Implementation of knowledge-based palliative care at nursing homes: The professionals' perspective

Abstract: Dying in older persons precedes often by a prolonged period of frailty and multimorbidity. The global increase in the aged population means more death at an older age and highlights the need to integrate palliative care in elderly care. Knowledge-based palliative care is lacking outside the specialist units, for which reason there is insufficient access to palliative care for older persons. Thus there is a need to implement knowledge and training in palliative care for the professionals in nursing homes. Putting evidence to proper use in practice is experienced as challenging, which calls for an exploration of experiences connected to the implementation of change in order to enhance the readiness for change in the future.The thesis is a part of a larger project, Knowledge-Based Palliative Care for Frail Older Persons in Nursing Homes (Swedish acronym KUPA). The overall aim of the thesis was to explore the professionals’ experiences of signs preceding dying in older persons and of the implementation of knowledge-based palliative care through an educational intervention at nursing homes. The thesis includes three qualitative focus group studies (I-III) and one quantitative study (IV) with pre-post design.In Study I, experiences of early and late signs preceding dying in older persons in nursing homes were explored. The multidisciplinary team found it difficult to identify early signs since it was not part of their ordinary practice, nor indeed something they had an awareness of. Late signs were found obvious and easy to identify, and dying was something that just happened not seen as a process.In Study II, professionals’ expectations and preparedness to implement knowledge-based palliative care in nursing homes were explored. They hoped to gain increased knowledge and improved consensus in the team but questioned the organization’ preparedness to change. Study III investigated experiences of readiness for change after the educational intervention in knowledge-based palliative care at nursing homes. The professionals were hopeful about the implementation of palliative care in the nursing homes and about continuation of the education, despite barriers in the organization. The education increased their knowledge and awareness. In Study IV, the professionals’ experiences of palliative care delivery before and after the educational intervention in nursing homes was evaluated. Some improvements in the experiences of symptom management, of conversation and support and of encounter were found between and within the intervention and control groups.There is a need to introduce palliative care early in the older person’s disease trajectory to increase quality of life. This calls for more knowledge and awareness among the professionals about early-stage palliative care. Furthermore the older person and the next of kin must be informed that palliative care is a part of the care in nursing homes. Increasing the professional’s readiness is a facilitation for all leaders in the health care section when a change is going to be implemented.