Perceived enablers and barriers to the provision of quality palliative care to older persons in nursing homes in France: multiple case study with professionals, leaders, residents, and family caregivers

The integration of palliative care within nursing homes is increasingly recognised as a crucial strategy to improve access to palliative care for a growing number of residents with complex life-limiting conditions. Despite various strategies aimed at supporting this integration, access to palliative care in these facilities remains suboptimal. This study aimed to explore the factors that enable or hinder the provision of quality palliative care to residents in nursing homes in France, drawing on the perspectives of professionals, leaders, residents, and family caregivers. A multiple case study was conducted. Individual interviews were held with residents, family caregivers and leadership team members. We held focus group discussions with healthcare professionals. Data was complemented with participant observation. Data was collected from April 2021 to September 2022 and was analysed using thematic content analysis. This study identified a complex, multi-contextual dynamic between four main factors influencing quality palliative care provision in nursing homes. Practice-based and organisational factors inherent to the nursing home, structural factors and individual factors interact to facilitate or constrain the provision of quality palliative care. Leadership, resources availability, decision-making process, access to palliative care external support, and knowledge and attitudes towards palliative care, all play critical roles in shaping both care provision and resident and family experiences with care. These interrelated factors create a disconnect between expected quality palliative care and currently enacted palliative care practices. This study reveals how practice-based, organisational, structural and individual dynamics converge to shape the provision of quality palliative care within nursing homes in France. These findings point to the need for a multifaceted, system-level response to strengthen palliative care delivery. Cultivating a supportive organisational culture, embedding palliative care principles across care practices, building the capacity of nursing home professionals, and including patients and families in the decision-making are essential to closing the gap between ideal and actual palliative care provision within nursing homes. Such an approach offers the potential to improve provision of timely, person-centred palliative care, enhance the experiences of residents and family caregivers, and support quality of life and quality of dying within nursing homes.