Restricted accessReview articleFirst published online 2026-2
How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review
The challenges of implementing evidence-based palliative care in residential aged care are widely acknowledged. Facilitation is often cited as an effective implementation strategy to address these challenges. However, there is limited guidance on how this strategy applies specifically to this context.
Aim:
To understand the contextual factors and causal processes (mechanisms) that influence the facilitation of interventions designed to improve palliative care in residential aged care, and to develop a realist programme theory that explains how best to support their implementation.
Design:
Realist review guided by the RAMESES standards. Protocol is registered on PROSPERO (CRD42023447043).
Data sources:
MEDLINE, CINAHL and PsycINFO databases were searched for studies on palliative care interventions in residential aged care that used facilitation, published between 2000 and 2024. Data extraction and synthesis followed realist principles to identify context-mechanism-outcome configurations.
Results:
Twenty-three articles describing 16 palliative care interventions were included in the review. Facilitation was found to be effective when it fostered a shared understanding of the intervention, tailored its components to fit staff workflow and built trust among stakeholders. These processes contributed to normalisation of the intervention and transition of ownership of both the intervention and facilitation process. Proactive support from the facilitator in addition to action learning was most effective at developing learning systems and staff comfort and confidence.
Conclusions:
The realist programme theory developed in this study provides a foundation for ongoing testing and refinement, with the aim of accelerating evidence uptake by residential aged care staff and ultimately improving palliative care outcomes for residents.
MooreDCPayneSVan den BlockL, et al. Strategies for the implementation of palliative care education and organizational interventions in long-term care facilities: a scoping review. Palliat Med2020; 34: 558–570.
2.
van Riet PaapJVernooij-DassenMSommerbakkR, et al. Implementation of improvement strategies in palliative care: an integrative review. Implement Sci2015; 10: 103.
3.
HockleyJFroggattKVan den BlockL, et al. A framework for cross-cultural development and implementation of complex interventions to improve palliative care in nursing homes: the PACE steps to success programme. BMC Health Serv Res2019; 19: 745.
4.
ProctorEKPowellBJMcMillenJC. Implementation strategies: recommendations for specifying and reporting. Implement Sci2013; 8: 139.
5.
McArthurCBaiYHewstonP, et al. Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis. Implement Sci2021; 16: 70.
6.
MassoMMcCarthyG. Literature review to identify factors that support implementation of evidence-based practice in residential aged care. Int J Évid Heal2009; 7: 145–156.
7.
TolesMColón-EmericCMoretonE, et al. Quality improvement studies in nursing homes: a scoping review. BMC Health Serv Res2021; 21: 803.
8.
KoernerJJohnstonNSamaraJ, et al. Context and mechanisms that enable implementation of specialist palliative care needs rounds in care homes: results from a qualitative interview study. BMC Palliat Care2021; 20: 118.
9.
MassoMMcCarthyGKitsonA. Mechanisms which help explain implementation of evidence-based practice in residential aged care facilities: a grounded theory study. Int J Nurs Stud2014; 51: 1014–1026.
10.
CoffeyAHartiganITimmonsS, et al. Implementation of evidence-based guidance for dementia palliative care using participatory action research: examining implementation through the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun2021; 2: 137.
11.
FroggattKAMooreDCVan den BlockL, et al. Palliative care implementation in long-term care facilities: European Association for Palliative Care White Paper. J Am Med Dir Assoc2020; 21: 1051–1057.
12.
PowellBJWaltzTJChinmanMJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci2015; 10: 21.
13.
DamschroderLJReardonCMWiderquistMAO, et al. The updated consolidated framework for implementation research based on user feedback. Implement Sci2022; 17: 75.
14.
BaskervilleNBLiddyCHoggW. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med2012; 10: 63–74.
15.
HunterSCKimBKitsonAL. Mobilising implementation of i-PARIHS (Mi-PARIHS): development of a facilitation planning tool to accompany the integrated promoting action on research implementation in health services framework. Implement Sci Commun2023; 4: 2.
16.
HunterSCKimBKitsonAL. Interactive workshop to develop implementation framework (i-PARIHS) resources to support practice facilitation. Implement Sci Commun2020; 1: 56.
17.
PerryLBellchambersHHowieA, et al. Examination of the utility of the promoting action on research implementation in health services framework for implementation of evidence based practice in residential aged care settings. J Adv Nurs2011; 67: 2139–2150.
18.
NonakaI. A dynamic theory of organizational knowledge creation. Organ Sci1994; 5: 14–37.
19.
BertaWCranleyLDearingJW, et al. Why (we think) facilitation works: insights from organizational learning theory. Implement Sci2015; 10: 141.
20.
Rycroft-MaloneJMcCormackBHutchinsonAM, et al. Realist synthesis: illustrating the method for implementation research. Implement Sci2012; 7: 33.
21.
ZibrowskiECarrTMcDonaldS, et al. A rapid realist review of patient engagement in patient-oriented research and health care system impacts: part one. Res Involvement Engagem2021; 7: 72.
MacDonaldMPaulyBWongG, et al. Supporting successful implementation of public health interventions: protocol for a realist synthesis. Syst Rev2016; 5: 54.
24.
SmithJDLiDHRaffertyMR. The implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects. Implement Sci2020; 15: 84.
25.
WaltzTJPowellBJMatthieuMM, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implement Sci2015; 10: 109.
26.
ProctorESilmereHRaghavanR, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health2011; 38: 65–76.
27.
BauerMSKirchnerJ. Implementation science: what is it and why should I care?Psychiatry Res2020; 283: 112376.
28.
Veritas Health Innovation. Covidence systematic review software, www.covidence.org (2024).
29.
PageMJMoherDBossuytPM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ2021; 372: n160.
30.
KantilalKHardemanWWhitesideH, et al. Realist review protocol for understanding the real-world barriers and enablers to practitioners implementing self-management support to people living with and beyond cancer. BMJ Open2020; 10: e037636.
31.
DadaSDalkinSGilmoreB, et al. Applying and reporting relevance, richness and rigour in realist evidence appraisals: advancing key concepts in realist reviews. Res Synth Methods2023; 14: 504–514.
BoothAHardenAThomasJ, et al. Chapter 16- Realist synthesis. Draft version (November 2024) 1–31. for inclusion. In: NoyesJHardenA (eds). Cochrane-Campbell handbook for qualitative evidence synthesis. Version 1. London: Cochrane.
35.
PawsonRGreenhalghTHarveyG, et al. Realist synthesis – an introduction. ESRC, 2004.
36.
LawsonT. Economics and explanation. Rev Int Philos2001; n° 217: 371–393.
37.
HockleyJKinleyJ. A practice development initiative supporting care home staff deliver high quality end-of-life care. Int J Palliat Nurs2016; 22: 474–481.
38.
KinleyJPrestonNFroggattK. Facilitation of an end-of-life care programme into practice within UK nursing care homes: a mixed-methods study. Int J Nurs Stud2018; 82: 1–10.
39.
KinleyJStoneLDeweyM, et al. The effect of using high facilitation when implementing the Gold Standards Framework in Care Homes programme: a cluster randomised controlled trial. Palliat Med2014; 28: 1099–1109.
40.
CharmillotPAVan den BlockLOosterveld-VlugM, et al. Perceptions of healthcare professional about the “PACE Steps to Success” palliative care program for long-term care: a qualitative study in Switzerland. Nurs Open2023; 10: 4413–4423.
41.
Oosterveld-VlugMOnwuteaka-PhilipsenBten KoppelM, et al. Evaluating the implementation of the PACE steps to success programme in long-term care facilities in seven countries according to the RE-AIM framework. Implement Sci2019; 14: 1–19.
42.
BuckleyCHartiganICoffeyA, et al. Evaluating the use of participatory action research to implement evidence-based guidance on dementia palliative care in long-term care settings: a creative hermeneutic analysis. Int J Older People Nurs2022; 17: 1–11.
43.
BrazilKWalsheCDohertyJ, et al. Implementation of an advance care planning intervention in nursing homes: an international multiple case study. Gerontologist2024; 64: gnae007.
44.
MooreKJCandyBDavisS, et al. Implementing the compassion intervention, a model for integrated care for people with advanced dementia towards the end of life in nursing homes: a naturalistic feasibility study. BMJ Open2017; 7: e015515.
45.
DobbsDYaukJVogelCE, et al. Feasibility of the palliative care education in assisted living intervention for dementia care providers: a cluster randomized trial. Gerontologist2024; 64(1): 10.
46.
HansonLCSongMKZimmermanS, et al. Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia. Clin Trials2016; 13: 599–604.
47.
HewisonABadgerFCliffordC, et al. Delivering ‘Gold Standards’ in end-of-life care in care homes: a question of teamwork?J Clin Nurs2009; 18: 1756–1765.
48.
HockleyJWatsonJOxenhamD, et al. The integrated implementation of two end-of-life care tools in nursing care homes in the UK: an in-depth evaluation. Palliat Med2010; 24: 828–838.
49.
O’BrienMKirtonJKnightingK, et al. Improving end of life care in care homes; an evaluation of the six steps to success programme. BMC Palliat Care2016; 15(1): 53.
50.
WatsonJHockleyJDewarB. Barriers to implementing an integrated care pathway for the last days of life in nursing homes. Int J Palliat Nurs2006; 12: 234–240.
51.
GilissenJPivodicLWendrich-van DaelA, et al. Implementing advance care planning in routine nursing home care: the development of the theory-based ACP+ program. PLoS One2019; 14: e0223586.
52.
YaldenJMcCormackBO’ConnorM, et al. Transforming end of life care using practice development: an arts-informed approach in residential aged care. Int Pract Dev J2013; 3: 1–18.
53.
DavisJMorgansADunneM. Supporting adoption of the palliative approach toolkit in residential aged care: an exemplar of organisational facilitation for sustainable quality improvement. Contemp Nurse2019; 55: 369–379.
54.
DavisELMullanJJohnsonCE, et al. The experience of Australian aged care workers during a trial implementation of a palliative care outcomes programme. Int J Health Plann Manage2024; 39: 380–396.
55.
ErsekMHickmanSEThomasAC, et al. Stakeholder perspectives on the optimizing patient transfers, impacting medical quality, and improving symptoms: transforming institutional care (OPTIMISTIC) project. Gerontologist2018; 58: 1177–1187.
56.
SarakbiDGravesEKingG, et al. Gift of time: learning together to embed a palliative approach to care in long-term care. BMJ Open Quality2022; 11: e001581.
57.
CloutierDStajduharKIRobertsD, et al. ‘Bare-bones’ to ‘silver linings’: lessons on integrating a palliative approach to care in long-term care in Western Canada. BMC Health Serv Res2021; 21: 610.
58.
de BrúnTO’Reilly-de BrúnMO’DonnellCA, et al. Learning from doing: the case for combining normalisation process theory and participatory learning and action research methodology for primary healthcare implementation research. BMC Health Serv Res2016; 16: 346.
59.
MayCRMairFFinchT, et al. Development of a theory of implementation and integration: normalization process theory. Implement Sci2009; 4: 29.
60.
KilbourneAMGengEEshun-WilsonI, et al. How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy. Implement Sci Commun2023; 4: 53.
61.
McCormackBRycroft-MaloneJDecorbyK, et al. A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency. Implement Sci2013; 8: 107.
62.
Dixon-WoodsMBoskCLAvelingEL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q2011; 89: 167–205.
63.
DimaggioPJPowellWW. The new economic sociology. In: DobbinF (ed.) A reader. Princeton University Press, 2004, pp.111–134.
64.
WeinerBJMezaRDKlasnjaP, et al. Changing hearts and minds: theorizing how, when, and under what conditions three social influence implementation strategies work. Front Heal Serv2024; 4: 1443955.
65.
FreyRBarhamSBalmerD, et al. Palliative care delivery in residential aged care: bereaved family member experiences of the supportive hospice aged residential exchange (SHARE) intervention. BMC Palliat Care2020; 19: 127.
66.
FreyRFosterSBoydM, et al. Family experiences of the transition to palliative care in aged residential care (ARC): a qualitative study. Int J Palliat Nurs2017; 23: 238–247.
67.
HartmannCWEngleRLPimentelCB, et al. Virtual external implementation facilitation: successful methods for remotely engaging groups in quality improvement. Implement Sci Commun2021; 2: 66.
68.
PimentelCBMillsWLPalmerJA, et al. Blended facilitation as an effective implementation strategy for quality improvement and research in nursing homes. J Nurs Care Qual2019; 34: 210–216.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
