|Positive / facilitating factors||Negative / hindering factors|
• 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).
• 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 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.|