Table 3:

Strategies to Overcome Challenges Implementing the ADVANCE Protocol

Challenge	Strategy to Overcome Challenge
Nursing Home (NH) Recruitment
Identifying HRRs1 and NHs with varied intensity of advanced dementia care	Used Minimum DataSet to quantify tube-feeding and hospitalizations rates of advanced dementia residents in all US NHs. Focused on 9 states from diverse regions with known variations in care
Recruiting 4 NHs in 4 HRRs (total 16 NHs) varied intensity of advanced dementia care	Targeted HRRs with greatest number of high and low intensity candidate facilities. Leveraged connections with local academic and clinical colleagues to introduce our team to NH administrators. Expanded recruitment to adjacent HRR in Georgia with similar intensity of care profile as originally HRR.
COVID-19 interruption	Delayed NH recruitment in final HRR.
Staff and Proxy Recruitment
Develop trust with staff members	Attended staff meetings, forged relationships with leadership who facilitated staff introductions, “hung out” at nurses’ stations, ate meals with staff, brought food.
Recruit staff with varied perspectives	Targeted staff from varied disciplines providing advanced dementia care. Offered $25 incentive.
Identify and recruit proxies	Staff introduced research team members to proxies. Offered $25 incentive.
Recruit 2 Black proxies in each NH	Used Minimum DataSet to identify NHs with ≥ 3 Black residents.
Data Collection
Assure credibility and dependability.	Engaged in observations on various shifts and days, triangulated data sources and data collectors.
Be organizationally, culturally, and racially sensitive	Research team members experienced in NH research, staff received structured training in minority research, paired racially concordant interviewers and interviewees.
Inability to complete interviews during site visit	Interviews completed by telephone after site visit.
Manage complex data from multiple sources	All data collected and linked electronically using multiple platforms (e.g., REDCap, Sharefile, NVivo).
COVID-19 interruption	In fourth HRR, proxy and staff interviews were done by phone; on-site data collection deferred.
Emotional demand on data collectors	Training and preparation for data collection. Emotional support. Plan to respond to poor-quality care.
Qualitative Data Analyses
Need to accurately interpret and validate the experiences of participants	Remain sensitive to the need to incorporate cultural and racial knowledge. Included research team members in discussion and interpretation of findings.
Correctly transcribing interviews from interviewees with accents	Transcribers from different backgrounds were employed.

¹HRR = Health Referral Region