Table 6 Facilitators of and barriers to implementing ACP in the nursing home unit

Facilitators:

 • Clear impact on the organization, routines and responsibilities:

  - Systematic involvement of nursing home managers

  - Systematic training of all staff in the unit to clarify new routines

  - Assigning responsibility to all primary nurses

  - Routines for dialogue between the physician and nurses (clarifying responsibilities)

  - Enabling agreement on documentation

  - Clear schedules for internal training

  - Clear schedules for conversation with patient and family

  - Clarified routines for including the patient in relevant discussions

  - Routines for communications: e.g., telephone and email

  - List of questions to clarify the needs for the patient and family, including the family’s preferences for involvement

  - A specified routine for contacting the family without a specific reason

  - Defined space in staff schedule to discuss ACP as an important topic

 • Clear communication of the relevance and need for education regarding ACP:

  - The education conveyed ACP as important and inspiring

  - Education showed in what way there was potential for improvement

  - The training material was understandable and improved the competence on ACP

  - Flash cards were interesting and easy to use, even when time was limited

Barriers:

 • Lack of time:

  - to teach colleagues in the unit

  - for the physician to participate at the two-day education seminar, and meetings

 • Conflicting opinions and culture:

  - The patient considered not capable to participate at a shared conversation

  - Perception of already sufficient contact with family

 • Lack of staff competence:

  - Challenging to engage staff with lower education and understanding of ACP

  - Difficult to get everyone to read the documentation in the journal

  - Lack of documentation skills

  - Lack of Norwegian language skills

  - Too large quantity of training material for part-time or uneducated staff

  - High level of sick leave among staff leading to unskilled replacements