Life In The Slower Lane

Here is the PICO analysis for the ninth uploaded article:

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✅ PICO Analysis

Full Article Title:

Advance care planning for nursing home residents with dementia: Influence of ‘we DECide’ on policy and practice

Type of Study:

Quasi-experimental pre-test–post-test study with intervention and control groups

Journal and Year:

Patient Education and Counseling (2017); 100:139–146

DOI: 10.1016/j.pec.2016.08.010

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P – Population

• Setting: 18 dementia care units across different nursing homes in Belgium
• Participants:
  • Nursing home staff from both clinical and management levels
  • Residents with dementia and their family caregivers were involved in conversations analysed for ACP practice
• Sample Size:
  • ACP policy analysis: 90 staff members
  • Practice analysis: 21 ACP conversations (13 residents and 30 staff participants) 

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I – Intervention

• Name: ‘we DECide – Discussing End-of-life Choices’
• Description:
  • A structured communication training programme for nursing home staff
  • Based on the three-step shared decision-making (SDM) model by Elwyn et al.:
    1. Choice Talk – acknowledging that choices exist
    2. Option Talk – discussing available care options
    3. Decision Talk – making decisions collaboratively
  • Training included:
    • Two 4-hour workshops
    • A practical homework assignment
    • Roleplay and simulation of ACP conversations (at admission and in crisis)
  • Multidisciplinary teams (including managers) were involved to encourage systemic adoption 

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C – Comparison

• Control Group:
  • Nine nursing home units with similar baseline scores on ACP policy that did not receive the intervention during the study period
  • Post-test results were compared between the intervention and control groups, and against their own pre-test scores

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O – Outcomes

1. Policy Outcome (ACP Policy Compliance):

• Assessed using the ACP-audit tool (45-item audit based on best practice criteria)
• Result: Intervention group improved significantly from a mean score of 26.67 to 32.56 (p = 0.013)
• Control group showed no significant change (pre: 39.56; post: 37.67; p = 0.086) 

2. Practice Outcome (ACP Conversations):

• Evaluated through:
  • ACP Criteria: Level of discussion about advance care planning
  • OPTION Scale: Degree of resident/family involvement in SDM conversations (0–100 scale)
• Result:
  • No significant improvement in the intervention group in:
    • Frequency or depth of ACP discussions
    • Resident/family involvement (OPTION score: 38.82 vs control 40.10; p = 0.826)
  • Pre-post comparison showed no significant change in OPTION scores for either group 

3. Perceived Barriers and Facilitators (Qualitative Thematic Analysis):

• Barriers:
  • Hierarchy and unclear staff responsibilities (e.g. ACP “not in my job description”)
  • Time and work pressure
  • Lack of training, confidence, and structured processes
• Facilitators:
  • Support from supervisors and management
  • Involvement of all disciplines and staff levels
  • Continuing education and structured follow-up systems 

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Outcome Classification

• Policy outcome: Positive – Improved compliance with ACP policy
• Process outcome: No change – No measurable improvement in ACP practice or involvement of residents/families
• Person-centred outcome: Inconclusive – Residents were involved in over half of conversations, but practice remained unchanged overall

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Summary

While the ‘we DECide’ intervention improved institutional ACP policy alignment with best practices, it did not result in measurable improvements in day-to-day ACP practice. Barriers such as role ambiguity, lack of time, and insufficient reinforcement were prominent. Authors recommend long-term implementation strategies with broader organisational engagement and ongoing support.

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