Life In The Slower Lane

Here is the standardised PICO analysis for the fifty-fifth uploaded article:

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Full Title

Improving shared decision-making in advance care planning: Implementation of a cluster randomized staff intervention in dementia care

Authors: Bart Goossens, Aline Sevenants, Anja Declercq, Chantal Van Audenhove

Journal: Patient Education and Counseling, 2020; 103(4):839–847

DOI: 10.1016/j.pec.2019.11.024

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Type of Study

Cluster randomised controlled trial (cRCT) conducted in 65 nursing home wards in Belgium

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PICO Summary

Population (P)

• Nursing home staff (n = 311) from 65 wards in 46 Belgian nursing homes
• Residents with dementia, their families, and interdisciplinary staff
• Participants included nurses, nursing assistants, support staff, and managers 

Intervention (I)

‘We DECide optimized’: a structured training program to improve shared decision-making (SDM) during advance care planning (ACP) conversations in dementia care

• Two 4-hour workshops, spaced one month apart, including:
  1. Theoretical training on SDM and ACP
  2. Role-play exercises
  3. Review of internal ACP policies
• Supported by:
  • Pocket cards, posters, PowerPoints
  • Homework between sessions
  • Follow-up implementation support at 3 and 9 months 

Comparison (C)

• Control group: no intervention during the study period; received training after data collection
• Wards randomised at the facility level to avoid contamination

Outcomes (O)

Primary outcome:

• Level of SDM in ACP conversations (measured using OPTION-12 scores)
  • Significant improvement in SDM scores at 3 and 6 months in the intervention group
  • Mean score increased from 26.6 to 56.0 vs. control decline from 27.5 to 22.3
  • No increase in conversation duration (average remained ~30 minutes) 

Secondary outcomes (from IFC-SDM questionnaire):

• Perceived competence in SDM: improved and sustained at 6 months
• Perceived importance: improved at 3 months (p = 0.031), but not sustained at 6 months
• Frequency of SDM use: no significant change 

Implementation outcomes:

• Facilitators:
  • Inclusion of management in training
  • Dementia-specific roleplay
  • Peer exchange between nursing homes
• Barriers:
  • High staff turnover
  • Low GP engagement
  • Limited staff in charge of ACP conversations 

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Findings Summary

This study found that a time-efficient, team-based training program significantly improved observable SDM behaviour in ACP conversations without extending conversation duration. Participants felt more competent and initially perceived SDM as more important, but these gains were susceptible to erosion without ongoing reinforcement.

Notably:

• Gains were achieved in a complex, time-constrained setting (nursing homes)
• Resident and family participation remained low (~49% of ACP discussions)
• Improvements were sustainable at 6 months, but organisational barriers (e.g. GP non-involvement, turnover) limited wider adoption 

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Conclusion

‘We DECide optimized’ effectively enhances staff capability and SDM quality in ACP for people with dementia. However, broader implementation will require structural adjustments—like embedding ACP in quality frameworks and incentivising continuity of trained staff.

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