System Support Mapping Identifies Context-Dependent Determinants Across NICUs

A methodological study in five German neonatal intensive care units shows that implementation determinants can facilitate, inhibit, or simultaneously support and hinder the introduction of a new care programme, depending on a person’s responsibilities, needs and local circumstances. Researchers combined System Support Mapping with a Matrixed Multiple Case Study approach to produce a structured six-step method for examining these determinants within and across hospitals.

The demonstration used data from the Neo-MILK project, which aimed to implement a structured lactation support programme for mothers of very low birth weight infants and establish human donor milk banks in German neonatal intensive care units. The analysis was not an evaluation of clinical outcomes or a test of whether the Neo-MILK interventions improved care. Instead, it illustrated how the two methodological frameworks could identify and compare factors associated with implementation.

System Support Mapping, or SSM, is rooted in systems thinking and offers a structured way to explore the responsibilities, needs, resources and wishes of individuals within an implementation setting. The article notes that SSM had not previously been systematically described and applied as a methodology for identifying implementation determinants in a multi-site study. Combining it with the Matrixed Multiple Case Study approach created a sequence that began with individual perspectives and progressed to unit-level maps and a cross-site comparison matrix.

The empirical example consisted of semi-structured interviews with key persons from the five participating neonatal intensive care units. The interviews took place during the early intervention phase of the project. Investigators analysed the transcripts using directed content analysis, with SSM elements serving as deductive categories and context-specific codes developed inductively. The multiple case study framework was then used to organise, compare and synthesise findings within individual sites and across all five units.

The method’s first three steps generated individual System Support Maps for key persons and separate maps for each neonatal intensive care unit. These maps were intended to capture how people involved in implementation viewed their responsibilities, requirements, available resources and other system supports. The remaining three steps transformed this material into a sortable matrix that placed findings from different sites into a common structure, enabling investigators to examine similarities and differences in their organisational contexts.

Within-site analysis showed why implementation determinants cannot always be represented as simple, fixed barriers. The same resource category could be perceived as facilitating implementation by one participant, inhibiting it by another, or serving both functions. These differences were connected to variations in individual responsibilities, needs and local context. The finding indicates that the presence of a resource alone does not determine its practical effect; its relationship to a person’s tasks and the surrounding unit matters.

The cross-site matrix made two forms of determinant pattern visible. Homogeneous patterns appeared in comparable form across several or all neonatal intensive care units, whereas heterogeneous determinants took different forms from one site to another. This structure allowed investigators to distinguish determinants that appeared broadly shared from those expressed through context-specific manifestations. The authors state that the distinction offers a basis for differentiating cross-site implementation strategies from measures tailored to the circumstances of particular sites.

Overall, the study demonstrates how combining SSM with the Matrixed Multiple Case Study approach can account for the perspectives of individual interest-holders while supporting systematic comparisons within and between institutions. The findings concern the identification and analysis of implementation determinants rather than measured effects on infant health, breastfeeding, milk-bank use or other clinical outcomes. The authors also identify an important limitation: further research is needed to evaluate SSM across multiple evaluation timepoints and its integration into the initial and ongoing tailoring of implementation strategies.

Subject of Research: A six-step method for identifying and comparing implementation determinants in five German neonatal intensive care units

Article Title: Applying system support mapping combined with the matrixed multiple case study approach to identify and analyse implementation determinants: lessons from a multi-site implementation study in German neonatal intensive care units

Article References: Dymek, N. G., Jaschke, J., Meyer, S., Stirner, A. K., Wiesen, D., Dresbach, T., Scholten, N., Köberlein-Neu, J., on behalf of Neo-MILK, Scholten, N., Müller, A., Dresbach, T., Hellmich, M., Ernstmann, N., Hammer, A., Eyssel, F., Kribs, A., Köberlein-Neu, J., Lugani, K., … Rupprecht, C. (2026). Applying system support mapping combined with the matrixed multiple case study approach to identify and analyse implementation determinants: lessons from a multi-site implementation study in German neonatal intensive care units. BMC Health Services Research, 26(1), Article 1238. https://doi.org/10.1186/s12913-026-15507-w

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15507-w

Keywords: implementation science, neonatal intensive care, System Support Mapping, multiple case study, health services research, Neo-MILK, lactation support, donor milk banks, organisational context, determinant analysis, Applying, system