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| Author, year, and place | The aim | Development initiatives/interventions | Methods of evaluation | Conclusion |
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| Ling, 2005 [12], Ireland | To assess the current level of input from community-based clinical nurse specialists (CNSs) in palliative care into nursing homes in Ireland. | Telephone contact with nursing homes on pain and symptom management. The majority of nurses were involved exclusively in care of patients with cancer, although 40% of respondents cared for patients with nonmalignant diseases. | A national survey of all community-based CNS, 116 questionnaires, and 65 responses. | CNS in palliative care in nursing homes focuses on physical care. CNS specialists are ideally placed to provide education and support to nursing homes. |
| Edwards and Hirst, 2005 [25], UK | The intervention (new specialist nurse post) was to improve the accessibility and availability of generalist and specialist care and palliative care (PC) resources in the district and to ensure high-quality end-of-life care for patients in care homes (CH) in Wakefield. | All CHs received an updated resource file for PCS. Education: an “Introduction to PC” training session was developed for newly appointed staff in the CH about syringe drivers and pain assessment. Patient contact with the CNS. | Questionnaire to NHs (number is unclear). | The CHs were appreciative of the support and felt more able to care for their patients. An increase in post for further 22.5 hours a week. |
| Duffy and Woodland, 2006 [27], UK | To describe a pilot project to introduce the Liverpool Care Pathway (LCP) into care homes local to the Queen Mary’s Sidcup NHS Trust with a view to reducing the number of very ill elderly patients who are transferred to acute trust from care homes. | Implementation of LCP at a care home. Two flow charts were designed with a view to guide the staff. Audit pack. Meetings with the GPs and district nurses. Resource files for each of the units were produced. | Unclear, but involved audits, registration of deaths in home or hospital before and after implementation of LCP, feedback from the involved professionals including GPs. | LCP had empowered the staff to talk more openly to relatives and they felt more familiar with the paperwork; possibility to prepare ahead; ask the GP to prescribe drugs in advance. But it was difficult for staff to gauge when to start the pathway. GPs felt that overall the implementation had gone well. |
| Mathews and Finch, 2006 [28], UK | To outline a pilot project to introduce LCP to a 150-beds nursing home. | Implementation of the LCP included discussion with the local GPs, information to the local out-of-hours chemist, and ambulance service. Education of key professionals. All trained nursing staff received three hours of palliative care education. | Unclear, but involved audits of 10 patients on the LCP and a reflection group. | The audit showed improvement of documentation and assessment of the key symptoms they experienced. LCP ensured that the patients received a high standard of palliative care and were allowed to die in the comfort and security of the place they call home. |
| Fernandes, 2008 [26], Australia | To examine the process of how residents’ end-of-life care (EOLC) wishes are recorded and to ensure that the implementation of an advance care plan (ACP) is performed according to the best available evidence. | Implement and ensure the implementation of ACP. Developed audit criteria: (1) documented evidence that the RES has been involved in ACP, (2) documented evidence that RELs have had the opportunity to be involved in an ACP, (3) staff who complete ACP have received training in this area, (4) staff who implement ACP have received education regarding EOLC issues, (5) documented evidence that the relatives have received education regarding changes in the end-of-life phase. | Pre- and postimplementation audits of 100 residents’ documentation and 20 staff to determine compliance following the second stage. | Preimplementation audit indicated poor compliance with best practice, less than 50%. Compliance increased for all criteria after implementation of the process, ranging from 77% to 100 %. The evaluation showed seven barriers, which included deficits related to the knowledge and education of RES, REL, and staff, and issues related to administration and documentation, and concerns that any implementation process would not be sustainable. RES and REL expressed a high level of satisfaction with the changes. |
| Badger et al., 2009 [31], UK | To evaluate the impact of the introduction of the Gold Standards Framework for care homes (GSFNH) in nursing homes in England. | The research framework was based on a modified action research approach.
Implementation of the GSFNH (phase 1) included introducing the organisational tool, the GSFCH, support to homes from a local GSFCH facilitator, support by the development team, a helpline and conference calls, training for care home staff, and support of NH managers. | Pre- and postsurvey. The 95 NHs were invited to participate in the evaluation. NHs completed a baseline survey of care provision and an audit of five most recent resident deaths. The survey and audit were repeated post programme completion. 49 homes returned completed pre- and post- surveys, 44 returned pre- and postdata on deaths. | Statistically significant increases in the proportion of residents who died in the NHs and those who had an Advanced Care Plan. Crisis admissions to hospital were significantly reduced. |
| Hockley et al., 2010 [30], UK | To report the impact of implementing The Gold Standard Framework for Care Homes (GSFCH) and an adapted Liverpool Care Pathway for Care Homes (LCP) at seven private nursing homes (NH). | Implementation of GSFCH and LCP included workshops and a course, visits to each NH every 10–14 days by the facilitators. | Quantitative data from all clinical notes on deceased residents from two cohorts: those who had died a year previous to the project and those who had died during/following the implementation of the GSFCH/LCP. Staff audits: a sheet with 50 statements was sent to all trained nurses and carers who had been at the NHs for the duration of the project. | There was a highly statistically significant increase in the use of do not attempt Resuscitation (DNAR) documentation, Advance Care Planning and use of the LCP. A reduction in unnecessary hospital admissions and a reduction in hospital deaths from 15% deaths before study to 8% deaths after study. The staff felt more comfortable in addressing psychosocial and emotional needs; in talking to relatives and residents about dying; more confident in recognizing the different stages of the dying process. |
(Watson et al., 2010) [29], UK
(Same study Hockley et al., 2010) [30] | To report the impact of implementing The Gold Standard Framework for Care Homes (GSFCH) and an adapted Liverpool Care Pathway for care homes (LCP) at seven private nursing homes (NH). | Implementation of GSFCH and LCP. | Qualitative interviews with 22 bereaved relatives before, 14 bereaved relatives, and six care home managers after implementation of the GSFCH and LCP into seven care homes. | Care home staff changed their attitudes about dying. This enabled more informed end-of-life decision making involving REL, staff, and GPs. REL talked less about poor care. Improvements in care of the dying following implementation of both tools. |
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