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Table 2 Aim, methods and output of each step in developing Theory of Change map

From: How to achieve the desired outcomes of advance care planning in nursing homes: a theory of change

Step Aim Methods Output
1| To obtain full background information on ACP in Flanders and the nursing home context Contextual analysis by means of: (literature) review of existing policies, national guidelines, national studies of ACP in the Flemish nursing home setting (e.g. EU FP7 project 'PACE') and local/national ACP initiatives for the nursing home setting Background report listing possible barriers and facilitating factorsa for ACP in nursing homes related to 1) the resident (e.g. average time of stay in a nursing home is 3 years), 2) family (e.g. family listed as contact person often not according to regulated cascade systemb), 3) involved care professionals (e.g. GPs in Flanders are not employed by nursing home facilities), 4) facility (e.g. staff shortages), 5) Belgian/Flemish (healthcare) system (e.g. ACP policy not driven by law; existence of formal quality indicators)
2 | To identify the preconditions related to successful ACP in the nursing home setting Systematic review* of empirical studies and reviews (2005–2015) about ACP in nursing homes, by the core research team List of preconditions for ACP in the nursing home setting to be used during workshop 1 to trigger discussion
3 | To create a first draft of the ToC map ToC stakeholder workshop 1 by ToC facilitators (LVDB and LP) and stakeholders First draft of ToC map, including:
▪ Impact, ceiling of accountability and long-term outcomes
▪ Preconditions/intermediate outcomes, including their chronological order
▪ List of possible interventions, assumptions and rationales
4 | To create a second draft of the ToC map based on integration of output from steps 1, 2 and 3 Several meetings with core research team  to construct a draft ToC map Second draft of ToC map, including:
▪ Reformulated impact and long-term outcomes
▪ Preconditions chronologically ordered and coloured according to level to which they are applicable
▪ Precondition “support by an external trainer” (suggested by research team)
▪ Possible interventions (added by the research team) such as the availability of a trainer and a monitoring system
5 | To refine the second draft ToC map, to fill in the gaps and to get consensus on the chronological order of the hypothesised causal pathway ToC stakeholder workshop 2 by ToC facilitators and stakeholders in which second draft of ToC map (output of step 4) is presented Refined draft of second ToC map, including:
• Redefined secondary outcome to be measurable
▪ Additional elements, added in step 4, approved by stakeholders
▪ Details added by stakeholders (e.g. which healthcare professional is responsible for implementing ACP, re-named ACP facilitator as “ACP reference person”)
▪ Additional arrows added by stakeholders
6 | To develop the final draft ToC map that outlines the hypothetical causal pathway of ACP in nursing homes based on integration of output from steps 1 to 5 Several meetings with core research group to construct the ToC map, review by a ToC expert, comparison with existing ToC maps from other research projects and consultation of implementation science literature (in general and about ACP) and relevant theoretical models Further integration of outputs of steps 1–5 into a final draft of a ToC map (presented in Fig. 1) and narrative, including:
▪ Preconditions merged or reformulated and put in chronological order
▪ Numbers added to mark interventions
▪ Rationales and assumptions written up by the core research team in a separate document (narrative), based on stakeholders’ and researchers’ experience, literature and relevant theoretical models
  1. ToC Theory of Change, ACP advance care planning, GP general gractitioners
  2. *The results of this systematic review are elsewhere [35]
  3. aBarriers are defined as contextual elements that inhibit ACP in Flemish nursing homes; Facilitators are defined as contextual elements that can support ACP in nursing homes
  4. bA hierarchical system that regulates who functions as the legal representative/surrogate decision-maker if the person/patient has not assigned a legal representative him−/herself and lacks the mental capacity to make the decisions that have to be made: 1) the spouse or (legal) cohabiting partner, 2) an adult child of the patient, 3) a parent, 4) an adult sibling of the patient, 5) the professional carer representing the patient’s interests in multidisciplinary consultations