Thirty-five percent of nursing home residents have no type of advance directive. Despite the increasing emphasis on patient-centered care and the emergence of best practices for advance care planning (ACP), the process of discussing treatment options and identifying patient preferences does not always take place. This lack of ACP may increase transitional care burden through increased hospitalizations and decrease quality of life. In addition, a provider's or patient's race may impact decisions to engage in ACP discussions. African Americans are less likely than Whites to have advance directives and generally, are more leery of the ACP process. Identifying barriers to ACP is the first step in planning interventions that go beyond mandating compliance to ACP protocols and move towards the acceptance and adoption of ACP practices by providers. Ultimately, increasing the use of ACP practices should improve the quality of long term care by avoiding unwanted, questionable, and costly treatments. Purpose: To examine the contextual factors (characteristics of the residents, providers, and facilities) in predicting skilled nursing facilit (SNF) provider judgments. We focus on nurses and social workers because physicians often lack the time to discuss ACP and research shows that nurses, for example, have a greater familiarity than physicians with resident preferences within SNFs. Methods: Using a factorial survey approach, 350 registered nurses, licensed practical nurses, and social workers from 35 SNFs will judge vignettes with assigned situational features of a typical SNF resident. Factorial surveys are particularly useful when experimental designs would be impractical or unethical as in the controversial area of ACP and are less subject to social desirability, especially when addressing the impact of race and ethnicity. Multilevel modeling will be used to analyze the vignette responses to determine the factors related to the resident, the provider, and the facility that influence ACP professional judgments. Outcomes: The primary outcome is the professional judgment as to the degree in which a SNF resident is in need of an ACP discussion and the secondary outcome is the provider's sense of responsibility in ensuring that an ACP discussion takes place. Significance: Results from the study will inform future programs that disseminate ACP best practices into SNF settings by identifying biases and barriers that prevent the adoption of ACP best practices. Increased use of ACP best practices should ultimately increase patient-centered, quality care in which unwanted costly procedures are avoided.
Results from the study will inform educational programs and interventions for advance care planning best practices for skilled nursing facilities. The study wil identify misperceptions or biases toward ACP discussions, the impact of the provider's past experiences and professional background, and facility factors such as quality and staffing levels that may augment or impede the adoption of ACP best practices.