Running Side by Side: An Ethnography of Multi-Professional Involvement in the Advance Care Planning Process in Two Nursing Homes

Abstract

This thesis explores the involvement of health and social care professionals in advance care planning (ACP), as an exemplar of end-of-life care practice, and the impact of this involvement in two purposively selected nursing homes. Nursing homes are significant providers of end-of-life care and their role in this area of care is likely to increase given the ageing population. Multi-professional working is a key component of the espoused model of palliative care delivery. Yet, there has been limited research into multi-professional working in nursing homes. Ethnography was used for the study, with between six and seven months spent in each home. Data collection methods were observation; formal and informal interviews; and document review. Participants included nineteen nursing home staff, seven health and social care professionals, six residents and four relatives. Thematic analysis was integrated with documentary analysis, mapping of resident ACP trajectories and comparative analysis of data from the two nursing homes.

Three key findings were identified: the structure and organisation of professional practice was disjointed and disrupted the continuity and coordination required to enact ACP; challenges were encountered in the enactment of ACP which impact multi-professional involvement; and the dominance of a biomedical approach to ACP constrained the breadth of both ACP and multi- professional working. Multi-professional working was not integrated with ACP in either nursing home and a conceptual framework has been developed which represents ACP and multi- professional working as ‘Running Side by Side’. The conceptualisation of ACP, with a lack of collective understanding, and its construction as a professional process, defined in biomedical terms and controlled by professionals, meant there could be different professional ACP processes running side by side. Professional-led ACP frequently ran side by side with resident priorities for future planning. The involvement of relatives and a wider multi-professional team, beyond nurses and GPs, was not always recognised, so ACP they undertook could also run side by side with other strands of ACP. The conceptual framework provides one way to better understand this complex and under-researched area of practice. It highlights a reciprocal impact between ACP and multi- professional working which, to my knowledge, has not been identified in previous research. The conceptual framework could also be applied to end-of-life care more broadly and suggests greater inter-agency and inter-professional working is required to ensure nursing home residents’ future wishes are both known and honoured.

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Identifiers

ORCID for Nicola Andrews: orcid.org/0000-0003-2595-1825

ORCID for Susan Duke: orcid.org/0000-0002-4058-8086

ORCID for Michelle Myall: orcid.org/0000-0001-8733-7412

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