Here is the standardised PICO analysis for the sixty-fourth uploaded article:
Full Title
Barriers and Facilitators to Implementing a Pragmatic Trial to Improve Advance Care Planning in the Nursing Home Setting
Authors: Jennifer A. Palmer, Victoria A. Parker, Vincent Mor, et al.
Journal: BMC Health Services Research, 2019; 19:527
DOI: 10.1186/s12913-019-4309-5
Type of Study
Qualitative evaluation of implementation fidelity in a pragmatic randomised controlled trial (PROVEN trial) using the Consolidated Framework for Implementation Research (CFIR)
PICO Summary
Population (P)
- ACP Champions (mainly social workers) at 119 nursing homes involved in the intervention arm of the PROVEN trial
- Participants were responsible for delivering advance care planning (ACP) video interventions to residents and/or families across for-profit U.S. nursing homes
Intervention (I)
- Advance Care Planning (ACP) video intervention with 5 short educational videos (~6–10 minutes), adapted by clinical situation:
- General Goals of Care
- Goals for Advanced Dementia
- Hospice
- Hospitalization
- ACP for Healthy Patients
- Videos shown via tablet or online to short-stay and long-stay residents/families
- Champions were to offer videos within 7 days of admission and every 6 months thereafter
Comparison (C)
- No control group for this qualitative study, but thematic comparison of high- vs. low-adhering sites across five CFIR domains
Outcomes (O)
Implementation outcomes (themes synthesised via CFIR):
- Intervention Characteristics (Facilitators):
- Videos perceived as high-quality, understandable, and useful ACP conversation openers
- Visual format was advantageous over verbal discussion alone
- Adaptability was valued: multiple languages, choice of platform, and topic tailoring
- Duration (~6 minutes) viewed as short and manageable
- Inner Setting (Barriers):
- Major barrier: time constraints and staff workload
- Mixed communication quality across teams; new staff often unaware of the intervention
- Variable integration into workflows; some sites could align ACP videos with care planning sessions, others struggled
- Characteristics of Individuals (Barriers):
- Many Champions reported resistance from residents or families, often due to:
- Belief ACP wasn’t relevant (e.g., “I’m young” or “I’ve already done it”)
- Emotional unpreparedness to engage in end-of-life discussions
- Experienced Champions sometimes felt videos were redundant; others saw them as helpful tools for new staff
- Many Champions reported resistance from residents or families, often due to:
- Outer Setting (Barriers):
- Mandated delivery to all patients (vs. discretionary use) reduced perceived value
- Repeated video offers every 6 months created resistance, especially if clinical status was unchanged
- Required EMR documentation felt burdensome and lacking in clinical purpose
- Process (Mixed):
- Formal training was mostly effective, but inconsistently delivered to new Champions
- Champions valued cross-facility calls as “the best part” of implementation for sharing strategies
- Customization of the delivery method (e.g., adding snacks, tailoring language) was widely used and welcomed
Conclusion
This study highlighted the complex interplay between intervention design, organisational readiness, individual emotional preparedness, and implementation processes in delivering ACP in real-world nursing home settings. Despite strong facilitators (e.g., adaptability, visual engagement, short duration), barriers included:
- Rigid protocol mandates
- Competing clinical demands
- Variable engagement and readiness from families, patients, and staff
The findings advocate for:
- Early engagement of end-users (staff, families, residents) in pragmatic trial design
- Allowing flexible implementation strategies to maintain core fidelity without excessive burden
- Building ACP interventions that are simple yet sensitive to timing, readiness, and emotional context
Life In The Slower Lane 
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