Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

Objectives To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration. Design and methods A scoping review was undertaken based on the methodological framework of Arksey and O’Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes. Results Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal. Conclusions A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.

-Accessing alternative education programmes can act as a barrier to understanding purpose [69].

Perceived value & appraisal Input into development Training & education
Individual Specification -Do staff understand their specific tasks & responsibilities in relation to the intervention? What work has been done to ensure they are understood? -Do individuals understand how the intervention will impact upon the nature of their work? -Importance of training [36,48,52,68] & tailored education [36,39]  -Majority of interventions piloted or implemented within limited settings or specific services [32,44,46,60,61,63], often with input into the design from staff within these settings [44,46,63].
Communal appraisal -Is there communal agreement among staff as to the value of the intervention? -Has the worth of the intervention been evaluated collaboratively in formal or informal groups?
-One study evaluated staff perceptions in a collaborative setting, including focus groups & leadership meetings [69].
-The importance of individual & group methods in gauging attitudes was described, yet their relative efficiency was not explored [40,41,69].
-Communal staff appraisal may allow for a greater demonstration of impact than medical record audit data [69].

Perceived value & appraisal
Individual appraisal -What is the effect of the intervention on an individuals' workload? -Do individuals value the effect it has on their individual work? -High value attributed to the intervention by staff, due to positive impact on working practices: reduces negative associations with DNACPR due to its universal application [3]  -Perceived & noted increases in workload were a concern for staff. However, it was generally perceived to be a worthwhile investment due to clarity, patient benefit & time saved later on [1,3,44,60,61,69].