Table 3.

Hospice staff recommendations for behavior and intervention functions linked to COM-B model to address previously identified barriers in engaging hospice recipients and families

Barrier Themes	Recommendation for behavior change intervention or policy (definition) – example and quote
Barriers to Capability	Recommendations re: Capability
Lack of skillset to engage in ACP conversations	Training (imparting skills) – trainings led by specialists or experts “...we used our-- particularly our palliative-care certified physicians on staff are very good at this and using them to train our social workers and gain a level of comfort.” (Site 2, Nurse leader, female [s2-p34-leader-RN])
Overall fatigue, discouragement, or awkwardness in discussing death	Modelling (providing an example for people to aspire or to imitate) – using practice sessions and role-play “...as part of the education they get at orientation...we came up with some scenarios, and then we try to use volunteers to act as patients and families. And then we’re just showing different people’s approaches to having the advanced care planning kind of conversations...you can lecture people, but sometimes to have them have the opportunity to see it...could they shadow some of us that do it all the time?” (Site 2, Physician leader, female, [s2_p27_leader_MD])
Perception of ACP as a checklist (e.g. Hospice Item Set) vs. having a quality conversation and meeting patient’s physical needs and managing symptoms	Enablement (increasing means/reducing barriers to increase capability or opportunity) – focus on building rapport and having quality conversations “...I actually think that conversation can help with advance directives. I think it’s having a conversation first of all what the goals of care are can help someone to better decide about filling out a form for an advance directive. So yeah, I think it’s a more meaningful place to start than just, “Please fill out this form, select if you want to be resuscitated,” I don’t think that’s a very good way to start a conversation or I don’t think it’s a good way to build rapport or anything like that.” (Site 4, SW, female, [s4_p48_clinician_SW])
Barriers to Opportunity	Recommendations re: Opportunity
Time constraints – patient-related	Service provision (delivering a service), e.g. palliative care pre- hospice admission that encourages earlier ACP conversations “And I know that in our palliative care, they do a good job too. The social workers on that side, they do, because when our palliative care patients come to us, they’ve got those [documents].” (Site 1, SW clinician, female [s1_p23_clinician_sw])
Time constraints – staff-related	Education (increasing knowledge or understanding), e.g. provide education to clinicians and administrators in pre-hospice locations such as hospitals and nursing homes. “I would like to see if they could get more presentations in nursing homes and hospitals. That’s where we seem to struggle the most with understanding ... hospitals, they have their own training, probably nursing homes have their own training, but maybe they come from the aspect of how do advanced directives affect a hospice patient or a palliative care patient more so than just in general.” (Site 3, Leader, female, [s3_p4_leader]) Guidelines (e.g. creating documents that recommend or mandate practice, includes all changes to service provision), e.g. mandating ACP conversations for any healthcare encounter “I don’t think people know how important it is to do your care-- to talk, at least talk to your family about what you want. If something should happen to me, because we just see too many people who don’t have a clue, you know. And I hate that, because then I think they end up having a lot of interventions that maybe that patient didn’t want. So or just knowing, just knowing. But, you know, nobody’s really doing that out there. Nobody’s really talking about that... And so I think that, to me, is just the big lack, the big gap in our healthcare right now is folks just not having those conversations.” (Site 1, SW clinician, female [s1_p23_clinician_sw])
Patient and family are unprepared to discuss due to (i) young age, (ii) emotional state, and (iii) lack of appearance of serious illness	Communication/marketing (using print, electronic, telephone, or broadcast media), e.g. providing written manuals or check-lists to introduce and guide conversations “[Our company] has a really great manual that we give people at admission, a comfort and caring manual, and the nurses use that and the social workers and the chaplains as a way to introduce conversations. It’s broken up into a bunch of different chapters ... there’s one on signs and symptoms of you know, the end of life which is really helpful. ... The nurses can say, “Well, let’s look at the manual.. let’s look at chapter one,” and you know, they’re able to start those conversations early” (Site 2, RN clinician, female, s2-p38-clinician-RN)
Complex family dynamics, including conflicting perspectives on ACP and goals of care within families	Service provision (delivering a service), e.g. IDT continues to monitor and revisits at a later time; hospice organization creates a specific committee to handle tough cases “... if I were in a home and I talked with the family and they were adamant that they did not want to discuss the DNR I would typically leave it at that point, because if they’re not in an okay place I’m not going to push that with them .. typically later on it was okay to broach that topic again, but the team would keep that top of mind with that patient.” (Site 1, SW QI, female, [s1_p15_QI_SW])
Lack of resources to serve diverse communities (e.g. reliance on family as translators)	Environmental restructuring (changing the physical or social context), e.g. have the workforce reflect the patient populations one wants to reach “... we think about that strategically, of how to serve the underserved and get the diversity that we need. We need that in our workforce as well.” (Site 2, RN leader, female, [s2_p29_leader_RN]) Enablement (increasing means/reducing barriers to increase capability or opportunity), e.g. expand translator services for all languages “there might be a language barrier and if I’m using a translator, I know in the Vietnamese community ... it’s a small community, so if I got a translator they probably know that family and it’s not necessarily going to stay private. That’s been my experience. So families don’t always necessarily want to talk about some of those things.” (Site 4, SW, female [s4_p51_clinician_SW])
Barriers to Motivation	Recommendations re: Motivation
Personal estimates and perceptions on if and when ACP was done, whether it was documented, ability to find goals of care documentation in medical record, and whether it conflicts with existing patient/family preferences	Environmental restructuring (change the physical or social context), e.g. prompts or easy-access buttons to provide information on what portions of ACP and forms have been done, by whom, and when. “I think that communication of goals of care across sites and between teams could be better. So there are times when I’m asking patients what-- you know, what’s important and what they would like to have done or not done, they’ll say, “Well, I just told that to somebody yesterday, don’t you ever read--” you know, that sort of thing. So, you know, so do people have to kind of print and you need to repeat. So I think, from my standpoint, that could be a little bit better, as far as that communication piece.” (Site 3, MD leader, male, [s3_p1_leader_MD])
Lack of comfort in discussing death and in-depth goals of care conversations	Enablement (increasing means/reducing barriers to increase capability or opportunity), e.g. having clinicians “skilled” in having ACP discussion available “...there’s very skilled clinicians in this company. They make my job easy. They can deescalate folks and maybe they can’t turn around their thoughts that day, but they can certainly educate them within the next few days into understanding what’s going on.” (Site 2, MD leader, female, [s2_p34_leader_MD])
Personal biases, including perception of ACP as a tool which conflicts with (i) ability to have a conversation with the patient and family and (ii) staff’s own personal ability to focus on patient’s physical needs and symptom management (e.g. goals of care is a conversation)	Persuasion (using communication to induce positive or negative feelings or stimulate action) “contrasting the Hollywood approach of you’re going to be resuscitated and everything is great versus what things-- what it actually looks like in practice with some-- certainly there are some statistics we can provide about what the fact that a lot of people do not come back in the same condition after they’ve had CPR. And the potential for brain deterioration and so forth.” (Site 3, QI/NP clinician, female, [s3_p3_QI_NP])
Lack of awareness on cultural differences, difficulty engaging with non-English-speaking patients and families, and leaning on cultural stereotypes	Education (increasing knowledge or understanding), e.g. understand where different cultural and racial perspectives may come from, the meaning of death and dying in different cultures, structural inequalities “using people’s stories and to teach clinicians, we actually use that in the immersion course where we do poetry reading by African-Americans, and some of the issues they’ve had with the health care system and teach clinicians, you know, try to create empathy and understand people’s stories as a way to engage them. Because some of the time I think clinicians can be judgmental in why people are pursuing-- some of the kind of treatment they’re pursuing. And when you have an understanding for where people are coming from, and maybe some of the mistreatment and some of the issues around institutional racism and all that. I think that you can teach some of that to clinicians. So ... we created a one-day training, two four-hour blocks for clinicians. And it incorporates a lot of that specifically for African Americans. But we have that every year for new clinicians that are coming on board. So trying to create some of that cultural competency, where I think some of the biggest issues come with advance care planning and goals of care.” (Site 1, MD leader, female [s1_p24_leader_MD]) Persuasion (using communication to induce positive or negative feelings or stimulate action), e.g. use resources like community health workers to communicate to their own culture “We’re looking at getting culturally-based liaisons to go into various communities, folks that they can relate to, to educate regarding hospice and palliative care and alternatives to care as we move forward, as our census grows.” (Site 2, Nurse leader, female [s2-p34-leader-RN]) Enablement (increasing means/reducing barriers to increase capability or opportunity), e.g. increasing time to build trust to allow in-depth conversations “Trust is the key there to be able to have that conversation, well, like with any different culture, but that one’s for me personally have been a more challenging situation... I have found in my practice that usually it requires a more in-depth conversation and validating and showing more compassion” (Site 3, SW clinician, female [s3_p9_clinician_SW])”