Conceptual Confusion: A Barrier to Multi-Professional Involvement in Advance Care Planning in Nursing Homes - An Ethnographic Study.

Abstract

Objectives: How health and social care professionals need to work together to deliver advance care planning (ACP) in nursing homes is not fully understood, with a reliance on professionals external to the nursing home to support ACP in the United Kingdom. The objectives of this study were to (a) examine the factors that influence multi-professional involvement in the ACP process within nursing homes and (b) explore how multi-professional working impacts the ACP process in nursing homes.

Methods: Using ethnography, data was collected through observation, interviews and document review from 36 participants including residents (n = 6), relatives (n = 4), nursing home staff (n = 19) and visiting professionals (n = 7). Data analysis combined thematic analysis, mapping of ACP trajectories for participant residents, and documentary analysis of nursing home policies.

Results: There was conceptual confusion around ACP. How ACP was understood and what was prioritised for inclusion varied between residents and professionals, and between different professionals. That ACP was frequently integrated with routine care planning was not recognised in how professionals accounted for their ACP practice. Professionals prioritised biomedical concerns, despite this not reflecting resident priorities and policy suggesting a broader definition. This created difficulties in enacting ACP, with a holistic understanding of resident wishes not always captured.

Conclusions: A shared understanding of ACP was not consistently evident from those tasked with its enactment. This, combined with professional construction of ACP in biomedical terms, limits multi-professional working and can prevent a person-centred process being achieved for nursing home residents.