Life In The Slower Lane

Here is the standardised PICO analysis for the thirty-first uploaded article:

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Full Title

Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review

Authors: Yuxin Zhou, Ariel Wang, Clare Ellis-Smith, Debbie Braybrook, Richard Harding

Journal: International Journal of Nursing Studies, 2022; 133:104277

DOI: 10.1016/j.ijnurstu.2022.104277

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Type of Study

Realist Review guided by the Normalisation Process Theory (NPT)

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PICO Summary

Population (P)

• Older people living in long-term care facilities (LTCFs)
• Indirectly includes families, frontline staff, nurse facilitators, GPs, social workers, and care teams
• Included evidence from 48 studies across 10+ countries (e.g. Australia, UK, Norway, Taiwan, Hong Kong, China, Ireland)

Intervention (I)

• Advance Care Planning (ACP) implementation strategies
• Focused on how ACP can be normalised into routine LTCF practice
• Strategies included:
  • Sensitive, gradual ACP conversations
  • Staff training (e.g. blended or train-the-trainer models)
  • Collaborative negotiation and shared decision-making
  • Leadership engagement
  • Building multidisciplinary networks
  • Maintaining regular review and documentation
  • Identifying the “window of opportunity” for initiating ACP

Comparison (C)

• Not applicable (no comparator/control group); analysis was based on realist synthesis rather than effectiveness trials

Outcomes (O)

Mechanisms and system-level outcomes:

• Increased normalisation of ACP in LTCFs (embedding ACP into routine processes)
• Shared understanding of the purpose and benefits of ACP among residents, families, and staff
• Creation of collaborative networks and clearly defined staff roles
• More timely and person-centred initiation of ACP conversations
• Improvement in staff confidence, documentation, and decision consistency

Person-centred outcomes (inferred, not quantitatively measured):

• Increased resident willingness to engage in ACP
• Reduced crisis-based decisions and family/staff emotional burden
• Enhanced goal-concordant care through shared decision-making 

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Findings Summary

This realist review provides a comprehensive framework to understand how and why ACP interventions succeed or fail in LTCFs. The authors present seven key Context–Mechanism–Outcome Configurations (CMOCs), each supported by multi-country evidence:

1. Sensitive conversation, gradually introduced
2. Collaborative negotiation for shared decisions
3. Multidisciplinary teams including nurse facilitators and care assistants
4. Leadership buy-in to embed ACP in culture
5. Timing and triggers to initiate ACP early
6. Sustainable staff training models
7. Maintaining documentation and ongoing reflection

A logic model (see Figure 2, page 9) visualises the interaction between individual, organisational, and relational elements. The study concludes that ACP should not be a single task or document but a normalised cultural practice, developed with ongoing stakeholder reflection and tailored to individual LTCF contexts .

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