Zhou Yuxin, Wang Ariel, Ellis-Smith Clare, Braybrook Debbie, Feng Haixia, Harding Richard
Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing Midwifery & Palliative Care, King's College London, London, UK.
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Health Expect. 2025 Jun;28(3):e70291. doi: 10.1111/hex.70291.
Despite advance care planning (ACP) being associated with positive outcomes for residents in long-term care facilities (LTCFs), the causal pathways between ACP and these outcomes are context-specific and less understood. This lack of clarity can hinder the cultural adaptation and evaluation of ACP interventions. This study aimed to develop a programme theory that outlines the causal pathways through which the ACP is hypothesised to achieve impacts in Chinese LTCFs, with a focus on understanding its implementation, processes and outcomes.
Exploratory qualitative design incorporating Theory of Change (ToC) methodology. Two ToC workshops (one face-to-face and one online) were held with 37 participants experienced in caring for residents or older people. The process was informed by a realist review and primary qualitative study. A programme theory was developed through thematic analysis, generating a ToC map depicting implementation, processes and outcomes of ACP in LTCFs.
The programme theory was constructed to outline the causal pathways of ACP in LTCFs, populating five 'precondition' domains: (1) buy-in from government and facility leadership, (2) availability of external and internal resource, (3) adequate training and awareness for public and facility, (4) identification of residents who are ready for ACP and (5) culturally sensitive communication. Nine intervention components were identified that target preconditions, such as raising ACP awareness and providing staff training and mentoring. The potential impacts of ACP were identified, for example, fostering public attitudes towards a 'good death' and increasing public awareness and acceptance of palliative care.
Our mid-range programme theory can serve as a heuristic tool, adaptable for context-specific ACP interventions in other countries, enhancing the likelihood of achieving intended impacts. In particular, intervention components focused on family involvement can be transferable to East Asian regions, where relational autonomy and family-centred decision-making are emphasised. The programme theory is ready for feasibility testing for residents in Chinese LTCFs.
We were guided by patient and public involvement members including two residents and one family member of a resident throughout the study. They supported the overall development of programme theory, including reviewing the theory and interpreting findings.
尽管预先护理计划（ACP）与长期护理机构（LTCF）中的居民的积极结果相关，但ACP与这些结果之间的因果途径因具体情况而异，人们对此了解较少。这种不明确可能会阻碍ACP干预措施的文化适应和评估。本研究旨在建立一个项目理论，概述假设ACP在中国长期护理机构中实现影响的因果途径，重点是了解其实施、过程和结果。
采用结合变革理论（ToC）方法的探索性定性设计。与37名有照顾居民或老年人经验的参与者举行了两次ToC研讨会（一次面对面，一次在线）。该过程以实证审查和初步定性研究为依据。通过主题分析制定了一个项目理论，生成了一张ToC地图描绘了长期护理机构中ACP的实施、过程和结果。
构建了项目理论以概述长期护理机构中ACP的因果途径，涵盖五个“前提条件”领域：（1）政府和机构领导层的支持，（2）外部和内部资源的可用性，（3）对公众和机构的充分培训和认识，（4）确定准备好接受ACP的居民，以及（5）具有文化敏感性的沟通。确定了九个针对前提条件的干预组成部分，例如提高对ACP的认识以及提供员工培训和指导。确定了ACP的潜在影响，例如，培养公众对“善终”的态度，提高公众对姑息治疗的认识和接受度。
我们的中程项目理论可以作为一种启发式工具，适用于其他国家针对具体情况的ACP干预措施，提高实现预期影响的可能性。特别是，侧重于家庭参与的干预组成部分可以转移到强调关系自主性和以家庭为中心的决策的东亚地区。该项目理论已准备好在中国长期护理机构的居民中进行可行性测试。
在整个研究过程中，我们得到了患者和公众参与成员的指导，包括两名居民和一名居民的家庭成员。他们支持项目理论的整体发展，包括审查理论和解释研究结果。
