Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting
Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting
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DOI：
10.1186/s12913-019-4309-5
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发表时间：
2019-07-29
影响因子：
2.8
通讯作者：
Mitchell, Susan L.
中科院分区：
文献类型：
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作者：
Palmer, Jennifer A.;Parker, Victoria A.;Mitchell, Susan L.
背景疗养院视频教育的实用性试验 (PROVEN) 旨在测试预先护理计划 (ACP) 视频干预的有效性。人们对在疗养院 (NH) 环境中实施 ACP 干预措施所面临的挑战知之甚少，尤其是在一项务实试验中。为了弥补这一研究差距，本报告试图从负责向患者和家庭介绍 ACP 视频项目的倡导者的角度来确定实施 PROVEN 的促进因素和障碍。方法在 18 个月实施期的第 4 个月和 15 个月的半结构化电话访谈中，所有 PROVEN 干预设施的 ACP 倡导者 (N=119) 被问及他们对项目实施的看法。使用混合演绎/归纳方法进行主题分析，有目的地对 40 份访谈进行了抽样、转录和分析，其中纳入了实施研究综合框架的领域：干预特征 (IC)、内部环境 (IS)、个体特征 (CI)、外部环境 (OS) 和过程 (P)。 结果 冠军确定的实施促进因素包括：干预的适应性演示模式和最小时间负担 (IC)以及该计划向患者和家庭提供的可定制交付以及 ACP 冠军 (P) 之间对实施情况进行集体反思的机会。障碍包括计划中规定的协议驱动方面 (OS)、实施干预的时间有限 (IS) 以及利益相关者 (CI) 缺乏对 ACP 的认知相关性和情感准备。 结论 尽管 PROVEN 的干预措施有望改善疗养院的 ACP，但不可改变的环境和倡导者、患者和家庭成员的特征带来了实施障碍。除了企业层面的利益相关者之外，研究人员还需要让所有项目参与者（即设施工作人员、患者和家属）参与早期务实的试验设计，以尽量减少此类障碍。此外，尽管 PROVEN 的实施过程具有便利性，但该研究仍遇到了科学严谨性与现实世界需求之间的紧张关系。研究人员需要优化实用试验设计的现实世界真实性，同时避免实施方案过度偏差。试验注册ClinicalTrials.gov 标识符：NCT02612688。 2015 年 11 月 19 日注册。
BackgroundThe 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.MethodsIn semi-structured telephone interviews at 4 and 15months 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).ResultsImplementation 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).ConclusionsDespite 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 registrationClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.