This trial will evaluate whether the Supporting Transitions and Empowering Preferences (STEP) toolkit can improve decision-making about hospital transfers in long-term care residents and their substitute decision-makers and enhance decision self-efficacy in nursing staff.

The trial will answer the questions:

• Does the STEP tool reduce decisional conflict in residents and care partners at the time of transfer decisions?
• Does it improve nurse self-efficacy related to hospital transfer decisions?

Participants will:

• Use the STEP tool during key moments of care planning (admission, care conferences, and acute events)
• Complete a short survey measuring their decisional conflict
• Be supported by trained nurses who use STEP to guide hospital transfer discussions

Researchers will compare data collected before and after the STEP tool is implemented at two long-term care homes to see if it improves shared decision-making related to hospital transfers by reducing decisional conflict.

Background and Rationale: Transitions from long-term care (LTC) to hospital are complex and can offer both benefits and challenges to residents and care partners. While LTC-to-hospital transitions can improve health outcomes, particularly during acute deterioration, evidence also indicates that these transitions may disrupt continuity of care, increase stress, and misalign resident needs with hospital protocols. Nearly fifty percent of LTC residents in Canada experience hospital transitions annually, with approximately forty percent considered avoidable. Risks include non-evidence-based care, safety concerns, unnecessary interventions, and increased mortality rates. Transition decisions are influenced by residents' health status, medico-legal concerns, staff workload, and care partners' confidence in LTC care. These decisions are often reactive and shaped by unequal power dynamics rather than proactive, collaborative planning.

Given these challenges, and limitations in current monitoring systems such as the Minimum Data Set assessments, there is a critical need for a decision aid that supports informed, resident-centered planning. The Supporting Transitions and Empowering Preferences (STEP) tool was developed through interviews, co-design sessions, document analysis, and stakeholder engagement.

Objectives Primary Objective: Evaluate the impact of STEP on decisional conflict among residents and care partners.

Secondary Objective: Examine the effect of STEP on nurses' self-efficacy as decision coaches at the time of transition decisions.

Trial Design and Study Setting: A pre-post evaluation will be conducted at two LTC sites (Perley Health and Bruyère Health Saint-Louis LTC) to assess STEP's ability to support resident-care partner dyads in making hospital transition decisions. STEP will be implemented simultaneously at both sites.

Study Overview: Data will be collected for six months pre-intervention or until the target sample size is reached (n=100), followed by the intervention period. Nurses, nurse practitioners, social service workers, and physicians will receive STEP training, with designated champions supporting implementation. Data will be collected at three points: after intake/admission meetings, after care conferences, and after acute events in which a transfer is considered.

Vanguard Phase Implementation: An initial vanguard phase involving approximately ten residents over four to six weeks will test feasibility, refine recruitment, and assess staff comfort before broader rollout.

Description of the Intervention (Overview): The STEP intervention includes three resources: (1) an educational booklet about transition decisions, (2) a structured decision aid, and (3) a phone script for nursing staff calling substitute decision-makers at the time of a transfer decision. Staff will be trained on the use of these resources with sessions scheduled to accommodate different shifts. STEP will be introduced at admission (educational booklet), reviewed at post-admission or annual care conferences (booklet + decision aid), and used during acute health events (decision aid + phone script) to guide structured conversations about hospital transfer decisions.

Monitoring Fidelity: Implementation fidelity will be monitored through nurse logs, informal discussions, and champion reports, assessing feasibility, acceptability, and adherence.

Data Collection Procedures (Overview): Dyads will be identified through care reports and hospital transfer notifications, with eligibility verified prior to consent. Data will be collected using secure REDCap software. For nurses, care conference and physician call notes will be reviewed to identify eligible cases. Surveys and brief interviews will assess experiences, confidence, and barriers to STEP use.

Analysis: Analyses will follow an intention-to-treat approach using Generalized Estimating Equations for repeated measures. Differences between groups will be examined using t-tests or chi-squared tests. Missing data will be minimized through follow-up; cases lost after three unsuccessful contact attempts will be excluded from analysis.

Inclusion Criteria

Residents-care partner dyads:

• Must be residents of either Perley Health or Bruyère Health Saint-Louis LTC home.
• Residents must be 55 years of age or older.
• Must be able to communicate in French or English.

Both members of the dyad will be included where applicable. For dyads in which residents do not have the capacity to participate, inclusion will occur through the involvement of their substitute decision-maker (e.g., power of attorney for personal care).

LTC staff:

• Must be a nurse, nurse practitioner, social service worker or physician actively involved in care planning, annual conferences, or managing acute health events at Perley Health or Bruyère Health.
• Must have been employed at the LTC home for at least 6 months to ensure familiarity with the care environment and residents.
• Must play a role in facilitating discussions, providing clinical input (where applicable), or guiding decision-making processes related to hospital transitions or acute care management.
• Must be able to communicate in French or English.

Given the small sample size, the sensitive nature of data collected in long-term care settings, and the potential risk of participant re-identification, we do not plan to share IPD publicly. However, IPD may be shared on a case-by-case basis in response to reasonable, ethically approved requests. Aggregate results will be disseminated through publications and presentations.