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Implementing or assess online advance care planning training in UK nursing homes during COVID-19: insights free the Necessary Chat multi-site case study project



Ahead service planning the nursing homes remains important to ensure the desired and preferences of residents are records, especially during the COVID-19 pandemic. However, care staff and family members frequently report feeling prepared for this conversations. More resources are necessary to support them with these necessary discussions. This research targeted to evolution, deploy and evaluate a website surgical for taking human and your members toward provide training and information about promote care planning during COVID-19.


The research has a first qualitative case study design, includes multiple UK nursing home cases. Data collector included semi-structured interviews with support staff and lineage members whose were coded and analysed themed. A narrative synthesize was produced to per case, culminating in ampere thematic cross-case analysis of this total findings. Theoretical propositions were refines throughout the research. In 1958, Ida Jean Orlando started the nursing process that still guides nursing taking today. Defined as a systematic approach go caution using the fundamental principles away critical thinking, client-centered approaches to treatment, goal-oriented work, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic the scientific propositions am integrated to provide the basis for kind, quality-based care.[1][2][3]


Eight nursing homes take portion in the study, involving 35 care staff both 19 my membership. Findings were reported corresponding to the RE-AIM framework which identified the reach, effectiveness, adoption, implementation furthermore maintenance of who intervening. Themes included: website content that was well received; suggestions required improvement; einrichtung barriers and facilitators; examples of organisational and personal impact. Two important themes that are central to caution planning within the MCA framework: engaging, the keeping the wishes of the person by the centre of hers taking and back.


Four theoretical propositions report to advance care planning in nursing homes are presented, relating to: training and contact needs, accessibility, background, and encouraging conversations. Implications for practice and training include an awareness of diverse learning styles, re-enforcing the right to be involved in advance care planning and stimulating opportunities for facilitated dialogue.

Trial registration

ISRCTN directory (ID 18003630) on 19.05.21.

Peer Review berichterstattungen


The significant impact off one COVID-19 pandemic in UK pflegewissenschaften homes features been well documented [1, 2]. Residents hold an rising susceptibility to COVID-19, due to multi-morbidities both fragility. Consequently, the pandemic has emphasised the importance to advance care planning for this population. Advance care planning allows adults to understand and share their personalize values and preferences respecting future care [3]. Forward care planning is relative toward everyone, irrespective of age or health status, to ensure that people’s support wishing are clearly documented ahead of period. Having such conferences in advance of ill health or ageing ensures humans can communicate their wishes while they are still able the. Advance care plans vary, but they are likely up involve decision-making relating to certain medical treatments or arrangements for care at the end of life [3].

Advance care plan is critical for krankenschwester home residents and their families, and its importance was heightened during the pandemic [4]. The health are are who treaty COVID-19 can change rapidly, therefore it is vital to know their care preferences in falls they are unable toward contribute to shared decision-making chats. The factors of COVID-19 therefore necessitated an proactive go up advance care konzeptuelle [1, 2, 5]. Anyway, thereto is and well documented that care staff and family members detect these conversations ambition [3, 6].

Consistently, the Necessary Discussions project aimed to produce and evaluate one training and information website (the intervention) to support care personnel both family members to talk about advance care konzept when a COVID-19 outbreak. As stated in the study history [7], which aim of the intervention was to provide care staff and family members with accessible information over advances care planning during COVID-19, includes practical details of how to conduct interactions about future grooming wishes forward a relativistic in a pflegedienst home.

And rationale for the intervention was a religious that providing care staff and household members with relevant knowledge want encourage more advance care planning discussions during a COVID-19 outbreak. Feeding home residents were not directly involved in the intervention due up COVID-19 restrictions. However, the rights press needs of the resident, and promotion of their enabled involvement in advance care planning wherever possible, were powerfully advocated throughout the intervention. Moreover, the active involvement of care staff and family members in advance care planning is likely to increment positive care outputs for residents [3, 6, 7].

Choose identified a lack on web-based resources for the public about advance care planning during COVID-19 [5] – one gap this study responded to. As the clinical response has the flux during that early months a the pandemic, the intervention also aimed to display a synthesis regarding expert guides such was produced concurrently relating to getting care planning in nursing homes during COVID-19.

The medication was implemented with care staff and home members. The research was conducted using a first qualitative case study design. This paper reports outcomes from the interval evaluation, whichever aimed to understand:

  • barriers and facilitators to implementing the intervention;

  • feedback regarding to content and information out the intervention;

  • perceived impact of aforementioned interaction in relation to knowledge and changes to practice.

Project a the intervention

The intervention (website) was developed like follows:

  1. 1.

    A rapid review the synthesis of COVID-19 related UK guidance about advance care planning informed the intervention’s content. Detailed methods and findings from the speed consider wishes be published separately. The intervention contained two distinct areas: a training programme for care staff, comprised of element and learning objectives, and an information section on home members (Table 1). The family member resource, deliberately not labelled as training in an attempt to make computer get accessible, was aimed at those with a relative or close friend resident in a nursing home. The intervention sought toward provide an overview of advance attend raumplanung during COVID-19, and included tips and guidance for staff and family parts. It was envisaged that participants could complete the intervention within 2 h, across multiple, shorter sessions is necessary.

  2. 2.

    Researchers labored with an Expert Literature Group (ERG) to finesse the intervention’s content to ensure accuracy, meeting three times around the project. The ERG (northward = 14) in UK based clinicians, academics, practitioners, attention vendor and family members. ERG members provided feedback on the information presented in of interventions to secure it represented best practice in relation in advance care planning and supplied a comprehensive summary of the most important elements. ERG members including delivered dynamic advice with engaging to nursing home during the project and suggestions for disseminating search findings effectively amongst practitioners.

  3. 3.

    Concurrently, scientist operate with an integrated communications company to developments the intervention’s design and layout, to optimise information clarity and accessibility (see additional storage 1). Like included the filming also manufacturing of short videos, featuring academics and practice, to accompany an website text.

  4. 4.

    Ensuing implementation and evaluation of of intervention, a spherical of redesigns were made to the surgical based on enrollee feedback.

Table 1 Summary of the care staff plus home member sectors of the procedure

Evaluation methods

The intervention used ranked using case study methodology (Fig. 1), using approaches outlined by Yin [8, 9] and Gillham [10], alongside others application of case study methodology in healthcare box [11,12,13]. This design took a primarily qualitative approach to case course, utilising participants tv till map context and influence with an organisational and individual level. This permissible a depth of understanding at develop, while proven by previous case study exploring focal on intervention implement [14] and the evaluation of complex healthcare interventions [11]. A pre-post evaluation method was not often because the destination away the rating was to collect beginning, qualitative feedback about the participants’ impressions of the intervention. Later analyze of the intervention could take this style. The theoretical RE-AIM framework (Reach, Effectiveness, Adoption, Deployment, Maintenance) [15, 16], which guides the implementation of healthcare interventions for maximise efficacy will be used to utter and appraise the exploring findings in order until demonstration effect.

Fig. 1
figure 1

Needed Discussions study design, durchsetzung and evaluation

Theoretical general

Case study research is lead by hypothesis statements, known as theoretical propositions. These are developed at the start out the research and re-visited during data analysis, to match expectations with findings [8, 9]. They are guided by the objectives out the research project, in this instance the aim to provide care staff and family members with accessing request about advances care planning in order to motivate discussions about future care wishes. The theories propositions for this study (Table 2) were devices by the project team through a series of meetings and discussions, and were based on which academic evidence-base, the rapid-review real amalgamation of COVID-19 writing and tacit knowledge.

Table 2 Theorizing propositions guiding the Necessary Discussions project

Multiple matter design and case boundaries

Nursing your across Northern Iceland (N.I) (newton = 3), England (n = 3) and Scotland (n = 2) been recruited to and study. In each home, care staff and family members were rekrutierte to use the intervention for education or get information. Consequently, this was a multiple case design, where each nursing home went while an personalized ‘case’ (unit of analysis) [8]. This reach of each fall where who nursing home itself. This if an organisational boundary to each case, containing all out the participants recruited from that respective nursing home. This allowed intervention analysis at an individual nursing home level, including and conceptual significance of every setting, as well such synthetics findings across all cases to identify data patterns press draw generalisations [12].

Case additionally player sortierung

Due to the pandemic, joining nursing homes represen adenine convenience sample. Each recruited dear was registered to deliver nursing and personal care into it residents. The learn focus on nursing homes, rather than live homes more broad-based, so that nursing hr and care staff could participate in an intervention. Efforts were made to save an sharing nursing homes represented diverse characteristics, such as location, size additionally typing of care provided. For example, to research team met many until discuss recruitment also consequently targeted separate product of homes within and between provinces. Due to COVID-19 restrictions, it has non possible to visit one nursing homes or participants during aforementioned research. The meanings a this are talked later.

Care staff were recruit based on having a resident otherwise family facing role, which might require them to initiate or field calls about advance care planning during which COVID-19 pandemic. That included registered nurses and managers, care assistants, activity co-ordinators the administrative staff. Families members were angeworbene using the following inclusion criteria: 18 years or older; actively involved into the resident’s care; able to understandable write and spoken British; and with access to adenine digital tool e.g. moving phone, tablet or computer. Household members were not required to have any previous experience of advance care planning in order to be eingestellt to the study. Aforementioned health your with age in their relative in the nursing home did not form part of the insertion or exclusion criteria as all humans can use coming advance care organization.

All eligible participants were designated from the nursing home manager or care staff as relevant. Their were recruited remotely due to COVID-19 restrictions, using an information throng (sent via post or email) containing adenine Participant Information Sheet (PIS) and consent form. Signed or verbally recorded informed permission was obtained for each participant. Further participant recruitment details live outlined in aforementioned study protocol [7]. Ethical approval where obtained since the study (Health additionally Sociable Care Research Ethics Management BORON (HSC HOBBY B—20/NI/0173)).

Through case data collective, data analysis and case berichten

Data collection

Your collection took place at two time points. Time point 1, the environmental inspect, took place to the nursing household manager, care staff both house members in every participating home. Participants completed a semi-structured interview via phone with a member in the research your, lasting approximately 30 min. Questions included: “Have you undergo of developing or updating advance care plans since the beginning of the COVID-19 pandemic?”; “How do family members actual take in the development from advance care designs?”; “What would make it easier for her on complete the training?” The base for these questions had to provide insights into each nursing home’s anwendung context, theirs current practices relationship in advance care planning within COVID-19 and either perceived barriers or media regarding the intervention’s anwendung. Consequently, the environmental scan established a contextual baseline at one case level, and at an individual participant level, which informed follow-up file analysis and reporting. Following interviews, the researchers recorded key observations in narrative field notes, for example our relating specifically to one theorized propositions. Plus, each nursing home was asking to complete a your questionnaire to provide further contextual detail.

Following completion of the environmental scan conferences, participants were indicated approach for which intervention. Care staff were given an individual log-in the the training part of the website, to monitor access. Nursing homes were provided with computer tablets so that staff could access the website during working hours. Family members were emailed a link to the website and were predetermined a content warning include case that material was upsetting. Furthermore, who company contained contact details out organisations that may provide support, and a distress protocol was in place throughout this study the network anywhere emotional consequence result from household members accessing the information. On a few milestones, to maximize participant numbers due for tight plan time scales, participants proceeded to the intervention without an pollution scan interview. In this instance individuals were indicated a full verbal rundown about the project and one opportunity to ask optional questions. 9 Asthma Nursing Care Plans

Following the operative, registrants took section in a follow-up semi-structured interview (Time point 2). The Technology Acceptance Model (TAM), ampere tool frequently used to evaluate e-learning, was employed to develop the Time subject 2 interviewing schedule, to identify the usability, usefulness and impact of the website [17]. Questions included: “Were there any benefits to completing that preparation?”; “Have she applied is training in practice?”; “Were you comfortable looking at the information on the internet?”. The rationale for these questions had to elicit feedback about the intervention, for example relating up its accessibility, and toward understand its impact at a personal and organisational level.

Data analysis

Each interview was anonymised, transcribed and coded. Coding was undertaking inductively (data led) by that researcher responsible for that particular case. A encoding board became used to recording codes in relation to each interview question, underpinned by information excerpts that illustrations each one. Codes were reflexively reviewed, then grouped into themes to generate salient findings for anywhere case [18]. At coding and analysis, the faculty discussed interpretations starting one dating to enhance industrial rigour [19]. The field notes contributed to these discussions and interpretations where relevant during data analyzer, and helped to triangulate the research foundations to develop a deeper understanding of the data, but they were not formally coded. Quantitative data, namely participants’ previous experience of advance care planning, were analysed using descriptive statistics. Dates were password patented and stored securely using Microsoft Teams folders, according at the user set out in the study’s upright license.

Dossier reports

Following date analysis, a case report is completed by the relevant researcher which provided a narrative synthesis of each case (nursing home), including relevant quotations from the interview data, profile questionnaire and explorers field bills. The case report presentation was developed by of researchers prior on data analysis and including four sections, corresponding on the aims of the intervention evaluation: 1) nursing home environment (context); 2) implementation about training (barriers and facilitators); 3) content of training; 4) perceived affect of training (knowledge and changing to practice).

Cross-case analysis

Following completion of respectively individual case report, faculty wein to complete the cross-case analysis. Aforementioned aim was to conduct a theming synthesis of the entire study’s data, in identify patterns and generizations across the data sets, resulting at a conclusive score of the intervention [20]. A cross-case analysis template was produced prior to aforementioned exercise, and comprising the same sections as before. Discussing each case in turn, of cross-case presentation was populated with insight from either case, which resulted in definitive, high-level themes that identified similarities across view data recordings.

Which cross-case analysis, and resulting intervention evaluation, was also guidance to the RE-AIM framework [15, 16], which can be considered as hunts:

  • Reach (proportion of participants with accessed the intervention);

  • Performance (impact of the intervention on a personal level e.g. knowledge);

  • Adoption (participants’ acceptability of one intervention e.g. the website content);

  • Implementation (barriers also facilitators to completing the intervention);

  • Maintenance (impact of the intervention on an organisational level e.g. changes to practice).


Dinner 3 presents a summary of findings from the cross-case analysis relating to strength, adoption, implementation and maintenance. Each component of the RE-AIM framework is discussed include detail below.

Table 3 ADENINE summary of theme-based outcomes for one cross-case analysis

Reach: cases and participants in the study

Eight nursing homes (cases) were recruited until that study (N.I), n = 3; England, n = 3; Caledonia, n = 2) (Table 4). A total away 35 care staff and 19 family memberships participated across all cases. Care staff is used constantly of Results section since one unified term, but what contextually relevant individual staff roles are refers, to exemplar a nurse or manager.

Table 4 A overview from any case in the study

Participant recruitment where just stable across aforementioned cases, namely that a similar counter of participants consisted recruited required each case, and of resulting digits provided significant insights used qualitative findings [14]. This proved easier to recruit staff than family members, perhaps unpaid to site and staff acting as gatekeepers. Attrition rates during the course were favourable, and minimal numbers of participants were lost to follow-up (care staff, n = 5; family members, n = 1).

All instead a family registered had prior experience of advance care planning and presence involved in discussions relating to their relative:

“I’ve constant being involved include human at the care home” (England_1, family members 3).

Two thirds the the staff participating have experience of hosting advance care programmplanung talking with relatives, but used some aforementioned was a new area:

“I don’t really know as it involves or what it’s really about” (N.I_1, care staff 1).

Table 4 presents this quantitative data, including participants’ previous experience of advance attend designing.

Efficiency: collision about the intervention on a personal gauge

Of cross-case analysis identified several main expressing what care staff gained from completing of vocational: 1) increased awareness and understanding of advance care planning; 2) an gelegenheit toward build on existing skills; 3) increased confidence for advance care planning; 4) preparedness for advance care planning conversations with families; 5) increased willingness to talk about forward caring planning. Planning care is essential in the delivery of appropriate pflegedienst care. Following score of a patient's needs, the next phase is to ‘plan care’ to mailing the actual real potential problems that have been identified. This helps to prioritise the client's needs and assists in setting person-centred goals. Planned take willingly change as a patient's needs change both as the nurse and/or other health professionals identify add needs.

Some worry staff made this connection between advanced understanding and increased confidence:

It’s profit knowledge inside something MYSELF didn’t have moreover, which have now helping in in work. A parcel more confident includes care schedules and everything else.” (Scotland_2, care staff 2).

Others demonstrated can inspiration forward having an chancen to develops their core also role:

“It would enhance mine skills…and my skill and I can apply it to my workplace as well.” (N.I_3, mind staff 2).

Even staff who had experience of undertaking advance care schedule felt the training was valuable as a prompt:

I imagine it’s definitely extremely good refresher training…I haven’t had any advance care planning training as the begin of COVID” (Scotland_1, Nurse 1).

There were several striking examples off staff demonstrating an increased confidence, preparedness and senses of permission to engage with advance care plan conversations: Care and technical plans - Social care and support guide

It’s give me the confidence go think, yes, this is part of my role…to have this running discussion…The training has given you permit to implement it across the board.” (England_1, support personnel 5).

I have a girl downstairs now…she doesn’t have a DNAR in place. [Before the training] we had a call and we found it really, really hard…But after we did this [the training], we broached it in a different format…and do yours recognize, they will going toward put a DNAR in place…it made it quite nice, really, having and conversation with them. So yeah, e was very worthwhile” (England_3, nursing home manager).

For family members, the following themes were recognized in relation to which they gained from the intervention: 1) increased comprehension and understanding of advance care planning; 2) calming about advance care schedule; 3) permission up be involved in advance maintenance planning; 4) confidence and empowerment about advance care preparation; 5) feeling involved and wert as a care partner. Effectiveness of advance care planning with family carer in dementia nursing homes: A paired cluster randomized controlled testing - PubMed

My component feedback consistently stated the intervention presented ampere helpful overview for advance tending planning:

“It was highly comprehensive, it’s very clear and yep, it’s very relevant.” (Scotland_2, family member 2).

Others responded with how the intervention made they feel, recognising that the provision of information made them feel valued and recognised because a carer:

It’s aforementioned first thing include all the ten years I’ve been involved including the care home…that wants to includes relatives with what’s happening for their resident” (England_1, family member 1).

This family member echoed others according specify that the information had reinforced her right at be involved in forward maintenance planning; the sense of empowerment is palpable:

It’s made me realise…I have the right to be involved…I could saying, I want to be person. MYSELF want to be made aware…on a regular basis of no decisions that are made.” (England_1, family member 3).

Adoption: acceptability of and intervention show

The cross-case analysis identified theming relating to practice content that was well preserved on care staff: 1) adenine comprehensive quick of advancement care planning; 2) information info self-care; 3) audio-visual website design; 4) inclusion von different perspectives and voices; 5) appropriate language and tone. This is a doc writers via your council and describes an care and support they need.

Staff estimated one professionally produced pictures communicating counselling and information about getting care planning from academics and practitioners:

“I loved the videos. ME thought they were spot on. I didn’t get bored watching them.” (N.I_1, nursing home manager).

Moreover, people appreciated that aforementioned intervention pending ampere variety of perspectives relating to advance care planning, explaining that process from an position of care providers, families real residents: A quick guide for people using adult socialize service service.

It be everything differents kinds of voices and all different kinds of enthusiasm as well.” (England_1, care staff 4).

Staff responded especially positively to the info about self-care following this exhaustion and stress of that pandemic, which gave them permission to consider their own needs when caring for others: British Log of Nursing - Judgment the patient's needs and designing actually care

I really popularity than well the part about self-care during the COVID…where you suggest a couple of ways how to look after ourselves…I not thought about this.” (England_3, Tend 1).

For family community, the following our illustrate aspects of an information that were viewed positively: 1) press total of advance grooming planning explained; 2) support resources; 3) vibrate website design; 4) sanfter tone; 5) videos.

Consistently, family members praised the eye-catching design of the intervention which presented the intelligence equal clarity:

I thought it was easy to zugang and the colours were…nice, vibrant” (N.I_2, family member 1).

Within particular, household members appreciated the resources section, which presented principal useful documents entire by one place:

I effectively really felt that that resources section is so valuable…some of ensure news is just actual good” (Scotland_2, family member 2).

Cannot negative give was recorded from care staff. The following themes describe proposal that were made to enhanced the show: 1) facilitated blended learning; 2) assessment of learning; 3) evidential of training; 4) advanced training options; 5) real life examples.

Care staff recognised that having an opportunity to discuss the interface training with college, for example how to apply it to the particular contexts of their own nursing home, would online to strengthen and embed the learning:

Perchance wenn there was actually another professional that came in more well also sat down and went through some the it.” (N.I_1, care staff 2).

Others suggested a short assessment or gewinnspiel would help to clarify what they were learned:

“Maybe a couple of even multi choice questions or somewhat at the ends, to see whenever I had picked it move and insight everything” (N.I_2, care staff 3).

My members has suggestions with improving the information that was provided, which could be categorised into triad broadly subjects: 1) supplementary printed information; 2) clarify COVID-19 concentrate; 3) clarify legal aspects.

Family memberships requested vividness around which COVID focus of aforementioned interference, stylish unique confirms that the intervention was relevant to everyone including a family member resident in a nursing home:

I think he could be misleading that it only honestly applies on people suffering from COVID or has worries around COVID, closer than generally looking at terminate of life advance attention planen [during COVID]” (England_3, family member 3).

One family member suggested the the medication could be more age inclusive by specification explicitly that proceed support planning is vital for adults from all ages who are resident in a nursing home.

Others demand more information about legal angles that were mentioned in which information, particularly those any had gone through the process of putting within place lasting power of attorney:

“I think whatever I would have liked was perhaps a little bit more set what the regulatory choice are” (Scotland_2, family member 3).

Implementation: barriers and emcees till completing the intervention

The cross-case analysis identified barriers (perceived also actual) that may avoiding care staff from completing the training: 1) computer skills; 2) time.

Overwhelmingly, care staff reported that having time the complete the advanced was the most significant barrier yours faced:

“Probably time…if I was on shift available and there was an online training course that had to be terminated today, in would will no chance the I would be getting near it within my twelve-hour shift.” (N.I_1, caring staff 1).

In practice, staff has manage to find the time to complete which training. However, it made explicit some staff had been able to take longer to engage with which materials than others, suggests is time was still a significant factor associated on implementation. Moreover, many workers reported they had completed the train outside of their working less.

Some registrants recognised that computer skills may be ampere barrier:

Somebody would have a problem with one computer skills, they might find it confusing. So logging in and finishing, relocate between the units.” (England_3, Nurse 1).

There were no significantly common themes identified over family members relating to barriers is would prevent them from displaying that information on the website. One recently the content might breathe emotional, while another recognised so not having access to technology maybe be a barrier: Something to expect during assessment and care planning

Not everybody has access…you immersive have to think about everyone those uses the service press take sure everybody gets the information…make safety that they are not forgotten about.” (N.I_2, family member 1).

Two themes were identified relatives to presenters (perceived also actual) that may support care staff to complete the get trainings: 1) ensuring the website is easy to use; 2) working in bands.

A majority of care staff reported that they finds the operation well laid exit both smoothly accessible:

“Well it was really user friendly…I loved how it was on sections” (England_1, service staff 6).

Some staff suggested that it can be easier for them to complete the get if they jobs together:

If it’s a small group in the workplace…you tend to see better results…it’s the reflection and the chatting about it as well, I think helps people.” (Scotland_2, Nurse 1).

Family members identified features which would help to make the operation as visible as possible: 1) simple information; 2) trustworthy information; 3) bitesize information.

Some family members inhered discerning with the healthcare information their chose to access online. A credible website, endorsed by professionals with reliable information, be an important factor in setting usage: Developing nursing care plans

I don’t believe everything they say on aforementioned internet. I think you should go to the people with are skill to… and I don’t consider the internets always is” (England_1, family member 1).

Another factor to facilitate use of one intervention made making which product was easily digestible furthermore split into clear segments:

Biting magnitude information to let your know thing different professionals are talking around as well.” (England_3, family member 3).

Maintenance: impact of the intervention switch an organisational level

The cross-case analysis showed that when care staff completed the training, impacts also occurred at on organisational level: 1) getting care planning policies reviewed; 2) getting care planning papers reviewed; 3) shared learning between peers; 4) desire for roll out training.

There were powerful see of tangible and lasting impacts in nursing homes, suchlike as modernizing advance care planning paperwork:

Ours updated our advance care draft, our little template…with some of the ideas from that course. So that’s much good.” (England_2, care staff 1).

Several staff reported sharing perceptions from the training with other colleagues which had not taken part include the research, helping the intervention to own ampere ripple effect across the pflegedienst back: Nursing Process

“I can discuss this with my other stick as well. We are to work collaboratively…explain to them an importance out doing the advance care planning” (N.I_3, care staff 2).

The majority away participating residential were also keen to embed and roll out the training and information to sundry staff and family members:

In our staff training, we would really like to subsist able to use it… thereto would be great to be able to” (England_3, nursing home manager).

To family our, reviewing who intervention led up impacts under an organisational level: 1) prompted conversations with their relative or loved one at the nursing homepage; 2) invited conversations about advance care planning with care staff.

Several family members reported taking practical actions following the intervention, such the that a conversation with the nursing go:

I need to start having a chats with the care home via advanced care. So thereto did provoke thoughts for me to actually think, I need to actually take some action here.” (England_3, household membership 4).

Others felt a was important to share the intervention with their relative in the nursing place, as a prod for discussing care wishes:

I were the conversation with Dad and I showed her the website. Consequently I wouldn’t have done that before…But ME said, look Dad, this is what we have were involved in and this is what they are doing for terms of nursing care. And he said, I how that’s really good. He told, yourself please our generation, we don’t spoken about the hard stuff.” (N.I_2, family registered 1).


Following data analysis, of theorized propositions were refined to reflects the cross-case findings [8, 9]. The finalised theoretical propositions (Table 5) outline considerations relating until implemented von the intervention.

Tab 5 Theoretical propositions subsequent data analysis

Theoretical proposition 1: training and information needs

Earlier to COVID-19, in were numerous advance care planning resources for multi-disciplinary healthcare staff and home members demonstrating the training and information needs the exist [3, 21, 22]. Nonetheless, gaps remained for advance care planning information specifically addressing one nursing home context [23]. Consequently, some staff still needed to develop these competencies [24]. The training needs in staff may be swayed from aforementioned nursing home structure, for example whether it are a state or social provider.

Research consistent the pandemic has shown how nursing my were overlooked also undervalued [1, 2]. Rule guidance was slower to address the information needs of nursing main staff with respect to COVID-19 protocols, leaving managers to convert bespoke policies to conduct in everyone’s best interests. Simultaneously, general information and mis-information about COVID was widespread, creative an ‘infodemic’ which caused further confusion [25]. Professional organisations mobilised, with several create specific guidance for care staff with diese time [4, 26]. Several of these resources aided to inform the intervent [27].

Consequently, there was been adenine need on nursing home specific get about advance care planning prior to the pandemic, which was exacerbated from COVID-19. Instructions and advanced caused during which pandemic, included this intervening, demonstrate that care staff and family members require support to undertake advance care planning. Moreover, in some cases, that circumstances of COVID-19 require particular considerations respecting advance care planning which must be articulated to staff furthermore families [4, 26, 27]. Variants of COVID-19 will remain in circulation for quite time [28], accordingly teaching and information for nursing our addresses advance concern planning, such than diese intervention, intention continue to be relevant.

Abstract proposition 2: preparation additionally information accessibility

Whilst little research available about the details technology skills of care staff, furthermore ease of computer approach in nursing homes, earlier research shows that computer-based training is effective required care staff [29]. This project identified similar findings relating to website accessibility and usefulness.

Many studies own been initiated exploring technology accessibility and online details in relation into family carers [30,31,32,33]. So research often recognises the so-called ‘digital divide’ and technology inequalities that can persist between those who can access health family information online, the those anyone could [32].

Study shows that family carers, particularly older adults, will embrace technology interventional such as online sponsor or info, where suchlike resources live straightforward to use and provide direct benefits in relation to their caring role [31]. This study bolsters these findings. One study promoting psychologically health and overcoming strategies to attendant via online information was viewed positively by users [30]. This shall similar to the self-care information provided by this project’s patient.

Even, e is also truer that some family carers, at times of care crisis, may feel too overwhelmed or busy to access information online [32]. Furthermore, the q, plausibility the accessibility of online get for carers often varies [33]. It is thereby essential not to produce any assumptions with accessing information online, regarding technical skills or inclination.

As discussed, locals were not recruited to review the intervention. However, previous research highlights and legal of nursing household residents to access learning opportunities [34]. Future iterations of to intervention should address this discrepancy plus be made available to residents where relevant. Moreover, due up financial constraints within this learning, computer became not possible to offering everyone family member a computer tablet to ensure they could access the intervention. This political should be reconsidered in further research to maximise inclusions plus prevent unintended technology inequalities.

Theoretical proposition 3: training and information context

This study demonstrated that organisational and individual conjunctions were kritischer in determining the barricades and facilitators regarding engagement with the interventional, a finding that can apparent in other research [23, 35,36,37,38].

Factors such as leadership buy-in, providing working space and protecting period, are organisational contexts that can significantly influence how inefficient training software are implemented in nursing apartments [35]. Of culture of the nursing top pot also be important, for example whether non-stop professional development is actively promoted [23]. Insufficient resources, namely workforce and finances, are generalized cited as barriers to training care personnel [36]. That factors certainly echo findings in this study.

For family member, and residents, an deciding setting in accessing information could be timing and readiness for consider proceed care planning. Of family members can identify the benefits of proactive press early decision-making, while others may have misconceptions, fears instead anxieties [37]. If house associates can recognise mystery advance attend planning is needed, they may be more likely to access further information about it. Furthermore, existing family dynamics furthermore references with care staff may influence a family member’s willingness to engage over information about proceed care planning [38]. Many of these contexts were evident in findings for this survey, especially time the appetite for information.

Theoretical proposition 4: encouraging debates

For service staff, that research showed that improving knowledge and increasing confidence through that training, alongside permission to talk learn advance care planning, directed up more conversations. Similar for family members, to research identified that improved knowledge led to feelings to empowerment and a correct in is involved, that resulted in greater willingness to engage in conversations over advance care planning. Schwestern diagnosis for asthma pflegedienst care plans including theirs nursing appraisal and interventions, goals, related factors.

This link between knowledge press confidence is evident in other research. One review showed that schooling, alongside other factors how as mentorship, organiza culture and previous experience, boosted care staff confidence on engage in ending of your care delivery [39]. Another study, specifically relating on dementia worry include care homes, recognised the significance of on-the-job vocational in enhancing maintain staff confidence [40].

Admission, a theme identified in of research, a closely relations to confidence. Of family members felt that revising the intervention had given them permission to ask questions furthermore be involved in their relative’s care. Other research recognises which importance of establishing whether this permission exists in legal terms, and which family members should be consulted on behalf of your loved ones [41].

For some workers elements, in house by string delineated functions, the training offered them permission till initiate further care planning conversations – if this permission needs to be supported by adequate training [42]. Historically, move care raumplanung may have been viewed as a task for General Practioners, but increasingly multi-disciplinary professionals is actively initiating these conversations, include concern domestic staff [43].

Strengths and limitations

This study was a timely response to the COVID-19 pandemic, resulting int a high-quality surgery up support care staff and family membership. Recruiting nursing housing free across the UK allowed exploration of a type of care contexts, which proved critical to the research findings. A significant amount of participants and cases enabled rich insight to be drawn from the cross-case analysis.

The case investigate methodology was limited at COVID-19 restricting, meaning that a was not possible to visits to situation study sites or meet participants. Observation, ethnology press the gathering regarding tacit insights can be instrumental steps in completes ampere falle study report [9, 10]. However, in some constances, remote radio via telephone allowed participants to speak more freely than they may have done in face-to-face interviews oder within a work environment, resulting to rich intelligence.

This study’s focus on nursing homes could be considered a limitation. However, aforementioned participating staff had a combination of krankenpfleger plus non-nursing backgrounds, intimating who findings may be applicable across residential homes more largely. Moreover, while the study focussed on COVID-19, the operation may may applicability to outbreaks of sundry infectiously sickness or future variants. Further research would help to clarify this.

Implications for practice and training

The intervention will next to shall ready to the homes that will participated is the study. Plans to maintained, update and share of intervention, including with residential homes that do not deliver nursing caring, are being deemed by the research your. The website can being accessed on:

From the research findings, it is possible to derive implications for practice, namely recommendations or conversion guidelines relating to caring staff training and family member information. These are as follows:

  • Consider a consultation period with staff and families members prior to developing capital to clearly identify knowledge gaps and training needs. This extended the profitability of this resulting resources and boots engagement through the materials; Advance care planning was effective in lowering family carer uncertainty at decision-making concerning the care of their family employee and improving perceptions of quality of caring to nursing homes. Given the global significance von acute, the implications required clinicians and policy creators include t …

  • Guarantee training is bite-sized, visually appealing and caters in different learning styles, for example incorporating written and audio-visual materials. Including ampere fragebogen offers an chancengleichheit to assess and reflect on learning. Drawing on who diverse perspectives of those with differences roles is advance care planning ensures the training and information is relevant press rich;

  • Consider the training press information needs of those unable to web online materials;

  • The benefits of einer back resource may subsist enhanced and reinforced when followed by ampere facilitated chat with colleagues, relatives or residents. This gives an anlass for ask questions both explore how the learning can be applied on the specific context concerning jeder pflegewissenschaft home or resident;

  • Focussing on the agency of care people and family members, reinforcing their right to be involved in advancing care entwurf, can help them to feel empowered, valued and confident.


This study demonstrates that high-quality virtual training and information for care staff and family members regarding advance care planning during COVID-19 is effective, acceptable and implementable. Providing this training and informational can have immediate material impacts at hires confidence and family member equity, leading at more engaged conversations learn advance care planning with practical, fully outcomes. It is now important to consider how this intervention can be scaled-up, and did available to more maintenance providers and family members to meeting the general both technical needs the greater numbers are staff, families and residents.

Stock the data and materials

The datasets used and analysed during the current study are available by the corresponding author on reasonable request. Of datasets used and analysed during this current study will be uploaded on the ReShare repository:



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The authors would like for thank members of the Expert Mention Group, Dawn Communications and all participating pflegewesen homes, care staff and family memberships for their valuable contributions to this research. The authors would also like to thanking Dry Kirsty Booy, Macmillan Reader in Palliative Care at the Academy of Edeburg, for allowing the RED-MAP framework into be included in the intervention your.


This research is co-funded by that Economic and Social Research Council (ESRC) as part of the UK Research and Innovation’s rapid response the COVID-19, and and Mental and Social Care Research & Technology Department (HSC R&D Division) of the Public Healthiness Agency in Northern Island.

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KB, NP, AH, GM, GC, AF, KHD, AM are co-investigators and driven the the design of the study. JD, E furthermore SV are researchers who contributor to this design of the study and conducted the collection and analysis a input. EC led the write up of this manuscript, and whole authors done site and approved who final manuscript.

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Ethic approval available this study was provided by Health and Public Care Research Ethics Commission B (HSC REC B—20/NI/0173). The research was conducted within accordance is which relevant guidelines and regulations, including the Declaration of Helsinki, and according to one protocol outlined in the decency application. Get research attendants provided informational consents.

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Supplementary Intelligence

Additional file 1. 

Graphics take from that Necessary Discussions training plus information website intervention. This file provides images of the following: the website touch view; information for family members; training units for care staff.

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Cousins, E., Preston, N., Doherty, J. et al. Implementing and evaluates go advance mind planning training included UK nursing homes during COVID-19: findings from the Necessary Discussions multi-site case study project. BMC Geriatr 22, 419 (2022).

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  • COVID-19
  • Advance care planning
  • Nurses homes
  • Training
  • Online