title: Barriers to implementing an integrated care pathway for the last days of life in nursing homes.
abstract: OBJECTIVE
  this paper explores the barriers that needed to be overcome during the process of implementing an integrated care pathway for the last days of life as a way of developing quality end-of-life care in nursing homes.
  
  
  METHODS
  an action research methodology underpinned the study. Qualitative and quantitative data were collected in eight nursing homes before, during and after the implementation of the care pathway.
  
  
  RESULTS
  six main barriers were identified: a lack of knowledge of palliative care drugs and control of symptoms at the end of life; lack of preparation for approaching death; not knowing when someone is dying or understanding the dying process; lack of multidisciplinary team working in nursing homes; lack of confidence in communicating about dying; some nursing homes are not ready or able to change. These findings highlight a functional 'rehabilitative' culture that may not be so appropriate in the current context of nursing home care, and one that makes implementing an integrated care pathway for the last days of life less straightforward than in other settings.
  
  
  CONCLUSIONS
  it cannot be presumed that the implementation of a care pathway for the last days of life in nursing homes is straightforward. This study suggests that an action research framework was extremely useful in highlighting and overcoming some obstacles when developing evidence-based practice. Action at both local and public policy level is required to fully address barriers that prevent quality end-of-life care in nursing homes.
authors.affiliation: St Columbas Hospice, Boswall Road, Edinburgh, EH5 3RW. jwatson@stcolumbashospice.org.uk
authors.forename: Julie
authors.initials: J
authors.lastname: Watson
authors.forename: Jo
authors.initials: J
authors.lastname: Hockley
authors.forename: Belinda
authors.initials: B
authors.lastname: Dewar
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D001293:Attitude to Death; D001294:Attitude to Health; D002983:Clinical Competence; D019091:Critical Pathways / Q000458:organization & administration*; D005190:Family / Q000523:psychology; D005851:Geriatric Nursing / Q000193:education / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D020380:Needs Assessment; D015403:Nursing Evaluation Research; D009735:Nursing Homes / Q000458:organization & administration*; D015404:Nursing Methodology Research; D009740:Nursing Staff / Q000193:education / Q000458:organization & administration / Q000523:psychology; D015279:Organizational Culture; D010687:Philosophy, Nursing; D016730:Program Development; D015397:Program Evaluation; D036301:Qualitative Research; D011788:Quality of Life; D020377:Self Efficacy; D013727:Terminal Care / Q000458:organization & administration*