Evaluation of a Novel Educational Intervention for Mental Health Staff on Advance Care Planning with Older People with Mental Illness

Evaluation of a Novel Educational Intervention for Mental Health Staff on Advance Care Planning with Older People with Mental Illness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of a Novel Educational Intervention for Mental Health Staff on Advance Care Planning with Older People with Mental Illness Keanu Crous, Daniella Kanareck, Margaret Anne Thomas, Kate Anderson, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7843125/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose To evaluate the effectiveness of a novel educational intervention for mental health staff on Advance Care Planning (ACP). The aims were to improve staff knowledge, attitudes, and confidence in facilitating ACP with older people with mental illness and to increase staff engagement in ACP. Methods Pre-post intervention study conducted across two public mental health services in Australia. Multidisciplinary mental health clinicians and peer workers (n = 110) participated in a one-hour, evidence-informed educational session combining theoretical content, videos, interactive discussion of case vignettes and handout resources. Evaluation used paired pre- and post-intervention questionnaires assessing staff knowledge, attitudes, and confidence (Wilcoxon Signed-Rank and Exact McNemar tests). A pre-post audit of mental health consumer (patient) electronic medical records (eMR) at both sites quantified changes in ACP documentation rates (two-sample z-test for proportions). Thematic analysis of free-text feedback was conducted. Results The intervention led to statistically significant improvements in staff attitude (p < 0.001, r = 0.48), knowledge (p < 0.001, r = 0.51), and confidence (p < 0.001, r = 0.87). Consumer eMR audits (pre: n = 1104; post: n = 1118) showed no significant change in ACP documentation rates, which remained low (7.6% vs. 8.0%). Participants’ feedback emphasised further practical training (e.g. role play, sample questions, eMR documentation), discussion of complex cases, and reinforcement strategies. Conclusions A brief, standalone educational intervention improved staff readiness for ACP, but did not translate into change in clinical practice. This knowledge-to-practice gap suggests that overcoming systemic and other barriers to ACP requires multifaceted strategies beyond education, such as organisational change and governance processes, audit and feedback, skills practice and champions. education advance care planning end-of-life mental disorder mental health psychogeriatrics Key summary points Aim : To evaluate whether a brief educational intervention on Advance Care Planning improves mental health staff attitudes, knowledge, and confidence, and increases their engagement in Advance Care Planning with older patients. Findings : A brief educational intervention on ACP improved staff attitudes, knowledge and confidence and was well received, but did not result in significant change in rates of medical record documented engagement in ACP with patients over a 2-3 month follow-up period. Message : A brief educational intervention for mental health staff improves their readiness to engage consumers in ACP, but may require additional strategies such as organisational change, skills practice, audit and feedback to effect behavioural change. INTRODUCTION Advance care planning (ACP), a process that supports adults in understanding and sharing their personal values, life goals, and preferences for future medical care [ 1 ], facilitates optimised end-of-life care. The goal of ACP is to ensure individuals receive medical care consistent with their values and goals at a time when they may not be able to express their preferences, such as when critically ill [ 1 ]. Thus, engagement in ACP has been considered a human right. Effective ACP is associated with improved patient and family satisfaction, increased use of hospice and palliative care, and a higher likelihood of receiving goal-concordant care [ 2 , 3 ]. For patients and their families, it can reduce the emotional burden of end-of-life decision-making while extending a patient's autonomy, even after they have lost decision-making capacity [ 2 , 4 ]. In the Australian context, guardianship laws vary by state and territory, with each jurisdiction maintaining separate legislative frameworks for substitute decision-making arrangements. Decision-making models, including substitute decision-making and supported decision-making, vary internationally and across jurisdictions, though Australia has increasingly emphasised supported decision-making approaches that prioritise an individual’s will and preferences [ 5 ]. This is particularly important for people with serious mental illness, as ACP enables them to state their treatment preferences whilst capacitous. Despite these established benefits, access to ACP is suboptimal, particularly for people living with mental illness. This population experiences life expectancy 10–20 years shorter than the general population, largely due to high rates of chronic co-morbid physical illnesses [ 6 , 7 ]. People with mental illness face poorer end-of-life outcomes, including undertreated physical symptoms [ 7 , 8 ]. Adverse outcomes may be compounded for older people with mental illness, given the documented disparities in access to healthcare and social support [ 7 ]. Challenges like stigma and poor health service coordination often delay physical care and lead to complex co-morbidities [ 9 ]. Thus, while people with mental illness may have greater need for ACP due to their complex health profiles and shortened life expectancy, they paradoxically have less access to these crucial conversations. While efforts have been made to improve uptake of ACP in specific populations like oncology [ 10 ], people living with mental illness have received relatively less attention despite facing similar or greater barriers to ACP engagement [ 9 ]. A multifaceted demonstration project focused upon ACP with mental health patients, hitherto referred to as consumers, was described over 20 years ago [ 11 ], but there are no subsequent reports about the intervention or its sustainability. Recent efforts to address the gap in ACP for people with mental illness have included exploring perspectives of mental health clinicians [ 12 , 13 ], consumers and carers [ 4 , 14 ], discussion of complex cases [ 15 ], and developing targeted resources [ 16 ]. However, these efforts have not yet been tested in clinical settings. There are several reasons why older people living with serious mental illness infrequently engage in ACP. People living with mental illness and their carers may lack awareness about ACP, reporting clinicians never raised it with them [ 4 ]. Carers [ 4 ] and clinicians [ 13 ] may also be reluctant to engage in ACP with older people living with serious mental illness due to perceived complexity and fear of causing distress. Mental health clinicians report additional barriers including lack of training, systemic issues such as the fragmentation of care between services [ 9 , 13 ], a lack of policies to guide practice, insufficient time for ACP conversations [ 13 ], and uncertainty about decision-making capacity and choosing the timing of ACP discussions [ 13 ]. Clinicians may also be influenced by mentalism (discrimination on the basis of mental illness) in their appraisal of outcomes and aspects of care towards the end-of-life [ 17 ]. Objectives Educational interventions represent one strategy to address these barriers. To date, no published studies examine educational interventions targeting mental health clinician and peer worker engagement in ACP with older people living with serious mental illness. Building on prior qualitative research exploring clinician, consumer and carer perspectives on ACP for older people living with serious mental illness in Australia [ 4 , 13 , 17 ], this study aimed to evaluate the effectiveness of a novel evidence-informed educational intervention on ACP for mental health clinicians and peer workers. Specifically, the aims were to (i) improve clinician and peer worker knowledge, attitudes, and confidence in facilitating ACP discussions with older people living with serious mental illness and (ii) to improve staff engagement in ACP. METHODS Study Design This pre-post intervention study evaluated an evidence-based educational intervention on ACP for mental health clinicians and peer workers working with older people with mental illness. The study employed mixed methods, combining quantitative assessment of knowledge, attitudes, and confidence via questionnaires with objective evaluation of clinical practice change through electronic medical record (eMR) audits. The study was approved by the Concord Hospital Human Research Ethics Committee (2023/ETH02283). Setting This study was conducted across two public Mental Health Services in two government-funded Health Districts in Sydney, Australia: Sydney Local Health District (SLHD) Mental Health Service, and the Eastern Suburbs Older Persons Mental Health Service, South Eastern Sydney Local Health District (SESLHD). SLHD is located in central Sydney, covering a geographical area of 126 km with a population of approximately 740,000 people ( https://slhd.health.nsw.gov.au/organisation ). SESLHD covers an area of 468 km, serving a population of over 930,000 residents in the Eastern suburbs of Sydney ( https://www.seslhd.health.nsw.gov.au/services-clinics/directory/about-us ). Both Mental Health Services provide individualised care coordination through multidisciplinary teams comprising mental health clinicians from diverse professional backgrounds and peer workers, delivering care across both hospital and community settings ( https://slhd.health.nsw.gov.au/mental-health/community ; https://www.seslhd.health.nsw.gov.au/services-clinics/mental-health ). Participants Staff participants: All multidisciplinary mental health clinicians and peer workers employed at the study sites were eligible for inclusion. Staff were recruited through existing multidisciplinary and peer worker in-service/education programs, in a combination of in person only, hybrid, and online only formats. All sessions were facilitated by the lead investigator (AW) and another member of the research team, matched to the learner audience (e.g. nursing co-facilitator for nursing in-services). Clinicians and peer workers were invited to participate in evaluation of the intervention (i.e. questionnaires) at the start of each education session. Consumer eMR audit: The eMR audit included all active (non-discharged) consumers aged 55 years and older receiving services from the study sites. This cohort of consumers were under the care of staff targeted by the intervention and the focus of ACP engagement. The Educational Intervention The content of the educational intervention was directly informed by the research team’s previous studies exploring the barriers and facilitators to ACP with people with mental illness [ 4 , 13 ] and relevant literature [ 9 , 11 , 18 ]. The one-hour structured session (see Supplementary material) consisted of theoretical content, video excerpts demonstrating aspects of conducting ACP conversations with older mental health consumers and carers, and interactive discussion of case vignettes. The educational content and resources were designed specifically for the Australian context, incorporating principles of guardianship and supported decision-making frameworks relevant to Australian jurisdictions [ 5 ]. Tailored one-page summary handouts on ACP for each group (clinicians, carers, consumers) and links to these (including Arabic, Greek and Chinese translations) and other online resources for ACP, including the full training videos, were provided. These resources were previously developed by the research team [ 16 ], informed by the original empirical qualitative studies [ 4 , 13 , 17 ]. Questionnaires A questionnaire was developed to assess clinician/peer worker knowledge, attitudes and confidence regarding ACP with mental health consumers. The pre- and post-intervention versions of the questionnaires included the same domains of attitude (5 items), knowledge (8 items), and confidence (5 items). The pre-intervention questionnaire included demographic questions (age, gender, discipline, work setting, prior relevant experiences). The post-intervention questionnaire included two questions on intention to engage in ACP, and two free-text questions seeking feedback on the intervention; “What did you find most useful from the education session?” and “How could the education session be improved?’. Questionnaires were completed anonymously by participants immediately before and after the educational intervention and paired through a unique code. Electronic Medical Record (eMR) Documentation Audits of ACP documentation on eMR were conducted before the educational intervention sessions and repeated 2–3 months later. Data gathered at the two time points included the presence of an ACP or ACD document, an Enduring Guardian document, documentation of ACP discussions, an active resuscitation document and any ACP on HealtheNet (a State-wide clinical portal), alongside aged care facility residency status, and inpatient status. Statistical Analysis Two-sided p < 0.05 were defined as statistically significant for all analyses. 95% confidence intervals were calculated for mean differences using the t-distribution and for proportions using normal approximation. Questionnaire data: Participant demographics were summarised using means (SD) for continuous variables and frequences (%) for categorical variables. Due to non-normal distributions and ceiling effects identified in preliminary data inspection, non-parametric tests were employed: Domain scores were compared using Wilcoxon Signed-Rank tests with effect sizes calculated using Rosenthal’s r (small: 0.1–0.3, medium: 0.3–0.5, large: >0.5). Individual items used Exact McNemar tests with a Bonferroni correction for multiple comparisons (n = 18). Exploratory analyses used Mann-Whitney U tests to examine whether outcomes differed by delivery mode, age (< 35 or 35+), or prior experience. eMR Documentation: The proportion of mental health consumers aged 55 + with any ACP-related documentation was calculated at both timepoints, pre- and post- the educational intervention, to examine change in staff practice of engaging in and documenting ACP. Change in documentation rates was tested using two-sample z-test for proportions. Qualitative Analysis: Responses to the free-text feedback questions were thematically analysed following Braun and Clarke’s method [ 19 ]. This flexible process identifies, analyses, and reports patterns, or 'themes', within qualitative data that capture important aspects related to the research question. Two independent coders (AW, KC) performed this analysis. RESULTS Participant Characteristics and Response Rates Six education sessions on ACP were conducted across the study sites between April and May 2025, reaching 110 mental health staff (50 online, 60 in-person). The overall response rate for questionnaire completion was 79% (87/110), with marked differences between delivery modes: 100% for in-person participants versus 54% for online participants. Of the 87 respondents, 73 (84%) completed both the pre- and post-intervention questionnaires, enabling paired analysis. After excluding questionnaires with incomplete domain data, the final sample ranged from 66–69 paired questionnaires depending on the specific domain analysed. Demographics for the total sample and the analysed sample are presented in Table 1 . Table 1 Demographics of Staff Participants Characteristic Total Sample (n = 87) Analysed Sample a (n = 73) Age (years) n = 78 n = 65 Mean (SD) 39.2 (12.8) 38.8 (12.6) Gender, n (%) n = 86 n = 73 Female 64 (74.4%) 55 (75.3%) Male 21 (24.4%) 17 (23.3%) Other 1 (1.2%) 1 (1.4%) Discipline, n (%) n = 86 n = 73 Medical 29 (33.7%) 27 (37.0%) Nursing 25 (29.1%) 22 (30.1%) Social Work 14 (16.3%) 8 (11.0%) Peer Support 9 (10.5%) 7 (9.6%) Psychology 7 (8.1%) 7 (9.6%) Occupational Therapy 2 (2.3%) 2 (2.7%) Experience, n (% b ) n = 83 n = 70 Older adult (55+) Mental Health 76 (91.6%) 65 (92.9%) Prior ACP Training 9 (10.8%) 7 (10.0%) Prior ACP Experience 23 (27.7%) 18 (25.7%) a Participants who completed both pre- and post-education questionnaires and were included in at least one analysis b Percentages add to over 100% as participants could choose multiple answers for aspects of prior ACP Experience No significant differences were found when baseline domain scores were compared between participants who completed only the pre-intervention questionnaire (n = 13) versus those with complete paired data (n = 73) across any domain (all p > 0.315). Changes in Domain Scores (Knowledge, Attitudes, and Confidence) The educational intervention resulted in statistically significant improvements across all three domains [Table 2 ]. The largest effect size observed was for confidence (p < 0.001, r = 0.87), indicating substantial improvement in participants’ self-rated ability to engage in ACP discussions. Knowledge also showed a large effect (p < 0.001, r = 0.51), while attitude improvements showed a medium effect (p < 0.001, r = 0.48). Table 2 Pre- and Post- Intervention Scores by Domain Domain (correct response given) Attitude (5 items) (n = 68) Knowledge (8 items) (n = 66) Confidence (5 items) (n = 69) Pre- Mean (SD) 4.25 (0.82) 6.71 (1.22) 1.23 (1.32) Post- Mean (SD) 4.77 (0.46) 7.35 (0.94) 4.32 (1.05) Mean Δ (SD) 0.52 (0.91) 0.64 (1.1) 3.09 (1.32) % Pre- Mean (SD) 85.0% (16.3%) 83.9% (15.3%) 24.6% (26.4%) % Post- Mean (SD) 95.3% (9.2%) 91.9% (11.7%) 86.4% (21.0%) % Mean Δ (SD) 10.3% (18.1%) 8.0% (13.8%) 61.7% (26.3%) Mean Δ 95% CI 0.30, 0.73 0.23, 0.57 2.77, 3.40 5.9%, 14.7% 4.6%, 11.3% 55.4%, 68.1% Test Statistic (Z) 3.989 4.131 7.25 p-value* < 0.001 < 0.001 < 0.001 Effect Size (r) 0.484 (med) 0.509 (large) 0.873 (large) * P-value calculated using WSR test (2-tail) Item Analysis An analysis of individual questions showed large but non-uniform improvements across most items [Tables 3 – 4 ]. Significant increases were seen in two knowledge items [Table 3 ] and all confidence-related items [Table 4 ]. There was significant change in one attitude item [Table 4 ]. For the two intention items there were 68 respondents, with 60 intending to both engage in ACP discussions with mental health consumers and use the handouts, 3 to engage in ACP but not use the handouts, and 5 to use handouts but not engage in ACP. Table 3 Knowledge Items, Pre- Post- Intervention Question Answer [Agree / Disagree] OR Multiple Choice [Correct Answer Bolded] Correct (n) p-value * adjusted p-value ** Pre Post N 6 Next-of-kin can override a consumer's Advance Care Directive (ACD) [ Disagree ] 56 69 < 0.001 0.018 73 7 If a consumer is cognitively impaired, they cannot make an ACP [ Disagree ] 43 60 < 0.001 0.004 70 8 Nominated family members should be involved in ACP discussions with a consumer [ Agree ] 68 71 N/S N/S 73 9 Once written, an ACP cannot be changed [ Disagree ] 71 72 N/S N/S 73 10 If a consumer lacks capacity, supported decision making can be used to facilitate ACP [ Agree ] 68 72 N/S N/S 73 11 A 57-year-old woman with bipolar disorder is involuntarily admitted with a relapse of mania characterised by delusions that she is a medical professor who can cure illness through targeted eye-blinking, delusions of reference when reading books, and disorganised thoughts. During an eMR audit it is noted that she does not have any ACP documentation. Which one of the following is most correct? a. Defer the ACP discussion until her mania has improved b. As she is an involuntary patient it is not appropriate to discuss ACP c. Given her age and absence of physical comorbidities an ACP is not needed d. Discuss and document ACP with the patient now 54 61 N/S N/S 70 12 A 76-year-old man with dementia has been receiving treatment from the community mental health team for depressive symptoms over the last 8 months. He has prostate cancer and is receiving hormone therapy. His wife wants him to make an ACP. Which one of the following is most correct response? a. Let her know this is not possible as he has lost capacity b. Ask her to write an ACP on his behalf c. Recommend waiting until his depressive symptoms have fully resolved d. Engage the man in ACP using supported decision making 59 56 N/S N/S 71 13 A 61-year-old man with longstanding schizophrenia is receiving care and a depot antipsychotic under a community treatment order due to poor adherence to medication and lack of insight. He has chronic psychotic symptoms despite treatment. He has a sedentary lifestyle and smokes but is not known to have any physical comorbidities. He rarely sees his general practitioner. Which one of the following actions is most appropriate for his mental health case manager in relation to ACP? a. No action is required as he does not need an ACP b. Discuss the optimum timing of ACP with the multidisciplinary team c. Request his GP write an ACP d. No action. He cannot be engaged in ACP due to chronic psychosis 63 67 N/S N/S 69 * P-value calculated using exact McNemar’s test (2-tail). N/S = Non-significant. ** Bonferroni adjusted to reflect 18 tests. N/S = Non-significant. Table 4 Attitude and Confidence Items, Pre- Post- Intervention Question Correct Answer [Agree / Disagree] Correct (n) p-value * adjusted p-value ** Pre Post N Attitude 1 ACP is only relevant for people with serious medical illnesses [ Disagree ] 63 70 0.092 N/S 73 2 Discussing ACP with mental health consumers is part of my role [ Agree ] 56 70 < 0.001 0.009 71 3 Discussing ACP with mental health consumers damages the therapeutic relationship [ Disagree ] 69 72 N/S N/S 73 4 It takes too long to do ACP with consumers [ Disagree ] 55 61 N/S N/S 70 5 A person with schizophrenia can make decisions about their end-of-life care [ Agree ] 65 70 N/S N/S 72 Confidence 14 I feel confident initiating ACP discussions with consumers 19 54 < 0.001 < 0.001 69 15 I feel confident involving families/carers in ACP discussions 30 58 < 0.001 < 0.001 71 16 I know where to document ACP discussions on the eMR 19 70 < 0.001 < 0.001 72 17 I know how to determine the optimum timing for ACP 8 56 < 0.001 < 0.001 71 18 I know where to find information on ACP with people with mental illness 9 68 < 0.001 < 0.001 71 * P-value calculated using exact McNemar’s test (2-tail). N/S = Non-significant. ** Bonferroni adjusted to reflect 18 tests. N/S = Non-significant. Exploratory Subgroup Analyses There were no statistically significant differences in score improvement between age groups or modes of participation. Participants with no prior experience or training showed significantly greater improvements in both knowledge (p = 0.042) and confidence (p = 0.017) compared to those with prior experience. Thematic Analysis of Qualitative Feedback Emergent themes from thematic analysis of free-text responses (n = 60 for “most useful”; n = 33 for “improvements”) are presented in Table 5 with illustrative quotations. Overall, the feedback on the educational session was very positive, with remarks such as “ very beneficial ” (female, nursing), “ very informative, got me thinking ” (male, peer support worker), and “ great first introduction for the available time ” (female, psychology). Themes for the most useful aspects of the education were ‘Presentation delivery’; ‘Practical application’; ‘Theoretical content’; and ‘Empowering’. Themes for how the education could be improved were ‘Presentation delivery’; ‘Broader demonstration of clinical practice’; and ‘More resources’. Table 5 Thematic Analysis of Education Session Feedback Core Theme Illustrative Quote Most Useful Aspects of the Education (n = 60) (i) Presentation delivery "Very clear, engaging presenter. Useful handouts. Interesting vignettes." (male, medical) "The content is important and was easy to understand" (female, nursing) “Great to have the discussion” (female, psychology) (ii) Practical Application "The handouts, vignettes and videos were handy to demonstrate process and answer common barriers to completing ACPs" (nonbinary, medical) “Where to document ACP on EMR and ACD.” (male, nursing) (iii) Theoretical content "Differences between ACP and ACD. Capacity assessment in patients with mental illnesses." (female, medical) “Identification of key issues/concerns” (male, nursing) (iv) Empowering “It was helpful to know that this [ACP] is an option to give people a voice in their care.” (female, peer worker) How the Education Could Be Improved (n = 33) (i) Presentation delivery One participant noted the session was too long, while others requested more time. Technical issues like poor sound quality and the presentation starting early were also mentioned. (ii) Broader demonstration of clinical practice "More examples of challenging situations with patients with chronically poor therapeutic relationships." (male, medical) "More examples of phrases to use to start the discussion; how to respond when psychotic symptoms are raised by patient during ACP" (female, psychology) "Further elaboration on capacity assessment. Discussion on resuscitation plan for inpatient and what to do in emergency scenarios." (male, nursing) “Show an example of an ACP/what is documented in EMR” (female, medical) (iii) More resources "Standardised handouts to give to patients > laminated cards to put on lanyards." (female, medical) "Extra session on what to discuss in advanced care planning to help train and build confidence in all clinicians." (female, medical) Change in clinical practice: eMR Documentation Rates The eMRs of all eligible consumers at both study sites were audited for ACP documentation Table 6 . Pre-intervention 84/1104 (7.6%) consumers had some form of ACP-related documentation in their eMR compared to 89/1118 (8.0%) post-intervention. A two-proportion z-test showed no significant difference (p = 0.6643). Table 6 ACP-Related Documentation in Mental Health Consumer eMR Document Type Pre-Intervention N = 1104 | n (%) Post-Intervention N = 1118 | n (%) p-value * Delta % 95% CI ACP / ACD 28 (2.5%) 37 (3.3%) 0.051 0.77% -0.7%, 2.2% Enduring Guardian 18 (1.6%) 13 (1.2%) 0.890 -0.47% -1.5%, 0.5% Discussion Notes 47 (4.3%) 49 (4.4%) 0.419 0.13% -1.6%, 1.8% HealtheNet 2 (0.2%) 3 (0.3%) 0.247 0.09% -0.3%, 0.5% Resuscitation Plan a 7 (0.6%) 6 (0.5%) 0.659 -0.10% -0.7%, 0.5% Any ACP-specific documentation b 66 (6.0%) 73 (6.5%) 0.222 0.55% -1.5%, 2.6% Any ACP-related documentation c 84 (7.6%) 89 (8.0%) 0.332 0.35% -1.9%, 2.6% Setting factors Living in a nursing home 98 110 Current mental health inpatient 68 95 a Resuscitation plan is only documented for inpatients. b Any of ACP, ACD or ACP Discussion Notes. c Any of the above. * p-values calculated using Z-test (1-tail). N.B. The sample sizes are unequal as they reflect the number of active (non-discharged) consumers at each timepoint. DISCUSSION Following the brief intervention, there were significant improvements in mental health staff attitudes, knowledge and confidence regarding ACP with older people living with serious mental illness, with confidence items showing dramatic improvements. These findings, combined with positive endorsement of the intervention, more staff now considering ACP as part of their role, plus intention to engage consumers in ACP, highlight important shifts towards clinical translation and addressing the previous reservations of clinicians [ 13 ]. However, the prevalence of ACP-related documentation in mental health consumer eMRs following the intervention remained stable and low (7.6% to 8.0%), highlighting challenges in translating educational gains into clinical practice. To our knowledge, this is the first evaluation of a dedicated educational intervention for mental health staff on ACP with people with mental illness. Studies evaluating educational interventions on ACP are scarce, with most research addressing general populations or non-mental health settings [ 20 ], largely precluding direct comparison with other mental health contexts. The US-based “Do It Your Way” project provides the most relevant comparison, as it took a multifaceted approach to improving access to ACP in people with mental illness, including education for providers (cross-training, peer initiatives, brochures, and curricula on ACP barriers like capacity) [ 11 ]. Similar to our findings, they reported self-rated improvements in provider knowledge and confidence following education. However, in contrast to our study, they demonstrated increased health care proxy rates post-intervention from a baseline of 0.3%, reaching 1% at the one-year follow-up, 2.2% at two years, and 4.7% at three years. The contrasting outcomes may be explained by their multifaceted approach which included a coalition of stakeholders, community and patient outreach in addition to educating providers, as well as the considerably longer follow-up period of two years [ 11 ]. Another likely contributing factor was a new requirement for the providers to track and report the proxies as part of key performance metrics. The broader literature focusing on ACP with older adults was considered. A systematic review of ACP facilitator training programs for healthcare professionals (not specific to older adults or mental health) found that such programs significantly increased clinicians' knowledge, attitudes towards shared decision-making, perceived communication skills, and confidence in discussing end-of-life issues [ 20 ]. However, consistent with our findings, there was insufficient evidence that these training programs consistently increased the frequency of initiating ACP discussions in clinical practice, often attributed to workload and insufficient time [ 20 ]; barriers also identified by our clinicians [ 13 ]. It is also possible that consumers who were at the younger end of the 55 + age range, who considered themselves well or who did not have major medical comorbidity lacked impetus to engage in ACP [ 21 ], or their clinicians considered ACP not indicated for these reasons, although these explanations did not emerge in our initial qualitative studies [ 4 , 13 ]. A recent study demonstrated that an interactive educational model significantly improved mental health patients' knowledge and attitudes concerning ACP, although not intention to sign an ACD [ 22 ], echoing findings of knowledge-attitude improvements not necessarily translating to behavioural change. Another US-based study evaluated a multi-component intervention targeting primary care physicians and older adults (65+) over 12 months [ 23 ]. Their intensive approach combined interactive, interprofessional ACP education and training (including roleplay) and Practice Support Services Consultants with workflow redesign interventions, such as having front desk staff remind patients that their provider was interested in their care preferences [ 23 ]. The Consultants contacted providers and staff at least monthly with ACP resources and provided coaching every quarter. They achieved a significant increase of 1.4 times the baseline ACP documentation rates and twice the rate of discussions. Ongoing support was likely instrumental in achieving this outcome. However, not all multi-component interventions achieve practice change. A train-the-trainer model was used in nursing homes that incorporated coaching, supportive materials (e.g., conversation guides), multidisciplinary team meetings, and audits [ 24 ]. The intervention resulted in modest improvements in staff self-efficacy but not knowledge, and failed to enhance communication and documentation practices, attributed to implementation challenges and short follow-up periods [ 24 ], similar to our study. These contrasting outcomes suggest while education alone is insufficient, the specific design and implementation of multi-component interventions is crucial for practice change. Limitations Key limitations include the brief 2–3 month follow-up period, which may have been insufficient to capture sustained practice change [ 25 ], as evidenced by studies that successfully demonstrated ACP practice improvements over much longer periods (1–3 years) with ongoing support [ 11 , 23 ]. ACP/ACD documentation, arguably the most important type of eMR documentation, showed a trend toward improvement (p = 0.051) that did not reach statistical significance in the follow-up period. The modest questionnaire sample, although comparable with other pilot studies [ 17 , 26 ], had limited subgroup power, and ceiling effects from high baselines scores further limited the ability to detect true positive effects [ 27 ]. Social desirability bias [ 28 ] may have influenced the results despite mitigation measures such as anonymisation. Reliance upon eMR documentation as the primary outcome measure for practice change presents limitations. We were unable to determine what proportion of documentation was entered by trained mental health staff versus other clinicians. The eMR system itself appears to be an incomplete repository for ACP documents, with significant time lags between document creation and upload, and some ACP discussion documents not containing ACP content. ACP discussions may have occurred but not been documented or may not have been documented in the dedicated ACP tab and so not detected on audit. Staff requests for examples of documentation suggest these issues may have been relevant. Data accessibility is also compromised when ACP documents are not available at the point of care because they are stored elsewhere, e.g., a patient's home, and are not integrated into the medical record [ 29 ]. This is particularly pertinent for people residing in aged care facilities, where a resident’s ACP/ACD is usually completed as it is a care standard [ 30 ], but is not routinely shared with hospital eMR systems as we have demonstrated [Table 6 ]. This fragmentation was further highlighted by the lack of integration between the local eMR and the national My Health Record system, as no consumer had documents in both systems simultaneously. Implications for Clinical Practice This study was conducted with frontline mental health staff working in clinical settings. It was pragmatic, and therefore subject to real world conditions including competing demands for staff time and the logistics of delivering condensed education in hybrid formats within existing programs. The resources and educational intervention could readily be adapted for other contexts and legal frameworks, and are thus transferable to diverse healthcare settings. Integrating qualitative feedback, questionnaire scores, and eMR data revealed the intervention's potential to empower staff to engage consumers in ACP but also reveals specific areas needing attention. Participants endorsed practical elements (e.g., clinical vignettes, discussion) and theoretical clarifications (e.g., ACP vs. ACD), likely driving confidence gains. However, the emergent themes of ‘Broader demonstration of clinical practice’ and ‘More resources’, highlighted a need for more practical and ongoing training, with suggestions of sample questions or a framework for ACP discussions, further education sessions, including role-play, and creating quick reference cards (lanyards). These identified needs align with staff having poorer performance on clinical vignette questions, which require the application of theoretical knowledge to the nuances of clinical practice. Clinicians in the foundation study similarly identified lack of access to practical training in ACP as a barrier to implementation [ 13 ]. The qualitative feedback also suggests a need for more clinical examples of how and where to document ACP discussions. Future interventions should consider more intensive approaches. Sævareid et al. (2019) improved aged care facility resident participation in ACP through a train-the-trainer model involving two days of education seminars with role-play, quick reference guides, ongoing supervision, and follow-up [ 31 ], contrasting with our single session format. Follow-up sessions– to reinforce application and retention of theoretical concepts and practice engaging in ACP– may improve the impact of the intervention in terms of sustained knowledge gains and behavioural change, as suggested by approaches to delirium education [ 32 , 33 ]. Future interventions should also consider integrated tools and educational resources to bridge the gaps between improved confidence and practice change identified in our study. Digital decision support tools, such as video-based resources tailored for people with mental illness, could enhance understanding of complex ACP concepts, as demonstrated by Volandes et al. (2009) who found that video decision support tools improved knowledge and led to more stable treatment preferences compared to verbal descriptions alone [ 34 ]. Additionally, our qualitative feedback suggested enhanced training on decision-making capacity could help clinicians navigate the unique challenges of conducting ACP discussions with consumers experiencing ongoing symptoms of mental illness. A broad and multifaceted approach to education is recognised as more likely to be effective in changing practice, including strategies such as targeted peer-led education, small group or individual case-based discussions, audit and feedback, reminder systems and organisational change [ 32 ]. Change champions embedded within healthcare settings may complement educational interventions [ 35 , 36 ]. The potential value of change champions in mental health settings was demonstrated using "COSMOS ambassadors" within a comprehensive multimodal intervention comprising a 2-day education seminar (including role-play, and provision of training materials and flashcards), repeated teaching, a train-the-trainer model and ongoing telephone support in their ACP intervention [ 37 ]. Other studies in mental health settings have shown champions motivate behaviour change by modelling supportive attitudes [ 36 ] and clinical skills/techniques [ 36 ], the latter crucial in ACP given complexity of navigating family concerns and cultural considerations [ 4 ], capacity and ongoing symptoms of mental illness [ 13 ], and emphasised by participants in this study. Ensuring the effects of the intervention are sustained is relevant to evaluating cost-effectiveness and overall benefit [ 33 ]. Repeating educational interventions can lead to more sustained effects, likely due to repeated exposure [ 32 , 33 , 38 ], and was suggested by our participants. CONCLUSION This novel evidence-informed intervention significantly enhanced ACP readiness among mental health clinicians and peer workers, improving knowledge, attitudes and confidence and addressing a critical research gap. However, persistently low baseline and post-intervention eMR ACP documentation rates suggest more strategies are needed to change clinical practice. Clinician and peer worker feedback provided valuable insights into what additional training is needed to promote engagement in ACP with consumers and carers and its documentation, guiding refinement of this intervention. The next steps are to revise the education session itself to emphasise aspects of application to clinical practice, schedule follow-up sessions focused on practical training and explore ways of integrating ACP into clinical practice, including through change champions [ 37 ] and embedding ACP in governance processes (e.g. team business meetings, audits and regular feedback) to reinforce practice and sustain implementation [ 33 ]. A multipronged approach should also broaden the scope of training beyond clinicians to include consumers and carers, and be tested on larger sample sizes across geographically diverse mental health services over an extended follow-up period to evaluate change in practice and sustainability. These are crucial first steps to addressing the disparity in actualising autonomy of decision making and quality care towards the end of life for older people with mental illness. Declarations Ethics Approval The study was approved by the Concord Hospital Human Research Ethics Committee (2023/ETH02283). Author Contributions Conception and study design – AW, MT, DK, ST, KA; Acquisition of data and analysis – KC, AW; Interpretation of data – all authors; Writing original draft – KC, AW; Writing review and editing – all authors. Data Availability The deidentified data supporting the findings of this study may be available from Keanu Crous upon reasonable request if approved by the Concord Hospital Human Research Ethics Committee. Acknowledgments This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. However, there was financial support for the foundational qualitative studies and subsequently developed education and training resources referred to in the paper. Those studies were supported by a philanthropic grant, the Moyira Elizabeth Vine Fund for Research in Schizophrenia, awarded to Anne Wand. The sponsors had no involvement in any aspect of the study or the decision to submit the article for publication. Competing Interests The authors have no relevant financial or non-financial interests to disclose. References Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. Journal of Pain and Symptom Management 2017;53:821-832.e1. https://doi.org/10.1016/j.jpainsymman.2016.12.331. Brinkman-Stoppelenburg A, Rietjens JA, Van Der Heide A. The effects of advance care planning on end-of-life care: A systematic review. Palliat Med 2014;28:1000–25. https://doi.org/10.1177/0269216314526272. Blomberg BA, Quintana C, Hua J, Hargis-Fuller L, Laux J, Drickamer MA. 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Encyclopedia of Quality of Life and Well-Being Research, Dordrecht: Springer Netherlands; 2014, p. 631–3. https://doi.org/10.1007/978-94-007-0753-5_296. Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant 2013;47:2025–47. https://doi.org/10.1007/s11135-011-9640-9. Sands MB, Varndell W, Speir L, Rhodes H, Shield M. P30 Acute Care, Ambulance, Emergency Departments and Advance Care Plans; - In the sock drawer* or at the point of care?, Manly Beach, Sydney, Australia: 2018. Australian Government Department of Health and Aged Care. Revised Aged Care Quality Standards: Draft for Pilot. Canberra, ACT: Department of Health and Aged Care; 2023. Sævareid TJL, Thoresen L, Gjerberg E, Lillemoen L, Pedersen R. Improved patient participation through advance care planning in nursing homes—A cluster randomized clinical trial. Patient Education and Counseling 2019;102:2183–91. https://doi.org/10.1016/j.pec.2019.06.001. Wand APF. Evaluating the effectiveness of educational interventions to prevent delirium. Australas J Ageing 2011;30:175–85. https://doi.org/10.1111/j.1741-6612.2010.00502.x. Lee SY, Fisher J, Wand APF, Milisen K, Detroyer E, Sockalingam S, et al. Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings. Eur Geriatr Med 2020;11:1–32. https://doi.org/10.1007/s41999-019-00278-x. Volandes AE, Paasche-Orlow MK, Barry MJ, Gillick MR, Minaker KL, Chang Y, et al. Video decision support tool for advance care planning in dementia: randomised controlled trial. BMJ 2009;338:b2159–b2159. https://doi.org/10.1136/bmj.b2159. Santos WJ, Graham ID, Lalonde M, Demery Varin M, Squires JE. The effectiveness of champions in implementing innovations in health care: a systematic review. Implement Sci Commun 2022;3. https://doi.org/10.1186/s43058-022-00315-0. Morena AL, Gaias LM, Larkin C. Understanding the Role of Clinical Champions and Their Impact on Clinician Behavior Change: The Need for Causal Pathway Mechanisms. Front Health Serv 2022;2:896885. https://doi.org/10.3389/frhs.2022.896885. Aasmul I, Husebo BS, Flo E. Description of an advance care planning intervention in nursing homes: outcomes of the process evaluation. BMC Geriatr 2018;18:26. https://doi.org/10.1186/s12877-018-0713-7. Cervero RM, Gaines JK. The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews. Journal of Continuing Education in the Health Professions 2015;35:131–8. https://doi.org/10.1002/chp.21290. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Minor revisions 19 Nov, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers invited by journal 15 Oct, 2025 Editor invited by journal 15 Oct, 2025 Editor assigned by journal 13 Oct, 2025 First submitted to journal 12 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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points","content":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To evaluate whether a brief educational intervention on Advance Care Planning improves mental health staff attitudes, knowledge, and confidence, and increases their engagement in Advance Care Planning with older patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e: A brief educational intervention on ACP improved staff attitudes, knowledge and confidence and was well received, but did not result in significant change in rates of medical record documented engagement in ACP with patients over a 2-3 month follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMessage\u003c/strong\u003e: A brief educational intervention for mental health staff improves their readiness to engage consumers in ACP, but may require additional strategies such as organisational change, skills practice, audit and feedback to effect behavioural change.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eAdvance care planning (ACP), a process that supports adults in understanding and sharing their personal values, life goals, and preferences for future medical care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], facilitates optimised end-of-life care. The goal of ACP is to ensure individuals receive medical care consistent with their values and goals at a time when they may not be able to express their preferences, such as when critically ill [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Thus, engagement in ACP has been considered a human right. Effective ACP is associated with improved patient and family satisfaction, increased use of hospice and palliative care, and a higher likelihood of receiving goal-concordant care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For patients and their families, it can reduce the emotional burden of end-of-life decision-making while extending a patient's autonomy, even after they have lost decision-making capacity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the Australian context, guardianship laws vary by state and territory, with each jurisdiction maintaining separate legislative frameworks for substitute decision-making arrangements. Decision-making models, including substitute decision-making and supported decision-making, vary internationally and across jurisdictions, though Australia has increasingly emphasised supported decision-making approaches that prioritise an individual’s will and preferences [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is particularly important for people with serious mental illness, as ACP enables them to state their treatment preferences whilst capacitous.\u003c/p\u003e\u003cp\u003eDespite these established benefits, access to ACP is suboptimal, particularly for people living with mental illness. This population experiences life expectancy 10–20 years shorter than the general population, largely due to high rates of chronic co-morbid physical illnesses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. People with mental illness face poorer end-of-life outcomes, including undertreated physical symptoms [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Adverse outcomes may be compounded for older people with mental illness, given the documented disparities in access to healthcare and social support [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Challenges like stigma and poor health service coordination often delay physical care and lead to complex co-morbidities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Thus, while people with mental illness may have greater need for ACP due to their complex health profiles and shortened life expectancy, they paradoxically have less access to these crucial conversations.\u003c/p\u003e\u003cp\u003eWhile efforts have been made to improve uptake of ACP in specific populations like oncology [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], people living with mental illness have received relatively less attention despite facing similar or greater barriers to ACP engagement [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A multifaceted demonstration project focused upon ACP with mental health patients, hitherto referred to as consumers, was described over 20 years ago [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], but there are no subsequent reports about the intervention or its sustainability. Recent efforts to address the gap in ACP for people with mental illness have included exploring perspectives of mental health clinicians [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], consumers and carers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], discussion of complex cases [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and developing targeted resources [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, these efforts have not yet been tested in clinical settings.\u003c/p\u003e\u003cp\u003eThere are several reasons why older people living with serious mental illness infrequently engage in ACP. People living with mental illness and their carers may lack awareness about ACP, reporting clinicians never raised it with them [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Carers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and clinicians [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] may also be reluctant to engage in ACP with older people living with serious mental illness due to perceived complexity and fear of causing distress. Mental health clinicians report additional barriers including lack of training, systemic issues such as the fragmentation of care between services [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], a lack of policies to guide practice, insufficient time for ACP conversations [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and uncertainty about decision-making capacity and choosing the timing of ACP discussions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Clinicians may also be influenced by mentalism (discrimination on the basis of mental illness) in their appraisal of outcomes and aspects of care towards the end-of-life [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eEducational interventions represent one strategy to address these barriers. To date, no published studies examine educational interventions targeting mental health clinician and peer worker engagement in ACP with older people living with serious mental illness. Building on prior qualitative research exploring clinician, consumer and carer perspectives on ACP for older people living with serious mental illness in Australia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], this study aimed to evaluate the effectiveness of a novel evidence-informed educational intervention on ACP for mental health clinicians and peer workers. Specifically, the aims were to (i) improve clinician and peer worker knowledge, attitudes, and confidence in facilitating ACP discussions with older people living with serious mental illness and (ii) to improve staff engagement in ACP.\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis pre-post intervention study evaluated an evidence-based educational intervention on ACP for mental health clinicians and peer workers working with older people with mental illness. The study employed mixed methods, combining quantitative assessment of knowledge, attitudes, and confidence via questionnaires with objective evaluation of clinical practice change through electronic medical record (eMR) audits. The study was approved by the Concord Hospital Human Research Ethics Committee (2023/ETH02283).\u003c/p\u003e\u003ch3\u003eSetting\u003c/h3\u003e\u003cp\u003eThis study was conducted across two public Mental Health Services in two government-funded Health Districts in Sydney, Australia: Sydney Local Health District (SLHD) Mental Health Service, and the Eastern Suburbs Older Persons Mental Health Service, South Eastern Sydney Local Health District (SESLHD). SLHD is located in central Sydney, covering a geographical area of 126 km with a population of approximately 740,000 people (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://slhd.health.nsw.gov.au/organisation\u003c/span\u003e\u003cspan address=\"https://slhd.health.nsw.gov.au/organisation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). SESLHD covers an area of 468 km, serving a population of over 930,000 residents in the Eastern suburbs of Sydney (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.seslhd.health.nsw.gov.au/services-clinics/directory/about-us\u003c/span\u003e\u003cspan address=\"https://www.seslhd.health.nsw.gov.au/services-clinics/directory/about-us\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Both Mental Health Services provide individualised care coordination through multidisciplinary teams comprising mental health clinicians from diverse professional backgrounds and peer workers, delivering care across both hospital and community settings (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://slhd.health.nsw.gov.au/mental-health/community\u003c/span\u003e\u003cspan address=\"https://slhd.health.nsw.gov.au/mental-health/community\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.seslhd.health.nsw.gov.au/services-clinics/mental-health\u003c/span\u003e\u003cspan address=\"https://www.seslhd.health.nsw.gov.au/services-clinics/mental-health\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eParticipants\u003c/h3\u003e\u003cp\u003eStaff participants: All multidisciplinary mental health clinicians and peer workers employed at the study sites were eligible for inclusion. Staff were recruited through existing multidisciplinary and peer worker in-service/education programs, in a combination of in person only, hybrid, and online only formats. All sessions were facilitated by the lead investigator (AW) and another member of the research team, matched to the learner audience (e.g. nursing co-facilitator for nursing in-services). Clinicians and peer workers were invited to participate in evaluation of the intervention (i.e. questionnaires) at the start of each education session.\u003c/p\u003e\u003cp\u003eConsumer eMR audit: The eMR audit included all active (non-discharged) consumers aged 55 years and older receiving services from the study sites. This cohort of consumers were under the care of staff targeted by the intervention and the focus of ACP engagement.\u003c/p\u003e\u003ch3\u003eThe Educational Intervention\u003c/h3\u003e\u003cp\u003eThe content of the educational intervention was directly informed by the research team’s previous studies exploring the barriers and facilitators to ACP with people with mental illness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and relevant literature [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The one-hour structured session (see Supplementary material) consisted of theoretical content, video excerpts demonstrating aspects of conducting ACP conversations with older mental health consumers and carers, and interactive discussion of case vignettes. The educational content and resources were designed specifically for the Australian context, incorporating principles of guardianship and supported decision-making frameworks relevant to Australian jurisdictions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTailored one-page summary handouts on ACP for each group (clinicians, carers, consumers) and links to these (including Arabic, Greek and Chinese translations) and other online resources for ACP, including the full training videos, were provided. These resources were previously developed by the research team [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], informed by the original empirical qualitative studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eQuestionnaires\u003c/h2\u003e\u003cp\u003eA questionnaire was developed to assess clinician/peer worker knowledge, attitudes and confidence regarding ACP with mental health consumers. The pre- and post-intervention versions of the questionnaires included the same domains of attitude (5 items), knowledge (8 items), and confidence (5 items). The pre-intervention questionnaire included demographic questions (age, gender, discipline, work setting, prior relevant experiences). The post-intervention questionnaire included two questions on intention to engage in ACP, and two free-text questions seeking feedback on the intervention; “What did you find most useful from the education session?” and “How could the education session be improved?’.\u003c/p\u003e\u003cp\u003eQuestionnaires were completed anonymously by participants immediately before and after the educational intervention and paired through a unique code.\u003c/p\u003e\u003ch3\u003eElectronic Medical Record (eMR) Documentation\u003c/h3\u003e\u003cp\u003eAudits of ACP documentation on eMR were conducted before the educational intervention sessions and repeated 2–3 months later. Data gathered at the two time points included the presence of an ACP or ACD document, an Enduring Guardian document, documentation of ACP discussions, an active resuscitation document and any ACP on HealtheNet (a State-wide clinical portal), alongside aged care facility residency status, and inpatient status.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eTwo-sided p \u0026lt; 0.05 were defined as statistically significant for all analyses. 95% confidence intervals were calculated for mean differences using the t-distribution and for proportions using normal approximation.\u003c/p\u003e\u003col style=\"list-style-type: lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eQuestionnaire data: Participant demographics were summarised using means (SD) for continuous variables and frequences (%) for categorical variables. Due to non-normal distributions and ceiling effects identified in preliminary data inspection, non-parametric tests were employed: Domain scores were compared using Wilcoxon Signed-Rank tests with effect sizes calculated using Rosenthal’s r (small: 0.1–0.3, medium: 0.3–0.5, large: \u0026gt;0.5). Individual items used Exact McNemar tests with a Bonferroni correction for multiple comparisons (n = 18). Exploratory analyses used Mann-Whitney U tests to examine whether outcomes differed by delivery mode, age (\u0026lt; 35 or 35+), or prior experience.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eeMR Documentation: The proportion of mental health consumers aged 55 + with any ACP-related documentation was calculated at both timepoints, pre- and post- the educational intervention, to examine change in staff practice of engaging in and documenting ACP. Change in documentation rates was tested using two-sample z-test for proportions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eQualitative Analysis: Responses to the free-text feedback questions were thematically analysed following Braun and Clarke’s method [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This flexible process identifies, analyses, and reports patterns, or 'themes', within qualitative data that capture important aspects related to the research question. Two independent coders (AW, KC) performed this analysis.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eParticipant Characteristics and Response Rates\u003c/h2\u003e\u003cp\u003eSix education sessions on ACP were conducted across the study sites between April and May 2025, reaching 110 mental health staff (50 online, 60 in-person). The overall response rate for questionnaire completion was 79% (87/110), with marked differences between delivery modes: 100% for in-person participants versus 54% for online participants.\u003c/p\u003e\u003cp\u003eOf the 87 respondents, 73 (84%) completed both the pre- and post-intervention questionnaires, enabling paired analysis. After excluding questionnaires with incomplete domain data, the final sample ranged from 66\u0026ndash;69 paired questionnaires depending on the specific domain analysed. Demographics for the total sample and the analysed sample are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of Staff Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTotal Sample \u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eAnalysed Sample\u003csup\u003ea\u003c/sup\u003e \u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;78\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;65\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(12.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;86\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;73\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(74.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(75.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(24.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(23.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(1.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(1.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiscipline, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;86\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;73\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(33.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(37.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(29.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(30.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(16.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(11.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeer Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(10.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(9.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(8.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(9.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupational Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(2.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(2.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExperience, n (%\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;83\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;70\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOlder adult (55+) Mental Health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(91.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(92.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior ACP Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(10.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(10.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior ACP Experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(27.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(25.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Participants who completed both pre- and post-education questionnaires and were included in at least one analysis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Percentages add to over 100% as participants could choose multiple answers for aspects of prior ACP Experience\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNo significant differences were found when baseline domain scores were compared between participants who completed only the pre-intervention questionnaire (n\u0026thinsp;=\u0026thinsp;13) versus those with complete paired data (n\u0026thinsp;=\u0026thinsp;73) across any domain (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.315).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eChanges in Domain Scores (Knowledge, Attitudes, and Confidence)\u003c/h2\u003e\u003cp\u003eThe educational intervention resulted in statistically significant improvements across all three domains [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]. The largest effect size observed was for confidence (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;0.87), indicating substantial improvement in participants\u0026rsquo; self-rated ability to engage in ACP discussions. Knowledge also showed a large effect (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;0.51), while attitude improvements showed a medium effect (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;0.48).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePre- and Post- Intervention Scores by Domain\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain (correct response given)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003cp\u003e(5 items)\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003cp\u003e(8 items)\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConfidence\u003c/p\u003e\u003cp\u003e(5 items)\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePre- Mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.25 (0.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.71 (1.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.23 (1.32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePost- Mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.77 (0.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.35 (0.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.32 (1.05)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean Δ (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.52 (0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.64 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.09 (1.32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e% Pre- Mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85.0% (16.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.9% (15.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.6% (26.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e% Post- Mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95.3% (9.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.9% (11.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.4% (21.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e% Mean Δ (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.3% (18.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.0% (13.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.7% (26.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eMean Δ 95% CI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.30, 0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.23, 0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.77, 3.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.9%, 14.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.6%, 11.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55.4%, 68.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTest Statistic (Z)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.989\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ep-value*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEffect Size (r)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.484 (med)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.509 (large)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.873 (large)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e* P-value calculated using WSR test (2-tail)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eItem Analysis\u003c/h2\u003e\u003cp\u003eAn analysis of individual questions showed large but non-uniform improvements across most items [Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]. Significant increases were seen in two knowledge items [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e] and all confidence-related items [Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]. There was significant change in one attitude item [Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]. For the two intention items there were 68 respondents, with 60 intending to both engage in ACP discussions with mental health consumers and use the handouts, 3 to engage in ACP but not use the handouts, and 5 to use handouts but not engage in ACP.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKnowledge Items, Pre- Post- Intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAnswer [Agree / Disagree] \u003c/p\u003e\u003cp\u003e OR \u003c/p\u003e\u003cp\u003eMultiple Choice [Correct Answer Bolded]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCorrect (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value *\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eadjusted p-value **\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNext-of-kin can override a consumer's Advance Care Directive (ACD) [\u003cb\u003eDisagree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf a consumer is cognitively impaired, they cannot make an ACP [\u003cb\u003eDisagree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNominated family members should be involved in ACP discussions with a consumer [\u003cb\u003eAgree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOnce written, an ACP cannot be changed [\u003cb\u003eDisagree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf a consumer lacks capacity, supported decision making can be used to facilitate ACP [\u003cb\u003eAgree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eA 57-year-old woman with bipolar disorder is involuntarily admitted with a relapse of mania characterised by delusions that she is a medical professor who can cure illness through targeted eye-blinking, delusions of reference when reading books, and disorganised thoughts. During an eMR audit it is noted that she does not have any ACP documentation. Which one of the following is most correct?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ea. Defer the ACP discussion until her mania has improved\u003c/b\u003e\u003c/p\u003e\u003cp\u003eb. As she is an involuntary patient it is not appropriate to discuss ACP\u003c/p\u003e\u003cp\u003ec. Given her age and absence of physical comorbidities an ACP is not needed\u003c/p\u003e\u003cp\u003ed. Discuss and document ACP with the patient now\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eA 76-year-old man with dementia has been receiving treatment from the community mental health team for depressive symptoms over the last 8 months. He has prostate cancer and is receiving hormone therapy. His wife wants him to make an ACP. Which one of the following is most correct response?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea. Let her know this is not possible as he has lost capacity\u003c/p\u003e\u003cp\u003eb. Ask her to write an ACP on his behalf\u003c/p\u003e\u003cp\u003ec. Recommend waiting until his depressive symptoms have fully resolved\u003c/p\u003e\u003cp\u003e\u003cb\u003ed. Engage the man in ACP using supported decision making\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eA 61-year-old man with longstanding schizophrenia is receiving care and a depot antipsychotic under a community treatment order due to poor adherence to medication and lack of insight. He has chronic psychotic symptoms despite treatment. He has a sedentary lifestyle and smokes but is not known to have any physical comorbidities. He rarely sees his general practitioner. Which one of the following actions is most appropriate for his mental health case manager in relation to ACP?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea. No action is required as he does not need an ACP\u003c/p\u003e\u003cp\u003e\u003cb\u003eb. Discuss the optimum timing of ACP with the multidisciplinary team\u003c/b\u003e\u003c/p\u003e\u003cp\u003ec. Request his GP write an ACP\u003c/p\u003e\u003cp\u003ed. No action. He cannot be engaged in ACP due to chronic psychosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e* P-value calculated using exact McNemar\u0026rsquo;s test (2-tail). N/S\u0026thinsp;=\u0026thinsp;Non-significant.\u003c/p\u003e\u003cp\u003e** Bonferroni adjusted to reflect 18 tests. N/S\u0026thinsp;=\u0026thinsp;Non-significant.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAttitude and Confidence Items, Pre- Post- Intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCorrect Answer [Agree / Disagree]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCorrect (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value *\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eadjusted p-value **\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eACP is only relevant for people with serious medical illnesses [\u003cb\u003eDisagree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.092\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiscussing ACP with mental health consumers is part of my role [\u003cb\u003eAgree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiscussing ACP with mental health consumers damages the therapeutic relationship [\u003cb\u003eDisagree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIt takes too long to do ACP with consumers [\u003cb\u003eDisagree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA person with schizophrenia can make decisions about their end-of-life care [\u003cb\u003eAgree\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConfidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI feel confident initiating ACP discussions with consumers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI feel confident involving families/carers in ACP discussions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI know where to document ACP discussions on the eMR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI know how to determine the optimum timing for ACP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI know where to find information on ACP with people with mental illness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e* P-value calculated using exact McNemar\u0026rsquo;s test (2-tail). N/S\u0026thinsp;=\u0026thinsp;Non-significant.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e** Bonferroni adjusted to reflect 18 tests. N/S\u0026thinsp;=\u0026thinsp;Non-significant.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eExploratory Subgroup Analyses\u003c/h2\u003e\u003cp\u003eThere were no statistically significant differences in score improvement between age groups or modes of participation. Participants with no prior experience or training showed significantly greater improvements in both knowledge (p\u0026thinsp;=\u0026thinsp;0.042) and confidence (p\u0026thinsp;=\u0026thinsp;0.017) compared to those with prior experience.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eThematic Analysis of Qualitative Feedback\u003c/h2\u003e\u003cp\u003eEmergent themes from thematic analysis of free-text responses (n\u0026thinsp;=\u0026thinsp;60 for \u0026ldquo;most useful\u0026rdquo;; n\u0026thinsp;=\u0026thinsp;33 for \u0026ldquo;improvements\u0026rdquo;) are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e with illustrative quotations. Overall, the feedback on the educational session was very positive, with remarks such as \u0026ldquo;\u003cem\u003every beneficial\u003c/em\u003e\u0026rdquo; (female, nursing), \u0026ldquo;\u003cem\u003every informative, got me thinking\u003c/em\u003e\u0026rdquo; (male, peer support worker), and \u0026ldquo;\u003cem\u003egreat first introduction for the available time\u003c/em\u003e\u0026rdquo; (female, psychology). Themes for the most useful aspects of the education were \u0026lsquo;Presentation delivery\u0026rsquo;; \u0026lsquo;Practical application\u0026rsquo;; \u0026lsquo;Theoretical content\u0026rsquo;; and \u0026lsquo;Empowering\u0026rsquo;. Themes for how the education could be improved were \u0026lsquo;Presentation delivery\u0026rsquo;; \u0026lsquo;Broader demonstration of clinical practice\u0026rsquo;; and \u0026lsquo;More resources\u0026rsquo;.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThematic Analysis of Education Session Feedback\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCore Theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIllustrative Quote\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMost Useful Aspects of the Education (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e(i) Presentation delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"Very clear, engaging presenter. Useful handouts. Interesting vignettes.\" (male, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"The content is important and was easy to understand\" (female, nursing)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Great to have the discussion\u0026rdquo; (female, psychology)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e(ii) Practical Application\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"The handouts, vignettes and videos were handy to demonstrate process and answer common barriers to completing ACPs\" (nonbinary, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Where to document ACP on EMR and ACD.\u0026rdquo; (male, nursing)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e(iii) Theoretical content\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"Differences between ACP and ACD. Capacity assessment in patients with mental illnesses.\" (female, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Identification of key issues/concerns\u0026rdquo; (male, nursing)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(iv) Empowering\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;It was helpful to know that this [ACP] is an option to give people a voice in their care.\u0026rdquo; (female, peer worker)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHow the Education Could Be Improved (n\u0026thinsp;=\u0026thinsp;33)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(i) Presentation delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne participant noted the session was too long, while others requested more time. Technical issues like poor sound quality and the presentation starting early were also mentioned.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e(ii) Broader demonstration of clinical practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"More examples of challenging situations with patients with chronically poor therapeutic relationships.\" (male, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"More examples of phrases to use to start the discussion; how to respond when psychotic symptoms are raised by patient during ACP\" (female, psychology)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"Further elaboration on capacity assessment. Discussion on resuscitation plan for inpatient and what to do in emergency scenarios.\" (male, nursing)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Show an example of an ACP/what is documented in EMR\u0026rdquo; (female, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e(iii) More resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"Standardised handouts to give to patients\u0026thinsp;\u0026gt;\u0026thinsp;laminated cards to put on lanyards.\" (female, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\"Extra session on what to discuss in advanced care planning to help train and build confidence in all clinicians.\" (female, medical)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eChange in clinical practice: eMR Documentation Rates\u003c/h2\u003e\u003cp\u003eThe eMRs of all eligible consumers at both study sites were audited for ACP documentation Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Pre-intervention 84/1104 (7.6%) consumers had some form of ACP-related documentation in their eMR compared to 89/1118 (8.0%) post-intervention. A two-proportion z-test showed no significant difference (p\u0026thinsp;=\u0026thinsp;0.6643).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eACP-Related Documentation in Mental Health Consumer eMR\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDocument Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;1104 | n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;1118 | n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDelta %\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACP / ACD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (3.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.77%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.7%, 2.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnduring Guardian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (1.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.890\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.47%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-1.5%, 0.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiscussion Notes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (4.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.419\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.13%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-1.6%, 1.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealtheNet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.09%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.3%, 0.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResuscitation Plan\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.659\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.7%, 0.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny ACP-specific documentation\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66 (6.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73 (6.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.55%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-1.5%, 2.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny ACP-related documentation\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84 (7.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89 (8.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.35%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-1.9%, 2.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSetting factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving in a nursing home\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent mental health inpatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Resuscitation plan is only documented for inpatients.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Any of ACP, ACD or ACP Discussion Notes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003ec\u003c/sup\u003e Any of the above.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e p-values calculated using Z-test (1-tail).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eN.B. The sample sizes are unequal as they reflect the number of active (non-discharged) consumers at each timepoint.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFollowing the brief intervention, there were significant improvements in mental health staff attitudes, knowledge and confidence regarding ACP with older people living with serious mental illness, with confidence items showing dramatic improvements. These findings, combined with positive endorsement of the intervention, more staff now considering ACP as part of their role, plus intention to engage consumers in ACP, highlight important shifts towards clinical translation and addressing the previous reservations of clinicians [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the prevalence of ACP-related documentation in mental health consumer eMRs following the intervention remained stable and low (7.6% to 8.0%), highlighting challenges in translating educational gains into clinical practice.\u003c/p\u003e\u003cp\u003eTo our knowledge, this is the first evaluation of a dedicated educational intervention for mental health staff on ACP with people with mental illness. Studies evaluating educational interventions on ACP are scarce, with most research addressing general populations or non-mental health settings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], largely precluding direct comparison with other mental health contexts. The US-based \u0026ldquo;Do It Your Way\u0026rdquo; project provides the most relevant comparison, as it took a multifaceted approach to improving access to ACP in people with mental illness, including education for providers (cross-training, peer initiatives, brochures, and curricula on ACP barriers like capacity) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Similar to our findings, they reported self-rated improvements in provider knowledge and confidence following education. However, in contrast to our study, they demonstrated increased health care proxy rates post-intervention from a baseline of 0.3%, reaching 1% at the one-year follow-up, 2.2% at two years, and 4.7% at three years. The contrasting outcomes may be explained by their multifaceted approach which included a coalition of stakeholders, community and patient outreach in addition to educating providers, as well as the considerably longer follow-up period of two years [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Another likely contributing factor was a new requirement for the providers to track and report the proxies as part of key performance metrics.\u003c/p\u003e\u003cp\u003eThe broader literature focusing on ACP with older adults was considered. A systematic review of ACP facilitator training programs for healthcare professionals (not specific to older adults or mental health) found that such programs significantly increased clinicians' knowledge, attitudes towards shared decision-making, perceived communication skills, and confidence in discussing end-of-life issues [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, consistent with our findings, there was insufficient evidence that these training programs consistently increased the frequency of initiating ACP discussions in clinical practice, often attributed to workload and insufficient time [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]; barriers also identified by our clinicians [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is also possible that consumers who were at the younger end of the 55\u0026thinsp;+\u0026thinsp;age range, who considered themselves well or who did not have major medical comorbidity lacked impetus to engage in ACP [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], or their clinicians considered ACP not indicated for these reasons, although these explanations did not emerge in our initial qualitative studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A recent study demonstrated that an interactive educational model significantly improved mental health patients' knowledge and attitudes concerning ACP, although not intention to sign an ACD [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], echoing findings of knowledge-attitude improvements not necessarily translating to behavioural change.\u003c/p\u003e\u003cp\u003eAnother US-based study evaluated a multi-component intervention targeting primary care physicians and older adults (65+) over 12 months [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Their intensive approach combined interactive, interprofessional ACP education and training (including roleplay) and Practice Support Services Consultants with workflow redesign interventions, such as having front desk staff remind patients that their provider was interested in their care preferences [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The Consultants contacted providers and staff at least monthly with ACP resources and provided coaching every quarter. They achieved a significant increase of 1.4 times the baseline ACP documentation rates and twice the rate of discussions. Ongoing support was likely instrumental in achieving this outcome. However, not all multi-component interventions achieve practice change. A train-the-trainer model was used in nursing homes that incorporated coaching, supportive materials (e.g., conversation guides), multidisciplinary team meetings, and audits [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The intervention resulted in modest improvements in staff self-efficacy but not knowledge, and failed to enhance communication and documentation practices, attributed to implementation challenges and short follow-up periods [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], similar to our study. These contrasting outcomes suggest while education alone is insufficient, the specific design and implementation of multi-component interventions is crucial for practice change.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eKey limitations include the brief 2\u0026ndash;3 month follow-up period, which may have been insufficient to capture sustained practice change [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], as evidenced by studies that successfully demonstrated ACP practice improvements over much longer periods (1\u0026ndash;3 years) with ongoing support [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. ACP/ACD documentation, arguably the most important type of eMR documentation, showed a trend toward improvement (p\u0026thinsp;=\u0026thinsp;0.051) that did not reach statistical significance in the follow-up period.\u003c/p\u003e\u003cp\u003eThe modest questionnaire sample, although comparable with other pilot studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], had limited subgroup power, and ceiling effects from high baselines scores further limited the ability to detect true positive effects [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Social desirability bias [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] may have influenced the results despite mitigation measures such as anonymisation.\u003c/p\u003e\u003cp\u003eReliance upon eMR documentation as the primary outcome measure for practice change presents limitations. We were unable to determine what proportion of documentation was entered by trained mental health staff versus other clinicians. The eMR system itself appears to be an incomplete repository for ACP documents, with significant time lags between document creation and upload, and some ACP discussion documents not containing ACP content. ACP discussions may have occurred but not been documented or may not have been documented in the dedicated ACP tab and so not detected on audit. Staff requests for examples of documentation suggest these issues may have been relevant. Data accessibility is also compromised when ACP documents are not available at the point of care because they are stored elsewhere, e.g., a patient's home, and are not integrated into the medical record [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This is particularly pertinent for people residing in aged care facilities, where a resident\u0026rsquo;s ACP/ACD is usually completed as it is a care standard [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], but is not routinely shared with hospital eMR systems as we have demonstrated [Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e]. This fragmentation was further highlighted by the lack of integration between the local eMR and the national My Health Record system, as no consumer had documents in both systems simultaneously.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eImplications for Clinical Practice\u003c/h2\u003e\u003cp\u003eThis study was conducted with frontline mental health staff working in clinical settings. It was pragmatic, and therefore subject to real world conditions including competing demands for staff time and the logistics of delivering condensed education in hybrid formats within existing programs. The resources and educational intervention could readily be adapted for other contexts and legal frameworks, and are thus transferable to diverse healthcare settings. Integrating qualitative feedback, questionnaire scores, and eMR data revealed the intervention's potential to empower staff to engage consumers in ACP but also reveals specific areas needing attention. Participants endorsed practical elements (e.g., clinical vignettes, discussion) and theoretical clarifications (e.g., ACP vs. ACD), likely driving confidence gains. However, the emergent themes of \u0026lsquo;Broader demonstration of clinical practice\u0026rsquo; and \u0026lsquo;More resources\u0026rsquo;, highlighted a need for more practical and ongoing training, with suggestions of sample questions or a framework for ACP discussions, further education sessions, including role-play, and creating quick reference cards (lanyards). These identified needs align with staff having poorer performance on clinical vignette questions, which require the application of theoretical knowledge to the nuances of clinical practice. Clinicians in the foundation study similarly identified lack of access to practical training in ACP as a barrier to implementation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The qualitative feedback also suggests a need for more clinical examples of how and where to document ACP discussions.\u003c/p\u003e\u003cp\u003eFuture interventions should consider more intensive approaches. S\u0026aelig;vareid et al. (2019) improved aged care facility resident participation in ACP through a train-the-trainer model involving two days of education seminars with role-play, quick reference guides, ongoing supervision, and follow-up [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], contrasting with our single session format. Follow-up sessions\u0026ndash; to reinforce application and retention of theoretical concepts and practice engaging in ACP\u0026ndash; may improve the impact of the intervention in terms of sustained knowledge gains and behavioural change, as suggested by approaches to delirium education [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFuture interventions should also consider integrated tools and educational resources to bridge the gaps between improved confidence and practice change identified in our study. Digital decision support tools, such as video-based resources tailored for people with mental illness, could enhance understanding of complex ACP concepts, as demonstrated by Volandes et al. (2009) who found that video decision support tools improved knowledge and led to more stable treatment preferences compared to verbal descriptions alone [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, our qualitative feedback suggested enhanced training on decision-making capacity could help clinicians navigate the unique challenges of conducting ACP discussions with consumers experiencing ongoing symptoms of mental illness.\u003c/p\u003e\u003cp\u003eA broad and multifaceted approach to education is recognised as more likely to be effective in changing practice, including strategies such as targeted peer-led education, small group or individual case-based discussions, audit and feedback, reminder systems and organisational change [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Change champions embedded within healthcare settings may complement educational interventions [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The potential value of change champions in mental health settings was demonstrated using \"COSMOS ambassadors\" within a comprehensive multimodal intervention comprising a 2-day education seminar (including role-play, and provision of training materials and flashcards), repeated teaching, a train-the-trainer model and ongoing telephone support in their ACP intervention [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Other studies in mental health settings have shown champions motivate behaviour change by modelling supportive attitudes [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and clinical skills/techniques [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], the latter crucial in ACP given complexity of navigating family concerns and cultural considerations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], capacity and ongoing symptoms of mental illness [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and emphasised by participants in this study. Ensuring the effects of the intervention are sustained is relevant to evaluating cost-effectiveness and overall benefit [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Repeating educational interventions can lead to more sustained effects, likely due to repeated exposure [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and was suggested by our participants.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis novel evidence-informed intervention significantly enhanced ACP readiness among mental health clinicians and peer workers, improving knowledge, attitudes and confidence and addressing a critical research gap. However, persistently low baseline and post-intervention eMR ACP documentation rates suggest more strategies are needed to change clinical practice. Clinician and peer worker feedback provided valuable insights into what additional training is needed to promote engagement in ACP with consumers and carers and its documentation, guiding refinement of this intervention.\u003c/p\u003e\u003cp\u003eThe next steps are to revise the education session itself to emphasise aspects of application to clinical practice, schedule follow-up sessions focused on practical training and explore ways of integrating ACP into clinical practice, including through change champions [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and embedding ACP in governance processes (e.g. team business meetings, audits and regular feedback) to reinforce practice and sustain implementation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A multipronged approach should also broaden the scope of training beyond clinicians to include consumers and carers, and be tested on larger sample sizes across geographically diverse mental health services over an extended follow-up period to evaluate change in practice and sustainability. These are crucial first steps to addressing the disparity in actualising autonomy of decision making and quality care towards the end of life for older people with mental illness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Concord Hospital Human Research Ethics Committee (2023/ETH02283).\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eConception and study design \u0026ndash; AW, MT, DK, ST, KA; Acquisition of data and analysis \u0026ndash; KC, AW; Interpretation of data \u0026ndash; all authors; Writing original draft \u0026ndash; KC, AW; Writing review and editing \u0026ndash; all authors.\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eThe deidentified data supporting the findings of this study may be available from Keanu Crous upon reasonable request if approved by the Concord Hospital Human Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. However, there was financial support for the foundational qualitative studies and subsequently developed education and training resources referred to in the paper. Those studies were supported by a philanthropic grant, the Moyira Elizabeth Vine Fund for Research in Schizophrenia, awarded to Anne Wand. The sponsors had no involvement in any aspect of the study or the decision to submit the article for publication.\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. Journal of Pain and Symptom Management 2017;53:821-832.e1. https://doi.org/10.1016/j.jpainsymman.2016.12.331.\u003c/li\u003e\n\u003cli\u003eBrinkman-Stoppelenburg A, Rietjens JA, Van Der Heide A. The effects of advance care planning on end-of-life care: A systematic review. Palliat Med 2014;28:1000\u0026ndash;25. https://doi.org/10.1177/0269216314526272.\u003c/li\u003e\n\u003cli\u003eBlomberg BA, Quintana C, Hua J, Hargis-Fuller L, Laux J, Drickamer MA. Enhancing Advance Care Planning Communication: An Interactive Workshop With Role-Play for Students and Primary Care Clinicians. MedEdPORTAL 2020. https://doi.org/10.15766/mep_2374-8265.10973.\u003c/li\u003e\n\u003cli\u003eWand A, Karageorge A, Zeng Y, Browne R, Sands M, Kanareck D, et al. The perspectives on advance care planning of older people with psychotic illnesses and their carers. Eur Geriatr Med 2025. https://doi.org/10.1007/s41999-025-01161-8.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Neill, Nick, Peisah, Carmelle. Capacity and the Law. 4th ed. Sydney: Australian Legal Information Institute (AustLII); 2021.\u003c/li\u003e\n\u003cli\u003eChesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 2014;13:153\u0026ndash;60. https://doi.org/10.1002/wps.20128.\u003c/li\u003e\n\u003cli\u003eShalev D, Fields L, Shapiro PA. End-of-Life Care in Individuals With Serious Mental Illness. Psychosomatics 2020;61:428\u0026ndash;35. https://doi.org/10.1016/j.psym.2020.06.003.\u003c/li\u003e\n\u003cli\u003eRelyea E, MacDonald B, Cattaruzza C, Marshall DA. On the Margins of Death: A Scoping Review on Palliative Care and Schizophrenia. Journal of Palliative Care 2018;34:62\u0026ndash;9. https://doi.org/10.1177/0825859718804108.\u003c/li\u003e\n\u003cli\u003eEdwards D, Anstey S, Coffey M, Gill P, Mann M, Meudell A, et al. 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Clinician Perspectives on Palliative Care for Older Adults With Serious Mental Illnesses: A Multisite Qualitative Study. Am J Geriatr Psychiatry 2025;33:275\u0026ndash;86. https://doi.org/10.1016/j.jagp.2024.08.014.\u003c/li\u003e\n\u003cli\u003eWand APF, Karageorge A, Zeng Y, Browne R, Kanareck D, Naganathan V, et al. Why Mental Health Clinicians are Not Engaging in Advance Care Planning with Older People with Schizophrenia and Other Psychotic Illnesses. Psychol Res Behav Manage 2024;17:4195\u0026ndash;206. https://doi.org/10.2147/PRBM.S496651.\u003c/li\u003e\n\u003cli\u003eJerwood J, Ward G, Phimister D, Holliday N, Coad J. Lean in, don\u0026rsquo;t step back: The views and experiences of patients and carers with severe mental illness and incurable physical conditions on palliative and end of life care. Progress in Palliative Care 2021;29:255\u0026ndash;63. https://doi.org/10.1080/09699260.2021.1887589.\u003c/li\u003e\n\u003cli\u003eDePew R, Lal A, Sivertsen E, Smith A, Johnson LS, Taylor EP. Navigating the Ethical Challenges of Clinical Decision-Making for Patients with Mental Illness Presenting with Self-Inflicted Burns. J Burn Care Res 2024;45:1641\u0026ndash;4. https://doi.org/10.1093/jbcr/irae176.\u003c/li\u003e\n\u003cli\u003eWand APF, Browne R, Zeng C, Karageorge A, Peisah C. Development of evidence-informed educational resources for Advance Care Planning with older people with a mental illness. Palliative \u0026amp; Supportive Care 2025;In press.\u003c/li\u003e\n\u003cli\u003eDunn M, Peisah C, Wand AP. The perspectives of hospital doctors about end‐of‐life care in people with mental illness: an observational pilot study. Internal Medicine Journal 2024;54:742\u0026ndash;9. https://doi.org/10.1111/imj.16294.\u003c/li\u003e\n\u003cli\u003eJerwood J, Phimister D, Ward G, Holliday N, Coad J. Barriers to palliative care for people with severe mental illness: Exploring the views of clinical staff. European Journal of Palliative Care 2018;25:20\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77\u0026ndash;101. https://doi.org/10.1191/1478088706qp063oa.\u003c/li\u003e\n\u003cli\u003eChan CWH, Ng NHY, Chan HYL, Wong MMH, Chow KM. A systematic review of the effects of advance care planning facilitators training programs. BMC Health Serv Res 2019;19. https://doi.org/10.1186/s12913-019-4192-0.\u003c/li\u003e\n\u003cli\u003eSchickedanz AD, Schillinger D, Landefeld CS, Knight SJ, Williams BA, Sudore RL. A Clinical Framework for Improving the Advance Care Planning Process: Start with Patients\u0026rsquo; Self‐Identified Barriers. J American Geriatrics Society 2009;57:31\u0026ndash;9. https://doi.org/10.1111/j.1532-5415.2008.02093.x.\u003c/li\u003e\n\u003cli\u003eChen Y-C, Chu F-Y, Chang L-Y, Hsieh M-Y, Lee C-H. The influence of an interactive educational approach on advance care planning counseling in individuals with psychiatric disorders. BMC Palliat Care 2025;24. https://doi.org/10.1186/s12904-025-01723-4.\u003c/li\u003e\n\u003cli\u003eHenage CB, McBride JM, Pino J, Williams J, Vedovi J, Cannady N, et al. Educational Interventions to Improve Advance Care Planning Discussions, Documentation and Billing. Am J Hosp Palliat Care 2021;38:355\u0026ndash;60. https://doi.org/10.1177/1049909120951088.\u003c/li\u003e\n\u003cli\u003ePivodic L, Wendrich-van Dael A, Gilissen J, De Buyser S, Deliens L, Gastmans C, et al. Effects of a theory-based advance care planning intervention for nursing homes: A cluster randomized controlled trial. Palliat Med 2022;36:1059\u0026ndash;71. https://doi.org/10.1177/02692163221102000.\u003c/li\u003e\n\u003cli\u003eLum HD, Dukes J, Church S, Abbott J, Youngwerth JM. Teaching Medical Students About \u0026ldquo;The Conversation\u0026rdquo;: An Interactive Value-Based Advance Care Planning Session. Am J Hosp Palliat Care 2018;35:324\u0026ndash;9. https://doi.org/10.1177/1049909117696245.\u003c/li\u003e\n\u003cli\u003eWand APF, Draper B, Brodaty H, Hunt GE, Peisah C. Evaluation of an Educational Intervention for Clinicians on Self-Harm in Older Adults. Archives of Suicide Research 2021;25:156\u0026ndash;76. https://doi.org/10.1080/13811118.2019.1706678.\u003c/li\u003e\n\u003cli\u003eCeiling Effect. Encyclopedia of Quality of Life and Well-Being Research, Dordrecht: Springer Netherlands; 2014, p. 631\u0026ndash;3. https://doi.org/10.1007/978-94-007-0753-5_296.\u003c/li\u003e\n\u003cli\u003eKrumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant 2013;47:2025\u0026ndash;47. https://doi.org/10.1007/s11135-011-9640-9.\u003c/li\u003e\n\u003cli\u003eSands MB, Varndell W, Speir L, Rhodes H, Shield M. P30 Acute Care, Ambulance, Emergency Departments and Advance Care Plans; - In the sock drawer* or at the point of care?, Manly Beach, Sydney, Australia: 2018.\u003c/li\u003e\n\u003cli\u003eAustralian Government Department of Health and Aged Care. Revised Aged Care Quality Standards: Draft for Pilot. Canberra, ACT: Department of Health and Aged Care; 2023.\u003c/li\u003e\n\u003cli\u003eS\u0026aelig;vareid TJL, Thoresen L, Gjerberg E, Lillemoen L, Pedersen R. Improved patient participation through advance care planning in nursing homes\u0026mdash;A cluster randomized clinical trial. Patient Education and Counseling 2019;102:2183\u0026ndash;91. https://doi.org/10.1016/j.pec.2019.06.001.\u003c/li\u003e\n\u003cli\u003eWand APF. Evaluating the effectiveness of educational interventions to prevent delirium. Australas J Ageing 2011;30:175\u0026ndash;85. https://doi.org/10.1111/j.1741-6612.2010.00502.x.\u003c/li\u003e\n\u003cli\u003eLee SY, Fisher J, Wand APF, Milisen K, Detroyer E, Sockalingam S, et al. Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings. Eur Geriatr Med 2020;11:1\u0026ndash;32. https://doi.org/10.1007/s41999-019-00278-x.\u003c/li\u003e\n\u003cli\u003eVolandes AE, Paasche-Orlow MK, Barry MJ, Gillick MR, Minaker KL, Chang Y, et al. Video decision support tool for advance care planning in dementia: randomised controlled trial. BMJ 2009;338:b2159\u0026ndash;b2159. https://doi.org/10.1136/bmj.b2159.\u003c/li\u003e\n\u003cli\u003eSantos WJ, Graham ID, Lalonde M, Demery Varin M, Squires JE. The effectiveness of champions in implementing innovations in health care: a systematic review. Implement Sci Commun 2022;3. https://doi.org/10.1186/s43058-022-00315-0.\u003c/li\u003e\n\u003cli\u003eMorena AL, Gaias LM, Larkin C. Understanding the Role of Clinical Champions and Their Impact on Clinician Behavior Change: The Need for Causal Pathway Mechanisms. Front Health Serv 2022;2:896885. https://doi.org/10.3389/frhs.2022.896885.\u003c/li\u003e\n\u003cli\u003eAasmul I, Husebo BS, Flo E. Description of an advance care planning intervention in nursing homes: outcomes of the process evaluation. BMC Geriatr 2018;18:26. https://doi.org/10.1186/s12877-018-0713-7.\u003c/li\u003e\n\u003cli\u003eCervero RM, Gaines JK. The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews. Journal of Continuing Education in the Health Professions 2015;35:131\u0026ndash;8. https://doi.org/10.1002/chp.21290.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-geriatric-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EGEM","sideBox":"Learn more about [European Geriatric Medicine](https://www.springer.com/journal/41999)","snPcode":"41999","submissionUrl":"https://www.editorialmanager.com/egem/default2.aspx","title":"European Geriatric Medicine","twitterHandle":"","acdcEnabled":false,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"education, advance care planning, end-of-life, mental disorder, mental health, psychogeriatrics","lastPublishedDoi":"10.21203/rs.3.rs-7843125/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7843125/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo evaluate the effectiveness of a novel educational intervention for mental health staff on Advance Care Planning (ACP). The aims were to improve staff knowledge, attitudes, and confidence in facilitating ACP with older people with mental illness and to increase staff engagement in ACP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePre-post intervention study conducted across two public mental health services in Australia. Multidisciplinary mental health clinicians and peer workers (n\u0026thinsp;=\u0026thinsp;110) participated in a one-hour, evidence-informed educational session combining theoretical content, videos, interactive discussion of case vignettes and handout resources. Evaluation used paired pre- and post-intervention questionnaires assessing staff knowledge, attitudes, and confidence (Wilcoxon Signed-Rank and Exact McNemar tests). A pre-post audit of mental health consumer (patient) electronic medical records (eMR) at both sites quantified changes in ACP documentation rates (two-sample z-test for proportions). Thematic analysis of free-text feedback was conducted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe intervention led to statistically significant improvements in staff attitude (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;0.48), knowledge (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;0.51), and confidence (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026thinsp;=\u0026thinsp;0.87). Consumer eMR audits (pre: n\u0026thinsp;=\u0026thinsp;1104; post: n\u0026thinsp;=\u0026thinsp;1118) showed no significant change in ACP documentation rates, which remained low (7.6% vs. 8.0%). Participants\u0026rsquo; feedback emphasised further practical training (e.g. role play, sample questions, eMR documentation), discussion of complex cases, and reinforcement strategies.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eA brief, standalone educational intervention improved staff readiness for ACP, but did not translate into change in clinical practice. This knowledge-to-practice gap suggests that overcoming systemic and other barriers to ACP requires multifaceted strategies beyond education, such as organisational change and governance processes, audit and feedback, skills practice and champions.\u003c/p\u003e","manuscriptTitle":"Evaluation of a Novel Educational Intervention for Mental Health Staff on Advance Care Planning with Older People with Mental Illness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 09:49:39","doi":"10.21203/rs.3.rs-7843125/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revisions","date":"2025-11-19T08:28:46+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-10-22T05:58:23+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-15T10:33:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"European Geriatric Medicine","date":"2025-10-15T10:08:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-14T01:06:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Geriatric Medicine","date":"2025-10-12T18:44:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-geriatric-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EGEM","sideBox":"Learn more about [European Geriatric Medicine](https://www.springer.com/journal/41999)","snPcode":"41999","submissionUrl":"https://www.editorialmanager.com/egem/default2.aspx","title":"European Geriatric Medicine","twitterHandle":"","acdcEnabled":false,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6f0955ca-b53c-4488-8992-1dce18915e1a","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T10:12:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 09:49:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7843125","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7843125","identity":"rs-7843125","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}