A critical realist evaluation of advance care planning in care homes

• Published in: Journal of advanced nursing 2021-06, Vol.77 (6), p.2774-2784
• Main Authors: Spacey, Adam, Scammell, Janet, Board, Michele, Porter, Sam
• Format: Article
• Language: English
• Subjects: Advance directives; Bereavement; Care assistants; Care plans; Communication; Death & dying; death and dying; Dementia; Elder care; Emotional labor; Emotional support; long‐term care; Nurses; Nursing; Nursing assistants; nursing home care; Nursing homes; Nursing skills; palliative care; Residential care; Resilience; Workforce
• ISSN: 0309-2402; 1365-2648
• DOI: 10.1111/jan.14822

Aims To evaluate care planning in advance of end‐of‐life care in care homes. Design A qualitative study. Methods Qualitative data were collected from January 2018–July 2019 (using focus groups and semi‐structured interviews) from three care homes in the South West of England. The data were analysed using thematic analysis followed by Critical Realist Evaluation. Results Participants comprised of registered nurses (N = 4), care assistants (N = 8), bereaved relatives (N = 7), and domiciliary staff (N = 3). Although the importance of advance care planning was well recognized, the emotional labour of frequently engaging in discussions about death and dying was highlighted as a problem by some care home staff. It was evident that in some cases care home staff's unmet emotional needs led them to rushing and avoiding discussions about death and dying with residents and relatives. A sparsity of mechanisms to support care home staff's emotional needs was noted across all three care homes. Furthermore, a lack of training and knowledge appeared to inhibit care home staff's ability to engage in meaningful care planning conversations with specific groups of residents such as those living with dementia. The lack of training was principally evident amongst non‐registered care home staff and those with non‐formal caring roles such as housekeeping. Conclusion There is a need for more focused education to support registered and non‐registered care home staff to effectively engage in sensitive discussions about death and dying with residents. Furthermore, greater emotional support is necessary to help build workforce resilience and sustain change. Impact Knowledge generated from this study can be used to inform the design and development of future advance care planning interventions capable of supporting the delivery of high‐quality end‐of‐life care in care homes.