Implementing palliative care in intensive care units: assessing processes using the normalisation process theory NoMAD instrument

Background
The importance of palliative care for Intensive Care Unit (ICU) patients/families is known. Little is known about implementing this care in practice, and how to support healthcare professionals in this implementation. This study uses survey methodology informed by Normalisation Process Theory to assess implementation processes for providing palliative care in the ICU.

Methods
A descriptive cross-sectional survey was conducted with UK healthcare professionals involved in providing or organising palliative care in the ICU. Implementation processes were assessed using the validated 23-item Normalisation MeAsure Development (NoMAD) instrument. Absolute (n) and relative frequencies, median and interquartile ranges were reported. Mann–Whitney U Test assessed differences between specialist palliative care and ICU respondents. One open-ended item captured free-text responses, analysed using NPT-guided framework analysis.

Results
From 153 completed surveys, 69% of respondents were ICU professionals, 31% were specialist palliative care professionals. There was no statistically significant difference between responses from ICU and specialist palliative care professionals. Likert responses showed that respondents felt familiar with palliative care in the ICU and felt it was part of their normal work. Positive tendency was found toward implementation of palliative care in the ICU with coherence (sense-making work), cognitive participation (relational work) and reflexive monitoring (appraisal work). Rating of collective action (operational work) showed a more neutral tendency, highlighting this as a potential target for improvement. Free-text responses were categorised into themes within Normalisation Process Theory constructs: Coherence—recognising and stratifying need, and nuances within palliative care in the ICU; Cognitive participation—interdisciplinary interfaces and building capacity; Collective action—procedures for provision, pressures on provision, and perceived capability; Reflexive monitoring—perceived value.

Conclusion
This novel study uses NPT to assess professional processes relating to implementation of palliative care in the ICU. Findings suggest important perceived implementation gaps may lie within operational work such as tailoring utilisation of existing resources, ensuring leadership support, and building skill sets. Dedicated qualitative research is needed to explain how these issues operate in context and to examine potential patient- and family-related influences.