Table 1.
Coding and themes.
| iPARIHS component | Theme | Sub-theme |
|---|---|---|
| Outer (macro) | Care home sector & workforce | Absence, turnover & use of agency staff |
| Diverse nature of the care home sector | ||
| Pay, conditions, & opportunities for development | ||
| Staff levels & ratios | ||
| Commissioning | Commissioning process | |
| Funding levels | ||
| Priorities & services commissioned | ||
| Structure of health and social care system | ||
| COVID | Access | |
| Capacity & demand on services | ||
| Format of delivery | ||
| Impact on care home sector | ||
| Impact on relationships | ||
| Impact on space | ||
| Outbreaks | ||
| Risk | ||
| Policies & legislation | Anticipatory medications & medicines management | |
| COVID | ||
| Enhanced Health in Care Homes Framework | ||
| Verification of death | ||
| Regulation | ||
| Inner (meso) | Attitudes, culture & leadership | Attitudes of leaders |
| Attitudes towards care home staff/work | ||
| Culture & leadership | ||
| Policies & processes | Care home policies | |
| Hospice policies | ||
| Relationships | Communication (accessibility, accuracy & clarity, format, information sharing) | |
| Engagement (attendance, format, reach) | ||
| Multi-disciplinary working (fractured, fragmented/poor relationships; ownership; professional knowledge & expertise; proactive/partnership working; collaboration & empowerment; responsiveness & time) | ||
| Supporting families | ||
| Inner (micro) | Care giving/doing care | Acute care (discharge planning, reasons for hospitalisations) |
| Ambulance care (confidence, capability & training; emergency response; non-emergency, time; transporting to hospital) | ||
| Care homes (resources needed for implementation; confidence and competence motivation to change/buy in; past experience of innovation & change; workforce issues) | ||
| Hospice (services; space; staff mix) | ||
| Primary Care (district nurses; GP service provision; pharmacy) | ||
| Care Quality | Clinical & personal care | |
| Compassion, dignity & respect | ||
| Personalised | ||
| Relationships & knowledge | ||
| Safety & risk | ||
| Demographics | Ethnicity | |
| Geography | ||
| Malignant/non-malignant | ||
| Socio-economic levels | ||
| Innovation | Understanding | CH staff well informed of Needs Rounds |
| Understanding amongst wider stakeholders/organisational networks | ||
| Degree of fit | Strategic priorities in relation to palliative and end of life care | |
| Ethos of training, education, and quality improvement | ||
| Recipients | Perception of value | Motivation to change/buy in (amongst CH staff (and directors/senior management in chains), SPC (clinicians and senior management/trustees), primary care, ambulance staff, acute care) |
| Mechanisms of Change | Facilitation | Developing trusting, reciprocal relationships (safe space and mutual respect & recognition) |
| Addressing power hierarchies | ||
| Negotiating and influencing | ||
| Organising care home staff for attendance (rotating to ensure the rights kills mix and knowledge of the resident) | ||
| Liaising with external stakeholders (eg GP where existing NRs) | ||
| Buddying & mentoring | ||
| Facilitators | Micro - Care home leads – registered nurses, heads of unit, senior nurses, clinical leads, care team member with best knowledge of resident | |
| Meso - Care coordinators, clinical governance committees, trustees | ||
| Resources | Time | |
| Training & education (structure within CH & case based education, integration with existing education mechanisms) | ||
| Care planning and clinical actions (advance care planning, medication reviews, anticipatory medications & de-prescribing), symptom control & pain management) | ||
| Standardised yet contextualised information sharing (template to be used within existing systems, utilising existing documentation used in area (ag ReSPECT), tailored, clear communication | ||
| materials of the benefits of NRs to secure buy in; communication with policy makers/commissioners) | ||
| Payment (access to holistic services) | ||
| Space (for NRs to prevent disruption) | ||
| Alignment with existing proactive work (eg MDT meetings, weekly rounds, GSF meetings to prevent duplication & strengthen relationships) | ||
| Reasoning | Better understanding of how to communicate with professionals and relatives | |
| Care home ownership of NRs | ||
| Choice of staff attending NRs | ||
| Competence to recognise deterioration | ||
| Increased staff confidence | ||
| Visibility (collective view amongst stakeholders, formal & informal meetings) | ||
| Outcomes | Staff confidence & competence | Improved staff confidence in advance care planning (goals of care, ceilings of treatment and place of care, anticipatory medications) |
| Improved communication amongst care home staff and professionals, residents, and relatives | ||
| Improved recognition of deterioration and dying | ||
| Care homes perceived as experts in palliative and end of life care | ||
| Improved inspection ratings | Better documentation | |
| Evidence of quality improvement | ||
| Better support to families | Families involved in care planning | |
| Better relationships with families; less conflict | ||
| Families feel confident in staff ability to care for their loved ones | ||
| Improved inter-disciplinary working | Reduced inappropriate contact with GPs | |
| Improved discharge planning | ||
| Improved knowledge and understanding of professional roles & respecting boundaries | ||
| Strengthened relationships between care homes and hospices | ||
| Better quality palliative and end of life care for residents | Proactive advance care planning and documentation – goals of care, ceilings of treatment, dying in preferred place | |
| Proactive anticipatory medications & deprescribing reviews | ||
| Better symptom control and pain management | ||
| A good death, reflecting resident wishes. |