Implementing advance care planning: a qualitative study of community nurses' views and experiences

Abstract

BackgroundAdvance care planning (ACP) is a process of discussion about goals of care and a means of setting on record preferences for care of patients who may lose capacity or communication ability in the future. Implementation of ACP is widely promoted by policy makers. This study examined how community palliative care nurses in England understand ACP and their roles within ACP. It sought to identify factors surrounding community nurses' implementation of ACP and nurses' educational needs.MethodsAn action research strategy was employed. 23 community nurses from two cancer networks in England were recruited to 6 focus group discussions and three follow up workshops. Data were analysed using a constant comparison approach.FindingsNurses understood ACP to be an important part of practice and to have the potential to be a celebration of good nursing care. Nurses saw their roles in ACP as engaging with patients to elicit care preferences, facilitate family communication and enable a shift of care focus towards palliative care. They perceived challenges to ACP including: timing, how to effect team working in ACP, the policy focus on instructional directives which related poorly to patients' concerns; managing differences in patients' and families' views. Perceived barriers included: lack of resources; lack of public awareness about ACP; difficulties in talking about death. Nurses recommended the following to be included in education programmes: design of realistic scenarios; design of a flow chart; practical advice about communication and documentation; insights into the need for clinical supervision for ACP practice.ConclusionsNurses working in the community are centrally involved with patients with palliative care needs who may wish to set on record their views about future care and treatment. This study reveals some important areas for practice and educational development to enhance nurses' use and understanding of ACP.

Advance care planning for nursing home residents with dementia: Influence of ‘we DECide’ on policy and practice

“…This includes not only the clinical staff but also the management [6,[17][18][19][20][21]. That is why staff from both the management and clinical level were involved in 'we DECide'.…”

“…the choice to discuss ACP), the critical first step to realizing SDM. Secondly, the management's vision on ACP has an influence on the policy and on the conditions that permit implementation in practice [17][18][19]23], whereas the clinical staff discuss ACP with the residents and families in practice. If management staff do not believe in the importance of ACP, the clinical staff will not receive the proper support, time and resources for this.…”

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

“…There is evidence that many professionals lack confidence in undertaking ACP and tend to avoid such discussions. 13,14,35,53,67,87,88 Several studies suggest that, as there is uncertainty about which professional should undertake discussion of ACP, there is a tendency, particularly among GPs, to defer responsibility to someone else. 9,12,53,64,67,89 Evidence also suggests that, although patients tend to expect professionals to take the initiative, there is a tendency for professionals to wait for patients to open the discussion.…”

“…13,14,35,53,67,87,88 Several studies suggest that, as there is uncertainty about which professional should undertake discussion of ACP, there is a tendency, particularly among GPs, to defer responsibility to someone else. 9,12,53,64,67,89 Evidence also suggests that, although patients tend to expect professionals to take the initiative, there is a tendency for professionals to wait for patients to open the discussion. 5,43,87,90 As a result of this 'bystander effect' it is likely that the discussion never happens, or may occur too late, often in response to critical events, by which time options are restricted.…”

“…The recent trend has been to shift the focus of anticipatory planning towards more informal processes of discussion and reflection about goals of care. 3,43,[51][52][53] …”