Method The study used semi-structured interviews, gathering data from purposeful sampling of 8 community palliative care CNSs.

Findings The findings identified a number of themes, within which were driving and restraining factors in term of ACP facilitation. A characteristic of all of the themes was the need to balance a number of risks, this led to the development of the metaphor ‘walking the tightrope’ to describe the nature of the challenges that the CNSs experienced. This main theme was broken down into three categories which all had a balance of tensions within them. These categories were: opening the discussion; ethical issues; and how the personal attributes of the CNS influence the process. Key challenges were; when and how to open the discussion without harming the patient; dealing with emotional and ethical challenges; working with generalist colleagues. Facilitating factors were: building a relationship with the patient; CNS experience; and working as part of a team.

Contribution to the evidence This work adds to the evidence on ACPs and the experience of CNSs working in palliative care. Increased understanding of the driving and restraining factors can improve educational preparation, and ensure that organisational issues are addressed.