person centred care education

Domain 2: Person-Centered Care

Descriptor: Person-centered care focuses on the individual within multiple complicated contexts, including family and/or important others. Person-centered care is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate. Person-centered care builds on a scientific body of knowledge that guides nursing practice regardless of specialty or functional area.

Contextual Statement: Person-centered care is the core purpose of nursing as a discipline. This purpose intertwines with any functional area of nursing practice, from the point of care where the hands of those that give and receive care meet, to the point of systems-level nursing leadership. Foundational to person-centered care is respect for diversity, differences, preferences, values, needs, resources, and the determinants of health unique to the individual. The person is a full partner and the source of control in team-based care. Person-centered care requires the intentional presence of the nurse seeking to know the totality of the individual’s lived experiences and connections to others (family, important others, community). As a scientific and practice discipline, nurses employ a relational lens that fosters mutuality, active participation, and individual empowerment. This focus is foundational to educational preparation from entry to advanced levels irrespective of practice areas.

With an emphasis on diversity, equity, and inclusion, person-centered care is based on best evidence and clinical judgment in the planning and delivery of care across time, spheres of care, and developmental levels. Contributing to or making diagnoses is one essential aspect of nursing practice and critical to an informed plan of care and improving outcomes of care (Olson et al., 2019). Diagnoses at the system-level are equally as relevant, affecting operations that impact care for individuals. Person-centered care results in shared meaning with the healthcare team, recipient of care, and the healthcare system, thus creating humanization of wellness and healing from birth to death.

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Entry-Level Domain 2 Competencies

2.1 Engage with the Individual in establishing a caring relationship.

2.1a Demonstrate qualities of empathy.

2.1b Demonstrate compassionate care.

2.1c Establish mutual respect with the individual and family.

2.2 Communicate effectively with individuals.

2.2a Demonstrate relationship-centered care.

2.2b Consider individual beliefs, values, and personalized information in communications.

2.2c Use a variety of communication modes appropriate for the context.

2.2d Demonstrate the ability to conduct sensitive or difficult conversations.

2.2e Use evidence-based patient teaching materials, considering health literacy, vision, hearing, and cultural sensitivity.

2.2f Demonstrate emotional intelligence in communications.

2.3 Integrate assessment skills in practice.

2.3a Create an environment during assessment that promotes a dynamic interactive experience.

2.3b Obtain a complete and accurate history in a systematic manner.

2.3c Perform a clinically relevant, holistic health assessment.

2.3d Perform point of care screening/diagnostic testing (e.g. blood glucose, PO2, EKG).

2.3e Distinguish between normal and abnormal health findings.

2.3f Apply nursing knowledge to gain a holistic perspective of the person, family, community, and population.

2.3g Communicate findings of a comprehensive assessment.

2.4 Diagnose actual or potential health problems and needs.

2.4a Synthesize assessment data in the context of the individual’s current preferences, situation, and experience.

2.4b Create a list of problems/health concerns.

2.4c Prioritize problems/health concerns.

2.4d Understand and apply the results of social screening, psychological testing, laboratory data, imaging studies, and other diagnostic tests in actions and plans of care.

2.4e Contribute as a team member to the formation and improvement of diagnoses.

2.5 Develop a plan of care.

2.5a Engage the individual and the team in plan development.

2.5b Organize care based on mutual health goals.

2.5c Prioritize care based on best evidence.

2.5d Incorporate evidence-based intervention to improve outcomes and safety.

2.5e Anticipate outcomes of care (expected, unexpected, and potentially adverse).

2.5f Demonstrate rationale for plan.

2.5g Address individuals’ experiences and perspectives in designing plans of care.

2.6 Demonstrate accountability for care delivery.

2.6a Implement individualized plan of care using established protocols.

2.6b Communicate care delivery through multiple modalities.

2.6c Delegate appropriately to team members.

2.6d Monitor the implementation of the plan of care.

2.7 Evaluate outcomes of care.

2.7a Reassess the individual to evaluate health outcomes/goals.

2.7b Modify plan of care as needed.

2.7c Recognize the need for modifications to standard practice.

2.8 Promote self-care management.

2.8a Assist the individual to engage in self-care management.

2.8b Employ individualized educational strategies based on learning theories, methodologies, and health literacy.

2.8c Educate individuals and families regarding self-care for health promotion, illness prevention, and illness management.

2.8d Respect individuals and families’ self-determination in their healthcare decisions.

2.8e Identify personal, system, and community resources available to support self-care management.

2.9 Provide care coordination.

2.9a Facilitate continuity of care based on assessment of assets and needs. 

2.9b Communicate with relevant stakeholders across health systems.

2.9c Promote collaboration by clarifying responsibilities among individual, family, and team members.

2.9d Recognize when additional expertise and knowledge is needed to manage the patient.

2.9e Provide coordination of care of individuals and families in collaboration with care team.

Advanced-Level Domain 2 Competencies

2.1d Promote caring relationships to effect positive outcomes.

2.1e Foster caring relationships.

2.2g Demonstrate advanced communication skills and techniques using a variety of modalities with diverse audiences.

2.2h Design evidence-based, person-centered engagement materials.

2.2i Apply individualized information, such as genetic/genomic, pharmacogenetic, and environmental exposure information in the delivery of personalized health care.

2.2j Facilitate difficult conversations and disclosure of sensitive information.

2.3h Demonstrate that one’s practice is informed by a comprehensive assessment appropriate to the functional area of advanced nursing practice.

2.4f Employ context driven, advanced reasoning to the diagnostic and decision-making process.

2.4g Integrate advanced scientific knowledge to guide decision making.

2.5h Lead and collaborate with an interprofessional team to develop a comprehensive plan of care.

2.5i Prioritize risk mitigation strategies to prevent or reduce adverse outcomes.

2.5j Develop evidence-based interventions to improve outcomes and safety.

2.5k Incorporate innovations into practice when evidence is not available.

2.6e Model best care practices to the team.

2.6f Monitor aggregate metrics to assure accountability for care outcomes.

2.6g Promote delivery of care that supports practice at the full scope of education.

2.6h Contribute to the development of policies and processes that promote transparency and accountability.

2.6i Apply current and emerging evidence to the development of care guidelines/tools.

2.6j Ensure accountability throughout transitions of care across the health continuum.

2.7d Analyze data to identify gaps and inequities in care and monitor trends in outcomes.

2.7e Monitor epidemiological and system-level aggregate data to determine healthcare outcomes and trends.

2.7f Synthesize outcome data to inform evidence-based practice, guidelines, and policies.

2.8f Develop strategies that promote self-care management.

2.8g Incorporate the use of current and emerging technologies to support self-care management.

2.8h Employ counseling techniques, including motivational interviewing, to advance wellness and self-care management.

2.8i Evaluate adequacy of resources available to support self-care management.

2.8j Foster partnerships with community organizations to support self-care management.

2.9f Evaluate communication pathways among providers and others across settings, systems, and communities.

2.9g Develop strategies to optimize care coordination and transitions of care.

2.9h Guide the coordination of care across health systems.

2.9i Analyze system-level and public policy influence on care coordination.

2.9j Participate in system-level change to improve care coordination across settings.

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Person-Centered Care

The relationship between value-based care and person-centered care

In a value-based health care system, doctors and other health care providers deliver high-quality care using a person-centered care approach. This differs from a traditional fee-for-service system where patients get their health care from multiple, siloed specialists who focus on a specific health issue rather than patients’ comprehensive, long-term needs.

Person-centered care includes:

• Care that’s guided and informed by patients’ goals, preferences, and values
• Success measured by patient-reported outcomes 
• Integrated and coordinated care across health systems, providers, and care settings
• Managing chronic and complex conditions 
• Relationships built on trust and a commitment to long-term well-being

An example of person-centered care

Tyler meets with his doctor about breathing problems and is diagnosed with asthma. In addition to prescribing Tyler a rescue inhaler to treat the symptoms, his doctor follows up with a telehealth visit to identify contributing factors, including smoking and his current living conditions, and develop a treatment plan. Together they come up with a comprehensive plan that considers Tyler’s related health, behavioral, and social needs. For example, the plan includes connecting Tyler with a smoking cessation program when he is ready to quit. The plan also leverages community partners and public services who can help him understand what in his apartment might contribute to his asthma and where he can get help to improve his living situation. 

For more information about the CMS Innovation Center’s new strategy and the future of value-based care, visit our Strategic Direction webpage .

< Back to Key Concepts

• Research article
• Open access
• Published: 28 April 2021

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

• Mari Pakkonen   ORCID: orcid.org/0000-0003-4628-8874 1 ,
• Minna Stolt   ORCID: orcid.org/0000-0002-1845-9800 1 ,
• Andreas Charalambous   ORCID: orcid.org/0000-0003-4050-031X 1 , 2 &
• Riitta Suhonen   ORCID: orcid.org/0000-0002-4315-5550 1 , 3 , 4  

BMC Nursing volume  20 , Article number:  67 ( 2021 ) Cite this article

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Person-Centered Care is often seen as an indicator of quality of care. However, it is not known whether and to what extent person-centered care can be enhanced by continuing education interventions in older people’s long-term care settings. This systematic review 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.

Five databases were searched 6/2019 and updated 7/2020; PubMed (Medline), CINAHL, PsycINFO, Cochrane and Eric using the keywords person-centered car* OR person-centred car * OR patient-centered car* OR client-centered car* OR tailored car* OR resident-centered car* OR individualized car* AND older* OR elder* OR old person* AND Long-Term Care OR Nursing home OR 24-h treatment OR long-term treatment. Twenty-seven full texts from 2587 initially retrieved citations were included.

The continuing educational interventions found were divided into five themes: person-centered interventions focusing on medication; interaction and caring culture; nurses’ job satisfaction; nursing activities; and older people’s quality of life. The perspective of older people and their next of kin about the influence of continuing education interventions were largely absent. The background theories about interventions, the measurements taken, and the clarity around the building blocks of the continuing-care interventions need further empirical verification. The pedagogical methods used were mainly quite behavioristic mostly lectures and seminars.

Most of person-centered care continuing education interventions are effective. Still more empirical research-based continuing education interventions are needed that include learner-centered pedagogical methods, with measurable outcomes that consider the opinions of older people and their next of kin. Continuing educational interventions for nurses need to be further developed to strengthen nurse’s competence in person-centered care, job satisfaction and for better quality of care.

Peer Review reports

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 , 3 , 4 , 5 , 6 , 7 , 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 , 14 , 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 ].

Search strategy

A systematic search from five relevant databases was conducted on 06/2019 and updated on 7/2020, published articles written in English without any time limit: PubMed (Medline), CINAHL, PsycINFO, Cochrane and ERIC using keywords and Boolean operators. The search phrase PubMed (Medline) was: (“Patient-Centered Care”[Mesh] OR person-centered car* OR person-centred car* OR “person centered care” OR “person centred care” OR “patient centered care” OR “patient centred care” OR patient-centered car* OR “patient-centred care” OR “client centered care” OR “client centred care” OR tailored car* OR “resident centered care” OR “resident centred care” OR “resident-centred care” OR “resident-centered care” OR individualized car* OR individualized car*) AND (“Frail Elderly”[Mesh] OR “Aged”[Mesh] OR “Aged, 80 and over”[Mesh] OR “Senior Centers”[Mesh] OR older* OR elder* OR aged OR senior* OR resident* OR old people* OR old person*) AND (“Insurance, Long-Term Care”[Mesh] OR “Long-Term Care”[Mesh] OR “Nursing Homes”[Mesh] OR “After-Hours Care”[Mesh] OR “Conservative Treatment”[Mesh] OR long-term car* OR LTC OR nursing home* OR 24-h treatment* OR 24-h car* OR enhanced treatment* OR enhanced car* OR long-term treatment*).

Study selection

Studies were included in the review if they were: (1) experimental study designs; RCTs; controlled clinical trials (CCTs); quasi-experimental and pre-posttest studies with or without control groups. (2) intervention studies with person-centered care elements; (3) studies focused on continuing education interventions for nurses working in long-term settings for older people; and (4) peer-reviewed research studies published in the English language. Studies were excluded if they were (1) implementation studies or feasibility studies not assessing any outcomes and (2) interventions other than person-centered care-based continuing educational interventions for nurses working in long-term care settings for older people.

Retrieval of the studies was conducted in four steps [ 33 ] (Fig.  1 ). The initial search of the databases retrieved 2587 citations. After removing duplicate studies ( n  = 277), in the second step, three researchers (MP, MS and RS) screened the titles and abstracts to identify eligible records for full text analysis removing 2310 scripts. In the third step the remaining 47 papers were analyzed against the inclusion and exclusion criteria. During this analysis researchers eliminated 20 papers by consensus leaving 27 papers for further analysis. A manual search of the reference lists of the 27 included studies identified no further relevant studies.

Retrieval of the studies

Quality appraisal

The quality of the 27 included papers was assessed by Joanna Briggs Institute [ 34 ] checklist for quasi-experimental studies. The aim of the appraisals was to assess methodological quality of studies considering bias in designs, research conduct and the analyses with nine appraisal questions and a maximum score of 9. The quality appraisal was recorded but not used as part of the inclusion criteria.

Data analysis

Data were collected in tabular format: the author(s); year of publication; country of origin; design; aim of study; sample; participants; data collection instruments; and methods. The contents, pedagogical methods and outcomes from the perspective of Nurses (N), Next of kin (NK) and Older People (OP) were also collected within the same tabular format. The outcomes of the interventions, positive or no effect, were analyzed using a two-step categorization (+ = a positive effect of the intervention, 0 = no effect of the intervention). As the outcome variables differed from each other it was not possible to calculate meta-analysis. Data were analyzed using conventional content analysis [ 35 ]. The original expressions used by authors in their articles were used to reduce interpretation. The analysis was performed by one researcher and the results were confirmed in the research team before tabulation.

Characteristics of the studies

The studies (Table  1 ) were carried out mainly in Europe: Portugal ( n  = 5);Sweden ( n  = 1); UK ( n  = 2) Belgium ( n  = 3) Germany ( n  = 1) The Netherlands ( n  = 2) and also, in USA ( n  = 7); Australia ( n  = 4); Canada ( n  = 1) and Japan ( n  = 1). The studies were published between 2004 and 2019, mostly in 2015 or after ( n  = 19).

The design of the studies were RCTs ( n  = 9), experimental designs ( n  = 6), quasi-experimental design ( n  = 2), pretest-posttest designs ( n  = 10). All studies conducted pretests and posttests after the intervention. Four studies were carried out without control group and there were two experimental groups in one RCT design. The quality appraisal, mean and median scores using the JBI checklist, were 7.70 and 9, out of nine respectively.

The study informants were mainly older people ( n  = 11), nurses ( n  = 7) or both together ( n  = 6). In one study nurses responded as a team. In another study nurses and older people formed a dyad. The next of kin of the older people participated in one study together with older people and nurses. In the experimental groups, the mean and mode of the participants were 82 (range 6–677) and 24 respectively. In the control groups the mean and mode were 100 (range 6–660) and 29 respectively.

Implementation of the continuing education interventions

The pedagogical methods used in the continuing education interventions (Table  2 ) were contact teaching via seminars, workshops, or team sessions ( n  = 27), usually with the on-site support ( n  = 17). In some studies, a few “key nurses”, attended continuing education ( n  = 5). Within the continuing education sessions digital material such as videos were used ( n  = 8) and in one study simulation and role-playing games.

The continuing education interventions were categorized into five themes: (1) medication ( n  = 5); (2) interaction and caring culture ( n  = 11); (3) nurses’ job satisfaction ( n  = 3); (4) nursing activities ( n  = 5); and (5) older people’s quality of life ( n  = 3). In the medication themed interventions, the typical goal was to reduce the number of medications older people took and to learn to use person-centered care to reduce behavioral issues that disturbed other residents. The aim of the interaction and care culture themed interventions was to increase positive communication between nurses and the older people and to influence the caring culture, making it more person-centered. Some continuing education interventions focused on increasing nurses’ job satisfaction. Nursing activities themed interventions were aimed at influencing residents’ daily routines and activities.

Outcomes of the continuing education interventions

Most of the continuing education interventions about person-centered care had positive effects (Table  2 ) but four studies indicated that the interventions did not have the any effect [ 50 , 53 , 61 , 68 ].

Medication themed intervention outcomes described a significant decrease in use of psychotropic drugs [ 36 , 73 ]. The proportion of residents using neuroleptic drugs in research centers was significantly lower than in control homes [ 62 ] which reduced costs [ 38 ]. Continuing education intervention influence on the staff and older people’s behavior varied. The interventions had no effect on residents’ behavioral symptoms such as agitation and disruption in one study, but these symptoms also did not increase with fewer medications [ 62 ]. In another study, continuing education intervention did reduce residents’ agitation, their general neuropsychiatric symptoms and increased their positive interactions between nurses and residents [ 38 ].

Interaction and caring culture themed continuing education interventions had a positive influence on: nurses’ person-centeredness [ 42 ]; verbal communication [ 44 , 48 , 71 ]; non-verbal communication [ 44 ]; increased direct gaze duration between residents and nurses; reduced sadness and increased smiling [ 72 ]. In one study, both nurses and residents reported increased satisfaction in their relationship after the continuing education intervention and residents reported a closer relationship with nurses [ 57 ]. Nurses reported increased knowledge about meeting the needs of people with dementia and organizational culture change experiences and next of kin were also satisfied with these changes and quality of care [ 69 ]. Also, positive effects on care providers’ mood, burden [ 67 ] and residents’ behaviour were reported [ 63 ].

Nurses’ job satisfaction themed continuing education interventions seemed to positively influence nurse’s emotional exhaustion, emotional management, self-care awareness and enhanced cohesion within the group, which can reduce nurses burnout [ 47 ]. One study had no significant effect on job satisfaction based on quantitative data analysis but included details of a qualitative analysis which showed a positive impact of the intervention on daily work performance [ 49 ]. It was suggested that without managerial support, the influence of the continuing education intervention would not be as strong and would be less likely to be established in the workplace [ 65 ].

Nursing activities themed continuing education interventions demonstrated the abstract nature of person-centered care [ 14 ]. In one study, the continuing education intervention, delivered using a digital device, reported improved sleep for residents with dementia. The experimental group of residents had significantly more nighttime sleep ( p  = 0.03) and less daytime sleep ( p  = 0.01) in the post test [ 66 ]. Nursing activities such as bathing [ 64 ]; reduced agitation, aggression, and discomfort in persons with dementia [ 71 ] and oral hygiene [ 70 ] had a positive influence.

The quality of life of older people themed continuing education interventions outcomes varied. In some studies, there was no effect on the quality of residents life [ 53 ] but in another study the intervention has got effectiveness to the residents’ quality of life [ 75 ]. On these quality-of-life continuing education interventions is usually compared different education methods as person-centered care and Dementia Care Mapping [ 56 ].

Instruments used in continuing education interventions

Although all reviewed studies included person-centered care within the educational intervention, only one study [ 50 ] used a validated person-centered care instrument to measure person-centered care outcomes. The Person-Centered Environment and Care Assessment Tool was also used, but its validity is difficult to evaluate as it is within an unpublished PhD thesis [ 54 ]. The most commonly used quantitative instruments were, the Cohen-Mansfield Agitation Inventory [ 40 ] ( n  = 7), and the Maslach Burnout Inventory [ 59 ] ( n  = 4) (Table  1 ).

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 , 47 , 48 , 49 , 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.

Strengths and limitations

This review has some strengths. Firstly, this review focused on all research-based continuing education interventions about person-centered care, targeting nurses in older people’s long-term care. The review sought literature from five relevant databases without time limits to provide the best opportunity to find as much of the relevant literature as possible. Using the inclusion criteria, the review considered all available experimental designs, randomized controlled trials alongside those with no control group. This approach facilitated the capture of the widest variety of continuing education intervention studies in this field [ 86 , 87 ].

The computerized search from databases was conducted by one researcher with the support of an information specialist and then determined by research group.

Secondly, we used the whole research team to assist with study selection, reducing selection bias through discussion towards consensus. For example, in step one (Fig.  1 ) the citations were evaluated by two researchers first independently and then together. Where consensus was not found a third opinion was sought from another member of the research group.

The limitations of the review relate to the quality of the available studies, limited language only in English and unpublished studies. The research quality appraisal was challenging, because of the limitations of the study designs or number of participants, even though the quality score averaged 7.70 out of 9 [ 34 ]. Statistically, the meta-analysis was not applicable because the interventions were different in content and the outcome variables were not comparable [ 86 ].

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.

Availability of data and materials

The dataset from this study is available from the corresponding author upon reasonable request.

Abbreviations

Cumulative index to nursing and allied health literature

A world-class resource for abstracts and citations of behavioral and social science research

Education resources information center

Preferred reporting items for systematic reviews and meta-analysis

Randomized controlled trial

Controlled clinical trial

The Joanna Briggs Institute checklist for quasi-experimental studies

Next of kin

• Older people

A positive effect of the intervention

Non effect of the intervention

Primary outcome

Secondary outcome

Experimental group

Control group

All participants

• Person-centered care

Person-centered environment

Dementia care mapping

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Pakkonen, M., Stolt, M., Charalambous, A. et al. Continuing education interventions about person-centered care targeted for nurses in older people long-term care: a systematic review. BMC Nurs 20 , 67 (2021). https://doi.org/10.1186/s12912-021-00585-4

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DOI : https://doi.org/10.1186/s12912-021-00585-4

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Home » Reports » What is Person-Centered Care and why is it important?

What is Person-Centered Care and why is it important?

What is person-centered care?

Person-centred care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs. This means putting people and their families at the centre of decisions and seeing them as experts, working alongside professionals to get the best outcome.

Person-centred care is not just about giving people whatever they want or providing information. It is about considering people’s desires, values, family situations, social circumstances and lifestyles; seeing the person as an individual, and working together to develop appropriate solutions. 1 ,2,3 Being compassionate, thinking about things from the person’s point of view and being respectful are all important. This might be shown through sharing decisions with patients and helping people manage their health, but person-centred care is not just about activities. It is as much about the way professionals and patients think about care and their relationships as the actual services available.

In the past, people were expected to fit in with the routines and practices that health and social services felt were most appropriate. 4 But in order to be person-centred, services need to change to be more flexible to meet people’s needs in a manner that is best for them. This involves working with people and their families to find the best way to provide their care. This partnership working can occur on a one-to-one basis, where individual people take part in decisions about their health and care, or on a collective group basis whereby the public or patient groups are involved in decisions about the design and delivery of services. The underlying philosophy is the same: it is about doing things with people, rather than ‘to’ them.

There is no one definition of person-centred care. 5,6 People might also use terms such as patient-centred, family-centred, user-centred, individualised or personalised. 7,8,9,10 Regardless of the terms used, a lot of research has looked into what matters to patients and how to provide person-centred care to make sure people have a good experience. 11,12,13,14,,15,16,17,18 There are many different aspects of person-centred care, including: 19

• respecting people’s values and putting people at the centre of care
• taking into account people’s preferences and expressed needs
• coordinating and integrating care
• working together to make sure there is good communication, information and education
• making sure people are physically comfortable and safe
• emotional support
• involving family and friends
• making sure there is continuity between and within services
• and making sure people have access to appropriate care when they need it

Why is person-centred care important?

Person-centred care is a high priority.

Making sure that people are involved in and central to their care is now recognised as a key component of developing high quality healthcare . 20,21,22,23

There is much work to be done to help health and social services be more person-centred and this has become more of a priority over the past decade. 24,25 This is because it is hoped that putting people at the centre of their care will:

• improve the quality of the services available
• help people get the care they need when they need it
• help people be more active in looking after themselves
• and reduce some of the pressure on health and social services

In the UK there is increasing demand for health services and there are limited resources. People are living longer and may often have many health conditions as they age. 26,27 Research has found that person-centred care can help to improve people’s health and reduce the burden on health services, 28,29,30 so government policy is emphasising strengthening the voice of patients 31,32,33,34 and moving away from a paternalistic model where professionals ‘do things to’ people. 35,36,37 The NHS constitution in England has person- centred care as one of its seven core principles. This philosophy is also built into National Service Frameworks, monitoring requirements and legislation in all four countries of the UK.

Person-centred care can improve quality

Research has found that person-centred care can have a big impact on the quality of care. It can 38,39

• improve the experience people have of care and help them feel more satisfied
• encourage people to lead a more healthy lifestyle , such as exercising or eating healthily
• encourage people to be more involved in decisions about their care so they get services and support that are appropriate for their needs
• impact on people’s health outcomes , such as their blood pressure
• reduce how often people use services . This may in turn reduce the overall cost of care, but there is not as much evidence about this
• improve how confident and satisfied professionals themselves feel about the care provided

Reviews of research about this topic found that offering care in a more person-centred way usually improves outcomes. 40 Some of the most common ways that have been researched to improve person-centred care include helping people learn more about their conditions, prompting people to be more engaged in health consultations and training professionals to facilitate care that empowers people to take part. 41,42

Offering care in a more person-centred way can even improve outcomes for professionals. A review of seven studies about professionals delivering person-centred care in nursing homes found that this approach improved job satisfaction, reduced emotional exhaustion and increased the sense of accomplishment amongst professionals. 43

Research has found that some components or underlying principles of person-centred care may be most important for affecting outcomes, including: 44,45,46,,47,48,49,50,51,52,53,54,55,56,57

• getting to know the patient as a person and recognising their individuality
• seeing the patient as an expert about their own health and care
• sharing power and responsibility
• taking a holistic approach to assessing people’s needs and providing care
• including families where appropriate
• making sure that services are accessible, flexible and easy to navigate
• looking at people’s whole experience of care to promote coordination and continuity
• making sure that the physical, cultural and psychosocial environment of health services supports person-centred care
• making sure that staff are supportive, well trained in communication and striving to put people at the centre of their care

While the evidence is mounting that person-centred care can make a difference, there are not that many studies about outcomes yet and some research has mixed findings. 58, Person- centred care means different things to different people and this might be why there are mixed findings. This makes it even more important to think about how to measure and put person-centred care into practice, so that health services can better understand the benefits of this approach.

Towards person-centred care in South London

In order to be more person-centred, health services need to know what is most important to people. Person-centred care can focus on people’s individual health needs, but it is also about involving people in planning and evaluating services. Words such as ‘co-production’ and ‘co-design’ have been used to describe involving people in developing services and assessing their quality.

Based on all of the available evidence and feedback from patients and professionals, the Health Innovation Network – South London believes that beginning with a person-centred approach will lead to positive outcomes for patients and carers. Finding out what is important to patients and carers and making improvements in these areas will improve people’s experience of care and help them be more independent. For this reason, The Health Innovation Network is developing ways to measure the experience of health services in one of its key clinical priority areas: dementia. A Delphi technique is being used to get opinions from people with dementia, carers, patient and carer representative organisations, professionals and other stakeholders. People will be invited to rate the importance of various aspects of the quality of dementia care. Their responses will be summarised and circulated for discussion in repeated rounds until consensus is reached. This will help to make sure that the things being measured and improved upon are important to the people using services.

This is an innovative approach because although the concept of person-centred care puts patients at the heart of their care, few approaches to measurement have been driven by patients or build on aspects that patients and carers identify as most crucial. 59 However, it is important not just to focus on people’s preferences because these can change over time and people generally prioritise the things they are currently doing rather than the potential way things could be. 60 One of the challenges that the Health Innovation Network is tackling is how to define what services are fundamentally trying to achieve , and this is being done in partnership with patients and carers.

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• Enhancing Generalist Skills
• enhance learning resources

Person Centred Practice

This domain is about fostering an approach to your practice that invites and supports personalisation, empowerment and shared decision making. Person-centred practice, or personalised care is an approach that explicitly acknowledges that people want to be treated as a whole person by professionals they trust; involved in decisions about their health and care; be supported to actively manage their own health and wellbeing, and for their care to feel coordinated. This domain draws heavily, and deliberately, on the Curriculum of the Personalised Care Institute (2020).

Why is this important?

Ensuring that people are involved in, and central to their care, is seen as a key to the provision of high quality health and care services. Person-centred practices improve the experiences people have of their care, facilitate access to the most appropriate services, encourage healthier lifestyles and result in the most appropriate support for an individual's wants and needs. Such practices are safer, more effective, and have the potential to reduce health inequalities while reducing impact on health and social care resources.

Domain learning outcomes

On completing this domain of the enhance programme, you will be able to:

• Interact with patients and carers in ways that acknowledge their unique circumstances, supporting people to recognise and draw on their own strengths and resources in order to live an independent and fulfilling life
• Drawing on a range of communication strategies, enable people to make meaningful decisions about their health and wellbeing by understanding the outcomes that are important to them, exploring the risks, benefits and consequences of all available options and what these may mean in the context of their own lives.
• Work with an individual’s family, carers, advocates and network of healthcare professionals to ensure that care is coordinated, across teams, organisations and systems.
• Treat each person you encounter in the course of your work - patients, their families, carers and colleagues - compassionately, and with dignity and respect.
• Appreciate the different forms of patient and public participation and take action to support the various ways in which people may be invited, or wish, to participate in their health and care.

You can view the full chapter here. 

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Person-centred approaches in health and care

The value of a person-centred approach is increasingly recognised and for many health and social care workers, engaging in a meaningful way with people and communities is already part of their intrinsic motivation.

This is also seen through practices like health coaching, motivational interviewing, co-production and care and support planning. However, it's often less clear how best to develop the workforce to enable them to put person-centred approaches into practice and to create sustained behavioural change.

Standard five of the Care Certificate, the standards for new staff in health and social care roles, focuses on working in a person-centred way.

We have practical resources and workbooks to help you to implement the Care Certificate as part of induction.

Find out more about the Care Certificate

Person-centred approaches core skills education training framework

Skills for Health, Health Education England and Skills for Care have developed a framework to support person-centred approaches for the health and social care workforce.

This approach, outlined in the  Five Year Forward View , puts people, families and communities at the heart of health, care and wellbeing.  It encourages people to speak with staff about what is important to them, helping to develop a shared understanding of what matters to them.

Person-Centred Approches Core Skills Education and Training Framework

NICE: People's experience using adult social care services

NICE have developed a quality standard that covers the experience of adults using social care services. It applies to all settings where people use social care services, including people's own homes, residential care and community settings. Its aim is to help people understand what care they can expect and to improve their experience by supporting them to make decisions about their care.

NICE Quality standard

Finding high quality learning and development

We can help you choose the right learning and the right provider for you.

Our ‘ Guide to developing your staff ’ can help you plan, select and evaluate the right learning for your staff and service.

We can also help you to find high quality learning providers. Skills for Care endorsement finds and badges learning providers who we see as the best. Our endorsed providers deliver high quality learning and development to the social care sector.

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Person-Centred Care toolkit

The Person-Centred Care toolkit has been developed with NHS England to support GPs and primary care teams.

Introduction

The Person-Centred Care Toolkit has been developed with NHS England to support GPs and primary care teams deliver person-centred care.

People with multiple long-term conditions account for about 50% of all GP appointments but the current 10-minute GP consultation doesn't allow enough time to effectively address all health and well-being issues. The person-centred care approach gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you'.

Person-centred care provides care that responds to individual personal preferences, needs and values and assures that what matters most to the person guides clinical decisions. It looks to build upon strengths, resources and skills that an individual, their carers, family and communities have in order to enable and empower people. It provides care which does things 'with' people rather than 'to' or 'for' them. Person centred care as a term describes the ethos and approach that enables this to happen. It requires a whole system and team approach, with all stakeholders valuing the principles and processes of person centred care, and all providers ensuring their services are set up to deliver to these.

‘Person’ in this context refers to individual patients, but includes their carers and significant support networks if appropriate.

Key aspects of person-centred care include:

• Respect for the person’s values, preferences and expressed needs
• Personalised, co-ordinated and integrated health and social care and support
• Equal partnership in the relationship between health care professionals and patients
• Involvement of family, friends and carers
• Continuity of care
• High quality education and information.

Person-centred care resonates with the Wanless concept of a ‘fully engaged population’, with all the associated health, wellbeing and economic benefits. Using a person-centred approach has been shown to benefit patients, health professionals and health systems as well as reduce health inequalities. One of the key shifts in person-centre care is moving from a reactive to a proactive model where preparation is key, something that requires a change in processes.

It can improve concordance between the health professional and individual thereby improving the working relationship, health outcomes and GP job satisfaction as well as reducing the demand on primary care.

• The Health Foundation: Why person-centred care is important

Key tools include social prescribing, collaborative care and support planning, shared decision making and health coaching.

This toolkit has been developed in partnership between the RCGP and NHS England.

Please send any feedback or suggestions to [email protected]

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In this animation we look at person-centred care .

Kindness and respect mean different things to different people. That’s why it matters to be person-centred. Being person-centred means thinking about what makes each person unique, and doing everything you can to put their needs first.

This animation supports nurses, midwives and nursing associates to understand why being person-centred leads to even better care.

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• Person Centred Approach In Schools

Taking a person-centred approach in schools

Putting families at the heart of everything is vital, says Michael Surr…

Imagine the scene: a child wakes up in the morning, peers out of the window, and sees it is snowing thickly outside.

School is cancelled. All they want to do for the day is play. What’s important to the child in that moment? Most likely just one thing: running outside and immersing themself in the snow.

But what’s important for the child? Any responsible grown-up will spot it quickly: to be wrapped up warm so they can play without getting cold. This example gets to the heart of what person-centred practice involves.

What is person centred care?

When we work with children and young people, we not only look at what is important to them, but what’s important for them. To do so, we assess what information is relevant to their teacher, SENCo, parent and other professionals, as well as taking on the young person’s perspective.

Identifying “important for” allows us to examine provisions and approaches that might be required to meet a child’s needs. Identifying “important to” allows us to consider how to achieve this in a way that takes account of what motivates the young person.

The value of person-centred working, with children and families at the heart of everything, has been part of the SEND Code of Practice since 2001, and was further strengthened in the updated Code of 2015. The principles are clear that we must always have regard to:

• the importance of the child or young person, and their parents, participating as fully as possible in decisions
• the views, wishes and feelings of the child or young person, and their parents

I remember one non person-centred meeting with a TA and their student. The consensus within the room was that the TA support was having a positive impact and that no changes to the provision were needed.

But when working with the child in a person-centred way, I learnt that they often felt that having an adult at their side meant they were unable to work with their friends in the same way as their classmates.

Feeding this back, sensitively of course, led to subtle changes in how the TA was deployed. For example, when working with the child, they made sure that they weren’t always directly next to them, which made the student feel more comfortable and part of the group.

Person-centred practice can help us to notice, and identify, simple things that can make a massive difference. This way of working should be integral to our practice – not bolted on.

If you find yourself struggling with where to start, the following points built on Article 12 of the UN’s Convention on the Rights of the Child may be a good guide:

Space – provide a safe and inclusive space for expression of views Voice – provide appropriate information and facilitate the expression of views Influence – ensure that views are taken seriously and acted upon where appropriate Audience – ensure views are communicated to someone with responsibility to listen

As professionals, we can channel our power to navigate complex systems, securing the change and support that children – and their families – need most.

The type of power we use is important, of course: being the power with, rather than the power over. “Power with” means opening ourselves up to learn from young people, and those who care for them.

For some, this can feel like a daunting prospect – perhaps we fear parents will start telling us what to do and take over; or some children may struggle to express themselves verbally.

Perhaps the people you work to support are afraid of formal processes, or even of speaking up. There are many different ways to enable the hearing and sharing of views, and person-centred approaches employ a variety of tools. For example, communication charts can help practitioners “hear” through behaviours and actions.

Often, “hearing” involves communicating with individuals on terms that suit them, finding ways to make them comfortable to self-express without fear of judgement. So, in every interaction, ask yourself: Who am I doing this for? Whose needs am I meeting? And – crucially – which needs might I be missing?

Open your ears, and open up to new thought processes. We have the ability to make a real difference for those we serve, including creating positive, nurturing spaces, and strengthening authentic communities.

Share that power wisely, and whether it’s navigating social worries, easing the challenges of a difficult day, or plunging into the snow with glee – all of us can achieve better together.

Michael Surr is the interim head of education at nasen . Follow nasen on Twitter at @nasen_org .

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Understanding person-centered care within a complex social context: A qualitative study of Saudi Arabian acute care nursing

Affiliations.

• 1 Faculty of Nursing, University of Tabuk, Tabuk, Saudi Arabia.
• 2 School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA.
• PMID: 39074296
• DOI: 10.1111/nin.12650

Policy reforms implemented in Saudi Arabia in recent years aim to modernize the culture and infrastructure of healthcare delivery and are expected to integrate person- and patient-centered care principles throughout the national healthcare system. However, in a complex multicultural environment where most nurses are international migrant workers, unique challenges emerge that frame the delivery of care. Better understanding is needed about what nurses perceive to be high-quality, person-centered care in Saudi Arabia and how they manage to enact it in practice. Semi-structured interviews were conducted with 21 nurses working in two tertiary hospitals in Riyadh, the capital city. Participants included Saudi citizens (n = 9) and expatriates (n = 12) who were asked to describe their perceptions of quality nursing care and explain the obstacles that they encounter in providing such care. Nurses reported extensive efforts to achieve individualized, empathetic, developmentally appropriate care. Their descriptions of care aligned with principles of patient-centeredness in care but were not separable from challenges at the patient, organizational, and regional levels, including staffing and supplies shortages, gaps in regional care coordination, inadequate language translation services, variability in cultural beliefs about healthcare communication, and overt discrimination against expatriate workers. Nurses reported creative strategies to achieve professional nursing values while navigating a dynamic landscape of constraints. The findings add to literature suggesting that person-centeredness in care cannot be understood outside the social and organizational conditions that shape it.

Keywords: migrant nurses; nurse roles; nurse working conditions; nurse–patient relationships; person‐centered care; social context of care.

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• Abudari, G., Hazeim, H., & Ginete, G. (2016). Caring for terminally ill Muslim patients: Lived experiences of non‐Muslim nurses. Palliative & Supportive Care, 14(6), 599–611. https://doi.org/10.1017/S1478951516000249
• Akkoç, İ., Türe, A., Arun, K., & Çalışkan, A. (2022). Role of affective commitment in the relationship between emotional labor and life satisfaction in nurses. Perspectives in Psychiatric Care, 58(4), 2050–2058. https://doi.org/10.1111/ppc.13028
• Alanazi, M. S. (2023). Lack of interpretation services for limited English and Arabic proficiency patients in Saudi hospitals: Challenges and perceptions. Saudi Journal of Language Studies, 3(2), 61–75. https://doi.org/10.1108/SJLS-09-2022-0069
• Albejaidi, F., & Nair, K. S. (2019). Building the health workforce: Saudi Arabia's challenges in achieving vision 2030. The International Journal of Health Planning and Management, 34(4), e1405–e1416. https://doi.org/10.1002/hpm.2861
• Alhalal, E., Alrashidi, L. M., & Alanazi, A. N. (2020). Predictors of patient‐centered care provision among nurses in acute care setting. Journal of Nursing Management, 28(6), 1400–1409. https://doi.org/10.1111/jonm.13100
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• Open access
• Published: 30 July 2024

Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study

• Melissa Northwood 1 ,
• Margaret Saari 2 ,
• George Heckman 3 ,
• Ted Alexander 4 ,
• Bill Eastway 5 ,
• Patricia Gerantonis 1 ,
• Deanne Gillies 6 ,
• Susie Gregg 7 ,
• Jane McKinnon Wilson 7 ,
• Adam Morrison 8 ,
• Heebah Sultan 9 &
• Luke Turcotte 10  

BMC Health Services Research volume  24 , Article number:  864 ( 2024 ) Cite this article

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Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada.

Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan.

Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument’s ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance.

Conclusions

Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.

Peer Review reports

Integrated and interprofessional team-based care is recommended internationally as a strategy to strengthen health-care systems [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ]. Implementing team-based models of care has received renewed attention after long-standing health system issues and health inequities were intensified and emphasized because of the COVID-19 pandemic [ 1 , 4 , 7 ]. Integrated care with a community-oriented focus, where older adults and health- and social-care providers partner to shape health-care delivery, can facilitate comprehensive and holistic care [ 4 , 8 ]. Calls for a system re-design where care is delivered in a more compassionate way are born out of the experiences of many older adults (≥ 65 years) and their care partners, particularly those living with multiple chronic conditions. These individuals, who often require supports spanning multiple providers and health and social care sectors, often have their needs unmet because providers work in fragmented and uncoordinated silos [ 9 , 10 ]. Communication between these providers is unstructured and unstandardized, and thus sub-optimal [ 5 , 11 ]. Poor information sharing is further complicated by time-consuming over-assessment of some issues, and incomplete assessment of others, leaving less time available to understand the person behind the chronic conditions [ 12 ]. As a result, older adults continue to be exposed to preventable health crises, worsening quality of life, loss of independence, and care partner distress [ 9 , 11 ].

An essential feature of integrated care includes the effective use of standardized assessment instruments [ 8 , 11 , 13 , 14 ]. Standardized assessment instruments provide a common clinical language interpretable by all health- and social-care providers. When supported by interoperable digital tools and shared electronic health records, standardized assessments allow older adults, care partners, and providers to exchange information and create and share a common care plan [ 8 , 9 , 10 , 11 , 14 , 15 , 16 , 17 ]. As integrated technologies are employed across health care systems, compassionate care—care that raises awareness of and responds to suffering—should be enhanced rather than impeded [ 18 ]. A standardized assessment, combined with an in-depth exploration of an individual’s narrative, are both essential for compassionate care [ 19 ]. Self-report tools provide an opportunity for an older person to describe functional needs, and their impact, and express concerns often ignored in health-care interactions, including mood, loneliness, financial hardship, food insecurity, and stressful life circumstances [ 5 , 20 , 21 ]. Efficiencies gained by using self-report tools to identify client concerns prior to health care interactions can be leveraged by the care team to better focus on the individual’s personal needs and goals, and thus develop a care plan most likely to alleviate suffering and support the older person and care partners throughout their health journey [ 5 , 10 , 19 , 20 ].

The interRAI Check Up (hereafter referred to as the “Check Up”) is a 90-item instrument that supports assessment of a broader range of health and social care needs. interRAI is a not-for-profit international network of clinicians and researchers which develops and maintains an integrated family of instruments to assess vulnerable persons across settings, such as home care and long-term care [ 11 ]. The Check Up is a self-report instrument, deployed on a software platform, targeting community-dwelling older adults, and can be completed by non-clinicians or older adults themselves [ 22 , 23 ]. It supports care planning and identifies areas of need (outputs) related to cognition, mood, loneliness, pain, instrumental and basic activities of daily living, falls, cardiopulmonary risk, care partner stress, financial trade-offs, health stability, and frailty [ 22 ]. The Check Up is based on the interRAI Home Care assessment, a clinician-driven instrument, which has demonstrated reliability, validity, and effectiveness in supporting care planning and fostering collaboration across the health-care system [ 11 , 22 , 24 ].

We have previously shown the feasibility of using a standardized self-report instrument for screening during the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS), in community support services, primary care, and assisted living settings to identify vulnerable persons and refer them to the required social- and health-care services [ 25 , 26 ]. The interRAI CVS was developed early in the COVID-19 pandemic based on items from the Check Up. Additionally, implementation of the Check Up in a geriatrician’s practice showed how the instrument helped flag, track, and prioritize all areas of need (social and medical) for immediate and future care planning [ 27 ].

In both of these studies, using standardized self-report instruments was determined to be feasible and have the potential to support better system integration, but suboptimal collaboration between community support services, specialized geriatric services, and primary-care providers persists, highlighting the need for more intentional planning around the use of these instruments [ 26 , 27 ].

The purpose of this study was to develop strategies to leverage an electronic wellness instrument (the Check Up) to support more compassionate and integrated health and social care for older adults and their care partners. This study aimed to: (1) identify needs and factors related to using integrated technologies to share the outputs of an electronic wellness instrument across health- and social-care providers and (2) develop strategies to use this information to provide integrated, person-centred and compassionate health and social care to older adults with multiple chronic conditions and their care partners.

Study design

The study used group concept mapping (GCM), a participatory mixed methods approach, where participants share and organize ideas to identify issues and establish consensus on a framework for action [ 28 , 29 ]. This design has been used extensively to consider the perspectives of community members in health and community-based research [ 20 , 30 , 31 ]. The GCM process involves five steps: (1) preparation, (2) idea generation, (3) sorting and rating, (4) generating maps and (5) interpreting and validating maps [ 28 ]. Groupwisdom™ software was employed to allow synchronous and asynchronous participation options and embedded analysis functions. The process occurred over a series of Zoom meetings (three with participants and four with the steering committee) from March to December 2022.

Setting and participants

This study engaged a community in south-western Ontario, Canada of both urban and rural geography with a population of approximately 700,000 persons, 14.9% being ≥ 65 years [ 32 ]. A steering committee was formed with older adults, co-investigators, and organizational collaborators, such as the Alzheimer’s Society, eHealth Centre for Excellence, and home care, community supports, mental health, and primary care organizations. Steering committee members provided study oversight, participated in data analysis, contributed to generating an action plan, and shared this plan with their organizations. Older adults participated on the steering committee to ensure the relevance and applicability of the study outcomes to older adults.

A purposive sample of research participants were recruited through the professional networks of the steering committee members, using email and phone recruitment scripts. Persons were eligible to participate if they were an older adult (≥ 65 years), a care partner of an older adult, or staff or leader of an organization providing services to older adults, including home care, community support services, specialized geriatric services, primary care, and digital health/health informatics. Members of the steering committee (excluding co-investigators and the research assistant) were also invited to contribute to the group concept mapping activities. We anticipated a sample size of 28 to 34 participants, with a goal to include 10 older adult and/or care partner participants and three to four persons from each of the different sectors.

Data collection and analysis

Step 1: preparation.

A focus prompt was proposed by the research team and refined by the steering committee. In GCM, a focus prompt is used during idea generation to describe participants’ opinions regarding the study topic [ 28 ]. The prompt used during data collection was: “To support the use of the interRAI Check Up, a digital health tool, as part of a compassionate care approach with older adults, we should consider …”.

Step 2: idea generation

During the idea generation step, participants independently created responses to the focus prompt. The goal of this step was to generate diverse ideas, including the voices of all the different participants. Utilizing the software platform, participants entered their ideas and could view the ideas, in real-time, being shared by the other participants. This step was completed during a Zoom session (lasting two hours), facilitated by the research team, but participants could choose to participate independently outside of the meeting time. The idea generation activity was open for three weeks following the Zoom meeting to give participants ample time to contribute. Participants were also asked to complete a short, demographic survey to collect information about their sector or role.

A total of 215 ideas were generated by participants. Members of the research team (MN, MS, PG, SG, HS) conducted an iterative analysis to consolidate the generated ideas into a manageable set of less than 100 ideas, suggested as best practice in GCM [ 28 ]. This process involved editing statements for clarity and splitting statements if they contained more than one idea to ensure only one idea was represented per statement [ 28 ]. To aid in identifying duplicate ideas, a topic area was identified for each statement and statements were grouped by the topics to visualize potentially similar statements. The research team and members of the steering committee reviewed the consolidated statement set to ensure original ideas were captured, statements were clear and understandable, and each statement was unique. Changes to wording to enhance the clarity of some statements were suggested and incorporated. The final statement list contained 98 statements.

Step 3: sorting and rating

At a second data collection meeting over Zoom (lasting two hours), participants contributed to the sorting and rating activities using the online software platform. One participant elected to do this activity with a hardcopy version. During the sorting activity, participants were asked to independently group the statements into categories based on their similarities and label each group with a name that they felt reflected the statements comprising the grouping. Participants were provided with detailed instructions ahead of and during the meeting to sort the ideas into a minimum of five categories, and devise labels for each. Following the sorting activity, participants were asked to independently rate each statement according to its “importance” and their perceived “community capacity” to support use of the Check Up as part of a compassionate approach to care with older adults. Participants were directed to consider their community’s capacity to use the Check Up at any of the following levels: individual (e.g., knowledge, skill, trust), organization (e.g., human resources, leadership, policies), or health system (e.g., resource allocation, policies, collaborations). Each statement was rated by participants on a scale of one (not at all important/no capacity) to four (very important/full capacity). The sorting and rating activities were open for two weeks following the Zoom meeting for participants to complete.

Step 4: generating maps

We used the groupwisdom™ software to perform multidimensional scaling and hierarchical cluster analysis to depict the results of the sorting activity in map form [ 28 , 33 , 34 ]. First, a similarity matrix was created that reflects the number of participants who sorted each pair of statements together in the sorting activity [ 28 ]. Using multidimensional scaling analysis of the similarity matrix, a point map was created that locates each statement as a separate point on a two-dimensional map [ 28 ]. The quality of this analysis was verified using a stress index, which measures the discrepancy between distances of points on the map and their original value in the similarity matrix [ 28 , 33 ]. A pooled analysis of GCM studies found the average stress value was 0.28 (SD = 0.04, range: 0.17-0.034, 95% CI [0.27, 0.29]) [ 33 ]. Each point represented an individual statement that was sorted by participants, with similar statements located closer to each other on the map and less similar statements located further apart [ 28 ].

Hierarchical cluster analysis was conducted to group individual statements into clusters, using Ward’s algorithm [ 28 ]. Agglomerative methods were used in the analysis, beginning with each statement, and merging them successively until they are in non-overlapping clusters [ 28 ]. This analytical approach produced multiple maps with a varying number of clusters. GCM methodology asserts that there is no definitive or “correct” number of clusters but rather the map is determined by the research team, in consultation with participants, to identify the number of clusters that yield conceptually meaningful and distinct domains [ 28 , 33 , 34 ].

A subgroup of the research team (MN, MS, PG) reviewed the possible cluster solutions, facilitated by the ‘cluster replay’ feature in the software, starting with a small number of clusters (five), and moving up to solutions with more clusters to review changing cluster compositions. Consideration was given to the logic of the clusters as a set and in the context of the other clusters [ 28 ]. Maps with nine, 10 and 11 clusters were shared with the steering committee. The decision to share these cluster solutions was based on discussion of what a reasonable number of cluster solutions to share during the meeting to facilitate consensus-building and most feasible to identify implementation strategies by cluster. By consensus, a 10-cluster solution was determined as the best fit to present to the participants for feedback and validation. The cluster names were reviewed and edited, considering the statements that were part of the cluster.

A go-zone graph was also generated, based on the importance rating data, to illustrate the prioritization of each idea according to importance. The purpose of including a go-zone map for this study was to understand the relative ratings of the statements within the clusters, identify initial priority issues to consider in developing strategies, and emphasize the perspectives of older adults. A go-zone graph is a bivariate plot that places each idea on a point, determined by its average rating of importance [ 28 ]. For this project, we created a go-zone graph that considered the importance as rated by older adults and the other participants. The go-zone graph is divided into four quadrants with the x-axis (older adults) and the y-axis (other participants), with ideas in the upper right quadrant representing the most important considerations for both groups.

Step 5: interpreting maps

At the final data collection meeting, the 10-cluster map was shared with participants. They were asked to provide their input on whether the statements were suitably grouped, if any statements should be sorted elsewhere, and if the cluster titles accurately reflected the statements. Three statements were relocated to adjacent clusters and some changes to cluster titles were suggested before consensus was reached on the map.

Participants also reviewed the go-zone graph and the set of statements that were rated as the highest relative importance. Participants were asked to identify which statements should be prioritized for action planning and those statements that reflected the vision of creating a compassionate community of digital health care. These recommendations were developed into an action plan by members of the research team, which included strategies to consider when sharing and using the outputs of the Check Up across health and social care sectors (MN, MS, PG, SG, AM, GH). The action plan was reviewed and discussed at the final steering committee meeting, and further refinements were made.

A total of 41 participants completed the idea generation step (refer to Table  1 for summary of their role or sector). For the sorting and rating session, 25 participants completed the sorting activity, and 19 participants completed the rating activity for importance and 15 for community capacity (refer to Fig.  1 for a schematic of the flow of participation).

A diagram of the activities involved in group concept mapping and the number of participants who participated in each activity

Cluster map

A ten-cluster map, reflecting all 98 statements, provides a framework of considerations for employing the interRAI Check Up as part of a compassionate care approach with older adults (refer to Fig.  2 ). The concept map highlights the concepts and the connections between ideas, represented by the distances between the clusters and statements. The smaller clusters indicate that these statements were most consistently sorted together (e.g., Health Information Integration ). The larger clusters show where participants may have sorted statements together but also with other clusters. For example, statements in Privacy and Confidentiality were often sorted with statements from the adjacent cluster, Training and Education for Providers . Health and Social Care Provider Coordination statements were also sorted with statements in Person-Centred Process as provider fragmentation can contribute to care that is experienced as not person-centred. Similarly for the Instrument’s Ease of Use and Accessibility of Assessment Process clusters statements were sorted together given that for an instrument to be easy to use, it must also be easy to access.

Cluster map represents which statements are contained in each domain. The smaller the cluster, the greater the interrelationship between ideas within the cluster

Refer to Table  2 for the cluster names, their associated importance and capacity ratings, and a sample of statements by cluster.

Engagement of older adults and care partners

The Engagement of Older Adults and Care Partners cluster includes six statements that describe a compassionate care approach to actively involve older adults and their care partners in their health care. The statements focus on the empowerment of older adults in their collaborative relationships with providers by ensuring older adults and their care partners: understand the purpose and results of the Check Up, know how to use the results to support their own wellbeing, and update their own profile and make it accessible to providers.

Instrument’s ease of use

The Ease-of-Use cluster is one of the largest, comprising 13 statements focused on suggestions to ensure the instrument is easy to use and understandable for older adults and their care partners. The statements focus on the user-friendliness of the software (e.g., easy navigation, simple instructions), provisions for translation into languages other than English, and avoidance of jargon or medical terminology. Providing technological support, as needed, for older adults independently completing the Check Up was suggested in the form of video instructions, phone support, or in-person instruction.

Accessibility of assessment process

Closely related to ease-of-use are the 11 statements in this cluster which reflect strategies for enhancing the Accessibility of the Assessment Process when using the interRAI Check Up with older adults. Accessibility refers to both access to technology (e.g., devices) and the internet and to supports to participate in the assessment (e.g., hearing aids, voice-to-text recognition), in any setting that the Check Up may be completed (e.g., home, primary care setting, etc.). Other considerations include checking the older adult’s and/or care partner’s capacity to independently complete the Check Up, as well as offering different options for completing the tool, such as online, in-person, on paper, or over the phone/video, and with and without the support of a provider.

Person-centred process

There are eight interrelated statements in the Person-Centred Process cluster, highlighting the importance of placing older adults’ needs and preferences at the forefront of encounters where the Check-Up would be used. These statements discuss a holistic approach ensuring that the care is tailored to the unique needs of each person. This care approach includes balancing the collection of digital information with face-to-face conversation, maintaining personal interaction as part of the assessment process, ensuring the older adult and their care partner have access to a copy (digital or physical) of the Check Up and its outputs and that they have been provided education on the meaning of those outputs. The focus of this cluster is ensuring that the care-planning process is person- centered and identifies what health means to the individual person even as technology is deployed.

How to use the check up in an assessment process

This cluster resides in the middle area of the map, where the clusters are about health- and social-care providers’ use of the Check Up. This cluster consists of seven ideas focused on How to Use the Check Up in an Assessment Process with older adults. These statements include considerations for providers when using the Check Up such as, effectively communicating the process for completing the Check Up so older adults understand what to expect and why it is being used. Participants also suggested that providers should determine the older adult population that would be best served by a self-report tool as opposed to a clinician-elicited assessment (i.e., interRAI Home Care) and that resources should be developed for both the use of software and the Check Up for providers and ones to share with older adults.

Training and education for providers

Located on the map beside the “how to” cluster is the Training and Education for Providers cluster. These nine statements are about equipping health- and social-care providers with the necessary knowledge and skills to effectively integrate the Check Up into their practice. They encompass strategies such as, leveraging existing interRAI provincial resources to develop and provide education on the use of software and the Check Up, providing education on self-management strategies and relevant community support services, and using the outputs of the Check Up in care planning. Establishing a shared understanding of how the Check Up can be used in the care of older adults and their care partners was also suggested as part of the training and education content.

Health and social care provider coordination

The three clusters at the bottom of the map capture statements that relate to the system-level use of the Check Up. The Health and Social Care Provider Coordination cluster contains the most statements (18) with content outlining how the sharing of the outputs of the Check Up would foster collaboration among health- and social-care providers. Statements include suggestions to develop referral pathways based on Check Up outputs and designate most-responsible providers and timelines to follow-up on any high-risk issues (e.g., significant mood issue). Participants noted that access to the Check Up outputs should be shared with all providers to reduce assessment burden on older adults and duplication of assessment.

Health information integration

The five statements in this cluster describe ways to support Health Information Integration from various sources into a comprehensive electronic record, allowing providers to have a more complete understanding of an individual’s health. Identified strategies include syncing digital information between all provider data sources, using automated processes (i.e., ‘bots’) to automatically identify older adults with known health issues to streamline care processes, and leveraging existing integration systems that would allow organizations to seamlessly share the interRAI Check Up results within the circle of care.

Health system decision support and quality improvement

Thirteen statements were sorted into the Health System Decision Support and Quality Improvement cluster and detail strategies to utilize the outputs of the Check Up at a system level to provide decision support as part of continuous quality improvement. Statements with a quality improvement perspective include selecting Check Up outputs for evaluating coordinated approaches to care, considering how this data may support identification of areas where increased service capacity is required, and considering if some of the items in the Check Up could be used as patient-reported outcome measures. Statements also focused on the technological side of quality improvement across the system by considering funding and access to software solutions to deploy and integrate the Check Up to automatically share information across system providers.

Privacy and confidentiality

The eight statements in the Privacy and Confidentiality cluster centred on the use and sharing of older adults’ health information through the Check Up assessment process. These statements include opportunities to maintain and describe privacy and confidentiality at both the older adult and system level. Participants generated ideas to ensure the older adult understands who has access to their data, where it will be stored, and how it will be used and can make an informed decision about sharing their personal data. To facilitate integrated care, participants noted that data-sharing agreements need to be developed between organizations that account for a broader circle of care than solely health-care providers.

Cluster ratings for importance and community capacity

The mean importance score for each cluster ranged from 2.92 to 3.19 out of four (refer to Table  2 ), with the Health System Decision Support and Quality Improvement cluster rated as the lowest relative importance and the Health Information Integration cluster rated as the highest relative importance. Most of the clusters ( n  = 7) were rated as greater than 3, representing the ‘important’ category on the 4-point Likert scale. With regards to community capacity, the mean scores ranged from 2.45 ( Health Information Integration cluster) to 2.82 ( Privacy and Confidentiality cluster). All mean ratings for capacity across clusters were between 2 and 3, reflecting the ‘a little capacity’ and ‘moderate capacity’ ratings. Of note, during and after the rating exercise, a number of participants commented that they found it challenging to rate the community capacity as they felt they did not know enough about the health- and social-care system capacity, for example related to staffing levels or budgetary restrictions.

Go-zone graph

The go-zone graph displays the agreement between older adults and all other participants related to the importance rating of statements (refer to Fig.  3 ). Data on the importance rating of all statements was available for only six older adults and 10 other participants. The statements in the left lower quadrant represent agreement on the statements of the lowest relative importance and the statements in the upper right quadrant reflect agreement on the statements of the highest relative importance. The other quadrants contain statements where there was less agreement on importance ratings between older adults and other participants. A total of 35 statements are in the upper right quadrant with representation from all ten clusters and a sample of these statements is reported in Table  2 . The rankings by older adults and the other participants were moderately correlated ( r  = 0.58).

Go-zone graph of priorities comparing older adults (x-axis) to other participants (y-axis). Ratings range from 1 to 4, with 1 indicating low importance, and 4 indicating high importance. Numbers correspond to statement numbers

Older adult participants rated two statements from the accessibility of the assessment cluster higher compared to all other participants: ensuring that older adults have access to required technology (i.e., devices) and the internet to complete the Check Up. Notably, providers rated items from the decision support cluster regarding shared benchmarking for quality improvement and using the Check Up outputs in care planning, as higher importance than did the older adult participants.

Action planning strategies

A number of strategies to use the outputs of the interRAI Check Up as part of the integrated care of older adults with multiple chronic conditions were generated based on the set of statements from the go-zone graph that were rated as the highest importance by both older adults and other participants. These strategies are organized by cluster in Table  3 . Considerations included strategies for the efficient and integrated administration and use of the Check Up, for example, developing workflow plans for how the Check Up would fit into care processes. Strategies were also developed to foster health- and social-care provider coordination, such as providing education on working as a team based on a shared care plan informed by a standardized self-report instrument.

This mixed methods study identified a number of practical strategies related to using the outputs of the interRAI Check Up as part of integrated health and social care for older adults with multiple chronic conditions and their care partners, considering: older adult engagement, instrument’s ease of use and accessibility, assessment process, training and education for providers, care provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality. Participants generated ideas to ensure the maintenance of a compassionate, person-centred approach when leveraging a digital health tool in the care of older adults. Strategies generated from these factors highlight the importance of preparing, intervening, and evaluating at older adult and provider, organizational, and system levels when introducing a new digital health tool. While participants were reflecting on the use of the interRAI Check Up Self Report instrument, the findings have relevance for the use and implementation of other electronic wellness instruments and digital tools.

The group concept mapping activities generated only two clusters about the digital health tool itself (instrument’s ease of use and how to use the Check Up in an assessment process), demonstrating that the instrument’s selection and thoughtful use are important but additional factors beyond the implementation of the instrument need to be considered. This finding is supported by previous research explaining the factors that influence the adoption of technology in health-care settings [ 35 , 36 ]. To support the integration of new digital tools, Shaw and colleagues [ 36 ] suggest that care delivery must be “re-invented”, and they propose a [Tool + Team + Routine] heuristic to guide implementation and sustainment of new digital tools. The team must see value in the tool ’s ability to enhance their care of older adults and to make that care more efficient [ 36 ]. The team must also agree that there is an issue in the current care delivery (i.e., fragmented health and social care) and plan for new ways of working together that will incorporate the digital health tool into routine practice [ 36 ]. The Health- and Social-Care Provider Coordination cluster, the largest cluster, contained strategies to ensure there is ‘buy-in’ for the use of the Check Up but also intentional planning for coordination amongst providers that may not have historically worked closely together. Careful planning of new practice routines is also important to ensure that introduction of the Check Up into interprofessional team practice does not further fragment care by creating “data silos” [ 37 ]. Participants also noted that that it takes time and effort to learn to work as a coordinated, interprofessional team and this finding has been noted in other evaluations of interprofessional teams caring for persons with complex chronic conditions [ 2 , 38 ]. Strong and trusting relationships in the interprofessional team is regarded as a critical component of workforce capacity in implementing integrated care programs and in the context of these findings, these relationships must extend beyond providers in the health-care sector and with social-care team members [ 7 , 39 ].

Health information integration is considered a facilitating factor for integrated care and was supported by this study’s findings [ 7 , 13 , 14 , 17 , 40 ]. The Health Information Integration cluster was rated as highly important but with the lowest community capacity rating across the clusters. This cluster also was the smallest (i.e., the fewest number of statements). The lower community capacity and smaller number of statements generated for this cluster may indicate that participants are unsure of how the integration of personal health information could occur across the health- and social-care sectors or reflect the reality that sophisticated data-sharing infrastructures are not in place in their community. Given that rating capacity was noted as challenging for participants, this may be another sign of system fragmentation. Local and other jurisdictions have felt tensions balancing privacy requirements with the benefits of more integrated information-sharing arrangements [ 41 ]. In an international survey of integrated care programs, only one-third of programs had secure data infrastructure platforms that supported patient information sharing among providers and many programs relied on team meetings or one-on-one communication to share information [ 13 ]. However, this study highlighted that both older adults and care providers rated the cluster of privacy and confidentiality as very important and high community capacity, indicating a community willingness and perceived ability to share information in a secure manner. A recent literature review of patient perspectives on consent related to sharing personal health information digitally noted that patients are willing to share their information to inform their care if it is done carefully, maintaining the privacy and security of their data [ 37 ]. Additionally, participants in the included studies wanted clear information on why their personal health information was being collected and shared, with whom it would be shared, and for what purpose [ 37 ]. Information technology expertise and support will be critical in moving from traditional forms of data sharing (e.g., team meetings) to more seamless, data infrastructure platforms informed by harmonized information management plans [ 40 , 42 , 43 , 44 ].

Health information integration is a prerequisite for continuous quality improvement, for example, aggregating information to understand population health needs and health system impact [ 7 , 43 ]. The Health System Decision Support and Quality Improvement cluster was a large cluster in this study, but participants rated the cluster as the relative lowest importance and of low capacity, with older adults rating some of the ideas in this cluster lower than other participants. This may represent another area where providers and older adults are uncertain of the importance of continuous quality improvement to foster a responsive learning health system for the developing needs of the community [ 11 ]. In reality, there are relatively few examples in the intersectoral care of older adults with multiple chronic conditions of continuous quality improvement efforts that engage both providers and older adults [ 16 , 45 ]. The suite of standardized interRAI instruments were designed with this purpose in mind: to not only inform care planning at the person-level but also program planning and cross-sectoral comparisons through embedded aggregate reporting features and quality indicators [ 46 , 47 ]. The Check Up also has interoperability and shared language with other interRAI instruments, such as those used in home care, given the shared items and outputs, which also facilitates on-going assessments over time and across settings [ 22 ]. Implementation planning for the use of the Check Up across health- and social-care sectors will need to include strategies to enact continuous quality improvement at both individual program and system levels.

Participants were able to generate many ideas around using a digital health tool in the care of older adults and their care partners, in contrast to the notion that older adults do not want to use technology in care interactions or that technology interferes with compassionate care [ 18 , 48 ]. Instead, they proposed ideas to engage older adults in using the Check Up and ensuring an accessible and easy-to-use process, including the provision of the Check Up in an older adult’s preferred language. Older adult participants highlighted the importance of providing access to devices and the internet when using a digital health tool in practice, which is a very relevant consideration given the cost implications for older adults [ 49 ]. Recommendations in the Accessibility and Ease-of-Use clusters are critical to ensuring that use of digital health tools does not create health inequities for older adults, in particular those experiencing socioeconomic disadvantages [ 49 ].

Strengths and limitations

A main strength of this study is its adherence to the group concept mapping methodology, which allows input from persons with diverse perspectives and roles in a local community and the subsequent co-creation of a concept map and action-planning strategies. Group concept mapping has advantages over traditional data collection methods, such as interviews or focus groups, due to its participatory nature and the creation of community-authored visual representations of ideas that guide planning [ 50 ]. The study employed a patient-oriented approach with active participation of older adults on the steering committee, increasing the relevance and applicability of the findings. Several limitations should be considered. One of the limitations was the potential for bias in the selection of older adult participants. The researchers recruited these individuals through existing networks (e.g., patient partners on organizational boards), which may not have been representative of the broader population of older adults. The number of older adults ( n  = 6) represented in the go-zone is very small for this type of analysis [ 28 ]. Further, some participants struggled with rating the statements on community capacity, which limited the number of responses in this data set. Due to the exploratory nature of this study, future research will be required to validate, refine, and test these strategies in this community and tailor for consideration in other communities. As well, work should be directed to considering how these strategies could be used to inform implementation of electronic wellness instruments and digital tools.

Older adult and provider, organizational, and system level factors need to be considered when implementing and using the outputs of an electronic wellness instrument across health- and social-care providers. This study extends and supports the existing evidence base on digital health tool adoption by providing a co-created, community action plan from the perspectives of older adults, care partners, health and social care providers and administrators, digital health experts, and researchers. Older adults, care partners, and the care team favourably regarded the use of the Check Up from both self-report and digital perspectives. The breadth of considerations in implementing and sustaining the use of the Check Up, from ensuring a person-centred assessment process to using the outputs as part of continuous quality improvement, would be relevant in the implementation of other electronic wellness instruments and digital tools or the re-implementation of an existing instrument to optimize its potential to support integrated care. This study also showcased a helpful research methodology (GCM) to gain important perspectives in a manner where all voices are heard and valued.

Data availability

Data requests should be submitted to the first author.

Abbreviations

Group concept mapping

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Acknowledgements

We thank the participants in this study and the steering committee members for giving of their time and valued expertise. We also thank Ms. Nayab Gohar for her support in data analysis during her research practicum with Canadian Mental Health Association Waterloo Wellington in the summer of 2022. We would like to dedicate this paper in the memory of Mr. Len Carter, a patient partner on the steering committee, whom we lost in March of 2023. His advocacy for persons with dementia remains a source of inspiration to us and his community.

Funding for this project was provided by AMS Healthcare. The funding body did not have any role in the design of the study, data collection, analysis and interpretation, or manuscript development.

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MN, MS and GH were responsible for the conception and design of the study. MN, MS, PG were responsible for the data collection. All authors contributed to the analysis and interpretation of study data during steering committee meetings (MN, MS, GH, TA, BE, PG, DG, SG, JMW, AM, HS, LT). MN and PG were responsible for the first drafts of this paper, which was critically revised by GH, MS, TA, SG, AM, HS, and LT. All authors read and approved the final manuscript (MN, MS, GH, TA, BE, PG, DG, SG, JMW, AM, HS, LT).

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Northwood, M., Saari, M., Heckman, G. et al. Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study. BMC Health Serv Res 24 , 864 (2024). https://doi.org/10.1186/s12913-024-11320-5

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InCHARGE: Co-creating, implementing and evaluating interventions to utilize nurses' competence and achieve person-centred fundamental care—A research protocol describing an action research approach

• Hauffman, Anna
• Björk, Elin
• Edfeldt, Katarina
• Fröjd, Camilla
• Gunnarsson, Anna-Karin
• Nyholm, Lena
• Avallin, Therese
• Jangland, Eva

Aim and objectives This research protocol presents an action research project with the aim to demonstrate the value of person-centred fundamental care to nurses and nurse managers in surgical care units to encourage a far-reaching change in this direction. The objectives are to describe this process and to evaluate the effects on missed nursing care and person-centred fundamental care. Methods In a novel collaboration between nursing science and medical humanities the action research design will be used to interact with nursing staff and leaders in three surgical care units and design interventions with the purpose to affect the direction of nursing. Initially, the care units will be presented with interactive workshops including evidence-based education on person-centered fundamental care, person-centredness, nurse role responsibility and leadership. This will be followed by cocreation of interventions to stimulate person-centered fundamental care. The Fundamentals of Care framework will be used as the overarching theoretical framework. Data on missed nursing care, person-centred climate and person-centered fundamental care will be collected repeatedly from patient- and nursing stakeholders through interviews and validated questionnaires. Additionally, data from written reflections following clinical observations and focus group interviews will be included. The duration of the study will be approximately five years from ethical approval. Discussion It has been previously reported that the current working environments of registered nurses are forcing them to ration their caring responsibilities, leading to a lack of fulfillment of patients' fundamental care needs, with possible severe consequences for patients. The action research design helps researchers gain an understanding of the contextual factors important for forthcoming interventions, enabling reflective processes and cocreation of interventions with stakeholders. This may lead to feasible interventions and strengthen nursing leadership in the involved units.

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Effects of a Comprehensive Person-Centered Care Education Program for Nursing Students

Associated data.

The study data are available upon request from the corresponding author.

Background and Objectives : The aim of this study is to develop and implement a comprehensive person-centered care (PCC) education program for nursing students and assess its effects on individualized care, empathy, communication competence, and clinical practice stress. Materials and Methods : A non-equivalent control group non-synchronized design was used. Participants were 60 third-year nursing students undergoing clinical practicum in a nursing school. They were assigned either to the control group (29 students) or experimental group (31 students). The experimental group participated in a comprehensive PCC education program, while the control group did not. Four 65-min sessions were conducted over two weeks; each session comprised 5 min of introduction, 50 min of education, and 10 min of sharing of thoughts and training. Individualized care, empathy, communication competence, and clinical practice stress were measured. Data were collected immediately before the education program and two weeks after program completion. Results : After the education program, the experimental group showed significant improvements in individualized care, empathy, and communication competence and significantly reduced clinical practice stress compared to the control group. Conclusions : The comprehensive PCC education program is a potentially beneficial intervention for nursing students to help them practice person-centered care with confidence. Longitudinal randomized controlled trials are needed to substantiate these findings.

1. Introduction

The paradigm of global healthcare is shifting from a disease-centered to a person-centered perspective. Person-centered care (PCC) refers to a type of care that considers individuals’ values and preferences, informs the patient about all aspects of health management, and supports realistic health and life goals [ 1 ]. In other words, it is a type of care that focuses on the patient, respects the patient, actively responds to the patient, and ensures the patient’s rights and autonomy in treatment decisions [ 2 ]. Essential elements of PCC are individual focus, empathy, communication, respect, and coordinated care [ 1 , 3 ]. Patients who receive PCC feel more respected through individualized care, develop more confidence in improving their own health, and feel that they are given more support [ 4 ]. PCC enhances patients’ health-related quality of life by reducing chronic disease morbidity and improving lifestyle [ 5 ]. It also improves nursing care providers’ job satisfaction [ 6 ] and quality of care [ 7 ]. Thus, PCC is a core competency that must be continually advanced.

Nursing students become partially involved in patient care during their clinical practicum [ 8 ]; therefore, it is imperative that PCC competence is cultivated through effective education programs so that nursing students who will be prospective nurses can provide quality patient care. Existing studies on nursing students conducted abroad have focused on PCC learning experiences for a semester [ 9 ] and introduction to teaching approaches [ 10 , 11 ]; studies developing PCC education programs are scarce. In Korea, one study showed that a PCC education program based on a design-thinking approach improved the perceptions of individualized care [ 8 ], but most of the published studies investigated the predictors of PCC competence in nursing students [ 12 , 13 , 14 ]. Although not PCC education programs for nursing students, a prior study implemented a person-centered dementia education program with nursing care providers in long-term care facilities [ 15 ], while another applied a PCC education program among clinical nurses [ 16 ]. However, research on developing a PCC education program with practical applications for nursing students and evaluating its effectiveness has been insufficient.

An effective educational approach is critical to enhance nursing students’ levels of caring [ 9 , 17 ]. Furthermore, as PCC education focused on case studies helps nursing students to gain an understanding of PCC fundamentals and broadens their view of PCC [ 9 ], case study-based education is as important as theoretical education in cultivating knowledge and attitudes to promote PCC practice. This study utilizes case studies that would help students apply their learned knowledge in practice as well as theoretical education for PCC. Nursing students must also be taught effective communication skills to build an empathetic relationship with their patients to provide PCC [ 2 , 18 , 19 ]. In other words, carefully listening to and communicating with patients is crucial to accurately understand their motivations, priorities, and preferences [ 1 ]. Empathy is also an important factor for practicing PCC [ 3 ]. It is important in providing meaningful care, which enhances patients’ well-being [ 20 ]. Thus, PCC education for nursing students must also address empathy as well as communication skills.

No study has yet reported the effects of a comprehensive PCC education program that encompasses a theoretical approach, PCC cases that help apply knowledge in practice, and education to boost communication competence and empathy. Therefore, this study developed a comprehensive PCC education program for nursing students undergoing clinical practicum and investigated the effects of the program on the key elements of PCC—individualized care, empathy, and communication competence—and clinical practice stress.

2.1. Study Design

This study used a non-equivalent control group non-synchronized design. Conducting the study simultaneously with the experimental and control groups would have elevated the risk of diffusion effect, as participants were undergoing clinical practicum at the same hospital. Therefore, this study used a non-synchronized design, wherein the control group underwent the study first, followed by the experimental group.

2.2. Participants

The inclusion criteria were (1) third-year nursing students who had experienced clinical training for more than one semester at a general hospital, (2) scheduled for clinical practicum during the study period, and (3) no prior participation in a similar PCC education program. The exclusion criteria were (1) unavailable to undergo at least two weeks of on-campus practicum and clinical practicum in the hospital after the completion of the education program and (2) unable to participate in all sessions of the education program.

Sample size was calculated using the G*Power 3.1 software. For independent t-tests with a significance (α) of 0.05, power of 0.8, and effect size of 0.8, the minimum sample size was 26 for each group. The dropout criteria were missing any of the four sessions of the program or failure to complete the pre-test or post-test.

2.3. Enrollment, Allocation, and Blinding

Participants were recruited among third-year nursing students at a nursing school in C city in South Korea through social network service and bulletin board. The researcher anticipated a high dropout rate as the study was conducted during clinical practicum. Considering about 30% dropout, the researcher intended to recruit 68 participants, but 73 participants were enrolled. The recruiting process, educational intervention, and surveys were conducted from 18 May 2021 to 10 December 2021.

A third person not involved in the study arbitrarily assigned participants into the experimental group and control group. Participants were given a detailed explanation about the study procedure during the informed consent process; they were aware of which program they were participating in. The researcher administered the education program; therefore, the researcher was also aware of the provided content. To reduce the consequent bias by these problems, this study used a non-synchronized design to ensure that the control group and experimental group did not have any contact with each other, and the researcher followed a manual when providing education to ensure consistency in each session.

The experimental group completed the pre-test immediately before beginning the education program and completed the post-test after two weeks of on-campus and clinical practicum following program completion. The control group also completed the post-test after two weeks of on-campus and clinical practicum following the pre-test. The researcher and research assistants administered the pre-test and post-test.

Of 73 participants, 6 participants who could not undergo at least 2 weeks of on-campus and clinical practicum following the completion of the education program were excluded. Of 67 participants meeting the criteria, the control group was expected to have a higher dropout rate because they only complete the pre-test and post-test without intervention; therefore, 36 participants were assigned to the control group and 31 were assigned to the experimental group. A total of 7 participants in the control group failed to complete the post-test, resulting in a total of 29 participants, and all 31 participants in the experimental group were included. Thus, a total of 60 participants were included in the final analysis ( Figure 1 ).

Research flow diagram.

2.4. Development Process of Comprehensive PCC Education Program

Existing studies were reviewed to identify the essential contents for the comprehensive PCC education program. Nursing students need to know the concept and principles of PCC to perform PCC during clinical practicum. Thus, this study reviewed previous studies [ 1 , 2 , 3 , 21 ]. Detailed PCC education that provides practical assistance is needed for nursing students, and case studies help students understand PCC fundamentals [ 9 ]. Thus, this study included PCC cases proposed by Price [ 4 ] that can be applied in clinical practicum.

Moreover, empathy, communication, respect, relationship, and individualized focus are important factors in PCC [ 3 ]. This study examined previous research on improving empathy and communication training in nursing students [ 3 , 22 , 23 ].

The program was structured to include the definition of PCC, core premises, and effects of PCC to help students gain an understanding of PCC, broaden their view, and cultivate a positive attitude toward PCC. Case studies of PCC were taken from the book written by Price [ 4 ] and translated into Korean. Three cases were included: helping a patient understand their situation (patient with multiple sclerosis), helping a patient learn about the treatment, care, and recovery (pediatric patient with diabetes), and helping a patient cope with changes and anxiety (patient with colorectal cancer).

Empathy training included contents about understanding the concept of empathy, knowing one’s emotions, expressing emotions, and listening. The goal of the empathy training was to ensure that the students had an accurate understanding of empathy, knew how to express empathy, recognized their own emotions, and listened correctly to identify others’ emotions. Communication training comprised open-ended questions, affirmations, I-message, and reflective listening. The goal of communication training was to help nursing students to build a relationship of trust with the patient, identify the patient’s values, needs, and preferences, deliver information individually, and help patients actively improve their own lifestyle.

This study set the program to 4 sessions with reference to the 2–6 sessions used by a study providing a person-centered dementia care education program to nursing care providers in long-term care facilities [ 15 ] and a study providing a PCC education program to clinical nurses [ 16 ]. Each session was set to last 65 min based on the 60min session used previously [ 16 ], and each session comprised an introduction (5 min), education (50 min), and hands-on practice and sharing of thoughts (10 min). The educational approaches used were lectures, role play, hands-on practice, and sharing of thoughts based on previous studies [ 16 ]. The study parameters were assessed before and after the program using self-report questionnaires. The questionnaires were administered at baseline and after two weeks of on-campus and clinical practicum following the intervention.

The educational materials were written in 12-point font size to provide to the participants at each session. Moreover, a training manual for each session was developed to ensure consistency in the education program. The lectures consisted of 20 min of understanding of PCC and case study analysis, 15 min of empathy training, and 15 min of communication training for each session ( Table 1 ).

Educational contents of comprehensive person-centered care (PCC) education program.

The content validity of the developed comprehensive PCC education program was evaluated. The content on understanding of PCC and the case studies were reviewed by a professor with experience in PCC research and two nursing students, and the empathy and communication training contents were reviewed by three professors with experience in administering relevant education and two nursing students.

2.5. Intervention

The developed comprehensive PCC education program consisted of a total of four sessions (two sessions per week) for 65 min per session. The researcher conducted the program in a quiet lecture room. The students were divided into three-person or four-person groups to promote interaction.

In the initial part of the program, the researcher introduced the outlines for the corresponding session and had students share their thoughts on the changes they had during clinical practicum since the preceding session. During hands-on training, the students could practice what they learned during the education, and during sharing of thoughts, they shared their thoughts after each session. Both lecture and practice were included in each session to enhance students’ understanding and utilization of educational contents. In addition, the researcher tried to identify and solve students’ difficulties during practice. The researcher asked students to think about and express what appropriate empathy and communication should be provided to patients and how to address situations through a case study. However, whether the students understood the contents of each session well was not objectively evaluated in each session.

The lectures were given according to the manual, and the students were given educational materials and a book containing PCC cases. The education program was administered by the researcher, who has experience in research on communication-enhancing programs and PCC and has translated a book on PCC.

2.6. Measurements

Participants’ sex, age, religion, health status, satisfaction with college, satisfaction with nursing major, and academic performance in the preceding semester were surveyed. Individualized care, empathy, communication competence, and clinical practice stress were measured immediately before the intervention and two weeks after the intervention using the self-report questionnaires. The pre-test was written based on students’ experience of providing care to patients during clinical practice before the comprehensive PCC education program, and the post-test was written based on the experience of providing care to patients during the on-campus practicum and the clinical practicum in the hospital after the completion of the education program.

Individualized care was assessed using the Individualized Care Scale-Nurse A version (ICS-A-Nurse) developed by Suhonen et al. [ 24 ] and adapted to Korean for use among nursing students by Park [ 25 ]. The Individualized Care Scale measures individualized patient care based on nurses’ perceptions and includes the following: (1) assessment of patients’ needs, preferences, and perceptions; (2) patients’ participation in their care; and (3) care based on patient’s individualized information [ 24 ], which are key elements of person-centered care. This 17-item instrument uses a 5-point Likert scale, and a higher score indicates greater individualized care. The Cronbach’s α was 0.89 in the study by Park [ 25 ] and 0.87 in this study.

Empathy was assessed using the Jefferson Scale of Empathy-Health Profession Students’ version (JSE-HPS) developed by Hojat et al. [ 26 ] and adapted to Korean and validated by Hong [ 27 ]. Permission to use the Korean version of the instrument was obtained from Thomas Jefferson University. This instrument contains 20 items (10 negatively worded, 10 positively worded) and uses a 7-point Likert scale, wherein a higher score indicates greater empathy. The Cronbach’s α was 0.88 in the study by Hong [ 27 ] and 0.85 in this study.

Communication competence was measured using the Global Interpersonal Communication Competence (GICC) scale developed by Hur [ 28 ]. This 15-item instrument uses a 5-point Likert scale, and a higher score indicates better communication competence. The Cronbach’s α was 0.72 in the study by Hur [ 28 ] and 0.80 in this study.

Clinical practice stress was assessed using the instrument developed by Beck and Srivastava [ 29 ] and adapted to Korean and modified by Lee and Kim [ 30 ]. This 24-item instrument uses a 5-point Likert scale, and a higher score indicates greater clinical practice stress. The Cronbach’s α was 0.91 in the study by Lee and Kim [ 30 ] and 0.89 in this study.

2.7. Data Analysis

The collected data were analyzed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). The baseline homogeneity of general characteristics between the experimental and control groups was tested using the chi-squared test, Fisher’s exact test, and independent t-test, and the normality of the dependent variables was analyzed with the Shapiro–Wilk test. The baseline homogeneity of the dependent variables and the effects of the comprehensive PCC education program were analyzed using the Mann–Whitney test or independent t-test depending on the normality of the data.

2.8. Ethical Considerations

This study was approved by the Ethics Committee of Kangwon National University (IRB No.: KWNUIRB-2021-04-011-001) prior to data collection and intervention administration. All participants volunteered to participate in the study and were provided detailed explanations about the purpose and procedure of study, guarantee of anonymity of collected data, benefits and risks, confidentiality, and withdrawal from the study both verbally and in writing. The study began after obtaining written informed consent.

3.1. Test of Homogeneity for the General Characteristics of Subjects

There were no significant differences in sex, age, religion, subjective health status, satisfaction with college life, satisfaction with nursing major, and academic performance in the preceding semester between the two groups, confirming baseline homogeneity in the general characteristics between the two groups ( Table 2 ).

Homogeneity of general characteristics of participants between groups before intervention (n = 60).

† Fisher’s exact test, M: mean, SD: standard deviation.

3.2. Baseline Homogeneity of the Dependent Variables

With the exception of individualized care (experimental group W = 0.964, p = 0.363, control group W = 0.919, p = 0.029), all dependent variables, namely empathy (experimental group W = 0.945, p = 0.116, control group W = 0.933, p = 0.067), communication competence (experimental group W = 0.969, p = 0.500, control group W = 0.987, p = 0.965), and clinical practice stress (experimental group W = 0.948, p = 0.139, control group W = 0.971, p = 0.579), were normally distributed. There were no significant differences in these dependent variables between the two groups, confirming baseline homogeneity ( Table 3 ).

Homogeneity test of the dependent variables before intervention (n = 60).

‡ Mann–Whitney test; Exp.: experimental group; Cont.: control group; SD: standard deviation.

3.3. Effects of Comprehensive PCC Education Program

Table 4 shows the changes after the comprehensive PCC education program. The changes in individualized care, empathy, communication competence, and clinical practice stress scores after the education program significantly differed between the experimental group and the control group. Compared to the control group, individualized care (Z = −2.44, p = 0.024), empathy (t = −2.76, p =0.008), and communication competence (t = −3.25, p = 0.002) were significantly improved. Individualized care scores increased in the experimental group (5.61 ± 11.38) but decreased in the control group (−0.24 ± 6.26). Empathy scores increased in the experimental group (3.29 ± 6.90) but decreased in the control group (−2.96 ± 4.48). Additionally, communication competence scores in the experimental group increased (0.77 ± 4.42) but decreased in the control group (−2.96 ± 4.48). Finally, clinical practice stress (t = 2.90, p = 0.005) was significantly reduced in the experimental group compared to the control group. Clinical practice stress scores decreased in the experimental group (−1.41 ± 7.93) but increased in the control group (4.48 ± 7.81) ( Table 4 ).

Comparison of dependent variables between the two groups after intervention (n = 60).

§ Mann–Whitney test; Exp.: experimental group; Cont.: control group; SD: standard deviation.

4. Discussion

This study aimed to evaluate the effects of a comprehensive PCC education program on nursing students undergoing clinical practicum in the hospital. No study has yet reported the effectiveness of a comprehensive PCC education program for nursing students in Korea and abroad. Therefore, this study is significant as the first study investigating the effects of a comprehensive PCC education program on individualized care, empathy, communication competence, and clinical practice stress among nursing students undergoing clinical practicum.

First, the comprehensive PCC education program significantly improved individualized care compared to the control group. We could not compare our results directly with those in the literature since the study that applied flipped and simulated learning to enhance nursing students’ understanding of PCC [ 11 ]. However, it is consistent with the study that showed individualized care improved after an education program based on a design-thinking approach in nursing students [ 8 ]. In our study, there are several reasons why the comprehensive PCC education program was effective. First, the fact that the comprehensive PCC education program in this study was effective in enhancing individualized care may be attributable to case study-based education. A theoretical approach to PCC alone does not adequately help nursing students to understand PCC in nursing practice and consider their personal views toward PCC [ 9 ]. Thus, we speculate that including case-based learning in PCC education for nursing students was effective. Furthermore, the program simultaneously improved empathy and communication competence, which are the essential factors of PCC [ 3 , 19 ], and this is presumed to have contributed to boosting individualized care in nursing students. Finally, the students were given an opportunity to apply what they had learned in the education program during on-campus and clinical practicum for two weeks, which also would have contributed to enhancing individualized care.

Second, the comprehensive PCC education program also significantly enhanced empathy compared to the control group, and empathy is an essential attribute for nursing students to promote PCC, owing to its strong association with PCC competence [ 14 ]. Understanding the patient’s stance and expressing empathy are key features of PCC [ 22 ]. Korean nursing curricula include one semester of a communication course in the first year, and although students learn about empathy as part of this course, it is difficult to enhance empathy only through a short class. Thus, various scenarios of empathy applicable to clinical practicum should be developed to train students. In a systematic review of the literature on empathy education for nursing students [ 31 ], the most effective empathy education was indicated to be involved immersive and experiential simulation-based interventions. The results of this study highlight the importance of not only theoretical education about empathy but also its practice directly through case studies.

Third, the comprehensive PCC education program significantly improved communication competence compared to the control group. Effective communication between patients and nurses is an essential requirement for PCC [ 23 ]. Among the five aspects of professional nursing competence in nursing students, communication was most strongly associated with PCC competence [ 14 ]. In this sense, an improvement of communication skills after completing a comprehensive PCC education program is meaningful. As previously mentioned, nursing students in Korea take a communication course only in their first year of school. However, first-year students lack a deep understanding of the nursing discipline and person-centered care; therefore, it would be more effective to provide intensive communication education during the third year, in which students begin their clinicals, such that they can effectively communicate with patients with confidence. Moreover, students should be continuously trained for communication skills applicable in future clinical settings.

Finally, the comprehensive PCC education program significantly reduced nursing students’ clinical practice stress compared to the control group. Nursing students have been reported to be under heavy stress during clinical practicum, primarily due to fear of unknown situations, lack of competence, and lack of control in their relationship with patients [ 32 , 33 ]. The program seemed to help students provide patient care with more confidence and effectively communicate with patients, thereby reducing their clinical practice stress. Previous findings that PCC increases job satisfaction while reducing stress in healthcare providers [ 6 , 7 ] partially support our result.

This study is significant as the first study in Korea and abroad to implement and evaluate a comprehensive PCC education program in nursing students. Moreover, the fact that we developed a feasible comprehensive PCC education program for nursing students undergoing clinical practicum adds to the significance of this study. Nursing students who completed the education program applied what they had learned into practice during on-campus and clinical practicum and evaluated the effectiveness of the program themselves, thereby improving the accuracy of the assessment. Finally, this study showed that a program that simultaneously boosts empathy and communication competence as well as PCC through theoretical and case-based education is effective, thereby establishing evidence supporting the implementation of a comprehensive intervention.

This study has a few limitations. We could not use a randomized experimental design and used a non-synchronized design to prevent any diffusion effects between the experimental group and control group. Hence, bias caused by various exogenous variables that might have occurred during this period could not be controlled. Moreover, we conducted the comprehensive PCC education program at one university in Korea; therefore, these results have limitations in generalizing the findings. Lastly, although we administered the post-test after the students had about two weeks of on-campus and clinical practicum following the completion of the intervention, we did not use a longitudinal design and thus could not evaluate whether the effects are retained in the long term.

In the future, longitudinal randomized controlled trials are needed to substantiate the findings of this study. Moreover, replication studies are needed with nursing students from diverse universities. Finally, studies should develop more patient scenarios for case-based learning, an essential component of comprehensive PCC education, and assess the effects of such education.

5. Conclusions

This study developed, implemented, and evaluated the effects of a comprehensive PCC education program in nursing students undergoing clinical practicum. The program improved nursing students’ PCC competence, empathy, and communication competence while reducing their clinical practice stress. Thus, a comprehensive PCC education program could be utilized as a pre-practicum intervention for nursing students to boost their confidence and promote PCC practice during clinical practicum.

Funding Statement

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. NRF-2019R1G1A1009444).

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Kangwon National University (IRB No. KWNUIRB-2021-04-011-001).

Informed Consent Statement

Written informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The author declares no conflict of interest.

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