Tracking the route to sustainability: a service evaluation tool for an advance care planning model developed for community palliative care services

J Clin Nurs. 2012 Aug;21(15-16):2136-48. doi: 10.1111/j.1365-2702.2012.04179.x.


Aims and objectives: The study aim was to develop a service evaluation tool for an advance care planning model implemented in community palliative care.

Background: Internationally, advance care planning programmes usually measure success by completion rate of advance directives or plans. This outcome measure provides little information to assist nurse managers to embed advance care planning into usual care and measure their performance and quality over time. An evaluation tool was developed to address this need in Australian community palliative care services.

Design: Multisite action research approach.

Methods: Three community palliative care services located in Victoria, Australia, participated. Qualitative and quantitative data collection strategies were used to develop the Advance Care Planning-Service Evaluation Tool.

Results: The Advance Care Planning-Service Evaluation Tool identified advance care planning progress over time across three stages of Establishment, Consolidation and Sustainability within previously established Model domains of governance, documentation, practice, education, quality improvement and community engagement. The tool was used by nurses either as a peer-assessment or self-assessment tool that assisted services to track their implementation progress as well as plan further change strategies.

Conclusion: The Advance Care Planning-Service Evaluation Tool was useful to nurse managers in community palliative care. It provided a clear outline of service progress, level of achievement and provided clear direction for planning future changes.

Relevance to clinical practice: The Advance Care Planning-Service Evaluation Tool enables nurses in community palliative care to monitor, evaluate and plan quality improvement of their advance care planning model to improve end-of-life care. As the tool describes generic healthcare processes, there is potential transferability of the tool to other types of services.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Advance Care Planning*
  • Advance Directives
  • Community Health Services* / organization & administration
  • Health Services Research
  • Humans
  • Models, Organizational*
  • Nursing Staff
  • Palliative Care*
  • Program Evaluation / methods*
  • Qualitative Research
  • Terminal Care
  • Victoria