Table 3 Summary of results

Study context

• HCS were satisfied with the conduct of the study and the collaboration with the universities

• Participating HCS were highly motivated to test a new intervention to improve service for their patients.

• Recruitment difficulties on the level of HCS (resource scarcity)

• Recruitment difficulties on the level of patients (main reasons: not interested in the topic, felt sufficiently prepared, topic to burdensome)

• The SARS-CoV-19-pandemic interfered with the STADPLAN study regarding the intervention and data collection.

Context of nurses and home care services

• NFs had the qualification and experience required.

• NFs had a positive attitude towards ACP and were motivated to perform the intervention.

• Conversations on advance directives and power of attorney partly established in HCS or activities planned.

• NFs anticipated obstacles on patient level and had doubts regarding the applicability of ACP in the home care setting.

• Organisational barriers (resources and workflow).

Implementation

• Both workshop days were performed as planned.

• All NFs were reached at day 1

• NFs were highly satisfied with the workshops.

• Not all NFs present on day 2, due to illness, workload and change of employer.

Process outcomes NFs

• Knowledge, self-perceived competencies, and motivation on NFs level reached.

• NFs described feelings of insecurity and doubts.

• NFs anticipated obstacles regarding caregivers’ and patients’ acceptance of the intervention.

Context of patients, caregivers, and the dyad

• Patients and caregivers describe high satisfaction with HCS and trusting relationship.

• Open-mindedness of caregivers and patients for ACP.

• NFs observed difficult decision-making processes in families.

• High variety of contextual factors on patients’ and caregivers’ level.

• Deviating perception of NFs and caregivers regarding caregivers’ engagement in decision-making and ACP.

Intervention

• Intervention mostly implemented as planned.

• NFs developed strategies to overcome obstacles.

• Patients and caregivers were mostly satisfied.

• Information brochure rated as useful by most participants.

• Not all patients reached, not all patients received two conversations

• Some conversations too short for in-depth reflection and communication.

• Obstacles on level of patients (acceptance and capability to participate), NFs (competencies and personality) and organisations (resources).

• Conversations and information brochure too complex for some patients.

• Adverse events (three patients stopped participation feeling overburdened by data collection or intervention).

Process outcomes individual level (patients, caregivers, and dyad)

• Patients felt well informed and gained clarity about their wishes.

• Patients’ increased awareness and activities like communication, documentation reported by all participant groups.

• Caregivers reported deeper understanding and conversations in the dyad, reflection, awareness and plans for activities.

• Patients and caregivers describe that the intervention had no additional benefit or made no changes for themselves and the dyad.

• NFs reported caregivers were difficult to integrate in conversations (time constraints, patients refusing to involve them).

• NFs reported persistent insecurities and deviances in decision-making in dyads.

Process outcomes on the level of HCS

• Heads of HCS and nursing staff better informed and aware of ACP, motivated to further implement the topic.

• Organisational changes like redesigning the assessment of patients’ ACP activities and documents took place.

• Plans for further activities regarding ACP services in the organisation were described.

• HCS and nurse staff were severely disappointed to be randomised into control group.

• Study participation was too demanding and time consuming.

Context macro level

• HCS are an important access point to ACP.

• Interprofessional and trans sectoral collaboration supports ACP and treatment according to patients’ preferences.

• The general population develops increasing awareness of the relevance of ACP and palliative care.

• Currently, ACP services are fragmented and access for people with impaired health or care-dependency is too burdensome.