Here is the standardised PICO analysis for the fifty-sixth uploaded article:
Full Title
Implementing Advance Care Planning in Routine Nursing Home Care: The Development of the Theory-Based ACP+ Program
Authors: Joni Gilissen, Lara Pivodic, Annelien Wendrich-van Dael, et al.
Journal: PLOS ONE, 2019; 14(10): e0223586
DOI: 10.1371/journal.pone.0223586
Type of Study
Intervention development study (pre-implementation phase using MRC framework, Theory of Change, and TIDieR reporting)
PICO Summary
Population (P)
- Nursing home staff and management from five Belgian facilities
- Multidisciplinary expert group and a palliative care nurse-trainer
- Residents and families were not directly involved in this developmental phase, but their preferences were considered in prior work
Intervention (I)
ACP+ Program – a theory-based, multicomponent intervention for embedding Advance Care Planning (ACP) in nursing home routines
- Composed of 10 components, 22 activities, and 17 materials
- Key features:
- Stepwise implementation over 8 months
- External ACP Trainer support initially, then internal handover to ACP Reference Persons
- Inclusion of non-clinical staff (e.g., cleaning staff, volunteers as ACP “Antennas”)
- Training, coaching, multidisciplinary meetings, family and GP engagement, audit, and tailoring of delivery strategies
Comparison (C)
- No control or comparator group in this development phase
- The programme was based on comparative analysis of previous ACP programs and expert review
Outcomes (O)
Developmental outcomes:
- Feasibility and acceptability assessed through interviews with 17 participants and expert review
- Generally rated as feasible if sufficiently tailored and resourced
- GP engagement deemed challenging due to scheduling and role clarity issues
- Need for simplified materials and flexible delivery pathways noted
Implementation design outcomes:
- Clear roles defined:
- ACP Trainer (external): initiates and supports change
- ACP Reference Persons (internal): sustain and embed ACP
- ACP Facilitators: conduct conversations
- ACP Antennas: detect readiness/signals
- Activities include initial shadowing, family/GP information sessions, audits, come-back seminars, and specialised training in dementia and communication
- The programme addresses organizational culture, communication norms, and structural constraints (e.g., time, staff turnover)
Findings Summary
The ACP+ program is a comprehensive, adaptable framework to embed advance care planning into day-to-day nursing home practices. Unlike many earlier programs, ACP+:
- Targets all levels of the organisation – from leadership to auxiliary staff
- Uses a trainer-to-trainer cascade model
- Allows for structured tailoring at the local facility level
- Includes multidisciplinary and non-clinical stakeholders
- Is described using the TIDieR checklist for clarity and replicability
Participants recommended:
- Flexible training schedules
- Embedded ACP in existing routines (e.g. team meetings)
- Simplified documents (e.g. the ACP Conversation Tool and checklists)
- Optional reflection sessions due to time constraints
Conclusion
The ACP+ program was found to be feasible, acceptable, and tailored for real-world integration. It is now undergoing testing in a cluster RCT. This paper serves as a detailed blueprint for replication, adaptation, and evaluation in other long-term care contexts.
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