Search

Objective: The climate crisis necessitates urgent decarbonisation. The health sector must address its large carbon footprint. In the present study, we sought healthcare thought leaders' views about a future environmentally sustainable health system. Methods: The present study was a qualitative exploratory study consisting of semistructured, in-depth interviews with 15 healthcare thought leaders from Australia, the UK, the US and New Zealand. Audio recordings of the interviews were transcribed and analysed by matrix display and thematic analysis. Results: Overall, healthcare thought leaders believe that to reduce the carbon footprint of healthcare we need to look beyond traditional 'green' initiatives towards a more fundamental and longer-term redesign. Five main themes and one 'key enabler' (information communication technology) were identified. In this paper we draw on other relevant findings, but chiefly focus on the fifth theme about reshaping the role of healthcare within society and using the size and influence of the health sector to leverage wider health, environmental and societal benefits. Conclusions: These ideas represent potentially low-carbon models of care. The next step would be to pilot and measure the outcomes (health, environmental, financial) of these models. What is known about the topic?: The health sector needs to reduce its large carbon footprint. Traditional 'green' initiatives, such as recycling and improving energy efficiency, are insufficient to achieve the scale of decarbonisation required. What does this paper add?: Healthcare thought leaders surveyed in the present study suggested that we also consider other, non-traditional ways to achieve environmental sustainability. In this paper we discuss their ideas about adopting an anticipatory approach to healthcare using predictive analytics, and using the size and influence of the health sector to effect wider health and environmental benefits. What are the implications for practitioners?: Achieving an environmentally sustainable healthcare system is likely to require broad and fundamental (i.e. transformational) change to the current service model. Health practitioners throughout the sector must be closely engaged in this process. [ABSTRACT FROM AUTHOR]

Midlife, beginning at 40 years and extending to 65 years, a range that encompasses the late reproductive to late menopausal stages, is a unique time in women's lives, when hormonal and physical changes are often accompanied by psychological and social evolution. Access to sexual health and sexual well-being (SHSW) services, which include the prevention and management of sexually transmitted infections, contraception and the support of sexual function, pleasure and safety, is important for the health of midlife women, their relationships and community cohesion. The objective was to use the socio-ecological model to synthesise the barriers and enablers to SHSW services for midlife women in high-income countries. A systematic review of the enablers and barriers to women (including trans-gender and non-binary people) aged 40–65 years accessing SHSW services in high-income countries was undertaken. Four databases (PubMed, PsycINFO, Web of Science and Google Scholar) were searched for peer-reviewed publications. Findings were thematically extracted and reported in a narrative synthesis. Eighty-one studies were included; a minority specifically set out to study SHSW care for midlife women. The key barriers that emerged were the intersecting disadvantage of under-served groups, poor knowledge, about SHSW, and SHSW services, among women and their healthcare professionals (HCPs), and the over-arching effect of stigma, social connections and psychological factors on access to care. Enablers included intergenerational learning, interdisciplinary and one-stop women-only services, integration of SHSW into other services, peer support programmes, representation of minoritised midlife women working in SHSW, local and free facilities and financial incentives to access services for under-served groups. Efforts are needed to enhance education about SHSW and related services among midlife women and their healthcare providers. This increased education should be leveraged to improve research, public health messaging, interventions, policy development and access to comprehensive services, especially for midlife women from underserved groups. Plain language summary: Sexual health and sexual wellbeing services for midlife women in high income countries Midlife, beginning at 40 years and extending to 65 years, a range that encompasses the late reproductive to late menopausal stages, is a unique time in women's lives. Access to Sexual Health and Sexual Wellbeing (SHSW) services, which include the prevention and management of sexually transmitted infections, contraception and the support of sexual function, pleasure and safety, is important for the health of midlife women, their relationships and community cohesion. The objective of this systematic review was to use the socio-ecological model to synthesise the barriers and enablers to SHSW services for midlife women in high income countries. Eighty-one studies were included; a minority specifically set out to study SHSW care for midlife women. The key barriers that emerged were the intersecting disadvantage of under-served groups, poor knowledge, about SHSW, and SHSW services, among women and their HealthCare Professionals (HCPs), and the over-arching effect of stigma, social connections, and psychological factors on access to care. Enablers included intergenerational learning, interdisciplinary and one-stop women-only services, integration of SHSW into other services, peer support programmes, representation of minoritised midlife women working in SHSW, local and free facilities, and financial incentives for under-served groups to access services. The appetite for education about SHSW and SHSW services among midlife women and their HCPs should be capitalised upon, and utilised to improve research, public health messaging, interventions and access to holistic services, particularly for midlife women from under-served groups. [ABSTRACT FROM AUTHOR]

cook c. (2012) Email interviewing: generating data with a vulnerable population. Journal of Advanced Nursing 68(6), 1330-1339. Abstract Aims. This paper describes online recruitment and the email interviewing data collection method with women diagnosed with a viral sexually transmitted infection. The paper highlights the advantages of the method to researchers and participants when conducting research where face-to-face participation may difficult. Background. Online recruitment and in-depth email interviewing have been used by only a small number of nurses internationally. The method enables inclusion of people who might otherwise be excluded from research, for reasons such as geographical distance, incompatible time frames, clinicians''gate-keeping' and participants' desire for anonymity for physical or emotional reasons. Methods. In-depth email interviews were conducted with 26 women in New Zealand, United States of America, Canada and England who had a diagnosis of either human papilloma virus or genital herpes simplex virus. Data were collected during 2007-2008 and analysed using a poststructuralist, feminist thematic analysis. Results. Participant retention was high. Women emphasized satisfaction with the process. Asynchronous interviews allowed for additional reflexivity in the researcher's responses and rich data generation. Conclusion. This method has the potential to enable nurses to include vulnerable and relatively inaccessible participants in 'sensitive' research. In-depth email interviews may generate rich data through a process participants deem to be of personal value. [ABSTRACT FROM AUTHOR]

Background: Speech and language therapists can improve the quality of life of people receiving palliative care through the management of communication and swallowing difficulties (dysphagia). However, their role in this domain is poorly defined and little is understood about the current international professional practice in this field. Aims: To examine how speech and language therapists perceive their role in the delivery of palliative care to clients, to discover current international speech and language therapist practices and to explore the similarities and differences in speech and language therapists’ practice in palliative care internationally. This will inform professional clinical guidelines and practice in this area.Design:Anonymous, non-experimental, cross-sectional survey design.Participants:Speech and language therapists working with adult and paediatric palliative care populations in Republic of Ireland, United Kingdom, United States, Canada, Australia and New Zealand where the speech and language therapist profession is well established. Method: Purposive and snowball sampling were used to recruit participants internationally using gatekeepers. An online survey was disseminated using Survey Monkey (http://www.surveymonkey.com). Results: A total of 322 speech and language therapists responded to the survey. Speech and language therapist practices in palliative care were similar across continents. Current speech and language therapist practices along with barriers and facilitators to practice were identified. The need for a speech and language therapist professional position paper on this topic was emphasised by respondents. Conclusion: Internationally, speech and language therapists believe they have a role in palliative care. The speech and language therapist respondents highlighted that this area of practice is under-resourced, under-acknowledged and poorly developed. They highlighted the need for additional research as well as specialist training and education for speech and language therapists and other multidisciplinary team members in the area of palliative care. [ABSTRACT FROM AUTHOR]

Introduction: The global nursing workforce is predominantly female, with a large proportion working in the 45–55 age group. Menopause is a transition for all women, and; therefore needs recognition as it can impact work performance and consequently staff turnover. Background: Women will go through the menopause, but not all women are affected. The menopause transition presents a range of signs and symptoms both physical and psychological which can impact the quality of life and individuals' work/life balance. The nursing workforce is predominantly women that will work through the menopause transition. Objectives: The study explored perspectives on digital health interventions as strategies to support menopausal women and to understand the requirements for designing health interventions for support in the workplace. Design: A qualitative explorative design. Settings: Nurses working in a range of clinical settings in England, Finland, Denmark, New Zealand, Australia and USA. Methods: Nurses (n = 48) participated in focus groups from six different countries from February 2020–June 2022 during the pandemic from a range of acute, primary care and education settings. Nurses were invited to participate to share their experiences. Thematic analysis was used. Results: All participants were able to describe the physical symptoms of menopause, with some cultural and possible hemisphere differences; more noticeable was the psychological burden of menopause and fatigue that is not always recognized. Four themes were identified: Managing symptoms in the workplace; Recognition in the workplace; Menopause interventions; and Expectation versus the invisible reality. These themes revealed information that can be translated for implementation into digital health interventions. Conclusions: Managers of nursing female staff in the menopausal age range need greater awareness, and menopause education should involve everyone. Finally, our results demonstrate design attributes suitable for inclusion in digital health strategies that are aligned with likely alleviation of some of the discomforts of menopause. Patient or public contribution: No patient or public contribution. [ABSTRACT FROM AUTHOR]

Dystonia is a neurological disorder characterised by involuntary muscle contractions. Pain is the primary non-motor symptom, and limited studies have investigated how dystonic pain is experienced. This study aimed to investigate how people with isolated dystonia describe their pain and compare across subgroups of dystonia. Anonymous online survey via social media asking participants to describe their pain in their own words, complete the McGill Pain Questionnaire (MPQ), and answer demographic questions. Thematic analysis identified common themes and frequencies were calculated for demographic and MPQ data. One-hundred and sixty-five respondents were included (mean age 51 years, 85% female). Thematic analysis identified four major themes "Physical sensations", "Temporal features", "Destruction", "Impact on life" with several sub-themes. The most chosen MPQ descriptor was "exhausting" followed by "tight," "sharp," "pulling," and "aching". The most common descriptors showed similar prevalence across subgroups of dystonia. As no objective tests for pain exist, pain sufferers must use language to describe their pain experience. People with isolated dystonia used sensory words combined with metaphorical language to detail temporal features of pain, as well as destructive internal battles or feelings of external forces acting upon them, and the significant toll pain has on everyday life. Pain is a common and debilitating non-motor symptom for people living with dystonia and should be discussed in a persons treatment plan. Pain sufferers use language to discuss their pain experience with others and report they don't feel well understood by others including health professionals. People with dystonic pain commonly described physical sensations, temporal features, destructive forces, and the impact on life caused by their pain. Findings suggest the experience of pain with dystonia is varied and better pain management options for people with dystonia are needed. [ABSTRACT FROM AUTHOR]

There is minimal research about the military-to-civilian transition (MCT) from the perspective of the family. The goal of this scoping review was to identify what is known about military families across the Five Eyes Nations (FVEY) (Australia, Canada, New Zealand, the United Kingdom, and the United States) during this phase as well as identify gaps in the evidence base. Scoping review methods were employed with a narrative review process to conceptualize and organize results. The initial search returned 2,219 sources. From these, 27 sources about military family experiences during MCT were identified. Overall, there was limited research on this topic with the majority of sources being from gray literature. A contributing factor to this lack of literature could be the conflation of the MCT with other military transitions (i.e. deployments). Sources highlighted four major themes that influenced identified needs and current services for military families during MCT: (1) mental health; (2) barriers to care; (3) financial needs; and (4) targeted transition support. The limited literature documents promising family skills-based interventions during MCT. However, there is a need for more empirical research on existing family-based interventions and experiences and needs of the family as a unit during MCT. [ABSTRACT FROM AUTHOR]

Background: Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern. Objectives: To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples' preferences, needs, opportunities and barriers to palliative care. Methods: A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly's hierarchy of evidence-for-practice in qualitative research. Results: Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples' experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements. Conclusions: The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas. [ABSTRACT FROM AUTHOR]

Aims and objectives: To compare the communication and practice experiences of migrant nurses in geographically distant, culturally dissimilar countries in Eastern and Western contexts. Background: Considerable research has focused on the experience of acculturation of migrant nurses into geographically diverse locations. However, there remains scant comparative research which considers the ways in which migrant nurses interpret their experience through making "sense" of events encountered in their practice. Design: An exploratory qualitative study was conducted using face‐to‐face interviews with 36 migrant nurses currently practising in New Zealand and 20 migrant nurses practising in the United Arab Emirates. Methods: The same question schedule was used to explore influences on communication and practice in both settings. Thematic analysis and sensemaking theory guided coding and analysis of data. COREQ guidelines informed the reporting of qualitative data. Results: Qualitative analysis resulted in five representative themes, three illustrating similarities across diverse cultures and two that demonstrate the differences migrant nurses require to navigate across contrasting cultural environments successfully. Conclusion: Cultural value‐based differences in both locales caused both systemic and interpersonal sensemaking challenges for migrant nurses that emphasise the importance of orientation and education programmes for internationally qualified nurses. However, cultural conflicts also exist within groups. Orientation programmes should address culturally patterned responses among different groups of internationally qualified nurses. Relevance to clinical practice: Findings demonstrate a need for migrant nurses to be willing to embrace ambiguity in order to acculturate into a collaborative team culture in each of the geographical locations in this study. As registered nurses (RNs) also carry their cultural imprint, orientation interventions targeting the cultural variations of nurses in less standardised orientation programmes may be more beneficial in enhancing acculturation and in turn, staff retention. [ABSTRACT FROM AUTHOR]

Background: Aphasia services are currently faced by increasing evidence for therapy of greater intensity and comprehensiveness. Intensive Comprehensive Aphasia Programs (ICAPs) combine these elements in an evidence-based, time-limited group program. The incorporation of new service delivery models in routine clinical practice is, however, likely to pose challenges for both the service provider and administering clinicians. This program of research aims to identify these challenges from the perspective of aphasia clinicians from six countries and will seek to trial potential solutions. Continual advancements in global communication technologies suggest that solutions will be easily shared and accessed across multiple countries. Aims: To identify the perceived and experienced barriers and facilitators to the implementation of 1) intensive aphasia services, 2) comprehensive aphasia services, and 3) ICAPs, from aphasia clinicians across six countries. Methods and procedures: A qualitative enquiry approach included data from six focus groups (n = 34 participants) in Australia, New Zealand, Canada, United States of America (USA), United Kingdom (UK), and Ireland. A thematic analysis of focus group data was informed by the Theoretical Domains Framework (TDF). Outcomes and results: Five prominent theoretical domains from the TDF influenced the implementation of all three aphasia service types across participating countries: environmental context and resources, beliefs about consequences, social/professional role and identity, skills, and knowledge. Four overarching themes assisted the identification and explanation of the key barriers and facilitators: 1. Collaboration, joint initiatives and partnerships, 2. Advocacy, the promotion of aphasia services and evidence-based practice, 3. Innovation, the ability to problem solve challenges, and 4. Culture, the influence of underlying values. Conclusions: The results of this study will inform the development of a theoretically informed intervention to improve health services' adherence to aphasia best practice recommendations. [ABSTRACT FROM AUTHOR]

Background: Little is known about cystic fibrosis patients, who are not considered to be terminally ill, and who die after voluntary cessation of treatment. Aim: This study was undertaken to provide an international snapshot of this issue. Design: An online survey was distributed across three continents. Setting: Distribution to the medical directors of the cystic fibrosis centres affiliated with the US Cystic Fibrosis Foundation, Cystic Fibrosis Australia (inclusion of New Zealand) and to every clinician member of the European Cystic Fibrosis Society. Results: More than 200 cystic fibrosis patients not considered to be terminally ill and, who voluntarily ceased treatment, were reported by the clinicians surveyed. Detailed data were reported in 102 patients (4 children, 25 adolescents and 73 adults). Only one child, six adolescents and one adult were judged by clinicians not to be competent to make the decision to stop treatment. Time-consuming and low immediate-impact therapies, such as respiratory physiotherapy, were most frequently discontinued. Resignation was the main reported reason for discontinuing treatment, followed by reactive depression and lack of familial support. A total of 69% of the patients received palliative care and 72% died in the 6 months following cessation of treatment. Conclusion: Death of cystic fibrosis patients, not considered to be terminally ill, is reported in Europe, the United States and Australia due to voluntary cessation of treatment. [ABSTRACT FROM AUTHOR]

Talanoa is an established format for generating discussion about complex topics used throughout the Pacific. Pacific researchers use talanoa to gather data with migrant Pacific Island populations, in countries such as the United States of America, Australia, and Aotearoa/New Zealand (A/NZ). Using talanoa in this way, changes the way that the approach is used as, on the one hand it is out of its original context, and on the other hand, extends its use to gather data with Pacific Islanders. In this article, we discuss the implementation of talanoa in an explorative qualitative research project, and discuss its effectiveness and usefulness for getting to the heart of the story about Tongan interpretations of mental illness and distress. [ABSTRACT FROM AUTHOR]

Aim: The study's main aim was to gain in ‐ depth understanding of how nurse scholars engage with electronic theses and dissertations. Through elicitation of opinions about challenges and opportunities, and perceptions of future development, the study also aimed to influence the design of a new international web ‐ based forum for learning and sharing information on this topic. Background: Electronic theses and dissertations provide an opportunity to radically change the way in which graduate student research is presented, disseminated and used internationally. However, as revealed by a multi ‐ national survey in 2011, many nurse scholars in vanguard universities have little awareness of how to find and exploit this ever ‐ expanding global knowledge resource that is increasingly available free in full text format. Within this context more detailed understandings of nurse scholars’ thinking and actions are required. Methods: A qualitative approach using a semi ‐ structured interview guide was utilized to elicit perceptions from 14 nurse scholars. Results: Thematic analysis of the interviewees’ responses identified six major themes: initial exposure and effect; searching; accessing; handling; using; and evaluation. Insights were gained about the value of these resources and behaviours in using them as exemplars for structure, format and methodology. Conclusion and implications for nursing and nursing policy: Despite the small study size, the findings added valuable new insights to the overview gained from the 2011 survey. These have been used to inform development of a new global initiative: the International Network for Electronic Theses and Dissertations in Nursing. Featuring an educational website (www.inetdin.net), this initiative aims to support and challenge nursing's policy makers, practitioners and especially educators to utilize this neglected but exponentially increasing wellspring of international nursing knowledge. [ABSTRACT FROM AUTHOR]

Aim To explore the concept of sustainability in nursing using social media as a vehicle for discussion on the topic. Background There is a need for an increased awareness among nurses of the issues that are crucial for the healthcare sector to prepare for climate change and contribute to sustainable development. However, topics about sustainability and climate change are not a requirement of nursing curricula in Europe; social media provides an opportunity to raise issues and promote discussion. Design A thematic analysis of a Twitter discussion. Methods A Twitter discussion session hosted by @WeNurses took place on 24 March 2015 over 1 hour. Data were gathered via this online discussion hosted on Twitter, a social media platform. Following the discussion a thematic analysis of the posted Tweets was conducted. Findings One hundred and nineteen people posted nine hundred and ninety six Tweets, a reach of 3,306,368. Tweets broadly followed the questions posted by the team. Several threads related to the sustainable use of healthcare resources and the need to reduce waste was evident. A Word Cloud of the Tweets highlighted prominent words in the discussion: sustainability, nursing/nurses, curriculum, important, waste, practice, resources, student, plastic, health, gloves. Conclusion Social media is an effective way of engaging nurses and students in a discussion on challenging issues. Sustainability appears to be important for nurses, with a particular emphasis on resource use and the importance of sustainability topics in nurse education. [ABSTRACT FROM AUTHOR]

Purpose: The study examined the barriers faced, the goals selected, and the optimization and compensation strategies of older workers in relation to career change. Method: Thirty open-ended interviews, 12 in the United States and 18 in New Zealand, were conducted, recorded, transcribed verbatim, and analyzed for themes. Results: Barriers to finding and maintaining work included task difficulty, problems with coworkers and management, lack of self-confidence, health/physical limitations, ageism, and stereotyping. Respondents’ most frequently selected goals for a new career were the desire to help others, work satisfaction, and acquisition of learning. Seventy-five percent of respondents in paid employment had earning an income as a goal. Optimization strategies included drawing on past experience, assessing skills, seeking careers/organizations that fitted their values, and a willingness to accept lower pay or unpaid work. Attitudinal strategies included focus and persistence, optimism, and positive attitudes toward change. The compensation strategies reported were on-the-job training; help from coworkers, clients, or customers; friends and family social support; and professional networks. Management practices considered helpful were flexible work schedules, supervisors’ patience, and formal recognition of the value of older workers. Conclusion: This qualitative study, using the SOC framework, showed that evaluating one’s skills and values, being positive about change, and being part of a supportive work environment were key contributors to adaptive competence. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to examine how older people make sense of their capacity to maintain sports performance. Performance maintenance is predominantly examined from a quantitative perspective, with little attention given to how people themselves account for it. We interviewed 44 competitors (23 females, 21 males) from the 2009 Sydney World Masters Games (aged 56–90 years; mean = 72 years). The major themes were: ‘Use it or lose it’ (performance preservation required specific ‘training’ and the continuation of general physical activity); ‘Adapt’/‘modify’ (participants compensated for their decline in speed, strength and endurance so they could continue competing in sport); ‘It's in my genes’ (participants attributed their ‘family history’ and/or innate ‘determination’ to performance maintenance); and ‘I like to push myself’ (participants valued improved performance, pushing their bodies and winning which motivated them to continually train and compete). The findings are discussed within a framework of three key performance maintenance theories: (a) preserved differentiation, (b) selective maintenance and (c) compensation. Although compensation and continued training are effective ways to counter decline in later life, this study extends past research by showing how older athletes tend to combine and/or generalise stable and unstable attributes of performance preservation. In particular, this research highlights the importance individuals and Western society place on self-responsibility for health, competition and performance maintenance, which act as key motivating factors. [ABSTRACT FROM PUBLISHER]

Background: Women need access to evidence-based information to make informed choices in pregnancy. A search for health information is one of the major reasons that people worldwide access the Internet. Recent years have witnessed an increase in Internet usage by women seeking pregnancy-related information. The aim of this study was to build on previous quantitative studies to explore women's experiences and perceptions of using the Internet for retrieving pregnancy-related information, and its influence on their decision-making processes. Methods: This global study drew on the interpretive qualitative traditions together with a theoretical model on information seeking, adapted to understand Internet use in pregnancy and its role in relation to decision-making. Thirteen asynchronous online focus groups across five countries were conducted with 92 women who had accessed the Internet for pregnancy-related information over a 3-month period. Data were readily transferred and analyzed deductively. Results: The overall analysis indicates that the Internet is having a visible impact on women's decision making in regards to all aspects of their pregnancy. The key emergent theme was the great need for information. Four broad themes also emerged: 'validate information,''empowerment,''share experiences,' and 'assisted decision-making.' Women also reported how the Internet provided support, its negative and positive aspects, and as a source of accurate, timely information. Conclusion: Health professionals have a responsibility to acknowledge that women access the Internet for support and pregnancy-related information to assist in their decision-making. Health professionals must learn to work in partnership with women to guide them toward evidence-based websites and be prepared to discuss the ensuing information. (BIRTH 38:4 December 2011) [ABSTRACT FROM AUTHOR]

Background: ACP involving a facilitated conversation with a health or care professional is more effective than document completion alone. In policy, there is an expectation that health and care professionals will provide ACP support, commonly within their existing roles. However, the potential contributions of different professionals are outlined only broadly in policy and guidance. Research on opportunities and barriers for involving different professionals in providing ACP support, and feasible models for doing so, is currently lacking. Methods: We identified twelve healthcare organizations aiming to offer system-wide ACP support in the United States, Canada, Australia and New Zealand. In each, we conducted an average 13 in-depth interviews with senior managers, ACP leads, dedicated ACP facilitators, physicians, nurses, social workers and other clinical and non-clinical staff. Interviews were analyzed thematically using NVivo software. Results: Organizations emphasized leadership for ACP support, including strategic support from senior managers and intensive day-to-day support from ACP leads, to support staff to deliver ACP support within their existing roles. Over-reliance on dedicated facilitators was not considered sustainable or scalable. We found many professionals, from all backgrounds, providing ACP support. However, there remained barriers, particularly for facilitating ACP conversations. A significant barrier for all professionals was lack of time. Physicians sometimes had poor communication skills, misunderstood medico-legal aspects and tended to have conversations of limited scope late in the disease trajectory. However, they could also have concerns about the appropriateness of ACP conversations conducted by others. Social workers had good facilitation skills and understood legal aspects but needed more clinical support than nurses. While ACP support provided alongside and as part of other care was common, ACP conversations in this context could easily get squeezed out or become fragmented. Referrals to other professionals could be insecure. Team-based models involving a physician and a nurse or social worker were considered cost-effective and supportive of good quality care but could require some additional resource. Conclusions: Effective staffing of ACP support is likely to require intensive local leadership, attention to physician concerns while avoiding an entirely physician-led approach, some additional resource and team-based frameworks, including in evolving models of care for chronic illness and end of life. [ABSTRACT FROM AUTHOR]