Table 6 Analysis and Interpretation of Study Findings according to PAGER: Patterns, Advances, Gaps, Evidence for Practice and Research Recommendations

Care and Relationships

Good strong relationships with patients, residents, families, and colleagues contributed to nurse engagement in ACP

Reading patient cues and determining patient readiness was another considerable contributor

Nursing culture with focus on improving health and care of patients was evident

Respecting the patient’s and family’s cultural background through allowing time with ACP was important

Some of the nurses suggested that ACP had the potential to negatively affect relationships

Risk of diminishing hope or causing distress to patients, caused nurses to avoid the topic of ACP

Family dynamics/conflicts were identifiable barriers to ACP

Some patients and their families did not fully understand ACP or palliative conditions

More home visits where nurses could build on the topic of ACP over several visits could enable and maintain pivotal ACP engagement

Sensitive cultural awareness training for nurses would also be beneficial

Nurses to have education in ACP and thus, educate their colleagues, patients, residents, and families enabling awareness

Further education and training in ACP for all nurses working in community-based care

Cultural training to ensure nurses maintain timely and sensitive ACP

Opportunities to enhance communication in difficult topic conversations are recommended

Workload and Resources

Engaging ACP from an approach of shared responsibility

Optimising this value-based team approach offered continuity and support

Adequate resources would enable optimum ACP and end-of-life care or transitions

Nurses had more time for ACP than GPs and thought this to be an important facilitator

GPs were known to initiate ACP and prognostic uncertainty had a strong influence

The medical hierarchy was a barrier for nurses with ACP as medical focus on ‘curative cultures’ was evident

Lack of resources affecting how nurses could deliver optimum palliative care in line with a patient’s ACP was a barrier

Increased pressures of workload with restricted resources (i.e., staffing, support)

Appropriate allocation of workload for staff is vital, including the potential placement of designated key workers in care settings for care continuity

Readily available resources would ensure wishes of patients can be upheld

Auditing and reviewing the workloads as well as resource accessibility for nurses providing palliative care in the community

Evaluating the use of structured tools to support ACP initiation and discussion from community settings as well as the skills required implement these tools in practice effectively

Evaluating the effectiveness of shared responsibility of ACP in community nursing settings

Education and Experience

Nurses with experience in ACP were more likely to carry out ACP conversations in practice

Nurses with formal training in ACP was a facilitator

Having a go-to mentor was seen as beneficial to nurses

Nurses without training in ACP or communication were found to disassociate from any ACP task

Nurses lacked the skill and confidence to have these conversations in practice

Ensuring there are mentorships or preceptorships available to provide necessary support

Ensuring equal opportunities for nurses who would benefit from training in ACP and/or palliative care

upskill these nurses in providing ACP for their palliative patients

Provision of Palliative and EOL care training for all nurses who care for these specific patients

Mentoring programs for nurses, to enhance confidence and competence in practice should be explored

Considering on the job training to open access around training in ACP and/or palliative care