Background
Methods
Study setting
Study participants
Nursing home | Educational background | Age (years) | Years as manager | Number of staff in the nursing home |
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A | Social worker | 56 | 2.5 | 32 |
B | Registered nurse | 42 | 5.5 | 32 |
C | Registered nurse | 60 | 25 | 60 |
D | Registered nurse | 65 | 25 | 74 |
E | Registered nurse | 62 | 28 | 57 |
F | Social worker | 48 | 6 | 44 |
G | Human resources education | 67 | 10 | 41 |
H | Social worker | 55 | 2 | 51 |
I | Registered nurse | 62 | 35 | 34 |
J | Social worker | 50 | 8.5 | 34 |
K | Social worker | 58 | 33 | 45 |
L | Several educations | 37 | 1 | 45 |
M | Social worker | 61 | 40 | 60 |
N | Social worker | 42 | 9 | 48 |
O | Social worker, nurse practitioner | 58 | 17 | 43 |
P | Sociologist | 61 | 13 | 110 |
Q | Social worker, nurse practitioner | 55 | 38 | 80 |
R | Social worker | 52 | 19 | 78 |
S | Social worker | 49 | 28 | 38 |
T | Human resources education | 45 | 3 | 90 |
U* | Behavioral science education | 49 | 12 | Not applicable |
V* | Social worker | 49 | 23 | Not applicable |
The educational intervention
Data collection
Theoretical framework
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Change efficacy: organization members’ beliefs in their capabilities to execute the planned actions involved in the change. Can they implement this change effectively given the situation they currently face?
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Change commitment: organization members’ resolve to pursue the courses of action involved in change implementation. To what extent do organization members value the specific impending change?
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Context: resources, structure, and culture that influence the organization members’ preparedness to implement the change. How does the context affect the organizational members’ willingness or ability to take action?
Data analysis
Results
Category in ORC | Sub-category | Explanation |
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Change efficacy | Competence and confidence (F/B) | Competence and confidence have to do with the staff’s experience and knowledge concerning palliative care issues and their beliefs that they can learn the principles of palliative care and develop evidence-based palliative care in the nursing home |
Face dying persons (B) | Facing dying persons concerns the staff’s beliefs in their capabilities to address or handle death and dying persons to be able to develop evidence-based palliative care in the nursing home | |
Change commitment | Motivation (F/B) | Motivation concerns the staff’s willingness and determination to develop evidence-based palliative care in the nursing home |
Attitudes to work in general (F/B) | Attitudes to work are associated with the staff’s interest and engagement in their work in general of potential relevance for developing evidence-based palliative care in the nursing home | |
Attitudes to changes at work (B) | Attitudes to changes at work are related to the staff’s resolve to pursue development of evidence-based palliative care in the nursing homes despite experiencing many concurrent changes at work | |
Context | Resources (B) | Resources refer to the availability of financial and personnel resources of relevance to developing evidence-based palliative care in the nursing home |
Time (B) | Time has to do with the availability of time to allow the staff to learn the principles of palliative care and develop evidence-based palliative care in the nursing home | |
Plans (F/B) | Plans relate to developing structures or concrete strategies for continued efforts to develop evidence-based palliative care in the nursing home | |
Leadership (F) | Leadership deals with the influence of the nursing home managers and other leaders on the staff in order to develop evidence-based palliative care in the nursing home | |
Decisional latitude (F/B) | Decisional latitude refers to the nursing home managers’ autonomy to make work-related decisions conducive to developing evidence-based palliative care in the nursing home |
Change efficacy
The biggest obstacle is [lack of] knowledge. (1)
Yes, the [ability] varies, I believe. I think some feel very… that I can do this gallantly, but there are also those who think, ‘Can I do this?’ (2)
According to the managers, many nursing home staff members express reluctance to face dying persons. They do not appreciate talking about death or being too closely involved when older people are dying in the nursing home. Managers noted that such situations tend to be perceived as uncomfortable for some staff who may struggle with what to say or how to act. The managers’ descriptions thus mean that hesitation in addressing or facing death or dying persons constitutes a barrier to developing evidence-based palliative care in the nursing homes.I think it [trust in one’s own ability] is mixed. But I think it’s very dependent on how long you’ve worked. (3)
Some have fear, because it exists. (3)
Especially those [older people] who may have lived here for a while, you have created a relationship with them. Then some may think that it is very difficult when the person becomes palliative and will die. Some think that it becomes too personal. (4)
Change commitment
After all, it’s very individual among the staff, how they commit to this and how they handle it. ... And I think it’s important to try to highlight the staff who have the dedication and knowledge, and the desire to work with this. (5)
The managers acknowledged that most of the nursing home staff members are engaged in their work and assume a shared responsibility for providing quality elderly care. The managers considered positive attitudes to work in general as an important asset for developing evidence-based palliative care. However, they also noted that there were staff members who were less passionate about their work and would therefore be less inclined to learn or practice the principles of palliative care. Based on the managers’ statements, attitude to work is therefore both a facilitator and barrier to developing evidence-based palliative care.I saw when I was out to gauge interest in the education, that it was considerable, so we had to make it a lottery. So there is an interest. ... They want knowledge about it. You just want to be safe and secure [in what you do]. (6)
I’m mighty proud of their commitment. In connection with palliative care, there is often an enormous commitment to the people it concerns. They take great responsibility. (7)
The managers believed that many staff members hold overall negative attitudes to changes at work, decreasing their commitment to learning the principles of palliative care. The nursing home managers and staff had experienced many changes over the years. The managers believed there was a risk that the aim to introduce principles of palliative care would meet with limited enthusiasm as a result of a certain “change fatigue” among many staff members, thus functioning as a barrier to the development of evidence-based palliative care.Then there are always exceptions and that’s the way it always is, with everything. There are those who sigh and think that this is futile. (8)
We have had a lot of changes here. I think they are quite fed up. ... What makes it difficult is all the changes we have made so far and they might be tired of changes or improvement work. (6)
It may happen that you get saturated. And it’s always about engaging and retaining this motivation among the staff. If it becomes too much I think you grow tired. (9)
We can never focus only on one thing because there is so much happening in the rest of the world, which affects us, decisions and changes of laws and everything. That [the changes] may be an obstacle. (10)
Context
Resources are needed if we are to educate ourselves, if we are to improve ourselves. ... We have a negative [economic] balance and we cannot sit here and have visions about doing many different things. (7)
The managers expressed that development of staff competence could not always be prioritized with regard to time to the extent they wanted. They recognized that acquiring and practicing knowledge and skills in palliative care will require time. According to the managers, time limitations restricted the staff’s ability to learn the principles of palliative care, thus functioning as a barrier to developing evidence-based palliative care.I don’t want to initiate too much [activities], because I feel that there is so much right now that we have to finish first. I shouldn’t mention the economy, but I have to lie low from time to time. You cannot start a lot of stuff which you could before when we had better economy. (10)
I think today everything goes so fast, so it’s never anchored. … And that’s why it isn’t so good either. (11)
In order to make a change, it must take time and how do we find time? Do we have the time? And when do we take it? (12)
The managers described various ambitions regarding plans to continue working towards evidence-based palliative care in the form of structures or strategies for the future, including having individuals as change leaders or quality improvement developers. However, there were also managers who admitted that they had not considered how the knowledge and skills acquired by staff members in the seminars should be transferred to colleagues or be maintained over time. Based on the managers’ statements, plans for developing evidence-based palliative care practice, therefore, function both as a facilitator and barrier for developing evidence-based palliative care.Everything has to be so fast and time is an opponent. ... We’re living in the future, we are not here in the present. (13)
We have something called change leaders who are chosen somehow ... We can use them as sounding boards and I can discuss all kinds of changes with them. (7)
Leadership was not only associated with the influence of the nursing home managers, but managers also viewed registered nurses as potential role models from which nurse assistants could learn how to talk about existential issues and obtain knowledge about other principles of palliative care. Competent leadership is therefore a facilitator to developing evidence-based palliative care on the basis of the managers’ descriptions.No, there is no plan at all. (14)
I think [registered] nurses have a key role in this. ... For the nurse assistants usually do as the nurses do. ... I have a really good nurse. She has competence and she is calm and secure, which is evident to the staff and [the residents’] relatives. (4)
The managers opinioned that their decisional latitude to pursue work-related initiatives of potential relevance for developing evidence-based palliative care was somewhat restrained because of the need to carry out many top-down actions initiated at higher political and management levels. Still, they believed that they had considerable autonomy to make decisions concerning nursing home activities and goals. Thus, according to the managers’ statements, room for decisions functions as a facilitator or barrier, depending on the mandate to make decisions to support the development of evidence-based palliative care practice.It’s a lot about management. It’s a lot about co-operation between manager and nurse, and how you work with the staff. (5)
I have a mandate for our activities here, but I get the decisions from above. … I must implement what I’m told from above, even if I do not like it. (3)
We are a politically controlled organization, so it [a directive] may come from politics, but there are things we can influence at our unit. If you have some ideas that are in line with what we are going to work for, then you can try it. (15)