Table 4 Implementation results – summary of analysis using NPT generated questions for interventions (Murray et al., 2010)

 Did co-researchers find the intervention easy to describe?

The intervention was more readily understood by those involved in the intervention development. Those not involved needed to see the intervention delivered or to deliver it themselves, ‘to get it’ (evaluation meeting B). Comprehension of the intervention was enhanced by thinking through how to phrase the intervention, so that it was congruent with their clinical style and patient population, and with experience of delivery (evaluation meetings A and B).

 Was it clearly distinct from other interventions?

Initially some co-researchers found it difficult to differentiate the intervention from their normal practice but as they delivered the intervention they described a subtle shift in their understanding from something professionally focused and ‘done to families’ to being family-centred (evaluation meeting B), ‘flipping the conversation to focus on the family (the meaning for the family’ and their concerns (evaluation meeting B).

Co-researchers also discriminated between the intervention and discharge ‘it’s not about discharge itself’ or ‘bits of kit’ or ‘a checklist’ (evaluation meeting B)

 Did it have a clear purpose for all those involved?

Co-researchers were self-selected and likely to already value and be motivated to provide family care.

 Did participants have a shared sense of its purpose?

Co-researches developed a shared purpose of the intervention by discussing their experience of intervention delivery as a team, often immediately after an intervention or when encouraged by the implementation lead for the team

 What benefits did the intervention bring and to whom?

Co-researches described they had ‘pulled apart their practice’ by delivering the intervention, which improved their practice by approaching family support from a ‘different angle’, ie from the family’s perspective, to ‘comprehend the impact of words and phrases on family members’ (evaluation meeting B).

 Were these benefits likely to be valued by family members?

Co-researchers described family benefits in terms of having the difficulty of the situation and their care acknowledged and providing time for them to think about the support they might need. They also thought that it helped family members with decision-making and problems-solving – gives family a voice in planning and helps them to work together to provide care.

 Did co-researchers and family members think the intervention a good idea?

Yes, see above.

However, co-researchers varied in their opinion about when the intervention was a good idea. Some delivered the intervention whenever they spoke to a family member about discharge care plans, irrespective of circumstances, whereas others discriminated depending on the circumstances, choosing not to use the intervention when, for example, there were disagreements between family members about where care might be provided.

Some co-researchers also described circumstances where they started to deliver the intervention but then stopped, because of the family member’s response – being unduly distressed or revealing a change in discharge plan.

 Did they see the point of the intervention easily?

Yes, co-researchers valued family-focused care, but see above how their perception of the intervention changed from being perceived as like normal practice to being distinct.

 Did they invest time, energy and work in it?

One person in each of the teams took a leadership role to explain the intervention to other members of the palliative care team, ward teams, discharge liaison leads and community teams. Cascading this information was influenced by the dynamics of the team but all teams developed strategies to overcome encountered difficulties.

Some co-researchers described how they became increasingly invested in the intervention with the more experience they had of delivering it – the benefits becoming increasingly clear with increased delivery.

 How did the intervention affect the work of co-researchers?

Some co-researchers initially thought that the intervention would take more time than normal care and explained that it felt ‘clunky’ at first (evaluation meeting A). However, as they became experienced, they found that the intervention flowed and conversations became more focused - it helped to identify family concerns quicker than usual practice and overall saved time.

 Did it promote or impede their work?

Some evidence was provided that the intervention promoted co-researchers satisfaction with their work: ‘I actually quite enjoy discharge now’; ‘discharge feels less onerous now’ (evaluation meeting B)

Some co-researchers described how the intervention had changed what might be expected of families, enhanced their appreciation of families and what they are doing in end of life care transitions.

Some co-researchers described how the intervention had enhanced all of their work, integrating within their practice the habit of asking both patients and family members ‘what are your concerns’.

 What effect did it have on their consultations?

Co-researchers needed to deliver the intervention a few times before it felt a natural process. Initially co-researchers used the intervention in consultations specifically directed at discharge planning but as some co-researchers became confident in its use, they incorporated it into other conversations.

 Did co-researchers require extensive training before they could use it?

Co-researchers were experienced practitioners in palliative care and had considerable expertise in communication skills and service development. Training consisted on a half day explanation and demonstration of the intervention, followed by team-based discussion, rehearsal and reflection.

 How compatible was it with existing work practices?

The intervention was considered compatible with existing work practices but assessment about the appropriateness of delivery was influenced by contextual challenges such as resource constraints. Some co-researchers explained how organisational pressures, and the resulting increase in their workload ‘prevented meaningful conversations with families’ (evaluation meeting B). Some also described how these pressures resulted in insufficient time to set up a meeting with family members before discharge or where family conversations had already taken place by other staff.

 What impact did it have on the division of labour, power and responsibility between different professional groups?

Implementation raised the way in which end of life care work is distributed in hospitals and how this influences access to family members and the provision of support. Implementation was influenced by the division of labour between specialist and ward teams. Specialist and ward teams typically have working arrangements about each other’s roles in discharge. Some co-researchers were concerned the intervention would disrupt these agreements and give a contradictory message to colleagues about their role in discharge and family support. During this pilot phase, co-researchers tended to focus the intervention on situations where discharge conversations had yet to take place with family members and were therefore likely not to occur when death was imminent.

 Did it fit with the overall goals and activity of the organization?

The intervention was considered an alternative for measuring effectiveness of specialist palliative care – a process by which quality standards could be achieved and demonstrated.

 How did co-researchers perceive the intervention once it has been in use for a while?

Several co-researchers described how the intervention had ‘changed their practice’ and provided satisfaction in relation to discharge planning and family support.

 Was it perceived as advantageous for family members and staff?

Co-researches described how the intervention ‘makes a difference to families’ and has ‘outcomes for the family in terms of their resilience’.

Some gave examples of benefit:

• helping a wife to express concerns that she would not be allowed to take her husband home to die and thus enabling this to happen;

• helping a wife to understand the care that would be available at night and to problem-solve how to manage this with her children’s help;

• a cousin of a patient who received the intervention reported to the co-researcher ‘you are the first person to ask what are my concerns’, explaining that his concerns had been overlooked up until that point

 Are the effects of the intervention clear?

Co-researchers considered that the intervention results in families gaining better psychological support compared to normal practice.

Consequently, co-researchers were beginning to think about involving families earlier in conversations about care transitions.

 Can the intervention be adapted or improved?

Some co-researchers reported altering the order in which the interventional components were delivered, for example delaying the acknowledgement statement (meaningfulness) until later in the intervention if it felt ‘flippant’ to use at the beginning. They also reported that comprehensibility and manageability components tended to flow into each other.

Co-researchers also described how they occasionally delivered the intervention over more than one consultation, sometimes ending the intervention after providing information which addressed family concerns and asking them to talk together before coming back and delivering the last component, focused on problem-solving and making an action plan.

They also discussed delivering the intervention by telephone.