Implementing palliative reasoning in multiprofessional palliative care: A participatory action research in the Netherlands

CONTEXT: In the Netherlands, two interventions exist to support healthcare professionals in assessing palliative care needs and providing multidimensional generalist palliative care. Separate use hindered communication, interprofessional collaboration, and multidimensional care. To address this, the two existing interventions were integrated into a single multiprofessional intervention, Palliative Reasoning. The Palliative Reasoning Working Method (PRWM) was developed to support its implementation in daily practice.

OBJECTIVES: To iteratively adapt and implement the PRWM in primary care, hospice, and nursing home settings, and to explore determinants, implementation strategies, implementation outcomes, and healthcare professionals perceived impact.

METHODS: A multi-method participatory action research with three iterative cycles was conducted between October 2020 and January 2022 in Dutch primary care, hospice, and nursing home settings. Earlier phases included practice analysis and co-design of the PRWM. In this phase, PRWM was adapted and implemented within 20 multiprofessional teams. Primary outcomes were adaptation and implementation (acceptability, adoption, feasibility, fidelity, and sustainability); secondary outcome concerned healthcare professionals' perceived impact. FRAME guided adaptation documentation. A logic model, informed by CFIR, ERIC and COM-B, explored implementation outcomes. Qualitative and quantitative data were analyzed deductively and descriptively, respectively.

RESULTS: Fourteen content adaptations and seven supporting materials were developed. A logic model depicted key determinants, strategies, mechanisms, and outcomes of implementation. The PRWM was perceived as feasible and acceptable, improving recognition of palliative care needs, person-centered care, nursing empowerment, and team collaboration. Implementation proceeded largely as planned, adapted to local contexts, and continued in most teams. Integration into electronic health records and organizational embedding were crucial for sustainability. Healthcare professionals reported increased knowledge, motivation, and leadership skills.

CONCLUSION: PRWM shows promise for embedding Palliative Reasoning into routine palliative care across primary, hospice, and nursing home settings, strengthening proactive, person-centered, and collaborative practice, especially through nursing empowerment. Sustainable implementation requires behavioral-change strategies and supportive organizational and digital infrastructure.