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BMC Health Serv Res. 2019 Jul 29;19(1):527. doi: 10.1186/s12913-019-4309-5.

Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting.

Author information

1
Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. jennypalmer@hsl.harvard.edu.
2
Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. jennypalmer@hsl.harvard.edu.
3
Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA. jennypalmer@hsl.harvard.edu.
4
Peter T. Paul College of Business and Economics, University of New Hampshire, 10 Garrison Avenue, Durham, NH, 03824, USA.
5
Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.
6
Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.
7
Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, 830 Chalkstone Avenue, Providence, RI, 02908, USA.
8
Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.
9
Massachusetts General Hospital, Section of General Medicine, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA.
10
Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.
11
Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.

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

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