Table 3 Barriers and suggestions for successful implementation of advance care planning (ACP) into primary care and their alignment to Normalization Process Theory (NPT) constructs, identified by interviewed primary care providers (n = 7)

Barriers

Physician busy clinical schedules serve as a logistical challenge for conducting ACP (4).

“I think that intentionally setting aside time [for ACP] is so important, because [ACP] cannot ever happen opportunistically.” (Physician 1)

“Biggest barrier that I could see is physicians saying I don’t have time, and how can we make them realize that you do?” (Registered Nurse 1)

Cognitive Participation

(Enrolment)

Physician perceptions of patient preparedness for ACP (2). 

“The patient was taken aback, or very surprised, that, out of the blue at this visit, that you would bring in the topic of ACP.” (Physician 2)

Cognitive Participation

(Initiation)

Clinician discomfort or lack of confidence in having ACP conversations (1).

“There is still clinician discomfort around this whole topic, and so it is easier to say, “Oh I think this is as good as it gets” and not offer the follow-up because it is scarier and you’re really getting into [ACP] and you worry a little bit about what the patient’s response is going to be.” (Physician 2)

Cognitive Participation

(Legitimation)

Allied health scope of practice limitations, namely with prognostication (4).

“Unless I know that the patient has already discussed prognosis with the physician, then I feel that it is out of my scope to initiate [prognostication].” (Social Worker)

“[Prognostication] is not something that registered nurses learn in school, we are told that prognostication is beyond the scope.” (Registered Nurse 1)

Coherence

(Individual Specification)

Allied health difficulty in identifying appropriate patients for ACP conversations (2).

“Identifying folks, because I see folks from 14 to 87-year-olds, so it is a wide scope. Unless someone is facing something life changing, I am not going to have this conversation with a 14-year-old, or a 37-year-old, because we are usually focused on something else, they came in for.“ (Social Worker)

Coherence

(Individual Specification)

Suggestions

Conducting ACP conversations over multiple visits (4).

“I almost feel like, that we need to figure out a quick intro [to ACP] … and [invite them] back for another visit… because then, in my mind, it is more regimented and scheduled, and will prepare myself and the person coming in.” (Physician 2)

Cognitive Participation

(Enrollment)

Increased collaboration between physicians and allied health for ACP (2).

“I wonder, it might be something, they have already met with the doctor and have that conversation about prognosis, and then they say, ‘Maybe we can refer you to our social worker who has training in this’”. (Social Worker)

“So, a practice team needs to appreciate that this is everybody’s responsibility, everybody’s role. It doesn’t just have to be [the doctors]. So how can we do this as a team, to make this work.” (Registered Nurse 1)

Coherence

(Communal Specification)

Training to normalize ACP conversations, regardless of specialty or role, to reduce discomfort (2).

“I actually think [ACP training] should not be limited to primary care, so I think it should be something taught in medical school. I think every specialty, maybe not exactly this exact discussion, but needs to be able to set up the conversation, assess peoples understanding, talk about prognosis, because whatever specialty you’re in, you will be talking about prognosis about some type of illness.” (Physician 3)

“If you’re not delivering anything new, then you are not outside your scope of practice to talk about things, like decline, change, and illness trajectory. That is very much within the skilled RN scope of practice…for me that is very comfortable. For allied health that may not have had all the extensive training that I have had, and I can see why they would say that’s not for me. And why they would think that’s not within their scope. So, they would need more training to do it” (Registered Nurse 1)

“We have to make sure that health care providers are comfortable talking about death and dying, and they’re not. North Americans aren’t comfortable talking about dying and death so how do we change that?” (Registered Nurse 1)

Cognitive Participation (Legitimation)

Providing patients ACP resources to improve engagement (2).

“I usually direct [patients] to a website that has sheets for them to work on with their family member or friend, ‘Speak Up!’ they have a great worksheet, so I start the conversation, get the ball rolling, and then direct them to that resource. … And that’s the biggest thing, people love being able to have something after that conversation, or have some tools to work with, as opposed to having to remember everything we talked about” (Social Worker)

Cognitive Participation (Activation)