Characteristics of the studies
Nine research studies met the eligibility criteria for inclusion in the meta-synthesis, all of which were qualitative studies. The methods applied in the nine articles were mainly one-to-one interviews and focus group interviews. The articles are spread over time (from 2006 to 2022), mostly concentrated in 2018-2022. Among the nine papers, three were from Canada, two were from Australia, and four were from Ireland, United Kingdom, Netherlands, and America, respectively. The contexts of the studies were mainly community living or residential settings for older people. The study participants were diverse, including registered nurses, voluntary staffs, case managers, older people, family/friend caregivers, and clinicians. Further detailed results of the included studies are presented in Appendix Ⅲ.
Meta-synthesis of qualitative data
We extracted a total of 89 findings from the nine included studies, all of which were unequivocal. Those findings were aggregated into 12 categories based on the similarity of meanings, which were then meta-aggregated into three synthesised findings (Table 2). The study findings are listed in Appendix IV and the results of the meta-synthesis process are shown in Appendix V.
Synthesised finding 1: Stakeholder capability
It is crucial to recognize that stakeholder capability affects the implementation of PCC interventions. Communication skills and professional competence can be improved through providing tailored training education. Furthermore, older people and their caregivers should be encouraged in decision-making.
Trust and mutual communication are the cornerstones around which a humanistic care team is built; it should be done with understanding and respect and without regard for hierarchy. A person-centred communication style involves active or reflective listening that is advantageous to drive behaviour change.
I asked, like, he asked me questions and he doesn't focus with me. There's no that connection…between you. Like he has to listen to you first, but he's on the computer like “uh huh. What happened to you? — Uh huh”. I don't want that. Like, I want, like, personal connection. He has to understand me. What's my pain…and they don't look. (Manalili, K et al.,2021, p.8)
Communication can be number one no matter who you’re looking after. (McKenzie and Brown,2021, P.278)
Older people generally lack decision-making capabilities, and it is believed that competence in making decisions encourages personnel to participate more enthusiastically in decision-making processes.
And I said was there ever, was there any way that I could have somebody help me with my grocery shopping? And he said 'Oh, yes, you, they have this, uh, you give them a list and they go out and shop and they bring it back and, uh, you pay for it.' But that's not helping with my grocery shopping, that is just grocery shopping. (Giosa, J et al., 2021, P.8)
Yaa, so, being a valued member of the care team, and to be treated as a human being, versus just this patient… cause I had a lot of experience with that. (Manalili, K et al.,2021, P.9)
Meanwhile, HCPs in the community should develop care plan by combining experience with research literature. And the community managers should carry out targeted training to improve professional competence about PCC.
It’s a combination of your academic study on that person, your professionalism in getting to know that person. But really and truly it is your day-to-day work, working with that person on a physical, intellectual and intimate level. (Doody, C et al., 2013, P.1118)
I have probably psychoanalyzed a lot of the experiences that I’ve been through to learn from my mistakes. (Narayan MC and Mallinson RK, 2022, P.5)
Synthesised finding 2: Opportunities in the implementation of person-centred care
It is essential to note that opportunities are important factors influencing the implementation of PCC, including support from work environment resources, collaboration and multidisciplinary teamwork. And communication helps to establish a climate of trust and respect and facilitates making shared decisions. Financial and time constraints posed barriers to conducting the PCC interventions.
The workplace support (physical and cultural) is especially important to convince stakeholders if a person-centred approach is to be supported. Available resources (human and fiscal) and reasonable workload impact the implementation of PCC and, in particular, the choice of intervention methods.
One of the very huge issues affecting community nursing right now is financial compensation. I mean, you work in a hospital, you do pretty much the same thing you do out here – [but] you get paid more for it [if you work in the hospital] and it’s a hard thing to convince people that it’s worth coming to the community for personal reward rather than financial [remuneration]. (Brown, D et al., 2006, P.164)
Reinforcing multidisciplinary teams and collaboration are seen as an important part at PCC program. Older people with chronic diseases often need support in multiple domains, and also facilitate providing continuity of care for them over time.
One of the greatest barriers is the lack of understanding of person- centeredness. People think that the nurses are the only people to be person-centred but everybody from the maintenance man, cook, household staff and the team all have to be person-centred. (Doody, C et al., 2013, P.1117)
Establishing a trusting and respectful relationship is seen as key to promote a good social environment. The person-centred approach that guided communication might be crucial in creating trust between older people, family caregivers, health professionals. Significant time spent deliberately building trust and rapport, through which health outcomes are achieved, makes sense for the implementation of PCC programmes.
Caring doctors took participants seriously and were not dismissive, unlike doctors whose attitude was uhum, right, sure as they were writing the prescription. Caring doctors were responsive: He interacted with me, at my level. . . he treated me like a sentient, sensible, intelligent woman. . . looking at a situation and him recognising what his responses and reactions needed to be, he was not dismissive, he was engaged. (Gillespie, H et al., 2018, P.1060)
it is important because it’s also a part of building a relationship of trust. Clients apparently like the social aspect, having a nice time. Well, I do think that this is an important component, but it’s certainly not my main reason for coming. (Uittenbroek, R. J et al., 2018, P.6)
Time constraints are averse to implementing successful PCC programmes. This could be partly due to a lack of health staff and bureaucratic overload (lack of a whole service approach, staff turnover, sharp targets and complex procedures). The situation resulted in high work pressure, overtime, and reduced quality of care. This condition can cause stressful work environments, burnout, and decreased quality of care.
We’re only touching the tip of the iceberg in relation to person-centredness. We do our utmost in choice, in documentation, in family involvement, but we would need ten times more staff to do what possibly could be done for each service user to fulfil their dreams, we do the best we can with person centeredness at the core. (Doody, C et al., 2013, P.1117)
Synthesised finding 3: Motivation in the implementation of person-centred care
Motivation includes reflexive and automatic motivation, which guide the oneself to produce positive or negative emotions towards behavioral goals in PCC programmes through increasing knowledge and experiences. The resilient attitude of care professionals, especially proactive caring belief, facilitated the participation of all stakeholders in the process of person-centred care. Factors impeding implementation included lack of self-reflection, unclear responsibility for rewarding and accountability, and pre-existing ways of providing tailored personal health care.
The managers facilitate self-directed learning and encourage self-reflection using critical thinking skills, which are beneficial to gaining insight into their beliefs, values, and attitudes from both a cognitive and emotional perspective.
I have probably psychoanalyzed a lot of the experiences that I’ve been through to learn from my mistakes” (Narayan MC and Mallinson RK, 2022, P.5)
The health professionals and family caregivers should consider proactive and compassionate caring as the heart of the practice, treat the older people with dignity and respect as an individual.
Actually, whenever I go to doctor, they call me by name. Once [they] call me by my name I feel close, attached to them. Otherwise, I'm going to feel bad. my relationship with my doctor is really good. (Manalili, K et al., 2021, P.8)
Strengthening rewards and accountability mechanisms are facilitators to implementing effective PCC. Some managers stated that the role of case managers and patients' rights should be clarified.
Doing the right thing is quality, right thing is a standard. So, if you are diagnosed with particular disease for a patient, then you have to do the right things, what you need to do, so quality, in my opinion he's doing the right things. (Manalili, K et al., 2021, P.10)
In the PCC programme, having a resilient, optimistic attitude and positive beliefs toward self-management of older people is a vital step in the direction of their activation. The stakeholders can side-step the barriers with a resilient attitude that allows them to embrace the positive aspects.
I make it work for me and for the patient. And I can make it work for the agency as well. I’m not afraid to think out of the box, change the way I do things. I am always thinking is there something that I could do differently to be more successful” (Narayan MC and Mallinson RK, 2022, P.6)
ConQual ‘Summary of Findings’
The CERQual approach provides transparent assessment and explanations of what level of confidence should be assigned to individual review findings [25]. The ConQual Scores and the summary of the synthesised findings are shown in Appendix Ⅵ. The ConQual Scores was moderate for three synthesised findings, where were downgraded one level due to dependability limitation issues. All findings are unequivocal, so the credibility of all included studies remains unchanged.