Navigating Barriers and Enablers to Advance Care Planning for Residents Living With Alzheimer’s Disease and Related Dementias Nursing Homes: Strategies for Effective Implementation of the Goals of Care Video a Content Analysis

Abstract

Background:

Providing high-quality advance care planning conversations for nursing home residents living with Alzheimer’s Disease and Related Dementias is a persistent challenge, but implementation of advance care planning interventions remains limited.

Objective:

This study explored barriers and enablers to implementing the Goals of Care video with nursing home staff and identified strategies to implement the video intervention.

Methods:

Nursing home administrators identified staff members involved in ACP discussions with residents and families. A research team member contacted these individuals by email or telephone. Fourteen staff members across six Florida nursing homes participated in in-person or virtual semi-structured interviews. A summative content analysis quantified the frequency of each CFIR construct coded as an enabler or barrier, with frequencies calculated at the nursing home level.

Results:

The primary enabler was the alignment of the Goals of Care video with nursing homes’ organizational mission. The most identified barrier was the video’s perceived length. Strategies to improve implementation included adapting materials, assessing readiness, and addressing site-specific challenges.

Conclusions:

Tailoring the Goals of Care video to the organizational context is essential. Addressing barriers, such as video concerns, while leveraging existing enablers can strengthen adoption and support more consistent advance care planning practices.

Keywords

long-term care advance care planning Goals of Care decision-making barriers and enablers implementation strategies CFIR 2.0 Alzheimer’s Disease and Related Dementias

Introduction

Nursing homes are a common site of end-of-life care for residents living with advanced Alzheimer’s Disease and Related Dementias (ADRD; Orth et al., 2021) but providing high quality, person-centered, goal-concordant care is a persistent challenge in this setting. Nursing home residents living with advanced ADRD often experience infections and eating problems, contributing to burdensome end-of-life care (Mitchell et al., 2009) that can result in higher rates of potentially avoidable hospitalizations (Estrada et al., 2024; Xing et al., 2013). Advance care planning (ACP) is a process that supports discussions and decisions about goals and preferences for future care and treatment with residents and their family members (Rietjens et al., 2017; R. Sudore et al., 2017). When residents living with ADRD lose decisional capacity, family members are often asked to serve as proxy decision-makers. However, they are often unprepared to participate in decision-making regarding goals of care, resulting in feelings of uncertainty, strain, depression, and anxiety (Anderson et al., 2009; Azoulay et al., 2005; Fetherstonhaugh et al., 2017, 2019).

Prior literature indicates ACP interventions significantly improve the documentation of end-of-life care preferences (Ng et al., 2022), which can align care with the individuals’ treatment preferences. ACP interventions for residents living with dementia include educating family proxy decision-makers about goals of care choices and preparing them to communicate these preferences with nursing home staff. The Goals of Care (GOC), an ACP intervention, includes a video decision-aid, a decision-making guide, and a structured care plan meeting (Hanson et al., 2017). In a randomized control trial, it improved the quality of communication for family caregivers compared to usual care planning in North Carolina nursing homes. Residents were transferred to the hospital half as often, but overall survival was unchanged (Hanson et al., 2017). While the GOC intervention is effective, less is known about how to implement it in nursing homes.

Although ACP interventions have been found to be efficacious, less is known about detailed implementation strategies (Ng et al., 2022) associated with successful engagement. Even well-designed interventions may encounter contextual factors that hinder the intervention from being implemented as planned (Chisholm et al., 2022; Hawe et al., 2004; Palmer et al., 2019). For example, while nursing home staff perceived the GOC intervention positively in the original trail (Chisholm, Zimmerman, et al., 2018), the availability of nursing home resources influenced the level of implementation (Chisholm et al., 2022). Similarly, a large ACP nursing home pragmatic trial of an ACP video for long-stay residents with advanced illness which included those with ADRD had no significant effect on hospital transfers (Mitchell et al., 2018), which was particularly due to the high variability in implementing the intervention across nursing homes (Mitchell et al., 2018; Palmer et al., 2019). These findings suggest it is important to understand determinants that may hinder or enhance the use of ACP interventions to improve uptake. This study builds on existing literature by identifying barriers and enablers that may influence the implementation of GOC video. It advances current knowledge by conducting a pre-implementation assessment using the ACP pre-implementation tool, developed using the CFIR 2.0 framework, to systematically assess contextual factors that shape readiness for implementation. Additionally, this study identifies potential implementation strategies to mitigate identified barriers, offering actionable insight prior to intervention implementation. The aim of this study was to conduct a CFIR-guided content analysis to identify staff-perceived barriers and enablers to implement the GOC video in nursing homes, as well explore potential strategies to mitigate implementation barriers. This study was guided by the following research question: What staff perceived barriers and facilitators may influence the implementation of the GOC video in nursing homes?

Methods

Sample

The study was conducted with a convenience sample of six Florida nursing homes between September 2023 and May 2024. The 2021 LTCFocus data was utilized to obtain facility-level information on nursing homes (Brown University, 2021), including occupancy rate, bed size, payer mix, and racial composition of residents. Introductory emails providing an overview of the study were sent to nursing homes within a 25-mile radius of the University of Central Florida (N = 44), resulting in a 14% response rate. We did not find a significant difference between nursing homes that responded and non-responding facilities (table comparing responders to non-responders in Supplemental Material).

Nursing home administrators were asked to identify staff members involved in ACP discussions with residents and families for potential participation. Staff were contacted by a member of the research team by email or telephone and invited to participate in the study. A total of 14 nursing home staff were enrolled across the six facilities. In qualitative research, four to six groups are generally considered sufficient for capturing a board range of perspectives (Guest et al., 2017), and these groups are typically comprised of five to eight participants (Krueger & Casey, 2014). The sample size for this study is appropriate because we intentionally targeted key stakeholders involved in ACP discussions, which typically include 2 to 3 individuals in nursing homes. According to Hamilton and Finley (2019), engaging a smaller number of highly relevant participants allows for richer and more contextual insight, rather than the more superficial information that may result from larger but less targeted samples.

Prior to participating in the semi-structured interviews, each nursing home staff member received a copy of the informed consent and provided verbal consent. This study was approved by the University of Central Florida Institutional Review Board (IRB ID: Study00005646-). Each participant received an electronic $10.00 gift card after completing the semi-structured interview.

Researcher Characteristics and Reflexivity

Data collection was conducted by the study PI (LC). The PI has developed partnerships with Florida nursing homes and state organizations, but she is not a member of the nursing home staff. She has also conducted research primarily in nursing homes to improve quality and mitigate disparities through the implementation of evidence-based interventions. To support triangulation, multiple data sources were used, including the ACP pre-implementation checklist, which was used to collect information on barriers and enablers as well as text segments describing factors that may contribute to implementing the GOC video intervention. Additionally, secondary data, LTCFocus data, was used to assess nursing home characteristics. Attention to transferability was ensured through detailed documentation of the nursing home context and organizational processes, enabling readers to assess the applicability of the findings to other long-term care settings with similar structures or populations. Dependability was supported through systematic data collection procedures, consistent use of the checklist across sites. Confirmability was enhanced by grounding interpretations in the data and retaining clear links between raw data and analytic conclusions.

Data Collection

We used the Consolidated Framework for Implementation Research (CFIR) 2.0 framework (Damschroder et al., 2022), a well-established determinant framework. For this proposed study we focused on the three CFIR domains: (1) innovation-the intervention being implemented, (2) inner setting-environment where the intervention is being implemented, and (3) individual-roles and characteristics of individuals who are involved with the intervention. We excluded the outer setting and implementation process domains, as nursing home staff may have limited awareness of external factors influences on implementation, and the video was not actively implemented in facilities. Each selected domain includes several constructs that act as either barriers or enablers to successful implementation.

The CFIR 2.0 framework was used to guide the development of the ACP pre-implementation checklist (see Supplemental File for instrument). The checklist included columns that categorized CFIR 2.0 constructs as either enablers or barriers to implementing the GOC video, an 18-min decision aid intended to supplement but not replace ACP discussions. This video was developed using the International Patient Decision Aid Standards (Hanson et al., 2017). An additional column was included to capture additional information. To further inform the checklist, we reviewed existing literature to identify CFIR constructs related to ACP in nursing homes.

The study focused on perceptions of implementing the GOC video, a component of the GOC intervention used in the previously described successful trial (Hanson et al., 2017). Nursing home staff participated in 60-min semi-structured interviews-either individually or in groups, depending on the number of staff from each facility. The interviews were conducted in person at their facility in a room of their selection or via videoconferencing facilitated by a member of the research team and occurred between October 2023 and May 2024. Before the interviews, staff were informed that the study aimed to identify barriers and enablers to using the GOC video, as well as how constructs were barriers or enablers. Participants viewed the GOC video and then were interviewed using the ACP pre-implementation checklist. The checklist served as both a guide for the interviews to identify enablers and barriers to using the GOC video, and a tool for documenting field notes to describe detailed information on how constructs hindered or enabled use of the GOC video. For instance, staff were initially asked whether incorporating the GOC video into routine care would function as an enabler or barrier. Subsequently, they were asked to describe how the video could be integrated into routine practice within the nursing home, specifically addressing the work infrastructure construct.

Saturation was assessed by examining whether new themes emerged regarding how the CFIR constructs functioned as enablers or barriers to implementing the GOC video. This process was monitored iteratively, with the ACP pre-implementation checklists reviewed and coded concurrently with ongoing semi-structured interviews. After conducting a total of six interviews with one to six staff members in each group, the research team observed that the core themes related to CFIR constructs identified as enablers and barriers to implementing the GOC video were consistently repeated. No new insights emerged regarding how these constructs functioned as barriers or enablers (see Supplemental File for saturation table). Prior literature indicates qualitative research can reach saturation with approximately 7 to 19 interviews, particularly when the goal is to identify major themes (Hennink & Kaiser, 2022; Wutich et al., 2024). Furthermore, because our sample was smaller and more homogenous, based on staff discipline, we were able to achieve saturation with the six interviews.

Analysis

The coding process followed a deductive qualitative approach, guided by the ACP pre-implementation checklist to structure our analysis. After a research team member (LC) conducted semi-structured interviews with nursing home staff, two research team members (LC & WC) individually reviewed the staff responses regarding categorization of constructs as enablers or barriers at each nursing home. Prior to individual reviews, LC and WC discussed the process for using the ACP pre-implementation checklist to verify staff responses from the semi-structured interviews. Discrepancies were reviewed with the study PI (LC), who also reviewed the research teams’ categorization to ensure they aligned with participants’ descriptions of constructs. A summative content analysis (Hsieh & Shannon, 2005) was conducted to calculate the frequencies of each construct coded as an enabler or barrier using Excel at the nursing home level. If a construct was identified as both a barrier and enabler by staff at the same nursing home, it was coded as both. Text segments from nursing home staff, identified through the field notes from the ACP pre-implementation tool, were reviewed by the research team to explore how various constructs may facilitate or hinder the implementation of the GOC video. This analysis allowed investigators to determine which barriers and enablers were the most and least commonly reported among nursing homes, supported by direct quotes that illustrate these findings.

Implementation strategies were identified using the results from the Expert Recommendations for Implementation Change (ERIC) project (Powell et al., 2015) and the CFIR-ERIC Implementation Strategy Matching Tool, an Excel-based tool, to match CFRI barriers with ERIC implementation strategies. The CFIR-ERIC Matching tool includes CFIR constructs that align with up to 73 implementation strategies derived from ERIC (Waltz et al., 2019). Implementation science experts and practitioners used a ranking method to select and rank the top seven strategies that best address CFIR barriers. The CFIR-ERIC Tool generates a set of corrective implementation strategies based on the CFIR related barrier (Waltz et al., 2019). Both techniques were utilized for this study because not all strategies are linked to CFIR constructs on the CFIR-ERIC Implementation Strategy Matching Tool.

Results

The six nursing homes that participated in the study had a bed size range from 60 to 133 beds and had an average occupancy rate of 75%. The nursing homes represented a diverse mix in terms of payer status and racial composition of nursing home residents. Group sizes ranged from one to six staff members with an average of two respondents from each nursing home (see Table 1). Participants included registered nurses (n = 5), social workers (n = 4), nursing home administrators (n = 4), and physical therapists (n = 1) from the six nursing homes, responses are reported at the nursing home level.

Table 1.

Characteristics of NHs (N = 6) Describing Enablers and Barriers to Implementing the GOC Video Intervention.

	NH 1 (n = 1)	NH 2 (n = 1)	NH 3 (n = 2)	NH 4 (n = 6)	NH 5 (n = 1)	NH 6 (n = 3)
NH characteristics
Bed size (n)	60	110	60	131	138	133
Occupancy rate (%)	65	99	82	76	49	77
Payer status (%)
Medicaid residents	0.00	37.61	38.78	65.66	51.25	53.92
Medicare residents	33.33	27.52	30.61	15.155	31.25	20.59
Racial/ethnic composition (%)
White	97.74	50.00	97.96	46.67	39.53	74.19
Hispanic	N/A	27.45	0.00	43.96	59.30	0.00
Black	0.00	19.61	N/A	N/A	N/A	22.58

Note. n = number of nursing home staff participants. N/A indicates percentages that are too small for reporting.

Participants reported nine CFIR 2.0 constructs as enablers and four CFIR 2.0 constructs as barriers to implementing the GOC video. The most commonly reported enabler included mission alignment or perceptions that implementing the GOC video aligns with the purpose of the organization. Additional enablers included having the physical and technology infrastructure in place to support implementing the GOC video (5 out of 6 nursing homes); an existing culture in the nursing home focused on recipient- and learning-centeredness (5 out of 6 nursing homes); a work infrastructure that supports ACP (4 out of 6 nursing homes); high quality formal and informal information sharing ( 4 out of 6 nursing homes); readiness to implement the GOC video ( 4 out of 6 nursing homes); and staff to facilitate the implementation of the video (4 out of 6 nursing homes).

Presenting the GOC video to residents/families was identified as a challenge by staff across the six nursing homes (innovation design). Most nursing home staff identified access to understandable health education (5 out of 6 nursing homes), resident and family readiness (4 out of 6 nursing homes), and different cultural and family backgrounds (4 out of 6 nursing homes) as barriers to implementing the GOC video with residents/families. See Table 2 for details.

Table 2.

CFIR 2.0 Constructs Reported as Enablers and Barriers to Implementing the GOC Video Intervention Across Nursing Homes.

Determinants	Type	Frequency	How determinants functioned as an enabler or barrier
Innovation domain
1. Innovation design: how the intervention is presented	Barrier	6/6	GOC video length may make it difficult to share during the care plan meeting.
Inner setting
Structural characteristics
2. Physical Infrastructure: the organization has the space.	Enabler	5/6	Availability of electronics and conference rooms can facilitate sharing GOC video during family nights and staff training.
3. Information technology/infrastructure: the organization has the technological system for tele-communication, electronic documentation, and data storage.	Enabler	5/6	A link of the GOC video can be emailed to family members prior to the care plan meeting.
4. Work infrastructure: the organization has developed task between individuals and teams.	Enabler	4/6	GOC video could be provided to families during the new admission intake or return from hospital.
Relational connections/communication
5. High quality formal and informal information sharing	Enabler	4/6	Interdiscplinary team and providers can be helpful with engaging families about the GOC video
Culture
6. Readiness to implement ACP	Enabler	4/6	ACP discussions are already occurring.
7. Recipient-centeredness: shared values supporting the needs of recipients.	Enabler	5/6	GOC videos aligns with person-centered care.
8. Learning centeredness: shared values around the psychological safety, continual improvement, and using data to inform practice.	Enabler	5/6	The GOC video can support ACP discussions prompted by resident-level data.
Additional characteristics
9. Mission alignment: implementing the innovation in line with the purpose in the inner setting.	Enabler	6/6	The GOC video aligns with NH workflow.
Individuals domain
10. Implementation facilitators	Enabler	4/6	GOC video can be shared with families through discussions facilitated by the social worker and interdisciplinary care plan team.
Innovation recipient
11. Access to understandable health education	Barrier	5/6	ACP education may be limited in NHs. The GOC video is an opportunity to educate staff and families of persons living with advanced ADRD.
12. Patient and caregiver readiness to engage in ACP	Barrier	4/6	Some families of residents living with advanced ADRD may not be ready to engage in using the GOC video. Working with clinicians and chaplains may facilitate the use of the video. (discussion)

Innovation Domain

Intervention Design

Although nursing homes are required to engage residents and families in ACP discussions, time constraints often limit the duration and content provided during the conversation. The GOC video may encounter similar implementation challenges, specifically because it is designed to be shown to families during resident care plan meetings. Staff across all six nursing homes identified the design of the intervention, particularly the video’s length, as a major barrier to sharing it with families during routine care planning. For example, a staff member at nursing home 1 reported, “Care plan meetings are only 15 minutes; we don’t have time to show the video during that meeting.”

“The video is way too long,” staff from NH 5.

Inner Setting

Physical, Information Technology, and Work Infrastructure

Nursing home staff reported having the space and equipment, such as conference rooms to present the video to residents and families. “Laptops can be used; we have the conference room for viewing” Staff member from nursing home 2

Additionally, nursing homes describe having the technology/infrastructure to support the implementation of the GOC video, indicating that emails are an effective method for sharing the video with families.

“Already send an email prior to care plan meetings.” Staff member from NH 3

“Email system is good way to provide video to families. Facility website with monthly newsletter (physical and digital).” Staff member from nursing home 4

Staff also noted that discussions about advanced directives typically occur during new admissions, hospital returns, or quarterly follow-up. These moments are an opportunity to present the GOC video before the next care plan meeting. As indicated, “Social worker engages families about goals of advance care planning during the admission and quarterly follow-up.” Staff member from nursing home 6

Relational Connection/Communication and Culture

High quality formal and informal information sharing was identified as potential facilitators for implementing the GOC video in nursing homes. Interdisciplinary teams-typically composed of nursing, social work, physical therapy, and dietary-have a central role in resident care. Their combined expertise, along with physician involvement, can create opportunities to engage residents and families in discussions about the GOC video. Specifically, nurses and providers who have established rapport with residents are well-positioned to initiate and guide these conversations. As noted, “Nurses and providers are helpful with goals of care discussions.” Staff member at nursing home 4.

“Initial discussion with social worker and family. Interdisciplinary team follows up once initial goal is decided.” Staff member at nursing home 1

Recipient-and Learned-Centeredness

The GOC video is an opportunity to facilitate resident-centered goals of care discussions. The video also aligns with the organizational culture of nursing homes that emphasize both recipient- and learning-centered care.

“ACP is a priority based on residents needs”. Staff at nursing home 1

“Upon admission, nurse starts ACP conversations. Inquiring with patients’ family if advance directive exist, what can be put in place.” Staff at nursing home 2

Mission Alignment

Additionally, the video supports the mission of nursing homes to provide continuous high quality to care residents. A staff member at nursing home 4 stated, “Our mission is to serve and care for residents, modify care to ensure we are meeting needs.” Since nursing homes routinely provide opportunities for ACP discussions, the GOC video can easily be integrated into existing processes to support these conversations. Nursing home staff indicated, “Ready to implement. GOC video could be included as part of the process.” Staff member at nursing home 1

Individuals Domain

Implementation Facilitators

Implementation facilitators are individuals with expertise in ACP discussions who can support and guide the implementation process. Nursing home staff identified the following personnel as implementation facilitators when introducing the GOC video:

“Care plan members.” Staff from nursing home 3

“Social worker likes to build rapport before having ACP conversation. Team meeting with nursing, clinicians, and social work.” Staff from nursing home 4

“Interdisciplinary team doing morning meetings to identify next steps of need for ACP. Social worker will approach the family.” Staff from nursing home 1

“Social worker.” Staff from nursing home 5

While implementation facilitators were identified as an enabler to implement the GOC video, the majority of the perceived barriers were related to constructs under the individual domain, specifically the innovation deliverers or individuals who are directly receiving the innovation construct.

Innovation Deliverers/Recipients

Residents and families of residents living with ADRD may not be aware of the need to discuss goals of care or what to focus on during these discussions due to limited education about ACP discussions, which may limit the use of the GOC video in nursing homes. Additionally, staff may lack the training to provide high quality resident-centered ACP discussions. As noted by staff from nursing home 2, “Patients/families and staff need education on this topic.”

“Families typically do not come with this education.” Staff from nursing home 6

“The more education the better.” Staff from nursing home 4

Recipient Readiness

Some residents and families of residents living with ADRD may not be ready engage in discussions about goals of care with nursing home staff, which can also be related to the limited education provided about the disease, the disease progression, and advance care planning. Furthermore, the culture and background of residents may influence the implementation of the GOC video. Some examples include:

“Religion and culture are potential barriers.” Staff member at nursing home 3

“The GOC video would need to be in Spanish.” Staff member at nursing home 4

Implementation Strategies

The CFIR-ERIC Strategy Mapping Tool suggested several potential strategies to address the implementation of two of the three barriers identified by participants. We used prior literature to identify the primary strategies for the additional barrier (recipient readiness) that was not mapped on the tool (Powell et al., 2015; see Table 3). One potential key implementation strategy would be to promote the adaptability of intervention across nursing homes. Furthermore, developing and distributing diverse educational materials related to the GOC video could improve the use of the video. It may also be important to identify and prepare champions to lead the implementation of the GOC video. These champions could assess readiness and identify barriers and facilitators to implement the intervention. Creating a learning collaborative in the facility to allow families and staff to use resident data to promote ACP discussions supplemented by the GOC video is another potential strategy.

Table 3.

Potential Barriers and Strategies to Implement the GOC Video Intervention.

Potential barriers	ERIC implementation strategies
1. Innovation design^a	• Promote adaptability • Develop educational materials
2. Access to Understandable education^a	• Conduct educational meetings • Develop educational materials
3. Patient/Caregiver Readiness	• Identify champions • Develop learning collaboratives

Strategies obtained from the CFIR-ERIC mapping tool recommended the most for the barrier.

Discussion

Prior literature has highlighted the benefits of implementing ACP interventions such as the GOC video in nursing homes (Ng et al., 2022). However, translating evidence into clinical practice remains a challenge across healthcare settings. This pre-implementation study identified enablers and barriers to implementing the GOC video with families of residents living with ADRD, which varied across nursing homes, suggesting organizational context influences the implementation process. The results are consistent with previous studies showing that implementation of the ACP interventions differs across nursing homes based on organizational characteristics (Chisholm et al., 2022; Palmer et al., 2019). Focusing on delivering the core components of the intervention while using tailored implementation strategies to facilitate implementation could improve implementation across nursing homes.

Mission alignment emerged as a significant enabler, with all six nursing homes reporting that the GOC intervention aligned with their organization’s purpose. This finding supports the priority of nursing homes to focus clinical care on person-centered care or care provided in a manner that reflects the individuals’ preferences (Corazzini et al., 2016; Rosemond et al., 2012), which aligns with the process of ACP (R. L. Sudore & Fried, 2010). Formal and informal leadership shapes the organization’s mission. As such, they can play an important role embedding interventions into the organizations’ culture (Aarons et al., 2015; Brazil et al., 2024; Finucane et al., 2013). Furthermore, interventions that are easily integrated into the clinical workflow of nursing homes may improve implementation and uptake by staff because of their alignment with organization’s culture (Basinska et al., 2022; Chisholm, Zhang, et al., 2018; Palmer et al., 2019).

In contrast, the length of the video was identified as a universal barrier, staff consistently cited it was incompatible with the short duration of the care plan meeting. Nursing home staff reported that while the GOC video aligned with their workflow, they lacked the time to implement the video. This is unsurprising, as contextual factors related to staff shortages and time pressures have been identified as constraints when implementing other kinds of nursing home interventions (Aasmul et al., 2018; Flo et al., 2016; Palmer et al., 2019; Tappen et al., 2017). These findings highlight that nursing homes may perceive the GOC video as conceptually important but may encounter structural and workflow challenges that can limit feasibility

Other enablers and barriers varied across nursing homes. A culture of resident- and learning-centeredness, which includes having shared values around continual improvement and using resident-data to inform practice, was highlighted as an enabler in five out of the six nursing homes. This indicates that a person-centered philosophy is beneficial for ACP interventions. Person-centered care emphasizes putting residents at the center of planning (Brazil et al., 2024) and focusing on individualized care that addresses the residents’ preferences, needs, and values (Basinska et al., 2022). ACP interventions, like the GOC video, also focus on similar principles for ACP discussions with residents (R. L. Sudore & Fried, 2010).

Physical and technology infrastructure was also crucial, with most nursing homes reporting they have the necessary resources to support the GOC video implementation. Prior literature has found that nursing home resources impact intervention implementation (Chisholm et al., 2022; McCreedy et al., 2024; Palmer et al., 2019). High resource nursing homes may have the staff and technology needed to implement ACP interventions, like the GOC video. Consequently, while some nursing homes may have the infrastructure and culture to facilitate ACP practices, they may not be uniformly available and should not be assumed.

Barriers related to family readiness, access to understandable education, and the influence of cultural and linguistic differences were reported by four to five nursing homes, indicating that individual-level variation may complicate implementation of the GOC video. Similar to other studies, these barriers highlight the complexity of implementing ACP interventions in diverse and dynamic environments like nursing homes (Chisholm et al., 2022; Flo et al., 2016; Palmer et al., 2019; Tappen et al., 2017).

It is crucial to identify and develop implementation strategies that can mitigate existing barriers to ACP (Aasmul et al., 2018; Gilissen et al., 2017; Tappen et al., 2017). Few studies have explored effective strategies for implementing ACP interventions in nursing homes, which may limit their adoption. Flo et al. (2016) conducted a scoping review to assess ACP implementation and strategies in nursing homes, which found staff education was a key implementation strategy in prior studies. This finding aligns with the results in this study. However, our results suggest that additional implementation strategies may be necessary in the successful implementation of ACP videos in nursing homes. Further research is needed to explore and refine these approaches.

Limitations

This study has several limitations that should be considered when interpreting the findings. A potential study limitation was barriers and enablers were self-reported by nursing home staff, which may introduce social desirability and recall bias. Although we used the ACP pre-implementation checklist to try and understand how resident/family determinants may influence the use of the GOC video in nursing homes, we did not include the perspectives of residents/family caregivers. Additionally, we did not collect information on nursing home staffs’ previous experience or training conducting ACP discussions, it is unclear how such factors may have shaped their perceptions of implementing the GOC video. The sample of nursing home staff that participated in this study was a small convenience sample, and as such, the study findings may not be generalizable to other nursing homes and may have the potential for selection bias. Furthermore, Florida nursing homes may have contextual differences that may reduce the generalizability of the findings to other states. The results are presented at the nursing home-level, and we do not link quotes to specific staff characteristics. However, we interviewed staff from various disciplines who reported similar barriers, as such, comments cited may reflect general views of nursing home staff.

Conclusion

This study highlights the importance of understanding both the enablers and barriers to implementing ACP interventions, like the GOC video and offers a model for evaluating the pre-implementation of other ACP interventions in the nursing home setting. Implementing evidence-based ACP interventions can lead to better alignment of care with residents’ preferences contributing to improved resident satisfaction. By aligning the intervention with nursing homes’ mission of providing resident-centered care and ensuring they have the necessary resources, nursing homes may enhance the uptake and impact of the ACP interventions. However, complex or time-consuming interventions may not align with the workflow of nursing homes, which may create challenges with integrating ACP interventions into nursing homes and may limit the effectiveness of the intervention. By using tools like the ACP pre-implementation checklist to leverage identified enablers and address barriers through targeted implementation strategies, nursing homes can improve the adoption and effectiveness. Future research is needed to explore how different organizational contexts influence the implementation of ACP interventions. Additionally, studies should continue to explore these factors and refine strategies to ensure implementation in diverse nursing home settings.

Supplemental Material

sj-docx-1-ggm-10.1177_30495334261436936 – Supplemental material for Navigating Barriers and Enablers to Advance Care Planning for Residents Living With Alzheimer’s Disease and Related Dementias Nursing Homes: Strategies for Effective Implementation of the Goals of Care Video a Content Analysis

Supplemental material, sj-docx-1-ggm-10.1177_30495334261436936 for Navigating Barriers and Enablers to Advance Care Planning for Residents Living With Alzheimer’s Disease and Related Dementias Nursing Homes: Strategies for Effective Implementation of the Goals of Care Video a Content Analysis by Latarsha Chisholm, Susan Hickman, Wan-Yun Chou and Kathleen T. Unroe in Sage Open Aging

Footnotes

ORCID iDs

Latarsha Chisholm

Susan Hickman

Kathleen T. Unroe

Ethical Consideration

This study was reviewed and approved by the University of Central Florida Institutional Review Board.

Consent to Participate

Verbal informed consent was obtained from all participants before their inclusion in the study.

Author Contributions

LC was involved in the writing, data collection, data analysis, and revisions of the articles. SC was involved in the data analysis. SH and KU provided guidance on developing and reviewing the manuscript. All authors agreed to contribute to the journal and are responsible for all aspects of the work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The funding was financially supported by the IMPACT Collaboratory Diversity Investigator Training Award (U 54AG063546).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Cite this data in your research.

Supplemental Material

Supplemental material for this article is available online.

References

Aarons

G. A.

Ehrhart

M. G.

Farahnak

L. R.

Hurlburt

M. S.

(2015). Leadership and organizational change for implementation (LOCI): A randomized mixed method pilot study of a leadership and organization development intervention for evidence-based practice implementation. Implementation Science, 10, 1–12.

Aasmul

Husebo

B. S.

Flo

(2018). Description of an advance care planning intervention in nursing homes: Outcomes of the process evaluation. BMC Geriatrics, 18(26), 1–11.

Anderson

W. G.

Arnold

R. M.

Angus

D. C.

Bryce

C. L.

(2009). Passive decision-making preference is associated with anxiety and depression in relatives of patients in the intensive care unit. Journal of Critical Care, 24(2), 249–254.

Azoulay

Pochard

Kentish-Barnes

Chevret

Aboab

Adrie

Annane

Bleichner

Bollaert

P. E.

Darmon

Fassier

Galliot

Garrouste-Orgeas

Goulenok

Goldgran-Toledano

Hayon

Jourdain

Kaidomar

Laplace

. . . Schlemmer

(2005). Risk of post-traumatic stress symptoms in family members of intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 171(9), 987–994.

Basinska

Zúñiga

Simon

DeGeest

Guerbaai

R. A.

Wellens

N. I. H.

Nicca

Brunkert

(2022). Implementation of a complex intervention to reduce hospitalizations from nursing homes: A mixed-method evaluation of implementation processes and outcomes. BMC Geriatrics, 22, 196.

Brazil

Walshe

Doherty

Harding

A. J. E.

Preston

Bavelaar

Cornally

Di Giulio

Gonella

Hartigan

Henderson

Kaasalainen

Loucka

Sussman

Vlckova

van der Steen

J. T.

(2024). Implementation of an advance care planning intervention in nursing homes: An international multiple case study. Gerontologist, 64(6), 1–11.

Brwon University. (2021). LTCFocus data. Retrieved April 13, 2025, from https://ltcfocus.org/

Chisholm

Hanson

L. C.

Zimmerman

McConnell

Rosemond

Weiner

B. J.

(2022). Implementation of goals of care communication innovation among nursing homes: A multiple case study design. Journal of the American Medical Directors Association, 23(7), 1215–1220.

Chisholm

Zhang

N. J.

Hyer

Pradhan

Unruh

Lin

F. C.

(2018). Culture change in nursing homes: What is the role of nursing home resources? INQUIRY: The Journal of Health Organization, Provision, and Financing, 55, 1–6.

10.

Chisholm

Zimmerman

Rosemond

McConnell

Weiner

B. J.

Lin

F. C.

Hanson

(2018). Nursing home staff perspectives on adoption of an innovation in goals of care communication. Geriatric Nursing, 39(2), 157–161.

11.

Corazzini

K. N.

Meyer

McGilton

K. S.

Scales

McConnell

E. S.

Anderson

R. A.

Lepore

Ekman

(2016). Person-centered nursing home care in the United States, United Kingdom, and Sweden: why building cross-comparative capacity may help us radically rethink nursing home care and the role of the RN. Nordic Journal of Nursing Research, 36(2), 59–61.

12.

Damschroder

L. J.

Reardon

C. M.

Widerquist

M. A. O.

Lowery

(2022). The updated Consolidated Framework for implementation research based on user feedback. Implementation Science, 17(1), 75.

13.

Estrada

L. V.

Barcelona

Dhingra

Luchsinger

J. A.

Dick

A. W.

Glance

L. G.

Stone

P. W.

(2024). Potentially avoidable hospitalizations among historically marginalized nursing home residents. JAMA Network Open, 7(5), e249312.

14.

Fetherstonhaugh

McAuliffe

Bauer

Shanley

(2017). Decision-making on behalf of people living with dementia: How do surrogate decision-makers decide? Journal of Medical Ethics, 43, 35–40. https://doi.org/10.1136/medethics-2015-103301

15.

Fetherstonhaugh

McAuliffe

Shanley

Bauer

Beattie

(2019). “Did I make the right decision?”: The difficult and unpredictable journey of being a surrogate decision maker for a person living with dementia. Dementia, 18(5), 1601–1614.

16.

Finucane

A. M.

Stevenson

Moyes

Oxenham

Murray

S. A.

(2013). Improving end-of-life care in nursing homes: Implementation and evaluation of an intervention to sustain quality of care. Palliative Medicine, 27(8), 772–778.

17.

Flo

Husebo

B. S.

Bruusgaard

Gjerberg

Thoresen

Lillemoen

Pedersen

(2016). A review of the implementation and research strategies of advance care planning in nursing homes. BMC Geriatrics, 16, 24.

18.

Gilissen

Pivodic

Smets

Gastmans

Vander Stichele

Deliens

Van Den Block

(2017). Preconditions for successful advance care planning in nursing homes. A systematic review. International Journal of Nursing Studies, 66, 47–59.

19.

Guest

Namey

McKenna

(2017). How many focus groups are enough? Building an evidence base for nonprobability sample sizes. Field Methods, 29, 3–22.

20.

Hamilton

Finley

(2019). Qualitative methods in implementation research: An introduction. Psychiatry Research, 280, 1–18.

21.

Hennink

Kaiser

(2022). Sample sizes for saturation in qualitative research: A systematic review of empirical test. Social Science, 292, 114523.

22.

Hanson

L. C.

Zimmerman

Song

M.-K.

Lin

F. C.

Rosemond

Carey

T. S.

Mitchell

S. L.

(2017). Effect of the goals of care intervention for advanced dementia. A randomized clinical trial. JAMA Internal Medicine, 177(1), 24–31.

23.

Hawe

Shiell

Riley

(2004). Complex interventions: how “out of control” can a randomised controlled trial be? BMJ, 328(7455), 1561–1563.

24.

Hsieh

H. F.

Shannon

S. E.

(2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.

25.

Krueger

R. A.

Casey

M. A.

(2014). Focus Groups: A Practical Guide for Applied Research. Sage Publications.

26.

McCreedy

E. M.

Dewji

Dionne

Zhu

Baier

R. R.

Reddy

Olson

M. B.

Rudolph

J. L.

(2024). Pragmatic Implementation of a music intervention in nursing homes before and during COVID-19. Journal of the American Medical Directors Association, 25(2), 314–320.

27.

Mitchell

S. L.

Shaffer

M. L.

Cohen

Hanson

L. C.

Habtemariam

Volandes

A. E.

(2018). An advance care planning video decision support tool for nursing home residents with advanced dementia: A cluster randomized clinical trial. JAMA Internal Medicine, 178(7), 961–969.

28.

Mitchell

S. L.

Teno

J. M.

Kiely

D. K.

Shaffer

M. L.

Jones

R. N.

Prigerson

H. G.

Volicer

Givens

J. L.

Hamel

M. B.

(2009). The clinical course of advanced dementia. New England Journal of Medicine, 361(16), 1529–1538.

29.

Takemura

Smith

Kwok

Cheung

Lin

(2022). The effects of advance care planning intervention on nursing homes residents: A systematic review and meta-analysis of randomized controlled trials. International Journal of Nursing Studies, 132, 1–10.

30.

Orth

Simning

Zimmerman

Temkin-Greener

(2021). End-of-life care among nursing home residents with dementia varies by nursing home and market characteristics. Journal of the American Medical Directors Association, 22(2), 320–328.e4.

31.

Palmer

J. A.

Parker

V. A.

Mor

Volandes

A. E.

Barre

L. R.

Belanger

Carter

Loomer

McCreedy

Mitchell

S. L.

(2019). Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting. BMC Health Services Research, 19(1), 527.

32.

Powell

B. J.

Waltz

T. J.

Chinman

M. J.

Damschroder

L. J.

Smith

J. L.

Matthieu

M. M.

Proctor

E. K.

Kirchner

J. E.

(2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10, 21.

33.

Rietjens

J. A. C.

Sudore

R. L.

Connolly

van Delden

J. J.

Drickamer

M. A.

Droger

van der Heide

Heyland

D. K.

Houttekier

Janssen

D. J. A.

Orsi

Payne

Seymour

Jox

R. J.

Korfage

I. J.

(2017). Definition and recommendations for advance care planning: An international consensus supported by the European Association for Palliative Care. Lancet Oncology, 18(9), e543–e551.

34.

Rosemond

C. A.

Hanson

L. C.

Ennett

S. T.

Schenck

A. P.

Weiner

B. J.

(2012). Implementing person-centered care in nursing homes. Health Care Management Review, 37(3), 257–266.

35.

Sudore

Lum

You

Hanson

Meier

Pantilat

Matlock

D. D.

Rietjens

Korfage

I. J.

Ritchie

Kutner

J. S.

Teno

Thomas

Heyland

D. K.

(2017). Defining advance care planning for adults: A consensus definition from a Multidisciplinary Delphi Panel (S740). Journal of Pain and Symptom Management, 53, 431–432. https://doi.org/10.1016/j.jpainsymman.2016.12.250

36.

Sudore

R. L.

Fried

T. R.

(2010). Redefining the ‘planning’ in advance care planning: Preparing for end-of-life decision making. Annals of Internal Medicine, 153, 256–261.

37.

Tappen

R. M.

Wolf

D. G.

Rahemi

Engstrom

Rojido

Shutes

J. M.

Ouslander

J. G.

(2017). Barriers and facilitators to implementing a change initiative in long-term care using the INTERACT^® Quality Improvement Program. Health Care Management, 36(3), 219–230.

38.

Waltz

T. J.

Powell

B. J.

Fernández

M. E.

Abadie

Damschroder

L. J.

(2019). Choosing implementation strategies to address contextual barriers: Diversity in recommendations and future directions. Implementation Science, 14(1), 42.

39.

Wutich

Beresford

Bernard

(2024). Sample sizes for 10 types of qualitative data analysis: An integrative review, empirical guidance, and next steps. International Journal of Qualitative Methods, 23, 1–14.

40.

Xing

Mukamel

D. B.

Temkin-Greener

(2013). Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations. Journal of the American Geriatrics Society, 61(11), 1900–1908.

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