Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Palliative Care
Published in: BMC Palliative Care 1/2022

Open Access 01-12-2022 | Care | Research

Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study

Authors: Shirin Vellani, Elizabeth Green, Pereya Kulasegaram, Tamara Sussman, Abby Wickson-Griffiths, Sharon Kaasalainen

Published in: BMC Palliative Care | Issue 1/2022

Login to get access

Abstract

Background

Residents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process.

Objectives

The aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs.

Methods

This study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada.

Findings

There were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs.

Discussion

The findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care.

Conclusion

The findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs.
Appendix
Available only for authorised users
Literature
1.
Tanuseputro P, Budhwani S, Bai YQ, Wodchis WP. Palliative care delivery across health sectors: A population-level observational study. Palliat Med. 2017;31(3):247–57.PubMedCrossRef
2.
3.
Ontario Long-Term Care Association (OLTCA). About long-term care in Ontario: Facts and figures. 2019.
4.
Marcella J, Kelley ML. “Death Is Part of the Job” in Long-Term Care Homes: Supporting Direct Care Staff With Their Grief and Bereavement. SAGE Open. 2015;5(1):2158244015573912.CrossRef
5.
6.
Hirdes JP, Mitchell L, Maxwell CJ, White N. Beyond the ‘Iron Lungs of Gerontology’: Using Evidence to Shape the Future of Nursing Homes in Canada. Can J Aging. 2011;30(3):371–90.PubMedCrossRef
7.
Kastbom L, Milberg A, Karlsson M. “We have no crystal ball” - advance care planning at nursing homes from the perspective of nurses and physicians. Scand J Prim Health Care. 2019;37(2):191–9.
8.
Bires JL, Franklin EF, Nichols HM, Cagle JG. Advance Care Planning Communication: Oncology Patients and Providers Voice their Perspectives. J Cancer Educ. 2018;33(5):1140–7.PubMedCrossRef
9.
10.
Beck ER, McIlfatrick S, Hasson F, Leavey G. Nursing home manager’s knowledge, attitudes and beliefs about advance care planning for people with dementia in long-term care settings: a cross-sectional survey. J Clin Nurs. 2017;26(17–18):2633–45.
11.
Wahl J, Partner M, Walton T. Healthcare consent, advance care planning, and goals of care practice tools: The challenge to get it right. Toronto, Ontario, Canada: Advocacy Centre for the Elderly; 2016.
12.
Lovell A, Yates P. Advance Care Planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008–2012. Palliat Med. 2014;28(8):1026–35.PubMedCrossRef
13.
14.
Capps C, Gillen L, Hayley D, Mason R. Better advance care planning in long-term care through starting the conversation. J Am Med Dir Assoc. 2018;19(3):B15.CrossRef
15.
Ahluwalia SC, Bekelman DB, Huynh AK, Prendergast TJ, Shreve S, Lorenz KA. Barriers and strategies to an iterative model of advance care planning communication. Am J Hosp Palliat Care. 2015;32(8):817–23.PubMedCrossRef
16.
Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665–73.PubMedPubMedCentralCrossRef
17.
Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.PubMedPubMedCentralCrossRef
18.
19.
Zhang B, Wright AA, Huskamp HA, Nilsson ME, Maciejewski ML, Earle CC, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Int Med. 2009;169(5):480–8.CrossRef
20.
Committee on Approaching Death: Addressing Key End of Life Issues, & Institute of Medicine. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: National Academies Press; 2015.
21.
Daaleman TP, Williams CS, Preisser JS, Sloane PD, Biola H, Zimmerman S. Advance care planning in nursing homes and assisted living communities. J Am Med Dir Assoc. 2009;10(4):243–51.PubMedPubMedCentralCrossRef
22.
Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision aids for advance care planning: an overview of the state of the science. Ann Intern Med. 2014;161(6):408–18.PubMedCrossRef
23.
Ampe S, Sevenants A, Smets T, Declercq A, Van Audenhove C. Advance care planning for nursing home residents with dementia: Influence of “we DECide” on policy and practice. Patient Educ Couns. 2017;100(1):139–46.
24.
Gilissen J, Pivodic L, Smets T, Gastmans C, Vander Stichele R, Deliens L, et al. Preconditions for successful advance care planning in nursing homes: A systematic review. Int J Nurs Stud. 2017;66:47–59.PubMedCrossRef
25.
Kirsebom M, Hedström M, Pöder U, Wadensten B. General practitioners’ experiences as nursing home medical consultants. Scand J Caring Sci. 2017;31(1):37–44.
26.
Jeong SYS, Higgins I, McMillan M. Experiences with advance care planning: nurses’ perspective. Int J Older People Nurs. 2011;6(3):165–75.PubMedCrossRef
27.
Hickman SE, Unroe KT, Ersek MT, Buente B, Nazir A, Sachs GA. An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting. J Am Geriatr Soc. 2016;64(11):2385–92.PubMedCrossRef
28.
Sussman T, Kaasalainen S, Lee E, Akhtar-Danesh N, Strachan PH, Brazil K, et al. Condition-Specific Pamphlets to Improve End-of-life Communication in Long-term Care: Staff Perceptions on Usability and Use. J Am Med Dir Assoc. 2019;20(3):262–7.PubMedCrossRef
29.
McAiney CA, Boger J, Conway E, Koch M, Beleno R, Boscart V, Taucar LS. Impact of COVID-19 on family care partners of persons with dementia in long-term care settings in Canada: Not a ‘one-size-fits-all’ story. Alzheimer’s & Dement. 2021;17(S7):e052186. https://​doi.​org/​10.​1002/​alz.​052186.
30.
Vellani S, Boscart V, Escrig-Pinol A, Cumal A, Krassikova A, Sidani S, McGilton KS. Complexity of Nurse Practitioners’ Role in Facilitating a Dignified Death for Long-Term Care Home Residents during the COVID-19 Pandemic. J Pers Med. 2021;11(5):433. https://​doi.​org/​10.​3390/​jpm11050433.
31.
Yost J, Ganann R, Thompson D, Aloweni F, Newman K, Hazzan A, et al. The effectiveness of knowledge translation interventions for promoting evidence-informed decision-making among nurses in tertiary care: a systematic review and meta-analysis. Implement Sci. 2015;10:98.PubMedPubMedCentralCrossRef
32.
Johnson MJ, May CR. Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open. 2015;5(9):e008592.PubMedPubMedCentralCrossRef
33.
Dave Davis DA, McMahon GT. Translating evidence into practice: Lessons for CPD. Med Teach. 2018;40(9):892–5.PubMedCrossRef
34.
Thorne S, Kirkham SR, O’Flynn-Magee K. The Analytic Challenge in Interpretive Description. Int J Qual Methods. 2004;3(1):1–11.
35.
Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405.PubMedCrossRef
36.
37.
Lambert SD, Loiselle CG. Combining individual interviews and focus groups to enhance data richness. J Adv Nurs. 2008;62(2):228–37.PubMedCrossRef
38.
Canadian Institutes of Health Research NSaERCoC, Social Sciences and Humanities Research Council of Canada. Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. 2018.
39.
O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.
40.
Kaasalainen S, Sussman T, Thompson G, McCleary L, Hunter PV, Venturato L, Wickson-Griffiths A, Ploeg J, Parker D, Sinclair S, Bello-Haas D. A pilot evaluation of the Strengthening a Palliative Approach in Long-Term Care (SPA-LTC) program. BMC Pall Care. 2020;19(1):107–107. https://​doi.​org/​10.​1186/​s12904-020-00599-w.
41.
Berterö C. Developing qualitative methods - or “same old wine in a new bottle.” Int J Qual Stud Health Well-Being. 2015;10:27679.
42.
Syed I, Daly T, Armstrong P, Lowndes R, Chadoin M, Naidoo V. How do work hierarchies and strict divisions of labour impact care workers’ experiences of health and safety? Case studies of long term care in Toronto. J Nurs Home Res Sci. 2016;2(1):41–9.PubMedPubMedCentral
43.
Arnett K, Sudore RL, Nowels D, Feng CX, Levy CR, Lum HD. Advance Care Planning: Understanding Clinical Routines and Experiences of Interprofessional Team Members in Diverse Health Care Settings. Am J Hosp Palliat Care. 2017;34(10):946–53.PubMedCrossRef
44.
Bollig G, Gjengedal E, Rosland JH. They know!-Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes. Palliat Med. 2016;30(5):456–70.PubMedCrossRef
45.
van Eechoud IJ, Piers RD, Van Camp S, Grypdonck M, Van Den Noortgate NJ, Deveugele M, et al. Perspectives of family members on planning end-of-life care for terminally ill and frail older people. J Pain Symptom Manage. 2014;47(5):876–86.PubMedCrossRef
46.
Seymour J, Almack K, Kennedy S. Implementing advance care planning: a qualitative study of community nurses’ views and experiences. BMC Palliat Care. 2010;9(1):4.
47.
Cresswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. California: Sage Publications; 2013.
48.
Patton MQ. Qualitative Research & Evaluation Methods. Thousand Oaks: SAGE Publications, Inc; 2015.
49.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.CrossRef
50.
Höbler F, Argueta-Warden X, Rodríguez-Monforte M, Escrig-Pinol A, Wittich W, McGilton KS. Exploring the sensory screening experiences of nurses working in long-term care homes with residents who have dementia: A qualitative study. BMC Geriat. 2018;18(1):235.CrossRef
51.
Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328–52.CrossRef
52.
53.
Kapinga L, Huizinga R, Shaker R. Reflexivity through positionality meetings: religion, muslims and ‘non-religious’ researchers. Int J Soc Res Methodol. 2022;25(1):103–17.CrossRef
54.
Lincoln YS, Guba, E.G. Naturalistic injury: Beverly Hills, CA: Sage Publications, Inc.;1985.
55.
Bacon J. The palliative approach: improving care for Canadians with life-limiting illnesses. Ottawa: The Canadian Hospice Palliative Care Association; 2013.
56.
Kaasalainen S, Mccleary L, Vellani S,  Pereira J. Improving End-of-Life Care for People with Dementia in LTC Homes During the COVID-19 Pandemic and Beyond. Can Geriat J. 2021;24(3):164–9.
57.
Teno JM, Gozalo P, Khandelwal N, Curtis JR, Meltzer D, Engelberg R, et al. Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents With Advanced Dementia and Intensive Care Unit Beds. JAMA Int Med. 2016;176(12):1809–16.CrossRef
58.
Dixon J, Karagiannidou M, Knapp M. The Effectiveness of Advance Care Planning in Improving End-of-Life Outcomes for People With Dementia and Their Carers: A Systematic Review and Critical Discussion. J Pain Symptom Manage. 2018;55(1):132–50 e1.
59.
Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53(5):821-32 e1.PubMedPubMedCentralCrossRef
60.
Orsulic-Jeras S, Whitlatch CJ, Szabo SM, Shelton EG, Johnson J. The SHARE program for dementia: Implementation of an early-stage dyadic care-planning intervention. Dementia. 2016;18(1):360–79.PubMedCrossRef
61.
Vellani S, Puts M, Iaboni A, McGilton KS. Voice Your Values, A Tailored Advance Care Planning Intervention in Persons Living with Mild Dementia: A Pilot Study. 2022. Forthcoming.CrossRef
62.
McCormack B. Autonomy and the relationship between nurses and older people. Aging Soc. 2001;21(4):417–46.CrossRef
63.
64.
Heyland DK, Allan DE, Rocker G, Dodek P, Pichora D, Gafni A. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Med. 2009;3(2):e101–10.PubMedPubMedCentral
65.
Song MK, Ward SE, Fine JP, Hanson LC, Lin FC, Hladik GA, et al. Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates. Am J Kidney Dis. 2015;66(5):813–22.PubMedPubMedCentralCrossRef
66.
Piers R, Albers G, Gilissen J, De Lepeleire J, Steyaert J, Van Mechelen W, et al. Advance care planning in dementia: recommendations for healthcare professionals. BMC Palliat Care. 2018;17(1):88.PubMedPubMedCentralCrossRef
67.
Thomas CM, Bertram E, Johnson D. The SBAR Communication Technique: Teaching Nursing Students Professional Communication Skills. Nurse Educ. 2009;34(4):176–80.PubMedCrossRef
68.
Baile WF, Blatner A. Teaching communication skills: using action methods to enhance role-play in problem-based learning. Simul Healthc. 2014;9(4):220–7.PubMedCrossRef
69.
Lally K, Tuya Fulton A, Ducharme C, Scott R, Filpo J. Using Nurse Care Managers Trained in the Serious Illness Conversation Guide to Increase Goals-of-Care Conversations in an Accountable Care Organization. J Palliat Med. 2019;23(1):112–5.PubMedCrossRef
Metadata
Title
Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study
Authors
Shirin Vellani
Elizabeth Green
Pereya Kulasegaram
Tamara Sussman
Abby Wickson-Griffiths
Sharon Kaasalainen
Publication date
01-12-2022
Publisher
BioMed Central
Keyword
Care
Published in
BMC Palliative Care / Issue 1/2022
Electronic ISSN: 1472-684X
DOI
https://doi.org/10.1186/s12904-022-01014-2

Other articles of this Issue 1/2022

BMC Palliative Care 1/2022 Go to the issue

Research

Finding their place – general practitioners' experiences with palliative care—a Norwegian qualitative study

Research

Contribution of Eastern Mediterranean Region countries to palliative care journals from 1991 to 2020 and its relationship to the development of palliative care

Research

A realist evaluation of a home-based end of life care service for children and families: what works, for whom, how, in what circumstances and why?

Research

Palliative care for rural growth and wellbeing: identifying perceived barriers and facilitators in access to palliative care in rural Indiana, USA

Research

Integrating patient- and caregiver-reported outcome measures into the daily care routines of specialised outpatient palliative care: a qualitative study (ELSAH) on feasibility, acceptability and appropriateness

Research

Personal positioning of oncology patients in palliative care: a mixed-methods study