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.