Here is the PICO analysis for the article:
Full Article Title:
Policy Without Technology: A Barrier to Improving Nursing Home Care
Authors: John F. Schnelle, PhD; Joseph G. Ouslander, MD; Patrice A. Cruise, RN, PhD
Journal: The Gerontologist (1997); 37(4):527–532
✅ PICO Analysis
Type of Study:
Narrative review and policy critique with supportive implementation studies
P – Population
- Setting:U.S. nursing homes subject to federal regulations under OBRA (Omnibus Budget Reconciliation Act) 1987
- Population Characteristics:
- Long-stay residents in skilled nursing facilities
- High prevalence of frailty, incontinence, cognitive impairment, immobility
- Care provided by aides with limited training; supervised by overstretched nursing and administrative teams
I – Intervention
Policy-driven implementation of best practice standards in nursing homes without sufficient enabling technology or resource planning:
- Focused domains:
- Urinary incontinence management
- Physical restraint reduction
- OBRA-mandated documentation and care planning (e.g., MDS and RAPs)
- Continuous Quality Improvement (CQI) strategies
- Specific interventions described:
- Prompted voiding protocols
- Control chart quality assurance systems for incontinence care
- Colored pad system for restraint monitoring
- Supervisor feedback loops and computerized compliance tracking
C – Comparison
- Implicit comparison between:
- Nursing homes attempting real clinical implementation of interventions vs those maintaining only paper documentation
- Homes with external research support vs post-research withdrawal
- Charted (paper) compliance vs actual care practices observed and measured
O – Outcomes
Person-Centred Outcomes (Inferred):
- Improved continence rates when prompted voiding interventions were supported
- Reduction in restraint time when visual monitoring systems were in place
- Quality of life potentially improved during periods of real intervention support
Process Outcomes:
- During implementation with research staff:
- 25–40% of incontinent residents improved with prompted voiding
- 56% restraint misuse fell to 15% using the colored pad monitoring system
- After research staff withdrawal:
- 7 of 8 homes discontinued incontinence program
- All 6 homes discontinued restraint monitoring system despite demonstrated success
Health System Outcomes (Inferred):
- Surveyors favoured documentation over real clinical improvements
- Facilities were incentivised to prioritise chart compliance due to the structure of regulatory surveys
- Recommendations included establishing applied research centres, internal CQI systems, and outcomes-linked surveys to support sustainable change
Summary Conclusion
This article provides a compelling critique of nursing home regulation and quality improvement efforts, arguing that without practical technologies, resource planning, and internal quality systems, even well-intended standards (e.g., for incontinence or restraint reduction) are unlikely to be implemented meaningfully. The authors show that research-supported interventions do work, but are not sustained without ongoing feedback, staff empowerment, and outcome-based survey reinforcement. They call for nursing home-based applied research centres and internal CQI systems integrated into external surveys to achieve durable, real-world improvements .
Life In The Slower Lane 
Leave a comment