Background
Aim
Methods
Design
Theory of Change approach
Terminology | Definition (adapted from De Silva, 2015 [36]) |
---|---|
Impact | The real-world change we are trying to achieve in nursing homes. |
Ceiling of accountability | The point at which we stop accepting responsibility for achieving those outcomes solely through the intervention programme. |
Long-term outcomes | The outcome that the programme is able to achieve on its own. This can inspire the choice for particular primary and secondary outcomes in the evaluation of the intervention. |
Preconditions | A precondition or intermediate outcome is a necessary requirement, condition or element that needs to be realized for the desired outcome to be achieved. In the context of ACP, these preconditions are the precursors or requirements for accomplishing successful ACP. |
Intervention | The different components of the complex intervention. They represent certain “actions” that need to be undertaken to bring about a certain result, intermediate outcome or precondition. These are “those things that the programme must do to bring about the outcomes”. |
Assumptions | An external condition beyond the control of the project that must or is assumed to exist for the outcome to be achieved. |
Rationales | The facts or reasons (based on evidence or experience) behind the choice of the intervention activities or strategies and each link of the causal pathway. |
Setting
Steps to develop the Theory of Change map
Step | Aim | Methods | Output |
---|---|---|---|
1| | To obtain full background information on ACP in Flanders and the nursing home context | Contextual analysis by means of: (literature) review of existing policies, national guidelines, national studies of ACP in the Flemish nursing home setting (e.g. EU FP7 project 'PACE') and local/national ACP initiatives for the nursing home setting | Background report listing possible barriers and facilitating factorsa for ACP in nursing homes related to 1) the resident (e.g. average time of stay in a nursing home is 3 years), 2) family (e.g. family listed as contact person often not according to regulated cascade systemb), 3) involved care professionals (e.g. GPs in Flanders are not employed by nursing home facilities), 4) facility (e.g. staff shortages), 5) Belgian/Flemish (healthcare) system (e.g. ACP policy not driven by law; existence of formal quality indicators) |
2 | | To identify the preconditions related to successful ACP in the nursing home setting | Systematic review* of empirical studies and reviews (2005–2015) about ACP in nursing homes, by the core research team | List of preconditions for ACP in the nursing home setting to be used during workshop 1 to trigger discussion |
3 | | To create a first draft of the ToC map | ToC stakeholder workshop 1 by ToC facilitators (LVDB and LP) and stakeholders | First draft of ToC map, including: ▪ Impact, ceiling of accountability and long-term outcomes ▪ Preconditions/intermediate outcomes, including their chronological order ▪ List of possible interventions, assumptions and rationales |
4 | | To create a second draft of the ToC map based on integration of output from steps 1, 2 and 3 | Several meetings with core research team to construct a draft ToC map | Second draft of ToC map, including: ▪ Reformulated impact and long-term outcomes ▪ Preconditions chronologically ordered and coloured according to level to which they are applicable ▪ Precondition “support by an external trainer” (suggested by research team) ▪ Possible interventions (added by the research team) such as the availability of a trainer and a monitoring system |
5 | | To refine the second draft ToC map, to fill in the gaps and to get consensus on the chronological order of the hypothesised causal pathway | ToC stakeholder workshop 2 by ToC facilitators and stakeholders in which second draft of ToC map (output of step 4) is presented | Refined draft of second ToC map, including: • Redefined secondary outcome to be measurable ▪ Additional elements, added in step 4, approved by stakeholders ▪ Details added by stakeholders (e.g. which healthcare professional is responsible for implementing ACP, re-named ACP facilitator as “ACP reference person”) ▪ Additional arrows added by stakeholders |
6 | | To develop the final draft ToC map that outlines the hypothetical causal pathway of ACP in nursing homes based on integration of output from steps 1 to 5 | Several meetings with core research group to construct the ToC map, review by a ToC expert, comparison with existing ToC maps from other research projects and consultation of implementation science literature (in general and about ACP) and relevant theoretical models | Further integration of outputs of steps 1–5 into a final draft of a ToC map (presented in Fig. 1) and narrative, including: ▪ Preconditions merged or reformulated and put in chronological order ▪ Numbers added to mark interventions ▪ Rationales and assumptions written up by the core research team in a separate document (narrative), based on stakeholders’ and researchers’ experience, literature and relevant theoretical models |
Theory of Change stakeholder workshops
Stakeholders
Characteristics | Workshop 1 (n = 12) | Workshop 2 (n = 15)b |
---|---|---|
Gender | ||
Male | 1 | 4 |
Female | 11 | 11 |
Primary profession | ||
Care professional | ||
General practitioner (GP) | 1 | 1 |
Coordinating and advisory physician (CAP) | 0 | 1 |
Nurse (including public health nurses) | 2 | 2 |
Palliative care reference nurse | 1 | 2 |
Psychologist (one of whom is involved in research linked to ACP) | 2 | 2 |
Social worker | 1 | 0 |
Physiotherapist | 1 | 1 |
Dementia reference person | 0 | 1 |
Other | ||
Nursing home management | 2 | 2 |
Ethicist | 1 | 1 |
Health sociologist | 0 | 1 |
Representative of council for the elderly | 1 | 1 |
Employera | ||
Nursing home | 7 | 7 |
Private practice | 1 | 0 |
University | 3 | 3 |
Overarching organisation | 1 | 1 |
National council for the elderly | 1 | 1 |
Procedure
Workshop 1 and 2 |
a) Problem description b) Introduction to ToC method and ground rules (e.g. “Everyone’s input is equally valid”, “Think outside the box”, “Give the facilitator time to write things down”, “Nothing that is written down is definitive. We are following an iterative process”) c) The question to initiate reflection: “In an ideal world, what would need to happen for a successful implementation of ACP?” |
Workshop 1 |
a) Agreement on impact: What is the fundamental change we want to see in the nursing home setting in Flanders? How will the Flemish nursing home community be different because of what we do? b) Ceiling of accountability c) The long-term outcomes of advance care planning in nursing homes d) What are the intermediate preconditions that are necessary to produce the long-term outcomes? Why do we think a given precondition will lead to (or is necessary to) reach the one that follows it? e) What contextual conditions or circumstances are necessary to achieve the preconditions? f) Consensus concerning the chronological order of preconditions |
Workshop 2 |
a) Presentation and discussion of the ToC map developed in workshop 1 b) Review and refinement of the ToC developed in workshop 1 and filling in the gaps: Is the ToC map presented here “feasible” (likely to work), “effective” and “sustainable”? Is the change logically displayed? Are there essential elements that are missing or that we should definitely consider or discuss? c) Which interventions should be initiated to achieve the preconditions and the long-term outcome? |