Table 1 Categories, subcategories, codes

Implementing advance care planning

Directing care

Essential for practice

Care planning for the future

Apprehensions and fears evaded by support and usable materials

Fear of unknown

Support from research team

User friendly resources

Emotive process

Emotive process

Benefits

Enhancing communication

Pathway for difficult conversations

Normalising death

Building relationships

Changing care culture

Composed care environment

Promoting multi-disciplinary awareness

Enhancing practice and profession

Avoiding crisis decision making

Reducing emotional distress

Family preparedness

Reduce end of life hospital transfer

Preference-based care

Knowing how to care

Dignity to decide

Challenges

Establishing capacity

Persons lacking capacity

Capacity assessment

Borderline capacity

Enactment of ACP

Ensuring compliance

GP involvement

Legal aspects

Indecision

Gaining consensus

Misperceptions of purpose

Not for everybody

Disadvantages

Resource Intensive

Time and Effort

Reviewing and updating

Recommendations

Education/training

Train the trainer model

Blended approach and simulations

MDT approach

Role of senior nurse and managers

Getting everyone involved

Documentation

Capturing conversations

Sticker alerts on charts

External support

Link facilitator

Freely available ACP tool kits

Introduce concept around admission

Introduce concept around admission