Person-Centered Gerontological Nursing: An Overview Across Care Settings

Abstract

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.

Figure 1.

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

Note. Adapted from McCormack and McCance (2006).

Table A.

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

Concept	Adapted McCormack & McCance Definitions	Operationalization for Gerontological Nurses
Characteristics of Gerontological Nurses
Commitment to gerontological nursing role	The dedication and sense that the nurse wants to provide care that is best for the care recipient.	Desire to provide care individualized for every older adult.
Competence & capability to provide gerontological nursing care	The nurse’s knowledge and skills to make decisions and prioritize both the physical and technical aspects of care.	Specialized gerontological knowledge and skills needed to manage and provide person-centered care.
Interpersonal communication skills	The ability of the nurse to communicate at a variety of levels.	Ability to communicate on an individual and group level with all person-centered care team members, including the older adult.
Knowledge of self, beliefs, & values	The clarity of the nurse’s worldview, (personal) beliefs, and values.	Understanding, owning, and setting aside personal beliefs and values to help the older adult.
Attributes of Care Environment
Appropriate gerontological nursing skill mix	The nursing skill mix refers to the ratio of registered and non-registered nurses in a nursing team.	Consideration of the skill level of advanced practice, registered, licensed practical/vocational nurses, and nursing assistants, dependent upon the setting.
Effective staff relationships	The effectiveness of staff relationships depends on empowerment of others by challenging existing practices that cause hierarchical power/domination rather than staff/team relationships.	Support for staff/team relationships, emphasizing equality among team members to promote person-centered care and better outcomes for older adults.
Potential for innovation & risk-taking	The nurse works in a person-centered way and exercises their accountability to balance the degree of risk involved in supporting the care recipient’s preference, negotiate a way forward, and justify the final decision made.	Use, support, and encouragement of appropriate innovation and risk-taking to promote person-centered care.
Shared decision-making systems and power	The nurse facilitates participation in shared decision-making that is underpinned by principles of person-centeredness (i.e., self-determination).	Facilitation of decision-making to support person-centered care for all healthcare team members, including the older adult and their family.
Person-Centered Nursing Approaches
Collective decision making between the older adult, the gerontological nurse, and healthcare team	The formation of an interdependent and interconnected relationship between the nurse, interdisciplinary team, and care recipient.	Communication focused on providing and receiving information to and from the older adult to facilitate participation in care and decision-making.
Empathetic engagement between the older adult and the gerontological nurse	The connectedness of a nurse to a care recipient.	Unique relationship supporting the older adult by recognizing and acting on verbal and non-verbal cues to achieve person-centered care.
Holistic, person-centered care	The nurse-care recipient interaction where care provided addresses physical, psychological, sociocultural, developmental and spiritual needs of the care recipient.	Meeting and addressing physical, psychological, psychosocial, and spiritual needs of the older adult to provide person-centered care.
Knowledge of what matters to older adult (e.g., their beliefs & values)	The understanding of the care recipient’s values and ability to work with their beliefs and values to facilitate shared decision-making.	Understanding the older adult and their family and what matters to them (e.g., their beliefs, values).
Indicators of Person-Centered Gerontological Nursing Care
Involvement with care	The extent to which care recipients feel involved in their care.	Older adults’ participation in all aspects of care.
Satisfaction with care	The care recipient’s satisfaction with care processes and the care environment.	Older adult and family satisfaction with care as an indicator of the successful provision of gerontological, person-centered care.
Therapeutic care setting	The extent to which the environment supports and maintains person-centered principles.	Care settings that are therapeutic include collective decision-making, collaboration among the older adult, family, and healthcare team members, setting specific positive leadership practices, and the use of innovative, evidence-based gerontological nursing care.
Well-being	The extent to which care recipients feel valued and experience positive health and non-health related outcomes.	Measure of person-centered care establishes a sense of receiving care specific to the older adult and their family.

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.

Table B.

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

Setting	Person-Centered Care Approaches and Models	Gerontological Person-Centered Nursing Approaches	Indicators of Person-Centered Nursing Care
Residential Care	Eden Alternative Green House Project Promoting Excellent Alternatives in Kansas Nursing Homes (PEAK) Preference-Based Care	Empathetic Engagement Holistic, Person-Centered Care Knowledge of What Matters	Improved Well-Being (e.g., fewer behavioral symptoms) Increased Satisfaction with Care Improved Therapeutic Care Setting (e.g., decreased staff turnover; increased job satisfaction)
Home and Community Based Care	Patient Centered Medical Home Patient Priorities Care Model	Collective Decision Making Holistic, Person-Centered Care Knowledge of What Matters	Improved Well-Being (e.g., improved self-management; lower hospitalizations; reduced treatment burden) Increased Involvement in Care Increased Satisfaction with Care Improved Therapeutic Care Setting (e.g., improved continuity of care; lower staff burnout)
Acute Care	Progressive Patient Care Model Patient Centered Approach Lean Approach	Collective Decision Making Empathetic Engagement	Improved Well-Being (e.g., improved care outcomes) Increased Involvement in Care Increased Satisfaction with Care Improved Therapeutic Care Setting (e.g., decreased staff turnover)

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).

Outcomes.

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).

Approaches.

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.

Outcomes.

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.

Approaches.

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).

Outcomes.

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.

CONCLUSION

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.