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Q&A: find out how a team worked to embed advance care planning at a systems level

Fraser Health Authority seeks to give nurses the tools they need

By Lauren Thomas, Cari Borenko, & Nicole Percival
September 12, 2022
Taking a systems level approach, the authors created a five-phase model that leverages peer-to-peer feedback, direct care staff engagement, and leadership support. This collaborative, grassroots style encourages a fluid process of continuous evolution and learning.

In her article, Lauren Thomas championed the idea that nurses are uniquely placed to do the thoughtful work of teaching, advocating for and engaging in the advance care planning (ACP) process. Her article challenges all of us to engage in tangible actions when working with patients and clients across Canada. Although this powerful message was directed at the individual nurse, all nurses are constrained by complex, flawed and challenging bureaucratic systems and know that “every system is perfectly designed to get the results it gets” (Heath, 2020, p. 26).

Thomas works at Fraser Health, one of five regional health authorities in B.C., which took action at the systems level to improve nurses’ ability to engage in the ACP process with their clients. Canadian Nurse wanted to learn more about what measures Fraser Health took, so we followed up with the regional ACP team and asked the following questions.

“The thing about living in a broken system is that you make broken choices” (Glass, 2018).

What prompted the need for the Fraser Health Authority ACP team to engage in systems improvement work?

Health care has long been stuck in a cycle of response — built to be reactive. Broke your leg skiing? We’ll fix it. Had a heart attack? We’ll fix that too. And we need this response to crisis. But what if we also built systems that could prevent problems before they happen? As the old public health adage goes, what if instead of endlessly pulling drowning children from the water, we went upstream to stop whoever is throwing them all in (McKinley, 1975/2019, as cited in Heath, 2020, p. 1).

The uptake on engaging in the ACP process has been a slow climb for everyone in health care, and we recognize that the individual is not “the problem.” In health care, education is often proclaimed as the solution to every problem. Yet, as nurses, we quickly come to understand that education alone is not enough; it does not equal behaviour and practice change (Joyce & Showers, 2002).

Anecdotal data from hundreds of direct care health-care workers have consistently said the same thing: we are wholeheartedly on board with the philosophy of ACP, but how do I:

  • Create time in my day for this?
  • Prepare documents and make them accessible to other care providers?
  • Have reminders or prompts available to me in my day-to-day practice?
  • Identify and target the right patients/clients who need this conversation more urgently?
  • Prepare patients and families ahead of time before they are sitting right in front of me?
  • Get employer support for professional development of these new skills?

With all the competing interests, why did Fraser Health’s ACP team decide to go in this direction?

As clinicians with direct care experience, our team is deeply aware of the existing system challenges. For years, we have provided ACP education without really moving the needle; ultimately, a broken system that doesn’t support individual efforts for change will deter even the most engaged health-care workers. And given that we are a small, regional team of seven people responsible for providing ACP support to an entire health authority, we needed a sustainable strategy. So we began to consider how we can set up systems so our nurses can engage in ACP more easily.

We created a five-phase systems model that leverages peer-to-peer feedback.

Upstream work is challenging and often voluntary (Heath, 2020). It takes more time and effort, and it is more difficult to measure. As such, it is not always valued or prioritized by a system that rewards immediate results. Despite this, we were motivated to learn about and implement systems-level work because, when successful, the outcomes are invaluable.

What is unique about the systems work that Fraser Health is doing with ACP?

After a thorough review of the literature, we created a five-phase systems model that leverages peer-to-peer feedback, direct care staff engagement, and leadership support. This collaborative, grassroots style encourages a fluid process of continuous evolution and learning, allowing the team we are working with to identify and direct their own priorities and strategies for embedding ACP into their workflows and practice.

The five phases are as follows:
1. Systems needs assessment. Examine current practice by gathering learning data about the operational flow of the specific clinical area. What are the workflow processes of each discipline? What is the typical journey of a client through this service? This assessment includes all disciplines of the team, together with leadership, medical staff, and support staff.

2. Education. Facilitate interdisciplinary cohort adult education, ensuring that all clinicians are knowledgeable about the basics of ACP, including specific provincial laws, and practise with scripted conversation interventions.

3. Recommendations and improvements. Reconvene the cohort — including leadership — to further examine the workflow process in the new knowledge context of ACP. Ask the right questions to prompt critical thinking and establish accountability for trialling improvements.

4. Coaching and consultation. Stay connected with the team and check in on their progress as they implement their improvement plan. Provide feedback and support for questions and challenges and celebrate successes.

5. Outcome measuring. Support leadership to identify outcomes and supporting data that is useful for direct care staff. Data should provide immediate feedback to facilitate active learning and support the adaptation of current practice to achieve systems improvement.

What successes have you had?

Our first success occurred after our team was approached by an outpatient neurology clinic. This team identified that clients lacked preparedness for what lay ahead in their illness. Clients supported by the clinic were interacting with all sectors of the health-care system: general practitioner offices, hospitals, and community services. Clinicians in these sectors were doing what they do — managing urgent and emergent symptoms — yet no one was starting these conversations. The clinic, distressed by client and family struggles, approached our team for support.

“I was not the one who created this problem. But I will be the one to fix it” (Heath, 2020, p. 38).

The ACP team engaged with the clinic staff in our five-phase systems approach. Following systems assessment and education, the clinic team identified the following strategies for improvement:

  • Request a flagging system in the electronic medical record for physicians to have these conversations at visits
  • Create a new “reasons for referral” to social work for complex situations
  • Engage the internal communications department in creating public-facing and provider-facing poster campaigns
  • Conduct a resource review and choose two to incorporate into existing processes
  • Start regular clinic rounds to identify clients who may require more urgent ACP conversations
  • Edit intake forms and add standardized assessment questions regarding ACP

What challenges have you had?

The challenges are not surprising; health care is an environment that is in constant evolution. One of the challenges we continue to face is the lack of recognition of the need for — and value of — systems improvement work. This is a challenge at both the direct care and leadership levels. In addition, we all face competing priorities, time constraints and financial barriers on a daily basis.

Together these challenges are often perceived as barriers to change. For most of us, it’s just not part of our thought processes yet; we still think in a reactive way. We are too busy pulling drowning kids from the water to think about how they are getting there, let alone what can be done about it. It would be unconscionable to just stop, wouldn’t it? A systems-focused mindset is critical to that process of identifying who is throwing them in and figuring out how to stop them. This will be a slow culture change for health care.


Glass, I. (Host). (2018, April 13). Damned if you do… (No. 643) [Audio podcast episode]. In This American life. WBEZ Chicago.

Heath, D. (2020). Upstream: The quest to solve problems before they happen. Avid Reader Press.

Joyce, B., & Showers, B. (2002). Student achievement through staff development (3rd ed). Association for Supervision & Curriculum Development.

The authors are all members of the Fraser Health Authority’s regional advance care planning team.
Lauren Thomas, RN, BSN, and Nicole Percival, RN, BSN, MHLP, are advance care planning nurse clinicians.
Cari Borenko, BA, BSW, MHS, is the manager and lead for the team.