Table 2.

Key barriers and enablers

Normalisation Process Theory Construct	Key enablers	Key barriers
Coherence (what is the work)	• CgDp signals a shift to a different type of care • CgDp valued by staff as it supports systematic approach to end of life care • CgDp legitimises caring for the dying in acute setting	• The need for CgDp suggestive of a failure in acute care provision • Lack of education and training in principles of palliative care and care of the dying • Professionals conceptualise CgDp as ‘everything’ or ‘nothing’ because challenged by uncertainty posed when variances or individualised care was required
Cognitive participation (who does the work)	• CgDp empowers nursing staff to discuss EOL care with medical staff • Guidance available from palliative care team • Clear lines of responsibilities e.g. medical team lead decision making • Medical profession willing to lead implementation of CgDp intervention • Recognition that effective patient and family communication required	• Lack of genuine multidisciplinary team working • CgDp being enacted without an interprofessional approach • Lack of understanding of roles related to CgDp • Allocation of roles and responsibilities tend to mirror acute practice roles (not recognising that a different approach is required e.g. MDT) • Usual expert guidance structures challenged because EOL care not usual part of practice
Collective action (how does the work get done)	• Familiar with CgDp documentation • Effective collaboration between nursing and medical staff • Established relationships with patients • Nursing staff creating environment conducive to EOL care • Palliative care team provides decision making support e.g. diagnosing dying; symptom management advice • Continuity of care within speciality considered to be important e.g. home-ward • Mentoring and learning occurring through practice	• Challenging to integrate effective EOL care in the context of acute setting (e.g. organisational pressures for discharge) • EOL care provision infrequent activity • Allied health tendency to disengage in and/or excluded from EOL care • Senior medical officers not fully engaged in CgDp intervention e.g. delegate to juniors • Absence of allied health engagement • Documentation considered burdensome and not aligned to technology e.g. electronic medical records • Lack of longitudinal palliative care planning resulting in reactive response to dying patients • Rostering and staffing arrangement hamper allied health and palliative care not able to fully integrate and support
Reflexive monitoring (how is the work understood and changed)	• Desire to integrate/improve EOL decision making processes • Recognition that structured debriefing sessions are required improve quality of CgDp care	• Systematic audit and feedback processes required to inform and improve outcomes • Few opportunities for meaningful clinical supervision to provide emotional support • Staff find it challenging to find ways to meaningfully appraise the effectiveness of CgDp practices and outcomes