A Program to Improve General Palliative Cancer Care Guideline Implementation: Development, Acceptability, and Feasibility of Implementation Strategies

ABSTRACT

Rationale

Implementing palliative care for patients with cancer in the healthcare sector is a complex task. Some patients with cancer do not receive timely and comprehensive palliative care tailored to their needs, potentially reducing their quality of life.

Aims and Objectives

The goal is to develop an Implementation Program to improve the implementation of the national guidelines for general palliative cancer care. Moreover, the study aims to evaluate the acceptability and feasibility of the implementation strategies among healthcare professionals.

Design

We used a participatory action research approach and the Quality Implementation Framework to guide the program. Additionally, we evaluated the acceptability and feasibility of the implementation strategies through a qualitative descriptive design.

Methods

Thirty‐one healthcare professionals from oncology, municipalities, and general practice took part in developing the Implementation Program with guidance from a facilitator. We utilized data triangulation, including qualitative interviews (n = 17), observation data from in‐person meetings (n = 5), virtual meetings (n = 50), and process data gathered from November 2021 to March 2023. We analyzed the data using Content Analysis methods.

Results

A program comprising 14 critical steps was developed. The implementation strategies were found acceptable and feasible, particularly for cross‐sectoral networking and a facilitator supporting collaboration. However, Plan‐Do‐Study‐Act cycles were considered problematic. The value of learning from experiences was recognized, and healthcare professionals appreciated the advantages of cross‐sector collaboration.

Conclusion

This study involved cross‐sectoral healthcare professionals in developing the Implementation Program for general palliative cancer care. Networking is vital in this context and should be considered a stand‐alone implementation strategy.

1. Introduction

1.1. Palliative Cancer Care

According to the World Health Organization (WHO), palliative care should be integrated into the care continuum for individuals with life‐threatening illnesses [1, 2]. However, implementing palliative care for patients with cancer is challenging, with some not receiving timely and comprehensive palliative care tailored to their needs. Suboptimal implementation of palliative care could thus result in reduced quality of life for patients and their families [3, 4].

In line with the recommendations of the European Association for Palliative Care, the Danish healthcare system should provide general palliative care through collaboration between primary care (general practitioners and municipalities) and secondary healthcare sectors (cancer clinics), as well as specialized palliative care delivered by specialized multidisciplinary teams [2, 5]. National guidelines (NG) for palliative cancer care developed by Health Authorities in 2018 [6], based on WHO recommendations [1], outlines the tasks, organization, and responsibilities for providing rehabilitation and palliative care to ensure quality and coherence across healthcare sectors [6]. In 2020, the Danish National Audit Office found that patients with cancer were not adequately assessed for their palliative care needs and might not have been timely referred to appropriate services [7]. This indicates that the NG for rehabilitation and palliative care in cancer [6], has not been fully implemented across hospital, municipality, and general practice sectors [8]. Therefore, there is a pressing need to address the implementation of NG.

1.2. Barriers to Implementation of National Guidelines in Palliative Cancer Care

Studies on the implementation of NGs in palliative cancer care have identified barriers at the individual, organizational, and healthcare system levels [5, 9]. They emphasized a lack of knowledge about NGs among healthcare professionals (HCPs) and the absence of a national strategy for NG implementation [5, 9]. A recent scoping review identified facilitators for integrating cancer care between primary and secondary sectors, emphasizing the importance of training, clear role delineation, effective communication, engagement, and guideline provision [10]. Integrated care is crucial across sectors to address the needs, especially of vulnerable patients and prevent oversights [11]. Previously, we showed that collaboration, coordination, and communication are vital for successful NG implementation [5]. These findings align with those of a Swedish study that explored HCPs' perspectives on implementing standardized Cancer Patient Pathways to tackle disparities in cancer care. The study highlighted collaboration and coordination as key elements for successful cross‐sector implementation [12].

1.3. Implementation Strategies

Owing to the intricate nature of healthcare systems, implementing NGs for general palliative cancer care may encounter significant challenges [13], and it is essential to develop effective strategies to enhance NG implementation [14]. Implementation strategies are defined as “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” [15]. Choosing suitable strategies can be guided by different approaches, including identifying barriers and exploratory methods like Intervention Mapping or theory‐based approaches.

Several pertinent strategies have been suggested to enhance the organization of palliative care across diseases. These strategies include education, process mapping, feedback, multidisciplinary meetings, and multifaceted strategies, which involve combining two or more strategies [16]. However, the effectiveness of the most effective strategy remains unassessed [16]. Although previous studies have examined the implementation of palliative cancer care in various settings and across different health professions [17, 18, 19], studies across the healthcare sector are lacking. Other settings, such as implementation strategies for transitional care innovations among older adults in long‐term care, have found that the involvement of HCPs ensured commitment and strongly influenced the extent of implementation [20, 21, 22, 23]. Furthermore, adapting implementation strategies based on HCPs' perceptions of their acceptability and feasibility is essential for sustainable implementation [23].

To enhance implementation of the NG in general palliative cancer care, this study aimed to:

• 1.Develop an Implementation Program comprising various strategies to facilitate the HCPs' implementation of the NG in cross‐sectoral general palliative cancer care.
• 2.Evaluate the HCPs' acceptability and the feasibility of selected implementation strategies in the Implementation Program.

2. Methods

2.1. Design

In the development of the Implementation Program, we utilized a participatory action research approach [24]. To assess the acceptability and the feasibility of the implementation strategies, we used a qualitative descriptive design involving interviews, observations, and process data.

2.2. Development of the Implementation Program

We aimed to develop an Implementation Program to facilitate HCPs' delivery of the NG in general palliative cancer care following the Quality Implementation Framework (QIF) [25]. QIF was selected for its inclusive and detailed approach, which considers the context and incorporates iterative implementation processes. This enabled us to develop and evaluate small‐scale interventions using Plan‐Do‐Study‐Act (PDSA) cycles. We utilized the QIF [25] to guide the implementation process through its 14 critical steps across four phases (Table 1):

• Needs assessment: Initial considerations regarding the host setting. This phase included three critical steps for assessment, one step for making decisions about adaptation, and four steps for capacity building.

• Preparation: Creating a structure for implementation. This phase includes two critical steps that focus on structural features.

• Implementation: Ongoing structure during implementation. This phase included three critical steps for implementing support.

• Improvement: Improving future applications. This phase included a critical step in learning from experience.

Table 1.

The Implementation Program, according to phases and critical steps adapted from the Quality Implementation Framework and our implementation strategies developed for this context. The selected critical steps evaluated in the analyses are marked with colored rows.

Critical steps		Aim	Implementation strategy	Actors	Dose and temporality
Needs Assessment Phase, 2021‐2022
Assessment strategies
1	Conducting a needs and resources assessment	Mapping existing evidence of barriers and facilitators for implementation of NG	Reviewing evidence Analysis of barriers and facilitators to National Guideline implementation in general palliative cancer care	Researchers in the study group	During the needs assessment phase
2	Conducting a fit assessment	Providing an overview of the key palliative cancer care challenges across sectors and forming an understanding of healthcare professionals' roles and perspectives across healthcare institutions	Involve and secure ownership of the Implementation Program and define a common goal through networking. In a workshop, healthcare professionals were asked to map key action points in the palliative cancer care trajectory for each institution and to join these across sectors	Healthcare professionals from the hospital, municipalities, general practice, the facilitator (DMS) and researchers An external consultant	One 4‐h workshop during the needs assessment phase
3	Conducting a capacity/readiness assessment	Defining collaborations between municipalities, hospital, and general practices to ensure capacity and readiness for healthcare professionals' participation	Meetings between the study group and managers from the municipalities, hospital, and general practice to make agreements on collaboration and reimbursement	Managers from the hospital, municipalities and a researcher (SOD). Three general practitioners and a researcher (DMS)	Three meetings during the needs assessment phase
Decisions about adaptation
4	Possibility for adaptation	Defining goals for and ongoing adaptation of five cross‐sectoral interventions to enhance palliative cancer care	In a workshop, the five cross‐sectoral teams define a goal for their intervention and a Plan (P) for testing and adapting their intervention using Plan‐Do‐Study‐Act (PDSA) cycles	Healthcare professionals from the hospital, municipalities, general practice, and researchers	One 4‐h workshop in the needs assessment phase
Capacity‐building strategies
5	Obtaining explicit buy‐in from critical stakeholders and foster a supportive community/organizational climate	Fostering and maintaining a supportive and secure climate between all healthcare professionals based on respect and understanding to promote networking	Involving healthcare professionals and managers to facilitate the formation of a network and ensure the security of collaboration	Healthcare professionals from the hospital, municipalities, general practice, and researchers Involving healthcare professionals and managers to facilitate the formation of a network and ensure the security of collaboration	During all phases of the Implementation Program
6	Building general/organizational capacity	Enhancing the quality of the interventions and motivation among healthcare professionals	Training of the implementation teams in the PDSA method	Two external specialists trained in using the PDSA method A clinical nurse specialist with expertise in patient needs assessment A clinical nurse specialist with expertise in electronic health records	Several meetings during the needs assessment, preparation and implementation phase
7	Staff recruitment/maintenance	Recruiting healthcare professionals involved in general palliative care to participate in the PDSA implementation intervention cycles	Presentations of the study across sectors	The facilitator (DMS)	Four presentations at the hospital and three presentations at the municipalities, while general practitioners were informed and invited through e‐mail and telephone in the needs assessment phase
8	Effective pre‐innovation staff training	Ensuring that healthcare professionals have sufficient knowledge of the National Guideline on palliative cancer care a common goal, and a mutual language	Two half training days focusing on:	An associate professor from the University College of Nursing and a district nurse specialized in palliative care Healthcare professionals from the hospital, municipalities, general practice and researchers	Two 4‐h sessions during the needs assessment phase
			­ recommendations of the National Guideline ­ needs assessment in general palliative care and the importance of referrals ­ cross‐sectoral communication and collaboration to illustrate the effect of networking in this complex context
			Mix of theoretical presentations, daily practice examples, and case‐based learning Learning outcomes were defined by the study group to address identified knowledge gaps Networking to foster mutual respect
Preparation Phase, 2022
Structural features for implementation
9	Creating implementation teams	Ensuring collaboration and relevant participation in the testing and implementation of the interventions	Recruiting to establish multidisciplinary cross‐sectoral implementation teams Cultivating relationships across sectors during implementation to maintain mutual respect	Healthcare professionals from the hospital, municipalities, and general practice	During the implementation phase
10	Developing an implementation plan	Ensuring a structure throughout the Implementation Program, including activities and a timeline, as well as in the individual implementation teams	The study group defines the overall implementation plan in collaboration with healthcare professionals Plans for the individual PDSA implementation teams and their PDSA interventions are developed and adapted at online or physical meetings.	Healthcare professionals from the hospital, municipalities, general practice, and researchers	During the needs assessment, preparation and improvement phases
Implementation Phase, 2022‐2023
Ongoing implementation support strategies
11	Technical assistance/coaching/supervision	Plan and execute activities and ensure information, structure, and progress	The facilitator supports the individual implementation teams (e.g., through information and problem solving) in their work with PDSA cycles and ensures study progress and networking to foster mutual respect and goals	DMS was a full‐time researcher/facilitator	During the implementation phase A total of 50 online and five physical meetings (á 30–60 min) were held by the implementation teams during the preparation and implementation phases
12	Process evaluation	Evaluating the efficacy of the PDSA interventions, as well as the acceptability and feasibility of the implementation strategies	Data (observations and process data) is collected during the Implementation Program Performing qualitative interviews at the end of the Implementation Program	Healthcare professionals from the hospital, municipalities, general practice, and researchers	During the implementation phase
13	Supportive feedback mechanism	Developing and refining the interventions to improve imple‐mentation of the National Guideline for general palliative care	Using PDSA cycles to develop, test and receive feedback on the interventions	Healthcare professionals from the hospital, municipalities, and general practice	During the implementation phase
Improvement Phase, 2023
14	Learning from experiences	Facilitating collaborative learning to improve the implementation of the national guideline	A workshop with presentations by the five implementation teams to share experiences across teams and sectors, and optimize further implementation of the National Guideline for general palliative care	Healthcare professionals from the hospital, municipalities, general practice and researchers Other healthcare professionals, such as managers and clinical nurse specialists	One 4‐h workshop in the improvement phase

Abbreviations: DMS, Dina Melanie Sorensen; PDSA, Plan‐Do‐Study‐Act cycles; SOD, Susanne Oksbjerg Dalton.

We evaluated seven (out of 14) implementation strategies that directly engaged healthcare professionals. Initially, the research team members (SOD and PB) drafted the Implementation Program, which was modified collaboratively involving both researchers and HCPs using a participatory action research approach [24]. The fourteen QIF critical steps were adapted to the local context to implement strategies pertinent to HCPs and patients in cross‐sectoral general palliative cancer care. The Implementation Program aimed to develop and implement five small‐scale interventions using PDSA cycles [26].

2.3. Study Setting and Recruitment

The lead author, DMS, worked full‐time in the oncology department and contributed to the project as a PhD student and facilitator during the implementation study. Managers from palliative cancer care settings were invited to join the study: one oncology clinic at a university hospital, two municipalities (responsible for healthcare in patients′ homes and nursing homes, rehabilitation, and health promotion), and three general practitioners. Financial agreements for reimbursements to municipalities and general practitioners were determined based on grant funds and the time and personnel dedicated to the project. The facilitator then conducted informational sessions to invite individual HCPs from the municipalities, hospital (including oncology clinic and specialized palliative care team), and general practices to participate in the Implementation Program and the ongoing evaluation of the implementation strategies. HCPs who left the Implementation Program due to maternity leave, new employment, or illness were not included in the qualitative evaluation of implementation strategies.

2.4. Data Collection

Using three types of data (interviews, observations, and process data), we assessed acceptability, which was defined as satisfaction with different aspects of the implementation strategies, including content, complexity, and comfort. Feasibility was defined as the actual suitability for everyday use of the implementation strategies, such as utility and practicability [27].

2.5. Semi‐Structured Interviews

Semi‐structured qualitative individual interviews [28] were conducted by DMS from May to August 2023 to explore how the target group experienced implementation strategies [13]. The study utilized the Consolidated Criteria for Reporting Qualitative Research, a 32‐item checklist for interviews and focus groups, to structure reporting [29]. The interviews included questions on implementation strategies to evaluate acceptability and feasibility [27]. The interview guide included themes such as complexity, simplicity, resources, support, practicality, and flexibility. Open‐ended and probing questions were used to facilitate detailed responses during the interviews [30] (online appendix). The interviews were transcribed verbatim. Additionally, HCPs were asked to rate the selected implementation strategies on a scale of 1 to 10, with 1 indicating the lowest feasibility and 10 indicating the highest. Each strategy was assessed with the question, “How feasible do you perceive the implementation strategy (name of the strategy) applied in the Implementation Program?”

2.6. Observations

During the Implementation Program, DMS conducted observations to obtain a detailed description of the participating HCPs and their work processes between November 2021 and March 2023. HCPs met in person for various meetings at the start and end of the program and had online meetings during the implementation phase.

2.7. Process Data

Data were collected during the Implementation Program from November 2021 to March 2023 at the same meetings as the observations. This data encompassed the attendance rate, defined as the number of participating HCPs in the relevant implementation strategies, types, and frequency of meetings, and completed PDSA cycles.

2.8. Data Analysis

Interviews and observations were analyzed using deductive and inductive content analyses [30]. Before analyzing the transcripts, DMS reviewed them alongside the audio recordings to verify accuracy, refresh recollections, and grasp the full interviews. In the initial deductive phase, all references to the acceptability or feasibility of individual implementation strategies were coded. Subsequently, two researchers (ER and DMS) discussed the codes, sub‐categories, categories and, by developing themes, offered a way to elucidate the phenomenon for enhanced comprehension and knowledge generation. The research group discussed and reviewed the themes across interviews, observations, and process data to ensure comprehensive coverage of the issues. DMS documented and tallied the data. Data triangulation (interviews and observations) was employed to gain thorough insights into HCPs' experiences regarding the complexity of the multifaceted implementation strategy. Moreover, ER and DMS collaborated in the coding process to discuss the results and address any analytical uncertainties. To establish credibility, the researchers assessed individual transcripts for consistency among all HCPs [31].

2.9. Ethical Considerations

The study was registered with the regional Data Protection Board, and permission was obtained to process and store personal data for research (REG‐072‐2021). Participation was voluntary, and the HCPs provided written informed consent and were informed that they could withdraw from the study at any time. Data were kept confidential, processed in accordance with the Data Protection Regulation, and presented in an aggregated form where individual HCPs could not be identified. Approval was not required from the regional ethics committee (EMN‐2022‐02483).

3. Results

3.1. Development of the Implementation Program

We developed an Implementation Program using the QIF and adapted it to our specific palliative care environment (Table 1).

• The QIF needs assessment phase comprises eight critical steps (Table 1). The researchers initially outlined considerations for resources, suitability, and readiness for implementing NG in general palliative cancer care across healthcare sectors. These steps involved meetings with managers from the hospital and municipalities involved to establish partnerships and confirm the readiness of the healthcare settings. The oncology department did not receive reimbursement, while the municipalities and general practitioners were reimbursed. Staff training included two half training days. Evaluation of implementation strategies was conducted for critical steps 2 (a workshop to present an overview of the field and identify cross‐sector collaboration barriers), 4 (a workshop to establish goals for five interventions), and 8 (two half‐day training sessions to enhance knowledge of general palliative care and national guidelines).

• The preparation phase included two critical steps (Table 1). The initial step involved developing an implementation plan with the participation of HCPs. The second step involved forming five cross‐sectoral implementation teams comprising HCPs from the various healthcare settings for specific interventions. These teams were established to promote mutual respect and facilitate networking. For instance, a team comprised a palliative care nurse, a municipal health consultant, a nurse from the municipality, and a nurse specialist from the hospital. Each of the five teams designated an HCP as the team captain to ensure ownership, continuity, and progress in the implementation process. We evaluated the implementation strategy outlined in Step 9, which involved experience in working within cross‐sectoral implementation teams.

• The implementation phase involved three critical steps (Table 1). Instead of attempting to implement all recommendations in the NG simultaneously, the implementation teams selected and developed five small‐scale interventions to optimize the implementation of the NG, which were tested using the PDSA cycles (Figure 1). These interventions aimed to optimize [1] needs assessment and referral [2], communication across healthcare sectors, such as admission reports and care plans [3], discharge summaries [4], cross‐sectoral online discharge meetings, and [5] cross‐sectoral knowledge sharing, thus targeting issues across the palliative care trajectory (Figure 1). The evaluation of the interventions is ongoing and will be described in future work.

  The facilitator (DMS) provided continuous coaching and supervision, particularly on PDSA cycles, to support the progress of the implementation teams. Clinical specialists were also involved in meetings to offer expertise and guidance for enhancing the development and implementation of interventions. Online meetings were preferred for their efficiency compared to in‐person meetings. The implementation phase was initially planned for 8 months but extended to ten months. Evaluation of the implementation strategies focused on critical steps 11 (facilitation throughout the Implementation Program) and 13 (experiences with using PDSA cycles as an implementation approach).

• The improvement phase included one critical step (Table 1). A concluding workshop was conducted for the HCPs to share and learn from their experiences. Each implementation team presented what they had been working on jointly across healthcare sectors in the implementation phase and, together with the researchers, critically discussed the lessons learned. Furthermore, future applications of these interventions are discussed. We evaluated critical step 14 (a workshop to share experiences and learn from other implementation teams).

Figure 1.

The five interventions in the Implementation Program.

3.2. Evaluation of Acceptability and Feasibility of the Selected Implementation Strategies

We collected qualitative data through individual interviews (n = 17), physical meetings (n = 5), and online meetings (n = 50), as well as processed data gathered during the Implementation Program across the needs assessment, preparation, implementation, and improvement phases. The majority of HCPs interviewed were clinical nurses or nurses specializing in palliative care. Other participants included oncologists, general practitioners, physiotherapists, and occupational therapists representing all participating organizations (Table 2). Fifteen HCPs had over 10 years of professional experience, while two had nearly 10 years of experience. Not all HCPs engaged in every implementation strategy; nevertheless, all strategies were both represented and evaluated.

Table 2.

Organization, occupation of participants, and quote numbers.

Organization	Quote number	Occupation
Municipalities	1	District nurse specialized in palliative care
	2	District nurse specialized in palliative care
	3	District nurse
	4	District nurse
	5	Nurse manager
	6	Municipal health consultant
	7	Patient home care coordinatora
	8	Patient home care coordinatora
	9	Physiotherapist
	10	Occupational therapist
Hospital	11	Clinical nurse specialist
	12	Nurse
	13	Nurse
	14	Oncologist
	15	Oncologist
General practice	16	General practitioner
	17	General practitioner

^a Responsible for evaluating and assessing healthcare services provided at the municipal level.

Overall, the HCPs found the implementation strategies to be acceptable and feasible. They expressed explicit satisfaction with the cross‐sectoral teamwork integrated into all four phases and implementation strategies involving HCPs. For instance, the HCPs highlighted the importance of well‐composed implementation teams. The absence of relevant mandates for decision‐making could unnecessarily prolong the implementation process. Throughout the implementation phase, the work within cross‐sectoral implementation teams highlighted the fragmentation of the healthcare system, posing challenges to implementation across sectors. This highlights the importance of a facilitator who can promote collaboration across sector boundaries in a complex palliative cancer care setting. The following section details the experiences of HCPs with the selected implementation strategies, supported by quotes. The numbers in parentheses correspond to the HCPs listed in Table 2.

3.3. Needs Assessment Phase

The goal of the needs assessment phase was to initially consider the settings and involve key HCPs in establishing networks.

3.3.1. Acceptability

The themes derived from the analysis of the needs assessment phase were as follows: networking provides security, cross‐sectoral networking provides new perspectives, and staff training helps break down barriers (Figure 2). Interviews emphasized that HCPs felt more confident and secure when they interacted with colleagues from different sectors or institutions early in demystifying the cross‐sectoral collaboration. Networking across sectors, particularly in the ‘conducting a fit assessment’ strategy, was found to be inspiring. Discussions on palliative cancer care revealed a lack of knowledge about the competencies of HCPs from other sectors. “It was meaningful to be a part of the process to identify exactly where the challenges were” [9]. Using the ‘possibility for adaptation’ strategy, HCPs were encouraged to adapt the interventions to local contexts across sectors, which was more challenging than the researchers expected. Nevertheless, the benefits of going through these processes and establishing a network were repeatedly highlighted in the interviews and observations. “It was an eye‐opener and helped me understand what was happening in the other sectors” [12]. During the needs assessment phase, it became clear how separately the HCPs worked across sectors. Sitting together provided new perspectives and broke down barriers to promoting collaboration and implementation. For example, the acceptability of effective pre‐innovation staff training was high. “I think it was perfect, and I could see how shared knowledge could lead to a common approach in palliative care for patients with cancer” [1]. Observations from staff training days supported the findings of the interviews about staff training.

Figure 2.

Themes related to acceptability and feasibility of the implementation strategies in selected critical steps (2, 4, 8, 9, 11, 13, and 14) of the Quality Implementation Framework.

3.3.2. Feasibility

The attendance rate was high, with 90% and 81% participation in the workshops on ‘conducting a fit assessment’ and ‘possibility for adaptation,’ respectively, and 85% and 65% attendance at the staff training days. These figures indicate that both HCPs and their organizations supported the Implementation Program.

HCPs rated the various implementation strategies with a feasibility score of 8.9 (Range: 7–10) for the ‘conducting a fit assessment’, 6.6 (range 3–10) for the ‘possibility for adaptation,’ and 8.5 (range 7–10) for the ‘staff training days.’

The theme identified from the analysis of the needs assessment phase was the importance of planning meetings well in advance (see Figure 2). Several HCPs highlighted that advanced planning of meetings improved feasibility and highlighted the importance of these meetings. One participant stated, “I prioritized attending the physical meetings, laying the groundwork for future project collaborations” [2]. The evaluation of the needs assessment phase emphasized the significance of HCPs convening to network and acquire insights into the provision of general palliative cancer care across different sectors.

3.4. Preparation Phase

During the preparation phase, the goal was to collaboratively establish a framework for the HCPs to use for implementation across healthcare sectors.

3.4.1. Acceptability

The theme identified from the analysis of the preparation phase was collaboration and involvement are vital (Figure 2). In the interviews, HCPs expressed a high acceptability of the implementation strategy ‘creating implementation teams.’ Collaborating with other HCPs from different sectors and being involved in all processes was vital for successful implementation: “I will say that you cannot implement if you do not involve others” [8].

3.4.2. Feasibility

Five cross‐sectional implementation teams were established during the preparation phase. In total, 31 HCPs volunteered for the implementation teams (12 from the municipalities, 15 from the hospital, and four general practitioners). Frequent replacements were observed in some of the implementation teams. In addition, municipalities rotate their HCPs within teams. Nevertheless, the HCPs were very satisfied with the implementation teams and rated the feasibility high at 9.5 (range: 7–10).

The theme identified from the analysis of the preparation phase was team composition affects the implementation (Figure 2). Team composition was deemed essential for the effectiveness of the cross‐sectoral implementation teams. Inadequate composition involving HCPs without mandates resulted in delays and was not feasible in the long run. Consequently, team composition was adjusted, and HCPs with mandates were engaged in multiple teams to address this issue. “This is how you build a network and support implementation” [3]. The assessment of implementation strategies during the preparation phase illustrated that implementation teams were vital for the HCPs and emphasized the critical role of their composition in sustaining progress in the Implementation Program.

3.5. Implementation Phase

The implementation phase aimed to test and develop interventions in a secure and continuous circular process across sectors.

3.5.1. Acceptability

The themes derived from the analysis of the implementation phase were promoting cross‐sectoral collaboration and continuity, and the PDSA method felt like an extra layer of work (Figure 2).

The interviews emphasized the implementation strategy of ‘technical assistance/coaching/supervision’, consisting of the facilitator providing motivation and the overview that the HCPs needed to maintain continuity and coherence through all phases. “With the facilitator's guidance, the implementation teams were able to identify the most important areas to develop in their intervention on their own” [1]. In addition, the observations highlighted that the facilitator bridged implementation across healthcare sectors. Online meetings are essential to facilitate collaboration during the implementation phase. However, many have highlighted the importance of prior physical meetings to ensure effective online collaboration, as these established relationships boost teamwork. Although the HCPs had received training in the PDSA circle method (‘supportive feedback mechanism’), they found the method highly complex, as highlighted in several interviews and observations. Some HCPs expressed that the PDSA method would have been more straightforward to apply locally rather than across sectors. “In general, the project was complex, so adding this model felt like an extra layer of work because we had to learn how to use it at first.” [5]. Overall, the interviews revealed that the acceptability of the method was limited. However, some stated that the PDSA cycles were used in a less structured manner, where their teams carried out tests, received feedback, and were tested again on a small scale.

3.5.2. Feasibility

During the implementation phase, the five implementation teams completed nine PDSA cycles across 55 physical and online meetings, corresponding to a mean of 11 meetings per team. The theme derived from the analysis of the implementation phase was facilitation is a prerequisite (Figure 2). Throughout the project, the facilitator was perceived as feasible and a prerequisite for the Implementation Program. The HCPs rated the PDSA cycles as having low feasibility (feasibility score 4.7 (range 1–10)) and not feasible for cross‐sectoral interventions. “My mindset was not suited to think in PDSA cycles” [8]. Evaluation of the implementation strategies in the implementation phase illustrated that the facilitator linked the sectors and that the PDSA cycles were challenging to apply across sectors.

3.6. Improvement Phase

The aim of the improvement phase was to improve the future applications of the Implementation Program by learning from the HCPs' experiences of the Implementation Program.

3.6.1. Acceptability

The theme derived from the analysis of the improvement phase was sharing knowledge of implementation experiences provided valuable knowledge (Figure 2). HCPs expressed that learning from their own and others' experiences (‘learn from experience’) was both engaging and satisfying. “It was perfect to receive feedback from the other participants” [13] and “I think it all came together that day” [15]. While some HCPs felt uneasy about presenting their work to other implementation teams, researchers, managers, and other interested HCPs, they were able to overcome this discomfort due to the safe and supportive environment fostered within the implementation team collaboration. Some HCPs also expressed a need to understand how the lessons learned during the Implementation Program would be integrated into future steps and showed genuine interest in sustaining and expanding cross‐sectoral collaboration.

3.6.2. Feasibility

During the improvement phase, the strategy ‘learning from experience’ required the attending HCPs to physically participate in a final workshop. The attendance rate was 80%, and the HCPs reported a feasibility score of 8.7 (range: 5–10).

The theme identified from the analysis of the improvement phase was a concluding workshop was a rewarding way to sum up (Figure 2). The HCPs perceived it feasible to convene and summarize through presentations while benefiting from shared experiences. “It was a good way to wrap up the project” [6]. As with the physical meetings during the needs assessment phase, challenges were perceived as the same concerning planning and time‐consuming. The evaluation of the improvement phase indicated that experiential learning was greatly appreciated, and HCPs from both sectors recognized the advantages of cross‐sectoral collaboration.

4. Discussion

Involving HCPs from municipalities, hospitals, and general practices facilitated a collaborative approach to developing a new Implementation Program for general palliative cancer care. Our findings demonstrate that prioritizing implementation strategies that actively engage HCPs in the process was appropriate. The HCPs appreciated their new networks for gaining insights into palliative cancer care across sectors. They emphasized the significance of team composition in advancing the Implementation Program and highlighted the facilitator′s role in connecting sectors. Using PDSA cycles across sectors posed challenges and was perceived as additional work; however, both HCPs and researchers highly valued the process of summarizing and learning from shared experiences.

Key barriers to general palliative cancer care across sectors identified in previous studies include a lack of coordination, communication, and engagement [5, 10]. We recognized that implementation across sectors increases complexity and that HCPs reported a lack of knowledge about competencies of other HCPs. We identified the need to establish a respectful culture to make HCPs feel secure and comfortable before and during implementation.

Networking was considered a strategy to address knowledge gaps across sectors, which should be specified in the QIF. In healthcare implementation, engaging HCPs is crucial [32]. Strategies to enhance implementation across healthcare sectors, such as supporting cross‐sectoral collaboration and engaging stakeholders, are important [8]. Moreover, the Expert Recommendations for Implementing Change highlight the strategy of promoting network weaving to leverage existing high‐quality relationships and networks within and outside organizations for information sharing, collaborative problem‐solving, and a shared goal in intervention implementation [14]. HCPs appreciate learning about each other and bridging sectoral knowledge gaps. We emphasized strategies for establishing and maintaining cross‐sectoral networks are essential. Future research should investigate the consistent inclusion of a network implementation strategy in the QIF.

Various teamwork theories have been proposed to address care fragmentation [13]. Gittell′s Relational Coordination theory suggests that effective coordination depends on timely, accurate, and problem‐solving communication, as well as high relationship quality characterized by shared goals, knowledge, and mutual respect among team members [33]. This theory highlights the crucial role of relationships and communication in influencing efficiency and outcomes within complex systems like healthcare [33]. These aspects are consistent with our study findings, particularly emphasizing the significance of relationships, as demonstrated by the importance of networks in the Implementation Program.

Other barriers in palliative care include a lack of time to upskill primary HCPs, undefined roles, and heavy workload [5, 10, 23]. Despite allocating resources, including time, for study participation, some HCPs found it challenging to integrate the study into their busy routines. Certain implementation teams required more meetings to develop and test interventions, posing difficulties for keeping up attendance. Additionally, some implementation teams lacked HCPs authorized to make decisions, leading to prolonged implementation. It is uncertain whether this was due to a lack of skills or ambiguity in roles and responsibilities among HCPs [10]. The resources and supportive environments needed for success are often underestimated [26]. Consistent with prior research, we observed the crucial role of the facilitator [34]. The facilitator, equipped with resources such as time and financial support, helped address implementation team challenges and coordinate across sectors, partially compensating for the lack of time and resources, decision mandate, and unclear roles in the implementation teams. In the future, the facilitator could have a more clearly defined role in QIF.

4.1. Strengths and Limitations

The main strengths of this study are that it used a participatory action research approach and included HCPs representing key disciplines and sectors to provide their experiences and perspectives on implementation strategies. Management supported the study and encouraged HCPs to participate, strengthening their engagement and anchoring in clinical practice across sectors.

However, this study has several limitations. When conducting action research in own organization, researchers must navigate the complexities of holding multiple roles simultaneously and be aware of their own preunderstanding [35]. The dual roles of DMS as both the facilitator and interviewer were thoroughly considered. To mitigate researcher bias, existing knowledge and assumptions were kept in mind, and reflexivity was applied throughout the research process to critically reflect on role dynamics and minimize bias [35]. Efforts were made in open and constructive communication to establish a trusting and supportive environment in which the HCPs felt safe and respected, thus reducing the obligation of participants to provide positive feedback. Since data is only available from one hospital and two municipalities, the participating HCPs from these sites may be more motivated for implementation and may not be representative of HCPs in general. Another limitation is the suboptimal representation of managers in the implementation teams. Despite their agreement to participate, many managers had difficulty prioritizing this task over others, leading to dropouts. Conducting cross‐sectional interviews before and after implementation, rather than longitudinal ones, provided a comprehensive understanding of the development of HCPs' experiences and the mechanisms at play. The implementation of NG in general palliative care for patients with cancer was tested within a single hospital and a small number of municipalities and general practices, potentially affecting external validity. While some experiences may be transferable to other regions or countries providing general palliative cancer care [23], conducting further research across multiple hospitals and municipalities would enhance generalizability. Despite these methodological issues, the triangulation of interviews, observations, and process data strengthened credibility.

Further, more information is needed regarding the most effective implementation strategies. It would be relevant to assess the impacts of various implementation strategies using a randomized controlled design [36].

4.2. Clinical Perspectives

Key steps in implementing cross‐sectoral palliative care include establishing or adopting a guideline and Implementation Program appropriate for the individual context, such as the one we developed here. The involvement of all relevant stakeholders across sectors, such as managers, HCPs from municipalities, hospital departments, and general practitioners [22, 23], and ensuring that the necessary implementation resources are available, especially in the needs assessment and preparation phase, for example, to facilitate networking, is essential to facilitate the process.

5. Conclusion

We engaged key stakeholders from the hospital, municipalities, and general practice to develop a cross‐sectoral Implementation Program for general palliative cancer care. We included 14 critical steps based on the Quality Implementation Framework. HCPs generally found the implementation strategies acceptable and feasible. It is crucial for HCPs to feel confident and gain insights into other healthcare sectors through cross‐sectoral networks and facilitators that promote collaboration. HCPs encountered difficulties in applying PDSA cycles across healthcare sectors; however, they highly valued learning from shared experiences and recognized the benefits of cross‐sector collaboration. For future cross‐sectoral implementations, networking should be considered an independent critical step. The subsequent phase will involve evaluating the interventions in the Implementation Program.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix Interview Guide.

Sørensen D. M., Egholm C. L., Dalton S. O., et al., “A Program to Improve General Palliative Cancer Care Guideline Implementation: Development, Acceptability, and Feasibility of Implementation Strategies,” Journal of Evaluation in Clinical Practice 31 (2025): 1‐14. 10.1111/jep.70335.

Data Availability Statement

The data that support the findings of this study are available upon reasonable request.