Continuing education interventions about person-centered care targeted for nurses in older people long-term care: a systematic review

The requirements for quality in the nursing care of older people has been written in most countries into: legislation [1], national guidelines [2, 3] and policy papers [4]. The requirements are also written into international ethical guidelines [5, 6] and e.g. in Finland’s legislation [7, 8]. (Ministry of Social Affairs and Health, 2018; Finlex, 980/2012). Person-centered care is often used as a quality indicator and is of ethical value [2‐8].

The conceptual roots of person-centered care are in theories based on the philosophy of humanism, which includes personhood and well-being theory [9], personality theory [10] and nursing theories [11, 12]. In the nursing literature, the concept of person-centered care is often used as a synonym for other terms, such as individualized care, patient-centered care, client-centered care, and personalized care [13]. However, these concepts have differences. The concept of individualized care considers an individual as a biopsychosocial integral whole, focuses on individual differences, preferences, and the values of individuals. Individualized care includes the patient’s clinical situation, personal life situation and decisional control [11]. Person- and patient-centered care concepts have different goals. Patient-centered care considers the patient as the center and prioritizes functional life, whilst the person-centered care takes a wider stance prioritizing the whole life, including the interactions with others and the achievement of a meaningful life [14]. The way in which people are cared for often defines which concept is used in practice, for example, if person is given the status of a client or patient [13]. The core of each of the care concepts is human autonomy and respect for dignity [11, 13‐15]. Person-centered care asserts its strong place in the care of older people because it is associated with the quality of life [16] and experiences of the quality of care [17] with a whole life orientation including, but not limited to a health problem orientation [14].

Continuing Education been defined in terms of continuing professional development, in-service training, or further training [18]. Usually the purpose of continuing education, which takes place after formal nurse registration education, is to develop nurses’ competence [19]. In different hospital settings, individual nurse’s competence consists of personal skills, abilities, and knowledge [20]. The collective competence of a group or team of nurses has a broader base and is greater than that of the sum of the individuals’ competence, facilitating the growth and development of individuals with varying competence within the team [21]. Organizational culture has been found to affect the quality of care delivery by nursing teams, both positively and negatively [22]. Therefore, the promotion of competence through in long-term care is important, not only for individual nurses but also the collective competence of the team.

Young people’s perceptions of the nursing profession are quite negative [23]. Nurses (Registered Nurses, Practical Nurses and Nursing Assistants) have reported a high level of job strain in nursing homes where the many residents suffer from dementia [24]. Nurses have and suggested there is poor support from the organization managers for the quality of their work in long-term care [25]. The use of person-centered care may mitigate these issues by reducing stress, burnout, and improving job satisfaction among dementia care nurses, though the research in this area is currently weak making firm conclusions difficult [26]. Person-centered care interventions that have a positive influence in older people’s long-term care discussed in the literature include: environmental changes; interaction relationships; relationships with managers; the empowerment of nurses; staff-resident relationships and the care culture so that care is more about the individual [27]. Psychosocial interventions in person-centered care of older people in long-term care include elements such as: communication training; emotional response support; dementia care mapping; retaining abilities; sensory strategies; integrity-promoting care; organizational level changes; and others not categorized by researchers [28]. The outcomes of these interventions seem to support the use of person-centered care approach although generalizability of the results is limited due to the complexity of the interventions [27, 28]. However, there seems to be little useful evidence about the effects of person-centered continuing education interventions on nurses working with older people in long-term care and even less from the perspective older people and their next of kin. Given the importance of the topic, more needs to be known about the efficacy of person-centered care continuing education interventions, especially as the older people population increases [29] and older people are expected to live longer, many with long-term health conditions [30].

The aim of this review was to analyze and synthesize the existing research literature about person-centered care-based continuing educational interventions for nurses working in long-term care settings for older people. The goal was to increase the understanding of the current pedagogical methods and results of continuing education interventions from the perspective of nurses, older people and their next of kin.

This study is a systematic review of the empirical research literature after Harris [31] focused on person-centered care-based continuing education interventions for nurses working in long-term care settings for older people. The review was conducted following internationally recommended scientific practice in every phase [32] and reported according to Preferring Reporting Items for Systematic Reviews and Meta-Analyses PRISMA [33].

This study aimed to analyze and synthesize the existing research literature about person-centered care-based continuing educational interventions for nurses working in long-term care settings for older people. The analysis revealed the focus of this continuing education is on: older people’s medication; the interaction and caring culture; nurses’ job satisfaction; nursing activities and older people’s quality of life. Much of the delivery of this continuing educational training used behaviorist, using pedagogical methods such as lectures and seminars. The method of delivery of education can have an influence on the effectiveness of the intervention [38, 42], but it may be useful to use more learner-centered approaches to improve outcomes in future research [76]. The outcomes of the continuing education interventions of person-centered care were largely collected e.g. from nurses [42, 48, 50] observation of older people or e.g. from older people’s documents [36, 38, 68]. It may be useful, if data on outcomes were also routinely collected from older people and their next of kin [77].

The content of the continuing education activities included person-centered care elements that were designed to influence the interactions between the residents and nurses, and through this, the care environment. However, the influence of continuing education on person-centered care was measured in only one study [50]. Differences in the type of design, outcomes, number of participants, and duration of continuing education intervention hindered study comparisons and generalizations. Moreover, a range of methodological weakness made it difficult to provide any conclusive indication about the effectiveness of these approaches. This heterogeneity of the background theories and measurements of the continuing education interventions used in the studies reviewed, gives the impression of conceptual imprecision. Other researchers support this view [26] thought there is evidence that theory-based educational interventions are effective [78]. Although person-centered care is an abstract concept and so difficult to measure, the creation of a stronger argument for its use requires more rigorous research including the wider use of valid, person-centered care measurement instruments.

Pedagogical methods were at the core of the effectiveness of the continuing education interventions. Some of the studies educated “key nurses,” leaving these nurses to help other nurses learn to implement change in their workplace [50, 53, 56, 61]. There are some risks associated with using “key nurses” in this way, as the process of implementing person centered care requires an understanding of the origin and content of the concepts alongside the practical uses in care situations. The work environment, level of job satisfaction, managerial approaches and the personalities of nurses can help or hinder the work of these “key nurses”, who will require stronger managerial support, encouraging flexible working practices and the involvement of nurses in care decisions [53]. Earlier studies have reported that the collective competence of a team is greater than one persons’ competence [21]. Studies in this review using “key nurses” to introduce person-centered care were not effective in developing the collective competence of the nursing teams directly, limiting the possible benefits of the education e.g. [50].

When introducing person-centered care, pedagogical methods such as face-to-face teaching, though important, were not seen to be sufficient generally [36] and most of the interventions in this review used additional on-site support and consultation e.g. [42, 48, 68, 70] video material e.g. [57, 61, 74] brainstorming [72] and role-playing [68, 72] to achieve their preferred outcomes. Additionally, more student-centered approaches such as simulation-based nursing education interventions have been shown to improve critical and creative thinking [79] though simulation was only used in one reviewed study [72].

Digitalization as part a pedagogical method can support learning activities [80, 81]. Appropriate applications including learner-centered approaches, improve communication between students and educators and enable a collaborative learning environment [82]. However, use of these digital platforms have strengths and weaknesses. It has been reported that Moodle promotes professionalism, ethical behavior and develops critical thinking, but the use of other participatory web-based platforms, including social media platforms may suffer from credibility of information and are open to student misinterpretation [83]. The choice of appropriate platform requires some competence [80].

In this review, after the continuing education, nurses: increased the number of positive interactions with residents [38], improved person-centered care delivery [42], communication [44], and satisfaction in relationship with older people [46, 57], and increased their knowledge about meeting the needs of people with dementia [69]. Other improvements delivered by the outcomes of the reviewed studies were: a reduction in the use of medicines [36, 73]; improved behavioral symptoms [38, 56, 62, 69, 71] and relationships with nurses [57, 64, 72, 74] improved the quality of life for the older people [48, 67, 75]; and increased the number of support for daily activities [66, 70]. These results demonstrate the usefulness of research of continuing education interventions, especially when these changes have been brought about in work practice: reduce nurses burnout [46, 47, 65] have positive effects on nurses mood and burden [67]; and influence organizational culture, changing nurses experiences for the better [48, 69]. This general increase in the quality of care and care environment after suitable continuing education is also supported by other evidence [17].

The data that informed the research came from: residents’ medication charts; nurse-completed questionnaires; video recordings and from observation. In only one study did researchers collect data from the next of kin, about person-centered care interventions [69]. This is disappointing as the opinions of the older people and their next of kin on the results of the continuing education intervention might facilitate a better understanding of the interventions that meet their needs. The lack of old people’s and their next of kin views and perceptions need to be addressed in future research.

Most of the interventions used, produced the positive outcomes described above. However, in some studies the sample sizes were quite small and not power analyzed e.g. [42, 57, 75]. In other studies the content or delivery of the intervention may not have been appropriate [50, 61, 68]. Many other weaknesses were described in the studies reviewed. Additionally, the drop-out rate from the research may have been a major difficulty [48, 50]. This drop-out occurs, for example through the mortality of the residents, and nursing staff turnover [84, 85]. Four studies did not report any positive outcomes from the continuing education interventions [50, 55, 61, 68]. There were quite several studies that did not follow the reporting guidelines, in which case the primary and secondary measures and outcomes were not clearly mentioned [42, 44, 46‐50, 57, 61, 63, 64, 67, 69, 74, 75].

This review has identified and analyzed the available continuing education interventions about person-centered nursing in studies from many different countries. Overall, the studies are difficult to evaluate thoroughly often lacking rigorous conceptual and theory bases. This situation could be improved by careful design, choice of research settings, and strict protocols designed to provide robust evidence about the effectiveness of continuing education interventions.

This review enhances the understanding about person-centered care-based continuing education interventions for nurses working in long-term care settings for older people. Firstly, we identified five themes describing the contents of this type of continuing education. However, concept person-centered care is used in quite different ways and the use of stronger theory-based interventions which can be measured with validated person-centered care instruments is still required. Secondly, we identified the pedagogical methods which were used in these continuing education interventions about person-centered care. Pedagogical methods are quite traditional and could be enhanced using more learner-centered approaches such as appropriate simulation, digital platforms and social media which were not used sufficiently in the reviewed studies. Thirdly, we found that the evaluation of the results of continuing education interventions were mainly conducted from a nurse’s perspective, through for example, medication charts or by qualitative methods such as observation. The perspective of the older person and their next of kin was not evident and should be taken into consideration in future research.

Continuing educational interventions for nurses working in long-term care settings for older people need to be further developed to strengthen nurse’s competence in person-centered care. The positive outcomes in the five themes identified in this review improve the quality of older people’s long-term care. More empirical research-based continuing education interventions are needed, that include a wider set of learner-centered pedagogical methods with measurable outcomes which consider the opinions of older people and their next of kin. These measurable outcomes should be quantified using validated instruments. These developments are important for the quality of care delivery, the quality of life of older people in care and nurses job satisfaction.