research & review journal of geriatric nursing and health sciences

A Scoping Review of the Evidence About the Nurses Improving Care for Healthsystem Elders (NICHE) Program

Affiliations.

• 1 Rory Meyers College of Nursing, New York University, New York, New York.
• 2 Division of General Internal Medicine, Langone School of Medicine, New York University, New York, New York.
• 3 Hartford Institute for Geriatric Nursing, New York University, New York, New York.
• 4 Nurses Improving Care for Healthsystem Elders Program (NICHE), Rory Meyers College of Nursing, New York, New York.
• PMID: 31681955
• DOI: 10.1093/geront/gnz150

Background and objectives: The Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help health care organizations improve the quality of care for older adults. To conduct a scoping review of the evidence associated with the NICHE program to (a) understand how it influences patient outcomes through specialized care of the older adult and (b) provide an overview of implementation of the NICHE program across organizations as well as its impact on nursing professionals and the work environment.

Research design and methods: Six databases were searched to identify NICHE-related articles between January 1992 and April 2019. After critical appraisal, 43 articles were included.

Results: Four thematic categories were identified including specialized older adult care, geriatric resource nurse (GRN) model, work environment, and NICHE program adoption and refinement. Specialized older adult care, a key feature of NICHE programs, resulted in improved quality of care, patient safety, lower complications, and decreased length of stay. The GRN model emphasizes specialized geriatric care education and consultation. Improvements in the geriatric nurse work environment as measured by perceptions of the practice environment, quality of care, and aging-sensitive care delivery have been reported. NICHE program adoption and refinement focuses on the methods used to improve care, implementation and adoption of the NICHE program, and measuring its impact.

Discussion and implications: The evidence about the NICHE program in caring for older adults is promising but more studies examining patient outcomes and the impact on health care professionals are needed.

Keywords: Aging; Geriatric nursing; Health care professionals; Intervention; Quality improvement.

© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].

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• Geriatric Nursing*
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• Published: 26 October 2022

Developing a competence framework for gerontological nursing in China: a two-phase research design including a needs analysis and verification study

• Bea L. Dijkman 1 ,
• Marina Hirjaba 2 ,
• Wenwen Wang 3 ,
• Marjo Palovaara 2 ,
• Marjolein Annen 1 ,
• Merle Varik 4 ,
• Ying’ai Cui 5 ,
• Jing Li 6 ,
• Cornelia van Slochteren 1 ,
• Wang Jihong 6 ,
• Chen Feiteng 6 ,
• Yudong Chen 5 &
• Wolter Paans 1  

BMC Nursing volume  21 , Article number:  285 ( 2022 ) Cite this article

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China faces a serious shortage of competent nurses who can address the healthcare needs of older people in an ageing society. Chinese higher education institutes face serious challenges when it comes to developing new curricula that are capable of educating sufficient numbers of competent gerontological nurses. Therefore, the aim of this research study was to identify and verify competencies for gerontological nurses in China that are needed to provide nursing care for the growing number of older people in all care settings. This study takes into account the possible opportunities that trends and developments may offer in the near future.

In this study, a two-phase research design was used. The first phase concerned needs analysis, including a situational analysis, a trend analysis and a competence analysis. This process resulted in a draft competence framework. The second phase addressed the verification of the competence framework through a two-round Delphi study with a panel of Chinese and European experts. This process led to the final competence framework.

The final competence framework for gerontological nursing in China included six competencies divided into 13 essential and five relevant learning outcomes. The competencies are: ‘providing gerontological care’, ‘communication and collaboration’, ‘organization of gerontological nursing care’, ‘health promotion’, ‘evidence-based nursing and lifelong learning’ and ‘professional behaviour’.

The framework comprehensively covers the six core competencies that nurses who care for older people should possess. These competencies are well-embedded in a Chinese context. The framework therefore offers concrete, practical suggestions for the competencies and skills that nursing graduates will need to work in current and future professions related to gerontological nursing education and practice.

Peer Review reports

China faces a serious shortage of competent nurses who can address the healthcare needs of older people in an ageing society. According to the seventh population census of China’s National Bureau of Statistics, 264.02 million people in China are aged 60 or older, accounting for 18.70% of the country’s total population [ 1 ]. In contrast, there were 4.7 million registered nurses in China at the end of 2020, and the ratio of registered nurses per 1,000 people was 3.35 [ 2 ]. This is far below average international ratio, which is 8.8:1000 [ 3 ]. The Chinese government has offered various methods to increase the number of registered nurses and to meet the growing needs of older people. According to the National Health Commission of the People's Republic of China, increasing the number of registered nurses will require further efforts in healthcare education, healthcare organisations and healthcare infrastructure [ 4 ]. These changes are visible in the Healthy China 2030 Plan for the WHO [ 5 ] and in the country’s ongoing healthcare reform, which aims to increase training for medical professionals and to enhance investments in healthcare and care facilities for older people, especially in rural area [ 4 ]. Additionally, global cooperation and investments in new technologies are promoted to improve healthcare [ 4 ].

Gerontological care providers and educational institutes need to consider how to cope with the existing problems in the field of care for older people and how to address the development of gerontological nursing in China [ 6 ]. The Chinese nursing curriculum concerning gerontological nursing is quite traditional. From its inception, nursing education in China adopted the bio-medical model [ 7 ]. It focuses strongly on disease and theory, but it neglects prevention, health rehabilitation and practical skills [ 7 , 8 ]. In general, graduates are neither motivated nor equipped with sufficient skills to work in the various healthcare environments that currently exist for older people [ 7 ]. Chinese higher education institutes (HEIs) face serious challenges when it comes to developing new curricula capable of educating sufficient numbers of competent gerontological nurses. Chinese nursing graduates need to acquire competencies to support healthy ageing today while also learning to understand the field’s future needs [ 7 ].

The GeNEdu project, which seeks to develop gerontological nursing education in China through multidisciplinary innovations, seeks to navigate the challenges in this field. In this Erasmus Capacity Building project, three Chinese HEIs work closely with three European HEIs. The main objective of the GeNEdu project is to renew nursing curricula by building the capacities of Chinese HEIs and by developing gerontological nursing education for future healthcare professionals to ensure that they can meet the needs of China’s ageing society [ 8 ]. Part of the project is the development of a competence framework for gerontological nurses in China. This framework is designed to guide the development of new educational programmes.

Competence frameworks typically are used to outline the characteristics of a competent workforce [ 9 ] and to serve as input for curriculum development [ 10 ]. In the field of healthcare, many competence frameworks exist, including several competence frameworks for gerontological nurses [ 11 , 12 , 13 ]. Most literature about gerontological nursing competences is based on research in western societies. China, in comparison to many other ageing societies, has distinctive national and cultural characteristics influencing gerontological nursing [ 8 , 14 ]. Due to the cultural differences between China and Western countries that influence the perception of what gerontological care delivery entails, the need arose to develop a new competence framework as part of the GeNEdu-Erasmus project. Erasmus projects aim to bring expertise from European universities together with universities outside Europe, in order to learn from each other, conduct research together, and improve curricula [ 8 ]. GeNEdu’s competence framework for gerontological nursing will support the development of new curricula to meet the rising care needs of older people in China. Therefore, the aim of this research study was to identify and verify competencies for gerontological nurses in China.

In this study, a two-phase research design was used. The first phase concerned the needs analysis, including a situational analysis, a trend analysis and a competence analysis. It resulted in a draft competence framework. The second phase concerned the verification of the competence framework through a two-round Delphi study with a panel of Chinese and European experts. It led to the final competence framework (Fig.  1 ).

Two-phase research design, including needs analysis and verification study

Needs analysis

The design of the needs analysis included three steps. Its goal was to identify the competencies that gerontological nurses in China need. The first step of the needs analysis was a situational analysis, which identified the needs in gerontological nursing practice and education in China on both a national and regional level. The second step was a trends analysis, which identified the international trends and developments in gerontological nursing. The third step was a competence analysis, which provided insight into existing competence descriptions for gerontological nurses.

Situational analysis

Performing a situational analysis identified the primary challenges, trends and developments in gerontological care and gerontological nursing in China. A DESTEP analysis approach was used to identify the demographic, economic, social, technological, ecological and political factors that are important to the future of gerontological care and gerontological nursing education [ 15 , 16 ]. During a one-day workshop, participants from three Chinese partner universities systematically mapped their findings onto national and regional levels. After the workshop, the Chinese partner universities performed desk research to deepen the DESTEP analysis. They used scientific articles, online information, policy documents and other relevant material written in Chinese. An additional six Chinese experts in the field of gerontological nursing practice were also interviewed. The outcomes of these interviews were shared and discussed during online meetings. This created mutual understanding about the current status and future needs of gerontological nursing in China.

Trends analysis

A comprehensive review of scientific and grey literature was performed to identify the main international trends in gerontological nursing and gerontological nursing education.

A scientific literature search was performed simultaneously in two databases: CINAHL and MEDLINE. The keywords used were ‘gerontology or elderly or aging or geriatric’ and ‘nursing or nursing care or nursing education or nursing competence’. The search was limited to peer-reviewed, full-text articles published from 2016–2020. They all addressed gerontological education and the care of older people in various settings. Additionally, a grey literature search was performed to discover handbooks, policy documents, educational material and other relevant material in the English or Finnish languages. Two researchers analysed the literature and independently listed the main trends (MH, MV). Rigour was addressed by discussing the findings with project team until a consensus was reached about the main trends present in gerontological nursing.

Competence analysis

The competence analysis was conducted to provide an overview of the existing core areas and competencies for gerontological nursing. A search was performed for documents that included competence descriptions relevant to gerontological nurses. The eligible documents included policy documents, professional reports, scientific articles and educational materials published after 2010 in Chinese, English, Finnish and Dutch. Materials were included until saturation was reached and no new competencies appeared.

The project members used a structured checklist to extract the relevant data, including competence descriptions, from the documents. BD performed a mapping exercise using an Excel spreadsheet to organise the competencies according to the seven CanMEDS roles [ 17 ]. The choice for CanMEDS roles was made on the basis of a consensus decision, which showed that the CanMEDS role model was widely known and recognized in nursing education. It also shows significant similarities with the competence framework of the European Federation of Nurses (EFN) [ 18 ]. This framework also has a good degree of implementation in various European countries.

After several face-to-face and online meetings among project members, consensus was reached about which competencies and learning outcomes to include in the draft competence framework. The results of the situational analysis and trend analysis were used as references to reduce the likelihood that important information would be missing from the draft competence framework.

Verification

A Delphi panel with experts was consulted to verify the set of competencies for gerontological nurses in China. A Delphi study was chosen because this consensus-building tool has been applied in a variety of fields, including the development of competence frameworks [ 9 , 19 ]. It is an appropriate method to use when experts are located at considerable geographic distances from each other, as was the case in this study. A Delphi study is predominantly qualitative in nature, but it also has a quantitative component whenever consensus is calculated [ 20 ].

The Delphi panel and procedure

A panel of experts was established by inviting 31 participants from China, Finland, Estonia and the Netherlands. Because the competencies should match the Chinese context, 75% of experts were selected from China. All experts were selected based on their authority and their high level of theoretical expertise in the field of gerontological nursing. Their professional backgrounds and settings included governmental organisations, long-term care facilities, community care providers and hospitals.

The Delphi study included two rounds of questionnaires concerning competencies and learning outcomes for gerontological nurses. The questionnaire for the first round was developed based on the results of the needs analysis. It included six competencies with a total of 21 learning outcomes. The questionnaire for the second round was composed based on the first round’s results. It included the competencies and learning outcomes that did not meet the consensus thresholds in the first round. Both questionnaires were translated from English to Chinese using the back-translation method [ 21 ]. The Chinese and English versions were distributed through Webropol.

Each participant received an individual link to the questionnaire via e-mail. They were all invited to rate the competencies and learning outcomes on a 3-point scale. For the first round, this scale included the following options: 1 (essential), 2 (useful but not essential) and 3 (not necessary) [ 22 ]. In addition, the questionnaire included open-ended questions to allow participants to provide additional comments. The 3-point scale in the second round included the following options: 1 (essential), 2 (very relevant) and 3 (relevant but not most important). No open-ended questions were included in the second round. Ratings were based on each participant’s personal opinions, and anonymity was guaranteed [ 23 ]. A reminder was sent after two weeks, and a second reminder was sent after four weeks.

Data analysis of the Delphi study

To analyse the first round’s ratings, content validity ratios (CVRs) were calculated. This is the appropriate technique to determine consensus among a panel of experts [ 22 ]. The CVR was determined as ( n e — N /2)/( N /2), in which n e is the number of panellists who indicated ‘essential’ and N is the total number of panellists. In a panel consisting of 25–30 people, a content validity ratio of 0.37 is regarded as the minimum value to define consensus [ 22 ].

In the second round of the questionnaire, competencies and learning outcomes with a CVR lower than 0.37 and a percentage higher than 50% were presented for validation again. If the percentage was lower than 50%, it was considered to be nonessential, and it was removed from the competence framework after discussing the interpretation of the data with the project team. Open answers provided evidence for changes in the formulation of the competencies and learning outcomes.

The situational analysis resulted in a summary of the specific characteristics that define the care of older people and the practice of gerontological nursing in China. Many older people live alone; these so-called "empty nesters" account for more than 54% of the country’s older population [ 24 ]. This group of people receives limited care and support – or none at all – from their family members. A large gap exists in the quality of life and poverty levels between the urban and rural populations. There are more women than men, and, especially in rural China, older women face great disadvantages in every aspect of life.

At present, gerontological nursing in China faces certain problems. These include a serious workforce shortage, the low payment of professional nurses in gerontological nursing and a lack of care institutions for older people. In addition, many nurses working in the gerontological care have lower education levels, and they may lack skills in technology or in other areas of contemporary nursing.

An important aspect of nursing practice is reflected in the Chinese cultural understanding of health and the use of traditional Chinese medicine (TCM) interventions to restore the overall balance, rather than simply treating the symptoms [ 25 ]. Experts agree that TCM should be integrated in future care as well because older people in China benefit from it. To obtain all-round development, nursing students should acquire basic theory, knowledge and skills of TCM [ 26 ].

Innovative models for gerontological care and the use of technology are needed to improve the quality of services for elderly people. China promotes new modes of nursing services, such as "smart elderly care" which is based on a sensor network system and information platform for elderly at home, communities and care organizations [ 27 ].

The scientific database search located 117 scientific articles. After screening by title, abstract and full text, 14 scientific articles were included for analysis. In addition, 22 documents were selected from the grey literature search.

Content analysis revealed five trends in gerontological nursing. The first is an emphasis on person-centred care, which relates to the needs of older people and their families [ 28 , 29 ]. Nurses should recognize individual and cultural factors and provide person-centred care in innovative ways. The second trend is a willingness to collaborate with and to account for the needs of family members and informal caregivers. Because family members often become part of the healthcare team, nurses require skills and knowledge to involve family caregivers accordingly [ 30 , 31 , 32 ]. The third trend in gerontological nursing is a focus on health promotion and healthy ageing via disease prevention and a healthy lifestyle [ 28 , 33 ]. The fourth trend is support for independent living at home; many older people remain at home and use technological solutions in gerontology [ 34 , 35 , 36 ]. The fifth trend is multidisciplinary collaboration, which is important when a patient has multiple health or social issues. Complex, multifactorial interventions can significantly improve older adults’ ability to remain living at home and avoid residential care admission [ 37 , 38 ].

It is possible to identify trends towards improved education programmes and the use thereof, particularly in settings such as home care, community care, long-term care and end-of-life care. Home care includes health maintenance, counselling and education to prevent illness; it also includes disease treatment, rehabilitation and palliative care [ 31 ]. Community nursing might be a cost-efficient way to decrease the burden of informal caregivers and primary care providers [ 39 ]. In long-term care settings, gerontological nurses ought to have the competence to recognize factors that contribute to a better quality of life for residents [ 31 , 40 , 41 ]. Additionally, nurses in these settings should emphasize their competence in pharmacotherapy [ 42 ]. For quality end-of-life care, a structured and evidence-based educational programme is recommended to nursing staff [ 30 , 43 ]. End-of-life care provision must be possible in settings such as hospitals, homes or community and rehabilitation placements [ 44 ]. Nurses and health team members provide the medical, emotional and spiritual support needed in end-of-life care [ 34 , 44 ]. Because HEIs educate the future workforce, it is important to incorporate these trends into nursing curricula.

Competence analysis and the draft competence framework

In total, 14 Chinese policy documents, 17 competence frameworks, 32 scientific articles and four educational materials were included in the competence analysis (see Table 1 an Appendix 1 ). The policy documents covered different fields of work for gerontological nurses in China. Competence descriptions in these policy documents focused primarily on competencies that belong to the expert or manager roles. The 17 competence frameworks included competencies covering all seven CanMEDS roles. Eight of the frameworks explicitly mentioned technology as part of the competencies. Additional competencies were retrieved from the scientific articles and the educational materials, which covered all seven CanMEDS roles.

Synthesis of the competence descriptions resulted in a draft competence framework of gerontological nursing. Its six competencies were: ‘providing gerontological care’, ‘communication and collaboration’, ‘nursing leadership and innovation’, ‘health promotion’, ‘evidence-based nursing and lifelong learning’ and ‘professional behaviour’. The six competencies were elaborated via 21 learning outcomes. For the purpose of the GeNeDU competence framework, competencies were defined as a dynamic combination of knowledge, skills, attitudes and values capable of being transferred to a certain context or real situation. Learning outcomes were defined as statements about what a learner is expected to know, understand and be able to demonstrate after the completion of learning [ 45 ].

Results verification phase

Participants’ characteristics.

The first round included 29 participants, and the second round involved 26. The majority of them had more than 10 years of work experience and a nursing background. The majority were working at healthcare organizations when they answered the questionnaires (see Table 2 ). Both Delphi rounds identified the same background characteristics among participants.

Delphi study

After the first round of the Delphi study, a high level of consensus was found for the competencies ‘providing gerontological care’, ‘communication and collaboration’ and ‘professional behaviour’ (see Table 3 ). The experts agreed that these three competencies and the learning outcomes associated with them are essential for gerontological nurses in China. The CVR score for these three competencies was 0.93. The CVR scores for the corresponding learning outcomes varied from 0.45–0.86.

The competence ‘nursing leadership and innovation’ showed a CVR of 0.31. Analysing the ratings according to the level of the learning outcomes associated with this competence showed that the learning outcome ‘quality management’ was the only one that experts agreed to be essential. With a CVR of 0.31, the learning outcome ‘planning and organisation’ was close to the threshold value. The other learning outcomes – ‘leadership’, ‘policy development’ and ‘innovation and technology’ – showed CVR scores between -0.24 and 0.17. Although the competence ‘health promotion’ was rated as essential, there was no consensus about the three learning outcomes associated with this competence; they had CVR scores between -0.10 and 0.24. For the competence ‘evidence-based nursing’, only the learning outcome ‘evidence-based nursing and critical thinking’ was below the threshold for determining consensus; it had a CVR of 0.31. Because the CVR could not determine a consensus regarding the essentiality of the three competencies ‘nursing leadership and innovation’, ‘health promotion’ and ‘evidence-based nursing and lifelong learning’, these competences were reformulated and presented to the panel of experts in the second round of the Delphi study. The reformulation of these competencies and learning outcomes was based on the CVR scores and remarks that participants made.

Table 4 presents the second round’s scores. The competence ‘nursing leadership and innovation’ was reformulated towards ‘organisation of gerontological nursing care’, which resulted in higher ratings for its essentiality. The reformulated learning outcome ‘innovation and technology’ was still not considered to be essential, but it was rated very relevant. For the competence ‘health promotion’, the learning outcome ‘plan person-centred health promotion’ was rated essential. ‘Perform health promotion’ was rated below the CVR threshold for essentiality. Therefore, it was considered very relevant.

The competence ‘evidence-based nursing and lifelong learning’ shows a diffuse pattern. In the first round, this competence and two of the three associated learning outcomes were considered to be essential. Only the learning outcome ‘evidence-based nursing and critical thinking’ was below the consensus threshold. In the second round, there only seemed to be consensus that the learning outcome ‘lifelong learning and professional development’ was essential. The other learning outcomes were considered very relevant.

The Delphi study resulted in a verified final competence framework that showed the essential and relevant competencies and learning outcomes (see Table 5 ). The competence "providing gerontological care" and the corresponding learning outcomes describe care and planning of care on the level on one individual patient. The competence "organisation of gerontological care" and the corresponding learning outcomes concern the organisational level.

The gerontological nursing competence framework for China includes six competencies and 18 learning outcomes. This framework comprehensively covers the core competencies that nurses who care for older people should possess. One strength of this comprehensive competence framework is its applicability to different care settings. The competence descriptions focus on the current and future needs of gerontological nursing.

We distinguished 13 essential and five relevant learning outcomes. The essential learning outcomes are all closely related to providing nursing care for patients and their family members. The learning outcomes that were rated as relevant are more supportive and more closely related to the organisation of care, innovation, personal development and professional development. Huizinga et al. (2016) explained that the more distant from patient activities a role is, the less frequently competencies are considered to be essential [ 46 ]. This includes competencies about social networks; research and innovation of care; legal, financial and organizational issues; professional ethics; and professional innovation [ 46 ]. Experts rated the learning outcome "Advocate for older people" as irrelevant for gerontological nurses in China, due to cultural and social values [ 14 ]. The competence framework targets vocational and bachelor levels. It includes the competencies related to organisation, leadership, research and innovation that are of foremost importance for bachelor-level students [ 18 ]. Although experts did not rate these competencies as essential, they should be part of gerontological education at a bachelor level.

The method used, in which Chinese gerontological nursing experts were involved in the needs analysis and the verification process, resulted in a competence framework that is well embedded in a Chinese context [ 14 ]. Although the competencies are specifically designed for gerontological nursing in China, the wording of the competencies and their associated learning outcomes is quite general. The GeNedu project used the results of the needs analysis to develop a handbook with more detailed descriptions of the required knowledge and assessment criteria for the learning outcomes that include specific cultural elements [ 8 ]. For example, the GeNEdu competence framework’s competencies and learning outcomes do not mention TCM, which is considered to be important for nursing practice in China. In the handbook TCM knowledge and skills are integrated in the competence "providing gerontological care" as part of holistic care. We recommend to take this into account during the curriculum development process, while specifying learning outcomes and developing educational content for the competencies associated with gerontological care.

The use of technology is becoming increasingly important for gerontological nurses. The competence framework’s learning outcome ‘innovation and technology’ shows this importance, but it is also embedded in all of the competencies. Further elaboration for educational purposes should include the key areas where digital technology is needed to provide high-quality, ethical patient care; social and communication skills; diagnoses and treatment; motivation and willingness to integrate digitalisation in a professional context; and collegial and organisational support for building positive experiences via digitalisation [ 47 ].

As most of the literature about gerontological nursing competences is based on research in western societies, our study focused on the transfer and application in Chinese culture. This is as far as we know the first study that compared and integrated information from different cultures in this way. In addition, the method we used may also be of interest to project leaders of similar curriculum development projects in other countries.

The Delphi method was suitable to reach consensus among the experts. Because of the extensive needs analysis, two rounds were sufficient [ 48 ]. One strong point of our approach is the feedback it provided to experts during the second round. It could be considered a limitation that we used a different scale during the second round of the Delphi study. On the other hand, this method provided deeper nuance in the competence set by distinguishing essential competencies from competencies that were relevant, but not essential.

Implications for practice

In China, this competence framework, which was developed through a process of international cooperation, will challenge Chinese institutions to meet international standards regarding the quality of nursing in higher education. The competence framework is available in Chinese and English. It will be a useful instrument for developing future gerontological nursing curricula in China. It offers concrete, practical suggestions about the competencies and skills that nursing graduates need for current and future gerontological nursing practice.

In general, the use of the competence framework will require a shift from theory-based to competence-based education. Training is recommended to help teachers develop competence-based education and to make learning outcomes specific, operable and comparative. Within the GeNEdu project, Chinese teachers who participated in such a training, developed successfully six modules for a gerontological nursing curriculum.

Since teaching and assessing learning outcomes is new to Chinese teachers, sustainable implementation of these modules will require training of all teachers. Additionally, the core competences for educators in gerontological nursing can help the Chinese institutes to develop these teacher trainings [ 49 ].

The gerontological nursing framework for China includes six competencies with 13 essential and five relevant learning outcomes. The competences are ‘providing gerontological care’, ‘communication and collaboration’, ‘organization of gerontological nursing care’, ‘health promotion’, ‘evidence-based nursing and lifelong learning’, and ‘professional behaviour’. The framework comprehensively covers the core competencies that nurses who care for older people should possess. These competencies are well embedded in a Chinese context.

Availability of data and materials

The datasets used and analysed during the present study are available from the corresponding authors upon reasonable request.

Abbreviations

Content validity ratio

Higher educational institute

Information and communication technology

World Health Organization

National Bureau of Statistics of China. Statistical data. Available at: http://www.stats.gov.cn/tjsj/sjjd/202105/t20210512_1817336.html . Accessed 5/12, 2021.

National Health Commission. Statistical Bulletin on health development in China 2020. Available at: https://www.med66.com/hushi/qita/lu2107159389.shtml [. Accessed 7/13, 2021.

OECD. Health at glance 2019: OECD indicators. Available at: https://www.oecd-ilibrary.org/sites/98e2d5de-en/index.html?itemId=/content/component/98e2d5de-en . Accessed 7/12, 2021.

National Health Commission of the People's Republic of China. The Twelfth Five-year plan for the development of China's ageing Career. Available at: http://www.nhc.gov.cn/lljks/zcwj2/201307/865bea09e8c2443390946eb8498e3635.shtml . Accessed 2/12, 2021.

WHO. Healthy China 2030 (from vision to action). Available at: https://www.who.int/teams/health-promotion/enhanced-wellbeing/ninth-global-conference/healthy-china . Accessed 7/13, 2021.

The State Council: Several Opinions on Accelerating the Development of the Elderly Service Industry (Document of State Council [2013] No. 35) [EB/OL]. 2013; Available at: http://www.moe.gov.cn/jyb_xxgk/moe_1777/moe_1778/201703/t20170308_298669.html.2017-2-28 . Accessed May, 2021.

Wang CC, Whitehead L, Bayes S. Nursing education in China: Meeting the global demand for quality healthcare. International journal of nursing sciences. 2016;3(1):131–6.

Article   Google Scholar  

JAMK. Developing Gerontological Nursing Education in China through Multidisciplinary Innovations / GeNEdu. 2019.

Batt AM, Tavares W, Williams B. The development of competency frameworks in healthcare professions: a scoping review. Adv Health Sci Educ. 2019;25(4):1–75.

Google Scholar  

Mulder M. Competence and the Alignment of Education and Work. Competence-Based Vocational and Professional Education: Springer; 2017. p. 229–51.

Traynor V, Inoue K, Crookes P. Literature review: understanding nursing competence in dementia care. J Clin Nurs. 2011;20(13–14):1948–60.

Mauk KL. Gerontological nursing: competencies for care. : Jones & Bartlett Publishers; 2010.

Britten N, Traynor V, Osmond T, Chenoweth L. Developing gerontological nursing competencies: An e-Delphi study. Australian Nursing and Midwifery Journal. 2018;25(7):42.

Chen Y. Chinese values, health and nursing. J Adv Nurs. 2001;36(2):270–3.

Article   CAS   Google Scholar  

Leis M. Challenges for the Future of Learning Until 2030. 2010.

R De Vlieger. DESTEP analysis. 2012; Available at: https://www.calltheone.com/en/consultants/destep-analysis . Accessed 3/20, 2020.

Royal college of physicians and surgeons of Canada. CanMEDS, better physicians, better standards, better care. Available at: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e . Accessed 12/06, 2020.

European Union. The European Qualifications Framework. Available at: https://europa.eu/europass/en/european-qualifications-framework-eqf . Accessed 2/16, 2021.

Humphrey-Murto S, Varpio L, Wood TJ, Gonsalves C, Ufholz L, Mascioli K, et al. The use of the Delphi and other consensus group methods in medical education research: a review. Acad Med. 2017;92(10):1491–8.

Avella JR. Delphi panels: Research design, procedures, advantages, and challenges. Int J Dr Stud. 2016;11(1):305–21.

Brislin RW, Freimanis C. Back-translation. An Encyclopaedia of Translation: Chinese-English, English-Chinese 2001;22.

Lawshe CH. A quantitative approach to content validity. Person Psychol. 1975;28(4):563–75.

Linstone HA, Turoff M. The delphi method. : Addison-Wesley Reading, MA; 1975.

Liu LY, Zheng ZW, Rao KQ. Blue Book of Elderly Health-Annual Report on Elderly Health in China. : Social Sciences Academic Press; 2019.

Smith DR, Tang S. Nursing in China: Historical development, current issues and future challenges. Journal of Oita Nursing and Health Sciences. 2004;5(2):16–20.

Hao Y, Jiang J, Gu X. Traditional Chinese medicine and nursing care. Int J Nurs Sci. 2017;4(3):328–9.

PubMed   PubMed Central   Google Scholar  

Rural smart elderly care model: China’s development and challenges. 2020 5th International Conference on Universal Village (UV): IEEE; 2020.

Harris J. Geriatric Trends Facing Nursing with the Growing Aging. Critical Care Nursing Clinics. 2019;31(2):211–24.

PubMed   Google Scholar  

Andrew N, Meeks S. Fulfilled preferences, perceived control, life satisfaction, and loneliness in elderly long-term care residents. Aging Ment Health. 2018;22(2):183–9.

Okumura-Hiroshige A, Fukahori H, Yoshioka S, Nishiyama M, Takamichi K, Kuwata M. Effect of an end-of-life gerontological nursing education programme on the attitudes and knowledge of clinical nurses: A non-randomised controlled trial. Int J Older People Nurs. 2020;15(3): e12309.

Rinnan E, André B, Drageset J, Garåsen H, Espnes GA, Haugan G. Joy of life in nursing homes: A qualitative study of what constitutes the essence of Joy of life in elderly individuals living in Norwegian nursing homes. Scand J Caring Sci. 2018;32(4):1468–76.

Ris I, Schnepp W, Mahrer IR. An integrative review on family caregivers’ involvement in care of home-dwelling elderly. Health Soc Care Community. 2019;27(3):e95–111.

Phurailatpam J, Clement I, Clement N. Trends, Issues and Practice in Geriatric Nursing Care. Research & Review. Journal of Geriatric Nursing and Health Sciences. 2019;1(2):1–9.

Mikkonen I, Sourtzi P, Turjamaa R, Äijö M, Ylinen E, Finnema EJ, et al. Trends and Developments in Health-Care and Social Services. Older People: Improving Health and Social Care: Springer; 2019. p. 103–138.

Technology to support aging in place. older adults’ perspectives. Healthcare: Multidisciplinary Digital Publishing Institute; 2019.

Panetta KG. 5 Trends Appear on the Gartner Hype Cycle for Emerging Technologies. Available at: https://www.gartner.com/smarterwithgartner/5-trends-appear-on-the-gartner-hype-cycle-for-emerging-technologies-2019/ . Accessed 06/19, 2020.

Luker JA, Worley A, Stanley M, Uy J, Watt AM, Hillier SL. The evidence for services to avoid or delay residential aged care admission: a systematic review. BMC Geriatr. 2019;19(1):1–20.

Santini S, Tombolesi V, Baschiera B, Lamura G. Intergenerational programs involving adolescents, institutionalized elderly, and older volunteers: Results from a pilot research-action in Italy. BioMed research international 2018;2018.

Ljungbeck B, Forss KS. Advanced nurse practitioners in municipal healthcare as a way to meet the growing healthcare needs of the frail elderly: a qualitative interview study with managers, doctors and specialist nurses. BMC Nurs. 2017;16(1):1–9.

James I, Blomberg K, Kihlgren A. A meaningful daily life in nursing homes-a place of shelter and a space of freedom: a participatory appreciative action reflection study. BMC Nurs. 2014;13(1):1–13.

Haugan G. The relationship between nurse–patient interaction and meaning-in-life in cognitively intact nursing home patients. J Adv Nurs. 2014;70(1):107–20.

Johansson-Pajala R, Jorsäter Blomgren K, Bastholm-Rahmner P, Fastbom J, Martin L. Nurses in municipal care of the elderly act as pharmacovigilant intermediaries: a qualitative study of medication management. Scand J Prim Health Care. 2016;34(1):37–45.

Hum AY, Wu HY, Ali NB, Leong IY, Chin JJ, Lee AO, et al. The dignity in advanced dementia (diadem) study: developing an integrated geriatric palliative homecare program. Progress in Palliative Care. 2018;26(2):65–72.

Evans CJ, Ison L, ELLIS‐SMITH C, Nicholson C, Costa A, Oluyase AO, et al. Service delivery models to maximize quality of life for older people at the end of life: a rapid review. Milbank Q. 2019;97(1):113–75.

Wagenaar R. Competences and learning outcomes: a panacea for understanding the (new) role of Higher Education? Tuning Journal for Higher Education. 2014;1(2):279–302.

Huizenga P, Finnema E, Roodbol P. Learnt and perceived professional roles of a new type of nurse specialized in Gerontology and Geriatrics, a qualitative study. J Adv Nurs. 2016;72(7):1552–66.

Konttila J, Siira H, Kyngäs H, Lahtinen M, Elo S, Kääriäinen M, et al. Healthcare professionals’ competence in digitalisation: A systematic review. J Clin Nurs. 2019;28(5–6):745–61.

Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–9.

Wyman JF, Abdallah L, Baker N, Bell C, Cartwright J, Greenberg SA, et al. Development of core competencies and a recognition program for gerontological nursing educators. J Prof Nurs. 2019;35(6):452–60.

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Acknowledgements

Our thanks for their contribution go to all GeNEdu project members and the experts participating in the Delphi study, which was one part of the whole GeNEdu project.

GeNEdu project, abbreviated from “Developing Multidisciplinary Innovations in Gerontological Nursing Education in China”, is co-funded by the Erasmus + Programme of the European Union, specifically a project of Capacity Building in the field of Higher Education started from 15 November 2019. The project reference is 610060-EPP-1–2019-1-FI-EPPKA2-CBHE-JP.

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BLD, MP, MA and WP: initiation and design of the research. WW, YCu, YCh, JI, WJ, CF and YL: situational analysis. MH and MV: trend analysis. BD, MH, MV, WW, YCu, YCh JI, WJ, CF and CS: competence analysis. BD, MA, MH, YCu, YCh, WW, JI, CF and YL: development of the Delphi questionnaires and collection of data. BD, MH, MA, YCu, WW, JI, CF and YL: analysis of the Delphi study’s results. All authors: development and writing of the final competence framework. BD, MH, WW, MP and MA: writing the paper. WP: editorial revision of the paper. All authors read and approved the final manuscript.

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Ethical approval was given by the International GeNEdu Academic Advisory Board, chaired by Hanze University of Applied Sciences Groningen. Approval aimed to ensure safety, efficiency and all ethical considerations needed before the start of the research activities. Approval for the situational analysis was granted on 10-01-2020 under number GeNEdu-2.1.1a. Approval for the Delphi review was given on 11-12-2020 granted on under number GeNEdu-2.1.2a. Participants were invited and informed about the study purpose and methods by e-mail or personal contact. Informed consent was obtained from all participants. Participant anonymity was maintained throughout the study. All methods were carried out in accordance with relevant guidelines and regulations, as mentioned in Dutch Code of Conduct for Research Integrity 2018 (43) and World Medical Association Declaration of Helsinki (44).

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Dijkman, B.L., Hirjaba, M., Wang, W. et al. Developing a competence framework for gerontological nursing in China: a two-phase research design including a needs analysis and verification study. BMC Nurs 21 , 285 (2022). https://doi.org/10.1186/s12912-022-01074-y

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Person-Centered Gerontological Nursing: An Overview Across Care Settings

Person-centered care (PCC) is the gold standard in care delivery for all people, including older adults. Key players, such as the National Academies of Sciences, Engineering, and Medicine, the Institute for Healthcare Improvement, and the Centers for Medicare & Medicaid, have highlighted PCC as a means to better meet people’s needs and improve their quality of care. Nurses are often a person’s primary point of contact throughout their care trajectory, thus essential in planning, coordinating, and delivering PCC. However, limited literature focuses on the application and evaluation of nursing-related PCC for older adults. The current article aims to provide a nursing-focused conceptual review of PCC for older adults across care settings. This review describes PCC from a gerontological nursing perspective and presents setting-specific approaches and person-centered nursing practice outcomes.

The concept of person-centered care (PCC) is not new to nursing; its origins can be traced to Florence Nightingale in the 1800s. PCC gained traction in the medical community via a paradigmatic shift from a provider-driven, disease-focused model of care to a person-driven, holistic model of care in the 1960s ( Groene, 2011 ). The adoption of PCC in the medical community encouraged innovations in practice and research, especially for older adults and people with dementia ( Kitwood, 1998 ), which translated into the “culture change movement” (p. 1396) for nursing home reform in the 1980s and 1990s ( Li & Porock, 2014 ). Today, the culture change movement has spread across care settings and beckoned nurses back to their roots as the planning, coordination, and delivery of PCC are major responsibilities of nurses ( American Nurses Association [ANA], 2019 ). The aim of the current review is to describe and define PCC from a gerontological nursing perspective and present setting-specific approaches and outcomes of person-centered nursing practice.

DEFINITION AND ATTRIBUTES OF PERSON-CENTERED CARE

The term PCC is often used interchangeably with patient-centered care, resident and family–centered care, and person-focused care as described by Kogan et al. (2016) . Each of these concepts comes with a unique perspective on the “person” and their relationship to care providers ( Kogan et al., 2016 ; Kumar & Chattu, 2018 ). Despite differences in perspectives, the underlying tenets of these terms aim to expand care beyond medical conditions or illness, including people’s social, physical, mental, and emotional goals and needs ( Kumar & Chattu, 2018 ).

To clarify PCC terminology and conceptualization for gerontological care and research, the American Geriatrics Society ( AGS; 2016 ) convened an interdisciplinary task force to establish a comprehensive definition of PCC for older adults. The task force defined PCC as an interdisciplinary shared decision-making process where “individuals’ values and preferences… guide all aspects of their health care, to support their realistic health and life goals…through a dynamic relationship among individuals, others who are important to them, and all relevant providers” ( AGS, 2016 , p. 2). The task force also operationalized essential elements or PCC practices. The AGS definition and essential elements have become the standard in defining and operationalizing PCC for older adults across settings and disciplines.

PERSON-CENTERED CARE IN THE CONTEXT OF GERONTOLOGICAL NURSING

PCC is inherent to gerontological nursing practice. Gerontological nurses specialize in providing care that encompasses the physical, psychosocial, spiritual, and other felt needs of older adults ( ANA, 2019 ). In the United States, gerontological nurses are typically licensed nurses or RNs, some with advanced practice licensure ( ANA, 2019 ). As a practice standard, gerontological nurses are required to become competent in delivering evidence-based, person-centered health care to older adults and families across health care settings ( ANA, 2019 ).

To guide person-centered nursing practice, McCormack (2003) and McCormack and McCance (2006) operationalize PCC specifically for nurses and the people and families they care for by developing and testing the Person-Centered Nursing Framework. The framework outlines characteristics of nurses, characteristics of optimal care environments, and specific approaches that are needed to provide effective PCC. The framework also highlights expected outcomes from effective person-centered nursing practice.

As depicted in Figure 1 , we adapted McCormack and McCance’s (2006) framework to illustrate how gerontological nurses can provide person-centered approaches to impact older adult and nursing outcomes across care settings. We re-organized the framework to emphasize the independent causal relationship of nursing characteristics and skills, environmental support, and nursing approaches on person-centered outcomes based on scant but existing evidence ( Brownie & Nancarrow, 2013 ; Hill et al., 2011 ). We condensed, adapted, and operationalized terminology, described in Table A (available in the online version of this article), within the framework for gerontological nursing practice, research, and education.

Adaptation of the Person-Centered Nursing Framework for Gerontological Nurses.

Note. Adapted from McCormack and McCance (2006) .

Adapted Definitions of the Person-Centered Nursing Framework Concepts for Gerontological Nurses

SETTING-SPECIFIC PERSON-CENTERED GERONTOLOGICAL NURSING APPROACHES AND OUTCOMES

Although our adapted framework provides a strong foundation for generalized gerontological, person-centered nursing care practices, there are multiple ways PCC has been approached and evaluated across residential, home- and community-based, and acute care settings. Table B (available in the online version of this article) summarizes existing evidence-based, person-centered models, related nursing approaches, and indicators (e.g., outcomes) of person-centered nursing care across settings as outlined in the adapted Gerontological Person-Centered Nursing Framework.

Summary of Evidence-Based, Setting-Specific Person-Centered Gerontological Nursing Approaches and Outcomes

Residential Care Settings

PCC is common vernacular in residential care practice and policy. Th rough the Nursing Home Reform Act and the Omnibus Budget Reconciliation Act, PCC was introduced to improve the quality of care in nursing homes. The resulting culture change movement encouraged models of care that meet a person’s holistic needs via care practices and the physical environment ( Li & Porock, 2014 ).

Approaches.

The Pioneer Network is a leader in the culture change movement in conjunction with organizations such as the Eden Alternative and Green House Project. The Eden Alternative provides international education and support on PCC and environments to improve quality of life for older adults, emphasizing the transformation of the physical environment to be more home-like with plants, animals, and intergenerational activities ( Li & Porock, 2014 ). Similarly, the Green House Project aims to promote PCC through the empowerment of certified nursing assistants (CNAs; e.g., participation in decision making at the person level) and the transformation of the physical environment to small communities to promote meaningful social and therapeutic interactions ( Li & Porock, 2014 ; Robinson & Gallagher, 2008 ).

For residential settings in the United States, PCC models are embedded in regulatory requirements by the Centers for Medicare & Medicaid Services (CMS). CMS requires PCC that supports residents’ autonomy and decision-making ( CMS, 2018a , b ) and recently changed their payment system (e.g., Patient-Driven Payment Model [PDPM]) to reflect the importance of PCC as an integral aspect of quality care. In the new payment system, instead of compensating providers based on the volume of services provided, the PDPM reimburses providers on the accuracy and appropriateness of services for care recipients, emphasizing the importance of personalized care.

In some states, person-centered pay for performance initiatives have been integrated into practice to promote PCC practices. In Kansas, the Promoting Excellent Alternatives in Kansas (PEAK 2.0) program, supported by the Kansas Department of Aging and Disability Services and Kansas State University, is used to encourage PCC practices among nursing home staff, especially nurses ( Kansas State University, 2019 ). Similarly, the Ohio Department of Medicaid (2015) previously implemented a pay for performance initiative requiring nursing homes to implement the Preferences for Everyday Living Inventory (PELI) to measure residents’ preferences for daily living. Interventions such as PEAK and PELI have resources available for nurses to enhance the person-centeredness of their practice along with PCC trainings and tools to honor residents’ choices and engage residents in care (access https://www.hhs.k-state.edu/aging/outreach/peak20/pcc-resources ; https://www.preferencebasedliving.com ).

Practice and policy initiatives in residential care have resulted in improved outcomes for residents and staff. Literature suggests increased time and interaction between residents and staff, particularly direct care staff, can improve job satisfaction and lower turnover ( Vermeerbergen et al., 2017 ). Person-centered interventions have been linked to better outcomes in older adults, including care satisfaction, well-being, and less behavioral symptoms and reliance on drug interventions to control symptoms ( Li & Porock, 2014 ; Poey et al., 2017 ).

Due to the regulatory environment in residential care and movement toward PCC models, nurses in the residential care setting are required to deliver PCC. By accessing resources and using specific intervention, such as PEAK and preference-based care, nurses can enhance the person-centeredness of their practice and positively impact residents’ care experiences ( Kansas State University, 2019 ; Ohio Department of Medicaid, 2015 ).

Home- and Community-Based Care Settings

Although PCC has been widely adopted in residential care, most older adults prefer to reside in their homes for as long as possible ( Binette & Vasold, 2019 ). However, PCC is still evolving in home- and community-based settings, and work remains to fully understand gerontological nurses’ approaches and outcomes in these settings ( Ruggiano & Edvardsson, 2013 ).

The most common applications of PCC in home- and community-based settings are the Patient-Centered Medical Home (PCMH; Jackson et al., 2013 ) and Patient Priorities Care Model (PPCM; Blaum et al., 2018 ). The PCMH is a transformation of primary care toward improving patient and informal caregiver experiences, outcomes, and interactions within the health care system ( Jackson et al., 2013 ). Basic tenets of PCMH include a patient-centered focus, care coordination across health care team members and settings, and emphasis on care quality and safety ( Jackson et al., 2013 ).

The PPCM is a care process designed for older adults with multiple chronic conditions aimed to align care with patient goals and values. PPCM uses a structured process where a facilitator guides the person to identify their (a) health outcome goals and (b) care preferences ( Blaum et al., 2018 ) and then discuss their goals and preferences with the interdisciplinary team to create a personalized care plan.

Using PCMH in home- and community-based care has resulted in increased access to care, better continuity of care across providers and settings, improved patient self-management and involvement of care, and increased use of health information technology in care ( Arend et al., 2012 ). Outcomes such as improved care recipient and caregiver satisfaction, lowered burnout and stress among health care staff, and fewer hospitalizations and emergency department visits have also been reported ( Nelson et al., 2014 ). However, evaluation of PCMH has primarily included person-level interventions or aspects of the model, rather than comprehensive program evaluation, and many outcomes are seemingly dose dependent ( Nelson et al., 2014 ; Rosland et al., 2018 ). To date, primary care physicians have led care coordination in the PCMH model, but there is an opportunity for gerontological nurses to shape how PCMH can look in primary and home- and community-based care.

PPCM processes in home- and community-based settings are associated with better alignment of individuals’ priorities, reduced treatment burden, and fewer added medications ( Ferris et al., 2018 ; Freytag et al., 2020 ). As PPCM becomes more widely implemented, nurses have the opportunity to establish themselves as integral in the PPCM process. Nurses are well-suited to serve in the role of facilitator to help elicit people’s priorities and guide them through the development of a personalized care plan (access https://patientprioritiescare.org/resources/publications for training and resources).

Acute Care Settings

The integration of PCC into acute care settings is multifaceted and challenging. However, understanding how to provide person-centered nursing care for older adults who are acutely and complexly ill is needed. Expectations, self-care knowledge, and skill of older adults in acute care and their families have risen, creating a need to change how acute care is delivered.

Changes in acute care toward PCC include (a) the progressive patient care model; (b) the person-centered approach; and (c) the lean approach ( Gabutti et al., 2017 ; Yevchak et al., 2017 ). The progressive patient care model shifts from traditional clustering of patient-based care on a specific disease process, such as telemetry, to pooling patients together based on the amount of care they require. Examples of these models of care include assigning levels of care to patients using a numeric rating scale; grouping patients by more standard sets, such as outpatient and inpatient surgeries; and stratifying inpatient surgical candidates based on expected length of stay ( Gabutti et al., 2017 ; Villa et al., 2009 ; Villa et al., 2014 ). Person-centered approaches emphasize the need for improved communication and continuity of care across providers and settings of care ( Gabutti et al., 2017 ). Except for emergency departments, relatively little of this work has focused on communication and care transfers within acute care settings ( Gabutti et al., 2017 ). The lean approach was originally created as a way to decrease unnecessary steps and waste in engineering and manufacturing processes ( Nicosia et al., 2018 ). In acute care settings, the lean approach focuses on improving patient flow by redefining health care team members’ roles and expectations, changing staffing models and scheduling, improving communication among staff, and redesigning workspaces ( Gabutti et al., 2017 ). Ways to achieve these changes toward PCC in acute care include information communication technology, managerial accounting, and human resource management tools.

In addition to Gabutti et al.’s (2017) work, Fiorio et al. (2018) support the need for organizational and nursing models of care to achieve more person-centered acute care. To shift toward PCC, a process-driven model, such as primary nursing, is needed to reduce fragmented care ( Vos et al., 2011 ). Typically, in acute care, functional or team nursing where a group of nurses are responsible for each patient’s care is employed. However, primary nursing means one nurse holds responsibility for the coordination and delivery of care throughout hospitalization to provide continuity of care ( Dal Molin et al., 2018 ; Fiorio et al., 2018 ; Vos et al., 2011 ). The primary nurse’s role may also shift from providing direct care to a nurse liaison or advocate, where the focus is on care coordination and communication among the patient, family, and all health care team members ( Gabutti et al., 2017 ).

Evidence on patient and nursing staff outcomes related to implementing person-centered approaches in acute care has mainly been positive. Staff experience decreased turnover, and patients have fewer pressure ulcers, falls, and urinary catheter infections ( Dal Molin et al., 2018 ). Patients also report that primary nursing results in more tailored care to their needs and preferences ( Naef et al., 2019 ). However, evidence also suggests that changes within organizational and nursing care delivery models result in increased workload and burden on nurses ( Gabutti et al., 2017 ).

A potential explanation of the variance in primary nursing outcomes is similar to those explored with other PCC setting-specific approaches; the implementation and uptake of primary nursing is inconsistent and often done without appropriate system and organization supports ( Naef et al., 2019 ). Additional evidence is needed on how primary nursing impacts outcomes for older adults and their informal caregivers, particularly for those with cognitive impairment, dementia, and/or delirium.

IMPLICATIONS FOR NURSING

Person-centered gerontological nursing care has been operationalized uniquely via setting-specific models in residential, home- and community-based, and acute care settings. Across care settings, person-centered gerontological nursing approaches are used, and indicators evaluated, but not comprehensively. The current article highlights gaps in person-centered nursing approaches and opportunities to evaluate person-centered nursing care indicators across care settings.

Delivering more comprehensive, person-centered nursing care that promotes positive outcomes for older adults can be conceptualized using frameworks such as the adapted Person-Centered Nursing Framework. Person-centered gerontological nursing approaches to care have resulted in positive outcomes for older adults, their families, and health care team members ( Table B ), but more work is needed to ensure that all aspects of the Person-Centered Nursing Framework for Gerontological Nurses are evident across approaches and settings. For example, it is not apparent in acute care settings that what matters to the older adult is always considered in a person-centered approach. We see changes through campaigns such as the Institute for Healthcare Improvement Age-Friendly Health Systems “What Matters to You,” but these are not embedded within large systematic person-centered approaches. Similarly, there is not an obvious indicator of care recipient involvement in residential care settings, which provides an opportunity for inclusion of measures that capture resident engagement.

The current article’s focus was on two main aspects of the adapted Person-Centered Nursing Framework for Gerontological nurses (i.e., person-centered gerontological nursing approaches and indicators of PCC). Our work is limited by the fact that we did not complete a systematic literature review, and therefore, our findings are not exhaustive nor totally representative of current PCC approaches and outcomes across settings. The goal of this work was to propose an adapted framework for person-centered gerontological nursing care and establish, generally, the current state of what PCC approaches and outcomes are evident across care settings. Future work needs to systematically explore our findings and review how the care environment and characteristics of gerontological nurses impact person-centered approaches and outcomes.

Gerontological nurses are responsible for delivering PCC across health care settings. The adapted Person-Centered Nursing Framework for Gerontological Nurses used in this article allows for a rethinking of the operationalization of person-centered nursing care approaches across settings and evaluation of associated indicators of PCC approaches. Gerontological nurses need to refine and reflect on their unique attributes and skills, evaluate the care environment they operate in, and use PCC approaches to ensure the delivery of high-quality care across settings.

Acknowledgments

The authors have disclosed no potential conflicts of interest, financial or otherwise. The work was supported, in part, by the Gordon and Betty Moore Foundation Early Career Award (GBMF 5301; Dr. Sillner); partially supported by the Center of Innovation in Long-Term Services & Supports at the Providence VA Medical Center via the Office of Academic Affiliation’s Advanced Fellowship in Health Services Research (Dr. Madrigal); and, in part, by the National Institute of Nursing Research Ruth L. Kirschstein National Research Service Award program (T32NR009356; Dr. Behrens).

The authors acknowledge Logan Sweeder for her contributions to preparing this paper.

• American Geriatrics Society Expert Panel on Person-Centered Care. (2016). Person-centered care: A definition and essential elements . Journal of the American Geriatrics Society , 64 ( 1 ), 15–18. 10.1111/jgs.13866 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• American Nurses Association. (2019). Gerontological nursing: Scope and standards of practice (2nd ed.). [ Google Scholar ]
• Arend J, Tsang-Quinn J, Levine C, & Thomas D (2012). The patient-centered medical home: History, components, and review of the evidence . The Mount Sinai Journal of Medicine, New York , 79 ( 4 ), 433–450. 10.1002/msj.21326 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Binette J, & Vasold K (2019). 2018 home and community preferences: A national survey of adults age 18-plus . https://www.aarp.org/research/topics/community/info-2018/2018-home-community-preference.html
• Blaum CS, Rosen J, Naik AD, Smith CD, Dindo L, Vo L, Hernandez-Bigos K, Esterson J, Geda M, Ferris R, Costello D, Acampora D, Meehan T, & Tinetti ME (2018). Feasibility of implementing patient priorities care for older adults with multiple chronic conditions . Journal of the American Geriatrics Society , 66 ( 10 ), 2009–2016. 10.1111/jgs.15465 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Brownie S, & Nancarrow S (2013). Effects of person-centered care on residents and staff in aged-care facilities: A systematic review . Clinical Interventions in Aging , 8 , 1–10. 10.2147/CIA.S38589 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Centers for Medicare & Medicaid Services. (2018a). Medicare proposed fiscal year 2019 payment & policy changes for skilled nursing facilities . https://www.cms.gov/newsroom/fact-sheets/medicare-proposes-fiscal-year-2019-payment-policy-changes-skilled-nursing-facilities
• Centers for Medicare & Medicaid Services. (2018b). Person and family engagement strategy: Sharing with our partners . https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Quality-InitiativesGenInfo/Downloads/Person-and-Family-Engagement-Strategy-Summary.pdf
• Dal Molin A, Gatta C, Boggio Gilot C, Ferrua R, Cena T, Manthey M, & Croso A (2018). The impact of primary nursing care pattern: Results from a before-after study . Journal of Clinical Nursing , 27 ( 5–6 ), 1094–1102. 10.1111/jocn.14135 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ferris R, Blaum C, Kiwak E, Austin J, Esterson J, Harkless G, Oftedahl G, Parchman M, Van Ness PH, & Tinetti ME (2018). Perspectives of patients, clinicians, and health system leaders on changes needed to improve the health care and outcomes of older adults with multiple chronic conditions . Journal of Aging and Health , 30 ( 5 ), 778–799. 10.1177/0898264317691166 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fiorio CV, Gorli M, & Verzillo S (2018). Evaluating organizational change in health care: The patient-centered hospital model . BMC Health Services Research , 18 ( 1 ), 95. 10.1186/s12913-018-2877-4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Freytag J, Dindo L, Catic A, Johnson AL, Bush Amspoker A, Gravier A, Dawson DB, Tinetti ME, & Naik AD (2020). Feasibility of clinicians aligning health care with patient priorities in geriatrics ambulatory care . Journal of the American Geriatrics Society , 68 ( 9 ), 2112–2116. 10.1111/jgs.16662 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gabutti I, Mascia D, & Cicchetti A (2017). Exploring “patient-centered” hospitals: A systematic review to understand change . BMC Health Services Research , 17 ( 1 ), 364. 10.1186/s12913-017-2306-0 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Groene O (2011). Patient centredness and quality improvement efforts in hospitals: Rationale, measurement, implementation . International Journal for Quality in Health Care , 23 ( 5 ), 531–537. 10.1093/intqhc/mzr058 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hill NL, Kolanowski AM, Milone-Nuzzo P, & Yevchak A (2011). Culture change models and resident health outcomes in long-term care . Journal of Nursing Scholarship , 43 ( 1 ), 30–40. 10.1111/j.1547-5069.2010.01379.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jackson GL, Powers BJ, Chatterjee R, Bettger JP, Kemper AR, Hasselblad V, Dolor RJ, Irvine RJ, Heidenfelder BL, Kendrick AS, Gray R, & Williams JW Jr. (2013). The patient centered medical home. A systematic review . Annals of Internal Medicine , 158 ( 3 ), 169–178. 10.7326/0003-4819-158-3-201302050-00579 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kansas State University. (2019). PEAK 2.0 https://www.he.k-state.edu/aging/outreach/peak20/
• Kitwood T (1998). Toward a theory of dementia care: Ethics and interaction . The Journal of Clinical Ethics , 9 ( 1 ), 23–34. [ PubMed ] [ Google Scholar ]
• Kogan AC, Wilber K, & Mosqueda L (2016). Person-centered care for older adults with chronic conditions and functional impairment: A systematic literature review . Journal of the American Geriatrics Society , 64 ( 1 ), e1–e7. 10.1111/jgs.13873 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kumar R, & Chattu VK (2018). What is in the name? Understanding terminologies of patient-centered, person-centered, and patient-directed care! Journal of Family Medicine and Primary Care , 7 ( 3 ), 487–488. 10.4103/jfmpc.jfmpc_61_18 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Li J, & Porock D (2014). Resident outcomes of person-centered care in long-term care: A narrative review of interventional research . International Journal of Nursing Studies , 51 ( 10 ), 1395–1415. 10.1016/j.ijnurstu.2014.04.003 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• McCormack B (2003). A conceptual framework for person-centred practice with older people . International Journal of Nursing Practice , 9 ( 3 ), 202–209. 10.1046/j.1440-172X.2003.00423.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• McCormack B, & McCance TV (2006). Development of a framework for person-centred nursing . Journal of Advanced Nursing , 56 ( 5 ), 472–479. 10.1111/j.1365-2648.2006.04042.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Naef R, Ernst J, & Petry H (2019). Adaption, benefit and quality of care associated with primary nursing in an acute inpatient setting: A cross-sectional descriptive study . Journal of Advanced Nursing , 75 ( 10 ), 2133–2143. 10.1111/jan.13995 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nelson KM, Helfrich C, Sun H, Hebert PL, Liu C-F, Dolan E, Taylor L, Wong E, Maynard C, Hernandez SE, Sanders W, Randall I, Curtis I, Schectman G, Stark R, & Fihn SD (2014). Implementation of the patient-centered medical home in the Veterans Health Administration: Associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use . JAMA Internal Medicine , 174 ( 8 ), 1350–1358. 10.1001/jamainternmed.2014.2488 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nicosia FM, Park LG, Gray CP, Yakir MJ, & Hung DY (2018). Nurses’ perspectives on lean redesigns to patient flow and inpatient discharge process efficiency . Global Qualitative Nursing Research , 5 , 2333393618810658. 10.1177/2333393618810658 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ohio Department of Medicaid. (2015). Bureau of LTCSS nursing facility provider update . https://www.leadingageohio.org/aws/LAO/asset_manager/get_file/117615
• Poey JL, Hermer L, Cornelison L, Kaup ML, Drake P, Stone RI, & Doll G (2017). Does person-centered care improve residents’ satisfaction with nursing home quality? Journal of the American Medical Directors Association , 18 ( 11 ), 974–979. 10.1016/j.jamda.2017.06.007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Robinson GE, & Gallagher A (2008). Culture change impacts quality of life for nursing home residents . Topics in Clinical Nutrition , 23 ( 2 ), 120–130. 10.1097/01.TIN.0000318908.08617.49 [ CrossRef ] [ Google Scholar ]
• Rosland A-M, Wong E, Maciejewski M, Zulman D, Piegari R, Fihn S, & Nelson K (2018). Patient-centered medical home implementation and improved chronic disease quality: A longitudinal observational study . Health Services Research , 53 ( 4 ), 2503–2522. 10.1111/1475-6773.12805 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ruggiano N, & Edvardsson D (2013). Person-centeredness in home- and community-based long-term care: Current challenges and new directions . Social Work in Health Care , 52 ( 9 ), 846–861. 10.1080/00981389.2013.82714 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vermeerbergen L, Van Hootegem G, & Benders J (2017). A comparison of working in small-scale and large-scale nursing homes: A systematic review of quantitative and qualitative evidence . International Journal of Nursing Studies , 67 , 59–70. 10.1016/j.ijnurstu.2016.11.006 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Villa S, Barbieri M, & Lega F (2009). Restructuring patient flow logistics around patient care needs: Implications and practicalities from three critical cases . Health Care Management Science , 12 , 155–165. 10.1007/s10729-008-9091-6 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Villa S, Prenestini A, & Giusepi I (2014). A framework to analyze hospital-wide patient flow logistics: Evidence from an Italian comparative study . Health Policy (Amsterdam) , 115 , 196–205. 10.1016/j.healthpol.2013.12.010 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vos L, Chalmers SE, Dückers ML, Groenewegen PP, Wagner C, & van Merode GG (2011). Towards an organisation-wide process-oriented organisation of care: A literature review . Implementation Science , 6 ( 1 ), 8. 10.1186/1748-5908-6-8 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yevchak A, Fick DM, Kolanowski AM, McDowell J, Monroe T, LeViere A, & Mion L (2017). Implementing nurse-facilitated person-centered care approaches for patients with delirium superimposed on dementia in the acute care setting . Journal of Gerontological Nursing , 43 ( 12 ), 21–28. 10.3928/00989134-20170623-01 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]