Normalisation of Advance Care Planning (ACP) for People With Chronic Diseases in acute and community settings

Registered Nurses (RNs) will be specially trained to introduce and engage in Advanced Care Planning (ACP) with patients with a Chronic Disease (CDs) at selected hospital and community health sites. The conversations will involve 2-3 face-to-face conversations with the patient and/or their substitute decision maker, each around 10 minutes in length. These conversations will discuss what ACP is and their future healthcare wishes. The nurses will be in place for a 6 month period at the intervention sites. Nurses will receive approximately two days of online, self-paced learning and an additional ~ two days of face-to-face training, given by research investigators and partners who are recognized experts in ACP (Peter Saul, Lisa Shaw, Tomiko Barrett, Sarah Jeong, Seok Ohr & Peter Cleasby). Prior to the two-day training course, the RNs will be directed to online, self-paced learning and will be expected to complete modules on: • Benefits of advance care planning • Medical decision-making • The role of the substitute decision-maker • Legal implications of advance care planning • Advance care planning conversations • Life prolonging treatments As NSW Health staff, they will also be directed to complete relevant training / modules from ‘My Health Learning’ (including ‘Introduction to Advance care planning’ and ‘SHAPE End of Life Conversations’). A two-day face-to-face training programme has been developed following recommendations from experienced ACP Coordinators both at HNELHD and CCLHD who have conducted numerous training sessions with medical and nursing staff in both health districts. This will cover: • Research aims, design, methods, • their role as RN ACP facilitators, • how to screen potential participants for inclusion, • how to discuss and clarify patient values, preferences for care and appointment of a PR or EG, • what constitutes an ACD and how to aid completion of a legally valid ACD. • How to broach, discuss and complete a Resuscitation plan, • Completion, use and storage of the ‘ACP Conversation card’. • Follow-up processes (after patient is discharges home or re-admitted to hospital). Training will focus on how to have conversations about ACP by addressing their concerns and questions. It will incorporate role-plays between experienced ACP Coordinators and the trainees, scenario-based learning and trouble-shooting sessions. The focus will be on enhancing the skills required to facilitate challenging conversations. Aboriginal Health Workers and Multicultural Liaison Officers will be involved in the training, to offer perspective and advice on cultural sensitivities. Training will be specific to the individual and the requirements of the study, and may not be limited to the initial two-day training. A ‘Needs Assessment’ will be completed by RN ACP Facilitators before and after their training, as part of training evaluation. If they are deemed to require further training, the training period can be extended. Ongoing support and input will be provided by members of the study team, who themselves are recognised experts in this area.