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Table 2 Analytic Themes by CFIR Construct with Illustrative Quotes

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

Analytic ThemeQuote
Intervention Characteristics
 Evidence Strength & Quality
Videos provided helpful detail and understandable framework for conceptualizing care options. Champion 1: “I just think it [the video] makes everyone more aware of what’s out there…it’s just the knowledge that there are things out there that aren’t just whether you want to be resuscitated or not…there’s a whole package of information that you really can consider.”
Videos were valuable “openers” to ACP conversations, instigators of advance directive completion, and educational tools for future decisions. Champion 2: “And many of them, where in the past if they don’t have written healthcare directives and I give them the packet, in the past a lot of times they just kind of put it in a folder. Where now that they’re watching the video, they’re like, ‘I really need to complete these forms. You know, that video was really encouraging. I can’t wait.’”
Champion 3: “I mean, everybody that’s watched it has been receptive. Like, ‘Oh, that’s good information,’ and it’s like they’re tucking it away for the future. And our long-term, the ones that we’ve done ... Like, I’m thinking of one family member in particular, it’s more they’re really kind of chewing on it for right now.”
Videos contained a “bias” against aggressive care options. Champion 3: “We had one person [patient] say that, ‘Are they trying to tell me that I should be a DNR?’…so I would say, if I personally was gonna change anything [about the video], it would just maybe be the tone of some of the conversation.”
 Relative Advantage
Videos’ visual nature made them particularly helpful compared to verbal conversations alone. Champion 2: “Again, it’s a great tool to have. What people most like is being able to see the visual of what CPR and what intubation is. It gives them something to visualize when they’re making their decisions. Otherwise, I think a lot of them wouldn’t always understand what we mean even though we explain it. I think seeing the video helps tremendously.”
 Adaptability
Linguistic translations, content specific to medical condition, and both tablet and on-line access to the videos maximized the ability to adjust for stakeholder needs. Champion 4: “And for me with long term [patients], I would say actually the fact that the links are available online [works well], because most people do not want to take the time in the moment when we bring it up to view a video. They’d rather watch it from, in their own time, so having the links has been most helpful, I think for us.”
Champion 5: “What has gone particularly well?...I guess I would just have to say the individualized videos that kinda coincides with what’s going on with that person at that time.”
 Cost
Video length did not typically introduce a time burden. Champion 2: “And I do like that it’s done in a concise fashion. You know, the General Care [video] is like six and a half minutes. I like that it’s short. If it were any longer I don’t think people would watch it. The fact that it’s short, I’ve been able to entice people to watch it by telling them that it’s only a six and a half minute video. And it’s like, ‘Oh, okay. Then I’ll watch it.’”
Inner Setting
 Available Resources (within Readiness for Implementation)
Organizational provision of staffing and dedicated time was not necessarily sufficient for implementation efforts. Champion 6: “Time. Like I said, things have come up where I think the original champion was our DON [Director of Nursing]. Our DON left, we got a new DON. We had an acting DON, so everything was put on me. I had other things arise within our census. I couldn’t prioritize them, and like I said, I asked for help, and medical records was helping. But time would be the most challenging part.”
Champion 7: “Well, it’s probably just that…not so that the videos are as long, it’s just to try to put so much in today in one little session. Sometimes if we have care plan meetings, the families use that as a bickering session, we try to inform and educate during that. Sometimes they just...I think it’s just the time.”
 Networks & Communications
Some champions actively informed other staff of the ACP video program (e.g., through staff meetings), while others did not. Champion 6: “They know about it, the nurse and nurse practitioners. The nurses should know. Everybody knows because we’ve talked about it at full staff meetings on multiple occasions. We have the cards [with on-line links to videos]. To my knowledge, I don’t think anybody’s not aware of it unless they’re new hires.”
 Compatibility (within Implementation Climate)
The video program could be incorporated into current ACP processes in some facilities. Champion 8: “It just becomes part of the routine. Like I said, we have a 72 h meeting and it’s part of that care plan. If we need to talk to them about advance directives, it’s just a natural kind of progression.”
Characteristics of Individuals
 Knowledge & Beliefs about the Intervention
Patient/family reticence to view ACP videos due to perceived lack of personal relevance or well-established advance directives was a barrier. Champion 5: “There are a few folks that, on our short term unit, you know, people who may be in their 50’s, 60’s and we see them as very ill and high risk for readmission and re-hospitalization, they do not see themselves as that, and they, some people they just say, ‘I don’t need to see that. I don’t need advance directives, I’m young, I’m not going anywhere.’”
Champion 9: “The long-stay patients, it’s mostly folks that have ... their powers of attorney are activated, and they’ll [the powers of attorney] say, ‘Well, we already have this stuff. We already talked about that.’”
Champion perceptions of the relevance of prior experience in engaging patients/families in ACP positively and negatively impacted implementation. Champion 10: “…there’s many of us that’s been in this industry for a long time, so we’ve been pretty well versed with talking to the residents at their level, and explaining advance directives, explaining hospitalization, explaining end of life care, so, not to be rude, but it’s [offering the videos] just an extra step at this point.”
Champion 11: “I think sometimes it’s hard if you’re brand new in a position if you’ve never had these kinds of conversations with families - it can be hard. I know me, starting out, I had to kind of grow into being able to talk about those things, so I think the video’s really gonna help close that learning gap. And I think it’s good because it’s something that not only social workers and nurses could use, but you can just give the links to family members and they can start having that conversation.”
 Individual Stage of Change
Champions felt that patients/family members were not always emotionally ready to engage in an ACP conversation. Champion 12: “Very much half - 50% of them are not interested. Or they don’t want to talk about it. Or they’re not ready to talk about it. So it’s a very hard conversation sometimes that we have to back off when that happen?”
Outer Setting
 External Policy & Incentives
External mandates of the prescribed program protocol hindered implementation efforts. Champion 13: “Um, I wish it was offered on an as-needed basis, for families who are thinking about making a change and experiencing challenges with what to do…I wish that it wasn’t something that we had to mandate to do on every new patient, and every readmission. That would definitely make it more, in my opinion, more worthwhile, to be on an as-needed basis.”
Champion 13: “…it’s [ACP] something that I already cover, so it’s just more work for me to do by completing the assessment [i.e., adherence documentation]. It’s something that I address on admission, and we address it at our care plan meetings quarterly. We address it when there are changes in conditions. So it’s just more work for me.”
Champion 14: “Families are gonna be up in arms! You already showed it once.”
Process
 Engaging
Formal Champion training, when received, was mostly perceived as effective. Champion 15: “Oh, I felt very prepared, because I watched every video so I would know what it was and the printed material was, was excellent going through that.”
When formal training was not received, some champions and/or supervisors instituted their own informal training. Champion 16: “It was dropped on my desk with instructions! No one—I think there might have been a[n] online thing. There might have been. I don’t know. But myself and the nurse practitioner figured it out.”
Non-Champion staff were at times tangentially involved in implementation, most often by referring patients/families to Champions when an ACP need was perceived. Champion 17: “…if they [senior leadership] want me to show the video to a patient, they will let me know. And sometimes if they have time, I’ll give it to them, but a lot of time they’ll ask me to just go ahead and do it like, when we have patients with change of conditions.”
 Executing
Latitude to customize the implementation protocol (e.g., the way in which patients/family members were approached) maximized program outreach. Champion 18: “…[when] it’s time for them [long-stay patients] to watch them [the videos] again or if there’s a change [in status]...I might get them popcorn, Little Debbies, that kind of thing and let them sit and make an activity out of it. That’s what I do, that’s how I use it.”
 Reflecting & Evaluating
Ongoing cross-facility conference calls were perceived as “the best part” of implementation training given the opportunity to learn from other Champions’ experiences. Champion 19: “Just getting the feedback from the other social workers or the other champions, just to make sure I was doin’ it how it should have been done, and their questions kinda helped me for the future, stuff like that. So I think the feedback was the best part of the training, ‘cause it’s, like I said, the videos are pretty self-explanatory as far as showing ‘em, but the challenges you run into, it was good to hear other ones- other centers had the same challenges, and what they were doing to kinda overcome those things.”
  1. ACP advance care planning
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