Here is the standardised PICO analysis for the forty-fifth uploaded article:
Full Title
Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review
Authors: Pauli J. Lamppu, Kaisu H. Pitkala
Journal: Journal of the American Medical Directors Association (JAMDA), 2021; 22(2): 268–278
DOI: 10.1016/j.jamda.2020.09.011
Type of Study
Systematic Review of 16 cluster-randomised controlled trials (cRCTs)
PICO Summary
Population (P)
- Nursing home residents, including subgroups with dementia or advanced disease
- Settings: long-term care facilities or residential aged care
- Total participants across included studies: over 40,000 residents, mostly aged 80–90 years, with a high proportion of females
Intervention (I)
- Staff training interventions related to end-of-life care or palliative care, including:
- Lectures, case-based learning, coaching, role-plays
- Structured advance care planning (ACP) education
- Multicomponent models (e.g. INTERACT, COSMOS, PACE)
- Train-the-trainer approaches in 9 studies
- Some studies also trained family caregivers or proxies
Comparison (C)
- Usual care, no training, or attention controls
Outcomes (O)
Primary outcomes:
- Resident-related outcomes, specifically:
- Quality of life (QOL)
- Quality of dying (QOD)
- Hospitalisations and emergency department visits
- Symptom burden and comfort
- Satisfaction with care (SWC)
Key findings:
- Only 1 high-quality trial and 2 moderate-quality trials showed reductions in hospitalisation
- No high-quality studies demonstrated improvement in QOL or QOD
- One moderate-quality study showed staff-reported improvement in QOD
- Training alone was often part of complex interventions, and its individual effect was difficult to isolate
- Interventions including family/proxy education were more likely to reduce hospital use
Findings Summary
This review revealed limited and inconsistent effects of staff training on end-of-life outcomes for residents. Most training programs:
- Were not guided by educational theory
- Had low fidelity or incomplete uptake
- Were embedded in complex interventions (e.g., ACP tools, system changes), making attribution to training difficult
The review suggests:
- Future trials should explore motivational and cultural change strategies
- Proxy involvement and specialist consultation (e.g. external palliative nurses) may enhance training impact
- Rigorous reporting of intervention fidelity, outcomes, and contextual factors is essential
Conclusion
While staff education in palliative care is often necessary, this review indicates it is not sufficient on its own to improve resident outcomes in a consistent way. Further research should focus on:
- Mechanisms of change, including motivation, role clarity, and organisational culture
- Pedagogically sound and targeted approaches tailored to context and population
- Exploring simpler, focused, lower-complexity models for greater impact
Life In The Slower Lane 
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