Table 6.
Facilitators of and barriers to implementing ACP in the nursing home unit
| Facilitators: |
| • Clear impact on the organization, routines and responsibilities: - Systematic involvement of nursing home managers - Systematic training of all staff in the unit to clarify new routines - Assigning responsibility to all primary nurses - Routines for dialogue between the physician and nurses (clarifying responsibilities) - Enabling agreement on documentation - Clear schedules for internal training - Clear schedules for conversation with patient and family - Clarified routines for including the patient in relevant discussions - Routines for communications: e.g., telephone and email - List of questions to clarify the needs for the patient and family, including the family’s preferences for involvement - A specified routine for contacting the family without a specific reason - Defined space in staff schedule to discuss ACP as an important topic |
| • Clear communication of the relevance and need for education regarding ACP: - The education conveyed ACP as important and inspiring - Education showed in what way there was potential for improvement - The training material was understandable and improved the competence on ACP - Flash cards were interesting and easy to use, even when time was limited |
| Barriers: |
| • Lack of time: - to teach colleagues in the unit - for the physician to participate at the two-day education seminar, and meetings |
| • Conflicting opinions and culture: - The patient considered not capable to participate at a shared conversation - Perception of already sufficient contact with family |
| • Lack of staff competence: - Challenging to engage staff with lower education and understanding of ACP - Difficult to get everyone to read the documentation in the journal - Lack of documentation skills - Lack of Norwegian language skills - Too large quantity of training material for part-time or uneducated staff - High level of sick leave among staff leading to unskilled replacements |