Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), Houghton Street, London, WC2A 2AE, UK.
BMC Palliat Care. 2018 May 24;17(1):78. doi: 10.1186/s12904-018-0333-1.
ACP involving a facilitated conversation with a health or care professional is more effective than document completion alone. In policy, there is an expectation that health and care professionals will provide ACP support, commonly within their existing roles. However, the potential contributions of different professionals are outlined only broadly in policy and guidance. Research on opportunities and barriers for involving different professionals in providing ACP support, and feasible models for doing so, is currently lacking.
We identified twelve healthcare organizations aiming to offer system-wide ACP support in the United States, Canada, Australia and New Zealand. In each, we conducted an average 13 in-depth interviews with senior managers, ACP leads, dedicated ACP facilitators, physicians, nurses, social workers and other clinical and non-clinical staff. Interviews were analyzed thematically using NVivo software.
Organizations emphasized leadership for ACP support, including strategic support from senior managers and intensive day-to-day support from ACP leads, to support staff to deliver ACP support within their existing roles. Over-reliance on dedicated facilitators was not considered sustainable or scalable. We found many professionals, from all backgrounds, providing ACP support. However, there remained barriers, particularly for facilitating ACP conversations. A significant barrier for all professionals was lack of time. Physicians sometimes had poor communication skills, misunderstood medico-legal aspects and tended to have conversations of limited scope late in the disease trajectory. However, they could also have concerns about the appropriateness of ACP conversations conducted by others. Social workers had good facilitation skills and understood legal aspects but needed more clinical support than nurses. While ACP support provided alongside and as part of other care was common, ACP conversations in this context could easily get squeezed out or become fragmented. Referrals to other professionals could be insecure. Team-based models involving a physician and a nurse or social worker were considered cost-effective and supportive of good quality care but could require some additional resource.
Effective staffing of ACP support is likely to require intensive local leadership, attention to physician concerns while avoiding an entirely physician-led approach, some additional resource and team-based frameworks, including in evolving models of care for chronic illness and end of life.
与健康或护理专业人员进行的 ACP 对话比单独完成文件更有效。在政策方面，期望健康和护理专业人员将提供 ACP 支持，通常在其现有角色范围内。然而，政策和指南中仅大致概述了不同专业人员的潜在贡献。目前缺乏关于让不同专业人员参与提供 ACP 支持的机会和障碍，以及可行的模式的研究。
我们确定了 12 家医疗保健组织，这些组织旨在在美国、加拿大、澳大利亚和新西兰提供系统范围的 ACP 支持。在每个组织中，我们对高级管理人员、ACP 负责人、专门的 ACP 协调员、医生、护士、社会工作者以及其他临床和非临床人员进行了平均 13 次深入访谈。使用 NVivo 软件对访谈进行了主题分析。
组织强调 ACP 支持的领导力，包括高级管理人员的战略支持和 ACP 负责人的日常密集支持，以支持员工在其现有角色中提供 ACP 支持。过度依赖专门的协调员被认为是不可持续或不可扩展的。我们发现许多专业人员，来自不同背景，都在提供 ACP 支持。然而，仍然存在障碍，特别是在促进 ACP 对话方面。所有专业人员的一个重大障碍是缺乏时间。医生有时沟通技巧较差，误解医学法律方面的问题，并且倾向于在疾病轨迹的晚期进行范围有限的对话。然而，他们也可能对其他人进行的 ACP 对话的适当性表示担忧。社会工作者具有良好的协调能力，了解法律方面的问题，但需要比护士更多的临床支持。虽然在其他护理的同时或作为其一部分提供 ACP 支持很常见，但在这种情况下，ACP 对话很容易被挤压或变得支离破碎。向其他专业人员的转介可能不可靠。涉及医生和护士或社会工作者的团队模式被认为具有成本效益，并支持高质量的护理，但可能需要一些额外的资源。
有效的 ACP 支持人员配备可能需要密集的本地领导力，关注医生的关注点，同时避免完全由医生主导的方法，一些额外的资源和团队模式，包括在慢性病和生命末期护理的不断发展的模式中。
