RPD306 - Staff Self-Efficacy and Increasing Advance Care Planning Discussions Among Dementia Residents in Assisted Living

Key Message : This cluster randomized trial (N=118 residents with dementia, 23 staff, 10 assisted living sites), implemented a palliative care education intervention tailored for dementia and tested if staff self-efficacy mediates the effects of increased documentation of advance care planning discussions. Approximately half of the total effect was mediated by staff self-efficacy.

Abstract: There is a growing need for palliative care (PC) in the assisted living resident population with Alzheimer's disease and related dementia (ADRD), due to increasing mortality rates.(1) Most assisted living (AL) staff report insufficient training to engage in advance care planning (ACP) discussions.(2) In the absence of social workers who typically in health care settings are responsible for ACP discussions, this often falls to nurses/administrators who may lack ACP training.(3) A recent feasibility cluster randomized trial in AL communities (N=118 residents with dementia, 23 staff; k=10 ALs), The Palliative Care Education in Assisted Living for Dementia Care Providers (PCEAL-DCP) intervention showed an increase in documentation of ACP discussions in the treatment group from 12% to 51% compared to control group (8% to 23%) from baseline to six-months (effect size 0.86, Cohen's d statistic).(4) This NIH Stage 1b pilot study tested if staff self-efficacy mediates the effects of increased documentation of ACP discussions.
Using the same study sample in the Stage 1a feasibility CRT, causal mediation analysis was used to examine whether the large effect of the PCEAL-DCP intervention on the rates of documentation of ACP discussions was mediated by changes in staff self-efficacy. The outcome was measured as percent of residents in sample with documentation in chart of any discussion of ACP with residents or family last 90 days or presence of advance directives. The measure of staff self-efficacy included two self-reported survey items that asked how much they agree with their ability to provide care for terminally ill persons (4-point scale from completely agree to completely disagree). Findings indicate that approximately half of the total effect was mediated by staff self-efficacy (proportion mediated=50.0%, 95% CI: 20.7%, 79.2%, p=0.001). In conclusion, PC education increases staff self-efficacy which is a mechanism to increase ACP discussions for ADRD residents in AL.

References: 1. National Center for Assisted Living. Assisted Living Facts and Figures Report 2022 Washington D.C.2022 [cited 2022]. Available from: https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/default.aspx.
2. Dobbs D, Kaufman S, Meng H. The Association Between Assisted Living Direct Care Worker End-of-Life Training and Hospice Use Patterns. Gerontol Geriatr Med. 2018;4:2333721418765522.
3. Abken ES, Perkins MM, Bender AA. Assisted Living Administrators' Approaches to Advance Care Planning. Journal of applied gerontology: the official journal of the Southern Gerontological Society. 2022;41(2):391-400.
4. Dobbs D, Yauk J, Vogel CE, et al. Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial. The Gerontologist 2023;64(1), doi:10.1093/geront/gnad018