Barriers and facilitators to implementing person-centred care among people living with dementia in nursing homes: a qualitative study

Abstract

Background

Person-centred care is considered the gold standard for long-term care of people living with dementia, yet there remains a significant gap between this standard and its actual implementation. Integrating this Western-developed approach into the distinct cultural context of Chinese nursing homes presents unique challenges. Currently, there is a lack of qualitative research exploring the barriers and facilitators faced by Chinese nursing home staff in implementing person-centred care for people living with dementia.

Objective

To investigate the barriers and facilitators encountered by nursing home staff in implementing person-centred care for people living with dementia.

Design

A qualitative descriptive approach was adopted.

Methods

Purposive sampling was employed to recruit a total of 17 staff members or managers (including dean, supervisors, nurses, caregivers, social workers, or interns) from two nursing homes in China. In-depth, face-to-face, one-to-one interviews were conducted with all participants using a semi-structured interview guide, with field notes taken after each interview. Data collection continued until data saturation. Qualitative content analysis was employed.

Results

Data analysis resulted in four themes, each encompassing both barriers and facilitators: nursing and care staff factors, family factors, organizational factors, resource factors. Notably, limited remuneration and benefits, low social status, high staff turnover rates, challenges in addressing the non-cognitive symptoms of dementia, and inadequate training were found to be the primary barriers to the implementation of person-centred dementia care.

Conclusions

The findings indicate that nursing home staff encounter numerous barriers and needs in implementing person-centred care for people living with dementia. To effectively address these challenges, there is a need to enhance staff education and training, improve benefits and working conditions for nursing home staff, and increase societal support for nursing homes. Collaborative efforts are required to promote dementia care practices, truly embodying the person-centered care philosophy and enhancing the quality of care for people living with dementia.

Trial registration

This study is part of a mixed-methods study, which has been registered with the Chinese Clinical Trial Registration Center. Available from:. Registration number: ChiCTR2400086418.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06642-w.

Background

Person-centred dementia care (PCDC) emphasizes the interaction between care provider and care recipients, with the aim of supporting and preserving care recipients’ current abilities, physical and mental health, well-being, and dignity [1]. PCDC, proposed by Tom Kitwood in the 1990s, is centred around the concept of supporting personhood and was initially developed following observations of people with dementia in long-term residential care settings [2]. In recent years, PCDC has been applied to more diverse life experiences and care settings, particularly community-based care and care for indigenous populations [3]. In doing so, the approach has taken more account of relationships between family carers and those living with dementia. It has also incorporated more of the direct voices of those living with dementia, rather than relying principally on observation [4]. The key idea however, remains the same: to respect and support each person’s individuality and unique response to living with dementia [5, 6].

Significant numbers of people with severe dementia live in nursing homes, which provide personal care, nursing supervision and limited medical care to persons who do not require acute hospital care [7]. PCDC is emphasized as a gold standard in these settings. The US Alzheimer’s Association Dementia Care Practice Recommendations highlight the importance of establishing a collaborative and supportive community among staff and enhancing authentic relationships between people living with dementia and their nursing and care staff [8]. In the context of nursing homes, staff are key to successful PCDC. They not only provide direct care but also assume roles as care managers [8]. However, they face numerous barriers in implementing PCDC [9–15].

Currently, qualitative research on the obstacles and facilitators faced by staff in implementing PCDC in nursing homes is relatively scarce [14]. Existing studies primarily focus on the understanding, implementation experiences, and challenges encountered by staff in nursing homes [16–18], For instance, Wang’s research [16] examined the difficulties Chinese nursing and care staff encountered in understanding PCDC. The article also pointed out that certain practices, labelled by Kitwood as personal detractors [1], such as infantilizing older residents with dementia and labelling them using “mother wit,” undermined the delivery of PCDC. However, the existing literature provides only fragmented insights into the barriers and facilitators of PCDC implementation and fails to provide a comprehensive and clear picture of the barriers and facilitators, making it difficult to develop effective strategies to improve the implementation of PCDC in nursing homes. Additionally, existing qualitative research has certain limitations, including a lack of purposive sampling, insufficient participant numbers, failure to encompass participants from different roles, and failure to achieve data saturation [11, 12, 14].

A previously conducted scoping review [19] by the research team provided the theoretical foundation for this study. This review examined and compared the barriers and facilitators of PCDC in long-term care facilities across Western and Asian countries, and identified four thematic factors influencing PCDC: nursing and care staff factors, people living with dementia and family factors, organisational factors, and resource factors. Building on this theoretical framework and in line with Sandelowski’s [20] assertion that researchers may use an associated interpretive theory or conceptual framework to guide their studies, accompanied by being prepared to alter that framework, we adopted a qualitative descriptive approach. This methodology allows us to present findings in straightforward language that clearly describes the phenomena of interest, while staying close to the data. It provides a flexible and systematic way to explore the research questions, ensuring that the study procedures, analysis, and representation of findings are guided by the theoretical framework, yet adaptable to the evolving understanding of the data [6]. Based on the framework established in our prior review, this study adopted a qualitative descriptive approach to explore the factors that hinder and facilitate the implementation of PCDC in Chinese nursing homes.

Methods

Design

A descriptive qualitative research design [21, 22] was chosen as the most suitable approach for directly describing the phenomenon, aligning with our aim of delineating the barriers and facilitators to PCDC implementation among staff in nursing homes. A descriptive qualitative method is particularly suited to this study because it provides a rich, context-specific understanding of participants’ perceptions and practices, without being constrained by predefined hypotheses. This flexibility is crucial for capturing the complexity and nuances of real-world healthcare settings, allowing better identification and delineation of both the barriers and facilitators in a way that is directly relevant to practice [6, 21–23].

Setting and participants

Participants were from two nursing homes in Liaoning Province, an administrative area with a population of approximately 41.55 million people in North-Eastern China [24]: a nationally-operated public nursing home with approximately 70 residents and a locally-operated private nursing home housing roughly 30 residents, ensuring maximum heterogeneity. Within these nursing homes, approximately one-third of residents were diagnosed with dementia. The nursing homes provided personal care including professional nursing services delivered by registered nurses. Both facilities were highly rated nationally.

In November 2023 and March 2024 respectively, initial contact was made by YL (senior clinical-academic) to ask the nursing home management if they were willing for their staff to be approached to take part and both managers agreed. The managers also agreed to make it clear that staff had a free choice about whether to participate and that there would be no consequences if they chose not to take part.

The inclusion criteria for individual staff participants were: (1) Staff engaged with people living with dementia or supervisors of such staff. (2) Staff or supervisors with a minimum of three months of work experience.

The sampling method was purposeful, aimed at ensuring maximum diversity, so as to comprehensively and deeply explore the research questions. Given that the study purpose was to investigate the implementation of PCDC, information needed to be obtained from staff in different roles to ensure a comprehensive understanding. Therefore, those approached were drawn from a range of roles including dean (a term used for the manager of the home), supervisors, nurses, caregivers, social workers, or interns, ensuring that all staff groups related to PCDC were included. To ensure diversity and representativeness of the sample, we collected participants’ sociodemographic information, including their role, age, educational level, years working in older adult care, and years working in dementia care. This enabled the researchers to assess diversity and informed further purposive recruitment.

Seventeen care staff (coded N1 to N17), ranging in age from 20 to 52 years (mean age = 30.94), participated in the interviews. The sample included dean, supervisors, nurses, caregivers, social workers, or interns. Participants varied in their educational backgrounds: one held a junior high school diploma, one had completed high school, ten held associate degrees, and one had earned a bachelor’s degree. On average, participants had 3.91 years of experience in care of older people and 3.32 years in dementia-specific care. Detailed demographic and professional characteristics of the participants are presented in Table 1.

Table 1.

Overview of participant characteristics (n = 17)

Variable	N = 17
Gender
Female	14
Male	3
Age(years)
Mean	28.29
Range	20 ~ 52
Years of Work Experience
Mean	3.91
Range	0.5 ~ 10
Years of Dementia Care Experience
Mean	3.32
Range	0.5 ~ 8
Position
Care Supervisor	4
Nursing supervisor	1
Dean	1
Caregiver	7
Intern	2
Social worker	1
Nurse	1
Education
Junior high school	1
High school	1
Technical secondary school	1
Junior college	13
Undergraduate	1
Major
Senior Services and Management	11
Nursing	3
Not applicable	2
Mechanical Engineering	1

Prior to individual recruitment, XG (Master’s dissertation student) spent time in the nursing homes to establish trust. XG immersed herself in the facilities, assisting with resident care and organizing recreational activities, to gain a deeper understanding of the environment and build positive relationships with the staff. Trust was established through consistent and respectful interaction, actively listening to the concerns of the staff, and maintaining confidentiality, when any staff member shared their experiences and insights. Once trust was established, the nursing home line manager, acting as a gatekeeper in a neutral and administrative role, helped distribute study information to staff who met the inclusion criteria. The manager was not involved in the recruitment process beyond this and did not influence staff decisions. Participation was entirely voluntary, and staff could contact the researcher directly if interested.

Prior to taking consent, the purpose of the interview and the commitment to confidentiality were meticulously explained to the participants through both verbal and written presentations. This ensured that potential participants had a clear understanding of the research objectives, procedures, and their rights, including the right to withdraw from the study at any time. The researchers then obtained verbal and written informed consent from participants to take part in the interview and to be recorded. To ensure anonymity, pseudonyms were assigned to all participants and to any individuals with dementia who were mentioned.

 Data collection

The first author, a Master’s student in nursing specializing in qualitative research and geriatric nursing, conducted in-depth interviews with participants at their convenience. The researcher’s role was limited to data collection, and she did not participate in caregiving or training within the nursing homes, beyond the initial period of building trust. Their primary responsibility was to facilitate interviews, without influencing the implementation of PCDC. Two professors (co-authors, PhDs) with extensive qualitative research experience promoted data collection quality by providing guidance and training to the research team. They conducted regular monitoring and reflective supervision, and gave feedback to the researchers to help them to hone their interviewing skills. For instance, they assured researchers that it was acceptable to allow moments of silence during interviews while participants were formulating their responses. Additionally, LY reviewed field notes and interview recordings to ensure data accuracy and alignment with the study objectives.

Each participant was interviewed once. All interviews were face-to-face, one-on-one, semi-structured, and took place in the nursing home. The interviews were conducted when the participants were not busy with work or resting, in a quiet, undisturbed space such as a staff lounge.

The first author developed an initial interview guide based on the research objectives, literature review, and feedback from the two professors. Pilot interviews were conducted with three staff members from one of the nursing homes included in the study. The pilot data were not included in the formal analysis. Based on revisions such as adding the question “How were they addressed?” to elicit more detailed responses, the final interview guide, consisting of five open-ended questions, was formed (Table 2).

Table 2.

Interview guide

➢ What do you perceive as person-centred dementia care?

➢ How do you provide person-centred care for people living with dementia?

➢ Can you share any barriers you encountered in implementing person-centred dementia care? How were they addressed?

➢ What do you believe can assist you in implementing person-centred dementia care, can you share any examples of what assisted you in implementing person-centred dementia care?

➢ Is there anything else you would like to add regarding the implementation of person-centred care for people living with dementia?

The initial question was included to warm up the participants to the interview by introducing the general topic of PCDC. To ensure mutual understanding of PCDC, the researchers gave some additional brief information on the definition of PCDC before the facilitators and barriers were discussed. The researchers mitigated their own subjective influence on the interview content by avoiding leading questions and using open-ended language to encourage full expression from the participants. Viewpoints were clarified and confirmed through repetition and summarization of the participants’ responses.

The interviews were recorded using a voice recorder and a mobile phone to ensure data backup. Each interview lasted approximately 30 min and was transcribed in Chinese within 24 h by one author. Another author independently reviewed the transcribed content to ensure consistency and accuracy with the original recordings. At this point, the original recordings on the voice recorder and mobile phone were deleted to maintain confidentiality. After 14 interviews, no new codes were identified during analysis. However, to confirm data saturation, three additional staff members were interviewed, following the guidelines of qualitative research to ensure no new themes emerged [25–28]. Throughout the process, electronic data were securely stored on password-protected computers. Paper-based data were kept in locked cabinets.

Data analysis

The 17 interview transcripts were analysed using inductive qualitative content analysis as described by Satu et al. [29], with each sentence serving as a unit of analysis. The two first authors, XG and Am-D, thoroughly immersed themselves in the data by reading each text multiple times before analysis and independently identified codes and developed categories. To ensure consistency and coherence, all authors collectively discussed and revised codes and categories, identifying sub-themes and themes. Data analysis was supported by the two professors (YL, JO). Analysis was facilitated using Nvivo12.0 software. All transcripts and quotes were originally in Chinese. Discussions of themes and sub-themes was conducted in English or Chinese depending on who from the research team was present. Chinese quotes were translated into English by YL, who is proficient in both Chinese and English, at the point of writing this manuscript.

Trustworthiness

The researchers addressed credibility, transferability, dependability, and confirmability [30] as well as reflexivity. To ensure credibility, as detailed in Sect. Data analysis, two authors independently analyzed the data and a bilingual author proficient in both Chinese and English ensured the credibility of translation. To enhance reflexivity the researchers reflected on their own roles and influences in the research process to minimize potential biases. Throughout data collection, the researchers continuously reflected on their interactions with the participants. We paid attention to our own body language, tone of voice, and the way we asked questions, as these could potentially affect the responses we received. This ongoing reflexivity helped us to become more aware of our own subjectivity and how it might influence the research process and findings. To enhance transferability, purposeful sampling was employed, selecting two diverse nursing homes and recruiting from a wide range of roles within the homes. Additionally, detailed descriptions of data collection and analysis were provided. To improve dependability, two authors conducted an audit of data collection and analysis, reviewing the entire process to ensure that the findings were grounded in the collected data [31]. This audit included a detailed review of the data collection methods, the data analysis process, and the steps taken to ensure the accuracy and consistency of the findings. For confirmability, an experienced qualitative researcher peer-reviewed data collection and analysis processes. This report of the study adhered to the Standards for Reporting Qualitative Research (SRQR) guidelines [32] (see Appendix S1).

Ethical approval

This study received approval from the Ethics Committee of China Medical University Medical Ethics Committee (Ethics Committee Number: [2023]120).

Results

The findings revealed data related to all four a priori themes, each including both barriers and facilitators to the implementation of PCDC in Chinese nursing homes. These themes were: (1) Nursing and care staff factors, (2) Family factors, (3) Organizational factors, and (4) Resource factors. Each theme consisted of several sub-themes, which are detailed below with supporting participant quotes. A summary of 13 barriers and 15 facilitators that were identified is presented in Tables 3 and 4.

Table 3.

Themes and sub-themes associated with the implementation of PCDC by nursing home staff

Themes	Subtheme
Nursing and care staff factors	Knowledge of personal experiences, likes and dislikes, and needs of people living with dementia
	Knowledge and understanding of dementia care
	Attitudes and behaviors towards people living with dementia.
	Professional identity and burnout
	The personal characteristics of nursing and care staff
Family factors	Trust level of family members
	Family members’ degree of concern for their relatives
Organizational factors	Education and training
	Communication and interpersonal relationships
	Cooperation
	Management
Resource factors	Physical environment
	Staffing shortages and turnover
	Workload and working hours
	Salary and benefits
	External support factors (social status, national policy, government support)

Table 4.

Barriers and facilitators to the implementation of PCDC by nursing home staff, categorized by sub-theme

Themes	Subtheme	Barriers	Facilitators
Nursing and care staff factors	Knowledge of personal experiences, likes, dislikes and needs of people living with dementia	-	Understanding the personal experiences, likes, dislikes and needs of residents (n = 7*)
	Knowledge and understanding of dementia care	-	Knowledge and understanding of dementia care (n = 7)
	Attitudes and behaviors towards people living with dementia.	Inappropriate attitudes and behaviors towards resident (n = 2)	Appropriate attitudes and behaviors towards individuals with dementia (n = 11)
	Professional identity and burnout	Disengagement and fatigue in the workplace (n = 5)	Identification with the profession (n = 7)
	The personal characteristics of nursing and care staff	Staff with low educational attainment, older age, limited work experience, impatience towards others, or poor communication skills (n = 5)	Staff with higher educational levels, younger age, extensive work experience, compassion, optimistism, and dedication (n = 12)
Family factors	Trust level of family members	Family members do not trust nursing and care staff (n = 3)	The trust and support of family members (n = 2)
	Family members’ care for the residents	Family members’ lacking concern for their relatives (n = 4)	-
Organizational factors	Education and training	Inappropriate training content and methods or negative attitude towards training (n = 5)	Education and training methods and content are appropriate (n = 6)
	Communication and interpersonal relationships.	-	Effective communication and interpersonal relationships among nursing and care staff, as well as between nursing and care staff, older adults and their families (n = 11)
	Cooperation	-	Collaboration between nursing and care staff and with families (n = 7)
	Management	Leadership is demanding (n = 4)	Leaders establish a person-centred organizational culture and atmosphere (n = 4)
Resource factors	Physical environment	Physical environment issues (n = 2)	Accessible facilities and cognitive training facilities are available (n = 2)
	Staffing Shortages and Turnover	Insufficient staffing and high turnover rate among nursing and care staff (n = 9)	nursing and care staff are familiar faces to the older adults with dementia (n = 4)
	Workload and working hours	Heavy workload and excessively long working hours (n = 6)	Working the right hours (n = 4)
	Salary and benefits	Inadequate wages and benefits, so nursing and care staff have insufficient incentive and support to provide PCDC to provide better PCDC services (n = 10)	Salary and workload match (n = 2)
	External support factors (social status, national policies, government support)	Low social status (n = 6)	National policy, government support (n = 5)

*Numbers indicate the times barriers or facilitators were mentioned by participants

We begin by exploring staff perspectives on the meaning and principles of PCDC, Thisserved as a foundation for understanding the challenges and facilitators they encountered in practice. In response to the initial interview topic concerning the nature of PCDC. the majority referred to one or more of its core principles. Some highlighted the importance of valuing those with dementia, such as one staff member who said, “PCDC is respecting people living with dementia”. Others made statements reflecting the principle of seeing the world from the perspective of the individual with dementia, such as: “We need to think from the people living with dementia’s point of view, put ourselves in their shoes, and really get what they need.” (N1, Care Manager). Some participants spoke about PCDC being about catering for individual needs, including Participant N17 (Caregiver) who said, “PCDC is caring for people living with dementia according to their living habits and hobbies.” and participant N2 (Nursing Supervisor), who stated, “PCDC is about creating the best care plan for people living with dementia based on their specific situation.” However, a minority of participants had a more limited understanding, for example, suggesting PCDC was about managers’ attitudes toward staff or that it was simply about following your best instincts as with participant N4 (Caregiver) who said, “PCDC is just following your own conscience to serve people living with dementia.” Understanding of PCDC was evident too in discussion of barriers and facilitators and is further reflected in the themes and sub-themes below.

Nursing and care staff factors

Knowledge of personal experiences, likes, dislikes and needs of people living with dementia

When nursing and care staff understood the personal experiences, preferences, and dislikes of residents with dementia, this enabled tailored care provision, fostering a person-centered approach to dementia care.

“Jack, this older man with dementia, was persecuted during the Cultural Revolution. He keeps replaying scenes from his past repeatedly. He’s been rejected by three nursing homes for his aggression. We’ve all dealt with his attacks. He barricades himself in his room, getting increasingly aggressive. Understanding his past helps us comprehend his behavior and makes it easier to accept.” (N2, Nurse Supervisor).

In the above quotation, the nurse supervisor indicated that hypothesizing that Jack’s aggression was based on his life history led to the staff being able to tolerate this, whereas he had been excluded from previous nursing homes where staff did not understand the origins of his behavior.

Knowledge and understanding of dementia

Staff’s knowledge and understanding of dementia appeared crucial for effectively managing residents’ behavior. This understanding enabled them to respond to residents’ needs in a more informed and compassionate manner, thereby enhancing the delivery of PCDC.

“He (a resident living with dementia) said I took his things, like I stole them or something. And I was like, ‘Who would take your stuff?’ I was pretty upset at first. But then it gradually dawned on me-it’s just part of what they’re going through. Once I got that, I knew it was all about giving him the best care possible.” (N6, Caregiver).

This quote illustrates how understanding dementia symptoms helped the caregiver reframe responsive behaviours, shifting from frustration to empathy and enabling more person-centred responses.

Attitudes and behaviours towards individuals with dementia

Staff who labelled diagnosed residents as “dementia cases” and viewed all their behaviors as abnormal appeared to believe challenging behavior was inevitable.

“Some individuals with dementia might even throw their faeces at you… I’ve seen it before, at my last job. It’s scary; we had to restrain them… They really resist getting undressed for bathing, which makes it tough.” (N4, Caregiver).

In the above example, the caregiver speaks as if all people with dementia will resist personal care and need to be restrained. The caregiver does not indicate any person-centred understanding. However, conversely when encountering non-cooperation from individuals with dementia, some staff used soothing and non-confrontational strategies, which eased behavioral distress and promoted a more person-centred care experience.

“You’ve got to coax them, not rush them or anything. Like, if they’ve just done their business, and we’re trying to clean them up, you know, we just gotta be patient and let them do it at their own pace, otherwise they might get upset or anxious. " (N5, Caregiver).

In this excerpt, this staff member recognised the importance of slowing down to match the residents’ pace. Her words suggest she has empathy and understands that someone with cognitive impairment might become flustered if out-paced.

Professional identity and burnout

The nature of dementia care in nursing homes sometimes seemed to cause physical and mental exhaustion, reducing work passion and impairing person-centred care provision.

“You know, working in the service industry isn’t just tiring physically; it’s mentally draining too, especially when you’re always dealing with disabled seniors. It really gets to you… After a couple of years, I started thinking about switching careers ‘cause I just didn’t wanna keep doing this.” (N7, Social Worker).

On the other hand, staff who took pride in their caregiving embraced their roles and appeared more satisfied in their jobs. Recognizing the importance of their work enhanced the provision of PCDC.

“You know, sometimes I think taking care of folks with dementia ain’t so bad; the best part is, it’s pretty rewarding. One thing’s for sure, this line of work really makes a difference for the seniors.” (N10, Caregiver).

In the first extract above, the staff member focuses mainly on her own exhaustion but in the second, the focus on the outcome for the residents is a source of satisfaction, motivating effective PCDC.

Personal characteristics of staff

Relevant staff characteristics included age, education, work experience, and aspects of personality. Senior staff observed that some of their supervisees lacked patience, failed to communicate procedures to residents and lacked respect and empathy, undermining person-centred care implementation.

Supervisors perceived older staff as being more motivated by the need for income than providing good quality care.

“Most of our staff are women in their fifties and sixties. [..]. Some just see it as a job to make money, rather than focusing on providing quality care. It’s hard to get them to change their ways and really care about the residents.” (N2, Nursing Supervisor).

By contrast, some staff spoke of the importance of being intrinsically motivated to provide good care, as in the quote below:

“Going the extra mile in care is all about having heart in your work. It’s not just about following a clock, like ‘I only do my job during these hours.’ Taking care of seniors is more personal; it’s about us staff showing love and feeling a responsibility.” (N7, Social Worker).

Here, we can see that compassion appeared to drive this social worker to go beyond basic caregiving tasks, providing additional care and kindness when needed.

Some staff indicated that as they gained experience, they learned to take a more person-centred approach, appreciating that many behaviours were due to dementia not to the person:

“Thinking back, you know, as I’ve gained more experience in this field and seen more seniors over the years, I realize that their issues stem from their conditions, not deliberate actions. It just makes it easier to handle some stuff.” (N1, Care Manager).

Family factors

Trust level of family members

Staff reported that some families of individuals with dementia tended to believe inaccurate information conveyed by their relative rather than trust that staff were providing good care.

“Like some of people living with dementia, they love to complain, you know? What they say might not always be true. And then their relatives believe them, which makes it hard for us to do our job.” (N6, Caregiver).

Due to inherent mistrust of nursing facilities, some family members adopted a vigilant attitude during visits, scrutinizing staff and reporting any issues to management. This mistrust hampered person-centred care provision when it arose between staff and family members.

“Quite a few relatives are like that, you know? They’ll rummage through cabinets, even check the floors. And if they’re not happy with something, they’ll go straight to the boss about it.“(N4, Caregiver).

On the contrary, when families of individuals with dementia trusted and supported the staff, this led to positive feedback, boosting staff confidence and sense of accomplishment.

“Families of the seniors really trust us. Like today, when Mike’s daughter left, she praised us again. Over the years, our good reputation has brought in many referrals through word of mouth, especially from families who know each other or other residents. So when someone new comes in, there’s probably less tension, or they won’t suspect mistreatment or abuse.” (N3, Dean).

In the example above, the staff member basks in the compliment from the resident’s family member. The dean suggests that compliments seem to ripple through the Home and generate a more relaxed and trusting atmosphere between staff, residents, and their families, facilitating the implementation of PCDC.

Family members’ lacking concern for their relatives

Staff described that some family members seemed to care more about their relatives than others. Where families were less supportive, the staff felt this subtly decreased their own attention to those particular residents, affecting the provision of PCDC.

“An old couple lives here. The grandma has dementia, but the grandpa doesn’t. Their son never visits. He just doesn’t seem to care about his parents. You know? He hardly ever calls. Maybe once in a while, he’ll do a video call. But it’s always the grandpa who holds the phone and asks a couple of questions. Then the son says, “Yeah, yeah, nothing’s wrong. Gotta go. I’m busy.” And that’s it.“(N4, Caregiver).

“If you say his family never shows up and doesn’t seem to care about him, then for sure, we’re gonna be less invested in him too. It’s like, maybe you haven’t noticed, but unconsciously, you end up caring less about him.“(N4, Caregiver).

This caregiver describes witnessing the son’s lack of respect for his parents and explicitly describes how this makes them less concerned about the resident’s welfare. The use of the term ‘unconsciously’ implies that perhaps the staff member feels a little ashamed of this but nonetheless, they state that ‘for sure’, they are less invested.

Organizational factors

Education and training

Some staff reported that some of their colleagues approached training with a negative attitude, and were unwilling to learn regardless of the content or timing of training.

“You know, it’s all just for show, you know? Like, you get it, but deep down, you know that whatever you teach them, they’re not really learning much. They just go through the motions. It’s all about making a buck, you know? Doesn’t matter if it cuts into your time off or not—either way, the training’s useless. If you’re not into it, it just feels like extra work, exhausting.” (N4, Caregiver).

Some staff were open to learning but found dementia care training, which was scheduled during rest times when they lacked energy. This could lead to poor learning outcomes, hindering knowledge acquisition and better care provision.

“Training cuts into our downtime, so that’s why many of us aren’t too excited about it. You see, sometimes we do 24-hour shifts, and then the next day, there’s training. But we’re already so exhausted by then, we can’t keep our eyes open during the sessions. We’re just too tired to absorb anything.” (N6, Caregiver).

In contrast, other participants noted that dementia education and training could target certain staff specifically or encompass all staff members, including kitchen and cleaning staff, to promote a resident-friendly environment.Furthermore, participants also emphasized that providing education to family members can enhance their understanding of the residents’ condition, reduce misunderstandings and conflicts, and thereby facilitate better cooperation in nursing work.

“Pretty much everyone in our facility interacts with the older adult, so even our social workers and cafeteria staff need to know how to handle wheelchairs and other technical skills. That includes emergency procedures, like what to do if an older adult falls. We also take the opportunity during interactions with family members to provide some educational information when appropriate. It help family members understand dementia, get to know the residents, build better relationships between them, and also better understand and support what we do.” (N3, Dean).

When dementia care training sessions were scheduled to avoid encroaching on staff’ rest time, this was conducive to providing PCDC.

“The way this facility operates now is different. They only call you back (to the facility) for something really important. So it’s not like before where they’d insist you come in even during your off time. It’s pretty humane, like they understand you need your rest too.” (N4, Caregiver).

This caregiver’s comment reflects the importance of scheduling training sessions that respect staff’s rest time. The caregiver feels she is treated in a person-centred way, which enhances her overall well-being and this is likely to, in turn, enable her to respond to residents in a person-centred manner.

Communication and interpersonal relationships

Effective communication among staff facilitated exchange about older adult residents’ preferences and helped address work-related issues, thereby alleviating staff stress.

“The relationship among us staff members is really great, you can definitely feel it.……We all talk to each other about the residents. Like, which resident can’t eat pork, which one has diabetes. We all pass that info along.……We all help each other out when there’s a problem. Like, if a resident gets mad at me, other staff will step in and help me take care of them.” (N10, caregiver).

This caregiver shared the benefits of her positive relationships with fellow staff members, as well as how communication, by conveying information about residents, facilitates the provision of PCDC. Additionally, communication between staff and family members also contributes to the implementation of PCDC.

“We have this WeChat group with the family members. We share updates about the older adult residents’ daily lives, interact with them, and if the residents have any issues, we let the family members know right away. I think this communication is really important.” (N1, Care Supervisor).

The Care Supervisor’s statement highlights the role of digital communication, such as WeChat, in strengthening the connection between staff and families.

Cooperation

When staff and family members recognized their common goal of promoting the health and quality of life of older residents and formed a cooperative relationship, this enhanced collaboration and proved beneficial for providing person-centred care and collectively caring for the older adult.

“Our team’s from all over. At first, we didn’t really click but now we get it - only through tight-knit cooperation can we solve nursing problems. Everyone, whether staff or family members, wants the elderly to be healthy and have a good quality of life. Once we’re on the same page and work together, things run smoother, and it’s a big help for putting PCDC into practice and jointly taking care of the elderly.”(N3, Dean).

In this example, the dean points out that their team, composed of members from different backgrounds, gradually realized that only through close cooperation can nursing problems be solved. He notes that when staff and family members, who all share the goal of ensuring the elderly’s health and good quality of life, reach a consensus and work together, things go more smoothly, and this collaboration significantly aids in putting PCDC into practice.

Management

In the facility, leaders served as the policy-makers and decision-makers. Some staff felt that the high expectations imposed on them by leadership had increased their workload and stress levels.

“The boss is really strict. If an older adult wets themselves, you gotta change them right away. If they get dirty, same deal. It’s exhausting, especially when the older adult is heavy, and the boss’s expectations are so high. You gotta follow the protocol.” (N4, Caregiver).

In this example, the caregiver focuses on the pressure she feels to comply with the protocol rather than on meeting the needs of residents who are incontinent. It sounds as if the manager is gaining compliance by being seen to be strict. This is echoed in the statement below where the participant talks about being reprimanded:

“When you get reprimanded by the boss, it feels like a ton of pressure, even if it’s not really your fault. It’s just such a headache at that moment.” (N8, Nurse).

These extracts imply that where there was a management style that focused on rules rather than residents, staff felt pressured and this hindered their active engagement in providing PCDC.

On the contrary, a management style that attended to employees’ psychological well-being and acknowledged the challenges of dementia care from their perspective was seen as nurturing staff wellbeing.

“Managers need to put their employees at the center and recognize that dementia care is really challenging. If there are issues that staff can’t handle, managers should step in to solve them. I think it’s easier for [a member of staff] this way, and if someone acknowledges his grievances, it definitely helps relieve his stress to some extent, don’t you think?” (N3, Dean).

In this excerpt, the senior staff member gives an example of how she responds in a person-centred way to her staff and she emphasizes a style which recognizes that employees needed care and support to effectively transmit care and energy to residents, facilitating person-centred care provision.

Managers established person-centred protocols, requiring staff to develop individualized care plans based on each resident’s needs, preferences, and past experiences. Regular meetings, daily briefings, and shift exchanges included discussions on each resident’s habits and preferences, aiding staff in understanding the residents and enhancing the provision of PCDC.

“Everyone gets to know about the older adult residents’ personal experiences and preferences. The management informs everyone, it’s discussed during shift changes, and their details are recorded for others to refer to. Each resident has a specialized care plan.” (N4, Caregiver).

This caregiver’s reflection underscored how management requirements and processes helped them understand people living with dementia and promote PCDC.

Resource factors

Physical environment

Participants reported that the absence of spaces for residents’ outdoor activities in the physical environment or the absence of dedicated dementia care units may have been detrimental to the implementation of person-centred care.

“One thing lacking in our physical environment is that we don’t have a big yard. So, our next step is to consider renovating the rooftop and turning it into a bit of a landscaped area.” (N3, Dean).

“I think older adults with dementia, especially those who are still active, are the hardest to take care of. There should be a special area just for them, with facilities tailored to their needs.” (N7, Social Worker).

On the contrary, well-equipped facilities are conducive to the implementation of PCDC.

“I think most of the accessibility facilities in this place are actually pretty good, haven’t noticed any issues. I just looked up and saw that soft padded cushion next to the metal box too.” (N12, Intern).

The intern’s comment mentions specific facilities they noticed, such as the soft padded cushion next to the metal box, and notes that the accessibility features appeared well-designed.

Staffing shortages and turnover

Participants raised concerns about staffing shortages of various professionals. This led to staff taking on multiple roles, reducing the specialization and authority of their respective tasks, increasing the difficulty of work, and hindering the provision of PCDC.

“I think it’d be better to have someone more experienced handling social work. I might not have that kind of expertise, I’ve just been figuring things out on my own. It’d be best if the front desk job and the social work position were separated, so we can ensure better quality of service for the older adult.” (N7, Social Worker).

Interns on temporary placements noted that despite studying geriatric services and management, most of them were unwilling to pursue caregiving roles in nursing homes after graduation.

“I have absolutely no interest in this nursing stuff, I’m totally against it.” (N12, Intern).

“I’m not keen on doing this (referring to caregiving work).” (N13, Intern).

Nurses also mentioned a wish to move from the nursing home setting to work in hospitals in the future, implying this would be ‘proper nursing’ and would allow for career progression.

“I feel like a hospital would be more suitable because, after all, I’m studying nursing. I’m aiming to work in a hospital, not a nursing home. I definitely see myself progressing further in a hospital setting in the future.” (N8, Nurse).

High turnover rates disrupted team stability, hindered the establishment of familiar relationships between staff and people living with dementia, and impeded the provision of PCDC. On the contrary, if nursing and care staff were familiar faces to older adult with dementia, this promoted the implementation of PCDC.

“Individuals with dementia sometimes recognize their family members, and sometimes they don’t. But they tend to get familiar with us over time, which significantly reduces incidents of aggression. We still encounter some, but it’s become quite rare now.” (N2, Nursing Supervisor).

The nursing supervisor’s comment illustrates the importance of continuity in caregiving. She observed that residents seemed to be more settled as they got to know staff, consonant with the emphasis on relationships which is a central tenet of PCDC.

Workload and working hours

Some participants reported long working hours and heavy workloads. Taking holidays was often difficult. Night shifts contributed to fatigue and could impact overall health. Moreover, due to staffing shortages, taking leave was challenging, and sometimes shifts became extended due to training or handover procedures.

“I still have to work night shifts as a caregiver. With my age and my body, I do feel exhausted sometimes. Especially when there aren’t enough staff, and you can’t find anyone last minute due to holidays or emergencies, it’s tough.” (N7, Social Worker).

By contrast, some employees reported that moderate workloads and adequate work hours, coupled with sufficient break times, were conducive to alleviating fatigue and maintaining ample energy levels for providing person-centred care.

“I think the workload is pretty reasonable. Before, I had a 12-hour shift, but now it’s an 8-hour one, and there’s still some time for breaks. This makes me feel less exhausted, and consequently, I have more energy to perform my duties effectively.” (N4, Caregiver).

The caregiver’s statement highlights how shorter shifts enhanced her ability to perform well at work.

Salary and benefits

Many participants perceived their salary and benefits as being poor.

“The pay for this job is pretty low, I mean, even waiters make more.” (N12, Intern).

“The pay cap is a real issue; the money you’re offering isn’t enough for the amount of work involved, especially considering it’s person-centred.” (N2, Nursing Supervisor).

The staff quoted here felt their hard work was undervalued and hinted that this detracted from motivation to provide high quality person-centred care.

Conversely, some staff highlighted satisfaction with their salaries and there was some indication that this reduced turnover rates, and facilitated PCDC.

“As for the pay situation, I think it’s alright, it matches the workload pretty well, Otherwise, I wouldn’t have been able to stick around this job for so long. And when pay matches the workload, it makes us more willing to provide better care to the elderly.“(N10, caregiver).

The nursing and care staff’ comments reflect the direct impact of fair compensation on job satisfaction and retention. When salaries were aligned with workload demands, staff felt more valued, which boosted their morale and enhanced their ability to consistently provide PCDC.

External support factors (social status, National policy, government support)

Working in older adult care facilities was often perceived as undignified and inferior, with staff lacking support and understanding from their families and respect from the older adults they were caring for.

“Caregiving work is both dirty and emotionally draining, and it takes a toll on your body, especially your back. It’s actually different from nursing; nurses get a bit more respect and are considered a step above us. At my previous job, some older adult residents would say, ‘Oh, you’re such a young girl, why are you doing this?’ implying that my job isn’t respected.” (N4, Caregiver).

This quote shows how this unqualified member of staff felt undervalued compared to qualified staff. She even felt that the residents she cared for judged her as wasting her life by caring for them. This situation resulted in staff feeling hesitant to share information about their work with others outside the care home.

External support from the government and other stakeholders in the form of policy incentives, financial aid, and media guidance was beneficial for eldercare facilities to improve facilities and equipment for residents, enhance caregiver compensation and benefits and facilitate the implementation of PCDC.

“The government does give us rewards, you know? Like, if I work in this field for five years, I’ll get a few tens of thousands of yuan. Even though I haven’t gotten the money yet, it really does motivate me to keep going in this line of work.” (N2, Nurse Supervisor).

“If the media would report more positive stuff about nursing homes, instead of always going for eye-catching stories like caregivers hitting residents, families and society would trust us more. And then we could focus more on taking care of the elderly.“(N3, Dean).

Discussion

This study employed a rigorous descriptive qualitative method to identify the barriers and facilitators encountered by staff in nursing homes when implementing PCDC. In comparison to prior research, our findings are more systematic and comprehensive. We categorized the barriers and facilitators of PCDC into four themes (see Table 4). These four themes encompass nursing and care staff factors, family factors, organizational factors, and resource factors. Within each theme, barriers and facilitators exhibit contrasting characteristics.

The first factor involved the staff. Our study was conducted in China. In many Chinese nursing homes, there are no requirements regarding the staff’ educational background or age [33]. Consequently, there are numerous older staff from rural areas who have little formal education [34]. Our findings echo previous Chinese research which found care staff who were older and poorly educated, patronised and infantilised residents, and struggled with person-centred care [16, 35]. Additionally, aligning with our findings, prior research has indicated that older employees may be motivated more by financial incentives, which in turn diminishes their enthusiasm for delivering PCDC [14, 36]. Furthermore, prior studies have indicated that some staff may label those with dementia pejoratively or respond disrespectfully to their distressed or disturbed behaviors, which contradicts the respect inherent in person-centred care [15, 16, 37].

Our analysis suggests that extended work hours may lead to burnout in staff. Daily exposure to a consistent group of residents and witnessing the gradual deterioration of their health conditions, along with physical and psychological exhaustion, may contribute to caregiver burnout, which is detrimental to the provision of PCDC. These circumstances have not been previously reported in Chinese research. Nevertheless, this has been found in a qualitative study in the UK which found that PCDC training could assist nurses in better comprehending and managing work-related stressors, thus alleviating burnout. This suggests that PCDC training can have a positive effect on reducing nursing and care staff burnout and further underscores the bidirectional relationship between PCDC and caregiver burnout.

The second factor involved residents’ families. Staff reported that some family members struggled to understand the progression of dementia, which could lead to frustration and a lack of trust in staff, especially if they attributed the deterioration of the resident’s condition to inadequate care [9, 14]. Additionally, our findings corroborate existing literature, suggesting that some family members may become disengaged after placing the resident in a nursing home, which could affect staff’s attention to the resident [9]. Achieving PCDC was found to be facilitated when family members understood the nature of dementia and took a cooperative supportive stance to working with staff.

Organizational implementation of PCDC was facilitated when leaders adopted a person-centred management style and supported staff by offering suitable training and education in PCDC. Further facilitators were open communication and collaborative relationships within the staff team as well as with families. Early literature suggests that staff education is one of the fundamental drivers of person-centred care [38, 39]. However, some staff in long-term care facilities are dissatisfied with the content and delivery of training, leading to poor training outcomes. Prior research has found that the content may be repetitive or overly theoretical, making it difficult to integrate with practical work [14, 17, 37, 40, 41]. Our findings additionally demonstrate that when training activities encroach on staff’ rest time it is less likely to be well received.

The final theme concerned resource factors. Within this theme, barriers were particularly prominent and these appeared to be key reasons for the challenges in implementing PCDC. Several of these have been echoed in previous research. Issues such as staff shortages, heavy workloads, long hours, and low salaries in long-term care facilities hinder the implementation of PCDC [11, 16, 17, 42, 43]. Moreover, nursing home staff often perceive their work as lacking dignity, leading to feelings of professional shame [16] and a diminished sense of professional worth, further impeding the implementation of PCDC and perpetuating a vicious cycle of staff turnover. There is a need to enhance societal recognition and respect for staff, as their work is vital to society.

To promote the implementation of PCDC in nursing homes, based on the barriers and facilitators identified in this study, the following recommendations are proposed: In order to address the current problem of older and less-educated care staff, national education departments could consider integrating modules and courses on PCDC into the education system, focusing on attracting young students in geriatric-related majors to work in nursing homes [44]. However, to achieve this, efforts would need to be made to reduce dementia-related stigma and enhance the professional recognition of dementia nursing and care staff through national policies and public education [6]. Additionally, for older staff members, continuing professional education on PCDC could be offered to enhance their knowledge and skills, ensuring that all staff, regardless of age, are well-equipped to provide quality care. This study also reveals that some participants either have an inaccurate understanding of PCDC or only a partial grasp of it. These findings highlight the urgent need to enhance nursing staff’s understanding of PCDC in Chinese nursing homes. Our study suggests it would be helpful to place emphasis on training to enhance employees’ ability to respond to the non-cognitive symptoms of dementia, and to adopt a blended training approach that combines online and offline methods so avoiding mandatory training during employees’ off-duty hours. Given that family members of people living with dementia also lacked relevant knowledge, educational tools such as ISUPPORT [45] or VIPS practice model (VPM) [46, 47] could be utilized, or caregiver support group [48] could be organized to provide education and support for families. Finally, concerning resources, governments and related institutions will need to increase investment in human, material, and financial resources for the nursing home sector to build a more sustainable and inclusive care infrastructure [49].

Strengths and limitations

Given the current lack of qualitative research on the barriers and facilitators faced in implementing PCDC in nursing homes in China, this study has provided valuable insights for the literature in this field. Our study aimed to address limitations and methodological shortcomings of previous studies. We were able to recruit 17 staff members (including male staff, nurses, managers, interns, and social workers) from two nursing homes with varying characteristics, sizes, ratios of staff to residents, and work hours, using purposive sampling, and collected extensive data until data saturation was achieved. However, this study also has certain limitations. As a descriptive qualitative study, the research may lack deep interpretative analysis, which could limit theoretical insights. Future research could take a more interpretivist stance to gain additional insights into the reasons behind some of the barriers and facilitators we found. Moreover, the exclusion of rural nursing homes and those of low quality might restrict the generalizability of the results. Furthermore, This study did not directly collect family members’ perspectives, and all descriptions of family attitudes were derived from staff’s subjective reports, which may be subject to bias. Future research should employ family interviews to further verify and enrich relevant findings.

Conclusions

Given the current lack of research on the barriers and facilitators faced by nursing and care home staff in implementing PCDC in China, this study systematically summarizes the barriers and facilitators of PCDC under four themes: nursing and care staff factors, family factors, organizational factors, and resource factors. The most frequently mentioned barriers were insufficient staffing, high staff turnover and inadequate wages and benefits, which limit the ability to provide quality PCDC services. Meanwhile, the most frequently mentioned facilitators included the personal attributes of staff, effective communication and interpersonal relationships between nursing and care staff, and between staff and those people living with dementia and their families.These findings offer valuable insights for improving the implementation of PCDC in Chinese nursing homes and could inform targeted interventions, workforce planning, and future policy development.

Authors’ contributions

X.G.: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data Curation, Writing-Original Draft, Visualization. A-m.D.: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Visualization. G-k.X.: Software, Validation, Resources, Writing-review & editing.J.O.: Conceptualization, Methodology, Validation, Resources, Writing-review & editing, Supervision, Project administration. Y.L.: Conceptualization, Methodology, Validation, Resources, Writing-review & editing, Supervision, Project administration, Funding acquisition. All authors reviewed the manuscript.

Funding

This work was supported by China Medical University School of Nursing Research Funding (grant number-2022HL-01), the Research on Practice Standards of Computer-Aided Cognitive Training (grant number: 2024CMFB09), 2024 Liaoning Province outstanding Student project (grant numbers-3110024174).

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Declarations

Ethics approval and consent to participate

This study adhered to the standards set forth in the Helsinki Declaration. Ethical approval was obtained from the Ethics Committee of China Medical University (Ethics Committee Number: [2023]120). Written informed consent was obtained from all participants prior to the commencement of interviews.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.