ADVANCE CARE PLANNING TRAINING POLST

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Advance Care Planning: Training Healthcare Professionals on the Physician Order for
Life-Sustaining Treatment

Shurine A. Pate
Edson College of Nursing and Healthcare Innovation, Arizona State University

Author Note
The author is a member of the POLST taskforce in Arizona, which may be seen as a
conflict of interest. The training event was presented by the Arizona Hospital and Healthcare
Association POLST Taskforce. Thank you to the organization for your assistance in this project.
Correspondence concerning this paper should be sent to Shurine Pate, Edson College of
Nursing and Healthcare Innovation, Arizona State University. Email: spate3@asu.edu

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Abstract
Background: An evidence-based project was performed to train and increase skills among
healthcare providers to perform advance care planning. Training decreases barriers and improves
attitudes and confidence to perform advance care planning. Advance care planning can include
the Physician Order for Life-sustaining Treatment, an out-of-hospital order that directs
emergency medical services of a patient’s wishes. Internal evidence found that many providers
are unfamiliar with the Physician Order for Life-Sustaining Treatment form. The Theory of
Planned Behavior was used to guide the project.
Objectives: To improve advanced care planning processes in a healthcare organization.
Design: A quality improvement project was performed at a medical center with outpatient
provider groups. Virtual training was provided by the Arizona Hospital and Healthcare
Association on the Physician Order for Life-Sustaining Treatment. Participants completed a
three-part survey to measure skills for advance care planning after a training event.
Setting/Subjects: Five (n=5) American palliative and primary care providers at a medical center.
Measurements: The East Midlands Evaluation Toolkit is a validated survey tool that measures
confidence and competence in advance care planning after training.
Results: Descriptive statistics, Friedman’s test, and the Kruskal-Wallis test were used for data
analysis. Results provided evidence to the healthcare facility that there is a significant need to
train their healthcare professionals on advance care planning.
Conclusions: Recommendations are made to focus research on larger studies looking at the types
of advance care planning, and differences in disciplines and specialties.
Keywords: advance care planning, Physician Order for Life-Sustaining Treatment,
palliative care, primary care

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Advance Care Planning: Training Healthcare Professionals on the Physician Order for
Life-Sustaining Treatment
Advance care planning (ACP) is important and can affect end-of-life (EOL) issues for
many individuals. Advance care planning and documentation is a means of providing healthcare
professionals (HCP), families, and loved ones a guide for providing someone’s desired care as
they get closer to death. Healthcare professionals can have EOL discussions with patients that
have chronic diseases but are not having these conversations consistently. Healthcare
professionals have barriers that affect ACP implementation, but challenges can be overcome
with policy, practice, and behavioral change. Theoretical and innovative frameworks guided an
evidence-based practice (EBP) project that improves ACP processes in a rural medical center.
Data analysis results show significant improvement in ACP after education and indicate the need
for organizations to consider this practice.
Background and Significance
Advance Care Planning
People with chronic diseases are often taken to the hospital and have unwanted and costly
procedures performed due to a lack of planning or healthcare providers not being aware of
patients’ wishes. One-third of people, with or without a chronic disease, have done ACP (Yadav
et al., 2017). Advance care planning is defined as making decisions in advance about a person’s
preferences so that their family and HCP can honor their wishes (National Institute on Aging,
n.d.). Advance care planning includes documents like the living will, durable medical power of
attorney (MPOA), and out-of-hospital provider orders. Out-of-hospital provider orders include
the out-of-hospital Do Not Resuscitate (DNR) which is used often in hospice patients or the
Physician Order for Life-Sustaining Treatment (POLST) form. The POLST form is intended to

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be used when a provider can say “yes” to the surprise question, “Would it surprise me if this
person passed away in the next year or two?”. Only recently has there been a statewide database
in Arizona for advance directives and there is still a limitation on who can access it. Hospitals
and private providers often have a copy of advance directives that patients have submitted to
their file, but emergency services rarely have a copy in hand when they arrive at a person’s home
to provide emergency services. The original intention of the POLST form was to have a written
order from the person’s provider intended to guide emergency personnel in the direction of care
that the patient wanted at home before they arrive at the hospital. In 2004, the National POLST
taskforce created standards for the POLST form that is now being used in several states as a
complement to the living will to better serve patients with advancing illnesses (National POLST,
2021). In patients with kidney disease (KD), 66% of patients had a surrogate documented but
10% or less had a POLST or living will that was documented by a provider other than their
general practitioner (Buggs et al., 2020).
When a patient does not have ACP in place it can redirect care from a patient’s
preferences and can be costly. Advance care planning can decrease costs related to inpatient
utilization (Bond et al., 2018). The lack of ACP can increase costs for both the patient and
healthcare system which contradicts national healthcare goals and the Quadruple Aim. In 2016,
total Medicare spending on KD was nearly $115 billion, and less than half of the people have an
advanced directive (Saran et al., 2019; Yadav et al., 2017). Kidney disease is progressive and is
among the top ten causes of death in Americans. Many of these people have not done ACP and
do not have a documented EOL plan which is important so that their family and people involved
with their care can honor the patient’s wishes. Providers with patients and their families should

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identify the need for ACP and EOL discussions, engage in those discussions, and then document
them for later reference to make ACP effective.
Purpose and Rationale
Everyone should have ACP in place, and it is especially important for those with
advancing age and disease. Due to evolving technology, the elderly population is growing in
number and includes patients with chronic diseases. Advance care planning is becoming more
common in ambulatory settings and with yearly Medicare wellness exams. Despite this, there are
still gaps in the process. The high-risk populations should not miss the opportunity to have ACP
conversations so their EOL wishes can be honored. Providers and nurses outside of the hospital
sometimes assist patients with ACP but this is not done regularly or methodologically.
Organizations should have structured training on ACP so that HCP can have valuable
conversations with patients. This is important for patient-centered care and to reach the Healthy
People 2030 goals of increasing communication between patients and HCP (Office of Disease
Prevention and Health Promotion, n.d.). The purpose of this paper is to provide the current
research on ACP training for HCP and assess the significance of this related to chronic disease,
and if possible, chronic KD. Furthermore, this paper will explore an evidence-based ACP
practice change in this population.
Epidemiology
Healthcare professionals should address ACP in primary, specialty, and acute care
settings for all patients and should have a special focus on patients with chronic diseases. This
population is important because 60% percent of Americans have a chronic disease and in
Arizona, approximately 63% of patients older than 65 years old have two or more chronic
conditions (Centers for Disease Control and Prevention [CDC], 2021; National Center for

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Chronic Disease Prevention and Health Promotion [CDPHP], 2021). Kidney disease is
increasing nationally and 90% of the nearly 37 million people in the United States are unaware
that they have the disease (CDC, 2019). This population should have ACP needs addressed due
to the high risk of healthcare costs and mortality rates.
Internal Evidence
Critical care nurses, palliative care providers, and the former ethics director at a rural
medical center have identified the need for organization to improve ACP conversations to
include the POLST when performing ACP discussions (J. Logan, personal communication,
October 2020). Patients that have KD, especially those receiving dialysis, are an under-identified
population, and quality of life (QOL) should be addressed in these patients because of their
symptom burden (S. Downing, personal communication, March 2021). Currently, ACP is not
consistent throughout the facility or among the HCP and most of these individuals are unfamiliar
with the POLST form or its use. The organization has recently merged with a larger organization
and the administration has identified that POLST is very well integrated into the parent
organization and standardization is necessary. Lastly, countless new residents are moving to the
area from nearby states where the POLST form is being used regularly with ACP.
PICOT question
This evidence led to the PICOT question. In healthcare providers caring for adults with
KD (P), how does education on advanced care planning (I), compared to no education (C), affect
advanced care planning completion rates (O)?
Evidence Synthesis
Healthcare Professionals and Kidney Disease

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Patients with chronic diseases like KD want to partake in ACP conferences with HCP.
Despite this, many HCP find that interactions with family and patients can often be a barrier to
ACP discussions (Flo et al., 2016; Littlewood et al., 2019; Luckett et al., 2017; Phillips et al.,
2018). Patients with chronic diseases, including patients with KD on dialysis, want their
providers involved with ACP planning but often are not ready for discussions because they are
not sick enough, they’re not ready for EOL talks, or they do not realize the disease is progressive
(Danziger et al., 2020; Phillips et al., 2018; Simon et al., 2015). In KD, 96% of nephrologyfocused HCP feel that there should be ACP programs specifically for dialysis patients (Luckett et
al., 2017).
Education and Training
Education for HCP that includes nurse practitioners is recommended to increase the skills
needed to perform ACP. Dube et al. (2015) found that 79% of nurse practitioners felt that
education would enrich ACP conversations. Training improves HCP confidence, attitudes,
comfort, skill, and readiness to have ACP discussions (C. Chan et al., 2019; Dube et al., 2015;
Glaudemans et al., 2018; Luckett et al., 2017; Pearse et al., 2021). Advance care planning
educational programs for HCP are encouraged and have been shown to help overcome
difficulties with ACP barriers (H. Chan et al., 2020; Dube et al., 2015). Provider and HCP
training is recommended to include skills for ACP and disease-specific conversations in
specialties like nephrology (Luckett et al., 2017; Simon et al., 2015).
Current Practice
Providers are expected to perform ACP, but obstacles are preventing them from having
consistency in their practices. Many clinicians find that they have not had enough training on
ACP (C. Chan et al., 2019; Dube et al., 2015; Littlewood et al., 2019; Luckett et al., 2017).

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Although it is recommended, there are no current guidelines for ACP training in primary care
(American Medical Association [AMA], 2021; Committee on Approaching Death: Addressing
Key End of Life Issues, 2015; Meghani & Hinds, 2015). It is also proposed that shared decision
making, early intervention, frequent reevaluations, and anticipatory guidance for possible health
status changes where dialysis may need to be initiated or withdrawn should be discussed with
patients with advanced KD (Davison et al., 2015). Providers find that time (actual time or time
during the patient’s disease course), stakeholder engagement, education, or lack of policy are
obstacles to ACP (Dube et al., 2015; Phillips et al., 2018; Simon et al., 2015; Tilburgs et al.,
2018). Thus, providers are having difficulty performing ACP consistently.
Advance Care Planning
Providers have impediments to ACP, but these can be improved so patient wishes can be
fulfilled. Luckett et al. (2017) found that nephrologists are hesitant to address ACP due to topic
discomfort, lack of ACP policy, or little experience. Healthcare professionals can address
decreased knowledge, family or patient engagement, and system problems by gaining or sharing
education, including patients and families in the discussions, and recruiting nurses to help
(Glaudemans et al., 2018). Additionally, researchers found that documentation was helpful for
both completion and retrieval of ACP (Dube et al., 2015; Glaudemans et al., 2018; Simon et al.,
2015; Stepan et al., 2019; Tilburgs et al., 2018). A large retrospective cohort study that included
patients with chronic illnesses found that when ACP was documented, 78% of the patients
passed where they had chosen, outside the hospital, which was significantly higher than people
that did not have preferences documented (Orlovic et al., 2020). Rural communities are no
exception to this evidence.
Search Strategy

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To answer the PICOT question, an exhaustive search of the literature was completed.
Four databases were thoroughly searched – PubMed, Cumulative Index to Nursing and Allied
Health Literature (CINAHL), PsychInfo, and the Cochrane library. The database searches show
that there is limited high-level research but found that grey literature showed that more
quantitative studies are being completed on the subject of education for HCP specifically caring
for patients with KD for ACP (Buggs et al., 2020; Danziger et al., 2020). Grey literature was not
included in the final evidence yield and synthesis.
The databases were searched by keyword, title/abstract, and Mesh/Boolean terms.
Population terms included: providers, physicians, nurse practitioners, primary providers,
specialty providers, palliative care providers, primary care, PCP, healthcare providers,
healthcare workers, healthcare professionals, medical professionals, advanced practice nurses,
doctors, nurses, chronic KD, end-stage renal disease (ESRD), KD, renal disease, or chronic
disease. Intervention terms included: education or teaching program and comparison terms
included: no education, current practice, or barriers. Outcomes were specified using: advanced
care planning documentation, advance care planning completion, advance care planning, ACP,
living will, advanced directives, medical power of attorney (MPOA), physician order for lifesustaining treatment (POLST), medical order for life-sustaining treatment, or out of hospitalphysician order. Inclusion criteria consisted of: healthcare personnel (any), chronic diseases
including KD, education or teaching, barriers or facilitators, and any type of advance care
planning or documentation. Research that focused on pediatrics, diseases that weren’t chronic, or
did not fit the PICOT question was excluded. Filters used were dates of publication of up to 10
years, age of greater than 19 years, English language, and limiters of clinical trials, metaanalysis, randomized control trials (RTC), and systematic reviews. The search resulted in 231

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articles between the databases. Titles and abstracts were reviewed for the relevance of the
PICOT question.
The details of what each database yielded are shown in Appendix C. After abstracts and
articles were individually reviewed for relevance, 33 articles were chosen for appraisal. The
articles with the highest levels of evidence were included in the evaluation tables (Appendix A).
The evidence produced level 1 evidence (four articles), level IV evidence (four articles), and
level VI evidence (two articles).
Critical Appraisal and Synthesis
The research was appraised for quality using rapid critical appraisal tools (Melnyk &
Fineout-Overholt, 2019). A synthesis of the research is presented in Appendix B. Overall, the
quality of the research was moderate but appropriate to the research question. There were three
systematic reviews and one scoping literature review. Four studies were lower-level quantitative
studies, and two studies were qualitative research. Bias, most commonly selection bias, was
present in seven of the studies.
The evaluation tables show a description of each article (Appendix A). Most of the
studies were international except for one conducted in America only. The theoretical and
conceptual frameworks were heterogeneous. Overall, the primary population was HCP with two
studies focusing on patients with chronic disease. The characteristics of each population were
varied. Sample sizes were adequate in quantitative literature except for one study and saturation
was achieved in qualitative studies. There were no patterns noted in the statistical analysis and
measurement tools, but this is understandable with the diversity of design and methods of each
study. The major weakness of the literature is the lack of blinding and randomization, the use of
non-validated tools, and the moderate quality of the research.

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Despite the average quality of the research, the strength lies in the themes and how they
show areas for possible improvement to current ACP practice. The commonality is seen among
independent variables, dependent variables, and population which is shown in the synthesis table
(Appendix B). The HCP population was primarily providers and nurses. The research studied
ACP education and training for HCP. It also focused on ACP prevalence, implementation,
barriers, and facilitators of ACP in the presence of chronic diseases including KD. Patient
perceptions of ACP were additionally reviewed. Education or training on ACP for HCP was
often poor or absent and this helped or halted ACP with patients. The amount of time that HCP
had to engage in ACP conversations determined whether these talks ensued. The timing when
HCP had EOL talks during the disease process and the relationships between patients, families,
and providers were important for success. Stakeholder and leadership engagement affected
positive ACP activities. Documentation availability and electronic health records were important
to patients and HCP for ease of ACP and future retrieval. Finally, providers were often seen as a
variable for whether there was a successful ACP completed.
Influencing the Project
The evidence shows that HCP feel they lack the adequate education to perform ACP with
their patients and desire to have more training. Advance care planning training was shown to
increase HCP confidence and improve skills to have ACP conversations. Stakeholder and
leadership engagement was important for success. Time and documentation should be considered
when improving ACP processes. Patients want to have ACP conversations with their providers.
For these reasons, the ACP training project was created.
Theoretical and Implementation Framework
Theory of Planned Behavior

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A person’s belief about behavior can be improved by their attitude, confidence, and other
core factors that can predict whether an individual will change their behavior. The theory of
planned behavior (TPB) was used to describe the behavioral concepts for the proposed EBP
project that show behavioral change after training, and the model is shown in Appendix D
(Ajzen, 1991). This framework was chosen because if a healthcare system changes a process or a
policy, but participants resist change, the process will fail. The TPB is a theoretical framework
that links a person’s beliefs to a behavior change. Ajzen (1991) described the major concepts of
TBP as attitudes, subjective norms, perceived behavioral control, intention, and behavior.
Attitudes are personal beliefs that a person has about a behavior. Subject norms are the pressure
that the individual has to perform the behavior and perceived behavioral control is the ability to
perform a behavior due to having the confidence to perform that behavior (Ajzen, 1991). A
behavior can be predicted by how attitudes, subjective norms, and perceived behavioral control
lead to intentions. An intention is what a person is willing to do to achieve a behavior change.
These elements can predict whether a behavior will be adopted. The behavior is more likely if a
person has positive views of the behavior and it can also be altered if events occur that change
the person’s beliefs before the behavior change is achieved (Ajzen, 1991).
The Ottawa Model for Research Use
In addition to the theoretical framework, an EBP implementation strategy was used. The
Ottawa Model for Research Use (OMRU) guided the execution process of an EBP project. The
OMRU is a planned action model for continuity-of-care innovations that are used for large
practice or organizational changes (Graham & Logan, 2004). The OMRU model is shown in
Appendix E. The OMRU has three assumptions: the process is completed over time, improving
patient health outcomes is always a final goal, and external factors such as society and healthcare

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environments and their effects must be considered (Graham & Logan, 2004). The steps to the
OMRU and how it aligned with the project are defined in the following sections.
Getting Started
Initially, organizational leaders in the hospital system and the individual practices were
identified as the decisional authorities to make the change, and the change agents were identified
(Graham & Logan, 2004). The Chief Executive Officer (CEO) approved the project. The
palliative care and gerontology director and primary care section leader were supportive of the
project and helped to initiate meetings with the potential participants. The organizational ethics
committee members who have a great influence on ACP interpretation also supported the
project.
Clarifying the Innovation
This step included defining the innovation (Graham & Logan, 2004). The innovation was
defined as an ACP policy change and a practice change after HCP training for ACP. The
intervention included a training session on ACP and POLST.
Assessing the Innovation, Adopters, and the Practice Environment
Negative impacts will be assessed and resolved early (Graham & Logan, 2004). The
project facilitator assessed barriers and identified potential change adopters. The facilitator
explained the gaps in the current practice to the organization’s administration and the ethics
committee. The current culture was assessed and the likeliness for change was low but possible.
Organizational culture and availability of resources are considered (Graham & Logan, 2004).
Organizational resources were limited but available. Current policies and expectations were
reviewed and documented.
Selecting and Monitoring the Implementation Intervention

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Planning for the implementation started by addressing the areas where barriers were seen
(Graham & Logan, 2004). Healthcare professional participants were educated on the ACP
interventions, barriers, and alternatives. An example of a barrier that was identified in the
literature was time, so the facilitator identified a way to increase the amount of time available for
ACP conversations. This included educating HCP that they could initiate conversations and have
staff finish them and help with ACP paperwork including POLST. This would decrease the
amount of time that the provider was spending with the patient for this conversation while
getting comparable reimbursement and still benefiting patients with ACP conversations. The
project facilitator was present during all educational and training sessions to evaluate the
intervention, encourage change, and answer questions.
Monitoring the Adoption
Decisions on measurement and data collection were completed next so that adoption
could be evaluated and reasons for hesitancy identified (Graham & Logan, 2004). The facilitator
conducted email correspondence and onsite visits to assess practices. It was identified early that
the practice change was not being readily adopted so the facilitator offered ways to improve
practices and identify ideal patient populations. A population that was suggested for the primary
care participants to focus on were patients that were being seen for a hospital follow-up because
these patients often had a recent change in health status. Palliative care providers had more
opportunities to initiate ACP during goals of care discussions and were encouraged to include
POLST at that time.
Evaluating the Outcomes
During the final step, outcome measures, time frames, and data collection tools will be
defined (Graham & Logan, 2004). The facilitator assessed how each of the stakeholders was

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affected by the ACP process changes by analyzing survey comments, aggregate data, and ACP
with POLST completion rates.
Methods
Ethical Considerations
The project was approved by the Arizona State University Institutional Review Board
(IRB). The organization did not have an IRB, so approval was received by the organizational
project mentor and palliative care director. Informed consent was received from each participant
before partaking in the project. The ethical principles of beneficence, non-malfeasance,
autonomy, confidentiality and data protection, and integrity were also used to guide the project.
Stakeholders, Setting, and Population
Stakeholders included the facilitator and a palliative care/gerontology director and together
they organized the process and are among the most knowledgeable about the EBP project, ACP,
and the POLST form. The Arizona State University project mentor was also a stakeholder and
gave insight into the project progression. In addition, the medical center’s ethics committee, six
additional palliative care providers, and their staff are affected because they have the most
knowledge of end-of-life preferences and the issues that surround these. They are also resources
for their patients and other stakeholders.
The organization is a medical center in the rural southwest United States. The medical
center has a hospital with two campuses with outpatient primary and specialty services. The
medical center serves mainly four small towns and some of the towns have an increased number
of retired elderly people. Stakeholders for the EBP project involved providers and patients in the
hospital, outpatient practices, and the community.

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The populations most impacted by the EBP project will be patients with chronic diseases
and their families, as well as primary practice providers and their staff. This is because their health
status, provider recommendations, wishes, and family opinions will be the defining the future of
their healthcare and desired QOL. The healthcare organization includes six primary care clinics
which are a mixture of family practice and internal medicine practices and a palliative care group.
In total, 40 providers from primary and palliative care in seven outpatient practices were the target
population for the project.
Project Description and Timeline
The project intervention was a training class for the Introduction to POLST that was
presented by the Arizona Hospital and Healthcare Association (AzHHA) who is also the leader
of the Arizona POLST taskforce. The complete timeline for the project from proposal to
completion was from August 2021 until January 2021 with the final data analysis being
completed in April 2022. The project proposal was given to the administration in August of
2021, project interventions were presented at two virtual meetings via Zoom on September 14th
and 17th, 2021. Each session was held during lunchtime breaks so provider clinics were not
disrupted. After attending a training session, the participants were instructed to collect aggregate
data on any ACP with POLST conversations they had. Aggregate data collection and participant
support by the facilitator were given from the intervention training until the final survey was
given in December 2021. Data analysis was completed from January until April of 2022.
Instrumentation, Data, and Analysis Plan
Instrument
Healthcare professionals were trained on ACP and POLST. The intervention was
measured by calculating the provider’s comfort to have ACP discussions. The East Midlands

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Evaluation Toolkit (EMET) is a 27 question survey that assesses HCP competence and
confidence to perform ACP (Whittaker et al., 2018). Whittaker et al. (2018) defined confidence
as the person’s awareness to complete a goal and term competence as the skill to complete the
task. There are three tools in the toolkit. The EMET tools are all the same but intended to be
given at different times of the assessment, so they are labeled differently. Initially, “Tool A” was
given at pretraining which was sent to the providers before the ACP training sessions. The
second survey, “Tool B”, was given after the training session. The final survey, “Tool C”, is
optional but should be given six to 12 months post-training but, in this case, was used three
months post-intervention.
The five domains, or core competencies, that the EMET tool measures are
communication, assessment and care planning, symptom management, ACP, and overarching
values and knowledge. The tool measures the HCP’s self-reported interaction with the patient
and/or their family. The description of the five core competencies is: The ability to communicate
with patients and their families during the dying process; the assessment and care planning of a
holistic plan; the ability to maintain the patient’s comfort and symptoms; having ACP
discussions while maintaining ethical and legal standards; and knowing oneself and how their
values may interfere with ACP interactions (Whittaker et al., 2018). The EMET tests the overall
ability to perform ACP as well as assesses each core competency related to ACP.
The assessment tool showed to have a test to test reliability over four years with a
Pearson’s r overall value of 0.840 and internal consistency of greater than 0.8 Cronbach’s alpha
in communication, assessment and care planning, symptom management, ACP, overarching
values and knowledge (Whittaker et al., 2018). Whittaker et al. (2018) found the tool to be valid

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with a small number of imperfections after pooling 16 trainers from multiple organizations after
23 different end-of-life training sessions.
Data Collection
The participants completed the three surveys from the EMET. The presurvey was given
to the participants before the training interventions in September 2021. The post-survey was
given after the participants attended the Introduction to POLST class. After the training session,
members were given POLST forms and an aggregate data collection form. They were advised to
use the POLST form when they were having ACP conversations with the patients if they
qualified by the “surprise question”. They were instructed to collect data on these patients that
included the patient’s age, whether a POLST only or a POLST and advance directive were
completed at the time, why they chose to use the POLST in the specific situation, and whether
there was a presence of chronic disease. If the patient had KD, they were asked to record what
stage of KD the patient had. No personal health information was to be collected on the patients.
The facilitator continued to have onsite and email correspondence with the participants during
the aggregate data collection phase. The final survey was given on two separate days in
December 2021 aligning a three-month intervention date.
Data Analysis Plan
Statistical analysis was conducted using SPSS Intellectus software (Intellectus Statistics,
2021). Data analysis was used to answer the research questions: (a) for adults with KD, does
ACP training for HCP improve confidence and competence for ACP conversations, (b) is there a
difference between HCP types and specialties, and (c) what were the demographics and specific
disease-related reasons the patient had ACP with POLST? The outcome variable was confidence
and competence to perform ACP after a training event. Descriptive statistics was used to analyze

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the data of ACP and each of the five domains of ACP with five levels of agreement being
strongly agree to strongly disagree. The Friedman’s test and Kruskal-Wallis test were used to
examine the differences between the participants responses in the three survey tools of the
EMET and the differences between provider type and specialty. This project is like an
exploratory pilot study to generate a hypothesis. For the purpose of this study, due to the
importance of detecting small to moderate differences with a small sample size (p values > 0.05
but < 0.10 are referred to as a trend); therefore, significance was tested at the p < 0.10 (Fugate
Woods et al., 1997). Aggregate data was collected from the participants on any patients that they
performed ACP with POLST on and free text comments were collected by the facilitator.
Funding
The medical center is a non-profit organization and the funding for the training
intervention was provided by the medical center’s foundation. The training session was given
and the bill for $400 was submitted for reimbursement from the palliative care department of the
medical center. POLST forms that were delivered to the providers were funded by the project
facilitator and the cost was minimal.
Results
Outcomes and Statistical Significance
Descriptive Statistics
Descriptive statistics were calculated for the total score of the outcome variable and each
domain (communication, assessment and care planning, symptom management, ACP, and values
and knowledge) for each of the three surveys. The observations were calculated for the total
score of the outcome variable of ACP from the three surveys along with the individual five

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domains. The summary statistics of average score, standard deviation (SD), and range can be
found in Table 1.
Table 1
Summary Statistics Table for Interval and Ratio Variables
Variable
n
M
Total.prepost3m
5
332.00
PreCommunication
5
21.40
PostCommunication
5
22.20
3mCommunication
5
21.20
PreAssessment_and_Care_Planning
5
22.80
PostAssessment_and_Care_Planning
5
25.80
3mAssessment_and_Care_Planning
5
25.80
PreSymptomManagement
5
21.40
PostSymptomManagement
5
21.80
3mSymptomManagement
5
21.80
PreACP
5
18.20
PostACP
5
18.80
3moACP
5
17.40
PreOverarching_Values_Knowledge
5
23.00
PostOverarching_Values_Knowledge
5
23.40
3mOverarching_Values_Knowledge
5
22.80

SD
24.34
1.95
2.59
1.64
2.17
3.27
3.27
1.52
2.05
2.95
1.30
1.79
1.52
2.00
2.07
2.59

Min
301.00
19.00
19.00
20.00
20.00
22.00
22.00
20.00
20.00
19.00
16.00
16.00
16.00
20.00
20.00
20.00

Max
356.00
24.00
25.00
23.00
25.00
30.00
30.00
23.00
24.00
25.00
19.00
20.00
19.00
25.00
25.00
25.00

Friedman Rank Sum Test
A Friedman rank sum test was conducted to examine whether the medians of each survey
(pre, post, and three-month) of the EMET tool were equal or if there was a significant change
from one to another in the overall score for ACP. The Friedman rank sum test was also
conducted on each of the five domains of ACP: Communication, assessment and care planning,
symptom management, ACP, and overarching values and knowledge. The Friedman test is a
non-parametric alternative to the repeated measures one-way ANOVA and does not share the
ANOVA's distributional assumptions (Conover & Imam, 1981; Zimmerman & Zumbo, 1993).
Post-hoc interpretations were run on any of the significant results to identify in which surveys
the significant differences were present.

ADVANCE CARE PLANNING TRAINING POLST

21

The results of the Friedman test indicated significant differences in the total score median
values of the three surveys. Additionally, there were significant differences in the survey median
values of both the assessment and care planning and the ACP domain. There were no significant
differences in the median values of the pre, post, or three-month surveys for the domains of
communication, symptom management, or overarching values and knowledge. Table 2 presents
the results of the Friedman rank sum test.
Table 2
Friedman Rank Sum Test
Variable
Mean Rank
PreSurvey
1.20
PostSurvey
2.20
3mSurvey
2.60
PreCommunication
1.70
PostCommunication
2.30
3mCommunication
2.00
PreAssessment_and_Care_Planning
1.00
PostAssessment_and_Care_Planning
2.50
3mAssessment_and_Care_Planning
2.50
PreSymptomManagement
1.70
PostSymptomManagement
2.20
3mSymptomManagement
2.10
PreACP
1.90
PostACP
2.70
3moACP
1.40
PreOverarching_Values_Knowledge
1.80
PostOverarching_Values_Knowledge
2.00
3mOverarching_Values_Knowledge
2.20
Note: Levels of p < 0.1 level indicate significance

χ2
5.20

df
2

P value
.074

1.20

2

.549

10.00

2

.007

.93

2

.627

6.62

2

.037

.62

2

.735

Pairwise (post-hoc) comparisons were examined between each combination of significant
variables. The results of the multiple comparisons indicated significant differences, based on an
alpha value of .10, between the following variables: The pre and three-month survey, the pre and
post-assessment and care planning survey, and the pre and three month post assessment and care
planning surveys. Pairwise comparisons were examined between each combination of the

ADVANCE CARE PLANNING TRAINING POLST

22

domain ACP variables. The results indicated that none of the individual pairwise comparisons
were significantly different. Table 3 presents the results of the pairwise comparisons of the
significant findings of the Friedman’s Rank Sum test.
Table 3
Pairwise Comparisons for the Rank Sums
Comparison
Observed difference
Critical difference
Presurvey-Post.Survey
5.00
6.73
Presurvey..S.-3m.Survey
7.00
6.73
Post.Survey-3m.Survey
2.00
6.73
PreAssessment_and_Care_Planning7.50
6.73
PostAssessment_and_Care_Planning
PreAssessment_and_Care_Planning7.50
6.73
3mAssessment_and_Care_Planning
PostAssessment_and_Care_Planning0.00
6.73
3mAssessment_and_Care_Planning
PreACP-PostACP
4.00
6.73
PreACP-3mACP
2.50
6.73
PostACP-3mACP
6.50
6.73
Note. Observed differences > critical differences indicate significance at the p < 0.1 level
Kruskal-Wallis Test
A Kruskal-Wallis rank sum test was conducted to assess if there were significant
differences in total EMET scores between the disciplines of the participants. The Kruskal-Wallis
test is a non-parametric alternative to the one-way ANOVA and does not share the ANOVA's
distributional assumptions (Conover & Imam, 1981). The results of the Kruskal-Wallis test were
not significant based on an alpha value of .10, indicating that the mean rank of total scores for
ACP was similar for each discipline of medical doctor, physician assistant, and registered nurse.
Additionally, the results were not significant for ACP scores for each specialty of primary care
and palliative care. Table 4 presents the results of the Kruskal-Wallis rank sum test.
Table 4
Kruskal-Wallis rank sum test for total scores for ACP by discipline and specialty
Mean Rank
χ2
df
P value
Discipline

ADVANCE CARE PLANNING TRAINING POLST
Medical Doctor
3.17
2.67
Physician Assistant
4.50
Registered Nurse
1.00
Specialty
Primary Care
2.50
0.35
Palliative Care
3.33
Note: Levels of p < 0.1 level indicate significance

23
2

.264

1

.554

Aggregate Data and Participant Comments
There was limited execution of performing ACP with POLST in the three months
following the intervention. One palliative care provider performed POLST in an in hospital
setting with the assistance of the facilitator during a goals of care meeting with a patient.
Aggregate data on the patient showed that the patient was a 68-year-old female with alcoholic
end-stage liver disease and the provider indicated that the POLST was used because the patient
wanted aggressive care. None of the other participants used the POLST during ACP
conversations on patients after the intervention. One HCP indicated that they had POLST
conversations on “an outpatient basis a few times” and that they were “able to speak with family
members on the patient’s condition and recommend palliative care or hospice in a number of
cases and mostly went well”. Another HCP commented, “lack of time available”, “increased
demand during pandemic”, and “hoping to still implement POLST into the group practice
eventually”. Another comment on the final survey was, “seeking out advance directives as a
fundamental part of each consult” and “if there are none, we utilize our medical social workers to
assist the patients”.
Impact of the Project
The results show that organizational policy change should be considered to include better
processes for patient education and assistance for ACP. The proposed system change will include
the ACP policy to include the POLST form. In the state of Arizona, the advanced directive will

ADVANCE CARE PLANNING TRAINING POLST

24

override the POLST form if there is a contradiction. To decrease the possibility of this
happening, the policy will advise providers completing the form to update the advanced directive
and the POLST at the same time and include surrogates. It will designate the POLST form as an
extension of the advanced directive and is to be honored upon using the emergency department
or having admission to the hospital as an expression of the patient’s wishes.
With this new process and policy for ACP with POLST, all employees and providers that
use the medical center will be aware of the POLST form and its relation to patient wishes. The
new policy will make everyone aware of ACP, differences in forms, what the POLST form is
and when it is used, and lastly, when the POLST form should be reviewed and updated. All of
this will be with the final goal of improved patient care and honoring patients’ wishes at the
EOL.
Sustainability
After approval from the organization and implementation of the new policy, a monitoring
process including chart audits will be structured so that the process change continues to be
successful which will include an ACP leader that is available for assistance. At this time,
education will be revisited so that all employees are familiar with the new process. Yearly
education will be given to preserve knowledge of the ACP process by those who do not have
ACP conversations and to retain skill for those HCP that do have ACP conversations. The new
procedure will be system-wide both inside the hospital and in all the medical group practices to
maintain sustainability. All of this will be with the final goal of improved patient care and
honoring patients’ wishes at the EOL.
Discussion
Summary

ADVANCE CARE PLANNING TRAINING POLST

25

The results of this EBP project are important for the future of healthcare for several
reasons. The project results show us that ACP training for HCP significantly improves
assessment and care planning and ACP after training so healthcare organizations should consider
offering training for their healthcare professionals. The decreased use of the POLST forms
indicates that training for HCP can improve comfort to perform ACP but may need a mandate or
incentive to get buy-in. The type of training should be evaluated before offering to see if a more
interactive ACP training session is beneficial. In this project, a registered nurse was the only
ancillary staff that was involved with the training. As mentioned by one of the participants,
including social workers may increase the use and understanding of POLST to them and to their
patients or the providers that they assist. The project was completed in 2021 which is about a
year and a half after the COVID pandemic started. Many of the primary care HCP were not
having in person visits with their patients due to restrictions. The types of patient exams that
were conducted also may have not provided an opportunity to have the ACP conversations as
they would have in a pre or post covid clinic schedule.
Limitations and Challenges
There were several limitations and challenges to the project. The TPB guided the project
well but possibly could have been more effective if subject norms were higher. The providers all
had a preconceived attitude about ACP before the training. Additionally, they each had different
levels of confidence (behavioral control). The literature shows that training can improve
attitudes, confidence, and skill to perform ACP. At the current facility, the subject norm
(pressure to adapt) is relatively low due to most people being unfamiliar with the POLST process
and low organizational interest at implementation time. The organization is recently merged with

ADVANCE CARE PLANNING TRAINING POLST

26

a larger company where POLST is very well integrated into its processes. This makes the
possibility of subject norms increasing in the future likely.
Other limitations were also present. The first is the small sample size. There was limited
organizational interest at some levels which likely affected the small participant pool and
possible outcomes. The AzHHA POLST taskforce offers several different ACP training events.
The most limited training event was the Introduction to POLST class. The organization’s threehour interactive Difficult Conversations class offers live situations to practice using the POLST
form and having ACP conversations so that HCP can become more proficient. This class was
initially presented to organizational administration as the intervention and was rejected due to
time. The organization also decided not to mandate or incentivize the education. There was few
POLST forms used post intervention, so this may have affected how the participants viewed the
new process or how it would express their patient’s wishes. It is unclear whether there were ACP
conversations during that time without POLST, so it is unknown whether overall ACP
conversations were limited or if the POLST form alone was limited.
Parallels in the Literature
There are several parallels with this project and current literature on ACP. Healthcare
professionals expressed that time was a barrier to completing ACP (Dube et al., 2015; Flo et al.,
2016; Glaudemans et al., 2018). The facilitator explained to the participants how to increase their
“time” by involving their staff but more detailed teaching on staff involvement may need to be
shown to the providers. This could expand to billing also because ACP conversations are
reimbursable by Medicare (DiBello, 2021). Time could be increased by utilizing staff which has
a two-fold benefit because longer conversations has higher reimbursement when billing for ACP.
Education on this may need to be expanded on in the future. Some administration in the

ADVANCE CARE PLANNING TRAINING POLST

27

organization was hesitant to the initial scale of the proposed project. This and the impending
merger that the organization had may have decreased any stress for the HCP to complete the
project. Organizational and systematic support can be a barrier or a facilitator to ACP (Dube et
al., 2015; Flo et al., 2016). Overall, the results showed that ACP training improved the
competence and confidence (or ability and intent) to perform ACP after training. This is
consistent with the current literature that training improves knowledge, attitudes, comfort,
readiness, and likeliness to perform ACP (C. Chan et al., 2019; H. Chan et al., 2020; Dube et al.,
2015; Flo et al., 2016; Glaudemans et al., 2018; Luckett et al., 2017; Pearse et al., 2021). The
growing research on the subject shows that ACP should be focused on the in the future.
Future Recommendations
This EBP shows us the need for larger studies that compare the differences between
primary care, palliative care, types of ACP training, and complex system support. Despite the
small sample size, there was enough statistical significance to show that future studies should
include larger studies on the subject. There were no significant differences between the
disciplines or specialties of the HCP, but it would be interesting to see if there were more
disciplines or specialties if this would still be the case. In addition, due to the limited use of the
POLST form after the intervention, clinical significance was difficult to assess.
Conclusion
Advance care planning that includes the POLST form represents patients’ wishes at EOL
and should be considered in patients with chronic diseases. The evidence shows that when HCP
are trained on ACP conversations, their comfort and skill to have these conversations improve.
Theoretical and innovative frameworks guided a change in a complex rural organization. The
results of an EBP project shows that ACP training significantly improves confidence and

ADVANCE CARE PLANNING TRAINING POLST

28

competence to perform ACP. Organizations should consider supporting education and
decreasing barriers for their HCP to increase ACP conversations between HCP and their patients.
These changes will help influence better care of our elderly patients, especially those with
chronic disease, at the end of their life.

ADVANCE CARE PLANNING TRAINING POLST

29

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PROVIDER ACP TRAINING

35
Appendix A

Table 1
Evaluation Table of Quantitative Research
Citation

C. W. H.
Chan et al.
(2019). A
SR of the
effects of
ACP
facilitators
training
programs
Country:
USA,
Australia,
UK, Canada,
Korea
Funding:
None
Bias:
selection

Theory/
Conceptual
Framework

Inferred:
Theoretical
framework of
knowledge,
attitudes, and
behaviors

Design

Design: SR of
RCT and QE
studies with
control
Purpose:
Evidence for the
effectiveness of
ACP programs.

Sample/
Setting

Major
Variables
&
Definitions

Measurement/
Instrumentation

n= 4025
participants
N = 10
studies
2 RCT, 2
QE (preposttest), 1
prospective
NRCT/QE,
5 cohort

IV: ACP
training
program for
HCP

Original studies
used: validated
tools – DSA,
FIHPPSMHD,
BNC, PP, EOL
performance
scale

DS:
MEDLINE,
CINAHL,
PubMed,
EMBASE,
Cochrane
library, JBI,
EBP,
PsychInfo,
Health and

DV2:
Improving
HCP
attitudes for
ACP

DV1:
Improving
HCP
knowledge
for ACP

DV3:
Improving
HCP
competence
for ACP

Data
Analysis
(stats
used)
PRISMA
guideline
3 reviewers
Appraisal
tool:
EPHPP
Study
appraisal
quality = 2
strong, 2
moderate, 6
weak

Findings/
Results

Findings: ACP
training
increased:
DV1
knowledge
DV2 attitudes
DV3
communication
, confidence,
comfort, and
experience
DV4 didn’t
address ACP
frequency

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
LOE = I
Strengths:
High quality,
small sample
Weaknesses:
Blinding is not
consistent. No
Meta-analysis
Conclusions:
ACP training
has a positive
effect on HCP
Feasibility:
ACP training
programs
increase HCP
skill,
knowledge,

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Theory/
Conceptual
Framework

36
Design

bias/original
studies

Sample/
Setting

Psychosocia
l
Instruments.
Population
type: HCP –
3 hospital, e
IM, 2 CC, 2
MS
Inclusion:
HCP
working
with a
terminal
illness

H. Chan et
al. (2020).
Association
between
training
experience
and

Stated: TBP

Design: Crosssectional
Purpose:
Identify the
relationship
between ACP

Exclusion:
Community
or home PT,
neonatal, or
pediatric
n = 250
Convenienc
e sample
Population
type: HCP

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

Findings/
Results

Survey created by
experts
(Palliative Care
& ACP). Likert
scale.

SPSS 25.0
Descriptive
Statistics

Attitudes of
HCP readiness
for ACP with
and without
ACP training
(P ≤ 0.001)

DV4:
Improving
frequency
of ACP

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
and attitudes
for ACP

Training
program:
program,
workshops,
in-person or
online, RP

IV- ACP
training
DV(attitudes)
conducting
ACP

Chi-square
test,
independen

LOE: IV
Strengths:
Variety of
HCP, adequate
sample size,
data analysis

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Theory/
Conceptual
Framework

readiness for
ACP among
HCP: A
crosssectional
study.

37
Design

Sample/
Setting

education and
HCP readiness to
perform ACP

(Physicians,
nurse, SW)

Country:
Hong Kong
Funding:
none
Bias:
Possible
selection
bias

Dube et al.
(2015).
Advance
care
planning
complexities

Demograph
ics: Female
(66.4%), Inhospital
(70.7%)
Mean age:
41.8 years
Average
clinical
experience:
17.9 years
Site/Setting
: Online

Stated: Kolcaba’s
Comfort Theory

Design:
Quantitative
Nonexperimental
descriptive

Inclusion:
HCP
Exclusion:
none noted
n = 160
(13%
response
rate)

Major
Variables
&
Definitions

Measurement/
Instrumentation

Training =
didactic
alone or
with/withou
t web or inperson
learning,
blended
learning, or
“local/overs
eas”
placement

Data
Analysis
(stats
used)

Findings/
Results

t t-test,
MannWhitney U
test, &
ANOVA,
multiple
linear
regression

HCP with
didactic
training
significantly
lower
confidence for
ACP (P =
0.012)

IV –
prevalence
of ACP

Weaknesses:
Instrument not
validated,
online survey,
convenience
sampling.
Conclusions:
HCP with
training
Feasibility:
Identifies HCP
comfort to
address ACP
training in
different
formats

Attitudes =
Relevancy,
willingness,
and
confidence

Research
questions

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

EOLCDQ II
Likert Scale for
barriers/facilitator

SPSS
version 22
EOLCDQ
II measured
with central
tendency,

IV – 65% of
NP having
ACP talks
sometimes

LOE: IV
Strengths: NP
focused study,
validated tool

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

for nurse
practitioners
Country:
USA
Funding:
none
apparent
Bias: none
evident

Theory/
Conceptual
Framework

38
Design

Sample/
Setting

Purpose: To
assess ACP
discussions and
identify barriers
and facilitators to
these barriers by
nurse
practitioners

Power
analysis
80%
Population
type: NP
Demograph
ics:
F (94.7%),
white
(92.5%),
married
(77%), 92%
between 30
– 65 years,
Site/Setting
: online
survey over
75 days
Inclusion:
Member of
State NP
organization
Exclusion:
none noted

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

Findings/
Results

DV1 –
Barriers to
ACP

1-way analysis of
variance
(Kruskal-Wallis)

crosstabulations
for NP
education,
EOL,
training,
experiences
opportunity

79% felt
training would
increase ACP

DV2 –
Facilitators
to ACP
Barriers =
personal,
system,
professional
Facilitators
= personal,
system,
professional

72-86% felt
like more ACP
talks were
happening after
CE
DV1- time (P >
0.05)
- EMR, forms,
education,
leadership (P <
0.05)
DV2
-time – staff,
appointment
-EMR, forms,
education,
leadership
support

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Weaknesses:
Online survey,
low response
rate,
sample=white,
married F
Conclusions:
Training, time,
EMR,
leadership
increase ACP
discussions
Feasibility:
Dated research
but NP-specific
study on ACP,
barriers, and
facilitators of
ACP

ACP themes
-lack of
knowledge

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Flo et al.
(2016). A
review of
the
implementat
ion and
research
strategies of
ACP in NH
Country:
USA,
Canada, UK,
Hong Kong,
New
Zealand,
Australia
Funding:
Research
Council of
Norway
Bias:
possible
methodologi
cal and

Theory/
Conceptual
Framework

Inferred:
Theoretical
Domains
Framework

39
Design

Design: Scoping
literature review
Purpose: To
review research
and
implementation
strategies for
ACP

Sample/
Setting

Major
Variables
&
Definitions

n = 1939
participants
N = 16
studies

IV- ACP
Implementa
tion strategy
in NH

DS:
CINAHL,
Medline,
PsychInfo,
Embase,
Cochrane
library

DV1
content of
ACP
intervention
DV2
implementat
ion (target
group/traini
ng)
DV3
outcomes of
intervention
DV4 study
design/meth
ods
DV5
barriers/pro
motors for
ACP

Population
type: HCP
Setting: NH
Inclusion:
NH
PT/family/H
CP, QL &
QT
Exclusion:
Home
/hospital PT,

ACP =
conversatio

Measurement/
Instrumentation

Data
Analysis
(stats
used)

Original studies
(tools):

PRISMA
guideline

POLST, GSFCH,
Let me talk, Let
me decide,
Advance
Directives,
Making Health
Choices

7
researchers
with group
agreement
for article
inclusion
Themes:
1-Clinical
interventio
n studies
2-Tools
with
ACP/AD
goal
3-ACP
process
papers

Findings/
Results

-practice issues
-culture
Staff education
is most
common
DV1: learning
courses,
training
DV2: HCP
including
physicians and
NH staff
DV3: ACP
documentation/
stated
preferences
DV4: ACP
implementation
studies, MM
studies
DV5:
-barriers: HCP,
time,
engagement

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
LOE = I
Strengths:
Scoping review
of QL & QT
research
Weaknesses:
few blinded
studies, power
analysis not
addressed,
heterogeneous,
ACP tools
variable
Conclusions:
ACP is a
process,
interventions
vary.
Feasibility:
Education and
provider
involvement
important for

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Theory/
Conceptual
Framework

40
Design

statistical
bias in
original
studies,
selection
bias
Luckett et
al. (2017).
ACP in
chronic
kidney
disease: A
survey of
current
practice in
Australia

Stated: TPB

Design: Crosssectional survey
Purpose: To
identify current
practice, barriers,
and facilitators

Sample/
Setting

Major
Variables
&
Definitions

guidelines,
nonEnglish/Sca
ndinavian,
no abstract,
DNR

ns with
family/PT

n = 375

Research
questions:

Population
type: HCP

Country:
Australia,
New
Zealand

Demograph
ics:
nephrology
HCP, mean
age 48.7
years, 80%
F, 91% no
religious
view, 77%
dialysis unit

Funding:
none noted

Site/Setting
: Online
Inclusion:
HCP self-

IV - current
ACP
practice
DV1barriers/faci
litators to
ACP
DV2determine
need for and
content of
CKD
specific
education

Measurement/
Instrumentation

Survey developed
by ACP experts
(palliative care,
nephrology HCP,
psychology, and
health
economist), nonvalidated, piloted
10 ties with renal
HCP

Data
Analysis
(stats
used)

SPSS
V23.0 stats
software
Descriptive
statistics,
inferential
stats for
variable
relationship
(bivariate,
multiple
variates),
Student ttest,
Multiple
linear
regression

Findings/
Results

-promotors:
support,
education,
physician
involvement,
relationships,
early
intervention
IV - 88% no
regular ACP
but 88% ACP
willing; 79%
no ACP
experience,
DV1-85%
recommend a
trained
designee
DV2- ACP
conversations
significant with
HCP (not a
nephrologist)
(OR 4.96, 95%
CI 1.47-14.07)
and conform on
ACP discussion
(OR 1.29-95%

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
ACP
implementatio
n. ACP
interventions
increase ACP
completion.
LOE: IV
Strengths:
target
population,
variety of renal
HCP
Weaknesses:
online survey,
mostly F
Conclusions:
Nephrology
needs CKD
focused ACP
training
Feasibility:
HCP/nephrolo
gists need

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Theory/
Conceptual
Framework

41
Design

Bias:
Selection
bias

Pearse et al.
(2021). CE
outcomes for
ACP: A SR
of the
literature.
Country:
Australia
Funding:
none evident

Sample/
Setting

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

identified as
HCP caring
for CKD
Exclusion:
none
identified

Inferred:
Theoretical
framework of
knowledge,
attitudes, and
behaviors

Design: SR
Purpose:
Review evidence
and recommend
improvements in
education for
HCP in ACP.

n = 3954
participants
N = 45
28 QN, 14
MM, 3 QL
DS:
CINAHL,
ERIC,
PubMed,
Web of

IVContinuing
education
DV1
changes in
confidence,
knowledge,
skill
DV2
practice
change

Original research
instruments for
QN (n = 28)
included 7 with
control groups,
21 used post-tests
with 15 of those
using a pre-test
also; 14 were
MM; 3 QL with
reflection

SR
measureme
nts of
articles
were done
by
individual
critical
appraisal of
each article
by 3
researchers

Findings/
Results

CI 1.12-1.48),
CKD focused
training
programs may
increase ACP
(OR 10.88,
95% CI 2.3849.47); less
likely if >45
years old (OR
0.25, 95% CI
0.08-0.75); or
believed it
wasn’t their
role (OR 1.29,
95% CI 1.121.48)
DV1 more
confidence,
knowledge,
skill 84%
DV2 Changes
in practice 44%
DV3 response
to learning 40%
DV4 PT benefit
<1%,

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
training in
ACP for CKD

LOE = I
Strengths:
high LOE,
HCP specific
Adequate
appraisal by
multiple
researchers.
Weaknesses:
Original

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Bias: No
apparent
bias in SR,
possible
selection
bias in
original
studies,
possible
publication
bias in
JCEHP

Theory/
Conceptual
Framework

42
Design

Sample/
Setting

Science,
Scopus
Population
type: HCP
Setting:
Studies used
from UK,
Australia,
Netherlands,
Belgium,
Canada,
Japan, US.
Inclusion:
CE for ACP,
HCP, QL,
QN, MM,
Outcomes
(HCP =
skill,
knowledge,
PT, clinic),
English

Major
Variables
&
Definitions

Measurement/
Instrumentation

DV3
Response to
learning
DV4 the
benefit to
the patient
DV5
organization
change

Both validated
and non-validated
tools were used
in the original
studies

Continuing
Education:
didactic
teaching or
workshops,
videos,
manuals,
RP,
computerize
d learning

Data
Analysis
(stats
used)
using the
NHMRC
evidence
hierarchy

Findings/
Results

DV5
organizational
approach <1%

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
studies are
heterogeneous
(can also be a
strength) and
have nonvalidated tools
Conclusions:
Practice and
RP activities
helpful.
Measured
outcomes were
limited.
Feasibility:
ACP CE
interventions to
improve ACP
consistent with
PICOT

Exclusion:
EOL focus,
non-English,
Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Phillips et
al. (2018).
Advance
care
planning and
chronic
kidney
disease:
What do
patients
know and
what do they
want?
Country:
Canada
Funding:
None noted
Bias: none
evident

Theory/
Conceptual
Framework

Inferred: Health
Belief Model

43
Design

Design: Cohort,
Non-probability,
consecutive
sampling
Purpose: To
explore the
knowledge of
patients with
CKD on:
Q1 – supportive
care knowledge
Q2 – supportive
care and
psychosocial
needs
Q3 – EOL
preferences in
CKD

Sample/
Setting

OB, Peds,
MH
n = 133
64%
response
rate
Population
type: CKD
PT
Setting:
Hospital or
community
based
Demograph
ics: mean
age 60-79
years
(58.9%), M
(56.4%),
White
(81.2%),
dialysis PT
(56.4%),
high school
education,
English

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

Findings/
Results

IV-CKD PT
knowledge
of ACP

Supportive care
survey
3 sections - EOL
-Demographics
-general care
-medical care

Descriptive
statistics

DV1 - 88% PT
did not have
provider
discuss ACP

LOE: IV

PT gets info
from specialists
(58.6%), GP
(49.6%)

Weaknesses:
population
rural, white,
English, survey

57.1% Never
heard of ACP
but familiar
with hospice
(63.9%) and
palliative
(69.2%)

Conclusions:
PT wants ACP
when ill,
symptom
management,
family care
important by
HCP.

DV1identify
knowledge
of ACP
DV2 –
psychosocia
l and
support
need
DV3 – EOL
preference

DV1 – 84.2%
want prognosis,
but 88% had
not been
informed
DV3 – 36.1%
want to die at
home

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Strengths: no
apparent bias

Feasibility:
PT wants GP
involved with
PT and family
with prognosis,
symptom
management,
and ACP when

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Theory/
Conceptual
Framework

44
Design

Sample/
Setting

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

-15% want to
die in the
hospital
-probably or do
not want CPR
(57.4%)
- want ACP
discussions,
family (80.5%),
GP (34.6%),
nephrologist
(33.8%)

Site/Setting
: Dialysis
treatment
center

Tilburgs et
al. (2018).
Barriers and
facilitators
for GPs in
dementia
advance care
planning: A
systematic
integrative
review
Country:
UK, USA,
Belgium,

Stated: Integrated
review
methodology for
theoretical, QL,
and QT studies

Design: SR
Integrative
Purpose:
Identify barriers
that GPs face
with initiating
ACP in people
with dementia

Inclusion:
>18 years,
CKD stage
> stage 4,
GFR < 30
ml/min,
English, +
cognitive
n = 16
10 QL, 5QT
(crosssectional),1
MM
DS:
Embase,
Psychinfo,
Medline,
CINAHL,
Cochrane
Library

Findings/
Results

IV- barriers
and
facilitators
of ACP in
PWD
DVInitiation of
ACP by GP

Original
Research: QL and
QT research
independently
run by QL
ATLAS software
to code and
identify themes.
Critical appraisal
from each article
by 2 researchers
with MMAT

PRISMA
guideline
for article
selection
ATLAS for
QL coding

Q1 – Timely
ACP
Facilitator –
cognitive
decline (QT),
acute illness
(QL), 85% GP
should initiate
ACP
Barrier –
Timing of ACP
(86% - QT),
PWD (QL)

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
they are ill.
Applies to the
population of
the PICOT
question.

LOE = I
Strengths: QL
and QT review,
common
themes
Weaknesses:
Not culturally
diverse,
moderate
quality
research

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
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Germany,
Singapore
Funding:
ZonMw
Memorabel
program,
#79-7330598-420
Bias: none
evident

Theory/
Conceptual
Framework

45
Design

Sample/
Setting

Population
type: PWD
or family,
GPs, HCP,
Inclusion:
articles for
GP barriers
or
facilitators
for ACP in
people with
dementia
Exclusion:
Not about
dementia,
nonempirical

Major
Variables
&
Definitions

Measurement/
Instrumentation

Original studies =
moderate quality
Perceived
barriers scale –
used for QT data

Data
Analysis
(stats
used)

Findings/
Results

Q2 –
Stakeholder
engagement
Facilitator –
(QT) shareddecision
making PT/GP
(mean 2.20 of
scale 1-4)
Barrier – poor
relationships
PT/GP, PWD
(QL), no sign
difference with
PWD and
family or GP
(r= 0.05, r =
0.17).
Q3 – Aspects
of ACP
Facilitator –
QOL, EMR,
(QL), PWD
social decisions
housing (mean
1.28, SD 0.7),
driving (mean
1.39, SD 0.63)
(QT)

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Conclusions:
GP can do
ACP in PC,
timely
initiation,
PT/family
engagement,
and HCP
education/train
ing important
for success.
Feasibility:
GP/HCP
relationships
and training
increase ACP
initiation in
chronic
diseases such
as dementia.

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Theory/
Conceptual
Framework

46
Design

Sample/
Setting

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

Findings/
Results

BarriersEMR, poor
ACP
knowledge
(QL)

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Q4 –
Prerequisites
ACP
Facilitator –
ACP
knowledge
(QL), PWD
less negative
ACP (t=2.47, p
= 0.015) (QT)
Barrier – ACP
unpredictable
(QL)

Table 2
Evidence Table of Qualitative Research

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

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Citation

Theory/
Conceptual
Framework

Method

Glaudeman
s et al.
(2019). How
do Dutch
Primary
Care
Providers
overcome
barriers to
advance care
planning
with older
people? A
qualitative
study.

Inferred:
Phenomenological
Concept of
Experience

Method:
Phenomenology,
semi-structured
interview

Country:
Netherlands
Funding:
NOHRD
Bias:
selection
bias

Purpose:
Identify how
Dutch HCP
overcome
barriers to ACP
in people > 65
years old

Sample/
Setting

Major
Variables
&
Definitions

Measurement/
Instrumentation

N = 47
n = 14
saturation
achieved at
11
Purposive
sampling

IVpersonal
intervention
used to
overcome
ACP
barriers

Semi-structured
interview

Population
type: Dutch
HCP

DVcomplete
ACP in
elderly
patients

2 interviewers

Setting: in
subject’s
home,
practice, or
research
center
Demograph
ics: Median
age 50
years, 10 F,
4 M,
8 GP, 3
GCP, 3
nurses

Barriers =
practices,
beliefs,
attitudes,
knowledge,
time

Tape recorder
Interview guide
not included

Post-interview
conference

Data
Analysis
(stats
used)

Findings/
Results

Interviews
transcribed
from a
recording.
MAXQDA
software.

Themes:
IV1
Improving
expertise/skilleducation
- research
- teaching
(peers/patients)
- practice
IV2 –
Approaches to
elderly/family
- involvement
of
patient/family
- involve nurses
IV3 –
organization
of care/time
- ageappropriate
teaching tools
- delegation

Independen
t analysis
by 2
researchers

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
LOE = VI
Strengths:
Identifies ACP
barrier
strategies
Weaknesses:
Small number
of respondents,
bias
Conclusions:
Practicing,
education,
exchange, and
reflection
overcame
barriers.
Communicatio
n skills opened
up talks with
patients/family
Feasibility:
Barrier
resolution HCP
for geriatric PT

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Littlewood
et al. (2019).
ACP in rural
South Wales
from the
perspective
of general
practice
registrars
and recently
fellowed GP
Country:
Australia
Funding:
GP synergy
Bias:

Theory/
Conceptual
Framework

Inferred:
Phenomenological
Concept of
Experience

48
Method

Method:
Qualitative
descriptive,
Phenomenology
Purpose: To
understand GP
current
involvement,
barriers, and
facilitators of
ACP

Sample/
Setting

Inclusion:
HCP with
experience
in ACP with
elderly
Exclusion:
No
experience
with ACP in
the elderly
n = 13
purposive
sampling
saturation
achieved at
13
Population
type: GP
Setting:
Primary care
Demograph
ics: mean F
25-30, GP in
a rural area,
born/trained
in Australia

Major
Variables
&
Definitions

Measurement/
Instrumentation

IV- current
level of
ACP

Semi-structured
face to face and
telephone
interviews

DV1- ACP
training
DV2barriers of
ACP
DV3facilitators
of ACP

One interviewer
for all interviews

Data
Analysis
(stats
used)

QSR
NVivo 11
software
for coding
6
interviews
coded by 3
researchers
for
reliability

Findings/
Results

Themes:
IV1 – Poor
ACP uptake
DV1 – 77% no
formal ACP
training
DV2 –
-no ACP (PT)
understanding
-time
-no specialists
in the rural area
(ex: palliative
care)
DV3- PT/GP
relationship

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

LOE = VI
Strengths: GP
represented
Weaknesses:
possible
selection bias,
rural only
Conclusions:
Lack of
provider
training and
time is ACP
barrier
Feasibility:

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

PROVIDER ACP TRAINING
Citation

Selection
bias,
confirmation
bias

Theory/
Conceptual
Framework

49
Method

Sample/
Setting

Inclusion:
GP and
registrars in
South
Wales,
training < 5
years

Major
Variables
&
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats
used)

Findings/
Results

-PT right to
choose EOL

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Rural GP
needs support,
time, and
training for
ACP. Applies
ACP to PT
with chronic
disease.

Key: ACP - Advance Care Planning, AD - Advanced Directive, AGNP - Adult Gerontology Nurse Practitioner, BNC - Bad News Conversations, CC - Critical Care, CE - Continuing Education, CI confidence Interval, CINAHL - Cumulative Index to Nursing and Allied Health Literature, CKD - Chronic Kidney Disease, DNR - Do Not Resuscitate, DS - Database Searched, DSA - Decision
Support Analysis, ECP - Elderly Care Physician, EMR - Electronic Health Record, EOL - End-of-Life, EOLCDQ II - End of Life Care Decision Questionnaire II, EPHPP - Effective Public Health
Practice Project appraisal tool, ERIC - Institute of Educational Sciences, F – Female, FIHPPSMHD - Factors Influencing Health Professionals Providing Support for Patients Preparing to Make Health
Decisions, FNP - Family Nurse Practitioner, GP - General Practitioner, GSFCH - Gold standards frame-work for care homes, HCP – health care personnel, IM - Internal Medicine, JCEHP - Journal of
Continuing Education for Health Professionals, LOE - Level of Evidence, M – Male, MH - Mental Health, MM - Mixed Methods, MMAT - Mixed Methods Appraisal Tool, MS - Medical Students,
NH - Nursing Home, NHMRC - National Health and Medical Research Council, NOHRD - The Netherlands Organization for Health Research and Development, NP - Nurse Practitioner, NRCT Non-Randomized Control Trial, OB – Obstetric, OR - Odds Ratio, PC - Primary Care, Peds – Pediatrics, POLST - Physician Order for Life Sustaining Treatment, PP - Patient Preferences, PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PT – Patient, PWD - People with Dementia, QE - Quasi-experimental, QL – Qualitative, QN – Quantitative, RP - Role Playing,
SR - Systematic Review, SW - Social Workers, TBP - Theory of Planned Behavior, UK - United Kingdom, USA - United States of America

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Appendix B

Table 1
Synthesis table
Author

Type of study
Design/method/LOE
Sample

Bias
Country
Independent
variables
Education/Training
ACP
PT knowledge
Dependent
Variables
Education/Training
Time/Timing
Relationships*
Stakeholder/System
EMR/ACPD
Provider
Chronic Disease
HCP Setting
Type of HCP

C. W. H.
Chan et
al.
(2019)
QN
SR/I

H. Chan
et al.
(2020)

Dube et al.
(2015)

Flo et al.
(2016)

QN
CS/IV

QN
QN NE/IV

QN
CS/IV

QN
SR/I

10
studies
4025
HCP
X
USA, I

250 HCP

160 nurse
practitioners

QN
Scoping
LR/I
16 study;
1939
HCP

375 HCP

USA

X
USA, I

X
I

45
studies
3954
HCP
X
I

X

X

X

X

X

↑, Ť=B
B (T)

↑, B
B (T, Ti)
B, F
B
↑
↑
PWD
NH
P, N, O

↑, Ť
B

↑

X
I

Ť=↓, ↑

B, F
B, F
TI
C
P, N, O

H
P, N, O

Varied
P, N

Luckett
et al.
(2017)

Pearse
et al.
(2021)

QN
Cohort
NP/IV
133 CKD
patients

I

X
X
↑
Ø

↑
CKD
Varied
P, N, O

Phillips
et al.
(2018)

Varied
P, N, O

F (Ti)
F
B, F
CKD
DC
P

Tilburgs et
al. (2018)

Glaudemans
et al. (2019)

Littlewood
et al. (2019)

QN
SR/I

QL
Phenom/VI

QL
Phenom/VI

16 general
practitioners

14 HCP
saturation 11

13 general
practitioners

USA, I

X
I

X
I

X

X

X

↓
B, F(Ti)
B
X
B, F
B, F
PWD
PC
P, N

↑
B (T)
F

↓Ť
B
B
B

PC
P, N

PC
P

Key: * = PT/family/provider, ↑ = Increases (knowledge, attitude, comfort, readiness, likeliness of ACP), ↓ = Decreases ACP, ACP - Advance Care Planning
ACPD - Advance Care Planning Documentation/completion, B = Barrier, C = Community or home, CKD - Chronic Kidney Disease, CS - Cross-sectional
DC = Dialysis center, EMR - Electronic Medical Record, F = Facilitator, H – Hospital, HCP - Healthcare Personnel, I – International, LOE - Level of Evidence
LR - Literature review, N – Nurse, NE - Non-experimental, NP - Non-probability, Ø = not statistically significant, O = other HCP (social worker, manager, medical assistant), P = Provider, PC Primary Care, Phenom – Phenomenology, Provider = General Practitioner, specialty practitioner, Nurse Practitioner = involvement, engagement, relationship, PT – Patient, PWD - People with
Dementia, SR - Systematic review, Ť = lack of ACP training or no ACP experience, T = Time, TI - Terminal Illness, Ti = Timing, USA - United States of America

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Appendix C

Figure 1
Search Strategy

Note: This figure shows the search strategy, screening, and eligibility of the research.

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Appendix D

Figure 1
Theory of Planned Behavior model

Note: This figure shows the Theory of Planned Behavior and the relationship between the
components and intention to change behavior. (Ajzen, 1991, p. 182).

PROVIDER ACP TRAINING

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Appendix E

Figure 1
Ottawa Model of Research Use

Note: This figure shows the process of assessment, monitoring, and assessment for the
implementation steps of evidence-based research. (Graham & Logan, 2004, p. 100).