A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings

The purpose: of this study was to explore the content and essential components of implemented person-centered care in the out-of-hospital context for older people (65+). Method: A systematic review was conducted, searching for published research in electronic databases: PubMed, CINAHL, Scopus, PsycInfo, Web of Science and Embase between 2017 and 2019. Original studies with both qualitative and quantitative methods were included and assessed according to the quality assessment tools EPHPP and CASP. The review was limited to studies published in English, Swedish, Danish, Norwegian and Spanish. Results: In total, 63 original articles were included from 1772 hits. The results of the ﬁ nal synthesis revealed the following four interrelated themes, which are crucial for implementing person-centered care: (1) Knowing and con ﬁ rming the patient as a whole person; (2) Co-creating a tailored personal health plan; (3) Inter-professional teamwork and collaboration with and for the older person and his/her relatives; and (4) Building a person-centered foundation. Conclusion: Approaching an interpersonal and inter-professional teamwork and consultation with focus on preventive and health promoting actions is a crucial prerequisite to co-create optimal health care practice with and for older people and their relatives in their unique context. © 2020 The Author(s). Published by Elsevier Inc. This


Ageing population
As a result of the ageing population and its consequences for aged care systems, the provision of cost-effective, high-quality care of older people has been established as one of the major challenges. 1 To cope with this demographic change, elderly care continues to be a key priority for government and institutions. 2Person-centered care (PCC) can be an approach to meeting these aims but there is no agreed-upon consensus for delivering such care. 3n the present paper, the concept 'PCC' is used as an umbrella term to cover all of the different terms used to convey the same meaning, such as 'person-centered practice', 'client-centered care', 'residentfocused care', etc.

Person-centered care
PCC is a concept that involves meeting the multidimensional needs and preferences of older people dependent on care, by acknowledging the carers as well as the familytaking into account each individual's needs, goals, and abilities.4À7 PCC focuses on the whole person and involves shared decisionmaking as well as better communication between health care professionals and patients. 8,9PCC reflects principles of philosophy and ethics, based on mutuality and respect. 4PCC is increasingly emphasized in aged care policies and national guidelines to promote health in old age across Scandinavia, Europe, the US, Australia and beyond. 1 Although PCC has a long established tradition in nursing, the awareness of this approach has increased over the past few years, with the aim being to improve patient-related outcomes.Even though there is an overall consensus about the relevance of a person-Person-centered care in the hospital setting PCC has been implemented and explored with regard to the integration of communication and shared decision-making in care for people with cancer; 36 in the context of perioperative nursing; 37 and self-management support in long-term conditions across settings; 38 as well as PCC as a concept of time, 39 reconciling conceptualizations of the body, 40 and space. 41Researchers affiliated to Centre for Person-Centred Care University of Gothenburg (GPCC) have evaluated PCC in patients with different diagnoses and conditions. 42For example, patients hospitalized with chronic heart failure, who were treated in line with PCC showed a shorter duration of hospital stay, 29 a better discharge process 43 and a reduction in patients' uncertainty about their disease and its treatment. 44A reduction in health care costs and maintained functional performance was also found, 45 and after an event of acute coronary syndrome, 38,46 significantly higher self-efficacy was found in patients with an education below university level when PCC was followed, which indicates that person-centeredness does not only support equal access to care, but also actively contributes to reducing social inequality in health care. 38,47rson-centered care in the out-of-hospital setting The importance of viewing health from the standpoint of functional, cognitive and social disability dimensions is critical in outof-hospital settings. 4850À56 The complexity of the interventions and range of outcomes examined in the studies makes it difficult to draw accurate conclusions about the impact of the PCC interventions adopted and implemented in aged-care facilities.
A systematic review 57 evaluating the evidence of PCC interventions with aged-care residents and nursing staff found that studies incorporated a range of different outcome measures to evaluate the impact of PCC interventions on these two groups.Only two studies in a Cochrane review described their PCC interventions to be multidisciplinary and goal-directed. 58Structural conditions and the balance between organizational policies and client autonomy has been shown to be challenging in the out-of-hospital setting, 59 but staff education has been shown to increase both residents' well-being and staff satisfaction. 60These studies represent different PCC models to guide person-centered practice in long-term care settings, while McCormack's theory on person-centered practice is one of the most commonly used as a framework in several studies focusing on PCC in elderly care.The cornerstones of this theory are: "(1) being in relation; (2)  being in a social world; (3) being in place; and 4) being with self " (11).Being in relation and in a social world emphasizes the importance of relationships and being interconnected with one's social world.Being in place recognizes the impact of the surroundings and the values one holds about one's life and how it makes sense, which has also been emphasized by Edvardsson and co-workers in their research. 61A systematic literature review based on 132 studies on older adults with chronic conditions identified 15 descriptions of PCC addressing 17 central principles or values.Although multiple definitions and elements of PCC abound -with many commonalities and some overlap-the field would benefit from a consensus on essential components to clarify how to operationalize PCC in health care and services for older people. 6There is a great need for PCC approaches for older people in the out-of-hospital setting. 62Hence, agreement on the crucial components of PCC is essential for researchers and clinicians to guide PCC development and implementation.

Objectives
This paper aims to explore the content and essential components of person-centered care implemented in the out-of-hospital setting for older people (65+).The following research questions guided the search: 1. What is the content/mode of PCC in care for older people implemented in the out-of-hospital setting? 2. What components are crucial in person-centered care in the outof-hospital setting?

Material and method
This systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. 63

Search strategy
A comprehensive literature search was conducted using six electronic databases related to health care: PubMed, CINAHL, Scopus, Psy-cInfo, Web of Science and Embase.The searches -for research articles published from 1997 to 2019-were carried out between July 2017 and December 2019.The search databases and search terms used to identify relevant articles for this review are shown in Table 1.The same search terms, strategy and limiters used with PubMed were adopted for other databases.The searches were carried out on several occasions, the first of which was in July 2017.Two additional searches were conducted in October and December 2019 to update with newly published articles, including the articles that described person-centered care as person-centered approach or practice.See the search terms for the initial search in Table 1.

Eligibility/Inclusion and Exclusion Criteria
Papers were included if they were intervention and/or implementation studies of PCC regarding older people (65+) in the outof-hospital setting.The studies were published in English, Swedish, Danish, Norwegian and Spanish between 1997 and 2019.Only original, peer-reviewed studies were included.Study protocols, instrument evaluation studies and review articles were all excluded.See Fig. 1 for a flow chart outlining the procedure for the selection of studies.

Screening and data extraction
All database searches were conducted by the first author (ZE) assisted by an experienced university librarian.The hits were imported to Rayyan (a screening program) during the reviewing process.In Rayyan, an independent, blind screening of the abstracts was performed by the researchers (ZE, HP, POC).During the screening process, any difference of opinion was discussed by the researchers.A senior researcher (HW) screened any remaining articles considered borderline for inclusion.A total of 63 articles were included for quality assessment and analysis.The process of extracting data was conducted by 3 researchers (ZE, HP, POC) working independently.The key information in these studies was extracted and tabulated in Table A1 (see Appendix).

Quality assessment
The Effective Public Health Practice Project Quality Assessment (EPHPP) 64 was selected to assess the methodological quality of the quantitative studies.This tool includes components of study design and methods including selection and allocation bias, study design, confounding, blinding, data collection methods, and withdrawals.An overall quality rating was assigned to each article: if no weak ratings were given, the quality of the article was estimated to be "strong," one weak rating categorized the article as "moderate".The quality in qualitative studies was assessed using the Critical Appraisal Skills Programme (CASP) Qualitative checklist, 65 which consists of 10 questions assessing different aspects of quality in qualitative studies.No article was excluded in this step.All of the included articles were considered to be of good quality -from moderate to high quality, besides two articles, that were assessed as weak.

Analysis
The quantitative data was analyzed by one of the authors (POC) using a deductive thematic analysis (Clark & Brown, 2017).The qualitative data was analyzed by the first author (ZE) through an inductive thematic content analysis, 66 according to the following steps.In the first step, all articles were read several times to build an overall understanding of the content.The meaning units were then identified, condensed and coded.Codes with similar content were put together to create a category.The last step was to interpret the common patterns of the categories in order to find the crucial components of person-centered care for older people in an out-of-hospital setting; the resulting crucial components are presented in five interrelated themes.Other authors (HW, HP, IE) independently reviewed Table 1 Databases and search terms used for the initial search.

Database
Search terms

Pubmed
("Patient-Centered Care" or "patient-centered" OR "patient-centred" OR "person-centered" OR "person-centered" OR "resident-centered" OR "resident-centred" OR "client-centred" OR "client-centered" OR "patient-focused" or "individualized" OR "individualised" AND care) [Mesh]) And ("home care" or "home care services" or "home help" or "elderly care center" or "home help services" or "home care nursing" or "home health care" or "community setting care" or "home based care" or "care home residents" or "nonhospitalized care" or "nonhospitalized care" or "residential aged care" or "home and community based service" or "household care" or "household services" or "household help" or "hospital in the home" or "home health and services" or "home care agencies" or "homemaker services" or "housebound care" or "domiciliary care" or "in-home care" or "home social services" or "community care" or "community based services" or "community health nursing" or "homebound patient" or "health services for aged" or "eldercare services" or "municipal elder care" or "continuing care setting" or "aged care facilities" or "aged care residents" or "aged care services" or "housing for the elderly" or "nursing care facilities" or "long-term care facilities" or "old age home" or "nursing home" or "residential care facilities") [Mesh]) And ("older" or "older adults" or "elderly" or "elder" or "elders" or "older person" or "older people" or "oldest old" or "elderly people" or "geriatric patient" or "older patient" or "elderly care recipient" or "community dwelling patient") AND Humans the validity of the findings.The last step involved continual discussion between all authors to reach a consensus and synthesize the crucial components of PCC from the findings.

Results
A total of 63 original articles were included in the final analysis -17 articles with qualitative methods, 2 articles with mixedmethods and the remaining 44 articles were studies using a quantitative method (sample size: 14À1042).The articles included varied widely in terms of the countries and settings.A total of 35 studies were from diverse countries around Europe, 20 studies were from USA and Canada, 4 studies were from New Zealand and Australia, and there were 4 studies from China, Japan, Taiwan and Korea.In total, 32 studies were conducted in nursing homes, and 31 studies took place in the ordinary home with either primary care or home care.For further details on the articles included, see Table A1 in the Appendix.An overview of the content, identified components and crucial components of implemented PCC is described in Table 2.

Key findings from quantitative data
The components of applied PCC for older people in the out-of-hospital context from a quantitative perspective is interpreted and presented in two themes and three sub-themes.Key findings from these studies showed that PCC was implemented through knowing, engaging and empowering the older people, their family, and staff.Furthermore partnership operationalized through mutual communication, trusting relationships and shared responsibility.Advance care plan and goal setting through narratives, shared responsibility and decision-making

Knowing the person's needs, resources and preferences
Knowing the older person and his/her needs, resources and preferences was emphasized as an essential component of PCC.For instance, the incorporation of pre-specified and discretionary in-person home visits was essential, as this afforded the opportunity to visually identify a wide range of home and personal safety needs (e.g., fall risk, clarifying prescribed medications, risk of wandering), as well as the physical condition of participants and study partners.67À69 The personal care moment, interactive and step-wise increased the staff self-reported person centeredness and reduced their 'stress of conscience' by enabling them to provide the care and activities they wanted to provide.70À73 Furthermore older people rated a person-centered environment as being in a hospitable, welcoming, safe, homely, neat and clean environment. 74The multicomponent supportive care programs to care for people with dementia at home improved the ability to age in place; the dementia care coordination model with the Maximizing Independence (MIND) at Home reported significant reductions in unmet care needs related to safety. 67hese approaches represent an alternative to better prepare and interact with older people with dementia, addressing emotional and relational skills with PCC. 72,73,7576À80 Goal setting through storytelling, shared power and responsibility Health care providers and organizations need to promote PCC by engaging people in partnership, i.e., shared decision-making and participation. 81,82This was verified in a Swedish study with non-Swedish older people that focused on determining how they perceived leadership in the nursing home, while also focusing on the particular skills that staff chose as those required to lead PCC effectively and how this approach had or had not contributed to the level of the teamwork in the household. 83hared power and responsibility were also observed when monitoring the quality of care involving both the older people and their families. 81Engaging older people in an activity-oriented/goal program showed that the residents met their personal goals related to, for example, self-care.84À87 It was confirmed that the process of personal goal setting was a strategy in and of itself for increasing motivation toward achievement of the goals. 84,88,89The PCC further aimed to create encounters where participants support one another to make decisions in daily life to improve their overall health. 8390À92 A face-to-face motivational approach, along with the provision of information and advice by geriatrician and nurses to older people with chronic diseases who were being treated by polypharmacy, clarified prescribed medications and seemed to improve the level of medication taking. 93The interventions meeting goals for preference fulfillment improved the quality of care and quality of life. 94In addition, the preference for everyday living intervention showed "having regular contact with family" as an important priority.Having privacy, choice about what to eat, when to bathe, and activity options were also important preferences for most of residents. 94However, other interventions such as the "Multimethod program", did not show the effectiveness of each single intervention. 92This is a good example of "one-size does not fit all".95À97 Advance Care Planning -including the patient 'storytelling' approach that brings the focus back onto the person-encouraged the older people to communicate their preferences and mitigated their existential distress, in both older people with chronic conditions and, particularly, in those at the end of life. 82,94,98,99The "On the Move" program focused on the timing and coordination of movements critical for preventing functional decline and disability without any increased risk to the older people.In this program, older people and stakeholders were involved in the design and execution of the study, and it was found that it is critical to build lasting relationships and that it was therefore important "to take the time to listen to and socialize with the resident." 82,89tual communication and trusting relationship between staff, the older person and his/her relatives Communication based on relationship, trust and respect Mutual communication characterized by trust and respect was found to be a cornerstone in all the interventions, and they were also dependent on the older person's cognitive function and the staff's skills in communicating with those who were cognitively impaired.77,99 Some of the interventions focusing on reaching specific goals or needs of the older people did not appear to engage the staff in iterative communication where the patient could tell the story or improve his/her self-determination.These interventions did not give older people a voice to prioritize their goals.96,100 Home-based programs addressed specific or multiple and varied needs of older people with chronic health conditions and have customized the specific services to the older people, leading to a positive effect on diverse outcomes such as an improvement in daily activities of life, nutritional status, incontinence, physical condition, or mood.82,86,87,92,95À97,101À107 The exercise-based programs, i.e., task-specific exercises -focusing on, e.g., muscular strength, coordination and cognitive function-had a greater impact on older people with mild cognitive impairment than on those with moderate to severe cognitive impairment.86,88 Exercise improved function in frail older people, 97 resulting in reduced depressive symptoms in older people with depression compared with usual care.108 Trials of activity programs in the community have also yielded increases in activity levels but without improvement or changes in quality of life, self-management outcomes, or depression.86,92,109,110 Person-centered training promoted interdependence, trust and reciprocity as a basis for older people with low cognitive function -and their families-to engage in a partnership with staff.77,89,104,111 The individualized interaction between the older person and the staff helped older people with dementia to cope with their fears, agitation, aggressive behavior and isolation.68,71,72,76,78,79,112 Additionally, individualized interactions involving the family and care assistant significantly improved positive interactive behavior of care-dependent older people with dementia.73,76,78,81 Key findings from qualitative data The components of applied PCC for older people in the out-of-hospital context from a qualitative perspective is interpreted and presented in three interrelated themes and seven sub-themes.The key findings from these studies showed the importance of conducting a tailored personal health plan, knowing, confirming and empowering the older person in the teamin order to enhance the older person's capabilities, support preventive care and facilitate self-care through an inter-professional teamwork based on friendship and distance with and for older people.
Conducting a tailored personal health plan through knowing and confirming the patient as a whole person

Conducting a tailored personal health plan through relation-based approaches
Creating a tailored personal health plan was an essential component in implementing PCC. 111 Trusting relational practice and engagement to know the person as a whole 113 through respectful dialogue with the person and his/her relatives were among the other prerequisites for conducting the tailored care plan. 114The dialogue with the older people was practiced by carefully listening to the older people's description and experiences of the illness and life situation, in order to get a better understanding of their needs, problems and wishes. 111A nuanced care plan enabled the older people to have more control over their own life situation, 114 supported them in their daily routines and reinforced their capacities to self-manage. 111mong the crucial prerequisites were the older people's narrative of their own experience, 115 attention to their bodily and existential needs, 116 involvement of the older person and their relatives in the planning of care, 117 and the sharing of information and decisionmaking via interdisciplinary team meetings. 111,114owing the older person as a whole Creating a well-functioning relationship between the older people, their relatives and the staff was among the crucial components in developing PCC. 118The professionals appreciated the relation-based practice, which raised their awareness of diversity in its broadest sense. 119For example, role-play scenarios in drama-based education increased the practitioners' awareness, insight, patience and optimism with regard to supporting the older people with dementia in their strive towards an independent life. 114The professionals realized that the older people are not a homogenous group and therefore "one size does not fit all". 119Appreciating this made it possible to know every single person's reality, which was described as a more nuanced effort beyond culture, gender, race, and religion.Research indicates that embedding awareness of diversity in practice can be achieved through active listening and respectful communication. 119Applying relation-based practice increased the professional's confidence and stimulated a behavioral change toward being less prejudicial of older people based on their associated stereotypes. 119There was another point related to knowing the patient as a wholethat is, the intention to avoid reducing the patient to his/her disease/diagnosis.Furthermore, emphasis was placed on the significance of understanding the illness from the patient's perspective, giving spaces for the patient's voice and comprehending how the disease affects the patient's entire life situation. 99The professionals underlined the importance of "all little things" that they expressed or did to confirm the older patient as a person. 119For example, integrating the older person's life history into the conversations was among the efforts made to recognize the patient as an unique person. 120However, knowing the older people with dementia as a person was challenging and depended on the professional's authentic engagement in establishing professional relational practice and discovering the person's life history, priorities and wishes. 121The importance of shifting from a task-oriented approach to person-centered relational practice with the older person was underscored by professionals. 113ter-professional teamwork and consultation with and for the older person and his/her relatives

Confirming the older person as part of the team
Partnership as a co-creation process was crucial in implementing person-centered teamwork, which was perceived as both a limiting and improving factor for change in individual behavior and organizational procedures and policies. 119User-involvement was an intention that was appreciated by the staff, and is one that requires a flexible approach, including spending sufficient time and having patience during the initial stage of an intervention. 122This long-term process required a modification in the professional's attitudes and practicea transition from "doing for" to "doing with" 122 and from "providing" to "co-creation". 119A well-functioning interdisciplinary relationship and cooperation between the older people, their relatives and the staff 118 were among the crucial prerequisites to create a tailored care plan and to follow up on planned goals. 111,119This minimized overlapping tasks but was perceived as time-consuming. 111Continually adapting co-creation processes could increase users' awareness of their own potential for improved activities of daily life function through professional user meetings and the inclusion of dialogue with open-ended questions, active listening, and appreciation of users' views. 122ter-professional consultation and co-creation Older people's involvement in decision-making regarding their own care was another essential component in PCC, which required attentive engagement and a trusting relationship. 121Frail older people appreciated their independence, and preferred taking their own decisions and finding solutions by themselves. 111Mechanisms that support older people's involvement in decision-making include actions aimed at (i) increasing the older people's autonomy, control and privacy 123 ; (ii) ensuring that they are taken seriously by health care professionals 111 ; and (iii) providing appropriate information and patient education. 114,116Establishing the basis for decision-making was challenging for health care professionals caring for people with dementia. 121Having an inter-professional teamwork and consultation with the older people, their support networks and key relationship was essential to accurately interpret the person's needs and wishes and thereby involve the person in a meaningful decisionmaking process. 121Furthermore, relation-based care of people with dementia was practiced through forging a friendship, sharing experience, developing trust and feeling appreciated, as well as taking time and making time. 124Relational care through the shared experience of living with dementia connected and developed bonds with others and helped people to feel a sense of safety and equality, which led to development of trust and appreciation among community health care staff, people living with dementia, and family care partners. 124n addition, factors such as having greater flexibility, staff education and developing skills to engage older people in decision-making were highlighted. 125Studies emphasized the impact of the involvement of older people and their relatives in the creation of an education package to meet needs and take diversity into account, 126 building tailored care plans and sharing both information and decision-making by an interdisciplinary team. 111,116ilding a flexible proactive foundation to strengthen the older persons' capabilities and relatives' engagement in the person-centered cocreation process Enhancing the older person's capabilities, supporting preventive care and facilitating self-care Another essential component of PCC was to support the older people in their self-care and enable them to remain independent. 111rail older people desired to remain independent; they preferred to take their own decisions and to find solutions by themselves in order to have more control over their daily lives. 111,127Accessibility was another important aspect in self-care, which was described in the following terms: older people's access to transparent information about available services; the impact of such services on their health; how to navigate within the health care system; cultural and social factors that affect older people's acceptability; as well as autonomy and capacity to choose appropriate health care services.Furthermore, whether health care services are available and can be reached physically in a timely manner -together with the economic capacity of frail older people to spend their time and resources using health and social care services-were described as factors affecting accessibility. 127rom the patient's point of view, a person-centered approach was characterized by: being taken seriously as a 'worthy' person by the health care professional with resources and capacities, 111,122 being part of the team, 119 being involved in decision-making, 121 being supported in self-care and maintaining independent lives. 111PCC was described as a shifting focus from reactive care to proactive and preventive care, 113 supporting older people's connection to everyday life, which increased their feeling of well-being and enhanced their capabilities to be 'in charge of' their self-care. 111,116naging of competing values in the team by engagement, professional friendship and keeping distance, a flexible organization and situational leadership Competing priorities in clinical and organizational practice were perceived as a hindrance to the goal of achieving PCC; for instance, the conflict between safety and autonomy 117or, for example, being effective and working quickly according to old traditional practices competing with the time required to facilitate user's involvement. 122ules were discussed as an area of focus to avoid rigidity and improve flexibility in care plans.In addition, limited resources -particularly staffing-were commonly mentioned as a reason for lack of followthrough on the older person's goals. 117Perceived conflicts between PCC and medical care were the most frequently reported source of arguments among physicians and nurse practitioners. 125Supporting the resident's and their family's involvement in care planning through regularly scheduled care conferences, and informal engagement between residents or family members and staff in the form of an open door policy were emphasized.Furthermore, the importance of broad commitment across staff roles to the overarching principle of PCC was highlighted. 117In post-acute care situations, the importance of health/medical goals over the older people's preferences needs to be explicitly documented in care planning in order to reduce doubt and perceived conflicts. 125aving a person-centered leadership, a flexible organization and an ongoing critical reflective process to facilitate person-centeredness among staff were among the most important prerequisites for implementing PCC. 128Changing the focus from "doing" to "being" person-centered was stressed, as was building a functioning and integrated team through collaboration, open communication, appreciation and trust. 128A person-centered foundation was characterized by a combination of developing culture and transformational leadership.In addition, the supportive organizational systems put in place to achieve these changes and the practitioners were open to learn from each other and there was a high level of interaction between older people and organizational management to enable practitioners to identify and resolve issues by themselves. 115

Appropriate person-centered communication skill and documentation
The importance of appropriate person-centered communication was underscored. 120Person-centered communication was characterized by four indicators: first, to recognize older people as each being a unique person by incorporating their life histories into conversation; second, to negotiate about older people's preferences, desires and needs by consulting them and their relatives; third, to facilitate older people's involvement in the conversation or action; and fourth, validationwhich involves expressing and understanding the feelings of the older people with dementia. 120The importance of communication and collaborative skills in motivating and stimulating older people to improve their self-management abilities and independence -such as listening and asking the right questions, understanding implicit messages, and providing feedback-was also emphasized. 113Additionally, allowing sufficient time, speaking clearly and directly, explaining the different options available, pausing to allow the person to process information and repeating information were among the professionals' communication skills and strategies designed to enable a person with dementia to be meaningfully involved in decision-making. 121Furthermore, "listening to the other person with the heart" by being alert and giving the other person full attention 128 and also "being attentive to non-verbal cues" were among other important points regarding person-centered communication . 121Providing PCC was experienced as a learning process that delivered opportunities for personal and professional growth; for instance, attentive listening was undervalued by the staff at the start of the intervention and was described as actually doing nothing, but staff members later realized that attentive listening was indeed "doing something". 113uilding a trusting relationship by taking sufficient time, being attentive, and by keeping their promises 113 and confirming the individual as a person by calling him/her by name reinforced the sense of self. 120Furthermore, creating a sociable atmosphere enhanced the sense of connectedness and partnership. 113There were contexts in which missed opportunities for person-centered communication occurred; for instance: when the older person said something but the staff member ignored it and/or moved onto the next topic; when staff began and ended their interactions; when staff members told older people what to do without providing options or without inviting their help in completing the task; when staff did not ask for permission prior to performing an action; when staff members failed to acknowledge the older person's feelings, uncertainty, distress, discomfort, lack of confidence or self-deprecating emotions. 120any nursing records were incomplete and information regarding psychosocial aspects of care was often lacking, despite the fact that value was placed on documentation of the person's involvement in the health care processes, shared decision-making and care plan. 129The nursing documentation was not completed in partnership with the older people.Nevertheless, documentation focusing on the older person's beliefs and values was perceived as a factor promoting more meaningful relationships between nurses and older people. 129Formulating and documenting a tailored personal care plan through interdisciplinary cooperation minimized the overlapping of tasks.Digitalization may avoid such task overlap, facilitate the exchange of data with other professionals, reduce time-consuming tasks, and increase interdisciplinary cooperation. 111

Synthesis
A PCC perspective requires ethics as a basis for analysis and interpretation.Such an ethical view can briefly be formulated as follows: "Aiming at the good life with and for others, in just institutions". 34In health care, a significant part of the complex biology of human beings can be readily explained.However, in the case of old, ill and dependent people, tracing biological weakness in order to cure the disease -or at least alleviate inconvenience-through relevant treatment and care is not enough.There is also a clear need for knowledge about health and human existential dimensions as well as good and ethical care.Ricoeur is one of the philosophers who -through dialogical thinking-has tried to build a bridge between the two worlds of science (culture and nature) and helped to redefine science.Since PCC is based on an epistemology that includes these dimensions of the human being, we have used Ricoeur's ethics as a theoretical frame of reference in this paper in an attempt to describe important components published in scientific journals on PCC in the care of older people. 35ccordingly, the components of PCC from both quantitative and qualitative findings have been interpreted and synthesized according to Ricoeur's ethics.
Knowing and confirming the patient as a whole person and co-creating a tailored personal health plan PCC is not a 'one-size-fits-all' model, but it is about achieving 'practical wisdom' based on an apparent action ethic.Furthermore, PCC is a relation-based approach, which is about being attentive to diversity, knowing and confirming the patient as a whole person, and it thus aims to achieve a nuanced, tailored personal health plan that reinforces the older person's internal and external capabilities in practice.
Inter-professional teamwork and collaboration with and for the older person and significant others A person-centered inter-professional teamwork is characterized by efforts and processes that aim to include the patient as an equal person in the team and establish the basis for collaboration.Conducting a person-centered health plan involves "aiming at the good life with and for others" through a co-creation process between the professionals, the older person and often his/her relatives/significant others.These collaborative processes involve a professional friendship, mutual communication and ongoing shifting between closeness and distance.Neither the naturalistic objective-nor the humanistic subjective perspective alone can achieve person-centered practice.Hence, ongoing inter-professional team collaboration and co-creation between the inside and outside knowledge "with and for" the older person is essential for implementing PCC.

Building a person-centered foundation
Creating a person-centered foundation in all health care levels and processes is another crucial component, which -in practice-is a challenging ambition.Implementing PCC requires an appropriate "just institutions" foundation, where the opportunities of everyone (all staff, older people and their relatives) to take responsibility are reinforced, with the team members working in mutual respectful partnership, perceiving each other as experts and encouraging and improving each other's abilities.Confirming the older people as members of the team, knowing and supporting them with self-care, and endorsing their resources and capabilities are among the factors that create a proper foundation to implement PCC for older people.Other such factors include reinforcing their access to the health care system in an appropriate manner, time and place, and having a flexible organization based on trusting relationships and authentic engagement.

Discussion
Essential components for implementing PCC, which were confirmed in both the quantitative and the qualitative studies, included knowing the older patient as a person, building a relationship of trust, confirming and utilizing the person's resources, working in an interprofessional team with and for the older person, empowering the person and co-creating a tailored personal health plan with a focus on health promotion and preventive efforts and supporting the older person's opportunities for self-care.
Enhancing the person's capabilities and co-creation of an appropriate health plan with and for the older person were cornerstones for implementing PCC.However, some of the interventions focused on reaching specific goals or needs of the older people and did not involve mutual communication between the older people and the staff. 96,100Furthermore, the majority of these interventions focused on varied needs and impairments of the older people with chronic health conditions and the customization of specific services to older people. 82,87,92,95,96,101PCC should not only focus on the person's needs and impairment, but also on his/her resources and abilities and, furthermore, the health plan should be created in collaboration with the older personas well as with his/her relatives. 98ven though the target group in the present study were older people in general (65+), most of the included studies concerned people above 80 years.In 15 of the included studies, the participants were diagnosed with dementia in various stages from mild to moderate and severe, and in 32 studies the participants were living in nursing homes.It is well known that high age is a predictor for disability, frailty 130,131 and dementia 132,133 among the oldest old.However, it is likely that implementing the crucial components of PCC revealed from this review (see Table A1), will be valuable for all persons above 65 years including those with disability and cognitive impairment.For example using the life story approach enabled care staff to see and know the person behind the diagnosis and thereby to enhance PCC to the older persons and their families.It has also been shown to be more effective in preventing and managing behavioral and psychological symptoms of dementia. 134,135urthermore, implementing PCC in dementia care improved staff awareness and reduced stress.76À80,98 Abilities and capabilities are defined and redefined in different contexts, based on one's physical and non-physical resources, as well as problems and obstacles in relation to the environment. 136Frail older people face a constant challenge in creating harmony and balance in their everyday lives 137 despite comorbidity, disability and dependence.In this redefining process, person-centered team collaboration enables consultation between different professionals, supporting the frail older person to redefine themselves and their abilities in relation to the environment's resources and obstacles.A person-centered health plan should be created with and for the older person in the team.PCC based on an established and sustainable philosophy of ethics, originally conceived by Paul Ricoeur, is an appropriate solution.Aiming at a good life with and for older people requires collaboration and partnership, where everyone's expertise and knowledge is appreciated and recognized.In the same way, the older person's experience of illness and well-being must be recognized and valued in all health and care processes.
Raising awareness of the value of the engagement and the conflicts that will be present in the creation of a person-centered team is essential for creating a person-centered foundation for care.The person-centered health plan is the 'practical wisdom' that is co-created through team collaboration and partnership in a just foundation, where interpretation conflicts between inside and outside perspectives will encourage each other and drive the health care system from fragmented, reactive and task-oriented efforts towards a person-centered, proactive and coherent continuum of health care processes with and for older people.

Strengths and Limitations
The complexity of PCC and a lack of consensus regarding the definition of 'person-centered' leading to a wide variation in the implementation of PCC were among the factors that were challenging in choosing relevant search terms for this review.For instance, for person-centered care within some disciplines -for example, occupational therapy-the word 'care' is not used; the terms 'personcentered practice' or 'person-centered approach' are employed.However, the search for relevant studies for this review was performed on three occasions.In the first search, the terms used were as per Table 1; in the second, we used the same search terms but replaced 'care' with 'practice' and 'approach'; and the third and final search was conducted to update the latest published studies.This approach may reduce the reproducibility of the searching process.
However, the approach was unique in that it included a large range of definitions of person/patient/client-centered care/approaches and practice regarding older people in different communities, cultures and countries, which can also be considered a strength of this review.
Another strength of this review is that it includes studies that describe PCC from the point of view of older people, in addition to that of staff and stakeholders.Furthermore, the included studies have explored PCC from different perspectivesinter-personal and professional relationships, environmental considerations, the health care process and health care organization.
Another strength of this review is the application of a congruent ethic for approaching the review throughout all of the steps including choosing different search terms of PCC from diverse disciplines, including studies with qualitative and quantitative methods, and rigorous analysis of the data.Ricoeur's ethic was also chosen to synthesize the results in order to confirm and stress the importance of dialectical movement between different views about science that describe PCC from both natural/objective and cultural/subjective perspectives. 35This review emphasizes that, in order to understand and implement PCC, an intertwined web of sciences and knowledge is clearly required

Conclusion
Approaching interpersonal and inter-professional teamwork and consultation with a focus on preventive and health promoting actions is a crucial prerequisite to co-create optimal health care practice with and for older people and their relatives in their unique context.Awareness of the ethical basis of PCC facilitates the provision of genuine and collaborative care that is flexible and can be adapted by all health care professionals together with the older person and significant others.

Fig. 1 .
Fig. 1.Flow chart outlining the identification, screening, eligibility assessment and inclusion of studies.

Table 2
An overview of the content and components of person-centered care (PCC) implementation.