From leadership research to district action: Managers’ experiences of implementing palliative care in nursing homes: a qualitative follow-up study after an educational intervention for the staff

AI-assisted editorial implementation guide. Proposed district actions are separate from the original authors’ findings and recommendations. Independent peer review of this guide is not asserted.

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Background It is crucial to implement knowledge-based, high-quality palliative care for the increasing number of frail older people with multimorbidities in nursing homes. The manager’s role in a successful implementation is often taken for granted despite scarce evidence. Therefore, the aim of this long-term follow-up study was to explore how managers experienced the implementation of palliative care in nursing homes after a multicentre educational intervention for staff. This Implementation of Knowledge-Based Palliative Care in Nursing Homes (KUPA) program consisted of workplace seminars, reflective activities, and practice-based tasks between seminars. The implementation was research-led before the participating managers took over its governance. Methods This qualitative follow-up study considered semi-structured interviews with 22 managers responsible for implementing palliative care in 20 nursing homes in Sweden. The analysis was conducted using a reflexive thematic approach. Results Our findings are presented under three main themes: Navigating Organisational Barriers, Empowering the Action Plan, and Ripple Benefits of Education. The managers navigate organisational barriers by establishing stability, maintaining continuity and supporting staff members’ knowledge development despite structural barriers and limited resources. Empowering the action plan meant supporting staff to maintain motivation and a positive attitude towards workplace change. Managers emphasised their responsibility for the continuation of implementation of palliative care. The ripple benefits of education, from the managers’ perspective, include increased knowledge and use of holistic palliative care, a shared language, and a consensus on the meaning of palliative care, thereby expanding cooperation and mutual understanding across the team’s professions. Conclusions This long-term follow-up study revealed several challenges to the implementation of palliative care and underscored the demanding work of managers. Staff shortage, limited budget and support led to work-related instability. Closer interprofessional collaboration and a broader approach to palliative care as a process from early signs to the end of life need to continue and deepen to be knowledge-based nursing care. From a leadership perspective, a successful implementation requires a long-term commitment, financial resources, a supportive organisation, and manager competence. Trial registration NCT02708498. Date of registration: 26 February 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-026-02276-w.

Study methods

We conducted this follow-up study 1.5 years after the initiation of the KUPA educational intervention for staff. The study employed an explorative qualitative design based on semi-structured interviews with the responsible first-line managers taking part in palliative care education. We used the reflexive thematic analysis approach of Braun and Clarke [17, 18], which incorporates the analysts’ reflections of their backgrounds and preconceptions into theme construction. This study was conducted and reports results in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [19].

Limitations

Five of the 20 front-line managers (25%) had changed positions to another nursing home by the time the data were collected, creating greater uncertainty regarding the events and decisions that occurred during implementation. This leadership instability is concerned to have adversely affected the richness of these five interviews. Furthermore, during the interviews, some managers expressed uncertainty regarding plans for the continuation of palliative care implementation. One possible explanation is that managers with an educational background in social work need more support before taking full responsibility for continuing the implementation of a palliative care approach, an issue addressed previously [16]. The educational background of facilitating managers needs to be considered in future implementations. Finally, a limitation of the KUPA project is that staff attendance at each seminar was recorded in only half of the nursing homes, which limits the ability to assess whether attendance rates affected progress towards the goal of implementing palliative care.

A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Choose one school improvement question with teachers. Protect a short shared planning cycle, agree an instructional change and use a common rubric for examining student work. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Review implementation fidelity, teacher time and independently scored student work against a recorded baseline. Examine access differences and competing explanations before attributing changes to leadership. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Helene Åvik Persson; Anna Sandgren; Gerd Ahlström. Managers’ experiences of implementing palliative care in nursing homes: a qualitative follow-up study after an educational intervention for the staff. BMC Palliative Care (2026-08-11). https://doi.org/10.1186/s12904-026-02276-w

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.