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Table 4 Barriers to and facilitators for using specific implementation strategies

From: Barriers to and facilitators for implementing quality improvements in palliative care – results from a qualitative interview study in Norway

Subtheme Code Quotation
Implementation strategy: Educational strategies
Timing • B: Daytime We also have internal educational sessions every other week from 14.15 to 15.00. However, we see that it is difficult for the daytime staff to attend these sessions (Assistant head nurse, H-GU).
• B: Half-day (leaving the clinic) Nurse H2: Leaving [the clinic] towards the end of the day – that was the challenge with these half-day or two hour courses.
Nurse H1: It is really frustrating for those who remain [in the clinic], who then have to take over the patients with all the responsibility this entails. (Nurses, H-PCU)
• B: After large changes have been implemented We were the ones that called out: “If these patients are supposed to be here from now on, then we need training”, and then the training was arranged a while after the fact. A nurse from that department came 2–3 mornings and gave us a light briefing (…) and it is very challenging to care for these patients (Nurse 2, H-PCU).
• F: Evenings We have arranged quite a few training courses in the evenings in order to reach everyone (Head nurse, NH).
• F: Half-day (easier to organize) In the beginning, we had full-day sessions. Since then, we have been arranging half-day sessions, because having them from noon to three-thirty is easier to organize (Executive director, LMC-PCU).
• F: Full-day Nurse L3: I think it was a good thing that we were taken out of the clinic, because then we didn’t have to feel stressed about going to the course.
Interviewer: Being released for the whole day?
Nurse L3: Yes, that worked much better.
(Nurse, LMC-PCU)
• F: Arranged repeatedly We repeated the program a second time so that everyone would have the opportunity to participate despite working shifts (QI nurse, LMC-GU).
• F: Before (large) changes have been implemented In my experience, it is great to get good information and training in advance. That is something we see works well. Include them in whole day training sessions, so that we have plenty of time (Head nurse, H-GU).
Funding • B: Lack of funding We cannot afford whole days, i.e. we have only allowed ourselves two days [of educational sessions]. This is not much for a whole year (Executive director, NH).
• F: Hiring substitutes We finish this project formally this summer. The money has first and foremost been used to hire substitutes for the employees. When employees participate in educational courses, we can’t just empty out the ward. We need substitutes there during that time, because the patients are still there (Executive director, LMC-PCU).
• F: Extra project funding
Organizational aspects • B: High staff turnover Physician (H-PCU): We spent a lot of time on in-house educational sessions in the community services, but it just frittered away, so we gave it up. It was a waste.
Interviewer: Do you know why?
Physician (H-PCU): Yes, because they were replacing staff constantly. So you need to consider what you’re spending your resources on, and that was not the way to go.
• F: Mandatory attendance You must require it of them. It must be compulsory, like the fire drills, because these are compulsory, and we see that this works, because then they have to attend (Head nurse, NH).
Implementation strategy: Local champions
Personal characteristics • F: Expert If there was someone who had the expertise, whom you could call and make an appointment with and say “today I need to learn this”, then you would learn it, but that you could also call them back on the phone if you needed to. (…) Because if you are implementing something new, then it is a good idea to have someone who knows it better than others (Physician, H-PCU).
• F: Attitude towards project I think it is very important to choose the right people. One thing is the knowledge aspect, but another important factor is believing in the project and having the guts to follow through with it. (QI nurse, LMC-GU)
• F: Legitimacy And that this person has legitimacy in the work environment and is available. This makes implementation a lot easier (Physician, H-PCU).
• F: Availability
Organizational aspects • F: Regular updates The pain resource nurses are summoned regularly throughout the year by a nurse anesthetist (…) There they are updated on the latest information about assessment and treatment (Head nurse, H-GU).
• B: Lack of opportunity to disseminate knowledge I’ve learned things that I should share with my colleagues, but there hasn’t really been room for it during our regular training days (Head nurse assistant, H-GU).
Implementation strategy: Formal meetings
Timing • B: Too few staff meetings It is a challenge to reach everyone. It is a challenge to reach staff working the night shift; I only have two meetings a year with them (Executive director, NH).
Group size • B: Large It was in the physicians group that we managed to create a shared environment. While the nurses…there are so many of them. (…) It was easier to arrange [meetings], because we were not that many physicians (Physician, H-PCU).
• F: Small
Organizational aspects • B: Varying attendance rates Physician (PCT): We experienced that some municipalities were unable to send physicians [to regional meetings], but then the physicians would ask us to come extra and participate in their internal meetings and educational sessions and we tried to accommodate them.
Interviewer: Sounds like you made a great effort to make this happen –
Physician (PCT): Yes, but it was very time consuming.
• F: Arrange additional meetings
Implementation strategy: Reminders
Type of medium • B: E-mail/ phone I’ve tried e-mailing and phoning, but there is something about getting to see the person who asks about these things face-to-face. I think that works better. I think there is something about the psychology in that (Physician, H-PCU).
• F: Face-to-face
• F: Laminated cards It should be a smooth pedagogical program in combination with, in my opinion, something written that is easily available, to help us remember, as we have with the [name of] project. Something that can lay there readily available. Something laminated (Head nurse, H-GU).
Frequency • F: Repetition And I had to go again and again [to remind staff] (Physician, H-PCU).
Social context • F: Personal relationship Interviewer: You said you knew them personally, do you think this had an effect?
Physician (H-PCU): Yes, I think so. That I had a personal connection to them.
Implementation strategy: Change of professional role
Educational policy • F: Improved general education The nurse competence is much greater now than before. They learn much more during general training, which makes it easier to give them more responsibility (Physician, H-PCU).
Gradual implementation • F: Gradual transfer Often, there will be a small transition, it [the change in tasks] is not implemented suddenly from one day to the next, but you observe how things go (Physician, H-PCU).
• F: Trial period
Staff involvement and motivation • F: Involving staff It is not just one person who decides anymore. Now it is more something you discuss in the group until you find a solution (Physician, H-PCU).
• F: Motivated staff They had to be willing to attend [educational] sessions, so we tried to find staff members who seemed motivated to take on this task (Head nurse, LMC-GU).
  1. B barrier, F facilitator, GU geriatric unit, H hospital, LMC local medical center, NH nursing home, PCT palliative care team, PCU palliative care unit