Table 2 Aim, methods and output of each step in developing Theory of Change map

1|

To obtain full background information on ACP in Flanders and the nursing home context

Contextual analysis by means of: (literature) review of existing policies, national guidelines, national studies of ACP in the Flemish nursing home setting (e.g. EU FP7 project 'PACE') and local/national ACP initiatives for the nursing home setting

Background report listing possible barriers and facilitating factors^a for ACP in nursing homes related to 1) the resident (e.g. average time of stay in a nursing home is 3 years), 2) family (e.g. family listed as contact person often not according to regulated cascade system^b), 3) involved care professionals (e.g. GPs in Flanders are not employed by nursing home facilities), 4) facility (e.g. staff shortages), 5) Belgian/Flemish (healthcare) system (e.g. ACP policy not driven by law; existence of formal quality indicators)

2 |

To identify the preconditions related to successful ACP in the nursing home setting

Systematic review* of empirical studies and reviews (2005–2015) about ACP in nursing homes, by the core research team

List of preconditions for ACP in the nursing home setting to be used during workshop 1 to trigger discussion

3 |

To create a first draft of the ToC map

ToC stakeholder workshop 1 by ToC facilitators (LVDB and LP) and stakeholders

First draft of ToC map, including:

▪ Impact, ceiling of accountability and long-term outcomes

▪ Preconditions/intermediate outcomes, including their chronological order

▪ List of possible interventions, assumptions and rationales

4 |

To create a second draft of the ToC map based on integration of output from steps 1, 2 and 3

Several meetings with core research team  to construct a draft ToC map

Second draft of ToC map, including:

▪ Reformulated impact and long-term outcomes

▪ Preconditions chronologically ordered and coloured according to level to which they are applicable

▪ Precondition “support by an external trainer” (suggested by research team)

▪ Possible interventions (added by the research team) such as the availability of a trainer and a monitoring system

5 |

To refine the second draft ToC map, to fill in the gaps and to get consensus on the chronological order of the hypothesised causal pathway

ToC stakeholder workshop 2 by ToC facilitators and stakeholders in which second draft of ToC map (output of step 4) is presented

Refined draft of second ToC map, including:

• Redefined secondary outcome to be measurable

▪ Additional elements, added in step 4, approved by stakeholders

▪ Details added by stakeholders (e.g. which healthcare professional is responsible for implementing ACP, re-named ACP facilitator as “ACP reference person”)

▪ Additional arrows added by stakeholders

6 |

To develop the final draft ToC map that outlines the hypothetical causal pathway of ACP in nursing homes based on integration of output from steps 1 to 5

Several meetings with core research group to construct the ToC map, review by a ToC expert, comparison with existing ToC maps from other research projects and consultation of implementation science literature (in general and about ACP) and relevant theoretical models

Further integration of outputs of steps 1–5 into a final draft of a ToC map (presented in Fig. 1) and narrative, including:

▪ Preconditions merged or reformulated and put in chronological order

▪ Numbers added to mark interventions

▪ Rationales and assumptions written up by the core research team in a separate document (narrative), based on stakeholders’ and researchers’ experience, literature and relevant theoretical models