Implementation of improvement strategies in palliative care: an integrative review

Background The European population is ageing, and as a consequence, an increasing number of patients are in need of palliative care, including those with dementia. Although a growing number of new insights and best practices in palliative care have been published, they are often not implemented in daily practice. The aim of this integrative review is to provide an overview of implementation strategies that have been used to improve the organisation of palliative care. Methods Using an integrative literature review, we evaluated publications with strategies to improve the organisation of palliative care. Qualitative analysis of the included studies involved categorisation of the implementation strategies into subgroups, according to the type of implementation strategy. Results From the 2379 publications identified, 68 studies with an experimental or quasi-experimental design were included. These studies described improvements using educational strategies (n = 14), process mapping (n = 1), feedback (n = 1), multidisciplinary meetings (n = 1) and multi-faceted implementation strategies (n = 51). Fifty-three studies reported positive outcomes, 11 studies reported mixed effects and four studies showed a limited effect (two educational and two multi-faceted strategies). Conclusions This review is one of the first to provide an overview of the available literature in relation to strategies used to improve the organisation of palliative care. Since most studies reported positive results, further research is needed to identify and improve the effects of strategies aiming to improve the organisation of palliative care. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0293-2) contains supplementary material, which is available to authorized users.


Hospital / Taiwan
Nurses (n=88) Intervention group received a 50-minute lecture on artificial nutrition and hydration.
Pre (n=88) and post-intervention (n=88) structured questionnaires showed a significant improvement in knowledge, attitudes and behavioural intentions within the intervention group. Changes in knowledge and attitude were significantly different between experimental and control group. Changes of behavioural intentions between experimental and control group were not significant. A two-day palliative care educational resource team train-the-trainer workshop was provided. The workshop consisted of 16 modules (from the philosophy of end-of-life care to ensuring quality end-of-life care) and were conveyed through didactic presentations. Participants received a manual and CD with all course information.
Pre-and post workshop teaching effectiveness was assessed through self-evaluation and showed a significant improvement in all areas. Participants assessed the course materials as comprehensive, appropriate and useful for clinical practice. Confidence in teaching end-of-life content increased significantly for participants who used the course materials to prepare and present inservice.
Average pain scores decreased from pre-intervention 2.9 (n=30) to 2.0 (n=28) as there was an increase in pain assessment, discussion about pain and requests for transcutaneous electrical nerve stimulation (TENS) machines. Decrease in referrals to acute pain team. Post intervention evaluations showed that sessions on chronic pain were considered more useful compared to session on acute pain. A study day (including lecture and group work) was used to teach health care assistants how to help patients cope with the symptoms of advanced disease.
Post-intervention evaluation forms (n=47) and pre and post-test selfreport questionnaires (n=42) showed improvements in knowledge and self-confidence. A biannual, 4-day residential communication skills workshop for 20 fellows per workshop was provided. Content of the workshop was focused on: 1) developing a relationship and dealing with uncertainty, 2) giving bad news, 3) discussing transition to palliative care, and 4) discussing DNR orders. The workshop was organized around 5 simulated patients (actors) and most of teaching done in small groups of 5 participants and 1 facilitator.
A preretreat questionnaire, and 2 preretreat and 2 postretreat patient encounters (n=106 pairs) showed improved communication skills in the postretreat encounters.
Pre and post-test questionnaires (n=18) showed improved ethical and legal knowledge and confidence in communication. Bruneau, 2004 Quasiexperiment al study

Interactive education
Hospital / UK Nurses (n=18) Two sessions of 2-hours each. First session explored participants' knowledge and experience of stress. Second session reviewed the issues explored in the first session and provided an opportunity to practice relaxation techniques.
Pre and post-test questionnaires and interviews (n=18) indicated no conclusive evidence that the stressreduction programme had any impact on participants' stress levels or their capacity for coping with stress. Cooke, 2004 Quasiexperiment al study Hospital / USA Nurses, psychologists, physical therapists, occupational therapists, social workers, physicians, administrators (n=unknown) 1-hour, rotating, monthly program of case presentations and analysis to assist clinical nurses in translating research and ongoing knowledge into practice: facilitator introduced purpose of presentation, staff nurse presented the case study. 5-minute presentation about evidence based practice was given, 3 team members presented for 10 minutes on relevant nursing issues using EBP from the literature, a 20-30 minute discussion followed.
Pre-post intervention evaluation revealed that confidence in knowledge increased by almost one point on a five-point scale.

Outreach visit
In the preintervention period, formal family meetings were usually held after the provider team had reached consensus that restoration of function or survival was unlikely. In the intervention period, an initial formal multidisciplinary meeting with the patient, family or both was held within 72 hours after admission to the ICU. Purpose of the meeting was: 1) review medical facts and options for treatment; 2) discuss patients' perspectives; 3) to agree on care plan; and 4) to agree on criteria by which the success or failure of this Educational session about artificial hydration therapy for terminally ill cancer patients, which consisted of a 10-minute lecture, four interactive 60-minute seminars and discussion.
Pre and post-test (n=76) knowledge, confidence, selfreported practice, and overall evaluation showed that knowledge and confidence scores significantly increased.

Hospital / Australia
Physicians (n=30) Two groups of physicians, one intervention group and one control group. The intervention group received a booklet summarizing the evidence underpinning the recommendation before the workshop. Then they underwent a 1.5-day intensive face-to-face communication skills training with 3-6 participants each time, Simulated patient interviews and questionnaire were administered to all physicians, including those from the control group. The intervention group was also assessed immediately after the training, and at 6 and 12 months. Results show

Description of strategy Results
including presentation of principles, a DVD modelling ideal behaviour and role-play practices, followed by four 1.5 hour follow-up video-conferences incorporating role-play. The participants conducted the role-play with actors, while the facilitator joined in through video-conference.
that physicians displayed more creating environment and fewer blocking behaviours at follow-up, but were not significant. Physicians valued the training highly, but did not report substantial reduction in stress and burnout. GPs (n=22) GPs attended weekly patient case conferences to review their own practice, they were asked to keep a diary of patient related activities, they were also required to take part in the hospice team's normal on-call roster, they participated in tutorial-type educational sessions (covering: pain management, symptom control, oncology, and psychosocial and ethical issues in palliative care), and they held a weekly discussion with a mentor.
Pre and post-intervention questionnaires indicated statistical significant improvement in the GPs perceived level of knowledge, skills and confidence in providing palliative care.

Nurses (n=unknown)
To introduce a care pathway, consisting of interdisciplinary care path, nurses' daily flowsheet, and a standardized physician order sheet, nurses received educational session about end-of-life care and house staff and physician assistants received a case-based teaching round. On each study ward, a nurse leader acted as liaison to the project. Evaluation tools were used to assess and feedback the progress made.
Pre and post-intervention chart abstraction (n=101;156), process audit, and knowledge questionnaire (n=138) indicated that the mean number of symptoms assessment increased significantly; Significant decrease in the number of problematic symptoms identified and interventions employed in the palliative care unit; Significant An audit-feedback approach was used to implement 1) Monthly meetings, 2) External assistance: 2.1) assistance with the development of an implementation strategy and assistance with system changes, 2.2) twoday training and additional one-to-one assistance with an experienced mentor, 3) Information sessions on advanced care planning including introductory discussion and information kits for doctors who were not able Pre and post-implementation audit of residents' files (n=46) indicated improvements in documented evidence that the resident has been involved in advanced care planning, significant others have had the opportunity to be involved in advanced care planning and there is evidence of ongoing assessments. Pre-and post-

Description of strategy Results
to attend the sessions, and 4) Documenting and implementing guidelines. During the course of the project, regular but optional support meetings were used to discuss personal encounters. At the end of the project, a short session about advanced care planning was added to a mandatory study day. 1) A decision coaching protocol was introduced to provide a stepped approach to assessing callers needs; 2) Online decision support tutorial to be able to recognize decisional conflict, describe concepts of decision support, tailor decision support callers needs, be aware of decision aids and use the decision coaching protocol; 3) 3-hour skill-building workshop to further develop the participants skills, via: role-play using the protocol, feedback, and discussing a real patient-nurse call; 4) Training of supervisors in decision support; 5) Having the director of the helpline to address workshop participants the importance of decision support.
Pre-post intervention evaluations (n=32) showed an increase in knowledge (from 61% to 84%) and quality of decision support (from 56% to 86% Senior geriatricians gave seminars about definitions and trajectories of various endstage diseases, common end-stage symptoms, and their management. An end-of-life care manual was placed in each nursing station. Forms to guide symptoms monitoring, interventions, and investigations were included in patients' files. A care pathway was developed with ongoing review and consultation with staff. Forms and electronic alerts were used to inform staff about discharge options and end-of-life-care status. Workshops including role-play and interactive discussions were also conducted. Pre (n=80 and post-test (n=89) patient symptoms and caregiver assessment showed a reduced duration of stay, fewer investigations, and fewer transfers back to the acute care hospital. Improvement in patient symptoms was achieved for pain and dizziness. Caregiver and patient satisfaction improved after the initiative. Pre-(n=118) and posttest (n=121) staff evaluations showed no significant differences regarding burnout and anxiety.