Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Implementing a quality improvement programme in palliative care in care homes: a qualitative study

Authors: Hall S, Goddard C, Stewart F, Higginson IJ

Journal: BMC Geriatrics (2011); 11:31

DOI: 10.1186/1471-2318-11-31

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✅ PICO Analysis

Type of Study:

Qualitative descriptive study using semi-structured interviews and thematic framework analysis

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P – Population

• Setting:Nine nursing homes for older people in two boroughs in London, UK
• Participants:
  • 9 care home managers
  • 8 nurses
  • 9 care assistants
  • 11 residents
  • 7 family members
• Characteristics:All participating care homes had engaged with the Gold Standards Framework for Care Homes (GSFCH) programme at different phases of implementation. All homes had on-site nursing and were privately funded. Participants were drawn from ethnically diverse populations with variable experience in palliative care and end-of-life discussions.

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I – Intervention

• Gold Standards Framework for Care Homes (GSFCH):A structured, multi-component quality improvement program aiming to enhance end-of-life care in care homes.
• Key Elements (7 Cs):
  • Communication (e.g., supportive care registers, advance care planning)
  • Coordination (appointing a palliative care lead)
  • Control of symptoms (assessment tools, management protocols)
  • Continuity (out-of-hours handover forms)
  • Continued learning (staff training and reflective learning)
  • Carer support (for staff and bereaved families)
  • Care in the dying phase (use of the Liverpool Care Pathway)
• Support Structures:Implementation supported by external GSFCH facilitators and local palliative care teams.

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C – Comparison

• No formal comparison groupThis was an exploratory qualitative study. However, informal internal comparisons were drawn between:
  • Earlier phase vs later phase homes
  • Homes that withdrew from or completed the programme
  • Residents/families with vs without direct experience of GSFCH tools

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O – Outcomes

Reported Outcomes:

1. Perceived Benefits (Process and Person-Centred Outcomes):
   • Improved symptom control (person-centred)
   • Enhanced team communication and coordination
   • Increased staff confidence and knowledge (process)
   • Greater resident choice around dying in place
   • Boost to the reputation of the home (system/organisational)
2. Perceived Barriers (Process and System Outcomes):
   • Time burden, paperwork, and staff workload
   • GP engagement issues and limited feedback loops
   • Cultural/language barriers in discussing death
   • Reluctance around advance care planning conversations
   • Unclear documentation uptake in hospital settings
   • Infrequent use of pathways like the LCP led to skill attrition
3. Implementation Challenges:
   • Low implementation fidelity in some homes
   • Difficulties coding stage of illness or estimating prognosis
   • Limited resources for staff training and bereavement support

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Outcome Classification

• Person-Centred Outcomes:
  • Symptom control
  • Resident and family satisfaction with care
  • Choice in place of death
  • Perceptions of dignity and support
• Process Outcomes:
  • Use of supportive care registers
  • Advance care planning documentation
  • Team meetings and interprofessional collaboration
  • Use of symptom assessment tools
  • Staff confidence and training
• System-Level Outcomes:
  • Organisational barriers (e.g. staffing, time, financial resources)
  • Challenges in sustaining implementation
  • External coordination with GPs and hospitals

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