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

Background 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. Methods 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. Results 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. Conclusion 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.

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 patientcentered care concepts have different goals. Patientcentered 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.

Methods
This study is a systematic review of the empirical research literature after Harris [31] focused on personcentered 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

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) peerreviewed 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 personcentered 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.

Quality appraisal
The quality of the 27 included papers was assessed by Joanna Briggs Institute [34] checklist for quasiexperimental 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 twostep 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.
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-      -Person-centered care: 2day education off-site and 2-day on-site guide to implement person-centered care. Support by phone for 4 months. -Dementia care mapping: 3day education off-site and alongside worked with selected nurses after the education. Support by phone for 4 months.
Staff burnout, general wellbeing, attitudes, and reactions towards residents behavioural disturbances, perceived managerial support and quality of care interactions were assessed at baseline, immediately after intervention and at 4 months' follow-up. P: Dementia care mapping was more effective than person-centered care to reduce the staff members' jobrelated burnout and emotional exhaustion. The support of managers is important. Without the managers support the influence of intervention is weaker and lasts less time. S: There were no significant differences in terms of staff attitudes and reactions towards behavioral disturbances and care quality. N = + Jeon et al. [65], 2012 -5 X 2 h education seminars Person-centeredness education intervention effectiveness on the staff's perception of providing person-centred palliative care for older people in nursing homes was assessed at baseline and 3 months after the 6 months intervention.
OC: The intervention was not effective, because results showed no improvement in any outcomes. The only perceived improvement area in person-centered care was the managers' and organization's support of the staff's everyday work to maintain person-centered care. N = 0 Bökberg et al. [50], 2019 -Education about the person-centered approach to showering and and towel baths focusing on residents' needs, the accommodation of residents' preferences, attending to the relationship and interaction with residents, using effective communication and interpersonal skills, adapting the physical environment and bathing procedures to decrease distress and discomfort. Residents' oral hygiene were assessed at baseline via videotaped performing mouth care by CNAs and during the 6 weeks intervention by measurements and video recording by CNAs. P: The intervention had a significant effect on the residents' oral hygiene outcomes as Plaque Index and Gingival Index. S: after the intervention mouth care was more thorough, took more time and consistency of care appeared to be more important for natural teeth than dentures. OP = + 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  [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 personcentered 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).

Discussion
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 personcentered care is an abstract concept and so difficult to measure, the creation of a stronger argument for its use requires more rigorous research including the wider use of valid, person-centered care measurement instruments.
Pedagogical methods were at the core of the effectiveness of the continuing education interventions. Some of the studies educated "key nurses," leaving these nurses to help other nurses learn to implement change in their workplace [50,53,56,61]. There are some risks associated with using "key nurses" in this way, as the process of implementing person centered care requires an understanding of the origin and content of the concepts alongside the practical uses in care situations. The work environment, level of job satisfaction, managerial approaches and the personalities of nurses can help or hinder the work of these "key nurses", who will require stronger managerial support, encouraging flexible working practices and the involvement of nurses in care decisions [53]. Earlier studies have reported that the collective competence of a team is greater than one persons' competence [21]. Studies in this review using "key nurses" to introduce person-centered care were not effective in developing the collective competence of the nursing teams directly, limiting the possible benefits of the education e.g. [50].
When introducing person-centered care, pedagogical methods such as face-to-face teaching, though important, were not seen to be sufficient generally [36] and most of the interventions in this review used additional on-site support and consultation e.g. [42,48,68,70] video material e.g. [57,61,74] brainstorming [72] and role-playing [68,72] to achieve their preferred outcomes. Additionally, more student-centered approaches such as simulation-based nursing education interventions have been shown to improve critical and creative thinking [79] though simulation was only used in one reviewed study [72].
Digitalization as part a pedagogical method can support learning activities [80,81]. Appropriate applications including learner-centered approaches, improve communication between students and educators and enable a collaborative learning environment [82]. However, use of these digital platforms have strengths and weaknesses. It has been reported that Moodle promotes professionalism, ethical behavior and develops critical thinking, but the use of other participatory web-based platforms, including social media platforms may suffer from credibility of information and are open to student misinterpretation [83]. The choice of appropriate platform requires some competence [80].
In this review, after the continuing education, nurses: increased the number of positive interactions with residents [38], improved person-centered care delivery [42], communication [44], and satisfaction in relationship with older people [46,57], and increased their knowledge about meeting the needs of people with dementia [69]. Other improvements delivered by the outcomes of the reviewed studies were: a reduction in the use of medicines [36,73]; improved behavioral symptoms [38,56,62,69,71] and relationships with nurses [57,64,72,74] improved the quality of life for the older people [48,67,75]; and increased the number of support for daily activities [66,70]. These results demonstrate the usefulness of research of continuing education interventions, especially when these changes have been brought about in work practice: reduce nurses burnout [46,47,65] have positive effects on nurses mood and burden [67]; and influence organizational culture, changing nurses experiences for the better [48,69]. This general increase in the quality of care and care environment after suitable continuing education is also supported by other evidence [17].
The data that informed the research came from: residents' medication charts; nurse-completed questionnaires; video recordings and from observation. In only one study did researchers collect data from the next of kin, about person-centered care interventions [69]. This is disappointing as the opinions of the older people and their next of kin on the results of the continuing education intervention might facilitate a better understanding of the interventions that meet their needs. The lack of old people's and their next of kin views and perceptions need to be addressed in future research.
Most of the interventions used, produced the positive outcomes described above. However, in some studies the sample sizes were quite small and not power analyzed e.g. [42,57,75]. In other studies the content or delivery of the intervention may not have been appropriate [50,61,68]. Many other weaknesses were described in the studies reviewed. Additionally, the drop-out rate from the research may have been a major difficulty [48,50]. This drop-out occurs, for example through the mortality of the residents, and nursing staff turnover [84,85]. Four studies did not report any positive outcomes from the continuing education interventions [50,55,61,68]. There were quite several studies that did not follow the reporting guidelines, in which case the primary and secondary measures and outcomes were not clearly mentioned [42, 44, 46-50, 57, 61, 63, 64, 67, 69, 74, 75]. This review has identified and analyzed the available continuing education interventions about personcentered 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].

Conclusion
This review enhances the understanding about personcentered 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.