Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada.
J Am Med Dir Assoc. 2023 Nov;24(11):1761-1766. doi: 10.1016/j.jamda.2023.06.027. Epub 2023 Jul 31.
Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families.
Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts.
A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP.
Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis.
Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises.
Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.
在养老院（NH）中进行预先医疗指示（ACP）是以居民为中心的护理的一个组成部分，但仍然是一个需要不断改进的领域。本研究探讨了医疗保健提供者在与居民及其家属进行 ACP 讨论时的经验。
解释性描述被用来探索意义并产生适用于临床环境的知识。
来自加拿大 3 个省的 29 家 NH 中的 27 名工作人员（2 名护理主任、3 名助理护理主任、1 名执业护士、11 名注册护士、3 名注册实习护士和 7 名社会工作者）参与了一项旨在改善 ACP 的整群随机干预研究，作为一个有目的的样本参与其中。
在 2020 年 1 月至 7 月期间进行了半结构化访谈。使用解释性描述方法进行分析。
确定了三个主题。“在与家属进行 ACP 时应对关系紧张”捕捉到了参与者在与居民及其家属进行 ACP 过程中所经历的关系紧张。第二个主题“医生在哪里？”突出了医生普遍缺乏参与 ACP 讨论的情况，以及参与者在支持居民和家属时面临的后续压力。最后一个主题“危机改变了最佳计划”说明了参与者在居民发生医疗危机时试图坚持现有护理计划所面临的挑战。
参与者的经验表明，NH 中的当前 ACP 流程不能满足居民、家属或护理团队的需求。需要来自医生的额外支持和对结构流程的更改，以在这种护理环境中支持以居民为中心的临终规划。
