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To explore the associations between depression, anxiety, decisional conflict and advance care planning engagement and the potential mediating role of decisional conflict in the associations between depression, anxiety and advance care planning among community-dwelling older adults.
A cross-sectional study was conducted with 262 community-dwelling older Australians across metropolitan, regional and rural communities between August and October 2022.
Validated self-reported questions were used to collect data on anxiety, depression (Hospital Anxiety and Depression Scale), decisional conflict (Decisional Conflict Scale), advance care planning engagement (Advance Care Planning Engagement Survey) and covariates (demographic characteristics, health literacy [Health Literacy Screening Questions]), overall health status (Short form 36). Data analysis included descriptive statistics, bivariate association analysis, general linear modelling and path analysis.
Anxiety and decisional conflict were directly associated with advance care planning engagement even after controlling for potential effects of demographic characteristics, health literacy and overall health status. The model, including age, gender, country of birth, language spoken at home, education, overall health status, anxiety, depression, decisional conflict and interaction between anxiety and decisional conflict, explained 24.3% of the variance in their advance care planning engagement. Decisional conflict mediated the association between anxiety and advance care planning engagement.
Increased anxiety and decisional conflict were associated with reduced advance care planning engagement directly, even among community-dwelling older adults with higher levels of education and health literacy. Increased anxiety was associated with reduced advance care planning engagement indirectly via increased decisional conflict. Healthcare professionals should assess community-dwelling older adults' anxiety and implement interventions to manage their anxiety and decisional conflict, as these may facilitate their engagement in advance care planning.
Understanding factors associated with advance care planning engagement among community-dwelling older adults may inform strategies facilitating their future engagement in advance care planning. Findings from this study may be used as evidence for future implementation to facilitate the engagement of community-dwelling older adults in advance care planning.
The STROBE statement checklist was used as a guide to writing the manuscript.
The study was advertised publicly through social media (e.g. Twitter and Facebook) and newsletters (e.g. Advance Care Planning Australia, Centre for Volunteering, Palliative Care Australia and a large home care service provider with approximately 7000 older clients receiving support or services) to recruit participants. People aged 65 years and older living independently in the Australian community who could communicate in English were invited to participate and answer the questionnaire.
Primary healthcare (PHC) workforce shortages remain a critical global and national challenge, threatening progress toward Universal Health Coverage. Limited research has examined career-stage-specific motivations and deterrents. This study explores how perceptions of PHC careers differ between final-year medical students and current PHC providers, offering insights for targeted recruitment and retention strategies.
We conducted semi-structured face-to-face and online interviews (November 2023 to December 2024) with final-year medical students and primary healthcare providers (PCPs) from Greater Bay Area institutions. Participants were purposively sampled to ensure diversity in key characteristics. Interviews continued until thematic saturation was reached. Data were analysed thematically using Braun and Clarke’s six-step framework.
Interviews with 17 PCPs and 13 students identified five themes: systemic and institutional factors, education and training, professional development, community perceptions and personal motivations and trade-offs. The analysis identified common barriers across the participant groups, including inadequate resources, fragmented health information systems, unstructured career pathways and inequitable pay-for-performance mechanisms. Career-stage differences were notable: students associated success with hospital-based specialisation and viewed PHC as a fallback option, influenced by limited PHC training exposure, unclear advancement pathways and prevailing stigma. In contrast, PCPs described professional fulfilment through developing niche expertise and fostering continuity of care, increasingly perceiving PHC as an innovative platform for specialised practice. PCPs with prior hospital experience described their transition from hospital settings as motivated by burnout and the pursuit of better work–life balance, an opportunity often overlooked in workforce planning.
Career-stage-specific recruitment strategies are essential to strengthen the PHC workforce. Policies that address early-career and mid-career needs, establish structured development pathways and enhance the societal value of PHC will be critical to building a resilient primary care system. Findings offer practical implications for health system reforms in China and other countries advancing toward Universal Health Coverage.
This study engaged key stakeholders—older adults, family caregivers, home care support workers, nurses, and home healthcare leaders—to explore perspectives on essential components and integration into home care models, and to explore the role of their technology readiness for health smart homes adoption.
A qualitative methodology with a quantitative component, early-phase exploratory design.
Semi-structured interviews underwent qualitative thematic analysis, with cross-case analysis comparing stakeholder perspectives to identify convergences and divergences. Descriptive statistics were used to analyse Technology Readiness Index (TRI 2.0) survey data to provide background and context to the qualitative findings.
Among 18 participants—older adults (n = 6), family caregivers (n = 2), nurses (n = 7), and support workers/healthcare leaders (n = 3)—findings reflected optimism for health smart home adoption and its potential to support ageing in place. Nurses and care workers saw health smart home as a tool for improving care coordination and quality of life. Key adoption considerations included education, data visualisation, privacy, and security. Technology readiness scores were moderate, with nurses scoring highest (3.52), followed by caregivers (3.41), support workers (3.13), and older adults (3.10).
While stakeholders were open to integrating health smart home into home care, concerns around usability, security, and training must be addressed to facilitate adoption.
Findings suggest that while health smart home technology holds promise for enhancing ageing in place, varying levels of technology readiness across stakeholders highlight the need for tailored education and support strategies to ensure successful implementation.
Despite a strong preference for ageing in place among older adults, integrating health smart home technologies into home care remains challenging. Key issues include ensuring intuitive functionality, protecting privacy, and clarifying the roles of caregivers and healthcare professionals in a technology-enhanced care model. This study addresses the critical gap in understanding how health smart home solutions can be effectively tailored to support the diverse needs of older adults, family caregivers, and home care nurses and support workers.
Stakeholders were generally optimistic about health smart home technologies supporting ageing in place and improving quality of life. Nurses and support workers highlighted the need for tailored data visualisations, alert parameters, and clear role guidelines. A novel finding was that older adults and family caregivers viewed health smart home as a way to reduce intrusive monitoring, promote independence, and maintain a familiar living environment. Family caregivers valued the ability to stay involved remotely through activity data, offering reassurance and peace of mind. Across all groups, privacy safeguards were seen as essential, with strong concerns about data security, transparent usage policies, and user control over data sharing.
Findings have implications for community-dwelling older adults, family caregivers, home care professionals, researchers, and technology developers. Insights from this study can inform the design of user-friendly health smart home technologies, shape future research, and guide tailored implementation strategies in home care settings.
An advisory group of community-dwelling older adults in Western Australia provided input on study design and methodology. Their recommendations led to the use of one-on-one interviews to ensure accessibility and relevance for older adults when exploring technology readiness and smart home integration. While the advisory group did not contribute to the data itself or its analysis, their feedback shaped the method of engagement to ensure its relevance and accessibility to potential participants.
To explore determinants impacting an Electronic Health Record-based information system implementation and their association with implementation fidelity based on the Theoretical Domains Framework (TDF) from nurses' perspectives.
Exploratory sequential mixed-method design.
In stage one, semi-structured interviews with 53 purposively selected nurses informed the exploration of TDF domains influencing the implementation of the information system with directed content analysis. In stage two, a cross-sectional survey, informed by the qualitative findings, was conducted among 482 nurses to identify the most relevant and relatively important TDF domains by running generalised linear regression models.
The qualitative interviews generated 13 TDF domains that were identified as major influencing factors, including technology characteristics, knowledge, attitudes, role agreement, self-efficacy, goal-setting, information circulation, and communication among nurses. Quantitative findings showed that 70% of nurses used and printed the written form through the information system, and only 34% offered verbal education consistently. Regression analysis identified nine domains that were relevant and important factors for implementation fidelity, including knowledge, skills, role identity, beliefs in consequences, beliefs in capabilities, intentions, goals, memory and decision processes, and environmental context.
Our findings confirmed previous evidence on determinants of implementing digital health technologies, including knowledge, competencies, perceived effectiveness, role agreement, intentions, decision processes, and environmental context. Additionally, we highlighted the importance of goal-setting for successful implementation.
This study investigated the relatively important associated factors that can impact the successful implementation of the nurse-led information system for post-acute care based on nurses' perspectives. These results can guide nurse practitioners in implementing similar initiatives and support evidence-based decision-making. Researchers can also further investigate the relationships between the identified determinants.
Journal Article Reporting Standards for Mixed Methods Research.
No patient or public contribution.
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