Table 2 Themes, categories, codes and associated quotes

Innovation

Accessibility

Time of training, Availability of education, Frequency of contact

[…] we are trying to organize different moments during the year when all our professionals come here […] to update all together their training program (psychologist, primary care, Italy).

Attractiveness

Method of presentation, (lack of) tailoring, Extrinsic motivation, Extrinsic incentives

Cases were presented, cases from our own organization, cases which really increased motivation of the staff (manager, hospice, The Netherlands).

Usefulness of change

Usefulness, Impact of research, Use of new knowledge

[…] it is important that you will also see the results of what you are doing (nurse, hospice, The Netherlands).

Individual professional level

Attitude

Intrinsic interest, Intrinsic motivation, Decision making process

[…] I say 'interest', I don't know - but maybe it is more interest in end of life care or dementia or whatever and that obviously makes life a lot easier when new initiatives and services are available (nurse, hospice, England).

Not all professionals have the proper motivation, time, availability or willingness to involve themselves in something that goes beyond their daily work (psychologist, primary care service, Italy).

Professional skills

Practitioner autonomy, Placing responsibility, Stepwise introduction of new responsibilities

We [physicians] used to administer the chemotherapy. This has now been completely delegated to the nurses. […] the doctor became more an observer. […] the number of patients has increased, so you could not sit there and watch the treatment proceed for 3 hours, so things had to change. The nurses' competence is much, much more extensive than before (physician, hospital, Norway).

Knowledge

Level of knowledge, Knowledge of palliative care services, (lack of) skills, (lack of) experience

If you only experience 20–25 deaths per year within the entire organisations, it is difficult for the individual nurse to maintain the necessary skills to care for these patients (physician, nursing home, The Netherlands).

Nurses need to know what they can improve before they can improve […] (physician, nursing home, The Netherlands).

Awareness

(lack of) awareness of palliative care

We should make professionals understand that palliative care doesn't represent the last step […] (physician, hospice, Italy).

Despite all our efforts and education provided, there isn't a culture about palliative care in everyone yet. For example, it is frustrating when GPs don't refer their patients to us because they are still conscious (nurse, hospice, Italy).

Group dynamics

Team climate

(lack of) group support, Culture of change, Fear and avoidance, Participation

The team doesn't support each other, […] those who are motivated to change are so few that it is too difficult for them to stand up against those who are against changes (manager, hospice, The Netherlands).

We were trained so traditionally that most of the time, the doctors led the meetings. The others who were present just sat there and answered the questions they were asked, instead of considering themselves as equal members of the team with an active role in the meeting (manager/nurse, palliative care unit, Norway).

Network

Forced network, Knowing other professionals/services, Competition between services

[…] there is an increasing number of services and offers, meaning it is becoming much more complicated […] (social worker, palliative care unit, Germany).

[…] within such a network, people interact who cannot stand each other, but we ask them to do so (physician, nursing home, The Netherlands).

Professional guidance

Role modeling, Mentoring, Feedback

We have a retired GP who is really good, […] who goes out to see the GPs in […] that worked really well, he was well regarded in his role. So, of course, him going back to the GPs, they think that's marvelous, you know, they respect him (nurse, hospice, England).

With that colleague I took the time to discuss what the possibilities were and showed him what he could improve. This practical contact really made a difference (physician, hospital, The Netherlands)

Organizational context

Organizational processes

Physical structures, Managing complexity, Extrinsic interest, Use of technology

[…] we need to work a lot with temporary personnel, which brings along the problem that they cannot take part in meetings of quality circles. This means that it is extremely difficult to implement agreed standards (head nurse, primary care, Germany).

Organizational structures

Structure of organization, Place of care

[…] the hospital itself has changed from being one big building to several big buildings. We used to meet colleagues in the cantina. But now we're too busy, so we never go to the cantina and if you do, you go to different cantinas, so you don't meet colleagues like you used to. The lobbying you could do earlier, you can't do that anymore (physician, hospital, Norway).

Staff

Staff size, Staff turnover, Availability of staff, Hiring new staff, Depletion of other service

[…] sometimes you have to deal with a culture that is very much dependent on the persons working there. If some of these persons leave, it becomes very difficult to maintain innovations (physician, nursing home, The Netherlands).

[…] there are only few people interested in qualifying, choosing this profession is becoming increasingly unattractive […] (physician, palliative care unit, Germany).

Time

Time constraints, Burden of information

[…] so busy with caseload stuff that you haven't got the time or as much time as you'd like to do that education bit and training (nurse, hospice, England).

[…] you are so busy every day that you don't find the time to meet people (physician, palliative care unit, Norway).

Economic and political context

Financial arrangement

(lack of) resources, Financial aspects, Financial incentives

If you […] need an additional employee […], this will cost money. If I don't have the money, I won't have the employee, if I don't have the manpower for this task, I may put less effort in documentation work. And if then someone comes and says: The documentation is not appropriate … Well, what would be the reason? Lack of resources. I think, this is where one shoots oneself in the foot (physician, hospital, Germany).

Other medical areas […] receive funding from large (pharmaceutical) industries. Palliative care doesn't have that kind of support (general practitioner, The Netherlands).

Regulations

Availability of (existing) guidelines/rules, Formalization of change

Everything, […] yes, it needs to be in concordance with the principles of the whole organization (director, nursing home, Germany).

When palliative care was introduced, the national organisation was primarily focused to improve cure within the hospital and not care within primary care (general practitioner, The Netherlands).