Implementing Advance Care Planning: Barriers and Facilitators

The aim of the quality improvement (QI) project by Izumi, Burt, Smith, McCord, and Fromme (2019) in the current issue of the Oncology Nursing Forum is to determine the effect of a brief educational intervention to improve bone marrow transplantation (BMT) nurses’ confidence in their knowledge and practice about advance care planning (ACP). Interview data also were collected at preintervention and at six months to identify ACP barriers. Although the findings from this small-scale QI project alone are insufficient to change practice, the project provides a detailed roadmap and lessons learned that could benefit others wishing to implement ACP interventions. It also provides a blueprint for the design and testing of future interventions to address barriers to ACP.

ACP is an ongoing process that encompasses more than completing an advance directive (AD); it is a multistep process to help individuals make decisions regarding value-based choices about life-saving treatments at the end of life (Schickedanz et al., 2009). ACP offers a means through which patient and family preferences are identified, negotiated, and recorded. Although ACP provides valuable direction to families and healthcare professionals, conversations about and documentation of patients’ wishes are often suboptimal—too little and too late. Evidence suggests that expanding ACP in populations undergoing aggressive but potentially curative oncology treatments, such as hematopoietic stem cell transplantation, can have a positive effect on survival rather than adverse outcomes, as some believe (Ganti et al., 2007). Despite evidence-based guidelines and policies, barriers at the individual, clinician, organization, and health-system level can hamper implementation of ACP. Strategies to increase the adoption of ACP have included communication skills training for clinicians, community-based education for patients and family members, and improving efficiencies of documentation and workflow at the system level (Lin et al., 2019).

Prior to the intervention, nurse participants reported that their lack of training and knowledge were obstacles to ACP activities. As expected, training and knowledge barriers decreased after the intervention (Izumi et al., 2019). Another encouraging finding is that the nurses reported increased confidence in conducting ACP activities immediately after the intervention. Confidence, however, was only partially maintained three months later. Compared to preintervention, the proportion of nurses assisting patients in ACP sometimes or all the time increased at three months, but did not reach statistical significance. These mixed findings may be due, in part, to the small sample, psychometrically untested measures, or the short testing period. Also, a brief educational intervention may not necessarily influence individual factors, such as a nurse’s belief that ACP takes away a patient’s hope or a nurse’s readiness for ACP activities, such as initiating conversations about end-of-life choices. Lasting behavior change often requires a change in attitude, readiness to change, and internal motivation. It is possible that desired ACP behaviors would be sustained if the intervention addressed attitudes, readiness, and motivation, as well as included ongoing organizational support.

The rate of AD completion on the BMT unit did not increase as a result of the education, which may be related to some of the unaddressed patient, organizational, or health-system barriers. The proportion of nurses who identified “patients do not want to talk about ACP” increased three months postintervention, suggesting nurses’ perception of patient interest remains a major challenge. Organizational culture may influence nurses’ views about ACP, such as “not a nurse’s job,” “ACP may conflict with treatment plan,” and “physicians do not want nurses to initiate ACP.” These concerns declined after the intervention, which appears to be consistent with an increase in knowledge and confidence. Concerns about lack of time to perform ACP increased three months postintervention, indicating that organization- and system-wide time-saving strategies are needed.

The findings raise questions about designing and testing of effective, feasible, and comprehensive ACP interventions for patients and clinicians within complex health systems. Significant ACP improvements will not take place without exemplary interprofessional teamwork and communication, consistent organizational support, and a well-defined and expanded role for nurses.

Role of Nurses in Advance Care Planning

Nurses have a critical responsibility in the ACP process, including providing information about ADs. However, informing patients and assisting with AD completion is a time-consuming and complex process, involving various documents and in-depth, individualized discussions. Many hospitals have adopted an electronic health record (EHR) system in the admission process to support nurses in screening patients to determine if they have previously completed an AD and/or if they would like to have further information. Although it is helpful to know a patient’s AD status, it does not necessarily reduce the time spent locating the AD, updating patients’ wishes, or continuing the conversation. Izumi et al. (2019) emphasize that enhancing nurses’ knowledge and confidence is needed because ACP is an essential role for nurses, even in curative treatment settings.

Advance Care Planning Process Framework

The ACP process involves multiple stages and levels and, therefore, requires interventions that effect the ACP process at all levels (individual patient and clinician, organization, and healthcare systems). Schickedanz et al. (2009) developed a patient-centered framework, based on the transtheoretical behavior change model, with the goal of improving the ACP process (see Figure 1). This action-oriented framework requires patients to discuss their wishes with family, friends, and clinicians to improve the ACP process and AD completion. The framework posits that patients and family members move through four stages: (a) preparation (values clarification), (b) precontemplation, (c) contemplation of treatment wishes and values, and (d) maintenance (reflection on choices). It is important to note that these stages do not happen in a linear pattern because of the ever-changing nature of the patient’s illness.

Although the aim of Izumi et al.’s (2019) QI project is to improve ACP through nursing education, it is worth considering the intervention in the context of Schickedanz et al.’s (2009) framework. With guidance from the framework, clinicians may be more adept at identifying patient barriers and meeting the informational and emotional needs of patients at different stages of the ACP process. Nurses who understand the framework may feel more prepared to initiate or continue ACP conversations and have confidence to pass along information to other team members. The framework also may be helpful as an organizing framework for the educational intervention.

Implementation of Comprehensive Advance Care Planning Programs

Education of nurses and other clinicians, although valuable, will have a limited impact on the integration of ACP within health systems if other factors are not considered. For long-term systematic integration of ACP, strategies must take into account organization and system factors in addition to patient and family and clinician factors. The voices of key stakeholders in ACP need to have shared decision making in implementation projects to ensure integration and sustainability.

One way to increase successful implementation of ACP as part of routine care in real-world settings is to apply a guiding framework, such as RE-AIM (Glasgow, Vogt, & Boles, 1999). The acronym stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance (see Figure 2). For example, to influence nurses’ ACP practice, the first step may be to reach the target population of all stakeholders (e.g., patients, family, clinicians from many disciplines, unit and organizational personnel, administrators) and understand implementation barriers of the stakeholders (e.g., unclear roles of team members). Second, assess the strengths and barriers of an intervention, such as ACP clinician training, and agree on an appropriate measure of its effectiveness (e.g., AD completion rate). Third, determine how the program can be adopted in other units, departments, or organizations and what adaptations are needed in different settings. Fourth, plan for program implementation by staff with a variety of roles and experiences, maintain fidelity to the original design, and monitor effectiveness outcomes. Among other things, implementation can involve workflow improvement, tech support for documentation, and audit and feedback of performance depending on the needs and resources of the setting. Finally, developers need a plan to maintain the intervention or program over time and prevent relapse. Implementation of increased ACP and AD completion requires monitoring and meticulous communication between team members, often in the form of EHR documentation. Izumi et al. (2019) astutely underscore the importance of having user-friendly documentation to improve team communication and making nursing roles in the ACP process visible. Solutions include developing more efficient EHR documentation that fits into clinician workflow and is accessible to all team members (Izumi et al., 2019).

Implications for Practice

The educational intervention is intended for nurses; however, joint interventions with other clinicians and patient/family education are likely to substantially improve ACP outcomes. The addition of ongoing education and organizational support for the entire clinical team after a formal education session may sustain improvements in ACP and result in clinically significant increases in completed and updated ADs. In addition, delivery of education through cost-effective modalities, such as the Internet and mobile applications, may be helpful to reduce costs and increase efficiency.

Conclusion

This project addresses an important and timely problem of how to increase and improve the ACP process by oncology nurses, and brings up a larger concern about the role of nurses in ACP conversations and documentation of ADs. This project is a very important first step in recognizing the critical role and informational needs of nurses related to ACP.

About the Author(s)

Heather Coats, PhD, APRN-BC, is an assistant professor of research in the College of Nursing at the University of Colorado and a nurse practitioner at the University of Colorado Hospital Palliative Care Consult Service in Aurora; Yuki Asakura, PhD, RN, ACHPN, ACNS-BC, OCN®, is an advanced practice palliative care nurse and nurse scientist at the Parker Adventist Hospital and Penrose–St. Francis Health Services in Colorado Springs; and Ellyn E. Matthews, PhD, AOCNS®, CBSM, FAAN, is an associate professor in the College of Nursing at the University of Colorado in Aurora. Matthews can be reached at ellyn.matthews@ucdenver.edu, with copy to ONFEditor@ons.org.