Nursing home staff members’ knowledge, experience and attitudes regarding advance care planning: a cross-sectional study involving 12 Italian nursing homes

  • Giovanni OttoboniEmail author
  • Rabih Chattat
  • Claudia Camedda
  • Martina Galletti
  • Sonia Macripò
  • Elena Mariani
  • Francesca Ingravallo
Original Article



Advance care planning may be beneficial for nursing home residents, but its implementation is suboptimal in several countries.


To investigate knowledge of, attitudes towards, and experience with advance care planning of nursing home staff members in Italy.


Cross-sectional survey involving all healthcare professionals working in 12 Italian nursing homes. Statistical analyses investigated interactions between participants’ characteristics, knowledge, attitudes and frequency of advance care planning discussion with residents.


Of the 185 participants (80.5% female, mean age 43.6 ± 9.2 years), 29.7% reported that they had heard of advance care planning, but their actual knowledge was suboptimal. Participants had positive attitudes towards advance care planning, and most of them clearly recognized its benefits. Apprehension about upsetting the patient or their family, or that patients were not ready for these conversations were the main concerns. Only 16% of respondents discussed advance care planning at least sometimes, usually upon patient/family input. Greater knowledge was significantly correlated with more positive attitudes towards advance care planning. The issues of healthcare professionals’ knowledge and training in advance care planning, and of knowledge and awareness of advance care planning in patients, their families, and the general population were considered either main barriers or facilitators.


Nursing home staff members’ concerns towards advance care planning seemed to be related to a misconception about patient and family willingness to discuss it.


A multifaceted strategy including educational and training programmes and the increase of public awareness is needed to implement advance care planning in Italian nursing homes.


Advance care planning Older people Caregivers Healthcare professionals Residential care facilities Italy 



The authors would like to thank all the nursing home staff members who participated in this study, and they also thank Ilaria Cerquetti and Veronica Mignani for their valuable help in data collection and management.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Due to the study anonymous data collection, formal consent was not required.


  1. 1.
    Rietjens JA, Sudore RL, Connolly M et al (2017) Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol 18:e543–e551. CrossRefGoogle Scholar
  2. 2.
    Martin RS, Hayes B, Gregorevic K et al (2016) The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc 17:284–293. CrossRefGoogle Scholar
  3. 3.
    Weathers E, O’Caoimh R, Cornally N et al (2016) Advance care planning: a systematic review of randomised controlled trials conducted with older adults. Maturitas 91:101–109. CrossRefGoogle Scholar
  4. 4.
    Gilissen J, Pivodic L, Smets T et al (2017) Preconditions for successful advance care planning in nursing homes: a systematic review. Int J Nurs Stud 66:47–59. CrossRefGoogle Scholar
  5. 5.
    Mignani V, Ingravallo F, Mariani E et al (2017) Perspectives of older people living in long-term care facilities and of their family members toward advance care planning discussions: a systematic review and thematic synthesis. Clin Interv Aging Vol 12:475–484. CrossRefGoogle Scholar
  6. 6.
    Sharp T, Moran E, Kuhn I et al (2013) Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis. Br J Gen Pract 63:657–668. CrossRefGoogle Scholar
  7. 7.
    Flo E, Husebo BS, Bruusgaard P et al (2016) A review of the implementation and research strategies of advance care planning in nursing homes. BMC Geriatr. Google Scholar
  8. 8.
    Beck E-R, McIlfatrick S, Hasson F et al (2017) Nursing home manager’s knowledge, attitudes and beliefs about advance care planning for people with dementia in long-term care settings: a cross-sectional survey. J Clin Nurs 26:2633–2645. CrossRefGoogle Scholar
  9. 9.
    Froggatt K, Vaughan S, Bernard C, Wild D (2009) Advance care planning in care homes for older people: an English perspective. Palliat Med 23:332–338. CrossRefGoogle Scholar
  10. 10.
    van der Steen JT, Galway K, Carter G et al (2016) Initiating advance care planning on end-of-life issues in dementia: ambiguity among UK and Dutch physicians. Arch Gerontol Geriatr 65:225–230. CrossRefGoogle Scholar
  11. 11.
    Network Non Autosufficienza (2017) L’assistenza agli anziani non autosufficienti in Italia, Il tempo delle risposte. Maggioli Editore, Rimini, ItalyGoogle Scholar
  12. 12.
  13. 13.
    Giantin V, Siviero P, Simonato M et al (2012) Physicians’ and nurses’ experiences of end-of-life decision-making in geriatric settings. Aging Clin Exp Res 24:537–547. Google Scholar
  14. 14.
    Ingravallo F, Mignani V, Mariani E et al (2017) Discussing advance care planning: insights from older people living in nursing homes and from family members. Int Psychogeriatr. Google Scholar
  15. 15.
    Smets T, Pivodic L, Piers R et al (2018) The palliative care knowledge of nursing home staff: the EU FP7 PACE cross-sectional survey in 322 nursing homes in six European countries. Palliat Med 32:1487–1497. CrossRefGoogle Scholar
  16. 16.
    Di Giulio P, Toscani F, Villani D et al (2008) Dying with advanced dementia in long-term care geriatric institutions: a retrospective study. J Palliat Med 11:1023–1028. CrossRefGoogle Scholar
  17. 17.
    Ingravallo F, Govi A, Gnucci V et al (2014) Are the Italian municipal Registries of Advance Directives going in the right direction? Minerva Anestesiol 80:1357–1358Google Scholar
  18. 18.
    Govi A, Veshi D, Orsi L et al (2017) The Italian municipal registries of advance directives: characteristics, effectiveness and limits. Riv Ital Med Leg e Dirit Campo Sanit 3:1233–1244Google Scholar
  19. 19.
    Yee A, Seow YY, Tan SH et al (2011) What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease? Nephrol Carlton 16:232–238. CrossRefGoogle Scholar
  20. 20.
    Beaton DE, Bombardier C, Guillemin F et al (2000) Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 25:3186–3191CrossRefGoogle Scholar
  21. 21.
    Del Greco L, Walop W, Eastridge L (1987) Questionnaire development: 3. Translation. Can Med Assoc J 136:817Google Scholar
  22. 22.
  23. 23.
    Miccinesi G, Puliti D, Paci E (2011) End-of-life care and end-of-life medical decisions: the ITAELD study. Epidemiol Prev 35:178–187Google Scholar
  24. 24.
    Stone L, Kinley J, Hockley J (2013) Advance care planning in care homes: the experience of staff, residents, and family members. Int J Palliat Nurs 19:550–557. CrossRefGoogle Scholar
  25. 25.
    Shaulov A, Frankel M, Rubinow A et al (2015) Preparedness for end of life—a survey of Jerusalem district nursing homes. J Am Geriatr Soc 63:2114–2119. CrossRefGoogle Scholar
  26. 26.
    Fosse A, Zuidema S, Boersma F et al (2017) Nursing home physicians’ assessments of barriers and strategies for end-of-life care in Norway and The Netherlands. J Am Med Dir Assoc 18:713–718. CrossRefGoogle Scholar
  27. 27.
    Robinson L, Dickinson C, Bamford C et al (2013) A qualitative study: professionals’ experiences of advance care planning in dementia and palliative care, ‘a good idea in theory but…’ Palliat Med 27:401–408. CrossRefGoogle Scholar
  28. 28.
    Badzek LA, Leslie N, Schwertfeger RU et al (2006) Advanced care planning: a study on home health nurses. Appl Nurs Res 19:56–62. CrossRefGoogle Scholar
  29. 29.
    Ampe S, Sevenants A, Smets T et al (2016) Advance care planning for nursing home residents with dementia: policy vs. practice. J Adv Nurs 72:569–581. CrossRefGoogle Scholar
  30. 30.
    Baron K, Hodgson A, Walshe C (2015) Evaluation of an advance care planning education programme for nursing homes: a longitudinal study. Nurse Educ Today 35:689–695. CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of BolognaBolognaItaly
  2. 2.Department of Medical and Surgical Sciences, DIMECUniversity of BolognaBolognaItaly
  3. 3.Department of Diagnostic-Clinical Medicine and Public HealthUniversity of Modena and Reggio EmiliaModenaItaly

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