Life In The Slower Lane

Here is the standardised PICO analysis for the article titled:

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Full Title

A Framework for Cross-Cultural Development and Implementation of Complex Interventions to Improve Palliative Care in Nursing Homes: The PACE Steps to Success Programme

Authors: Jo Hockley, Katherine Froggatt, Lieve Van den Block, et al.

Journal: BMC Health Services Research, 2019; 19:745

DOI: 10.1186/s12913-019-4587-y

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Type of Study

Implementation research and framework development paper using mixed qualitative data and process observations from a cluster randomised controlled trial (RCT) conducted across seven European countries.

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PICO Summary

Population (P)

• Nursing home residents in 78 nursing homes across seven European countries
• Indirect participants: over 3,600 nurses and care assistants, nursing home managers, trainers, and PACE coordinators 

Intervention (I)

PACE Steps to Success Programme

• A structured six-step palliative care intervention:
  1. Discussions about current and future care
  2. Assessment and review
  3. Monthly multidisciplinary palliative care review meetings
  4. Symptom management (especially pain and depression)
  5. Care in the last days of life
  6. Care after death
• Implemented using a train-the-trainers cascade model:
  • International trainers → Country trainers → PACE coordinators → Frontline nursing home staff
• Cross-cultural adaptation of training materials, documentation, symptom tools, and delivery methods to suit local legal, ethical, and cultural norms 

Comparison (C)

• Not explicitly a comparison study, though the paper discusses cross-national differences in implementation and adaptation outcomes
• Evaluation occurred across intervention vs control arms in the broader RCT (reported elsewhere)

Outcomes (O)

Implementation outcomes:

• Development of a three-phase framework:
  1. Adaptation and preparation of resources
  2. Training and delivery
  3. Ongoing facilitation and support
• Cross-cultural adaptation accounted for:
  • Language
  • Disclosure practices
  • Legal barriers (e.g., around advance directives, opioid prescribing)
  • Hierarchies in clinical roles (e.g., nurse vs physician status) 

Process outcomes:

• Training conducted for 16 national trainers, 73 PACE coordinators, and hundreds of nursing staff
• Tools translated and tested in two non-trial homes in each country for feasibility and acceptability
• Facilitation needs were high, especially in countries where palliative care was less integrated or where cultural norms discouraged direct end-of-life conversations 

Challenges identified:

• Staff turnover, limited internet access, and variable use of educational materials
• PACE coordinators often lacked formal authority to lead change
• Online peer support (e.g., a Facebook group in the UK) helped address staff isolation
• Not all nursing home managers gave consistent support; leadership buy-in was key 

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Conclusion

The PACE programme is a feasible and adaptable framework for improving palliative care in nursing homes through structured implementation, multilevel training, and cross-cultural adjustment. Its success depends on both internal champions and external facilitation, especially in settings with low baseline familiarity with palliative care.

This paper provides a valuable roadmap for implementing complex health interventions across diverse linguistic, clinical, and regulatory environments—balancing fidelity with local flexibility .

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