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Table 3 Summary of results

From: Contextual factors influencing advance care planning in home care: process evaluation of the cluster-randomised controlled trial STADPLAN

Positive / facilitating factors Negative / hindering factors
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.
  1. ACP Advance care planning, HCS Home care service, NF Nurse facilitator