Life In The Slower Lane

Here is the structured PICO analysis for the fifty-first article you uploaded:

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Full Title (verbatim and exact):

“Description of an advance care planning intervention in nursing homes: outcomes of the process evaluation”

Aasmul I, Husebo BS, Flo E

BMC Geriatrics (2018); 18:26

DOI: https://doi.org/10.1186/s12877-018-0713-7

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Type of Article:

Process evaluation of a cluster-randomised controlled trial (COSMOS study)

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PICO Analysis:

Population:

• 297 nursing home residents across 36 Norwegian NH units participating in the intervention arm of the COSMOS trial
• Mean age: 86.5 years; 73% female; nearly half (47%) had severe dementia (MMSE 0–10) 

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Intervention:

Advance Care Planning (ACP) intervention as part of the broader COSMOS trial

Key elements included:

• Train-the-trainer education model: 2-day seminar for COSMOS ambassadors (NH nurses and staff)
• Monthly family communication via phone or in person
• Quarterly structured meetings with family, physician, and nurse
• Documentation of ACP conversations and decisions
• Flash cards and checklists to guide staff discussions with residents and families 

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Comparator:

• Not applicable in this process evaluation (control group part of the larger COSMOS trial was not analysed here)
• Focus is on evaluation of ACP implementation in the intervention group

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Outcome:

1. Person-centred outcomes (indirectly assessed):

• ACP conversations focused on:
  • Patient and family values
  • Preferred treatment goals (e.g. hospitalization, symptom relief)
  • Cultural and spiritual needs
• Inclusion of residents with dementia was promoted, respecting communication limits and consent capacity 

2. Process outcomes:

• Successful implementation in 62% (183/297) of residents, defined by:
  • An ACP meeting with a physician or primary nurse
  • At least one documented family contact per month
• Most frequent tasks completed:
  • Family contact (76%)
  • Documentation of ACP conversations (73%)
• Facilitators:
  • Clearly defined roles and responsibilities
  • Staff use of flash cards and structured questions
  • Ongoing support via seminars and biweekly check-ins 
• Barriers:
  • Lack of time
  • Low physician engagement
  • Conflicting beliefs about dementia and ACP
  • Limited staff competence and language barriers 

3. Health system outcomes (indirect):

• Staff reported improved ability to initiate early ACP discussions
• Positive feedback on the practicality and relevance of training materials
• No quantitative data on hospitalisation, cost, or treatment intensity reported in this process-focused article 

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Summary Conclusion:

This process evaluation of the COSMOS ACP intervention in Norwegian nursing homes demonstrated moderate success in implementing structured ACP over 4 months. The intervention was well received, with staff engagement, defined roles, and practical tools cited as major facilitators. Barriers included time constraints, limited physician participation, and staff hesitancy—especially regarding involving people with dementia in ACP. Importantly, the study underscores the need for ongoing training, clear protocols, and organisational commitment to sustain ACP as a routine practice in dementia-inclusive aged care settings.

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