How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review

Abstract

Background:

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.

Keywords

Realist review realist synthesis implementation science facilitation homes for the aged palliative care terminal care

What is already known about the topic?

Lack of continuity in staffing, insufficient resources and time limitations are frequently cited barriers to implementing evidence-based palliative care into residential aged care.

There is a lack of understanding of the extent to which implementation strategies like facilitation can enable the uptake of evidence by residential aged care staff.

What this paper adds?

Facilitation was more effective in supporting the adoption of evidence-based palliative care into practice among residential aged care staff when accompanied by action learning.

Residential aged care staff benefit most from intensive support from facilitators to implement palliative care interventions as intended.

However, the sustainability of practice change following the withdrawal of facilitators post intervention requires further investigation.

Implications for practice, theory or policy

A realist programme theory is presented which can be further tested and refined to strengthen its applicability to policy and practice.

Further discussion is needed on the application of implementation theories and in the reporting of implementation to increase the likelihood of reproducing outcomes of those palliative care interventions proven to be effective.

Background

Residential aged care homes (also known as nursing/long-term care homes) are high-mortality settings, making good end-of-life care essential. Many studies report the difficulties in implementing evidence-based palliative care into residential aged care. A scoping review on implementation strategies used to implement palliative care interventions in residential aged care identified variation in the application of strategies but common challenges, including staffing continuity, poor contextual fit, resource limitations, unclear roles and time constraints.¹ How implementation strategies influence the uptake of palliative care interventions in residential aged care is poorly understood.^1–3 Implementation strategies are defined as the ‘methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice’ (p. 2).⁴ If an intervention is ‘what’ is being implemented, then the implementation strategy is the ‘how’. Implementation strategies are underreported and often difficult to differentiate from the intervention. More research is needed to understand how contextual factors interact with strategies to enable or hinder their success in residential aged care settings.^5–11 Without clear descriptions, accurate measurement and reproducibility of implementation outcomes is hindered.⁴

Facilitation is one such strategy, defined by the Expert Recommendations for Implementing Change (ERIC) as ‘a process of interactive problem solving and support that occurs in a context of a recognized need for improvement and a supportive interpersonal relationship’.¹² Facilitation is described in several implementation science frameworks including the Consolidated Framework for Implementation Research (CFIR) where facilitators are ‘Individuals with subject matter expertise who assist, coach, or support implementation’.¹³ Facilitators may be internal or external, and act in combination with other implementation strategies. Evidence from primary care suggests facilitation has moderate effects when tailored to context and need.¹⁴

Facilitation has a central role in the Promoting Action on Research Implementation in Health Services (PARIHS) framework. The framework argues that successful implementation results from the facilitation of an innovation with the intended recipients in their contextual setting.^15,16 The framework has shown good fit in residential aged care with an added temporal component.¹⁷ Residential aged care staff needed greater flexibility in time to adapt and adopt new practices at their own pace.¹⁷

Definitions and application of facilitation (as role and process) vary across the implementation science literature. Understanding the theoretical grounding of facilitation is key to effective implementation. Berta et al. conceptualise facilitation as a learning mechanism informed by organisational learning theory. This theory considers the impact of socio-organisational, individual and macro-environmental factors on the learning and application of new knowledge.^18,19 Facilitation thus supports the acquisition, application and retention of new knowledge through both internal and external learning processes.¹⁹ However, how and in what circumstances facilitation works in residential aged care specifically requires further investigation to hasten the uptake and integration of evidence-based practice to improve care outcomes for older people.

Research questions, aims and intended outcomes

Throughout the article, the term palliative care will be used inclusively to refer to both palliative care and end-of-life care. The primary research question is how and in what circumstances does facilitation work for residential aged care staff in the implementation of interventions designed to improve palliative care?

Sub questions are:

What does the literature say about the implementation theories, models and frameworks informing interventions designed to improve palliative care through facilitation?

What implementation outcomes are reported and how are they defined?

What are the mechanisms inherent in successful facilitation supporting effective implementation and how is success defined?

In what contexts and circumstances do these mechanisms trigger success in facilitating interventions designed to improve palliative care?

The aims are to (1) understand the (contextual) factors and causal processes (mechanisms) that influence the facilitation of interventions designed to improve palliative care in residential aged care, and (2) develop a realist programme theory that describes how to best facilitate such interventions.

Methods

Design

Realist synthesis was chosen for its ability to explain how and why interventions succeed or fail by accounting for context, mechanisms and outcomes.²⁰ A realist review, informed by RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines and publication standards, was completed in six steps iteratively.^20–23 The protocol is registered on PROSPERO (CRD42023447043).

Step 1: Define the scope

The review topic was refined drawing on the research team’s expertise in palliative care, residential aged care and implementation science.

Step 2: Preliminary theory selection

A preliminary search of peer-reviewed literature was undertaken with a focus on implementation theories, models and frameworks to develop an understanding of how implementation strategies were constructed and intended to work. While initially broad, the scope was narrowed to palliative care interventions using facilitation, frequently cited as a central strategy. This allowed for greater testability of implementation theories, models and frameworks specific to facilitation and more feasible, focused findings. For this review, facilitation was defined as a role or process separate to intervention activities that involved (1) coaching, mentoring or implementation support and (2) relationship or skill building to reduce the gap between evidence and practice. Findings informed a preliminary theory to be tested in the formal review, presented using the Implementation Research Logic Model (see Supplemental Appendix 1).²⁴ This Logic Model strengthened the reproducibility and testability of the preliminary theory as it draws on implementation theories. This includes the CFIR domains (to identify the determinants), the ERIC (to name implementation strategies), and the work of Proctor et al. (to define implementation outcomes).^12,13,25,26 It also takes a similar form to the Context-Mechanism-Outcome (CMO) configuration central to realist analysis. Eligibility criteria were finalised following the development of the preliminary theory (see Table 1).

Table 1.

Eligibility criteria.

Inclusion category	Description
Population	Residential aged care staff are active participants in the intervention/s
Intervention	Intervention/s that employ facilitation (internal or external), or activities that fit the definition of facilitation, as an implementation strategy
Context	Intervention/s set in residential aged care whereby 24-h supervision and/or care assistance is provided to older people.
Outcome	The intervention/s discussed aim to improve palliative care and/or end-of-life care outcomes for residents living in residential aged care, staff palliative care and/or end-of-life care practice, and/or uptake of evidence regarding palliative and/or end-of-life care into practice.

Step 3: Search strategy development and database selection

A librarian supported the development of the search strategy (Supplemental Appendix 2). Using purposive and snowballing methods, MEDLINE, CINAHL and PsycINFO were searched in May 2024, including key terms of ‘facilitation’, ‘palliative care’ and ‘residential aged care’. Exclusion criteria included non-English language publications, literature reviews, protocols and studies prior to 2000 to capture the relevant, contemporary and rigorous implementation research. This timeframe aligns with the emergence of implementation science as a distinct field, marked by the launch of the journal Implementation Science in 2006.²⁷

Step 4: Study selection and appraisal (by theory-testing potential)

Covidence was used to manage the review process.²⁸ Results of the screening process and study selection are reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA; Figure 1).²⁹ Reviewer 1 (KL) extracted initial records; titles and abstracts were screened independently by KL and LL, using a tool trialled on 20 articles. Articles where facilitation was unclear, but all other criteria were met were retained for further review. Full-text rescreening was conducted by KL and JT, applying the agreed definition of facilitation. This led to a substantial reduction in eligible studies due to limited description of facilitation.

Figure 1.

PRISMA flowchart.

Selection followed the RAMESES criteria of relevance, richness and rigour.²² A criterion of no to high relevance was developed informed by Kantilal et al.³⁰ A rating was assigned based on majority alignment across criteria. Drawing upon the work of Dada et al., richness was assessed conceptually and in relation to the research questions.³¹ Many studies mentioned facilitation but lacked sufficient detail, limiting their value for theory testing and leading to exclusion. Methodological rigour was assessed using Critical Appraisal Skills Programme (CASP)^32,33 checklists in line with the Cochrane Qualitative and Implementation Methods Group draft guidelines on conducting realist synthesis.³⁴ Quantitative methods were summarised alongside the data they produced. A bespoke appraisal process was developed (Table 2). Full text review and appraisal was conducted by KL (all), JT (half), and LL (half). Responses were recorded in a spreadsheet; conflicts were resolved through discussion or by a third reviewer. Studies were not excluded based on methodological quality.

Table 2.

Appraisal criteria and procedure informed by Kantilal et al.³⁰ and Dada et al.³¹.

Appraisal step	Criteria		Outcome
Step 1: Facilitation	• Does the facilitator role/facilitation process involve coaching, mentoring or supporting implementation? • Does the facilitator role/facilitation process involve relationship and/or skill building with the goal to reduce the gap between evidence and practice? • Is the facilitator role/facilitation process separate from the intervention activities?		If YES then assess relevance (step 2) If NO exclude
Step 2: Relevance	High	• Relates to an intervention designed to improve palliative care in residential aged care and includes a detailed description of the implementation. • Includes an in-depth description of the intervention and its implementation process which utilises facilitation as an implementation strategy. • Describes the context and setting the intervention is implemented in, including motivations behind implementation and changes in context following the introduction of the intervention. • Describes the outcomes of the intervention, specifically highlighting changes to the implementation outcomes. • Includes in-depth theoretical explanation for reported implementation outcomes.	Assign the study to the category that corresponds to the majority of the bullet points, and then rate according to that category If rated low, moderate or high, then assess richness (step 3) If NO relevance; exclude
	Moderate	• Relates to an intervention designed to improve palliative care in residential aged care and utilises facilitation as an implementation strategy. • Includes a description of the intervention and how it was implemented. • Describes the setting the intervention is implemented including motivations behind implementation. • Reports the outcomes of the intervention, highlighting the implementation outcomes. • Includes a brief theoretical explanation for reported implementation outcomes.
	Low	• Relates to an intervention designed to improve palliative care in residential aged care and utilises facilitation as an implementation strategy. • Includes a brief description of implementation but is not the focus of the article. • Describes the setting in which the intervention was implemented. • Includes the outcomes of the intervention. • Draws upon a theoretical explanation for the effectiveness of the implementation in the literature review.
	No	Does not meet any of the above criteria.
Step 3: Richness	Of concepts	• Conceptually rich: articles with well-grounded and clearly described theories and concepts. • Conceptually thick: articles with a rich description of a programme is provided, but without explicit reference to the theory underpinning it. • Conceptually thin: studies with weak programme descriptions where discerning theory would be problematic	If conceptual richness is RICH or THICK with a score of 2–4 in relation to the research questions, then assess rigour (step 4) If conceptual richness is THIN with a score of 0–1 in relation to the research questions; exclude and retain for future consideration depending on theory development
Step 3: Richness	In relation to research questions	0 = nothing of interest, not focused on design or implementation or use 1 = limited data of interest, likely to appear in other articles, 2 = limited data of interest, but quick to extract and could add weight to findings, 3 = some good quality data, 4 = much valuable data.
Step 4: Rigour	Does the study collect qualitative data? If YES complete qualitative CASP checklist. Does the study collect quantitative data? If YES extract and describe. Does the study include a control group? If YES complete Randomised Controlled Trial CASP checklist.		Based on checklist responses rate quality as either HIGH (meets majority of the criteria – methodologically sound), MODERATE or LOW (minimal criteria met or many unknowns – relatively poor methodology), add comments as needed.

Step 5: Data extraction, analysis and synthesis

Selected articles were re-read and data systematically extracted using a bespoke predefined data extraction tool including publication details, intervention description, description of facilitators and other implementation information. Analysis and evidence synthesis followed realist principles applying a generative view of causality to identify mechanisms linking context and outcomes.³⁵ Explanatory causal accounts were developed in the form of if-then-leading to statements for example, if (implementation enablers or barriers) was present, then (mechanism) was reported, leading to (implementation outcome). The set of explanatory accounts were then iteratively analysed to identify demi-regularities known as ‘partial event regularities’ or prominent recurrent patterns of contexts and outcomes.^22,36 Evidence from low quality articles were not weighted differently but were verified through triangulation across selected articles and the identification of demi-regularities. One author (KL) independently coded studies. Findings were discussed with team members. Demi-regularities were synthesised according to facilitator activities, and corresponding CMO configurations were developed.

Step 6: Identification of realist programme theory

A final realist programme theory was developed by refining the initial theory and linking the CMO configurations. While the original protocol aimed to develop a middle-range theory, as the scope of the study and sample of selected studies were refined it became clear the level of abstraction required for a middle-range theory was not feasible. Instead, the focus shifted to a more specific theory that better captured the nuances of facilitation as an implementation strategy in the context of palliative care in residential aged care settings.

Results

Overview of included studies

Twenty-three articles, reporting 16 interventions, were included in data extraction and analysis. Several articles reported on different components of the same studies. These included a trial of the Gold Standards Framework for Care Homes (GSFCH),^37–39 the PAlliative Care for older people in Europe (PACE) steps to success programme,^3,40,41 and the implementation of evidence-based guidance on dementia palliative care.^10,42 Many of the reported interventions informed the design of later iterations; the Liverpool Care Pathways informed GSFCH, the GSFCH informed the Steps to Success Program and consequently PACE. Interventions aimed to improve palliative care and reduce unplanned hospitalisations with a focus on staff education and care planning. Six studies reported dementia-specific palliative care interventions.^10,42–46 Interventions were implemented in the United Kingdom (n = 11),^{3,37–39,41,43,44,47–50} Europe (n = 7),^{3,10,40–43,51} Australia (n = 3),^52–54 United States of America (n = 3)^45,46,55 and Canada (n = 3).^43,56,57 Their duration ranged from 6 months to 7 years.

Key intervention activities included education for staff or implementing guidance documents, tools or resources. Twelve articles did not report the use of any implementation theories, models or frameworks informing the rationale for facilitation. Of those that did draw on implementation science, the CFIR and PARIHS frameworks were most used (n = 7).^{3,10,38,39,41,42,54} In 14 of the articles ‘facilitator’ or ‘facilitation’ was used to describe the strategy. Alternate terms included trainer, change agent, link nurse or interdisciplinary care leader. Supplemental Appendix 3 provides further information about how facilitators were described in selected studies. Often, within the timeframe of the intervention, resident care did not improve however, staff knowledge and confidence did. Table 3 provides an overview of the included studies and the appraisal results.

Table 3.

Overview of included studies and appraisal results.

Reference	Intervention					Implementation		Appraisal results
Reference	Name	Aim	Study type	Location	No. of homes	Theories, Models & Frameworks	Outcomes linked to facilitation^a	Relevance	Conceptual richness	RQs richness (0–4)	Rigour
Brazil et al., 2024⁴³	Family Carer Decision Support Intervention (mySupport study)	Adapt the application of an intervention for use in different countries to inform family carers about end-of-life care options available to a person living with advanced dementia.	Qual. & quant.	Canada, Czech Republic, Italy, Netherlands, Ireland & United Kingdom	17	Evaluation informed by RE-AIM	Acceptability Cost	Mod.	Rich	3	High
Buckley et al., 2022⁴²	Implementation of evidence-based guidance on dementia palliative care	To introduce guidelines to improve palliative care for persons with dementia.	Qual.	Ireland	3	PARIHS informed facilitation, participatory action research	Acceptability	Mod.	Rich	3	High
Charmillot et al., 2023⁴⁰	PACE steps to success	To train facility staff to provide high-quality palliative care to residents, thus improving the quality of death	Qual.	Switzerland	4	None reported	Acceptability Adoption Fidelity	Mod.	Thick	2	High
Cloutier et al., 2021⁵⁷	SALTY (Seniors Adding Life to Years)	To embed a palliative approach to care	Qual.	Canada	4	None reported	None explicitly linked	Mod.	Thick	2	High
Coffey et al., 2021¹⁰	Implementation of evidence-based guidance on dementia palliative care	To implement evidence-based guidance on dementia palliative care.	Qual. & quant.	Ireland	3	PARIHS & CFIR informed analysis, participatory action research	Acceptability Reach	Mod.	Rich	3	Mod.
Davis et al., 2024⁵⁴	Palliative Care Outcomes Collaboration (PCOC) Wicking Model for Residential Aged Care	To evaluate the feasibility of implementing the Palliative Care Outcomes model into residential aged care facilities.	Qual.	Australia	4	PARIHS informed implementation plan	Feasibility	Mod.	Thick	2	High
Davis et al., 2019⁵³	The Sub Acute Healthcare Linkages in Later Years (SALLY) project	To implement a palliative approach.	Qual.	Australia	13	None reported	Adoption	Mod.	Thick	2	Low
Dobbs et al., 2024⁴⁵	The Palliative Care Education in Assisted Living for Dementia Care Providers (PCEAL-DCP)	To examine the acceptability and feasibility of the Palliative Care Education in assisted living for Dementia Care Providers	RCT	United States of America	10	None reported	Feasibility Fidelity	Mod.	Thick	2	Mod.
Ersek et al., 2018⁵⁵	Optimising Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project	To reduce avoidable hospitalisations among nursing facility residents	Qual.	United States of America	19	None reported	Adoption Feasibility	Mod.	Thick	3	High
Gilissen et al., 2019⁵¹	ACP+ programme	To improve advance care planning in nursing homes	Qual.	Belgium	5	None reported	Acceptability Feasibility	Mod.	Rich	3	Mod.
Hanson et al., 2016⁴⁶	Goals of care intervention	To test whether a decision aid for goals of care in advanced dementia could improve (1) the quality of communication and decision-making, (2) the quality of palliative care, and (3) the quality of dying for nursing home residents with advanced dementia.	RCT	United States of America	22	None reported	Fidelity	Mod.	Thick	2	Low
Hewison et al., 2009⁴⁷	GSFCH	To improve management of symptoms, reduce elements of fear and uncertainty and enable more to attain their preference for place of care.	Qual. & quant.	United Kingdom	10	None reported	None explicitly linked	Mod.	Thick	2	Mod.
Hockley et al., 2010⁴⁸	GSFCH & Liverpool Care Pathways for Care Homes	To improve management of symptoms, reduce elements of fear and uncertainty and enable more to attain their preference for place of care.	Quant.	United Kingdom	7	None reported	Adoption	Mod.	Thick	2	Low
Hockley and Kinley, 2016³⁷	GSFCH	(1) Improve quality of end of life care all residents. (2) Improve collaboration with external healthcare professionals. (3) To reduce inappropriate hospital admissions in the last stage of life.	Quant.	United Kingdom	76	None reported	Sustainability	Mod.	Thick	2	Low
Hockley et al., 2019³	PACE steps to success	To improve palliative care for older people.	RCT	Belgium, United Kingdom, Finland, Italy, The Netherlands, Poland & Switzerland	78	PARIHS	Adoption Feasibility Fidelity Reach	Mod.	Rich	3	Mod.
Kinley et al., 2014³⁹	GSFCH	To improve management of symptoms, reduce elements of fear and uncertainty and enable more to attain their preference for place of care.	RCT	United Kingdom	38	PARIHS, participatory action research	Fidelity Cost	High	Rich	3	Mod.
Kinley, Preston and Froggatt, 2018³⁸	GSFCH	To improve management of symptoms, reduce elements of fear and uncertainty and enable more to attain their preference for place of care.	Qual. & quant.	United Kingdom	38	PARIHS, participatory action research	Fidelity Cost	High	Thick	4	Mod.
Moore et al., 2017⁴⁴	Compassion intervention	To examine the feasibility of implementing a model for integrated care for people with advanced dementia towards the end of life in nursing homes	Qual. & quant.	United Kingdom	2	Multi-level and whole systems change theories	Acceptability Feasibility Cost	Mod.	Thick	2	Mod.
O’Brien et al., 2016⁴⁹	Six steps to success programme	To help care home staff deliver the best end-of-life care.	Qual.	United Kingdom	6	None reported	Adoption	Mod.	Thick	3	Mod.
Oosterveld-Vlug et al., 2019⁴¹	PACE steps to success	To improve the quality of palliative care in long-term care facilities	Qual. & quant.	Belgium, United Kingdom, Finland, Italy, The Netherlands, Poland & Switzerland	37	Evaluation informed by RE-AIM, discusses CFIR and PARIHS	Adoption Feasibility Fidelity Reach	Mod.	Thick	2	Mod.
Sarakbi et al., 2022⁵⁶	Embedding a Palliative Approach to Care (EPAC)	To identify effective strategies for supporting the early identification of palliative care needs to improve the quality of life of residents in long-term care.	Qual. & quant.	Canada	7	None reported	Adoption	Mod.	Thick	2	Low
Watson, Hockley and Dewar, 2006⁵⁰	Liverpool Care Pathways for Care Homes	To develop high quality end-of-life care in nursing homes.	Qual. & quant.	United Kingdom	8	Participatory action research	Adoption	Mod.	Thick	2	Mod.
Yalden et al., 2013⁵²	Implementation of a palliative approach into residential aged care/‘palliative care chest of drawers’ (PCCOD)	To describe the creation of a space within which a multidisciplinary team with varying values, beliefs and knowledge was able to engage collaboratively in transforming end of life care.	Qual.	Australia	1	Participatory action research	Adoption	Mod.	Rich	2	Low

Qual.: qualitative data; Quant.: quantitative data; RCT: randomised controlled trial; Mod.: moderate.

Implementation outcomes defined using Proctor et al.²⁶

How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions?

Facilitation occurred pre-, during, and post-implementation of the palliative care interventions. Seven CMO configurations were developed spanning each of these phases. A realist programme theory visualising the intersection of the configurations is presented in Figure 2.

Figure 2.

Realist programme theory. (C): context; (M): mechanism; (O): outcome.

Pre-implementation

With exception to Kinley et al., limited information regarding the facilitators’ experience and qualification was provided. Facilitators were often researchers (n = 8).^{10,37–39,42,44,46,52} Other roles included registered nurses, general practitioners, palliative specialists or other clinicians. In 18 of the studies facilitators were external to the care home,^{10,38,39,42,44–57} while the remaining five had both an external and internal facilitator.^{3,37,40,41,43} Facilitators were reported as most effective if they were external to the residential aged care home and facilitation was their sole role and responsibility.^{3,38,39,43,55} Facilitators were better positioned for their role if they had experience in palliative care, residential aged care and training staff.^{41–43,55,56} They also had comprehensive knowledge of the intervention.^{3,38,39,51,55} The most common supporting implementation strategy for facilitation was identifying and preparing champions (n = 9),^{10,42,45,47–51,56} followed by tailoring the intervention and implementation to the local context (n=4)^3,45,49,56 and providing an intervention manual (n = 4).^3,45,49,51

Support provided to facilitators varied across studies. Clinical supervision was provided in four studies.^3,40,41,44 Pre-implementation training for facilitators occurred in nine studies which was important in strengthening knowledge and understanding of the intervention.^{3,37–41,43,45,51} In the PACE programme, pre-implementation training helped facilitators to train and prepare local intervention champions and tailor the implementation.^3,40,41 Tailoring of the intervention to the care home workflow was linked to reduced staff burden and greater role clarity.^3,43,51 For Davis et al.,⁵⁴ one site withdrew due to insufficient facilitator support to mitigate systemic barriers making the implementation feel unmanageable. In contrast, Hockley and Kinley reported that facilitators that built a relationship with staff before implementation established trust in the facilitator’s competence and reliability – a critical foundation for later discussions about death and dying.³⁷

CMO 1: When facilitators have access to pre-implementation training on the palliative care intervention as well as access to ongoing supervision (context), the facilitator then feels supported and has greater clarity over their role (mechanism). If the facilitator has previous experience providing training to aged care staff, they are then able to train local champions in the intervention pre-implementation (context), developing a shared understanding of the implementation process (mechanism). The feasibility of implementing the intervention as intended is then enhanced for the facilitator and champion (outcome).

CMO 2: The intervention design is flexible in its timing and clear on which components can be adapted (context) so that the facilitator can tailor the palliative care intervention pre-implementation in collaboration with the care home leadership and champions to be compatible with their workflow and needs (context). By doing so, the facilitator develops a foundation for trust as a reliable source of support (mechanism). Residential aged care staff also feel that implementation is more manageable and less burdensome (mechanism) increasing the feasibility of implementation (outcome).

During implementation

During implementation, external facilitators undertook a range of activities, mostly involving developing and delivering tailored training to residential aged care staff. In some interventions external facilitators also conducted intervention/clinical activities such as undertaking resident assessments.^43,44,55 External facilitators also provided research data through activity logs, field notes or reflective diaries.^{10,38,39,41–44,49,53} Educative functions of the facilitator role included role-modelling the intervention (n = 7)^{37–39,43–45,48} and mentoring (n = 5).^{44,53–55,57} Implementation support involved scheduling/attending meetings (n = 9),^{38,39,43,44,48,50,51,53,56} site visits for in-field support (n = 8),^{37–39,43,45,46,48,53} champion support (n = 6),^{3,40,41,48–50} network building (n = 4),^44,52,53,57 and fidelity feedback to care homes (n = 3).^45,46,54 Fidelity checks and follow up discussions with champions improved protocol adherence for Hanson et al.⁴⁶ and Dobbs et al.⁴⁵and led to additional training to reach new staff.

CMO 3: During the palliative care intervention rollout, if the facilitator undertakes fidelity checks to assess the care home’s progress and discuss the results with champions (context), then an opportunity is created for staff to reflect and problem solve with the facilitator’s support should there be barriers to mitigate (mechanism). Implementation can then be adapted if necessary to increase fidelity (outcome).

The PARIHS framework was used in seven articles for defining facilitation, informing implementation plans or analysis.^{3,10,38,39,41,42,54} Using this framework, it was generally agreed that IF the residential aged care home context is perceived as ‘low’ in knowledge and practice of palliative care, THEN ‘high’ evidence and ‘high’ facilitation is required.^{3,37–39,43,48} ‘High’ facilitation was described as proactive rather than reactive support and regular in-person presence. Hockley et al. recommend site visits by the external facilitator every 7–10 days. Adoption of the intervention was more likely where facilitators role-modelled the desired behaviour and supported staff in practising palliative care skills.^48,55 In the OPTIMISTIC intervention, role-modelling and regular in-person presence led to facilitators being perceived as a trusted ‘extra set of hands’ and mentor that could help staff to manage heavy workloads.⁵⁵

CMO 4: If a residential aged care homes is ‘low’ in use of palliative care evidence and knowledge (context), facilitators should have experience working in palliative care and facilitation should be their primary role (context) allowing them to provide ‘high’ facilitation with regular site visits to mentor, role-model and assist with problem solving (context). To residential aged care staff, they then become a trusted ‘extra set of hands’ to help manage heavy workloads (mechanism) and make adoption of the palliative care intervention more feasible (outcome).

Action learning (learning by doing and reflecting) combined with ‘high’ facilitation improved intervention fidelity and adoption. Action learning was reported in six studies.^{10,38,39,42,50,52} Through repeated sessions with staff, facilitators fostered a shared understanding and an aligned course of action leading to improved confidence and sense of ownership of the intervention.^{10,38,39,42,50,52} In dementia palliative care interventions, facilitators guided staff, with ‘lots of coaxing’, through problem-based reflections on their behaviours and assumptions around palliative care that interfere with individual learning and effective work.^10,42 Participation in action learning increased comfort to discuss death and dying and sharing experiences to adapt the intervention to local needs.^38,39,42,50 Attendance at action learning sessions and satisfaction with facilitators increased staff motivation and knowledge sharing with colleagues unable to attend.^10,42,50 In Kinley et al., care home managers from multiple sites implementing the GSFCH came together to participate in action learning guided by external facilitators. Their attendance and participation was significant to staff learning as it created an appreciative learning system in which managers learnt from each other and their joint experiences.^38,39 Facilitators were essential to initiate and maintain these links.^38,39

CMO 5: The care home has a learning centred culture (context) and enables protected time for staff to participate in a series of action learning sessions delivered by an enthusiastic facilitator (context). The facilitator leads the staff through problem-based reflections on their current practices and assumptions about palliative care to develop their comfort to express their knowledge, experiences and ideas (mechanism) forming an appreciative learning system (mechanism). This establishes a shared understanding and informs an aligned course of action between the staff (mechanism) leading to a sense of ownership to carry forward the implementation (outcome). This results in increased staff motivation and confidence to actively participate and adopt practice change (outcome).

Developing trust between stakeholders in palliative care interventions requires time, where facilitators played a key role.^42,44 In their cross-cultural implementation of the PACE programme, Hockley et al. noted that hierarchical relationships between professional disciplines influenced communication and decision-making around palliative care. Families lacked trust in the skills and knowledge of nurses, perceiving them to have a lower status than physicians despite their more frequent contact with residents.³ During the COVID-19 pandemic, Brazil et al. reported that infection control procedures intensified distrust as families blamed staff for infecting residents. To mitigate this, facilitators ran information sessions for families about the intervention, which helped to restore trust.⁴³ Facilitators external positioning allowed them to be perceived as ‘safe’ and trusted sources of information and support.^44,55

CMO 6: Distrust and reluctance from resident’s families to discuss death, dying and palliative care with residential aged care staff (context) can hinder implementation of the intervention as staff then feel that palliative care conversations can be difficult under time limitations. To mitigate this, facilitators can initiate in-person information sessions for resident families to discuss the intervention and its purpose (context). Families are then more likely to trust that staff are acting in the best interest of the residents (mechanism). Adoption of the intervention is supported (outcome).

Post-implementation

Implementation outcomes were inconsistently discussed and measured making data synthesis difficult. The most commonly reported implementation outcomes were the adoption of the intervention into practice (n = 10),^{3,40,41,48–50,52,53,55,56} followed by fidelity (was the intervention implemented as intended) (n = 7).^{3,38–41,45,46} Four studies explored the cost of facilitation, with Kinley et al. concluding that the cost savings outweighed the investment of facilitation.^38,39,43,44 Cost assessments like time commitment and financial implications were often limited by reliance on self-reported activity logs, which were subjective and inconsistent.^38,39,43 Many articles discussed the time-limited nature of facilitation and sustaining practice change as an area of concern.^{10,37–39,41,42,44,48,49,51,57} To address this, several studies required facilitators to transition responsibilities to local champions post-implementation.^{3,40,41,44,51} For successful transitions, intervention materials needed to remain accessible to care home staff and endorsed by organisational leadership and policies.^3,40,41 Implementation of the GSFCH introduced an accreditation process to promote sustained practice change. However, it was cautioned that without adequate funding, long-term planning and facilitation, few care homes would be able to maintain accreditation.^37,48 Sustained practice change was also supported by facilitator efforts to foster teamwork among aged care staff, though this was challenged by high staff turnover.^47,49 Resource-sharing and peer-mentorship within or between care homes showed promise in reducing isolation and promoting ownership of new practices.⁴⁹

CMO 7: Whereby the facilitator recognises that the ultimate outcome of their time-limited role is to transition responsibility to the local champion (context), they should encourage forums for staff resource-sharing and peer-mentorship (context) to reduce taboo about discussing death and dying (mechanism), and to strengthen a sense of teamwork (mechanism). The likelihood of normalising and sustaining palliative care practices beyond completion of the intervention is then increased (outcome).

Discussion

Main findings

In this realist review, a programme theory was developed on how facilitation works for residential aged care staff in the implementation of palliative care interventions. Facilitation was found to work by developing a shared understanding of the intervention, tailoring its components to staff workflows and building trust between stakeholders, resulting in transition of ownership of the intervention and facilitation process. Regular facilitator support, including role-modelling, mitigating barriers and action learning, was most effective in developing learning systems and enhancing staff comfort and confidence in providing evidence-based palliative care.

What this study adds

In examining use of facilitation to support uptake of evidence-based palliative care, patterns consistent with Normalisation Process Theory (NPT) were evident. These include early emphasis on coherence building (or sense-making), leading to cognitive participation and collective action on the intervention, followed by reflexive monitoring to appraise intervention benefits and costs.^58,59 Links between NPT, facilitation and action learning have been found in studies conducted in other healthcare settings.^58,60,61 Mechanism mapping by Kilbourne et al. to understand how facilitation in healthcare works similarly found that facilitation works via a process of sense-making of an interventions’ value, increased trust between stakeholders and adoption of the intervention through mitigation of barriers, resulting in normalisation and ownership of the intervention and facilitation process.⁶⁰ Another realist review of change agents, (including facilitators, champions and opinion leaders) highlighted the importance of promoting reflection on practice – a key function of action learning.⁶¹ De Brun et al. (2016) argued that when used together, NPT and participatory learning and action can be more effective to support implementation than either might be on their own. This is because of their combined heuristic force to stimulate thinking and engagement of expertise from key stakeholders leading to a deeper understanding of the implementation context.⁵⁸ The current findings of this review support the practical application of facilitation to ensure implementation of palliative care interventions in residential aged care are informed by theory.

The role of facilitation in initiating and maintaining a learning system was discussed in Kinley et al.,³⁸ particularly where managers from multiple care homes were brought together to participate in action learning. By sharing experiences of implementing the palliative care intervention and establishing horizontal links, normative pressures were created as organisations sought to conform to a perceived ‘right way of doing things’.⁶² This is the result of social forces created whereby participants seek to maintain their peers’ regard and are incentivised to remain committed to implementation.⁶² Care homes face similar challenges in providing quality palliative care and likely agree to implementing the interventions to comply with ethical standards and practices.⁶³ This phenomenon is known as institutional isomorphism which explains how organisations come to look like one another by adopting similar practices.⁶³ Thus, facilitation is significant in establishing networks for residential aged care staff across the sector to reduce a ‘silo’ effect where staff feel isolated. As a learning mechanism, facilitation enables aged care staff to absorb and retain new knowledge through both internal and external collaboration and supporting the transfer of that knowledge back to the care home, consistent with organisational learning theory.¹⁹

Some of the enabling contextual factors identified in this review are not unique to aged care, but rather ‘universal’ factors that influence most implementation strategies.⁶⁴ These include leadership support, time and resource availability, staff readiness for change and workforce factors, including continuity.⁶⁴ What differs for residential aged care is the extent to which certain contextual factors impact the facilitation of palliative care interventions. Staff’s varying education needs and openness to discussing death and dying must be considered prior to implementation to ensure the intervention is acceptable and can reach target groups. Engaging families and residents as part of the intervention design and the facilitator’s responsibilities is also pertinent. Previous research has shown that for residential aged care staff discussing palliative care with families is challenging, and families have expressed feeling ‘out of the loop’.^65,66 However, palliative care interventions that engaged families and supported staff to develop more effective communication pathways have shown promising results.⁶⁵ When facilitators undertake activities to build trust between families and staff implementation outcomes improve, indicating the importance of facilitation for enhancing staff/family engagement.

In the studies included in this review, implementation was more effective when facilitators maintained a regular in-person presence at the care home. The optimal formats, duration/frequency/intensity and types of facilitation used to support implementation of interventions into residential aged care remain unclear. Hartmann et al. proposed principles for virtual external facilitation in healthcare settings. These include piloting its use, incorporating a model to guide learning and ensuring opportunities to apply new information in practice.⁶⁷ The applicability of these for palliative care interventions should be investigated to ensure implementation is suitably flexible to the changing needs of residential aged care.

Pimentel et al. recommend that for quality improvement and research implemented into residential aged care ‘blended facilitation’, or a team-based approach involving both external and internal facilitators, is preferable.⁶⁸ Most care homes in the reviewed studies were supported by just one external facilitator who liaised with a team of champions. However, some referred to champions (‘individuals who dedicate themselves to supporting, marketing, and driving through an implementation’¹²) interchangeably as internal facilitator.^3,40,41 Lack of consistency in implementation terminology creates uncertainty regarding roles and responsibilities and how outcomes were achieved in those interventions. This highlights the importance of drawing on implementation theories, models and frameworks that seek to address these inconsistencies.

All included interventions were part of research or academic collaborations. In this context, facilitation and the intervention are likely provided as ‘free’ resources to residential aged care homes, which may not be the case where implementation occurs outside a research project setting. Additionally, the research study setting may introduce a Hawthorne effect, where staff behaviour is influenced by the awareness of being part of a study. This raises important implications for the transferability of the programme theory beyond the specific context of the studies. The realist programme theory should therefore continue to be tested and refined in future studies to increase its applicability to policy and practice. Across all the studies discussed, the facilitator (as a process) was closely aligned with the facilitator (as a role). Future research should explore the cost of ‘high’ facilitation in residential aged care, as well as the sustainability of practice change after external facilitators are withdrawn. Further attention should also be given to unpacking how facilitation impacts different staff roles, particularly considering the hierarchical nature of the residential aged care workforce.

Strengths and limitations

The realist approach offers a clearer explanation of how implementation strategies like facilitation work in particular contexts so that interventions proven to be effective can be replicated. The inclusion of studies published in English only may have created bias with included interventions taking place predominantly in English speaking contexts. Cultural and spiritual attitudes to death and dying and how that may have impacted the facilitators’ role were rarely discussed, with exception to the PACE steps to success and MySupport study. Inconsistent reporting and indexing of implementation literature meant the search strategy had to be broad, using multiple terms for facilitation. The final sample of articles were selected for their theory-testing potential and may not be exhaustive. Facilitation was not always well described or measured. Judgements regarding the effectiveness of the strategy during the analysis and synthesis phase relied on the authors’ reporting of implementation and intervention outcomes. It was often necessary to refer to multiple papers on the same intervention to get fuller picture of the implementation process. Thus, it was at times difficult to draw causal inferences to link the facilitation process to outcomes and specific contextual factors. This introduces potential bias in the conclusions reported here as they rely on the original authors’ interpretations however, all judgements have been transparently reported.

Conclusions

This review examined the role of facilitation in implementing palliative care interventions to support the uptake of evidence-based care among residential aged care staff. While considerable research has identified the barriers and enablers to implementation in this setting, the underlying mechanisms through which implementation strategies – such as facilitation – operate remain underexplored and warrant further empirical investigation. Drawing on a rigorous and theory-driven realist approach, it was found that regular support from the facilitator, combined with action learning, was the most effective method in cultivating learning systems and enhancing staff comfort and confidence in discussing death and dying. These elements were critical to improving intervention uptake and promoting the normalisation of palliative care practices within everyday routines. The realist programme theory developed through this review offers a valuable contribution to the evidence-base and should be further tested and refined to ensure its relevance and applicability to policy and practice. This review adds to the scant literature and informs the field about how to hasten the rate at which evidence-based palliative care is adopted by residential aged care staff thus improving care outcomes for residents.

Supplemental Material

sj-docx-1-pmj-10.1177_02692163251400110 – Supplemental material for How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review

Supplemental material, sj-docx-1-pmj-10.1177_02692163251400110 for How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review by Kayla Lock, Lysha Zhi Yan Lee, Anita Goh, Katrin Gerber, Wen Kwang Lim, Joanne Tropea and Brad Astbury in Palliative Medicine

Supplemental Material

sj-docx-2-pmj-10.1177_02692163251400110 – Supplemental material for How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review

Supplemental material, sj-docx-2-pmj-10.1177_02692163251400110 for How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review by Kayla Lock, Lysha Zhi Yan Lee, Anita Goh, Katrin Gerber, Wen Kwang Lim, Joanne Tropea and Brad Astbury in Palliative Medicine

Supplemental Material

sj-docx-3-pmj-10.1177_02692163251400110 – Supplemental material for How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review

Supplemental material, sj-docx-3-pmj-10.1177_02692163251400110 for How and in what circumstances does facilitation work for residential aged care staff in the implementation of palliative care interventions? A realist review by Kayla Lock, Lysha Zhi Yan Lee, Anita Goh, Katrin Gerber, Wen Kwang Lim, Joanne Tropea and Brad Astbury in Palliative Medicine

Footnotes

Acknowledgements

The authors acknowledge the IMPART Working Group and Steering Committee as well as the Melbourne Ageing Research Collaboration for their support.

ORCID iDs

Kayla Lock

Lysha Zhi Yan Lee

Anita Goh

Katrin Gerber

Joanne Tropea

Brad Astbury

Ethical Considerations

There are no human participants in this article.

Consent to participate

Informed consent is not required.

Author contributions

K.L., A.G., K.G., W.K.L., J.T. and B.A. were responsible for the planning, design, conduct and reporting of the work. K.L., J.T. and L.L. performed the study selection, data extraction and study appraisal process. K.L. and J.T. were involved in the data analysis and synthesis process. All authors contributed and agreed to the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The realist review is funded as part of a PhD stipend by a National Health and Medical Research Council (NHMRC) Project Grant (APP2006121) under the Targeted Call for Research into End-of-life Care for the IMPART (IMproving PAlliative care in Residential aged care using Telehealth) project, in addition to the 2024 Nicole King Scholarship.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

All relevant data are within the manuscript. Any other data are available upon request from the corresponding author.

Supplemental material

Supplemental material for this article is available online.

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