Implementing advance care planning in routine nursing home care: The development of the theory-based ACP+ program

Abstract

BackgroundWhile various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice.ObjectivesWe report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner.DesignTo develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling.Setting and participantsManagement and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer.MethodsThe work was carried out by means of 1) operationalization of key intervention components–identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes–into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis.ResultsThe original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning.ConclusionsThe multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice.

End-of-life programme for older care home residents: an evaluation study

“…26 A recent study reported that an ACP programme involving residents, family, and different groups of people working in the nursing home was feasible and acceptable by nursing home staff and management. 27 The present study demonstrated that ACP discussion was feasible in older RCHE residents, with 93% of them established DNACPR-NH and 96% established ACP. Nonetheless, some residents or relatives needed more time to consider and discuss among family members and did not establish the ACP and DNACPR-NH at the first geriatrician consultation in EOL clinic.…”

Advance care planning in nursing homes: new conversation and documentation tools

“…Moreover, on-the-job learning opportunities and management buy-in to support staff and create a safe learning climate are essential aspects of the intervention. 13 17 29 Other key elements are described elsewhere. 13 This paper serves as an important first step to provide practice with detailed tools to conduct both planned and spontaneous ACP conversations with the vulnerable nursing home population and their families.…”

“…13 17 29 Other key elements are described elsewhere. 13 This paper serves as an important first step to provide practice with detailed tools to conduct both planned and spontaneous ACP conversations with the vulnerable nursing home population and their families. Our tools are consistent with best practices for discussing care goals, as was outlined by Bernacki et al 30 identifying a structured format to guide discussions and record information to hold promise in optimising ACP conversations.…”

Timely short-term specialised palliative care service intervention for frail older people and their family carers in primary care: study protocol for a pilot randomised controlled trial

“…13 46 evaluating complex interventions. [31][32][33][34] As part of this, we integrated the evidence of a previously conducted systematic literature review of specialised palliative care services for older people in primary care 20 with qualitative research, including qualitative interviews and group discussions with older people and family carers, Theory of Change workshops with professional stakeholders (ie, bringing together key professional stakeholders to develop a Theory of Change map and to encourage stakeholder buy-in 31 ) and research group meetings.…”