A drive for structure: A longitudinal qualitative study of the implementation of the Carer Support Needs Assessment Tool (CSNAT) intervention during hospital discharge at end of life

Abstract

Background: Informal carers are essential in enabling discharge home from hospital at end of life and supporting palliative patients at home, but are often ill-prepared for the role. Carers’ support needs are rarely considered at discharge. If carers are less able to cope with home care, patient care may suffer and readmission may become more likely. Aim: To investigate the implementation of an evidence-based Carer Support Needs Assessment Tool (CSNAT) intervention to support carers during hospital discharge at end of life. Design: Longitudinal qualitative study with thematic analysis. Setting/participants: One National Health Service Trust in England: 12 hospital practitioners, one hospital administrator and four community practitioners. We provided training in CSNAT intervention use and implementation. Practitioners delivered the intervention for 6 months. Data collection was conducted in three phases: (1) pre-implementation interviews exploring understandings, anticipated benefits and challenges of the intervention; (2) observations of team meetings and review of intervention procedures and (3) follow-up interviews exploring experiences of working with the intervention. Results: Despite efforts from practitioners, implementation was challenging. Three main themes captured facilitators and barriers to implementation: (1) structure and focus within carer support; (2) the ‘right’ people to implement the intervention and (3) practical implementation challenges. Conclusions: Structure and focus may facilitate implementation, but the dominance of outcomes measurement and performance metrics in health systems may powerfully frame perceptions of the intervention and implementation decisions. There is uncertainty over who is best-placed or responsible for supporting carers around hospital discharge, and challenges in connecting with carers prior to discharge.

The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review

“…Although the NASSS was initially created to implement health and care technologies, it exhibits similarities with widely used implementation determinant frameworks designed for a broader range of health innovations, encompassing health technology and evidence-based practices. As such, we found four studies included in this review that used the NASSS for non-digital innovations [45,58,63,76], demonstrating the framework’s adaptability and utility.…”

“…<Insert Table 4> 15 26.3 [12,29,31,35,38,42,43,46,56,57,59,66-68,76] Concurrent with Implementation 8 14.0 [30,44,[47][48][49]60,62,70] Multiple Time Points 1 1.8 [50] Number of NASSS domains reported 1 domain 1 1.75 [59] 2 domains 1 1.75 [77] 3 domains 3 5.26 [43,69,70] 4 domains 11 19.30 [27,30,31,35,39,42,46,60,65,74,75] 5 domains 9 15.79 [32,34,41,45,48,51,58,61,64] 6 domains 13 22.81 [29,44,47,49,52,53,55,57,66-68,71,78] 7 domains 19 33.33 [12,13,25,26,28,33,36-38,40,50,54,56,62,63,72,73,76,79] *Not mutually exclusive In terms of timing, most studies conducted their analyses using the NASSS framework retrospective to implementation, for example to analyze why implementation did or did not succeed in terms of adoption, non-abandonment, scale, spread, and sustainability of the innovation in a given context (n=33). The rest applied the framework prospectively to inform future implementations (n=15), or concurrently with implementation (n=8).…”

A person-centred intervention remotely targeting family caregivers’ support needs in the context of allogeneic hematopoietic stem cell transplantation—a feasibility study

“…The Swedish CSNAT tool version 3 and its support plan were used [ 12 , 15 , 16 ]. The tool asks the FC “Do you need more support with…” and includes 15 domains.…”

“…The intervention is specifically developed to directly assess and address practical, emotional, existential, and social support needs [ 11 ]. Conversation-based assessments enable each FC to identify her/his specific support needs and prioritize the most important ones [ 12 ]. The CSNAT-I has two parts: an evidence-based tool and a five-stage person-centred process.…”

“…In a conversation with one healthcare professional, FC discuss and prioritize their support needs. The conversation results in a shared support plan to address the prioritized support needs, of which some can be directly dealt with during the meeting [ 11 , 12 ]. The CSNAT-I has been shown to facilitate the assessment of support needs and ensure adequate support [ 14 , 15 ].…”