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

Abstract

Background The STADPLAN study is a cluster-randomised controlled trial including 27 home care services in Germany. It assesses the effect of an advance care planning (ACP) intervention delivered by trained nurses to older care-dependent patients. Patients received two ACP conversations and an information brochure. Nurses were educated through a two-day programme and topic guides structuring the conversations. Objectives of the process evaluation were to determine: [1] whether the intervention was implemented as planned, [2] which change mechanisms were observed, [3] whether targeted process outcomes were achieved and [4] in which way contextual factors influenced the implementation process. Methods The process evaluation is based on a mixed methods approach following the recommendations of the UK-MRC framework for the development and evaluation of complex interventions. Qualitative and quantitative assessments were developed and analysed guided by a logic model comprising intervention, participants, mechanisms of change and context factors. The results of the main trial will be published elsewhere. Results Educational programme and topic guides were mostly implemented as planned and resulted in motivation, knowledge, and perceived competencies to facilitate ACP conversations in nurses. Deviances in the performance of ACP conversations indicated patients’ varied individual needs, but also obstacles like reluctance of patients and caregivers to participate actively and time constraints of nurse facilitators. Patients and caregivers reported increased awareness of ACP, planning and other activities indicating that targeted process outcomes could be achieved. The relevance of multifaceted contextual factors acting as barriers or facilitators for the engagement in ACP interventions on the individual, organisational and macro level was evident. Conclusions The process evaluation elicits obstacles and achievements of the ACP intervention. The logic model organised a plethora of mixed methods data into a holistic picture of multifaceted results. Nurses as ACP facilitators in home care can fulfil a crucial initiating role based on a trusting relationship with their patients. To support older care-dependent people’s ACP engagement, access should be simplified. Furthermore, education for nurse facilitators and sufficient resources for service provision are needed. Independent of monetary reimbursement, healthcare providers must respect patients’ choice for or against any ACP intervention. Ethics and trial registration Approved by the Ethics Committees of Martin Luther University Halle-Wittenberg (Ref.-No. 2019–045), Carl von Ossietzky University Oldenburg (Ref.-No. 2019–024), and University of Lübeck (Ref.-No. 19–080). German Clinical Trials Register: DRKS00016886. Registered retrospectively 04/06/2019, first participant included 29/05/2019.

Effects of advance care planning in care dependent community-dwelling older persons (STADPLAN): A cluster-randomised controlled trial

“…They reported it to be time-consuming as the study topic and the design were difficult for patients to understand. Still, of the 15 home care services documenting their recruitment contacts, a total of 36% of patients participated, 15 which is exactly the same proportion found in the Dutch study. 12 Therefore, recruiting home care services seems to be more challenging than recruiting patients.…”

“…Still, the process evaluation showed good knowledge, self-perceived competence and motivation of nurses. 15 In our study, on the other hand, the completion of appointments of surrogates increased in both groups during follow-up. Other studies lack information on this at baseline.…”

“…One cluster in the control group even reported having developed their own concept of ACP during the study, although they had to abandon it due to the COVID-19 pandemic. 15…”

“…The main reasons for non-participation were time-constraints and lack of qualified personnel. 15 This underlines that only highly motivated organisations participated, probably resulting in a positive selection. Recruitment of patients was perceived as difficult by home care services.…”

Development and evaluation of complex interventions in nursing

“…Bei der Entwicklung und Evaluation von komplexen Interventionen in der Pflege müssen verschiedene methodische Herausforderungen berücksichtigt werden, die für simple Interventionen weniger relevant sind. Das MRC-Rahmenmodell stellt eine hilfreiche Ressource zur Planung und Strukturierung des Prozesses dar und wurde in der Pflegewissenschaft bereits häufig verwendet [ 21 , 23 , 28 , 34 ]. Die aktuelle Fassung hebt die Bedeutung des Wirkmechanismus und der dazugehörigen Programmtheorie sowie des Einbezugs des Kontextes und der relevanten Interessenvertretungen hervor.…”