Due to copyright issues, an electronic copy of the thesis must be ordered from the faculty. For the faculty to have time to process the order, the order must be received by the faculty at the latest 2 days before the public defence. Orders received later than 2 days before the defence will not be processed. After the public defence, please address any inquiries regarding the thesis to the candidate.
Order a digital copy of the thesis here
Trial Lecture – time and place
See Trial Lecture.
Adjudication committee
- First opponent: Senior researcher Mette Kjærgaard Nielsen, Aarhus University,
- Second opponent: Associate professor Birgitte Graverholt, Western Norway University of Applied Sciences,
- Third member and chair of the evaluation committee: Professor Jarle Breivik, University of Oslo
Chair of the Defence
Professor emeritus Magne Nylenna, University of Oslo
Principal Supervisor
Professor Reidar Pedersen, University of Oslo
Summary
This thesis is situated within medical ethics, geriatric and personcentered care, implementation science and health services research. It evaluates the implementation of advance care planning (ACP) for older patients living with frailty admitted to acute geriatric hospital units. It examines barriers and facilitators at national and organizational levels, clinicians’ experiences of implementation, and whether structured implementation support improves the extent to which ACP is implemented as intended (implementation fidelity).
The thesis comprises a multimethod, multilevel evaluation embedded in a multicentre, hybrid type II cluster-randomized trial involving twelve acute geriatric units. Six units received comprehensive training and implementation support to integrate and conduct ACP conversations, including education, supervision, and the development of routines and structures. The research includes interviews with clinicians, managers at various levels of healthcare, and health policy stakeholders on barriers and facilitators to ACP implementation and the experiences with the implementation support, as well as longitudinal quantitative findings (implementation fidelity) across the twelve hospital units throughout the intervention period.
The findings shows that the structured implementation support was associated with improved overall implementation fidelity compared with control units, particularly for implementation structures and ACP quality. When ACP conversations took place, their quality was generally good. Nevertheless, the implementation degree remained low to moderate, improvements were difficult to sustain over time, and few patients were reached. The findings indicate that ACP was valued by clinicians, but the implementation effort and conducting the ACP conversations was challenged by several and complex factors, including time pressure, limited resources and incentives, and competing clinical demands within an increasingly pressured healthcare system emphasizing efficiency. The research also showed that insufficient prioritization of ACP at organizational and national levels hindered its implementation.
The thesis found that structured implementation support can facilitate ACP implementation in acute geriatric hospital units. However, a sustainable integration into routine care was challenging to obtain due to significant barriers to ACP implementation at individual, organizational and national levels. Better integration into routine care requires a dynamic interplay and actions across all levels, including long-term investment in dedicated implemention support, financial incentives, cultural change of healthcare delivery and a joint documentation and communication system across healthcare levels.
Additional information
The public defence will be conducted in Norwegian.
Contact the research support staff.