"Diving in the deep-end and swimming": a mixed methods study using normalization process theory to evaluate a learning collaborative approach for the implementation of palliative care practices in hemodialysis centers

Authors

Laura M. Holdsworth, Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA. l.holdsworth@stanford.edu.
Margaret Stedman, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.
Erika Saliba Gustafsson, Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA.
Jialin Han, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.
Steven M. Asch, Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA.
Glenda Harbert, School of Nursing, George Washington University, Washington, D.C, USA.
Karl A. Lorenz, Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA.
Dale E. Lupu, School of Nursing, George Washington University, Washington, D.C, USA.
Elizabeth Malcolm, Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
Alvin H. Moss, Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA.
Amanda Nicklas, School of Nursing, George Washington University, Washington, D.C, USA.
Manjula Kurella Tamura, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.

Document Type

Journal Article

Publication Date

12-11-2023

Journal

BMC health services research

Volume

23

Issue

1

DOI

10.1186/s12913-023-10360-7

Keywords

Collaborative; End-stage kidney disease; Hemodialysis; Mixed methods; Normalization process theory; Palliative care; Practice change

Abstract

BACKGROUND: Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers. METHODS: We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation. RESULTS: The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores. CONCLUSIONS: NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually reinforcing. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04125537 . Registered 14 October 2019 - Retrospectively registered.

APA Citation

Holdsworth, Laura M.; Stedman, Margaret; Gustafsson, Erika Saliba; Han, Jialin; Asch, Steven M.; Harbert, Glenda; Lorenz, Karl A.; Lupu, Dale E.; Malcolm, Elizabeth; Moss, Alvin H.; Nicklas, Amanda; and Tamura, Manjula Kurella, ""Diving in the deep-end and swimming": a mixed methods study using normalization process theory to evaluate a learning collaborative approach for the implementation of palliative care practices in hemodialysis centers" (2023). GW Authored Works. Paper 3981.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/3981

Department

Nursing Faculty Publications