Implementation of tools for identifying palliative care needs and supporting advance care planning: A scoping review of barriers and facilitators in hospital settings

Abstract

Background:

Implementing tools to identify and support palliative care needs remains challenging in hospitals, requiring a clear understanding of implementation determinants. This study defines tools as clinical resources for palliative care identification, needs assessment, and advance care planning support.

Aim:

This scoping review aimed to identify and categorise the barriers and facilitators influencing the implementation of tools in hospital settings.

Design:

Following the Arksey and O’Malley framework with PRISMA-ScR reporting, we employed a hybrid analysis combining inductive thematic coding with deductive mapping onto the Consolidated Framework for Implementation Research. Studies in English, Danish, Norwegian, or Swedish were considered eligible for inclusion.

Data sources:

In May 2024, the databases MEDLINE, Embase, Scopus, CINAHL, SocINDEX, and PsycINFO were searched for studies focusing on tool implementation by healthcare professionals in hospital settings.

Results:

From 4032 records screened, 25 studies were included. Determinants were identified across all five Consolidated Framework for Implementation Research domains, though primarily concentrated within the Inner Setting and Individuals. Key barriers included time constraints, lack of training, and fragmented communication. Facilitators comprised strong leadership support, clinical champions, multidisciplinary collaboration, and a supportive organisational culture.

Conclusion:

This scoping review identifies determinants that can inform the selection of implementation strategies for tools in hospitals. Our findings suggest that tool implementation likely requires multi-faceted strategies capable of addressing barriers across multiple levels, from individual training to organisational leadership and culture. Future research should focus on evaluating tailored strategies that account for the unique complexities of different hospital contexts to ensure sustainable adoption.

Keywords

palliative care needs assessment advance care planning implementation science hospitals

What is already known about this topic

Tools can improve the quality of palliative care in hospital settings.

The implementation of tools is often complex and challenging.

Identifying barriers and facilitators is important for sustainable implementation.

What this study adds

Provides an overview of barriers and facilitators for implementation of tools in hospital settings.

Highlights that implementation depends on leadership commitment, multidisciplinary collaboration, and a supportive organisational culture.

Identifies a theory-practice gap, as the majority of studies implemented tools without applying a formal implementation framework.

How this study might affect research, practice or policy

The findings can inform the design of targeted, multi-faceted implementation strategies.

It underscores the necessity of moving beyond individual training to address organisational and structural determinants.

It provides a foundation for future research to enhance tool adoption and sustainability.

Background

Growing interest in general palliative care reflects a broadening understanding of its importance within the healthcare system.¹ A key component is the early identification and assessment of palliative care needs to facilitate advance care planning and ensure a thorough understanding of patient preferences.² While validated tools are often employed to ensure systematic processes, this study defines tools as resources for identifying and assessing palliative care needs, and approaches supporting advance care planning. This encompasses validated identification tools (e.g., Supportive and Palliative Care Indicators Tool),³ assessment scales (e.g., Palliative care Outcome Scale)⁴ and communication frameworks (e.g., advance care planning).^5,6 By categorising these as tools, we emphasise their role as the specific objects of implementation within hospital settings.

Early identification of palliative care needs is essential to ensure timely care,⁷ yet delays in this process often hinder referrals to specialised palliative care, leading to potentially harmful consequences for both patients and their caregivers.⁸ Systematic use of tools can facilitate proactive treatment planning regardless of diagnosis.^9–13 Despite their potential to improve quality of life and reduce non-beneficial hospitalisations,^7,9,14 a persistent implementation gap remains,^15,16 particularly for non-malignant conditions.¹⁷ Addressing this gap requires a move beyond clinical efficacy toward understanding the implementation process itself.^18–20 A preliminary search of Cochrane, Open Science Framework, and PROSPERO confirms a lack of synthesised evidence regarding the implementation of tools in hospital settings. While previous research has explored the complexity of palliative care implementation strategies,^21,22 or focused specifically on patient-reported outcome measures,²³ there is a lack of synthesised evidence covering the broader spectrum of tools in hospital settings.

By utilising implementation science^24,25 this scoping review aimed to investigate the implementation determinants, specifically the barriers and facilitators that affect the use of tools in practice. The research question was: What are the barriers and facilitators that influence the implementation of tools for identifying and assessing palliative care needs, and approaches supporting advance care planning, in hospital settings?

Methods

Study Design

This scoping review was conducted following the framework originally described by Arksey and O’Malley,²⁶ refined by Levac et al.²⁷ and the latest standards from the Joanna Briggs Institute.²⁸ The reporting of this study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist,²⁹ ensuring transparent documentation of all steps. To ensure the transparency and reproducibility, a study protocol was registered on the Open Science Framework: https://osf.io/rud7s/.³⁰

Eligibility criteria

This scoping review includes studies focusing on barriers and facilitators to the implementation of tools used by healthcare professionals in hospital settings. The context encompasses medical and surgical specialties providing care to adult patients with life-limiting conditions. By including a diverse range of literature and methodological approaches, we sought to increase the depth and breadth of the findings.²⁷ Studies published in English, Danish, Norwegian, or Swedish were considered. No publication date restrictions were applied to the exclusion criteria (Table 1).

Table 1.

Eligibility criteria.

Variables	Inclusion criteria	Exclusion criteria
Participants	Healthcare professionals (e.g., doctors, nurses, allied health) involved in implementing or evaluating tools.	Patients, relatives, or studies exclusively reporting patient outcomes/experiences.
Phenomena of interest	Barriers and facilitators related to the implementation of tools.	Studies solely reporting clinical effectiveness or trials without implementation data.
Context	Hospital settings including studies conducted in, i.e., bed wards, inpatient, outpatient clinics, or emergency rooms. All medical and surgical specialties were considered involving adult patients with chronic and life-limiting conditions.	Primary care, GP practices, or community-based settings
Study types	Qualitative, quantitative, and mixed-methods. Grey literature (reports, theses, guidelines).	Protocols, conference abstracts, books, and editorials.
Language and period	English, Danish, Norwegian, or Swedish. No date restrictions.	Languages other than those specified.

Search strategy

A search strategy was developed using the Population, Concept, and Context framework³¹ to ensure alignment with the review’s objectives of identifying implementation determinants (Table 1). In May 2024, we systematically searched the electronic databases: MEDLINE, Embase, Scopus, CINAHL, SocINDEX, and PsycINFO. These databases were selected to provide coverage of both medical and social science perspectives. To ensure sensitivity, the search did not explicitly restrict results to the hospital setting, as preliminary searches showed that hospital-specific data are often embedded within multi-setting studies. Thus, any study featuring the hospital setting was eligible. The search terms were organised around three core conceptual blocks: (1) Palliative Care: which incorporated subject headings and keywords for concepts like ‘Hospice and Palliative Care Nursing’, ‘end-of-life or Terminal Care’, and the general scope of ‘Palliative Care’; (2) The tools: incorporating broad terms like ‘Needs Assessment’ to ensure sensitivity. Additionally, we included specific terms such as the ‘surprise question’, ‘supportive and palliative care indicators tool’, and ‘EORTC QLQ-C15-PAL’; and ‘Advance Care Planning’. These were selected as they represent the clinical gold standard for palliative care delivery as recommended by the Danish Health Authority (3) Implementation: including ‘implementation science’, ‘barriers’, and ‘facilitators’. To enhance the search, we conducted a forward and backward citation tracking in Scopus. A university librarian provided guidance throughout the search process, ensuring the development of a robust search strategy (Supplemental Material 1). While different terms were utilised as functional keywords to maximise the retrieval, the subsequent analysis was conducted under the conceptual definition of tools (Box 1).

Box 1.

Conceptual definition of tools.

Tool category	Conceptual definition
Identification	Tools designed for early recognition or screening of patients who may benefit from palliative care interventions.
Symptom/needs assessment	Instruments used to systematically measure and monitor the severity of physical, psychological, social, or spiritual concerns.
Functional/performance scales	Objective scales used to assess a patient’s functional status, physical capacity, or disease progression to inform prognostic clinical transitions.
Communication frameworks	Structured protocols or guides designed to facilitate dialogue, advance care planning, or clarify patient preferences and goals of care.

Conceptual definition of tools

To ensure conceptual clarity, the identified tools were categorised into four types: identification, symptom/needs assessment, functional/performance scales, and communication frameworks (Box 1). This taxonomy was developed iteratively during the data synthesis process to explicitly define the diverse tools analysed and to allow for transparent assessment of implementation determinants across the different tools identified in the search.

Grey literature

To complement the database searches and identify potentially valuable regional insights, a dedicated grey literature search in Danish was performed using Google to identify regional reports, clinical guidelines, and non-indexed resources specific to the Danish healthcare landscape. While the search was international in scope, the grey literature search was strategically prioritised for the local context to ensure relevance for the broader research project, which includes an ongoing clinical feasibility study in Denmark. This search, however, did not identify any additional sources that met the inclusion criteria.

Source of evidence selection

The Covidence platform was utilised throughout the review process, adhering to the PRISMA-ScR checklist for source selection, duplicate removal, and full-text retrieval.²⁹ Prior to the main review, a pilot test was conducted to establish inter-rater reliability and optimise workflow. The full review commenced once agreement was achieved on at least 75% of the pilot-tested articles. This threshold was determined pragmatically, balancing the need for sufficient reliability with the practical constraints of the review process. It was calculated by dividing the number of articles with agreed inclusion/exclusion decisions by the total number of articles screened. To maintain consistency and accuracy, all authors screened titles and abstracts in pairs, always including the first author as one of the reviewers. Disagreements were resolved through discussion and consensus between the reviewers. Subsequently, the first author independently reviewed all full-text articles twice, performing blinded exclusion within the Covidence platform.

Data extraction

For the descriptive summary, data extraction was performed using Microsoft Excel. Charting Table 2 contains information such as authors, publication year, country, aims/purpose, type of tool, methodology/methods, and theories/models/framework applied.

Table 2.

Study characteristics.

Author/year/country	Diagnosis/speciality	Aims	Study setting	Study type	Study methods	Tools	Theories, models, frameworks
Andersson & Sandgren, 2022. Sweden	Multi-unit	To identify barriers and enablers during the implementation of the Serious Illness Care Program	20 units in two hospitals	Research Article	Qualitative; individual and group interviews	Surprise Question, Serious Illness Care Program	Organisational Readiness for Change
Bausewein et al., 2018. Germany.	Palliative care unit	To describe the process of implementing routine outcome measurement into daily clinical work	Hospital palliative care unit	Brief Report	Descriptive	Integrated Palliative Care Outcome Scale, Phase of illness, Australian Karnofsky Performance Status	Implementation patient-reported outcome measures according to Antunes
Brown-Johnson et al., 2021. USA	Multi-unit	To describe the range of early implementation experiences	Four sites: inpatient, outpatient, homecare and primary care	Research Article	Qualitative; interview	Advance Care Planning	CFIR
Cathcart et al., 2020. UK	Cystic fibrosis	To improve end of life care for adults with cystic fibrosis	Large cystic fibrosis centre	Quality Improvement Report	Audit data and survey	Advance Care Planning
Chiu et al., 2021. Canada	Nephrology	To make Advance Care Planning discussions more frequent and achieve better documentation	Provincial Health Services Authority	Perspective	Descriptive	Modified Edmonton Symptom Assessment System Revised: Renal
Davison et al., 2021. Canada	Nephrology	To describe how Patient-Reported Outcome Measures have been implemented	In-centre haemodialysis	Report	Descriptive	Edmonton Symptom Assessment System Revised, Integrated Palliative Care Outcome Scale-Renal, EQ-5D-5L
Ernecoff et al., 2021. USA	Nephrology	To evaluate implementation outcomes of automated Surprise Question as electronic health record decision support	Hospital/emergency room	Research Article	Quantitative; survey	Surprise Question
Evans et al., 2019. Canada	Oncology	To evaluate the implementation of the INTEGRATE project that promoted early identification and support of cancer patients	Four cancer centres	Research Article	Mixed methods	Gold Standards Framework, Surprise Question, Edmonton Symptom Assessment System, Palliative Performance Scale, Advance Care Planning, Goals Of Care	CFIR
Garcia et al., 2023. USA	General medicine	To increase nurses’ capacity to engage in Advance Care Planning	Medicine transitional care unit	Implementation Project	Audit and feedback	Advance Care Planning	Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice
Goff et al., 2019. USA	Nephrology	To identify barriers and facilitators for implementation of "Shared Decision Making and Renal Supportive Care"	Outpatient dialysis units	Research Article	Qualitative; observations and audio-recordings of intervention sessionsQuantitative; surveys	Advance Care Planning	CFIR
Hart et al., 2022. Canada	Geriatrics	To describe the development and implementation of an Advance Care Planning policy	A post-acute care and long-term care setting	Research Article	Qualitative; focus groupsQuantitative; surveys and EHR data	Advance Care Planning	Replicating Effective Programs
Hjort et al., 2020. Norway	Thoracic medicine	To assess how patients, relatives, and clinicians experienced the acceptability and feasibility of performing Advance Care Planning	Inpatient wards of the Department of Thoracic Medicine	Research Article	Qualitative; patient interviews and clinician focus groups	Edmonton Symptom Assessment System Revised and Advance Care Planning
Karim, Levine & Simon, 2022. Canada	Oncology	To describe the Serious Illness Care Program implementation, and highlight ongoing barriers	Outpatient setting	Commentary	Descriptive	Surprise Question and Serious Illness Care Program
Lakin et al., 2020. USA	Multi-unit	To describe different strategies and methods of identifying seriously ill patients for a targeted palliative care intervention	Five health care sites across the USA and UK	Research Article	Implementation case series	Surprise Question, Serious Illness Care Program
Lind et al., 2019. Sweden	Multi-unit	To explore contributing or hindering factors on assessing palliative care needs with the Integrated Palliative Care and to explore healthcare professionals’ experiences of the use of Integrated Palliative Care	Acute care setting	Research Article	Qualitative; individual or group interviews.Quantitative; EHR data	Integrated Palliative Care Outcome Scale
Van Lummel et al., 2023. The Netherlands	Multi-unit	To evaluate the MUTUAL intervention and identify healthcare professionals’ experienced barriers and facilitators of the implementation	Hospital setting	Research Article	Mixed methods	Surprise Question, Advance Care Planning	Measurement Instrument for Determinants of Innovation
Marshall et al., 2024. Australia.	Geriatrics	To determine the feasibility and acceptability of a facilitated Advance Care Planning intervention	Outpatient setting	Research Article	Qualitative; focus groups	Supportive and Palliative Indicators Tool, Advance Care Planning	Proctor et al.’s taxonomy
Misselbrook et al., 2020. UK	Orthopaedics	To present the experience of implementing Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)	District general hospital	Case Report	Audit data	Rockwood Clinical Frailty Scale, Supportive and Palliative Indicators Tool
Moss et al., 2023. USA	Nephrology	To describe pragmatic lessons learned by implementation of kidney supportive care	Ten dialysis centres	Report	Descriptive	Surprise Question
Patel et al., 2020. USA	Hepatology	To implement a hepatologist-led Advance Care Planning intervention	Hepatology hospital clinic	Brief Quality Improvement Report	Audit data	Goals of Care, Advance Directive
Pusa, Baxter & Sandgren, 2023. Sweden	Multi-unit	To explore physicians’ perceptions and experiences of implementing the Serious Illness Care Program.	Hospital setting	Research Article	Qualitative; focus groups	Surprise Question and Serious Illness Care Program
Samara et al., 2013. Australia	Oncology	To assess the uptake of Advance Care Planning by healthcare professionals and explore nurses’ perceived barriers for implementing Advance Care Planning	Hospital setting	Quality Improvement	Pre- and post- implementation audit	Advance Care Planning	Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs
Scott et al., 2016. Australia	General medicine	To develop, implement, and explore the effects of a Advance Care Planning program	Hospital setting	Research Article	Pre- and post-exploratory mixed methods	Surprise Question, Supportive and Palliative Indicators Tool, Advance Care Planning
Song, Amatys & Khan, 2018. Australia	Multi-unit	To identify implementation and process issues influencing the implementation of an Advance Care Planning programme	Inpatient rehabilitation unit	Report	Pre- and post-Implementation measures. Focus groups and audit data	Advance Care Planning	RE-AIM framework
Thomas, Armstrong-Wilson & Clifford, 2022. UK.	Multi-unit	To give an overview of the Gold Standards Framework programme	Hospital setting	Case Study	Descriptive	Proactive Identification Guidance, Gold Standards Framework

Data analysis

Data analysis utilised a two-phase, inductive-deductive approach to identify and categorise implementation determinants. This approach ensured that findings were grounded in the empirical data while being systematically organised within the CFIR framework. Initially, an reflexive thematic analysis was performed, guided by the principles of Braun and Clarke,³² to identify recurring themes related to the practical application of tools. Subsequently, these themes were deductively mapped onto the Consolidated Framework for Implementation Research (CFIR).²⁴ As a meta-theoretical framework, the CFIR was selected to provide a systematic structure to distinguish between the attributes of the tools (e.g., complexity, design) and the contextual factors influencing their implementation.²⁴ Thus, the identified barriers and facilitators were mapped across the five CFIR domains: Innovation, Inner Setting, Outer Setting, Individuals, and Implementation Process (see Table 3). While the first author conducted the initial extraction and classification, researcher triangulation (performed by TR, HBZ, and CLE) was employed to validate the findings, ensure consistency of the mapping, and to resolve any discrepancies in classification.

Table 3.

Identification of barriers and facilitators within CFIR domains.

Domain	Barriers	Facilitators
Innovation domain	Healthcare professionals challenges due to complexity or cumbersomeness of tools^{33,35,37,40,42,46,49,51,54–56}	awareness on patient needs and symptom management^41,50 improved quality of care and shared decision-making^{33,35,39,41,44,52,54} improved patient-provider relationships and healthcare professional satisfaction^{33,35,41,44,52,54}
Outer setting domain	Difficult to access palliative care needs in acute care, with short patient stays, and in crisis situations^35,51,56 Legal and ethical matters^40,43,55 Shortcomings in healthcare professionals education^33,43	National guidelines and supportive policies facilitate implementation^{35,40,41,45,51} Collaborations and partnerships with e.g. social workers, hospice, and specialised palliative care^{33,37–42,47,48,52,54}
Inner setting domain	Time pressure^{33–36,38,41–44,46–57} Limited electronic health record capability to track patient data^{39,42,49,50,52–54,57} Frequent staff turnover and low staff self-efficacy^{35,36,38,46–48} Resistant organisational factors and competing priorities^{33,38,39,41–43,47–52,55} Lack of interdisciplinary team coordination and communication	Adequate financial resource allocation^38,41,48,52 A supportive organisational culture^{33–38,41,43,46,48,50–52,57} Dedicated staff time for palliative care innovation implementation^{38,39,41,43,46,50,52,54,55} Impact of electronic medical record templates and trigger mechanisms^{33,36,37,39,41–45,49,52} Modified clinical workflows^41,45,50,53 Broad-based staff training^{38–41,43,45,49,50,52,54,55}
Individuals domain	Healthcare professionals lack the confidence or skills necessary for implementation^{33,36,37,41,43,48,50–53,57} Healthcare professionals fear of causing patient distress, anxiety or loss of hope^{34,36,43,48,53,61} Insufficient support from senior physicians^37,38,46,54 Navigating the complexities of family involvement^35,39,45,51	Leadership support and engagement^{33–38,40,41,43–47,49,50,52,54,55} Healthcare professionals experience and readiness for change^{36–38,42–47,50} Motivation and behaviour change among healthcare professionals^{34,36–38,40,41,50,52}
Implementation process domain	Implementation across a large number of units simultaneously can pose logistical and resource challenges^34,43 Lack of healthcare professionals awareness and engagement over time^33,40,55	A multi-faceted approach^{36,38,42,43,52,54} Ongoing healthcare professionals support and training^{34–38,40,41,43–45,47–55} Champions for change in leading and supporting implementation efforts^{35,38,41,43,48–50,52,55} Evaluation and feedback using iterative processes^{36,37,39,40,43,45–47,49,52,57}

Results

Study selection and characteristics

The initial search yielded 5306 records. Following the removal of 1274 duplicate entries, 4032 records remained for title and abstract screening. From these, 128 full-text articles were assessed for eligibility, and 25 studies were ultimately included in this scoping review (Figure 1). While the systematic search did not impose a chronological filter, no articles published before 2013 were included in the final analysis.

Studies originated from a wide geographical range, including the Netherlands,³³ Sweden,^34–36 Germany,³⁷ the USA,^38–44 the UK,^45–47 Canada,^48–52 Norway,⁵³ and Australia^54–57 (Table 2). The scoping review included studies employing qualitative, quantitative, and mixed methods approaches encompassing a diverse range of clinical areas: 8 multi-unit settings,^{33–36,38,42,47,57} 5 nephrology,^{39,41,43,48,49} 3 oncology,^50,52,55 2 general medicine,^40,56 2 geriatrics,^53,56 1 palliative care unit,³⁷ 1 cystic fibrosis,⁴⁵ 1 thoracic medicine,⁵³ 1 orthopaedics,⁴⁶ and 1 hepatology.⁴⁴ Publication year: 1 from 2013,⁵⁵ 1 from 2016,⁵⁶ 2 from 2018,^37,57 3 from 2019,^35,41,50 5 from 2020,^{42,44–46,53} 4 from 2021,^38,39,51,52 4 from 2022,^34,47,51,52 4 from 2023^33,36,40,43 and 1 from 2024.⁵⁴

A variety of tools were employed. However, the implementation of communication frameworks, specifically advance care planning,^{33,38,40,41,45,50,51,53–57} was the most prevalent, frequently used in conjunction with other tools, including the Surprise Question,^{33,36,39,42,43,50,52,56} Supportive and Palliative Indicators Tool,^46,54,56 Serious Illness Care Program,^34,36,42,52 Integrated Palliative Care Outcome Scale,^35,37,49 Phase of Illness and The Australian Karnofsky Performance Status,³⁷ Edmonton Symptom Assessment System,^48–50,53 EuroQol 5-Dimension 5-Level questionnaire,⁴⁹ Goals Of Care,^44,50 Rockwood Clinical Frailty Scale,⁴⁶ Proactive Identification Guidance,⁴⁷ Palliative Performance Scale,⁵⁰ and Gold Standards Framework.^47,50 Eleven studies^{33,34,37,38,40,41,50,51,54,55,57} were explicitly guided by implementation theory, models, and frameworks, such as RE-AIM framework, CFIR, and Quality Improvement.

Identification of barriers and facilitators within CFIR domains

A substantial concentration of determinants emerged within the Inner Setting domain, indicating that organisational factors influenced tool implementation. Numerous factors also related to Individual Characteristics. In contrast, relatively fewer determinants were mapped to the Innovation, Outer Setting, and Implementation Process domains.

The Innovation Domain

This domain concerns the specific attributes of the tools being implemented.²⁴

Barriers: Tools were frequently perceived as complex, time-consuming and demanding of extensive documentation.^{33,35,37,40,42,46,49,51,54–56} The Supportive and Palliative Indicators Tool, while valuable, was found to be difficult and cumbersome to apply in acute care settings.^46,56 In contrast, the Surprise Question was perceived as simpler.^39,56 However, the Surprise Question alone was deemed inadequate for practices caring for large numbers of patients with a poor prognosis.⁴² Healthcare professionals faced several challenges when using the Integrated Palliative Care Outcome Scale. This included insecurity due to difficulty understanding and using the tool, particularly when combining free-text responses and Likert scale answers.³⁵ Despite these challenges, the use of the Integrated Palliative Care Outcome Scale facilitated the initiation of treatment for pain and other symptoms and enhanced healthcare professionals awareness of integrated palliative care.

Facilitators: Implementation was facilitated when tools were perceived as clinically beneficial.^41,50 leading to improved symptom management and patient-provider communication.^41,50 Tools also empowered shared decision-making^{33,35,39,41,44,52,54} and increased professional satisfaction.^{33,35,41,44,52,54} Implementation of tools was facilitated by their accessibility and their ability to enhance patient-centred care through patient-family involvement and the clarification of patients’ wishes.^{35,37,39,49,51}

The Outer Setting Domain

This domain encompasses the broader healthcare system and external hospital environment.²⁴

Barriers: Navigating legal and ethical complexities, such as data privacy, informed consent, and advance directives,^40,43,55 may hinder healthcare professionals engagement and documentation.^{33,37,38,40,43,51,54,55}

Contextual variations significantly impacted the implementation of tools, with distinct challenges arising across diverse hospital settings and patient populations.^{34,37,41,50,51,54,56,57} Studies highlighted the influence of setting-specific factors, demonstrating that certain tools were not universally adaptable. For instance, implementation especially faced obstacles in acute care units,^35,56 and in hospital rehabilitation facilities where the focus on functional restoration often conflicted with palliative care goals.⁵⁷ Moreover, specific patient populations, such as patients undergoing dialysis, were subject to restrictive hospice eligibility criteria,⁴¹ and those with dementia⁵⁴ presented substantial barriers to successful implementation. System-level factors such as a lack of resources were barriers that influenced the implementation of tools.^{33,38,39,41–43,48–52,55}

Facilitators: The presence of national guidelines and a supportive policy environment promoted tool adoption by providing resources for training and education, and establishing clear pathways for communication and collaboration between different healthcare professionals.^{35,39–41,45,49–51} Multidisciplinary teams and collaborative partnerships with external organisations, such as hospice providers and palliative care specialists, were important for implementation by providing essential support and better access to end-of-life care information.^{33,37,38,41–43,47,48,50,52,54}

The Inner Setting Domain

This domain refers to the specific organisational characteristics of the hospital settings²⁵

Barriers: Pervasive time constraints^{33–36,39,41–44,46–57} limited the capacity for patient identification and completing necessary documentation. A lack of standardised processes for patient selection, data storage, and data sharing also hindered implementation.^33,42,56 This challenge was further intensified by competing priorities and heavy workloads, as healthcare professionals often prioritised urgent clinical needs over proactive use tools.^{33,35,37,38,43,44,48,54} Furthermore, resource constraints, including staffing shortages,^{33–36,41,43,45,46,50–52,54,55} and a lack of dedicated time for palliative care activities,^33,37,43 may hinder implementation efforts. Staff turnover disrupts care continuity and impedes the development of expertise in tools.^{35,36,38,46–48} Findings indicated that cultural factors such as promoting a learning environment affected the readiness for change and acceptance of tools implementation.^{36–38,42–47,50} Several studies identified a confluence of organisational factors that hindered implementation of tools.^{33,38,39,41–43,47–52,55} These included communication^43,47,55 and coordination⁴⁸ among healthcare professionals. Further barriers to adoption included organisational inertia,^{34,36,38,41,57} limited physical space,^41,54,55 electronic health record limitations,^{39,42,49,52–54,57} and inflexible workflows.^36,40,49,54

Facilitators: Tool implementation was linked to a clear strategic direction,^47,48 adequate resource allocation,^{33,34,38,40,41,43,48–51,54,57} and a supportive organisational culture that fosters stakeholder engagement and commitment.^{36,38,40,48,51,52} Most studies underscored the importance of a supportive organisational culture characterised by a willingness to embrace change,^{33–38,41,43,46,48,50–52,57} open communication among healthcare professionals,^{35,36,43,50–53} and a solid commitment to patient-centred care.^40,46,52 Clear and accessible information about tools should be provided, and a culture of shared decision-making should be fostered.^{35,39,44,48,51,55} Other facilitators included dedicated time^{38,39,41,43,46,50,52,54,55} and fiscal resources for palliative care tool implementation,^{33,37,42,50,51} clearly defined roles and responsibilities,^{33,34,38,40–43,48,50–52,54} and comprehensive training and ongoing support.^{34–38,40,41,43–45,47–55} Robust structural supports such as telehealth,^38,39 user-friendly electronic health record templates, standardised note templates, trigger mechanisms, pre-visit letters to patients, and conversation guides facilitated implementation of tools and documentation.^{33,38,37,39,41–44,49,52} Further, standardised protocols would streamline implementation, improve consistency, and foster collaboration among healthcare professionals.^{35,40,43,51,55} Organisational changes were vital, including developing or updating procedures that encourage the use of tools.^{34,35,38,40,51,53} Findings showed that clinical workflows required modification to incorporate tools and specialised palliative care referrals.^41,45,50,53 Moreover, cultural adaptation of the tools was found to be necessary for implementation.^{33,34,36,51,52,57}

The Individuals Domain

This domain focuses on the healthcare professionals involved in the implementation process.²⁵

Implementation of tools was affected by knowledge,^{33,35,40,48,50,52–55,57} skills,^{33,36,37,41,43,48,50–53,57} and motivation^{34,36,42,52,57} among healthcare professionals, acting as a barrier when lacking and a facilitator when sufficient. The implementation was compounded by the dual influence of healthcare professionals readiness,^34,36,38,42 confidence^{34,36,40,42,46,50,54} and experience^{33–36,38,41,42,44,50,51,53,54,57} of tool implementation.

Barriers: It was a barrier to tool implementation when healthcare professionals feared upsetting patients or causing distress,^35,43,45,54 anxiety,^35,36 and loss of hope.^{34,36,43,48,53} Additionally, a barrier included healthcare professionals expressing discomfort or uncertainty about initiating an advance care planning conversation.^{33,35,36,38,40,41,48,51,53,57} Further, challenges included clarifying roles and responsibilities,^{34,38,50–52,54} potential resistance from physicians towards non-physician trainers,³⁸ and insufficient support from senior physicians.^37,38,46,54 Barriers also included varying patient and caregiver resources, readiness, and attitudes toward advance care planning, which often required additional time.^41,44,55 Implementation depended on the ability to navigate the complexities of family involvement, emphasising the need for ongoing support for both patients and families.^35,39,45,51

Facilitators: Across numerous studies, strong leadership support and active executive sponsorship emerged as essential for optimal implementation performance.^{33–38,40,41,43–47,49,50,52,54,55} Nurse site leads were repeatedly recognised as pivotal in achieving successful implementation outcomes.^{43,44,49,54,55}

The Implementation Process Domain

This domain addresses the strategies used to put the tools into practice.²⁴

Barriers: A simultaneous rollout of tools across multiple hospital units presented logistical and resource challenges.^34,43 Coordinating training, distributing materials, and ensuring consistent implementation across a large and varied setting proved to be a complex undertaking. Studies also demonstrated classroom education alone as deficient for implementation,^43,50 highlighting the need for ongoing support and mentorship. Furthermore, maintaining awareness and engagement with tools over time emerged as a barrier to implementation.^33,40,55 Initial enthusiasm often faded, leading to a potential decline in sustained practice change.

Facilitators: Champions at national, executive, and local levels provided critical support, leadership, and advocacy for implementation efforts.^{35,38,41,43,48–50,52,55} These efforts were further supported by advisory boards, which facilitated essential communication and collaboration among stakeholders.^38,41 Successful implementation of tools was supported by a multi-faceted approach,^{36,38,42,43,52,54} with comprehensive training for optimal utilisation of tools,^{38–41,43,45,49,50,52,54,55} encompassing awareness to normalise advance care planning conversations.^{33,35,36,40,43,50,57} The multi-faceted approach included regular workshops and mentorship, using, for example, “train-the-trainer” models, to develop and maintain necessary skills and knowledge.^{35,37,40,43,45–47,49–52,55,56} Educational resources like manuals, guidelines, and posters, alongside tailored training programs addressing specific needs and learning styles, further supported healthcare professionals.^{34–41,43–52,54–56} This also included implementing roadmaps, reminders, reference cards, and patient identification methods (e.g., ICD-10 codes, chart review). Ongoing evaluation and feedback, such as regular audits, were useful for palliative care tool implementation.^{36,37,39,40,43,45–47,49,51,57} These rigorous evaluation and feedback mechanisms comprised a data-driven approach involving tracking key metrics, like plan-do-study-act cycles, cause-and-effect diagrams, action plan templates, tests of change worksheets, and making iterative adjustments based on evaluation results.^{40,43,45,46,48,49,51,52}

Discussion

This scoping review demonstrates that the implementation of tools in hospitals is shaped by a complex interplay of organisational, professional, and cultural determinants. While earlier research, such as the 2014 review by Dalgaard et al.¹ established the broad preconditions for early palliative care, our findings specifically delineate the determinants influencing the implementation of tools within hospital settings. Furthermore, while previous literature has addressed specific types of assessment, such as patient-reported outcome measures,²³ our synthesis demonstrates that implementation challenges – such as time constraints and cultural resistance – are consistent across different categories of tools, ranging from identification to communication frameworks.

A significant proportion of included studies (14 out of 25) did not utilise a formal implementation science framework (Table 2). This underscores that clinical interventions are often introduced without the established theories of change necessary to embed them into routine practice.²⁵ This finding should be viewed alongside the foundational work of Sommerbakk et al.,²² and Van Riet Paap et al.,²¹ who have extensively documented the multi-level barriers and facilitators in palliative care, spanning practice characteristics, professional factors, and systemic influences. While our findings align with these established insights, this review’s sole focus is on the hospital setting. The heavy concentration of determinants within the Inner Setting domain suggests that implementation success depends on the hospital’s organisational climate, leadership support, and resource allocation. Conversely, the Innovation and Outer Setting domains yielded fewer factors, implying that while intrinsic qualities and external pressures are relevant, they may have less immediate influence on implementation than the local context.

The contextual imperative

Our findings indicate that the implementation of tools is not a uniform process but rather a context-dependent phenomenon. The Inner Setting of a hospital is not monolithic, for example, the intense time pressure and competing priorities prevalent in acute care units can make the sustained use of any tool difficult.^35,56 This aligns with the Dynamic Sustainability Framework,⁵⁸ which suggests that for a practice to persist, it must possess the fit and adaptability to survive within a shifting clinical environment. As Goff et al.,⁴¹ highlight, even when tools are technically sound, Outer Setting factors like restrictive hospice eligibility criteria can stifle their practical utility. This reinforces the necessity for flexible and adaptive implementation strategies. Rather than viewing tools as rigid instruments, they must be understood as clinical resources that require dynamic implementation strategies to ensure cultural and structural adaptation to the local context. For example, specific impediments arise in hospital rehabilitation settings; the restorative focus inherent in functional recovery creates an environment that is not optimally conducive to addressing palliative care needs.⁵⁷ From the perspective of Normalisation Process Theory,⁵⁹ this struggle may occur because the implementation strategies fail to facilitate the necessary contextual adaptation. As Chiu et al.⁴⁸ found in British Columbia, regional disparities and logistical constraints impact tool implementation even within a single healthcare system. This underscores the need for implementation strategies that acknowledge the heterogeneity of patient populations and contexts.

Resource constraints and cultural influences

A consistent theme was the pervasive impact of resource limitations – specifically temporal, financial, and technological.^{33–39,41–44,46–57} The integration of tool data within electronic health records emerged as a critical structural facilitator.^39,42,49 When a tool is siloed from the primary digital workflow, its implementation is likely to fail regardless of clinical value. This is supported by Ross et al.,⁶⁰ who emphasise that the seamless integration of interventions within electronic health records and their alignment with clinical workflows are critical determinants for implementation success. Beyond technological accessibility, the establishment of flexible clinical workflows was essential to accommodate the dynamic nature of tools.^{36,40,49,50,54} However, resources alone are insufficient. The influence of a supportive organisational culture that prioritises continuous improvement and a learning environment was pivotal.^34,38,52 Psychological safety within learning environments is a known prerequisite for clinicians to feel supported.⁶¹ Shortcomings in education and training act as a barrier, emphasising a disconnect between theoretical knowledge and the practical application.^43,50 Research points to a need for Implementation Support Practitioners, who provide ongoing coaching rather than one-time educational sessions to bridge this theory-practice gap.⁶²

The critical role of champions and collaboration

The cultivation of champions emerged as a salient factor at various levels.^{35,37,38,41,43,48–50,52,55} While nurse site leads were highlighted as pivotal,^{43,44,49,54,55} physician leadership was also essential in navigating organisational hierarchies.^63,64 Without physician backing, nurse site leads may encounter limitations in addressing clinical complexities. Leadership support manifested in the provision of resources, clear strategic direction, and the establishment of a supportive organisational climate.^{34,38,40,43,47,48,50,52} Recently, Magid et al.⁶⁵ emphasised that successful implementation relies on a synergy between champion commitment and site-level leadership engagement, identifying priority-setting as a key driver. However, leadership support is also mirrored in broader implementation literature^66,67 and prompts an examination of the distinction between leadership and champions’ roles. Research suggests that while formal leadership provides permission for change, champions provide the persistence.⁶⁸ Champions may fill a leadership gap, particularly when implementation of tools lacks managerial focus, highlighting their key role. This is consistent with the middle-manager role in the implementation of evidence-based practices, which argues that individuals, such as nurse leads, are essential for translating strategic goals into daily clinical practice.⁶⁹

The interplay of communication and iterative adaptation

An organisational culture that fosters open communication and promotes interprofessional collaboration is fundamental for the successful implementation of tools.^34,35,38,52 Effective communication channels among stakeholders, facilitated by, for example, advisory boards,^38,41 were central to inclusive decision-making. Furthermore, success was linked to a structured implementation plan with realistic timelines,³⁹ and comprehensive training.^{33,34,38,40,41,43,49–52,54,55} This multi-faceted approach to preparation aligns with Implementation Mapping,⁷⁰ which emphasises that training must be paired with organisational structural changes to be effective. Finally, the strategic use of iterative evaluation and adaptation – using monitoring and feedback mechanisms – helps ensure that implementation strategies remain responsive to evolving challenges.^{34,37,40,43,45,46,49–51} The audit and feedback literature⁷¹ demonstrates that data-driven performance insights can drive behavioural change. Such iterative cycles reflect the plan-do-study-act quality improvement methodology, where successful implementations treat the initial launch as a working hypothesis requiring ongoing refinement.⁷²

Strengths and Limitations

This scoping review offers a synthesis of the existing literature regarding the implementation of tools using the CFIR. Employing CFIR as an analytical lens allowed us to systematically categorise the complex interplay of factors influencing implementation. While CFIR offered a valuable structure, its broad scope risks oversimplification and may not fully capture the dynamic, non-linear nature of implementation. Interpretive biases in assigning findings to CFIR domains are acknowledged. The scoping review is also limited by the variability in study quality, and the included studies may not represent the full range of implementation experiences. Importantly, the review grouped highly heterogeneous tools, combining identification, needs assessment, and communication framework resources. While this inclusive approach was necessary to map the clinical reality of hospital settings, it prevents a direct comparative analysis of how CFIR domains differ based on tool types or clinical settings; we flag this as a critical area for future research.

Conclusion

This scoping review identifies a range of barriers and facilitators that can inform the selection of implementation strategies for tools in hospital settings. Our findings suggest that successful implementation is a complex process requiring multi-faceted strategies capable of addressing these factors across multiple levels—from individual training and clinical champions to organisational leadership and culture. Furthermore, structural factors and clear multidisciplinary roles emerged as critical for success. Future research should focus on evaluating tailored strategies that address specific barriers and leverage facilitators within unique hospital contexts to ensure systematic and sustainable adoption.

Supplemental Material

sj-docx-1-pmj-10.1177_02692163261465770 – Supplemental material for Implementation of tools for identifying palliative care needs and supporting advance care planning: A scoping review of barriers and facilitators in hospital settings

Supplemental material, sj-docx-1-pmj-10.1177_02692163261465770 for Implementation of tools for identifying palliative care needs and supporting advance care planning: A scoping review of barriers and facilitators in hospital settings by Tóra Róin, Jahan Shabnam, Stine G. Roikjær, Vibeke Ø. Steenfeldt, Cecilie L. Egholm and Heidi M. Bergenholtz in Palliative Medicine

Footnotes

ORCID iDs

Tóra Róin

Jahan Shabnam

Stine G. Roikjær

Vibeke Ø. Steenfeldt

Cecilie L. Egholm

Heidi M. Bergenholtz

Ethical considerations

This is a scoping review and therefore no formal ethics approvals were required.

Consent to participate

Consent procedures were not required as this is a scoping review.

Author contributions

HBZ and CLE contributed to the conception and design of the study, TR, HBZ, and CLE to the acquisition, analysis, and interpretation of data, all authors to the drafting and critical revision of the manuscript, and all authors approved the final version for publication. JS, SGR, and VØS contributed to title and abstract screening. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by MVU-fællespuljen, Region Zealand, Denmark.

Declaration of conflicting interests

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

Supplemental material

Supplemental material for this article is available online.

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