Enhancing Advance Care Planning in Nursing Homes Assessment

Advance Care Planning (ACP) has emerged as a central component of quality aged-care, particularly in nursing homes where residents often face progressive frailty, multimorbidity, cognitive decline, and reduced capacity to participate in medical decision-making. Despite strong evidence supporting ACP as a means to enhance person-centred care, respect autonomy, and improve end-of-life experiences, most nursing homes still struggle to integrate ACP effectively into daily practice. The ACP+ program, developed in Belgium by Gilissen and colleagues, presents a structured, theory-driven, multicomponent solution designed to embed ACP into routine nursing home operations. This blog provides an in-depth exploration of the development processes, implementation strategy, and practical implications of this program.

Understanding the Need for Systematic ACP in Nursing Homes

Nursing home residents are among the most vulnerable populations in healthcare systems worldwide. As ageing progresses, the likelihood of losing decision-making capacity increases substantially. Many individuals approach the end of life within institutional care, yet statistics consistently show a low uptake of documented preferences for care, such as Do-Not-Resuscitate (DNR) orders, advance directives, or surrogate decision-maker appointments.

Studies conducted across Europe and the United States highlight a gap between the known benefits of ACP and its real-world adoption. For instance:

• Few residents have documented advance directives.

• Family members often feel unprepared to make decisions during medical crises.

• Healthcare staff report limited time, training, and confidence in conducting ACP discussions.

• Nursing homes lack structured processes that make ACP a consistent and ongoing practice.

The ACP+ program was developed precisely to address these gaps by creating a model that is practical, adaptable, and sustainable within typical nursing home workflows.

Foundations of the ACP+ Program

The ACP+ program emerged from a previously established Theory of Change model specifically designed for nursing home ACP. Unlike single-session training initiatives, ACP+ functions as a system-level intervention. It recognizes that effective ACP requires coordinated efforts across management, clinical staff, support workers, residents, and families.

The development process included:

• A literature review of existing ACP interventions

• Multiple consultations with an expert multidisciplinary panel

• Qualitative interviews with nursing home staff and management

• Guidance from a palliative care nurse-trainer experienced in ACP implementation

This rigorous development ensured that the program was grounded in theory, practical in real settings, and shaped by insights from those who deliver and receive care.

Core Components of the ACP+ Program

Initially built on nine components, the final ACP+ intervention includes ten integrated components, each containing structured activities and supporting materials. Together, they work to train staff, engage leadership, prepare residents and families, and create lasting organizational readiness.

1. Engagement and Leadership Support

Effective ACP requires organizational commitment. Managers and coordinating advisory physicians participate in early engagement meetings to understand their responsibilities, endorse the program, ensure proper staffing, and create a culture where ACP becomes a priority.

2. ACP Trainers

ACP+ employs specially prepared external trainers who guide nursing homes throughout the implementation period. Their role is intensive at first and gradually reduces as internal staff become confident and autonomous.

3. ACP Reference Persons

Each facility nominates a group of staff:usually nurses, head nurses, palliative care reference persons, or psychologists:who receive advanced training. These individuals champion the program internally and support other staff in identifying opportunities for ACP discussions.

4. ACP Conversation Facilitators

Selected healthcare providers are trained to conduct structured ACP conversations using a standardized conversation guide. Their training helps them explore resident wishes, manage sensitive discussions, and document preferences effectively.

5. ACP Antennas

These include nursing assistants, administrative personnel, cleaning staff, volunteers, and others who have daily interactions with residents. Their role is to identify “triggers” indicating readiness or need for ACP discussion, such as emotional distress, a medical decline, or expressions about future care.

6. Structured ACP Conversations

The program includes:

• A first in-depth ACP conversation with the resident and family

• Follow-up conversations (yearly or after significant health changes)

• Clear documentation using standardized forms

• Collaboration with the resident’s family physician

7. Multidisciplinary Meeting Integration

ACP becomes part of monthly multidisciplinary team meetings, ensuring continuous discussion, shared understanding, and updates on resident preferences.

8. Training and Education Sessions

ACP+ includes:

• Two-day intensive training for ACP Reference Persons

• In-house training for ACP Conversation Facilitators

• Awareness sessions for all other staff

• A specialized module on ACP with people living with dementia

9. Reflection and Coaching

Staff participate in reflective sessions that allow them to discuss challenges, ethical questions, and experiences after residents pass away. One-to-one coaching supports ongoing growth.

10. Tailoring and Auditing

Programs cannot be one-size-fits-all. Tailoring sessions allow facilities to adapt components to their operational realities. Regular audits ensure continual quality improvement.

Ensuring Feasibility and Acceptability

Through interviews and evaluation sessions, several barriers and facilitators were identified:

Barriers

• Limited staff time and heavy workloads

• Difficulty engaging family physicians

• Need for more dementia-specific ACP training

• Concerns about the complexity of documentation processes

Facilitators

• Highly motivated ACP Reference Persons

• Strong leadership endorsement

• Flexible scheduling

• Combining sessions to reduce burden

• Clear communication materials for residents and families

As a result, several adaptations were made, such as offering evening information sessions for family physicians, integrating reflection into existing meetings, and providing additional modules on communication challenges.

Why ACP+ Is Unique and Effective

Most ACP interventions rely heavily on external specialists or focus on narrow training for nursing staff. ACP+ differs because:

• It is multicomponent and whole-system oriented. Everyone in the nursing home is involved, from management to volunteers.

• It creates internal champions. Reference Persons ensure sustainability even after the formal program ends.

• It focuses on continuous communication. ACP conversations are not isolated but ongoing, adaptive, and realistic.

• It respects the complexity of nursing homes. Tailoring and stepwise implementation acknowledges that each facility has its own routines, culture, and constraints.

• It builds long-term capacity. Instead of relying on one-off training, ACP+ builds a culture of thoughtful planning, compassion, and preparedness.

Implications for Global Nursing Home Care

While the ACP+ program was designed in Belgium, its principles apply internationally. With rising ageing populations, nursing homes worldwide face increasing pressure to deliver person-centred end-of-life care.

Key takeaways for global implementation:

• Leadership engagement is non-negotiable.

• ACP should be embedded into routine care:rather than treated as an optional add-on.

• Staff need ongoing support, not single-session workshops.

• Family involvement and communication with primary physicians are crucial.

• Tailoring is essential to respect cultural, legal, and operational differences.

Conclusion

The ACP+ program presents a robust, research-based, highly adaptable framework for integrating advance care planning into daily nursing home operations. Its strength lies in its systematic, collaborative approach involving residents, families, staff across all levels, and external trainers. By transforming organizational culture and developing internal ACP champions, the ACP+ program helps ensure that nursing home residents’ preferences, values, and care goals guide every clinical decision:ultimately enhancing the quality of life and dignity at the end of life.

If implemented widely, ACP+ has the potential to reshape aged care practices by making advance care planning a shared responsibility and a standard part of compassionate nursing home care.

Brief summary of assessment requirements

This assessment asks you to analyse the development and implementation of the ACP+ programme (Gilissen et al.) and to produce a structured, evidence-based report that demonstrates understanding of complex intervention design, feasibility testing, and standardised description for translation into practice.

Minimum content and structure to cover:

• Introduction / problem statement: why ACP is important in nursing homes; current gaps in uptake and practice.

• Programme development methods: literature review, expert group consultations, interviews with nursing home staff and management, input from a palliative care nurse-trainer.

• Programme components: translate the original theory into operational components, activities and materials (report the final 10 components, key activities, and supporting materials).

• Feasibility & acceptability findings: summary of staff/management feedback, barriers and facilitators uncovered in interviews, and the thematic changes made to improve acceptability.

• Implementation strategy: phased roll-out (preparation and follow-up), roles and responsibilities (ACP Trainer, Reference Persons, Conversation Facilitators, Antennas), training schedule and tailoring meetings.

• Monitoring & quality assurance: auditing, documentation forms, multidisciplinary meeting integration, reflection sessions, and tailoring/audit mechanisms.

• Ethical / legal / contextual considerations: documentation types, involvement of family physicians, dementia-specific adaptations, local legal context.

• Standardised description: present the final programme using a checklist approach (e.g., TIDieR): what, who, how, where, when, dosage, tailoring, materials.

• Conclusion & recommendations: implications for wider translation, limitations, and next steps (including evaluation plans such as the cluster RCT).

Formatting and academic requirements:

• Use clear headings, objective third-person voice, and Australian English.

• Support claims with references to the Gilissen et al. paper and any additional literature.

• If required, include appendices for sample materials (conversation guide, audit tool) and summary tables (components → activities → materials).

How the Academic Mentor guided the student 

The mentor used a structured coaching approach to build both conceptual understanding and practical deliverables. Steps below map to the report sections students are expected to produce.

Step 1 : Clarify scope & assessment rubric

• Reviewed the marking rubric with the student, confirming weightings for theory, methods, critical analysis, and recommendations.

• Defined the report’s audience (academic assessor, nursing home managers, implementation teams).

Step 2 : Rapid familiarisation with the ACP+ study

• Guided the student to read the Gilissen et al. article in full, highlighting the Methods, Results (Steps 1–3), Table 1, and TIDieR description.

• Asked the student to extract key data: initial 9 components → final 10 components; examples of activities and materials.

Step 3 : Draft the problem statement & rationale

• Coached the student to succinctly state the problem (low ACP uptake; need for whole-setting interventions) and justify why ACP+ addresses a practical evidence gap.

• Emphasised inclusion of prevalence and consequence statistics to contextualise need.

Step 4 : Map methods and programme development process

• Mentor explained how to present the mixed methods used (literature review, expert panel, interviews, thematic analysis) and why each method contributes to robustness.

• Student produced a concise subsection describing sampling, participants, and data-collection/analysis approaches.

Step 5 : Translate components into operational detail

• Worked with the student to convert the paper’s components into a table (component → activities → materials → actors → timing).

• Ensured the student captured roles (ACP Trainer, Reference Persons, Conversation Facilitators, Antennas) and phased implementation logic.

Step 6 : Summarise feasibility & acceptability findings

• Mentor modelled how to synthesise interview themes (barriers, facilitators) and document specific adaptations made (management engagement, tailoring meetings, dementia modules, evening sessions for family physicians).

• Student practiced writing concise thematic paragraphs with illustrative quotes (paraphrased and referenced).

Step 7 : Explain implementation strategy and operational issues

• Coached the student to describe stepwise rollout, time-commitment expectations (0.10 FTE for reference persons, initial intensive trainer support → tapering), and suggested scheduling practices to reduce burden (combine sessions, use lunch times).

• Advised inclusion of audit tools, documentation procedures and integration into multidisciplinary meetings.

Step 8 : Critical appraisal and recommendations

• Guided the student to critically assess strengths (whole-setting focus, internal champion model, tailoring) and limitations (resource/time intensity, family physician engagement challenges, potential exclusion of homes undergoing structural change).

• Developed practical recommendations mapped to barriers: e.g., remote/online info sessions for physicians, protected FTE time, dementia-specific communication training, streamlined documentation templates.

Step 9 : Produce standardised programme description

• Mentor instructed the student to apply TIDieR or similar checklist to present the final ACP+ programme in standardised form (why, what, who, how, where, when, how much, tailoring).

• Student prepared a one-page TIDieR summary for rapid reference.

Step 10 : Final editing, referencing and submission readiness

• Performed final review focusing on: logical flow, third-person voice, Australian English spelling (organisation, emphasise), accurate citation of Gilissen et al., and inclusion of appendices.

• Ensured the student had evidence of learning: reflective paragraph or short note on how mentor feedback shaped the final product.

Final outcome and learning objectives covered

Final outcome delivered:
A concise, academically rigorous report that: (a) explains the need for systematic ACP in nursing homes; (b) summarises the ACP+ programme development methods; (c) presents the final 10 components with activities and materials; (d) reports feasibility/acceptability findings and implemented adaptations; (e) describes implementation strategy and monitoring processes; (f) provides a critical appraisal with targeted recommendations; and (g) includes a standardised TIDieR description and appendices for key materials.

Concrete deliverables that can be appended

• One-page TIDieR programme summary.

• Component → Activity → Material mapping table.

• Sample ACP Conversation Tool (one-page).

• Short implementation checklist for management (selecting reference persons, protected FTE, tailoring meeting agenda).

Learning objectives and skills achieved

1. Applied research comprehension: Interpreting and translating a complex intervention study into operational detail.

2. Implementation science literacy: Understanding staged implementation, roles, tailoring and fidelity monitoring.

3. Critical appraisal: Identifying practical barriers and proposing evidence-based mitigations.

4. Professional communication: Producing a standardised, policy-relevant description (TIDieR) suitable for replication.

5. Practical planning: Designing feasible training and supervision models (trainers → reference persons → facilitators → antennas).

6. Ethical/contextual sensitivity: Recognising legal and cultural considerations (advance directives, dementia care, physician engagement).

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