title: Barriers to and facilitators for implementing quality improvements in palliative care - results from a qualitative interview study in Norway.
abstract: BACKGROUND
  Implementation of quality improvements in palliative care (PC) is challenging, and detailed knowledge about factors that may facilitate or hinder implementation is essential for success. One part of the EU-funded IMPACT project (IMplementation of quality indicators in PAlliative Care sTudy) aiming to increase the knowledge base, was to conduct national studies in PC services. This study aims to identify factors perceived as barriers or facilitators for improving PC in cancer and dementia settings in Norway.
  
  
  METHODS
  Individual, dual-participant and focus group interviews were conducted with 20 employees working in different health care services in Norway: two hospitals, one nursing home, and two local medical centers. Thematic analysis with a combined inductive and theoretical approach was applied.
  
  
  RESULTS
  Barriers and facilitators were connected to (1) the innovation (e.g. credibility, advantage, accessibility, attractiveness); (2) the individual professional (e.g. motivation, PC expertise, confidence); (3) the patient (e.g. compliance); (4) the social context (e.g. leadership, culture of change, face-to-face contact); (5) the organizational context (e.g. resources, structures/facilities, expertise); (6) the political and economic context (e.g. policy, legislation, financial arrangements) and (7) the implementation strategy (e.g. educational, meetings, reminders). Four barriers that were particular to PC were identified: the poor general condition of patients in need of PC, symptom assessment tools that were not validated in all patient groups, lack of PC expertise and changes perceived to be at odds with staff's philosophy of care.
  
  
  CONCLUSIONS
  When planning an improvement project in PC, services should pay particular attention to factors associated with their chosen implementation strategy. Leaders should also involve staff early in the improvement process, ensure that they have the necessary training in PC and that the change is consistent with the staff's philosophy of care. An important consideration when implementing a symptom assessment tool is whether or not the tool has been validated for the relevant patient group, and to what degree patients need to be involved when using the tool.
authors.affiliation: European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway. ragni.sommerbakk@ntnu.no.|Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. ragni.sommerbakk@ntnu.no.
authors.forename: Ragni
authors.initials: R
authors.lastname: Sommerbakk
authors.affiliation: European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.|Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway.
authors.forename: Dagny Faksvåg
authors.initials: DF
authors.lastname: Haugen
authors.affiliation: Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Aksel
authors.initials: A
authors.lastname: Tjora
authors.affiliation: European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.|Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway.
authors.forename: Stein
authors.initials: S
authors.lastname: Kaasa
authors.affiliation: European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.|Regional Centre for Excellence in Palliative Care, Department of Oncology, Oslo University Hospital, Ullevål, Oslo, Norway.
authors.forename: Marianne Jensen
authors.initials: MJ
authors.lastname: Hjermstad
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration / Q000592:standards; D001291:Attitude of Health Personnel; D002983:Clinical Competence / Q000592:standards; D003704:Dementia / Q000451:nursing*; D004059:Diffusion of Innovation; D004506:Education, Nursing / Q000458:organization & administration; D006291:Health Policy; D006295:Health Resources / Q000458:organization & administration / Q000592:standards; D061889:Healthcare Financing; D006760:Hospitalization; D006801:Humans; D007400:Interprofessional Relations; D007857:Leadership; D009042:Motivation; D009369:Neoplasms / Q000451:nursing*; D009664:Norway; D009735:Nursing Homes / Q000458:organization & administration / Q000592:standards; D015279:Organizational Culture; D016134:Organizational Policy; D010166:Palliative Care / Q000458:organization & administration / Q000592:standards*; D010349:Patient Compliance; D024382:Professional Role; D036301:Qualitative Research; D058996:Quality Improvement; D012941:Social Responsibility
keywords: Barrier; Cancer; Dementia; End-of-life; Facilitator; Implementation strategy; Norway; Organization of care; Palliative care; Quality improvement