Description of an advance care planning intervention in nursing homes: outcomes of the process evaluation

Abstract

BackgroundAdvance Care Planning (ACP) is the repeated communication and decision-making process between the patient, family, and healthcare professionals. This study describes an ACP intervention in nursing homes and evaluates the outcomes of the implementation process.MethodsThe ACP intervention was part of a 4-month complex, cluster randomized controlled trial (COSMOS). 37 Norwegian nursing homes with 72 units (1 cluster = 1 unit) and 765 patients were invited to participate and eligible units were randomised to the intervention group or control. Nursing home staff in the intervention group was offered a standardized education programme to learn early and repeated communication with patients and families and to implement ACP in their units. We used a train-the-trainer approach to educate staff in the units, supported by regular telephone calls and a midway seminar after two months. Individual patient logs consisting of different communication deliverables were used to evaluate the implementation process. Supported by Qualitative Content Analyses, we identified facilitators and barriers of the ACP implementation based on feedback during midway seminars and individual patient logs.ResultsThe ACP intervention was conducted in 36 NH units (n = 297); 105 healthcare providers participated at the education seminar prior to the study, and 3–4 employees from each unit participated in the midway seminar. NH staff reported the educational material relevant for the implementation strategy. The patient logs showed that ACP was successfully implemented in 62% (n = 183) of the patients using our predefined implementation criteria. The staff emphasized the clear communication of the relevance of ACP addressed to leaders and staff as important facilitators, along with the clearly defined routines, roles and responsibilities. Identified barriers included lack of competence, perceived lack of time, and conflicting culture and staff opinions.ConclusionMonthly communication with the family was the most frequently conducted communication, and the predefined criteria of successfully implemented ACP were largely achieved. Nursing home routines and engagement of leaders and staff were crucial facilitators, whereas lack of time and competence reduced the implementation success.Trial registrationThe COSMOS-trial was registered in the ClinicalTrials.gov (NCT02238652) July 7th, 2014Electronic supplementary materialThe online version of this article (10.1186/s12877-018-0713-7) contains supplementary material, which is available to authorized users.

Implementation of a complex intervention to improve participation in older people with joint contractures living in nursing homes: A process evaluation of a cluster-randomised pilot trial

“…Nevertheless, in our pilot study empowerment of a facilitator alone was not su cient to change practice. Here, our results are in line with Aasmul et al, indicating that a successful implementation did not depend on the facilitator alone [40]. It turned out that the facilitators can only act successfully when they can rely on a working environment that is supportive to inducing changes.…”

“…In our study, a mandatory approach with xed appointments right from the start, and a structured counselling based on speci c objectives have proven themselves. Such standardised procedures with regular contacts during the implementation process have been reported as successful in other studies [40,42]. Therefore, the training of peer-mentors should be extended, and the paths of communication should be further standardised.…”

“…The applied facilitation approach is a proven strategy for implementing interventions in nursing homes and for supporting changes in the daily nursing routine [40][41][42][43]. A successful implementation of knowledge into practice depends on the quality and type of the evidence, existing speci c nursing home characteristics and the modalities of facilitation [21].…”

Associations between Length of Stay in Long Term Care Facilities and End of Life Care. Analysis of the PACE Cross-Sectional Study

“…The term "end of life care" is often used synonymously with palliative care in the UK, and refers to "an extended period of 1 to 2 years during which the patient/family and health professionals become aware of the life-limiting nature of their illness" [11]. Previous studies have found that the adoption of a palliative care approach in LTCFs led to a reduction in deaths outside the LTCF [12], an increase in the numbers of completed advance directives [13], improvements in end-of-life communication between residents, relatives and health professionals [14-16] and improvements in staff knowledge [17][18][19].Numerous interventions have been developed to improve the provision and quality of end of life care in LTCFs, including staff education [20,21], inter-professional collaborations and care coordination [22,23], either through individual initiatives or as part of multicomponent interventions, such as the Liverpool Care Pathway [24], Gold Standards Framework for Care Homes [25] or the Steps to Success intervention [26]. The time point at which these initiatives aim to change the care provided to a resident varies; whereas the Liverpool Care Pathways focuses on care in the last days of life [24], interventions focusing on communicating preferences at end of life may be introduced either at admission or four to six weeks post admission.…”

“…Numerous interventions have been developed to improve the provision and quality of end of life care in LTCFs, including staff education [20,21], inter-professional collaborations and care coordination [22,23], either through individual initiatives or as part of multicomponent interventions, such as the Liverpool Care Pathway [24], Gold Standards Framework for Care Homes [25] or the Steps to Success intervention [26]. The time point at which these initiatives aim to change the care provided to a resident varies; whereas the Liverpool Care Pathways focuses on care in the last days of life [24], interventions focusing on communicating preferences at end of life may be introduced either at admission or four to six weeks post admission.…”