Abundance in physical resources but lack of human resources for education and data collection
Participants described the influence of various resources on the project’s implementation. On one hand, the project implementation was well supported by physical resources. A nurse shared, “whether it be funding so we could offer parking passes for our patient’s loved ones or funding so we could buy them something to eat that we otherwise couldn’t do so…it offered resources that allowed us to go that extra step.” [P10 ] Another nurse reflected, “I think that it provides us with the tools we need to better the EOL experience in the ICU.” [P11 ] In contrast, the human resources may have been insufficient to facilitate rapid, sustainable widespread expansion. A nurse emphasized the barrier of inadequate staffing, “[it’s] different in terms of even just like people. For example, if you are at a teaching hospital, you have medical students, residents, you have nursing students through the unit more. Perhaps if the bedside nurse has two patients, and he is busy or she is busy with next door but they need help implementing a wish, a resident could do that or they might have more time, because they are learning to talk to the patients and families and have the opportunity to find wishes.” [P6 ] Many clinicians also mentioned the heavy workload as an ICU staff in which they are “in and out of the room, [they’re] busy, [their] day is filled with tasks.”[P4 ] Given the shift based nature of the physician lead and frontline champions, there was not always someone who was there to support staff education and data collection. A nurse added that “in other centres they may have somebody that’s just dedicated to doing just 3 wishes and keeping track of this inventory, whereas we don’t have it and it’s kind of piecemeal.”[P6 ] The lack of mobilization of a non-clinical project support team left the scaling process to be taken up by clinicians who were already working at full capacity. A physician confirmed that, “…Part of it is also the infrastructure of our site in that we didn’t have a horizontal point of care person for a while..” [P4 ]
Discussion
This mixed-method study evaluated the implementation of the 3WP in a large community ICU in Canada from the perspectives of the clinicians and key stakeholders. The 3WP was perceived to improve the EOL experience for patients and families by personalizing care and encouraging meaningful conversations. The 3WP also promotes collaboration and job satisfaction amongst the interdisciplinary healthcare team. There is a desire from frontline staff to implement this kind of project, however there needs to be careful consideration of commensurate strategies to facilitate education and delivery including consistent communication to staff as the project spreads. Finally, in a community hospital ICU setting, physical resources can be collected and donated to empower staff to support patients and families through EOL, though limited human resources may strain project implementation as frontline staff take on additional duties beyond their normal workflow.
This study confirms the previously reported benefits of the 3WP for ICU patients, families and clinicians when implemented. Literature supports the findings that this individualized approach provides opportunities for more personalized discussions with families while honouring the patient’s identity and preferences.9 Similar to implementation outcomes at academic centers, the 3WP serves to make clinical work more meaningful and improves interdisciplinary team cohesion when working towards a shared purpose.9,21Moreover, our study adds to current literature by recognizing the complexities involved in implementing an EOL program in a community hospital.
Qualitative results indicate that the project spread was variable in the unit. Spread is defined as the process of communicating and implementing a project within a new environment, and can be influenced by project attributes.22 Based on the customizable nature of the project whereby the main focus is personalizing care, the key characteristic of the 3WP is that the output – terminal wishes implemented - depend on the patients, families, and clinicians involved in the care. This characteristic, which allows clinicians to be creative in the process of personalization, likely drives the sense of meaning derived from the project. Conversely, the complexity of implementing both individualized and meaningful wishes likely caps the rate of spread as clinicians are learning ‘in vivo’ a new skill set. Thus, the implementation team must plan and dedicate an additional period of time for ongoing education, practice and re-exposure for optimal retention in the case of a complex intervention.23,24 Spaced learning with a broader time horizon for implementation may be necessary to integrate this type of project effectively. This may be achieved through multi-modal techniques which take into account infrastructure capability and learning preferences of the clinicians.23–26
Another characteristic of the 3WP which may influence spread is the adaptable nature of the 3WP to the setting. Though a community ICU may be able to procure physical resources to support the implementation of the 3WP, there may be a limited rate at which the project can spread given human resource constraints including research project supports. Similar studies found staffing to be an issue when implementing evidence-based projects in community hospitals. Kim et. al implemented guidelines for targeted temperature management after cardiac arrest in 21 community and tertiary care centres and the most frequently mentioned and agreed upon barrier was the lack of manpower and increased workload.27 In order to facilitate implementation where human resources may be strained, the project adapted to local needs and capacities.22 In our study, a majority of the completed wishes (37 [55.2%]) relied on physical resources including keepsakes, music, celebrations involving food and beverages, humanizing the ICU room and family care. Keepsakes such as a printed copy of patients electrocardiogram or a computer generated word cloud image, facilitate a personalized memory-making experience for patients, families, and clinicians.16,28 Moreover, keepsakes are an intervention which are less dependent on clinicians which may facilitate spread, particularly in community-based settings. Thus, spread can be achieved in a community ICU through contextual adaptation focusing on interventions derived from more readily available physical resources, as opposed to interventions dependent on a fixed human resource.
There are several strengths of this study. First, this project explores project implementation in a Canadian community ICU where academic activity is generally less intense, given the lack of institutional mandate, financial support, research experience, and clinician workload.13 Another strength is exploring the clinician and key stakeholder experience through qualitative interviewing. Understanding the clinician and key stakeholder perspective is instrumental when studying the implementation of the 3WP since they directly deliver the intervention and support the project’s growth and buy-in. Finally, this study explores a project led by frontline staff who were involved in the initiation, adaptation and activation of this project. These findings may help other centers seeking to integrate similar projects at their own sites.
In terms of limitations of this study, only wishes elicited when the 3WP physician lead was on duty were recorded. Though the 3WP operated outside of these specified time periods, data were not collected due to human resource limitations, particularly in dedicated research staff. Patient and family views were not sought since our lens was that of clinicians and key stakeholders at this stage. In addition, one of the qualitative reviewers was a frontline clinician involved directly in the 3WP implementation which may have influenced analysis and interpretation. To attenuate this risk of bias, qualitative analysis was performed in triplicate and results underwent member checking. Finally, this study is a summative description of the implementation process in early stages of spread. Given the short and sparse period of quantitative data, temporal analysis, in the form of run charts or standard process control, relating implementation interventions to project process and outcomes was not performed.
In conclusion, this study describes the implementation of the 3WP in a Canadian community hospital ICU from the perspective of clinicians and key stakeholders. The 3WP is a valuable EOL intervention for patients, families, and clinicians. When implementing the project in the community ICU, investigators will need to consider adaptations to match the nature of the project with characteristics of the environment to facilitate spread.