Background This project emerged from the multicenter cluster-randomized controlled BEVOR-trial investigating the effectiveness of a complex ACP intervention in German nursing homes (NHs). The trial’s ACP intervention started in late summer 2020 and specifically addressed, besides the residents who were offered ACP conversations, nursing staff and aspects of nursing culture as well. The nested study reported here investigates how employees experience the implementation of ACP in their facilities two years after the program’s first introduction.
Methods Four focus groups exploring NH employees‘ subjective experience were conducted in four NHs (one each) in August and September 2022. Participants were guided to reflect upon barriers and facilitators of the ACP intervention, and invited to make suggestions for improvement. Four to nine employees of the following professional groups participated in each focus group: nurses, nursing assistants, nursing trainees, and social workers. An interprofessional team analysed transcripts of the focus groups using a structured qualitative content analysis according to Kuckartz.
Results Preliminary analysis indicates a breadth in perception of ACP implementation. Commonly named changes include an increased acknowledgement of residents‘ care preferences, increased staff confidence with regard to handling medical emergencies, and a critical appraisal of formerly reflective approaches. Critical remarks relate to the time necessary for the implementation process, insufficient educational opportunities (for nursing assistants), emotional distress following ACP conversations in some residents, and a regret both that ACP is offered when it is too late for many residents to participate actively, and that ACP is not offered to nursing staff as well.
Conclusion Implementing ACP in NHs moves respect for residents‘ autonomy into the centre of numerous concepts and chains of action, including approaches in medical emergencies. The facets, facilitators and barriers of cultural change identified in this study may guide future development of programs to implement ACP in nursing homes.
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