or more years, which meant strong institutional knowledge and possibly even a belief they were already adequately educating patients. In addition, as earlier stated, most of the physicians thought that the DA was not quite compatible with their current medication management; thus, they were less likely to continue using the DA. Experiential knowledge of what medications work best for their patients could have substantial influence on their prescription decisions and lead to variations seen in clinical practice [36]. Furthermore, high turnover among support staff meant that physicians were frequently the longest-tenured personnel in these clinics, making them critical for successful sustainment of the DA.

The financial and human resources required to develop evidence-based interventions (EBIs) are substantial, making it crucial for practitioners and researchers to learn how to sustain them. This study, based on the implementation of the DA in 15 clinics, highlights the importance of organizational context in sustaining change. The focus should be on enhancing organizational climate, such as readiness for change and learning, before implementation. This study showed that change efficacy had a positive association with perceived DA permanence, while change commitment was not significant. Therefore, early planning that includes all clinic members and discussing the benefits of the EBI can improve buy-in. Likewise, leadership, particularly from physicians, plays a critical role in sustaining innovations in health care settings. A deliberate strategy should be in place to strengthen physician buy-in. Furthermore, if a continued use of the DA requires changes in organizational logistics, organizational management should focus on maintaining flexibility and compatibility of the DA across diverse settings. This includes tailoring the DA’s format to meet the needs of patients and physicians, such as offering options to view it online, through an app, or in the clinic. Finally, a formal strategy for sustaining EBIs should include ongoing evaluation to identify improvement opportunities. Project tracking, reporting, and staff discussions can help address issues early in the implementation process. Regular dissemination of data on patient satisfaction and outcomes, as well as providing incentives for active DA use, can further strengthen the innovation’s presence and sustainability within the organization.

Several limitations should be considered when interpreting this study’s findings. The analysis was based on just 15 clinics, mostly within academic medical centers, limiting the power to detect statistically significant relationships and generalizability. The outcome variable, perceived permanence, may have been biased as data collection occurred during implementation, possibly pressuring participants to respond positively. In addition, limited longitudinal analysis was possible due to staffing turnover, though the qualitative data helped clarify underlying mechanisms behind climate factors from multiple stakeholders’ perspectives.

Our findings suggest that simply introducing a lupus DA does not guarantee its sustainment in clinical practice. Organizational climate can play a central role in shaping perceptions of an intervention’s permanence. Future research should use longitudinal and multilevel designs to examine how organizational learning, readiness for change, and psychological safety influence the long-term adoption of decision aids. Tracking shifts in perception across time and context can help identify which organizational strategies best support sustained use.

In addition, clearer communication about the DA’s relevance to different disease stages and care pathways is needed. Various versions of the DA were implemented during the COVID-19 pandemic, and confusion about their applicability likely reduced uptake. Future dissemination efforts should ensure that stakeholders understand how different versions of the DA align with specific patient populations. Doing so may improve fit, reduce resistance, and promote sustained integration into routine lupus care.