Life In The Slower Lane

Here is the structured PICO analysis for the sixty-ninth article you uploaded:

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Full Title (verbatim and exact):

“What, Why, and How Care Protocols are Implemented in Ontario Nursing Homes”

Berta W, Ginsburg L, Gilbart E, Lemieux-Charles L, Davis D

Canadian Journal on Aging (2013); 32(1):73–85

DOI: 10.1017/S0714980813000081

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Type of Article:

Cross-sectional survey study with organisational and implementation science focus

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PICO Analysis:

Population:

• Directors of Care (DOCs) from all 547 long-term care (LTC) homes in Ontario, Canada
• 392 surveys completed (72% response rate)
• Survey covered six clinical protocol areas:
  1. Preventative skin care
  2. Wound/ulcer care
  3. Restraint use
  4. Incontinence management
  5. Management of difficult behaviours
  6. Antimicrobial resistance 

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Intervention (Phenomenon of Interest):

Implementation of clinical care protocols (also referred to as practice guidelines or standards), including processes and strategies such as:

• Staff education (in-services, conferences, external expert input)
• Protocol selection methods (participatory vs managerial directive)
• Use of internal champions
• Performance feedback loops
• Adaptation to context (e.g., resources, literacy levels) 

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Comparator:

• No formal control group; analyses explored variation in implementation by organisational context, including:
  • For-profit vs not-for-profit vs government-run homes
  • Urban vs rural location
  • Size of home (small, medium, large)
  • Accreditation status
  • Chain vs independent ownership 

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Outcome:

1. Person-centred outcomes:

• Not directly measured
• Proxy outcome: degree of protocol implementation for resident-relevant clinical issues (e.g., skin integrity, behaviour management)

2. Process outcomes:

• Most homes were using or planning to use protocols for all six clinical issues
  • Skin care and wound/ulcer care protocols were most widely implemented
  • Incontinence and antimicrobial resistance protocols were least advanced 
• Motivations for implementation:
  • Continuous improvement (mean score 4.78/5)
  • Belief in evidence-based care (4.48)
  • Desire to standardise care (4.40) 
• Implementation supports used:
  • In-service education (most frequent)
  • Internal and external experts
  • Reminder and feedback systems
  • Individual champions and written implementation plans

3. Health system outcomes (contextual variation):

• Ownership differences:
  • For-profit homes reported more external education (e.g., conferences, expert-led in-services)
  • Government-run homes reported less training access
• Size effects:
  • Larger homes more likely to implement protocols via top-down management
• Accredited homes were more likely to use incontinence protocols, potentially due to regulatory requirements 

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Summary Conclusion:

This survey study provides insight into how Ontario nursing homes implement clinical care protocols, showing that most homes use structured, participatory approaches motivated by quality improvement and standardisation. The most important success factors included adequate resources, clear rationale for change, and staff engagement. Organisational context—especially ownership and facility size—significantly influenced how protocols were selected and implemented. The study highlights the importance of implementation science principles in translating evidence into practice in LTC and recommends further research into how different approaches affect resident outcomes.

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