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Wilkin K, Fang ML, Sixsmith J. Implementing advance care planning in palliative and end of life care: a scoping review of community nursing perspectives. BMC Geriatr 2024; 24:294. [PMID: 38549045 PMCID: PMC10976700 DOI: 10.1186/s12877-024-04888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Advance care planninganning (ACP) is a priority within palliative care service provision. Nurses working in the community occupy an opportune role to engage with families and patients in ACP. Carers and family members of palliative patients often find ACP discussions difficult to initiate. However, community nurses caring for palliative patients can encourage these discussions, utilising the rapport and relationships they have already built with patients and families. Despite this potential, implementation barriers and facilitators continue to exist. To date, no research synthesis has captured the challenges community nurses face when implementing ACP, nor the facilitators of community nurse-led ACP. Considering this, the review question of: 'What factors contribute to or hinder ACP discussion for nurses when providing care to palliative patients?' was explored. METHOD To capture challenges and facilitators, a global qualitative scoping review was undertaken in June 2023. The Arksey and O'Malley framework for scoping reviews guided the review methodology. Six databases were searched identifying 333 records: CINAHL (16), MEDLINE (45), PUBMED (195), EMBASE (30), BJOCN (15), IJOPN (32). After de-duplication and title and abstract screening, 108 records remained. These were downloaded, hand searched (adding 5 articles) and subject to a full read. 98 were rejected, leaving a selected dataset of 15 articles. Data extracted into a data extraction chart were thematically analysed. RESULTS Three key themes were generated: 'Barriers to ACP', 'Facilitators of ACP' and 'Understanding of professional role and duty'. Key barriers were - lack of confidence, competence, role ambiguity and prognostic uncertainty. Key facilitators concerned the pertinence of the patient-practitioner relationship enabling ACP amongst nurses who had both competence and experience in ACP and/or palliative care (e.g., palliative care training). Lastly, nurses understood ACP to be part of their role, however, met challenges understanding the law surrounding this and its application processes. CONCLUSIONS This review suggests that community nurses' experience and competence are associated with the effective implementation of ACP with palliative patients. Future research is needed to develop interventions to promote ACP uptake in community settings, enable confidence building for community nurses and support higher standards of palliative care via the implementation of ACP.
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Affiliation(s)
| | - Mei Lan Fang
- School of Health Sciences, University of Dundee, Dundee, Scotland
- Urban Studies and Department of Gerontology, Simon Fraser University, Vancouver, Canada
| | - Judith Sixsmith
- School of Health Sciences, University of Dundee, Dundee, Scotland.
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Romøren M, Hermansen KB, Sævareid TJL, Brøderud L, Westbye SF, Wahl AK, Thoresen L, Rostoft S, Førde R, Ahmed M, Aas E, Midtbust MH, Pedersen R. Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial. BMC Health Serv Res 2024; 24:220. [PMID: 38374100 PMCID: PMC10875743 DOI: 10.1186/s12913-024-10666-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions. METHODS This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis. DISCUSSION The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.
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Affiliation(s)
- Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Karin Berg Hermansen
- Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | | | - Linn Brøderud
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Færden Westbye
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Astrid Klopstad Wahl
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Marc Ahmed
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Eline Aas
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Health Science, Norwegian Institute of Public Health, Oslo, Norway
| | - May Helen Midtbust
- Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Punia H, Kaasalainen S, Ploeg J, Strachan P, Sussman T. Exploring the Role of Nurses in Advance Care Planning Within Long-Term Care Homes: A Qualitative Study. SAGE Open Nurs 2024; 10:23779608241249335. [PMID: 38690399 PMCID: PMC11060033 DOI: 10.1177/23779608241249335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/27/2024] [Accepted: 04/07/2024] [Indexed: 05/02/2024] Open
Abstract
Background Residents in long-term care homes (LTCHs) are often diagnosed with chronic, life-limiting illnesses, and it is now a common site to provide high levels of care and eventual death. There is an urgent need to address communication gaps and uncertainties surrounding resident's end of life preferences. Nurses are well situated to be key facilitators of necessary advance care planning (ACP), ensuring residents have discussions with family, substitute decision-makers and healthcare providers regarding future health and personal care preferences. However, LTCHs present unique challenges for nurses due to not only complex comorbidities but also staffing dynamics. Purpose This study explored the experiences and perceptions of Registered Nurses (RNs) and Registered Practical Nurse (RPNs) in LTCHs regarding their role in engaging residents and families in ACP discussions. Methods Qualitative interpretive descriptive methodology was used. Data were collected from two LTCHs in Southern Ontario with a sample of 15 nurses (7 RNs and 8 RPNs). Analysis involved review of semistructured interviews, field notes, and utilizing constant comparison within an inductive approach. Results Power and authority dynamics in LTCH's was an overarching theme in the data, with four subthemes: (1) Nurses lacking clarity about ACP, (2) nurses' uncertainty regarding their role in ACP, (3) nurses feeling uncomfortable engaging in ACP discussions, and (4) nurses struggling to support families in ACP discussions. Conclusion Recommendations for nurses, healthcare providers, LTCH administrators, and policy makers include: (1) development of policies which support, from a systemic level, nurses to feel safe while engaging in ACP; (2) reassessing LTCH's hierarchical structure, and clarifying RN, RPN, and interdisciplinary team members roles in ACP; (3) developing culture change that allows a team and person-centered approach to ACP; and (4) providing ongoing education and mentorship for nurses to manage family dynamics and expand their understanding of ACP beyond a biomedical lens.
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Affiliation(s)
- Harveer Punia
- School of Nursing, McMaster University, Hamilton, Canada
| | | | - Jenny Ploeg
- School of Nursing, McMaster University, Hamilton, Canada
| | | | - Tamara Sussman
- School of Social Work, McGill University, Montreal, Canada
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Kolstrøm A, Driller B, Aasen EM. From difficulty to meaning - Experiences of patients with advanced cancer having advance care planning conversations and a palliative care plan. Eur J Oncol Nurs 2023; 67:102456. [PMID: 37976754 DOI: 10.1016/j.ejon.2023.102456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This study aimed to explore the experiences of patients with advanced cancer with Advanced care planning (ACP) communication and drawing up a palliative plan in primary healthcare settings in Norway. METHODS In this exploratory qualitative study, data were collected using semi-structured interviews with five patients with cancer who had undergone ACP and had a palliative care plan. RESULTS The result shows three main themes with subthemes; (1) The difficult ACP conversation about cancer and death was tough, painful, and considered a "taboo." The patients wished they had been prepared for the conversation and had it in their own homes. (2) Interactions with the doctor/nurse about the palliative care plan helped the patients feel valued and involved and brought their wishes into focus. The next of kin was present but not involved in the process. (3) Having a palliative plan was meaningful for the patients; they felt safe, and it gave them a sense of security. CONCLUSIONS Patients with advanced cancer in a home setting in Norway experienced ACP for the preparation of a palliative plan as a process from difficulty to meaning. In this process, the context and interactions provided by the doctor/nurse and their competency in communicating with the patients and involving them as persons was important. The palliative plan gave the patients a sense of meaning, control, and safety connected to the time for the end of life.
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Affiliation(s)
- Adriana Kolstrøm
- Department of Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Ålesund, Norway; Home Care Department, Kristiansund Municipality, Kristiansund N, Norway.
| | - Bardo Driller
- Department of Oncology and Department for Research and Innovation, Møre og Romsdal Hospital Trust, Aalesund, Norway; Department for Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Elin Margrethe Aasen
- Department of Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Ålesund, Norway.
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Lereim Sævareid TJ, Aasmul I, Hjorth NE. Implementation of Advance Care Planning in Norway. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:163-167. [PMID: 37394337 DOI: 10.1016/j.zefq.2023.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/16/2023] [Accepted: 05/21/2023] [Indexed: 07/04/2023]
Abstract
Advance Care Planning has a relatively short history in the Norwegian health care services. This article gives an overview of advance care planning research and its implementation in the health care services in Norway. Advance care planning has received increased attention from policymakers and the health care services. Research projects have been performed, and several are on-going. Implementation has largely treated advance care planning as a complex intervention, with a whole-system approach that puts emphasis on the conversation and patient activation. Advance directives have a peripheral role in this context.
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Affiliation(s)
| | - Irene Aasmul
- The Dignity Centre - Care for the old, Bergen, Norway
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Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review. Int J Nurs Stud 2022; 133:104277. [PMID: 35717924 DOI: 10.1016/j.ijnurstu.2022.104277] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/10/2023]
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Saevareid TJL, Pedersen R, Thoresen L. Nursing home residents with cognitive impairment can participate in advance care planning: A qualitative study. J Adv Nurs 2020; 77:879-888. [PMID: 33230934 DOI: 10.1111/jan.14661] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 01/23/2023]
Abstract
AIMS To describe advance care planning in nursing homes when residents with cognitive impairment and/or their next of kin participated and identify associated challenges. DESIGN A qualitative study of nine advance care planning conversations in four Norwegian nursing home wards. During the implementation of advance care planning, we purposively sampled residents with cognitive impairment, their next of kin and healthcare personnel. The implementation followed a "whole-ward" approach aimed at involving the whole ward in fostering an inclusive, holistic advance care planning discussion. Involving as many residents as possible, preferably together with their next of kin, were central. METHODS From observed and audio-recorded advance care planning conversations that took place from November 2015 to June 2016, we conducted a thematic analysis of the transcripts and field notes. Reporting adhered to the COREQ guidelines. RESULTS Residents actively relayed their preferences regarding healthcare and end-of-life issues, despite the cognitive impairment. Next of kin provided constructive support and conversations were largely resident-focused. However, involving residents was also challenging, findings included: residents' preferences were often vague, relevant medical information from healthcare personnel lacked and the next of kin were sometimes unaware of the resident's previously held preferences. Moreover, residents tended to focus more on the past and present than the future end-of-life care. CONCLUSIONS Residents with cognitive impairment can participate actively and meaningfully in advance care planning, if the healthcare personnel actively listens. However, several challenges can arise. Supported decision-making can improve communication and resident involvement, reinforcing a relational understanding of autonomy. IMPACT Persons with cognitive impairment should be invited to participate in advance care planning. Their participation may make its benefits and more person-centred care attainable to persons that are often not involved. Successful involvement of persons with cognitive impairment in advance care planning may rely on robust implementation.
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Affiliation(s)
| | | | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Oslo, Norway.,Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
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