Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Barriers to and Facilitators of Clinical Practice Guideline Use in Nursing Homes

Authors: Colón-Emeric CS, Lekan D, Utley-Smith Q, et al.

Journal: Journal of the American Geriatrics Society (JAGS) (2007); 55(9):1404–1409

DOI: 10.1111/j.1532-5415.2007.01297.x

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✅ PICO Analysis

Type of Study:

Qualitative descriptive study using semi-structured interviews and thematic analysis informed by Rogers’ Diffusion of Innovation model

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P – Population

• Setting:Four randomly selected community nursing homes (NHs) in central North Carolina, USA
• Participants:
  • 35 nursing home staff across hierarchical and disciplinary lines:
    • 3 medical directors / physicians
    • 2 nurse practitioners
    • 3 directors of nursing
    • 1 assistant DON
    • 4 administrative nurses (quality assurance, staff development, supervisors)
    • 10 floor nurses
    • 1 medication technician
    • 11 certified nursing assistants (CNAs)
  • Inclusion targeted staff involved in or affected by clinical guideline or protocol implementation

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I – Intervention (Exposure)

• Clinical Practice Guidelines (CPGs) and associated clinical protocols for conditions common in nursing homes (e.g., falls, osteoporosis, fever evaluation)
• Intervention focus:The study investigated perceptions, barriers, and facilitators related to the use of CPGs and protocols—whether formalised or ad hoc—in daily clinical care and decision-making
• No direct implementation was tested; rather, the study explored naturalistic use or non-use within existing facility operations

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C – Comparison

• No comparison groupThis was an exploratory qualitative study. Comparisons were drawn across different roles, facilities, and levels of staff awareness and engagement with CPGs.

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O – Outcomes

Person-Centred Outcomes (inferred):

• Improved alignment of care with evidence-based standards and individual preferences when CPGs were applied appropriately
• Resistance to CPGs perceived as replacing individualised, resident-centred care

Process Outcomes:

• Barriers identified:
  • Low awareness and confusion about what CPGs are
  • Staff perceptions of CPGs as inflexible “checklists”
  • Beliefs that CPGs conflict with resident or family goals
  • Limited staff education and professional autonomy (especially CNAs and LPNs)
  • Time pressures, turnover, understaffing
  • Overload of competing protocols and paperwork
  • Restricted CNA access to resident information (due to misinterpretation of HIPAA)
  • Inadequate communication across shifts and disciplines
• Facilitators identified:
  • Embedding CPGs into standing orders, training tools, and mandatory documentation
  • Incorporating them into regulatory or corporate policy tasks
  • Use of protocols as reminders for novice or busy staff
  • Promoting empowerment and rationale understanding among front-line staff

System Outcomes (inferred):

• Potential improvement in care consistency and safety if CPGs were better understood and operationalised
• Risk of non-adherence and fragmented care processes if barriers not addressed

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Summary Conclusion:

This study found that awareness and systematic adoption of CPGs in nursing homes were very low. Staff frequently confused CPGs with state regulations or internal policies. Barriers spanned all stages of innovation adoption—from knowledge gaps to resource limitations and philosophical conflicts with resident-centred care. Facilitators included regulatory alignment, simplified training, and incorporation of protocols into routine practices. The authors argue that efforts to increase CPG use must go beyond dissemination, addressing entrenched workflow constraints, philosophical resistance, and training needs to enable real-world implementation in complex care settings like nursing homes .

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