Implementing a risk communication tool to support care planning conversations in long-term care: evaluation of healthcare provider training

Introduction

A palliative approach to care prioritizes quality of life for those with life-limiting illnesses, emphasizing communication, care planning, and psychosocial and spiritual support early on, adapting to changing needs as the illness progresses (1). Although palliative care is recommended from the time of diagnosis of a terminal or life-limiting illness, it is often conflated with end-of-life care, and few people receive it early in their disease course (2). Residents in long-term care (LTC) homes are often candidates for palliative care because many have progressive, incurable illnesses. In our study setting of Ontario, Canada, LTC home residents have an expected median survival of 18 months after admission (3). Despite their reduced life expectancy, according to a 2023 Canadian Institute for Health Information (CIHI) report, only 34% of residents in LTC with less than 6 months to live received palliative care; this number decreases to 19% for those in their last year of life (4).

Early palliative care allows healthcare providers, LTC residents, and their caregivers to understand the residents’ illness and care preferences, and act on these preferences before decline (5). Two key components to establishing care preferences are communication of prognosis and conversations around the residents’ wishes and goals for care (5).

The Risk Evaluation for Support: Predictions for Elder life in their Communities Tool (RESPECT) is a validated mortality risk communication tool that supports earlier identification of palliative care needs and goals-of-care discussions with personalized mortality risk estimates (www.respectcalculators.ca). RESPECT was originally created for individuals receiving home care (6) but has been adapted for LTC. RESPECT for LTC uses routinely collected health data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) to generate a life expectancy estimate, and presents this information in a patient-tested, user-friendly, personalized report (7).

While RESPECT provides prognostic information to trigger and inform goals-of-care discussions, many health care providers find these conversations challenging (8,9). Staff discomfort around goals-of-care conversations, a lack of training, perceived role ambiguity, and poor documentation often impede the advancement of these discussions (10,11).

The Serious Illness Care Program, developed by Ariadne Labs, is a framework for interdisciplinary healthcare providers to encourage earlier, higher quality discussions of what is most important to patients (12). In the context of palliative care, the Serious Illness Conversation (SIC) Guide is a tool that can be used to guide empathetic and productive discussions around the wishes and goals of care of someone with a life-limiting illness. The SIC Guide has been recommended as a best practice tool by several Canadian palliative care organizations, including the Canadian Society of Palliative Care Physicians and several provincial governments (13-15). However, to our knowledge, the tool has not been widely evaluated in an LTC setting.

Few palliative care tools are widely adopted into practice after their development and evaluated on their sustained use (16-18). Inadequate training and education are key barriers to sustainable implementation of palliative care tools (19). Furthermore, the effectiveness of training sessions in LTC settings varies with the context, material covered, and methods used (20-22)—highlighting the role and value of implementation frameworks in guiding the evaluation of these efforts in LTC settings (20,22).

The Theoretical Domains Framework (TDF) is a well-established implementation framework used to identify cognitive, emotional, social, and environmental factors that influence behaviour change, such as adopting new tools in practice (23). In this context, the TDF will be applied to systematically identify barriers and enablers to performing key palliative care behaviours, following the introduction of new palliative care tools. These drivers can then be mapped to targeted, evidence-based implementation strategies tailored to the healthcare context, increasing the likelihood of sustained practice change following adoption.

In this study, we used the TDF to guide a pre-post training evaluation of two complementary palliative care tools, RESPECT and the SIC Guide in LTC, with a focus on measuring healthcare providers’ ability to perform key palliative care behaviours in routine practice. We present this article in accordance with the SQUIRE reporting checklist (24) (available at https://apm.amegroups.com/article/view/10.21037/apm-2026-1-0007/rc).

Methods

Context

Three LTC homes in Ontario, Canada, each participated in a 4-hour in-person training session. These three sessions were held in June 2023, September 2023, and October 2023. All participating homes were medium-sized facilities with 100–300 licensed beds. Two were in an urban setting, while the third was in a rural setting. All three homes were not-for-profit.

Training was provided to interdisciplinary teams, including physicians, nurses, and other staff, who lead goals-of-care discussions with LTC residents and their families. An implementation leader within the LTC homes identified staff who would benefit from training. Protected time was provided to trainees through backfill pay support offered to the LTC home. Additionally, physician participants were offered Continuing Medical Education Credits, which contributed to their professional development requirements.

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This project has received exemption from ethics approval by ethics committee of The Bruyère Health Research Institute, as it is a quality improvement study. Each evaluation survey included an informed consent statement outlining the study purpose, confidentiality, voluntary participation, and indicating that completion of the questionnaire implied consent to participate. Please see Appendix 1 for the complete statement.

Training summary

The training sessions on RESPECT and the SIC Guide (Figure 1) included:

• A 1-hour session on RESPECT, covering research surrounding the development of the tool, how to use it, and how to interpret the outputs. Training was provided by members of the RESPECT Research Team.
• A 3-hour session on using the SIC Guide to increase participants’ capacity to screen and assess a resident’s values, wishes, and goals for current and future care. The communication training was conducted by Pallium Canada-certified SIC training facilitators. It featured a role-play component, where participants broke into smaller groups (1:3 or 1:6 ratio between facilitator and participants) and practiced various hypothetical scenarios using the SIC Guide.

Figure 1 Sample RESPECT personal report and Serious Illness Conversation Guide used in long-term care staff training on palliative care. (A) The RESPECT long-term care personal report. (B) Sample of the Serious Illness Conversation Guide, developed by Ariadne Labs: A Joint Center for Health Systems Innovation (www.ariadnelabs.org) at Brigham and Womenʼs Hospital and the Harvard T.H. Chan School of Public Health. Licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (http://creativecommons.org/licenses/by-nc-sa/4.0/). RESPECT, Risk Evaluation for Support: Predictions for Elder life in their Communities Tool.

Both sessions were interactive and included a question-and-answer segment at the end. Participants also received a take-home training package containing printed slides from both sessions, with space for note taking, and a copy of the SIC Guide.

Pre-post training evaluation

Using the TDF, we examined the co-delivery of RESPECT and the SIC Guide training in improving healthcare providers’ ability to perform palliative care behaviours. Specifically, the evaluation measured participants’ perspectives using two target behaviours associated with improving early end-of-life conversations: (I) identifying residents who may benefit from a palliative approach earlier; and (II) capturing ongoing discussions with residents and families about wishes and goals of care. These two target behaviours were selected through discussion and consensus between a group of experts in health services and behavioural science.

Pre- and post-training online surveys were administered to all participants immediately before and after the training. A follow-up survey was administered around 6 months into implementation, after staff have had the opportunity to implement the tools and skills obtained during training. Each survey took around 10 minutes to complete. The surveys were administered online via Microsoft Forms. A full version of the surveys can be found in Appendix 1.

Measures

For each target palliative care behaviour, participants responded to the same set of questions. Their ratings reflected the overall training experience, not the tools.

Questions included in the surveys were informed by the TDF, a validated framework designed to assist with the implementation and evaluation of new practices using cognitive, affective, social, and environmental factors to identify determinants of behaviour (23). It contains fourteen domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory, attention and decision processes, environmental context and resources, social influences, emotion, and behavioural regulation.

Two of the study’s investigators assessed the fourteen TDF domains to identify those most relevant to the target behaviours of interest. Domains that were irrelevant to each target behaviour were excluded. The ‘optimism’ and ‘memory, attention and decision processes’ domains, for example, were excluded for the first target behaviour (identifying residents earlier), meaning 12 domains were included in the final analysis. ‘Optimism’, ‘memory, attention and decision processes’, and ‘emotion’ were excluded for the second target behaviour (capturing goals of care discussions), meaning 11 domains were included in the final analysis.

Each question was set up as a Likert scale with five options, ranging from “strongly agree” to “strongly disagree”. Each survey contained 16–18 items that were considered in this analysis.

Analysis

Survey results were analyzed descriptively, and no inferential tests were performed. For ease of interpretation and due to our small sample size, some response categories were collapsed (i.e., “strongly agree” with “agree”, and “strongly disagree” with “disagree”). We computed and presented the proportions of respondents who agreed or strongly agreed with each statement between pre-training, post-training, and at the 6-month follow-up.

Results

A total of 35 training participants across three LTC homes were included. All participants completed the pre-training survey, 63% (n=22) completed the post-training survey, and 34% (n=12) completed the 6-month follow-up survey. Only two out of the three homes were able to participate in the 6-month follow-up. Most participants were physicians and registered nurses (see Table 1).

Target behaviour #1: identifying residents earlier who could benefit from a palliative approach

The survey responses for the first target behaviour are summarized in Table 2.

Participants consistently recognized early identification as part of their professional role (TDF domain: social/professional role and identity) and believed they were making a positive difference (domain: beliefs about consequences). Intentions to carry out this behaviour were strong and sustained over time (domain: intention), and nearly all participants felt earlier identification could benefit their residents (domain: beliefs about consequences).

Training led to marked, sustained improvements in capability-related domains. Participants reported increased confidence (domain: beliefs about capabilities, 26% increase post-training) and knowledge of steps involved (domain: knowledge, 31% increase post-training) in earlier identification of residents who could benefit from palliative care. They also reported having the opportunity to practice the target behaviour and felt they had received sufficient training to perform it (domain: skills, 43% increase post-training).

However, change was not sustained in several domains. While many participants believed their colleagues supported early identification immediately post-training, this decreased after 6 months (domain: social influences, decreased by 19%). Perceived importance of early identification as a priority (domain: goals, decreased by 32%) and perception of time availability (domain: environmental context and resources, decreased by 6%) were also lower after 6 months. Notably, plans or systems to support this behaviour were still lacking after 6 months (domain: behavioural regulation, decreased 15%). Recognition from peers remained limited throughout the training and implementation period (domain: reinforcement), and most felt competing demands could get in the way of early identification across all three time points (domain: goals).

Target behaviour #2: capturing discussions with residents and families around wishes and goals of care

The survey responses for the second target behaviour are summarized in Table 3.

Participants consistently felt that capturing discussions around wishes and goals of care was part of their professional role (domain: social/professional role and identity) and that it made a positive difference for their residents (domain: reinforcement). Nearly all agreed that these conversations were beneficial for residents (domain: beliefs about consequences) and expressed strong intentions to carry them out (domain: intention).

Training led to substantial, sustained improvements in confidence (domain: beliefs about capabilities, 20% increase post-training) and knowledge of steps involved in documenting the goals-of-care discussions (domain: knowledge, 41% increase post-training). Participants also felt they had opportunities to practice the target behaviour, and the training sufficiently prepared them to perform it (domain: skills, 51% increase post-training). This was supported by perceptions of having the necessary resources to perform the target behaviour (domain: environmental context and resources, 28% increase post-training). Most participants reported having a plan to capture discussions after training, though fewer reported having one after the 6-month period than immediately post-training (domain: behavioural regulation, decreased by 7%).

Systems for tracking discussions increased immediately after training but were not well maintained at the 6-month follow-up (domain: behavioural regulation, decreased by 19%). Similar to the first target behaviour, perceived time availability improved at first (domain: environmental context and resources, increased by 41% post-training), but declined after 6 months (−14%), resulting in only marginal long-term improvements. Also similar to the first target behaviour, competing demands were consistently seen as a barrier (domain: goals), and many participants did not feel adequately recognized (domain: reinforcement).

Discussion

Summary

Across both target palliative care behaviours—earlier identification of residents and capturing goals-of-care discussions—participants consistently reported positive attitudes, viewing them as part of their professional role and important to resident care. Training enhanced knowledge, skills, and confidence, with most gains sustained at 6 months. However, improvements in behavioural regulation (e.g., being able to monitor progress of key palliative care practices) and perceptions of environmental supports, such as time and access to tools, diminished over time. Persistent barriers included competing demands and limited recognition from colleagues. Although social support initially improved, it did not translate into sustained practice, suggesting palliative approaches are not embedded in organizational culture. Lasting change will require reinforcement across entire teams rather than training only a small subset of staff.

Interpretation

Our findings align with previous studies showing that most healthcare providers see the importance of having earlier conversations about palliative care needs (25) and the value of training in this area to improve practice (22,26). It is worth noting, however, that many studies did not follow up on the long-term effects of the one-off training sessions (22). This study shows that training improves knowledge and capability, and this improvement can be sustained over a longer period.

While training effectively improved individual knowledge and skills, improvements in behavioural regulation, perceived time availability, and resource access were less sustained at follow-up. This finding is consistent with existing literature, which highlights environmental factors like time constraints and limited resources as persistent barriers to implementing practice changes through education-based interventions (20,22,27). Clearly outlining actionable steps that staff can incorporate into their existing workflow may encourage more sustained changes in behaviour that support the implementation of palliative care tools (28). These changes must be clearly communicated, especially when the intervention will be integrated into existing organizational structures (28).

The barriers observed in this study align with broader challenges reported in the LTC sector. Past studies suggest that the effectiveness of training can vary based on context (20-22). In this study, several contextual barriers prevented the application of skills and knowledge gained through training. High workloads, staffing shortages, and frequent staff turnover have also been widely documented, and likely contributed to the competing demands and lack of structured systems reported by participants (22,27,29).

Notably, both limited time availability and competing demands emerged as potential barriers in this study. Perceived time constraints reflect insufficient time to complete tasks, whereas competing demands relate to the perceived urgency of multiple tasks. In LTC settings, staff often experience both concurrently, with many tasks required of them being perceived as urgent (30), limiting their capacity to integrate new practices.

Training participants also consistently reported a lack of recognition for performing the target behaviours well. Past studies have shown that recognition of healthcare staff’s efforts can encourage hope and reduce burnout (31). Recognition has also been shown to improve engagement with palliative care interventions in LTC homes (28). To encourage sustainable implementation of palliative tools, systems must be put in place to consistently recognise and reinforce positive changes in care practices.

Implications for practice and future research

The use of the TDF in this study provided a comprehensive lens for identifying both the strengths and limitations of the RESPECT and SIC Guide training program. By capturing cognitive, affective, social, and environmental influences on healthcare provider behaviour (23), the TDF helped pinpoint specific indicators of change as well as persistent barriers to implementation. These can be used to identify specific interventions aligned with each indicator to explore in future studies.

Ongoing evaluation post-implementation is critical to adapting interventions and training content in response to evolving needs. Future research should examine the effectiveness of implementation support strategies, such as coaching, audit and feedback, or digital reminders in maintaining behavioural changes over time.

Limitations

Differences in response rates across time points limit generalizability and introduce potential non-response bias. Although pre-training survey completion was 100%, only 63% completed post-training, and only two of three homes participated in the follow-up, with 48% of participants from those homes completing the 6-month survey. Despite multiple reminders from the point of contact in the third home, there was no engagement from the participants at the 6-month time point. This raises concern that follow-up respondents may have been more engaged in training and implementation, potentially skewing results positively. A sensitivity analysis excluding the third home was subsequently conducted and showed no change in the results (see Appendix 2). No statistical testing was conducted, as this quality improvement study did not include pre-specified hypotheses for formal testing.

In addition to variation in response rates, some target behaviours may have been interpreted differently by respondents. For example, “capturing goals of care discussions” may have been understood as documentation of discussions by some participants and as actively engaging in discussions by others, potentially influencing survey responses. Clearer a priori definitions of target behaviours, informed by greater clinician input and pilot testing, may have reduced this ambiguity.

This study also evaluated a one-off training session without follow-ups to reinforce and troubleshoot issues. Single-point training is helpful for seeing the initial boost in scores post-training and the sustainability of these changes over time without additional support, but a multi-session approach may have led to more sustained changes. Adapting training to the specific roles participants play in the palliative care process may also support more sustained practice change. For example, it was observed during implementation that physicians were often more comfortable sharing prognoses, while nurses and other allied health providers felt this was outside their scope of practice. This indicates that non-physician providers could benefit from additional training on how to share life expectancy-related data with LTC residents and their families. While there are similarities in the barriers faced by both physicians and non-physicians, role-specific training could facilitate clearer integration of palliative care tools into their individual workflows.

Although the TDF provides a comprehensive range of theory-based behaviour change indicators, it does not account for the interactions between determinants or offer a means of weighing their relative importance across different contexts (23). Previous studies using the TDF to assess healthcare provider behaviour have reported similar benefits and challenges (32-34).

Conclusions

This study evaluated training sessions designed to support the implementation of a mortality risk communication tool, RESPECT, and the SIC Guide into three Ontario LTC homes. While training improved the participants’ knowledge and skills around palliative care activities, behavioural regulation was not well sustained; competing demands and a lack of positive reinforcement were persistent barriers. Future training sessions should establish a clearer workflow based on the context of each LTC home, so there is easy access to resources and a tangible plan of action for implementation. Training should also be paired with system-wide supports to accommodate competing demands and create a supportive culture around palliative care.

Acknowledgments

We acknowledge the support of our SIC Guide training facilitators (Dr. Daniel Kobewka, Dr. Benoit Robert, Victoria Murray, Kathryn May, and Ruth E. Forbes). We also thank the three participating homes, which remain anonymous, and the staff within each home who coordinated the training and implementation.

Footnote

Reporting Checklist: The authors have completed the SQUIRE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2026-1-0007/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-2026-1-0007/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2026-1-0007/prf

Funding: This work was supported by the Canadian Institutes of Health Research (funding reference No. SL5-174747) and by Health Canada through the Health Care Policy and Strategies Program. The views expressed herein do not necessarily represent the views of Health Canada.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2026-1-0007/coif). S.A. is self-employed, through Quality Life Planning, and is also employed by Hamilton Health Sciences. She also provides consulting services to Cambridge LLP. These relationships are disclosed for transparency. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This project has received exemption from ethics approval by ethics committee of The Bruyère Health Research Institute, as it is a quality improvement study. Each evaluation survey included an informed consent statement outlining the study purpose, confidentiality, voluntary participation, and indicating that completion of the questionnaire implied consent to participate. Please see Appendix 1 for the complete statement.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. The Palliative Approach: Improving Care for Canadians with Life Limiting Illnesses. Available online: https://www.chpca.ca/wp content/uploads/2024/04/TWF-PA1.pdf
2. Zimmermann C, Wong JL, Swami N, et al. Public knowledge and attitudes concerning palliative care. BMJ Support Palliat Care 2021;bmjspcare-2021-003340.
3. Tanuseputro P, Roberts RL, Milani C, et al. Palliative End-of-Life Medication Prescribing Rates in Long-Term Care: A Retrospective Cohort Study. J Am Med Dir Assoc 2024;25:532-538.e8. [Crossref] [PubMed]
4. Canadian Institute for Health Information. Access to Palliative Care in Canada, 2023. Ottawa: CIHI; 2023. Available online: https://www.cihi.ca/sites/default/files/document/access-to-palliative-care-in-canada-2023-report-en.pdf
5. Kircher CE, Hanna TP, Tranmer J, et al. Defining "early palliative care" for adults diagnosed with a life-limiting illness: a scoping review. BMC Palliat Care 2025;24:93. [Crossref] [PubMed]
6. Hsu AT, Manuel DG, Spruin S, et al. Predicting death in home care users: derivation and validation of the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT). CMAJ 2021;193:E997-E1005. [Crossref] [PubMed]
7. Hsu AT, Espadero C, Tanuseputro P, et al. Using routinely collected data to develop and evaluate a clinical tool for early identification of palliative care needs in long-term care: The RESPECT Project. Int J Popul Data Sci 2022;7:1858.
8. Zhou Y, Wang A, Braybrook D, et al. What are the barriers and facilitators to advance care planning with older people in long-term care facilities? A qualitative study. J Clin Nurs 2024; Epub ahead of print. [Crossref]
9. Bruun A, White N, Oostendorp L, et al. Prognostication As an Interactionally Delicate Matter: A Conversation Analytic Study of Hospice Multidisciplinary Team Meetings. Health Commun 2025;40:956-64. [Crossref] [PubMed]
10. Gilissen J, Wendrich-Van Dael A, Gastmans C, et al. Mixed methods process evaluation of an advance care planning intervention among nursing home staff. Palliat Med 2025;39:113-25. [Crossref] [PubMed]
11. Brown J, Hu-Collins P. Communication training for effective Goals of Patient Care conversations in acute care: An integrative review of the literature. Palliat Support Care 2025;23:e81. [Crossref] [PubMed]
12. Beddard-Huber E, Strachan P, Brown S, et al. Supporting Interprofessional Engagement in Serious Illness Conversations: An Adapted Resource. J Hosp Palliat Nurs 2021;23:38-45. [Crossref] [PubMed]
13. Health Canada. The framework on palliative care in Canada – five years later. 2023. Available online: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/framework-palliative-care-five-years-later/final-pdf-english-report-to-parliament-palliative-care.pdf
14. Time to Talk. Available online: https://choosingwiselycanada.org/serious-illness-conversations/
15. Serious Illness Care Program Reference Guide for Clinicians. 2018. Available online: www.ariadnelabs.org
16. Gallagher E, Carter-Ramirez D, Boese K, et al. Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada. BMC Fam Pract 2021;22:58. [Crossref] [PubMed]
17. Meddick-Dyson SA, Boland JW, Pearson M, et al. Implementation lessons learnt when trialling palliative care interventions in the intensive care unit: relationships between determinants, implementation strategies, and models of delivery—a systematic review protocol. Syst Rev Internet 2022;11:186.
18. Bauer MS, Damschroder L, Hagedorn H, et al. An introduction to implementation science for the non-specialist. BMC Psychol 2015;3:32. [Crossref] [PubMed]
19. Saretta M, Doñate-Martínez A, Alhambra-Borrás T. Barriers and facilitators for an effective palliative care communication with older people: A systematic review. Patient Educ Couns 2022;105:2671-82. [Crossref] [PubMed]
20. Newbould L, Samsi K, Wilberforce M. Developing effective workforce training to support the long-term care of older adults: A review of reviews. Health Soc Care Community 2022;30:2202-17. [Crossref] [PubMed]
21. Lamppu PJ, Laakkonen ML, Finne-Soveri H, et al. Training Staff in Long-Term Care Facilities-Effects on Residents' Symptoms, Psychological Well-Being, and Proxy Satisfaction. J Pain Symptom Manage 2021;62:e4-12. [Crossref] [PubMed]
22. Iida K, Ryan A, Hasson F, et al. Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature. Int J Older People Nurs 2021;16:e12347. [Crossref] [PubMed]
23. Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci 2017;12:77. [Crossref] [PubMed]
24. Ogrinc G, Davies L, Goodman D, et al. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016;25:986-92. [Crossref] [PubMed]
25. Tietbohl CK, Dafoe A, Jordan SR, et al. Palliative Care across Settings: Perspectives from Inpatient, Primary Care, and Home Health Care Providers and Staff. Am J Hosp Palliat Care 2023;40:1371-8. [Crossref] [PubMed]
26. Yash Pal R, Chua MT, Guo L, et al. The Impact of Palliative and End-of-Life Care Educational Intervention in Emergency Departments in Singapore: An Interrupted Time Series Analysis. Medicina (Kaunas) 2025;61:173. [Crossref] [PubMed]
27. Sun AH, Crick M, Orosz Z, et al. An Evaluation of the Communication at End-of-Life Education Program for Personal Support Workers in Long-Term Care. J Palliat Med 2022;25:89-96. [Crossref] [PubMed]
28. Collingridge Moore D, Payne S, Van den Block L, et al. Strategies for the implementation of palliative care education and organizational interventions in long-term care facilities: A scoping review. Palliat Med 2020;34:558-70. [Crossref] [PubMed]
29. Havaei F, Sims-Gould J, Staempfli S, et al. Impact of the single site order in LTC: exacerbation of an overburdened system. BMC Health Serv Res 2023;23:666. [Crossref] [PubMed]
30. Ludlow K, Churruca K, Ellis LA, et al. Decisions and Dilemmas: The Context of Prioritization Dilemmas and Influences on Staff Members' Prioritization Decisions in Residential Aged Care. Qual Health Res 2021;31:1306-18. [Crossref] [PubMed]
31. Green J, Berdahl CT, Ye X, et al. The impact of positive reinforcement on teamwork climate, resiliency, and burnout during the COVID-19 pandemic: The TEAM-ICU (Transforming Employee Attitudes via Messaging strengthens Interconnection, Communication, and Unity) pilot study. J Health Psychol 2023;28:267-78. [Crossref] [PubMed]
32. Skoien W, Page K, Parsonage W, et al. Use of the Theoretical Domains Framework to evaluate factors driving successful implementation of the Accelerated Chest pain Risk Evaluation (ACRE) project. Implement Sci 2016;11:136. [Crossref] [PubMed]
33. Lawton R, Heyhoe J, Louch G, et al. Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study. Implement Sci 2016;11:113. [Crossref] [PubMed]
34. Smith JD, Corace KM, MacDonald TK, et al. Application of the Theoretical Domains Framework to identify factors that influence hand hygiene compliance in long-term care. J Hosp Infect 2019;101:393-8. [Crossref] [PubMed]