Here is the standardised PICO analysis for the twenty-ninth uploaded article:
Full Title
Effects of a theory-based advance care planning intervention for nursing homes: A cluster randomized controlled trial
Authors: Lara Pivodic, Annelien Wendrich-van Dael, Joni Gilissen, et al.
Journal: Palliative Medicine, 2022; 36(7):1059–1071
DOI: 10.1177/02692163221102000
Type of Study
Cluster randomised controlled trial (RCT) conducted in 14 Belgian nursing homes
PICO Summary
Population (P)
- Care staff in 14 nursing homes in Flanders, Belgium
- Includes nurses, care assistants, allied health professionals, and support staff
- 694 respondents at baseline, 491 at 8-month follow-up
- Residents were not direct participants, but the intervention indirectly targeted resident-centred care
Intervention (I)
ACP+ Intervention – a theory-based, multicomponent program over 8 months, including:
- Train-the-trainer model with 2 external trainers
- 10 structured components including:
- Designated “ACP Reference Persons” and “Conversation Facilitators”
- Education sessions (2-day training, follow-ups)
- Monthly multidisciplinary meetings
- Tools and manuals (SPICT, advance directive templates)
- Coaching and audit processes
- Tailored to each facility with implementation flexibility
Comparison (C)
- Usual care: no formal structured ACP training or implementation support
Outcomes (O)
Primary Outcomes:
- Self-efficacy in ACP: Significant improvement (Cohen’s d = 0.3; p = 0.003) in the intervention group compared to control
- Knowledge of ACP: No significant difference between groups (p = 0.339)
Secondary Outcome:
- Staff-reported engagement in ACP conversations and documentation: No significant difference (p = 0.145)
Exploratory Outcomes:
- No subgroup differences based on education level or fidelity score
- Implementation fidelity was generally high: all intervention homes implemented ≥13 of 17 intended activities
Findings Summary
The ACP+ intervention led to a modest but statistically significant improvement in care staff’s confidence (self-efficacy) to perform advance care planning, but not in their knowledge or reported engagement with ACP practices. Despite the structured, theory-driven, and multi-level design, the effect sizes were smaller than expected, potentially due to:
- Outcome measurement limitations
- Short follow-up duration
- Varying degrees of implementation success
- Challenges in targeting such a complex behaviour change process across staff roles
Authors highlight the need for:
- Longer consolidation periods
- Alternative or refined outcome measures
- Greater focus on co-design and staff role clarity
- A consensus-based core outcome set for future ACP trials
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