Barriers and Facilitators to Implementing a Pragmatic Trial to Improve Advance Care Planning in the Nursing Home Setting

Affiliations

PMID: 31357993
PMCID: PMC6664774
DOI: 10.1186/s12913-019-4309-5

Abstract

Background: The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families.

Methods: In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research's domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P).

Results: Implementation facilitators identified by Champions included: the intervention's adaptable mode of presentation and minimal time burden (IC) as well as the program's customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI).

Conclusions: Despite the promise of PROVEN's intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN's implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations.

Trial registration: ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.

Keywords: Implementation; Nursing homes; Pragmatic trial.

Conflict of interest statement

J.A.P., V.A.P., L.R.B., E.B., P.C., L.L., E.M., and S.L.M. declare that they have no competing interests.

V.M. holds stock in PointRight, Inc. an information services company whose clients are the nursing home industry; chairs the Independent Quality Committee for HRC Manor Care, Inc.; chairs a Scientific Advisory Committee for NaviHealth, a post-acute care service organization; serves as a Technical Expert panel member on several Center for Medicare/Medicaid quality measurement panels; and is a member of the board of directors of Tufts Health Plan Foundation, Hospice Care of Rhode Island, and The Jewish Alliance of Rhode Island.

A.E.V. is President of Nous Foundation, Inc., (www.ACPDecisions.org) a not-for profit (501[c]3) foundation that disseminates educational videos. Dr. Volandes has a financial interest in the not-for-profit, which was reviewed and is managed by Massachusetts General Hospital and Partners HealthCare in accordance with their conflict of interest policies.