Evaluation of a train-the-trainer implementation strategy on providers’ competency, opportunity and motivation for advance care planning in residential care homes: a mixed-methods study

Abstract

Background

Engaging staff in residential care homes in advance care planning (ACP) is an increasingly important area. The train-the-trainer strategy driven by the Capacity Opportunity Motivation-Behavior Change Model is a promising approach but has limited data. The study aims to evaluate a theory-driven train-the-trainer implementation strategy on ACP engagement.

Methods

An explanatory sequential mixed-methods study was conducted to evaluate an implementation strategy, the train-the-trainer ACP program consisting of an ACP workshop and individualized field coaching. Surveys of ACP competency and ACP readiness were measured pre- and post-workshop. Interviews were conducted after individualized field coaching.

Results

Sixteen enrolled nurses, 17 registered nurses, 18 health assistants, and 8 social workers (N = 59) were recruited from 10 care homes. The age of the care home residents ranged from 67 to 108 years old. Upon completion of the ACP workshop, participants had significant increases in their ACP competency scores from 80.44 ± 15.12 to 96.12 ± 10.79 (t = 5.953, p < 0.001), but no change in their readiness for engaging in ACP (Z = − 0.988, p = 0.329). Following individualized field coaching, participants further reported professional growth (communication skills, understanding of relevant practice guidelines, integration of ACP as a clinical communication tool, and additional role as an information provider and coordinator) and personal gains (appreciation of the health-illness trajectory, urgency to reflect on end-of-life planning, and being prepared to address the challenges of an aging population). Mixed methods analysis showed a distinct causal pathway revealing that participants’ capacity was mostly impacted by the ACP workshop, while their opportunity and motivation in ACP were impacted by the field coaching.

Conclusion

The ACP training program has successfully engaged staff in care homes by increasing their capacity, opportunity, and motivation.

Trial registration

The protocol (version 1.0, dated 20211201) of the trial was first registered on March 23rd, 2023, at ClinicalTrials.gov (identifier NCT06238063).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06898-2.

Text Box 1. Contribution to the literature •A train-the-trainer implementation strategy on advance care planning in residential care homes should include a training workshop and individualized field coaching. •Training workshop itself cannot improve providers’ readiness for advance care planning. •The individualized field coaching is needed to further enhance providers’ readiness for advance care planning by gaining communication skills, knowledge on local practice guidelines, and developing appreciation of the health-illness trajectory and urgency for providing end-of-life care. •A causal pathway connecting the implementation strategy to participants’ outcomes was illustrated based on the Competency Opportunity Motivation for Behavior Change (COM-B) theory.

Background

Advance care planning (ACP) is an opportunity for older adults to express and plan for their own end-of-life (EOL) care. Health and social service providers in residential care homes have established rapport with their residents and, thus, act as ideal coordinators for conducting ACP conversations with the residents and their family members and arranging the services according to the residents’ wishes. However, there were multi-level barriers to implementing ACP in the residential care settings. Lack of willingness in residents and family members to discuss EOL issues, lack of administrative support and limited resources within the system, such as staff turnover, and providers having difficulty in finding time to undertake or engage in ACP are the main determinants in conducting ACP trainings in residential care homes [1].

The COM-B framework refers to the capability, opportunity, and motivation in driving behavior changes [2] and has been successfully applied in the intervention development on tobacco control [3] and self-management of diabetes mellitus [4]. Combes S. et al.’s review of the literature on developing implementation strategies on ACP engagement in frail older adults was guided by the COM-B theory, and they identified that for the health and social professionals, (a) training on communication skills, impact of disease trajectory, liaison, values and beliefs, assessment, and engagement; (b) being proactive in offering ACP opportunities between older adults and family members; and (c) implementing ACP early as part of routine care are likely effective implementation strategies [5]. Though Combes S. et al. has proposed an educational toolkit prototype guided by the COM-B theory, there is a lack of evidence on the acceptability and effectiveness of the COM-B-based intervention in promoting ACP [6].

Given that ACP is not typically integrated into standard practices within residential care facilities in Hong Kong and was not a mandatory component in the nursing education curriculum prior to 2023, it is essential for providers to acquire the necessary knowledge and skills to actively implement and facilitate ACP opportunities. Train-the-trainer is an evidence-based implementation strategy commonly used to foster health and social service providers’ capabilities in promoting clinical behavior changes [7]. The effectiveness of the train-the-trainer program depends on the delivery mode of the program, the design of the training curriculum, and the quality of the accompanying learning materials [8]. In terms of capability in ACP engagement, previous studies have recommended training should focus on improving communication skills using role-play, mentoring, practice using core scripts, and attending programs such as Respecting Choices [5].

This study was part of a wider study implementing a nurse-led ACP in residential care homes (ACP-Care study) in Hong Kong. Residential care homes in Hong Kong are private, subsidized, or contracted by the government, and each home accommodates between 50 and 100 beds, staffed by 4 to 7 nurses, 1 social worker, and 10 to 20 health assistants to provide a full continuum of care. Older adults aged 65 or above with personal, social, health, and/or other reasons who cannot be taken care of at home can apply for a bed through the Social Welfare Department [9]. The train-the-trainer ACP program was delivered as one of the implementation strategies during the implementation phase. The study proposed an evidence-based, COM-B theory-driven train-the-trainer ACP program incorporating a face-to-face workshop and individualized field coaching to facilitate the health and social service providers in residential care homes in developing ACP knowledge, skills, and competency. Our hypothesis was that nurses who received the train-the-trainer ACP program would be able to effectively develop their capacity, opportunity, and motivation to carry out nurse-led ACP in clinical practice.

Methods

Study design and context

An explanatory sequential mixed methods design was adopted to evaluate the train-the-trainer ACP program, including ACP workshop and individual field coaching, and to understand the participants’ experiences [10]. The quantitative approach within the mixed methods design is a pre-and-post workshop assessment to evaluate the acceptability and effectiveness of the training curriculum and teaching approach. After the individual field coaching, semi-structured interviews were designed to describe nurses’ experiences of the ACP intervention delivery.

The train-the-trainer ACP program

The program aimed to train health and social care providers working in care homes to facilitate meaningful and effective ACP conversations and the coordination of services to address the residents’ EOL wishes or care preferences. A 2-day ACP workshop and individualized field coaching were two components designed to target behavior-change constructs of capacity, opportunity, and motivation. Health and social care providers referred to enrolled nurses, registered nurses, social workers, and health assistants. Health assistants in Hong Kong were those who received a certificate or diploma after attending a training course of 200 course learning hours, 16 clinical training hours, and 80 internship hours [11]. All the workshops were delivered on-site in a conference or activity room with multimedia facilities.

ACP workshop

The workshop included a group lecture delivered by an advanced nurse practitioner specialized in ACP in residential care homes to engage learners in learning the concept of ACP through reflection on their own values and experiences related to EOL care and ACP activities, guided presentations to familiarize learners with the ACP tools (pictorial ACP educational booklet and workbook), and simulation sessions using case scenarios and role-play to help learners to practice ACP conversation in an immersive and engaging environment. The curriculum of the workshop was presented in supplementary materials.

Individualized field coaching

Following the workshop, the one-to-one field coaching was delivered by the coach, a research nurse who was a certified ACP facilitator by Respecting Choices. The coaching was delivered to a designated nurse by the superintendent from each home, who subsequently took on the responsibility of coaching other nurses in the implementation of ACP at their institutions. The field coaching served as continuous support specifically for nurses who were actively delivering the ACP for the residents. The nurse first shadowed how the coach conducted ACP following the ACP intervention protocol. For the following cases, the nurses were accompanied by the coach in delivering the ACP intervention using the same ACP protocol until they were confident to deliver it independently. After the joint coaching cases, the nurses conducted the ACP intervention independently, and the coach followed up on each case with the nurse via telephone. Regarding complicated cases, the nurses received more coaching sessions from the advanced nurse practitioner and the research nurse via group discussion, debriefing, and refresher courses.

Design

Participant recruitment

As shown in the study flowchart, Fig. 1, the research team first recruited 10 residential homes with residents’ ages spanning from 67 to 108 by telephone or in-person promotion of the research project to their superintendents. All the health and social service providers, including registered nurses, enrolled nurses, health assistants, and social workers working from the 10 care homes, were eligible for the train-the-trainer ACP program. All the attendees at the workshops were invited to participate in the pre- and post-workshop surveys. After the individual field coaching, all the participants were invited for a semi-structured interview.

Fig. 1.

Study flowchart

Data collection

Structured quantitative data on ACP competency and readiness to deliver the ACP intervention were collected before and immediately after the ACP workshop. A course evaluation scale was also collected immediately after the ACP workshop. Qualitative data were collected via post-coaching interviews to understand participants’ experiences.

ACP competency checklist was to assess individuals’ ACP competency using a 3-point Likert scale (1 = Not met, 2 = Getting there, 3 = Met). It is a self-rating tool of 37 items on three domains, including the basic, beginner, or proficient ACP competency. The basic ACP competency subscale has 3 items on what ACP is. The beginner ACP subscale had 21 items on introducing ACP, supporting people to engage in ACP, and having uncomplicated ACP conversations. The proficient ACP subscale has 13 items on initiating, participating in, and facilitating the more complex ACP discussions and training the beginner ACP nurses in their organizations. The total score ranges from 37 to 111, with a higher score reflecting greater competency in ACP.

Readiness to deliver ACP utilized two open-ended questions: “What does ACP mean to you?” “Please describe how you see your role in the ACP process,” and one rating question of “How comfortable are you initiating or revisiting discussions regarding ACP with residents and their families on a scale of 0–10?” A higher score indicates an increased readiness for ACP.

Course evaluation collected feedback on the content, presentation, and overall performance of the workshop using 13 items on a 6-point Likert scale. An evaluation form that covers the relationship between content and learning—teaching programs/activities and the overall objectives of the educational program/activity, expertise of speakers and facilitators in teaching, appropriateness of teaching methods, and learner’s achievement in each objective.

Incidence of nurse-led ACP cases refers to the total count of ACP cases completed during and following the field coaching, which was documented according to the coach’s level of involvement in each case. This includes the number of cases completed independently by home nurses, those completed jointly by the home nurse and the coach, and those completed solely by the coach.

A post-coaching interview was conducted with participants who had participated in the train-the-trainer ACP program and had facilitated the implementation of the nurse-led ACP intervention in their practice. Interviews were conducted by research assistants experienced in qualitative interviews, either face-to-face or via telephone. The following three questions pertaining to the train-the-trainer ACP program were posed to facilitate participants reflecting on challenges, perceived utility, and training content: “What are your thoughts on the training provided by the research team (namely, the ACP workshop and the individual field coaching)? What was the most challenging part for you? And what was the most useful part for you?”

Analysis

First, a pre/post workshop survey measuring nurses’ ACP confidence and readiness was collected to gather quantitative data. Nurses’ experiences with the program were then examined in semi-structured interviews. Quantitative and qualitative findings were integrated to examine the effectiveness and usability of the overall program in clinical practice and were mapped according to the COM-B framework in order to comprehend the process or mechanism behind participants’ behavior changes.

Quantitative analyses were conducted in SPSS (v28.0, p < 0.05). Participants who did not complete both pre- and post-assessments were excluded from paired analyses. For categorical data, frequency and percentage were used for description. For continuous data, mean and SD were used when the distribution was normal, whereas median and range were used when the data did not conform to a normal distribution. Shapiro-Wilk tests (p > 0.05) confirmed normality for ACP competency scores (total and subscales), justifying paired t-tests. One-way ANOVA compared ACP competency scores across occupational groups, with Bonferroni post-hoc tests for significant results. ACP readiness and course evaluation did not meet normality assumptions, so Wilcoxon signed-rank tests were used for ACP readiness within-group comparisons and Kruskal-Wallis tests for ACP readiness and course evaluation between-group comparisons. Each item in the ACP competency checklist represented one ACP skill, and a score of 3 indicates that the participant is confident in performing the skill. The total number of items scored 3 were counted for each participant. For count data (number of items scored “3 = Met”), Wilcoxon signed-rank tests were used to evaluate changes before and after the intervention within groups. Chi-square tests (or Fisher’s exact tests) compared the proportion of subscales with “3 = Met” responses (recoded as 1 for any “3 = Met” response, 0 otherwise) across groups.

Interviews were audio-recorded with consent and transcribed verbatim in their original language, traditional Chinese. Qualitative data from the semi-structured interviews were analyzed using conventional content analysis, guided by Hsieh and Shannon [12], to generate concepts that will inform the development of the causal pathway between the train-the-trainer components and implementation outcomes on capacity, opportunity, and motivation. Two independent researchers scrutinized the Chinese transcriptions and conducted the analysis in MAXQDA 2020 software [13]. The initial step involved a thorough engagement with the data to grasp a sense of the whole, highlighting specific words for key thoughts, followed by organizing similar thoughts under a broader code and sorting related codes into distinct categories. Then, collaborative discussions focused on the differences in code interpretation and assignment to identify overarching patterns observed within the data. The selected quotations were translated into English, which was then reviewed by the interviewer for accuracy.

Results

We conducted seven workshops for 10 residential care homes in the study in order to accommodate health and social service providers’ schedules and locations for maximum participation. As shown in Table 1, a total of 59 staff from 10 residential care homes, including 16 enrolled nurses (27.1%), 17 registered nurses (28.8%), 18 health assistants (30.5%), and 8 social workers (13.6%), attended the workshop. A total of 83 residents or their family members received the nurse-led ACP. Then, 9 nurses, 2 superintendents, and 2 social workers participated in the post-coaching interviews. In the following sections, the quantitative and the qualitative results were presented, followed by a mixed assessment of them.

Table 1.

Participants’ responses to the questionnaires Pre- and Post-workshop (N = 59)

Outcome	Group	N (attended Day 1 workshop)	Pre-Workshop	N (attended Day 2 workshop)	Post-Workshop
ACP competency (scoring ranges from 37 to 111)
Total, Mean (SD)	All	56	78.96 (15.63)	55	96.05 (10.60)
	Enrolled Nurses	16	76.50 (15.30)	15	96.80 (12.04)
	Registered Nurses	16	80.13 (17.20)	15	90.67 (9.19)
	Health Assistants	17	87.57 (11.98)	17	100.06 (8.19)
	Social Workers	7	87.57 (11.98)	8	96.25 (12.36)
Basic ACP Subscale, Mean (SD)	All	56	7.11 (1.65)	55	8.49 (0.92)
	Enrolled Nurses	16	6.88 (1.45)	15	8.40 (0.99)
	Registered Nurses	16	7.19 (1.80)	15	8.13 (1.06)
	Health Assistants	17	6.88 (1.73)	17	8.88 (0.49)
	Social Workers	7	8.00 (1.53)	8	8.50 (1.07)
Beginner ACP Subscale, Mean (SD)	All	56	44.71 (8.98)	55	54.42 (6.12)
	Enrolled Nurses	16	42.63 (9.16)	15	55.33 (6.23)
	Registered Nurses	16	45.44 (9.97)	15	51.13 (5.69)
	Health Assistants	17	44.24 (8.58)	17	56.47 (5.35)
	Social Workers	7	49.00 (7.05)	8	54.50 (6.78)
Proficient ACP Subscale, Mean (SD)	All	56	27.14 (6.21)	55	33.15 (4.47)
	Enrolled Nurses	16	27.00 (5.75)	15	33.07 (5.38)
	Registered Nurses	16	27.50 (6.74)	15	31.40 (3.94)
	Health Assistants	17	25.53 (6.61)	17	34.71 (3.51)
	Social Workers	7	30.57 (4.39)	8	33.25 (4.95)
ACP readiness (Scoring ranges from 0 to 10)	All	55	7.98 (1.45)	52	7.98 (1.06)
	Enrolled Nurse	16	7.75 (1.39)	14	7.71 (0.73)
	Registered Nurse	16	7.94 (1.34)	16	8.13 (1.15)
	Health Assistants	16	7.88 (1.41)	16	7.81 (1.11)
	Social worker	7	8.86 (1.86)	6	8.67 (1.21)

Quantitative data

ACP competency

Table 2 presented the quantitative results from the pre- and post-workshop evaluation. The quantitative results indicate a significant improvement in participants’ ACP competency after attending the workshop. Overall, the mean total ACP competency scores significantly increased. This improvement was also statistically significant across all ACP competency subscales, including the basic ACP subscale, the beginner ACP subscale, and the proficient ACP subscale.

Table 2.

Pre- and post-workshop outcomes for participants completing both assessments

Outcome	Group	N	Pre-Workshop	Post-Workshop	Change (Post - Pre)	Statistic Value within groups	Pre-Workshop Statistic Value Between Groups	Post-Workshop Statistic Value Between Groups
ACP Competency (scoring ranges from 37 to 111)
Total, Mean (SD)	All	52	80.44 (15.12)	96.12 (10.79)	15.67 (18.98)	t = 5.953, p < 0.001	F = 0.939, P = 0.429	F = 2.913, P = 0.044
	Enrolled Nurses	15	77.47 (15.32)	96.80 (12.04)	19.33 (18.09)	t = 4.139, p = 0.001
	Registered Nurses	14	82.71 (16.55)	89.93 (9.06) a	7.21 (14.92)	t = 1.810, p = 0.094
	Health Assistants	16	78.13 (14.85)	100.94 (7.58) b	22.81 (19.46)	t = 4.689, p < 0.001
	Social Workers	7	87.57 (11.98)	96.00 (13.33)	8.43 (21.76)	t = 1.025, p = 0.345
Basic ACP Subscale, Mean (SD)	All	52	7.29 (1.56)	8.50 (0.92)	1.21 (1.94)	t = 4.495, p < 0.001	F = 0.842, P = 0.447	F = 2.983, P = 0.040
	Enrolled Nurses	15	7.00 (1.41)	8.40 (0.99)	1.40 (1.76)	t = 3.073, p = 0.008
	Registered Nurses	14	7.50 (1.70)	8.07 (1.07) a	0.57 (2.17)	t = 0.984, p = 0.343
	Health Assistants	16	7.06 (1.61)	9.00 (0.00) b	1.94 (1.61)	t = 4.810, p < 0.001
	Social Workers	7	8.00 (1.53)	8.43 (1.13)	0.43 (2.23)	t = 0.510, p = 0.629
Beginner ACP Subscale, Mean (SD)	All	52	45.50 (8.78)	54.50 (6.23)	9.00 (10.84)	t = 5.987, p < 0.001	F = 0.734, P = 0.537	F = 2.899, P = 0.044
	Enrolled Nurses	15	43.33 (9.02)	55.33 (6.23)	12.00 (10.79)	t = 4.307, p < 0.001
	Registered Nurses	14	46.50 (10.22)	50.79 (5.74) a	4.29 (8.79)	t = 1.824, p = 0.091
	Health Assistants	16	45.13 (8.01)	57.00 (5.05) b	11.88 (10.74)	t = 4.421, p < 0.001
	Social Workers	7	49.00 (7.05)	54.43 (7.32)	5.43 (12.63)	t = 1.137, p = 0.299
Proficient ACP Subscale, Mean (SD)	All	52	27.65 (5.99)	33.12 (4.57)	5.46 (7.69)	t = 5.122, p < 0.001	F = 1.187, P = 0.325	F = 1.873, P = 0.147
	Enrolled Nurses	15	27.13 (5.93)	33.07 (5.38)	5.93 (6.41)	t = 3.586, p = 0.003
	Registered Nurses	14	28.71 (5.85)	31.07 (3.87)	2.36 (6.02)	t = 1.465, p = 0.167
	Health Assistants	16	25.94 (6.60)	34.94 (3.49)	9.00 (8.78)	t = 4.101, p < 0.001
	Social Workers	7	30.57 (4.39)	33.14 (5.34)	2.57 (8.32)	t = 0.817, p = 0.445
Number of qualified items in ACP competency
Basic ACP Subscale, n (%)	All	52	82 (52.56%)	133 (85.26%)	32.69%	Z=−3.869, p < 0.001	X2 = 0.860, P = 0.890	X2 = 4.295, P = 0.135
	Enrolled Nurses	15	20 (44.44%)	37 (82.22%)	37.78%	Z=−2.553, p = 0.011
	Registered Nurses	14	25 (59.52%)	31 (73.81%)	14.29%	Z=−0.960, p = 0.406
	Health Assistants	16	22 (45.83%)	48 (100%)	54.17%	Z=−2.994, p < 0.001
	Social Workers	7	15 (71.43%)	17 (80.95%)	9.52%	Z=−0.408, p = 0.875
Beginner ACP Subscale, n (%)	All	52	337 (30.86%)	656 (60.07%)	29.95%	Z=−4.370, p < 0.001	X2 = 1.992, P = 0.639	X2 = 3.336, P = 0.317
	Enrolled Nurses	15	79 (25.08%)	205 (65.08%)	40.00%	Z=−3.015, p < 0.001
	Registered Nurses	14	105 (35.71%)	131 (44.56%)	8.84%	Z=−1.157, p = 0.267
	Health Assistants	16	95 (28.27%)	233 (69.35%)	43.45%	Z=−2.832, p = 0.002
	Social Workers	7	58 (39.46%)	87 (59.18%)	19.73%	Z=−1.183, p = 0.297
Proficient ACP Subscale, n (%)	All	52	190 (28.11%)	378 (55.92%)	27.81%	Z=−3.892, p < 0.001	X2 = 1.798, P = 0.658	X2 = 4.458, P = 0.194
	Enrolled Nurses	15	47 (24.10%)	111 (56.92%)	32.82%	Z=−2.894, p = 0.002
	Registered Nurses	14	59 (32.42%)	74 (40.66%)	8.24%	Z=−0.714, p = 0.524
	Health Assistants	16	46 (22.12%)	143 (68.75%)	46.63%	Z=−2.988, p < 0.001
	Social Workers	7	38 (41.76%)	50 (54.95%)	13.19%	Z=−0.736, p = 0.531
ACP Readiness (scoring ranges from 0 to 10), Mean (SD)/Median (Range)	All	48	7.92 (1.50)/8.00 (4.00–10.00)	8.04 (1.05)/8.00 (6.00–10.00)	0.13 (1.00)	Z=−0.988, p = 0.329	H = 3.707, P = 0.295	H = 5.104, P = 0.164
	Enrolled Nurses	14	7.71 (1.49)/8.00 (5.00–10.00)	7.71 (0.73)/8.00 (7.00–9.00)	0.00 (1.36)	Z=−0.122, p = 0.897
	Registered Nurses	15	8.00 (1.36)/8.00 (4.00–10.00)	8.27 (1.03)/8.00 (6.00–10.00)	0.27 (0.80)	Z=−1.265, p = 0.359
	Health Assistants	14	7.71 (1.44)/8.00 (5.00–10.00)	7.86 (1.17)/8.00 (6.00–10.00)	0.14 (0.77)	Z=−0.707, p = 0.750
	Social Workers	5	8.80 (2.17)/10.00 (5.00–10.00)	8.80 (1.30)/9.00 (7.00–10.00)	0.00 (1.23)	Z = 0.000, p = 1.000
Course evaluation (6–78), Mean (SD)/Median (Range)	All	39	NA	63.26 (5.33)/65.00 (43.00–71.00)	NA	NA	NA	H = 4.381, P = 0.223
	Enrolled Nurses	14	NA	62.64 (5.72)/64.00 (49.00–71.00)	NA	NA
	Registered Nurses	15	NA	64.60 (2.41)/64.00 (60.00–70.00)	NA	NA
	Health Assistants	4	NA	57.25 (10.14)/60.50 (43.00–65.00)	NA	NA
	Social Workers	6	NA	65.33 (3.50)/65.00 (60.00–71.00)	NA	NA

# of competent skills in basic ACP = # of responses scored 3 in the basic ACP subscale

# of competent skills in beginner ACP = # of responses scored 3 in the beginner ACP subscale

# of competent skills in proficient ACP = # of responses scored 3 in the proficient ACP subscale

Percentage of competent skills in basic ACP = # of responses scored 3 / # of total responses of the basic ACP subscale

Percentage of competent skills in beginner ACP = # of responses scored 3 / # of total responses of the beginner ACP subscale

Percentage of competent skills in proficient ACP = # of responses scored 3 / # of total responses of the proficient ACP subscale

ACP competency improvement varied among different occupational groups, and only enrolled nurses and the health assistants had significant improvements in total ACP competency scores. In the pre-workshop assessment, social worker participants had the highest score (mean = 87.57, SD = 11.98), and enrolled nurse participants had the lowest (mean = 77.47, SD = 15.32), while there was no significant difference among enrolled nurses, registered nurses, health assistants, and social workers. In the post-workshop evaluation, health assistant participants had the highest score (mean = 100.94, SD = 7.58), and registered nurse participants had the lowest (mean = 89.93, SD = 9.06). Furthermore, post-hoc tests revealed that health assistants had significantly higher mean scores compared to registered nurses in total ACP competency, Basic ACP, and Beginner ACP.

In the analysis to examine the number of items rated as ‘met’ (a score of 3) on the ACP competency assessment, significant increases were observed within-group on each ACP competency subscale. Enrolled nurses and health assistants demonstrated significant increases in the percentage of ‘Met’ items across these three subscales after attending the workshop. However, there were no significant differences in the number of items rated as ‘Met’ among the four occupational groups at the pre- and post-workshop assessments, respectively.

ACP readiness

No statistically significant improvement in participants’ ACP readiness post-intervention, with the overall median score remaining at 8.00. ACP readiness did not differ significantly for any occupational group. At the pre-workshop assessment, social workers reported the highest median readiness score at 10.00, while both enrolled nurses and health assistants had the lowest median scores at 8.00. Post-intervention, social workers continued to have the highest median score at 9.00 (mean = 8.80, SD = 1.30), with enrolled nurses and health assistants again showing the lowest median scores at 8.00.

Course evaluation

The average course evaluation score was 63.26 (SD = 5.33). Social workers rated the course highest (mean = 65.33, SD = 3.50), followed closely by registered nurses (mean = 64.60, SD = 2.41). However, no statistically significant difference was found in evaluation scores across occupational groups (H = 4.381, p = 0.223).

Incidence of nurse-led ACP cases

During the implementation period of the study, a total of 83 cases were recorded as shown in Fig. 1. This included 50 cases that were completed independently by 11 home nurses, 29 cases completed collaboratively by the home nurse and the coach, and 4 cases completed solely by the coach due to the unavailability of the home nurse. One case remained incomplete due to the unfortunate passing of the resident.

Qualitative data

This section will present the qualitative data collected from the post-ACP workshop course evaluation and the semi-structured interviews conducted after participants engaged in field coaching.

Post ACP workshop course evaluation (before field coaching)

New angle on viewing ACP

As part of the ACP readiness scale, one of the two open-ended question was ‘what does ACP mean to you?’ Data indicated that some participants expressed a new angle on viewing ACP. For instance, one participant (Nurse #1) stated before workshop, ‘ACP means EOL planning for residents,’ and after the workshop, ‘ACP is part of an individual care plan. End-of-life patients express their wishes while conscious, and patients understand and exercise their rights to refuse medical/emergency procedures.

Roles of information provider and coordinator

Many staff initially viewed their role in ACP more as a caregiver, and after completing the workshop, they viewed themselves also as a coordinator and information provider. For example, before workshop, one nurse (Nurse #3) stated, ‘my role in ACP is as a caregiver’; after workshop, ‘my role in ACP is as a caregiver, information provider, coordinator, and executor for patients and their families.’

Post-coaching interview

The participants perceived the train-the-trainer ACP program as opportunities for professional growth and personal gain. Codes under the professional growth category comprised the communication skills on EOL topics, knowledge on the ACP process and relevant practice guidelines, rethinking of nurses’ role in providing EOL care, and the integration of ACP as an EOL communication tool in their practice. Codes under the personal growth category were appreciation of the health and illness trajectory, enhanced urgency to introduce EOL topics for their residents and themselves, and nurses being prepared to address the challenges of an aging population.

Professional growth - communication skills on EOL topics

Nurses acquired techniques for initiating conversations, communication skills in EOL discussions, managing emotional responses, and recognizing appropriate timing for EOL discussions with residents and family members. Three participants stated the following:

“She (instructor) taught us that maybe when you see many cases being admitted or just being discharged from the hospitals. These are good teachable moments to talk to the family about the current situation and what might be happening (to the resident) in the future and set up a nursing care plan with the family members first and then the ACP plan. Or at the annual ICP meeting, …we can talk to them in depth, step by step.” (Nurse #13).

“… how to talk to family members. For example, when the family members are emotionally sensitive, you may need to stop talking about the topic.” (Nurse #15).

“We were also taught how to intervene with the residents and their families, how to bring up this topic with them, and the communication skills involved. Since this topic is quite complex to start the discussion without a clear rationale, this workshop is very useful.” (Nurse #12).

“The training program (one-to-one field coaching) we are doing this time is actually quite good. And it’s great that you (the research nurse) are now shadow training us to lead this discussion. At least I have gone from not knowing how to talk to them to gradually learning how to communicate with them.” (Nurse #39).

Professional growth—knowledge on EOL guidelines and practices

Additionally, the program deepened their understanding of EOL care practices, such as Advance Directives (AD) and Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) protocols, equipping them to implement medical directives and engage families more effectively. The Train-the-Trainer workshop has significantly enhanced staff’s understanding of EOL care practices, including AD, ACP, and DNACPR protocols. Three nurses noted:

“The workshop gave a lot of information about advance medical directives, especially what to expect after signing it or knowing the legal aspects.” (Nurse #31).

“That experience can refresh our understanding of what can be provided to the elderly in Hong Kong and what plans are available, such as AD, EOL, and DNACPR, and refresh our understanding in this regard.” (Nurse #12).

“We have gained a more concrete understanding of the ACP project. We can participate, engage, and ask questions. The biggest challenge is the specific terminology used in ACP—I am surprised at how much I misunderstood.” (Social worker #1).

Professional growth—Integrated ACP as a clinical tool to support EOL planning

One nurse reflected on how the ACP can help fill in the gap of existing services by serving as a communication tool on EOL care and recognized the importance of ACP for the providers in the residential care homes, residents, and their family members. Two nurses commented as follows:

“…Family members and residents may have made certain arrangements without informing the nursing home staff, leading to misunderstandings … When advanced care plans are put in place, we follow a set guideline to ensure thorough communication with the family.” (Nurse #5).

Professional growth—Recognition of the EOL care nurses can provide

Some nurses started to recognize the nursing care that can be accessible for residents. This rethinking of how to leverage existing resources for improving the EOL services in residential care homes has broadened their awareness of the resources available for elderly care and emphasized the significance of attentive, individualized approaches to resident needs, as seen below.

“The overall experience (from workshop to field coaching) actually taught me so much about the whole process. Leading up to ACP EOL, and most importantly, from that project, I realized that our institution is not limited to doing this much. We can indeed do more for our residents in some aspects … For example, when a resident expresses his love for listening to music, can we provide a radio to play his favorite songs? These are simple things we can do. But before this plan, did we really pay attention to these details?” (Nurse #13).

Personal gains - Appreciated the health illness trajectory

Nurses who joined the workshop reported a deeper comprehension of the progressive decline in residents’ health and gained practical knowledge on implementing medical directives and following up with families. They also enhanced understanding through role play and case scenarios. Three participants expressed that.

“Help in nursing and communication. For example, in terms of nursing care, when a resident’s condition gradually declines—such as swallowing ability and overall physical health—we now have a deeper understanding of this (health illness trajectory)”. (Superintendent #6)

“I find the most useful part of this workshop to be the case scenario role-play. I think adding more scenarios, along with time-to-time changes from early EOL care to terminal stages, would provide a more comprehensive view of ACP in EOL.” (Social worker #1).

“After training, we are aware of when to initiate end-of-life care, for example, when a resident has more frequent admissions or a decline in overall condition. We proactively discuss with social workers and convene a family meeting…” (Superintendent #1).

Personal Gains—Enhanced urgency to reflect on EOL plan

The program encouraged some nurses to introduce the advanced medical directives by reaching out to more resources for their residents and to reflect on their own preferences regarding medical directives, fostering personal development alongside professional growth. One participant stated the following:

“I now have a much clearer understanding of how to set up an advance medical directive. Before, I only had a general idea, but now I understand it in much more detail, including how to follow up afterward. In addition to working with you (the research team), we also reached out to the Kwong Wah (Hospital) outreach (team) and asked their nurses to follow up on issues related to the DNR.” (Nurse #17).

“Besides benefiting the residents, this experience has also made me think more about how I would set up my own advanced medical directive in the future. I feel that it has been helpful for me on a personal level as well.” (Nurse #15).

Personal Gains—Nurses being prepared to address the challenges of an aging population

Participants recognized the evolving clinical trend in Hong Kong’s elderly care facilities, which emphasizes a shift from traditional bedside care to a more informed and nuanced approach to EOL issues. This necessitates an increase in both knowledge and skill sets, as nurses must understand that not all conditions can be managed to a satisfactory outcome. Participants stated the following:

“Nurses need to understand that the current clinical trend has evolved beyond just providing routine bedside care. We must introduce the concept that, as Hong Kong residential care homes implement ACP … Not every illness can be fully treated and recovered…Therefore, we must shift our mindset.” (Superintendent #6).

“… after conducting several coaching sessions and showcasing (what they have learned), I noticed an increase in their confidence. They have become more proactive and ready to take the lead, especially when asked by their families. Some cases may have already required decisions during hospital stays or after being withdrawn, and in those situations, family members facilitate discussions, making it easier to grasp the topic and initiate conversations.” (Superintendent #1).

“I wish the project could be continuous to provide sustainable training to the nurses due to the high turnover rate of nurses.” (Social worker #1).

“…the training is important to help nurses better understand their role in the care home—not just in terms of daily care, medical, and physical care. Discussing ACP and assisting elderly residents and their families in facing and preparing for death are also essential parts of their responsibilities. If the training can plant this seed in their mindset, it will make it easier for them to carry out these duties.” (Service manager/social worker #2).

Mixed methods evaluation of the train-the-trainer ACP program

We hypothesized that nurse participants receiving both components of the train-the-trainer ACP program can successfully foster the capacity, opportunity, and motivation to perform nurse-led ACP interventions. Both qualitative and quantitative results were mapped to identify whether the program had been effectively operationalized to target key constructs of the COM-B theory. As illustrated in Fig. 2, data collected at the post-ACP workshop were coded in black, and data collected after field coaching in blue. Improvements in ACP skills, knowledge, and preparedness, as well as a perception of expanded responsibilities for nurses in ACP, were the outcomes of the ACP workshops, indicating a growth in nurses’ ACP capacity and opportunities. Additional outcomes following the personal field coaching section included improved mental preparedness for caring for the rising aging-specific needs, appreciation of the health-illness trajectory, integration of the ACP intervention as a clinical tool, and recognition of the pertinent EOL care nurses can provide. These findings suggested a further development of opportunities and motivation in nurses. Thus, our findings supported our hypothesis that the train-the-trainer ACP program was operationalized in accordance with the COM-B theory and facilitated the development of nurses’ capacity, opportunity, and motivation in implementing ACP into the routine care at residential care homes.

Fig. 2.

Causal pathway between the train-the-trainer components and intended outcomes

Discussion

Our train-the-trainer ACP program, comprising an ACP workshop followed by individual field coaching, successfully equipped social and health service providers, especially nurses, with the capacity, opportunity, and motivation to implement ACP as part of routine clinical practice. The workshop focused on enhancing capacity and creating opportunities, while the field coaching emphasized motivation and opportunity. This distinction underscores the unique role each component plays in facilitating effective behavior change.

All residential care home providers, including health assistants, should be included as a broad approach in the ACP training. The ACP Framework from the UK Marie Curie Palliative Care Institute [14] highlighted that ACP training for health and social care professionals should be conducted routinely, and previous research has shown that it is possible to train laypersons to conduct ACP talks in the community [15]. Our ACP workshop addressed the preparation and knowledge for varying levels of health and social workers as target ACP facilitators and demonstrated positive growth of their ACP competency. In the post-workshop assessment, both the enrolled nurses and health assistants had significant improvement in their ACP competency after attending the ACP workshop. We found engaging all the health and social service providers during the ACP workshop helped to build a consensus on promoting quality EOL care. For example, social workers were more willing to coordinate services for completing the wishes of residents. This could address the communication barriers across different providers commonly reported in the long-term care settings [16]. Furthermore, many service providers in the long-term care settings are in trusting relationships with the residents and thus are well placed to assist the ACP process and to advocate for the care according to residents’ preferences. Thus, it is essential that all providers of residential care homes are included in ACP training as part of a comprehensive approach.

In terms of capacity building, our evidence-based teaching strategies (role-play, case scenarios, and using pictorial ACP education material) [17] demonstrated a positive impact on physical and cognitive capacity building. This finding corroborates a previous review that found 43 training programs implemented simulation activities as the main educational strategy in palliative care training [18]. Notably, high-fidelity communication training ACP conversations following the SPIKE protocol (for disclosing unfavorable information to patients) demonstrated a medium effect size on improving knowledge and self-confidence scores [19]. ACP educational material was another teaching tool that was used during the workshop to guide the clinical workflow as a communication and documentation tool. Similarly, care providers in the US also stated that ACP education materials were beneficial in preparing for and complementing the complex, interpersonal, and interprofessional process [20]. In addition, the education materials with colored illustrations were likely to help reduce the distress and anxiety during the discussion on EOL care [21]. Furthermore, these visual or interactive strategies can engage providers to foster a positive perspective, which is beneficial for teaching EOL topics within the context of Chinese culture, where conversations about death are generally not welcomed by older adults.

When examining the impact of ACP training on the opportunity to engage in ACP, first, we found that the ACP training served as an external factor [22] that enabled nurses to better understand the needs of both residents and families in expressing their preferences for care and to seek opportunities in improving care quality and reducing misunderstandings. We observed nurses started to take on the roles of information provider and communication coordinator. The inclusion of the ACP role in nursing revealed that nurses would be more inclined to start and continue the ACP communication as part of their routine practice. Secondly, the ACP education material functioned as a ‘physical opportunity’ via ‘environmental restricting and modelling’ [22]. It restructured the communication and documentation process on EOL care because there are currently no practice guidelines for carrying out and recording EOL care planning. In accordance with the present results, previous studies have demonstrated that ACP training for care home staff was effective on ACP documentation and uptake of ACP practice [23].

Our train-the-trainer ACP program contributed to the participants’ reflective and automatic motivation in ACP. Reflective motivation refers to the conscious thought process in behavior planning and evaluation, whereas automatic motivation is the instinctive desire or affection for behavior change [22]. Transformation in perspective is crucial for adapting to the complexities of EOL care in a Chinese cultural context that sees death as a taboo topic [24]. Our ACP training encouraged nurses to adopt a mindset that acknowledged the limitations of care and appreciated the health and illness trajectory, motivating a more realistic and compassionate approach in their care planning for residents. In addition, the increase of automatic motivation, as shown by mental readiness and enhanced urgency to reflect on EOL planning, suggests that participants recognized the evolving clinical trend in Hong Kong’s long-term care facilities, which emphasizes a shift from traditional bedside care to a more informed and nuanced approach to EOL issues. This positive shift in providers is consistent with the findings from an earlier observational study that found older individuals initially embraced ACP with a concern for quality of life rather than quantity of life and that their main motive for joining ACP was early EOL planning with the aim of dying with dignity [25].

The synergistic effect of the behavior change techniques, specifically the ACP workshop and field coaching, underscores the significant contributions each made toward achieving the behavioral targets outlined in the key theoretical determinants of the COM-B framework. It is imperative to establish a solid foundation of knowledge and skills through simulated training or workshops prior to allowing providers to practice ACP in real-world settings. Our findings indicate that providers who possess limited background ACP knowledge or who failed to fully engage in the ACP workshop sessions demonstrated a decreased willingness to collaborate with the research nurse during field coaching. This suggests that nurses who are not adequately equipped with the necessary physical and psychological capacity through the ACP workshop may experience decreased confidence when initiating hands-on practice with the coach. Moreover, this means that each behavior change technique must be carefully tailored to the competency levels of individual providers, especially given the widespread lack of ACP capacity among providers within residential care homes.

Future ACP training programs in the care homes should have the following characteristics. First is to involve more service providers such as nursing assistants, social workers, service managers, superintendents, and other social and health service providers. Second is to implement simulation activities such as role play and case scenarios. Third is to have legible, user-friendly ACP education material as a teaching tool and an implementation strategy to drive the physical change in clinical practice, particularly documentation. Fourthly, the one-to-one field coaching that reinforces their knowledge, skills, and motivation in ACP is essential in engaging and sustaining nurses’ uptake of ACP. Lastly, considering the high turnover rates in most residential care homes, diverse educational initiatives should be implemented consistently to strengthen the workforce’s capacity in ACP.

Limitations

There are several limitations to the research described in this study. Due to the limited follow-up period, the evaluation primarily focused on the trainer aspect of the train-the-trainer strategy, and data were limited regarding the trainer’s effectiveness in successfully training other colleagues. Secondly, during the implementation phase, the ACP-Care project has employed various implementation strategies within residential care homes to enhance the uptake of ACP. The observed increase in the incidence of nurse-led ACP cases can be attributed to the cumulative effect of these strategies. Thirdly, it is important to note the train-the-trainer strategy that had an impact on increasing providers’ participation in ACP was specifically designed to address the unique contextual factors present in residential care homes, and its impact in alternative settings may not be assured.

Conclusions

Our findings corroborated our hypothesis that the ACP workshop and individualized field coaching of the train-the-trainer ACP program successfully enabled staff in care homes to actively engage in ACP. We identified effective ACP training components in long-term care settings and presented a causal pathway linking the training components to the targeted outcomes to demonstrate how the COM-B theory informed the training design and outcome evaluation.

Abbreviations

ACP

Advance care planning

EOL

End of life

COM-B

Capacity, opportunity, and motivation—behavior

AD

Advance Directives

DNACPR

Do Not Attempt Cardio-Pulmonary Resuscitation

Authors’ contributions

CL, CC and DC conceptualized the study. TW was responsible for the project management data curation. TW and JC conducted the final analysis, and wrote the original draft manuscript. CL, DC, and CC edited the manuscript. All authors read and approved the final manuscript.

Funding

The study was part of a larger trial titled ‘Implementing a nurse-led advance care planning (ACP) intervention to improve ACP update in residential care homes: An implementation science and mixed methods pragmatic cluster randomized controlled trial (05200158)” has undergone independent peer-review, and was funded by the Health Medical Research Foundation under the Health Promotion Scheme (1.5 million Hong Kong Dollar).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval has been obtained from Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster Institutional Review Board (reference number UW 22 − 021). All participants provided informed consent before joining the study. Ethical approval has been obtained for all phases of the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.