Feature ArticleNursing home staff perspectives on adoption of an innovation in goals of care communication
Introduction
Dementia is a progressive incurable disease that afflicts over five million Americans; most will die in nursing homes (NH).1, 2 In advanced dementia, end-of-life care issues include uncontrolled pain, diminished interest in eating, and infections.3 Communication to align overarching goals of care (GOC) with treatment plans is the recommended approach to advance care planning and decisions about end-of-life treatments.4, 5 Goals of care such as prolonging life or promoting comfort are first discussed, and then aligned to choices about treatment. Family caregivers typically make decisions about resuscitation, tube feeding, hospitalization and treatment of recurrent infections for persons with dementia in the NH, since these individuals lack decision-making capacity for many years prior to death.
Nurses lead the healthcare inter-disciplinary team in NHs, which also includes social workers, therapists, nutrition and activity staff. A Care Plan nurse typically completes a federally required health assessment that guides the care plan on admission. The health assessments are updated quarterly or if the medical status of the residents changes. Health care providers deliver medical care, but are rarely present for care planning meetings or family communication. A key component of resident-centered care for nurses could be goals of care discussions, which can be initiated during the health assessment.
Families and nursing staff both report that GOC discussions are not commonly used in NHs, and care plans rarely include advance care planning content.6, 7 Limited communication between NH staff and families contributes to poor end-of-life care quality.8 Notable barriers to GOC communication in NHs include lack of nursing education, time constraints, lack of health care providers involvement, unclear nursing staff responsibility, fear of legal ramifications, and limited family involvement.8, 9 Nurses may not view advance care planning discussions as a part of their job responsibilities, and time pressures result in prioritizing other tasks.10 Alternatively, nursing education and experience may facilitate acceptance of this role.11
The Goals of Care study tested the first systematic adoption of a video decision aid in the NH setting, to facilitate GOC communication. In addition to testing the intervention itself, investigators sought to understand nursing home staff perceptions that may hinder or support the adoption of this innovation in GOC communication. To use the GOC video decision aid, NH nurses and other staff must learn and adopt evidence-based practices, and do so accounting for the complex relationships and barriers to the adoption of innovations in NHs.12, 13 Roger's diffusion of innovation (DOI) framework (2003) guided the measures used in this study to examine nursing home staffs' perceptions of the GOC approach. The DOI framework focuses on the process by which an innovation – the GOC decision aid -- is adopted. Additionally, the DOI framework includes attributes of the innovation that determine its rate of adoption: relative advantage, compatibility, complexity, trialability, and observability.14
Characteristics of NH staff may affect readiness to adopt this innovation. Racial/ethnic disparities have been well documented in long-term care settings.15, 16, 17 Previous literature has identified potential individual-level factors that contribute to racial/ethnic disparities in advance care planning, including cultural and religious beliefs,18 mistrust of the healthcare system due to historical discrimination,19 and preference for more aggressive treatment.20 Similar beliefs may be held by Black NH staff, limiting comfort with GOC discussions. The GOC intervention may thus be particularly beneficial to Black NH staff. Furthermore, nurses or other NH staff who have greater training for or experience with advance care planning may be more comfortable having GOC discussions, and also see the GOC intervention more favorably.
Investigators designed a study to examine nursing home staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia, and to examine characteristics associated with these perceptions. In addition to descriptive findings, the study tested two hypotheses: 1) that Black nursing home staff would have more positive perceptions of the GOC intervention than White staff, and 2) that nurses and staff who have experience with end-of-life training will have higher perceptions of the Goals of Care intervention.
Section snippets
Design
This study was part of a cluster randomized clinical trial testing the GOC decision aid intervention in 22 NHs. Nurses and other inter-disciplinary care planning team members from 11 NHs in the intervention arm were eligible for an in-person or telephone survey, after training on and delivering the GOC intervention for at least 10 families of residents with advanced dementia.
Goals of care decision aid and care plan intervention
The parent study was a cluster randomized trial to test whether a GOC video decision aid is effective to improve the
Results
Sixty-five care plan staff were eligible to participate, and we enrolled 49 NH staff members. Thirty-nine percent of participating staff members were nurses, 31% were social workers, and 31% had other roles (Table 1). More than half reported they had formal training in end-of-life care, and 86% reported experience discussing end-of-life care with residents/families. In relation to the GOC intervention, 49% of NH staff indicated they were always or very frequently involved in the GOC
Discussion
This study addressed the systematic adoption of a decision aid in nursing homes, or any similar innovation in end-of-life communication skills. Nursing home staff responded positively to experience with the Goals of Care video decision aid intervention, endorsing its relative advantage over prior end-of-life communication, compatibility with nursing home practice, and ease of use. These findings indicate staff support for adoption and use of the GOC intervention. Participating nursing home
Conclusions
Evidence-based best practices evolve in response to research, but have little impact unless practicing clinicians can adopt these new approaches. Understanding staff perceptions of innovations in nursing home care is necessary in order to facilitate the adoption and sustainability of new best practices.12, 13 With the need to improve advance care planning discussions in nursing homes, administrators will need to identify strategies for nursing home staff that promote the adoption of
Acknowledgements
This work was supported by the National Institutes of Health/National Institute of Aging (grant NIA R01AG037483). We thank the staff and families participating in the Goals of Care Project for their time and commitment to understanding and informing care in nursing homes.
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