Implementing a clinical ethics support instrument for palliative care (CURA): facilitators, barriers, and strategies

Background To support healthcare professionals in dealing with moral challenges in palliative care, CURA, a clinical ethics support instrument, was developed. The aim of the present study is to identify facilitators for and barriers to the implementation of CURA in healthcare organizations, and to identify strategies for improving the implementation of CURA. Methods Design: We used a mixed-method design combining quantitative and qualitative methods (a questionnaire and group interviews). Setting: 13 healthcare facilities in which palliative care is provided and in which CURA is implemented: three general hospitals, five nursing homes, two hospices, three home care organizations. Data collection and participants: The quantitative part of the study comprised a questionnaire with determinants for successful implementation. Data were obtained 18 months after the start of implementation. Respondents were 47 care providers who were trained as so-called ‘CURA ambassadors’, i.e., pioneers in initiating, facilitating and implementing CURA in their organization. The qualitative part of the study consisted of both open questions to the respondents to the questionnaire and three group interviews (total n=10). Analysis : Quantitative data of the questionnaire were analyzed descriptively. Qualitative data were analysed using both deductive content analysis on main themes and inductive content analysis on subthemes. Results We identified facilitators, barriers and strategies at four levels of implementation: intervention, users, organization, and socio-political context. Important facilitators pertain to CURA’s time efficiency, perceived effectiveness, attitude and competences of CURA ambassadors, commitment and support from colleagues and management. Major barriers were a lack of (allocation of) time, and resistance towards new interventions in the organization. Strategies pertain to embedding the use of CURA in existing structures, and pro-actively convincing colleagues and management of the benefits of using CURA. Conclusions Our research on the implementation of CURA, adds to the scarce knowledge that we have on how to implement clinical ethics support in healthcare organizations. Our findings provide concrete suggestions to organizations providing palliative care that seek to implement CURA, such as using evidence on the effectiveness of CURA to convince management, or to embed the use of CURA during meetings that are already scheduled and part of work routines.