A Scoping Review of Health Promotion in the Nursing Home Setting

Tannys Helfer (1), Kathrin Sommerhalder (1), Jos M.G.A. Schols (2), Sabine Hahn (1)

About the authors:

1 Bern University of Applied Sciences, Department of Health Professions, Applied Research & Development in Nursing, Bern, Switzerland

2 Maastricht University, Caphri - School for Public Health and Primary Care, Department of Family Medicine and Department of Health Services Research, Maastricht, Netherlands

Abstract

Background Nursing homes in many countries continue to follow a traditional medical model of care. This study explored health promotion approaches in the nursing home setting, partly in order to move away from a medical model and to improve the well-being of residents and staff.

Methods A scoping study was conducted to review the scientific literature. The Integrated Model of Population Health and Health Promotion was adapted for utilization with the literature analysis.

Result A total of 64 publications met the inclusion criteria and were analysed. Five main approaches were shown to have applied health promotion in nursing homes, although gaps were present in the usage of systematically applied health promotion.

Conclusion A variety of approaches do exist for the nursing home setting which apply health promotion; however, their usage is fragmented. This study revealed that a framework designed to support nursing homes in the systematic usage of health promotion, could improve the well-being for both residents and staff.

Background

Globally, the population is aging at a rapid rate. According to Katz, “In 2000 there were 600 million older persons, triple the number of just 50 years earlier. By 2050 there will be 2 billion older adults” (1). Therefore, the well-being of older persons, including those residing in nursing homes (NHs), has become an common aim in health care systems of many countries, (2). Nevertheless, NHs in many westernized countries continue to follow or adapt a traditional medical model of care, which typically focuses on patient regimes, treating illness. and top-down decision making. NHs dominated by a medical model are more likely at risk of compromising basic human rights and liberties, such as the resident’s entitlement to independence, participation, care, self-fulfillment, and dignity (3).

The NH setting is complex and requires skilled and engaged workers. NH residents are often affected by multiple health challenges, particularly chronic diseases and/or cognitive difficulties, which frequently include dementia (4). In particular, well educated and experienced registered nurses and NH managers play a crucial role in the assurance of quality and safety for both the residents and other staff groups. Emphasis on the importance of their leadership qualities is increasing, as this affects the workplace environment and the health of nursing staff (5).

New and complementary approaches are necessary which meet the needs of both the residents and the nursing staff. Health promotion (HP), could potentially offer such an approach and thereby assist in improving the well-being of the NH residents and nursing staff. There are fundamental, key concepts which guide the planning and implementation of HP. These include the Ottawa Charter, which recommends the following HP action strategies: developing personal skills, creating supportive environments, strengthening community action, reorienting health services and building healthy public policy (6). Also included are the Social Determinants of Health, which are the social factors that affect peoples’ health. According to Harris & Grootjans (7), the most important external influencing factors affecting the health of older persons in the NH environment include governance, the physical environment as well as the social environment. The Ottawa Charter strategies are intended to target their actions on the Social Determinants of Health.

The World Health Organization (WHO) has specifically put forth a framework to assist in broadly addressing the issue of a growing aging population. As part of their framework, the WHO proposes the following Active Aging Determinants: culture, behaviour, personal factors, physical environment, social environment, economic characteristics as well as health and social care (8). Nevertheless, they are not entirely suitable for those residing in NHs. To address this deficit, it is proposed that meaningful leisure and participation be added to these already existing Active Aging Determinants (9).

In order to implement complementary approaches such as HP in the NH setting, it is first necessary to determine how it has been already applied. To the authors’ knowledge, no such overview exists, especially one examining which HP strategies have been integrated in NHs, which improve both the well-being of NH residents and the work environment for staff. Therefore, the first aim of this study is to provide this overview from the literature, describing how HP has been applied in the NH setting for both residents and staff. The second aim is to examine the extent in which HP has systematically been applied in the NH setting. This knowledge will reveal where progress has been made and where gaps still exist. In order to achieve these aims, the research questions to be examined are:

• Which approaches to HP in nursing homes are present in the literature (What has been done)?

• To what extent were the following key HP concepts systematically utilized: the Ottawa Charter action strategies, the Social Determinants of Health, and the active aging determinants (pertinent to NH residents)?

Methods

Scoping review design overview

To answer the the research questions, we have chosen a scoping review design because there appeared to be a paucity of literature which focused on current HP strategies and principles applied to the NH setting. Scoping studies are ideal to review complex areas (10) and to examine and summarize the extent, the range, the nature of research activity, and the findings (11). They offer an overview of the evidence, regardless of its quality, as they aim to map out and explore what evidence is available rather than only seek the best evidence. Therefore, they are very suitable for addressing the exploratory nature of our research questions (12). As a scoping review was conducted, the methodological quality of the included publications was not assessed. According to Arksey and O’Malley (10), the following six stage methodological framework should guide scoping studies: (1) identify the research question; (2) search for relevant publications; (3) select publications; (4) chart the data; (5) collate, summarize, and report the results; (6) consult with stakeholders to inform or validate study findings (optional). For the purpose of this study we omitted step 6, as our intention was to undertake an initial exploration of the literature.

Data collection and analysis

In alignment with step 2 of the scoping review methodology, relevant publications in accordance to our the research questions were searched for in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science databases. The inclusion criteria (see Table 1) consisted of publications which focused on HP in the NH setting from 2003 to 2020. This early time frame was chosen, because 2003 was when research focusing on assessing the living conditions for NH residents started to become more evident in the literature. Publications did not have to be labelled as utilizing HP; however, they did have to demonstrate usage of key HP strategies or concepts. MeSH terms and single text terms were combined for the literature search in the databases (see Table 1).

Table 1. Inclusion criteria and literature search terms

Table 1

Selection of publications

In accordance with step 3 of the scoping review methodology, relevant publications were selected (see Prisma Diagram – Figure 1 (13)). One author searched for and included all titles and abstracts which were congruent with the inclusion criteria. The total number of hits per database were as follows: Pub Med (267), CINAHL (168) and Web of Science (264). A total of 287 abstracts were identified for further analysis.

Figure 1. Prisma Flow Diagram. Diagram obtained from (13).

Figure 1

In the next step, these abstracts were reviewed by two authors. Upon analysis, 150 publications were excluded due to a clear lack of fit of the abstract with the inclusion criteria. In total, 137 publications remained and were retrieved to undergo further analysis of the full text (with the same authors as the abstract reviews). After this last step of analysing the full text, 64 publications remained and were included in this scoping review. The other 73 publications were excluded either because their main focus was not on the NH setting, or because upon further analysis, a lack of fit with the inclusion criteria became apparent.

Data Extraction and Documentation in Accordance to Structured Protocol

In order to chart the data as per step 4 of the scoping review methodology, key information from each publication concerning the two research questions was individually extracted and documented. This was undertaken according to a structured protocol (see Figure 2), which is based upon an internationally recognized tool in HP practice. This tool, the Integrated Model of Population Health and Health Promotion (14), is designed for assisting with program development and implementation among the general population. It includes the following three aspects: the Ottawa Charter action strategies, the Determinants of Health and the Population Health Levels. The Population Health Levels refer to with whom or at which level actions are focused upon: individual, family, community, sector/system and/or society.

Figure 2. The Adapted Integrated Model of Population Health and Health Promotion. Adapted by the authors. Based on (14).

Figure 2

For the purposes of this study, the Integrated Model of Population Health and Health Promotion (13;14) was adapted a-priori to data collection. The Ottawa Charter and the population health levels were not altered; however, we replaced the Determinants of Health with the Social Determinants of Health, as the social environment in which NH residents live in determines their health more than the Determinants of Health. As Social Determinants of Health specific to NH residents are, to the authors’ knowledge, not available in the literature, we based them upon what NH residents reported as being the most important external influencing factors to their health in the NH environment: governance, physical environment, social environment (7). The active aging determinants were also included as a Social Determinant of Health due to their influence on well-being for older persons (8;9). No pilot testing of the protocol was undertaken due to the exploratory nature of this study.

One author completed data extraction in accordance to the research questions, utilizing the structured protocol (see Figure 2). Another author was consulted when a second opinion was deemed necessary. First, it was determined which Ottawa Charter action strategies were utilized. Second, it was ascertained which population health levels within the Ottawa Charter action strategies were focused upon. Third, it was determined which Social Determinants of Health each publication was centered upon. The synthesis of these assessments revealed to what extent (no usage to strong usage) HP had been applied in each of the publications. In accordance with optimal HP practice, an approach is considered to be more and comprehensive when it targets multiple Ottawa Charter action strategies at as many levels as possible, and when it focuses its actions on the Social Determinants of Health.

Results

Due to the exploratory nature of this study and the methodology of a scoping review, the focus of the included 64 publications was broad. Inclusion of this wide range of publications was undertaken in order to gain an overview of how and the extent in which HP has been applied in the NH setting for both residents and staff. However, many publications included in this study were based upon expert opinions or were discussion papers, and fewer publications utilized rigorous methodologies. The publications in this study were not examined for their quality or chosen methodology, as per scoping review methodology.

In accordance to step 5 and to answer the research questions, the included 64 publications were thematically categorized into five approaches according to the main contents of the studies. This categorization also assisted in bringing clarity and organization to the study.

Approaches to HP in nursing homes utilized in the literature

In the literature, Creating Ecological and Comprehensive Settings, Improving Quality of Life for Nursing Home Residents, Offering Person-Centered Care, Offering Relationship-Centered Care , and Activities Focusing on Workplace Health Promotion, were identified as relevant approaches to fostering HP for residents and staff in the NH setting. In Offering Person-Centered Care, we have made further sub-categories, in order to aid in the understanding of this many-sided approach (see Table 2 for their brief description).

Table 2. Approaches and sub-categories applying health promotion in nursing homes

Table 2

Some conceptual overlap is present among the approaches, as HP is multifaceted and does intersect with many other concepts and practices in health care. However, each article was categorized according to its main focus (see Table 3).

Table 3. Approach and main focus of the included publications

Table 3a Table 3b Table 3c Table 3d Table 3e Table 3f Table 3g

In the Creating Ecological and Comprehensive Settings approach, four articles offered various perspectives as to how this approach could be integrated into NHs, and why it is especially suited for this setting (5;7;15;16). In the Improving Quality of Life for Nursing Home Residents approach, eight articles explored how this approach could be applied to NHs, as follows: via exploring the subjective perspectives of residents (3;17;18), through theories (9;19;20) and models (21;22), and through integration of aspects of residents’ spirituality (23).

Offering Person-Centered Care is a further approach facilitating moving away from a medical model towards promoting the health and well-being of NH residents and staff (24). Many publications were present for this approach, and they were focused on the following topics: its core concepts (25;26), promotion of a supportive environment (27-30), leadership and nursing competencies (31), the participation and empowerment of staff (32) and residents (33;34), evaluation (35-40), as well as design of spaces (41). The Culture Change Movement (CCM) (35;42-49), was organized as a sub-category of the Offering of Person-Centered Care (see Table 2). It was operationalized through specific models and programs such as the Eden Alternative (50;51), the Green House Model (52-54), the Well Spring Model (55), the HAtch Model (49), the Live Oak Regenerative Community (56), and the Pioneer Network (49).

Offering Relationship-Centered Care Approach has been considered as an alternative to the Person-Centered Care Approach, and this perspective was discussed in three publications (57-59). In 15 publications, activities focusing on Workplace Health Promotion in NHs were focused on through: leadership and management (60-62), empowerment strategies (63-65), quality improvement processes (66-69), examination of workplace stressors (70), and HP programs for staff (71-74).

Extent of health promotion systematically applied in nursing homes

In the previous section, the research question of how HP has been applied in the NH setting in the literature was examined through categorization of the included publications into five main approaches. In this section, the research question of the extent to which HP has systematically been applied in the NH setting, will be explored (see Figure 3).

Figure 3. Summary and categorization of included articles

Figure 3a Figure 3b Figure 3c

Ottawa Charter Action Strategies and population health levels

All Ottawa Charter action strategies were focused upon in the Ecological Approach and Comprehensive Settings Approach (see Figure 3). The two Ottawa Charter action strategies of creating a supportive environment and on re-orienting health services were strongly targeted in all of the approaches. The strategy of developing personal skills was minimally to moderately focused upon in all of the approaches. Strengthening community action was very minimally utilized with four of the five approaches, except for with the Ecological Approach and Comprehensive Settings Approach, which had a strong utilization of it. Building healthy public policy was either minimally or not focused on at all within all of the approaches. Utilization of the population health levels within the broader Ottawa Charter action strategies revealed that each approach predominately focused on the levels of the NH, the sector/system as well as the societal levels.

These results demonstrated the unity of all the approaches in their targeting of the Ottawa Charter action strategies of creating a supportive environment and of re-orienting health services. Significant gaps were present in the utilization of strengthening community action and building upon healthy public policy. Another gap present was with the population health level at the family level.

Social Determinants of Health

The Social Determinant of Health of the social environment was focused upon in all of the approaches. Governance was also focused on with all of the approaches, except for with the Activities Focusing on WHP, in which there was minimal usage of it. The physical environment was also targeted upon in all of the approaches, although the Offering Relationship-Centered Care utilized it minimally. The active aging determinants were only targeted in the QoL Approach.

These results highlight that even though they did not label their focus as being on a Social Determinant of Health, they did clearly target their efforts on the social environment and on governance. Most of the approaches also focused on the physical environment. In contrast, the Active Aging Determinants were only targeted in one of the approaches.

Discussion

This paper aimed to provide an overview of the literature, in order to address the research gap of a lack of information regarding HP strategies utilized in the NH setting. It focuses on examining which HP approaches exist in the NH setting, along with the extent HP has been systematically applied. In this paper, conceptual overlap was present among the approaches themselves and within the concepts of HP which were discussed, as HP intersects with many other concepts in health care. Based on 64 publications, five approaches have been identified. The publications within the approaches provide valuable insight as to the wide variety of ways in which HP has already been applied in the NH setting, with both residents and staff. In the earlier literature, both groups were seldom united into one initative. However, in the last 4 years, this has started to become more evident (24;67). This is very important, as the well-being of both the residents and staff in NHs are interrelated and greatly influence one another. Additionally, it also became evident that in many of the publications, HP was neither labelled nor recognized as being a part of the study. Even though programs or interventions were being implemented which were often directly related to HP practice, there was often no mention of it being HP. This has also started to slowly change in the more recent literature (22), especially in regard to workplace HP initiatives for staff. It was also revealed, that program or model development and delivery has generally been fragmented and applied unsystematically in the NH setting (34). However, use of the adapted structured protocol, enabled us to identify both strengths and areas for improvement within the approaches.

Strengths of the approaches in their application of health promotion in nursing homes

A major strength of the approaches is their strong focus on the Ottawa Charter action strategies of creating a supportive environment and of re-orienting health services, and is congruent with recommendations from major policy documents (75-78). The emphasis on these two action strategies clearly demonstrates the importance of changing the social and physical environment along with the accompanying policies, in order to make the transition from a medical model to a more age-friendly philosophy (e.g., the CCM). Additionally, a strength was the approaches moderate focus on developing personal skills. This was targeted, for example, with the empowerment, participation and skill building of care-workers, along with emphasis on empowering and participative leadership practices in the NH setting. Participation and empowerment are very important in HP practice when supporting individuals and groups with the development of their skills, as well as when promoting a healthy workplace.

The population health levels were predominately focused on at the sector/system and the societal levels. For example, with the Offering of Person-Centered Care, the multiple models and ideas have slowly progressed as a movement aiming for improvements in NHs at national levels. The very strong focus on the Social Determinants of Health of the social environment, governance, as well as the physical environment, indicate the important influence and significance that they have in improving the well-being of the residents and staff. Residents spend the vast majority of their time in the NH environment and their well-being is greatly affected by their social and physical environment, along with the governing policies of the NH. Therefore, NH residents are very vulnerable to any deficits in these areas. Staff are also vulnerable to them, as it is the policies of NHs which influence their daily operations and work culture.

Areas for improvement of the approaches in their application of health promotion in nursing homes

Significant areas for improvement among the approaches were, however, present in the utilization of two Ottawa Charter action strategies: strengthening community action and building upon healthy public policy. There was very little planning or acknowledgement given to the importance of integration of the NH with its surrounding community, citizens, and other generations (e.g. sharing of community gardens with NHs, activities for the very young and the very old together, suitable sidewalks and transportation for older persons). NHs targeting their efforts towards the formation of close-relationships are likely to make positive differences in the the social integration, social connectedness, and health outcomes of NH residents, and also thereby improve the quality of care being delivered (22;79). Utilization of existing frameworks which have been designed for the NH setting, such as those focusing on meaningful leisure and participation (9), could assist in increasing residents’ social inclusion with their surrounding communities.

A further area for improvement with three of the approaches, was with actions directed at the population health level of family. This lack of focus indicates that although much has been done in recent years, involvement and integration of the family is still not very visible in the NH setting. Especially when aiming to promote residents’ well-being, the establishment of close relationships with residents’ family members is very important (79).

One of the Social Determinants of Health, the active aging determinants, was only targeted in one approach. This is likely because it was designed for older persons in the community setting, and has only been recently proposed as being applicable to older persons in the NH setting (9). As recommended, activities which promote meaningful leisure and participation are especially important for NH residents (9), and could occur through participation with their surrounding community. The promotion of activities which are decided upon by the residents, could for example, be an easy-to-implement action.

Strengths and limitations

This scoping review focused on the analysis of approaches in the NH setting, utilizing a structured protocol, which allowed for extraction, documentation and synthesis of the data. To our knowledge, such a synthesis of systematic HP in the NH setting has not been done before, and it provided a unique lens through which to view the current situation. A major strength of this study is that it offers a comprehensive and systematic synthesis of the ways and extent in which HP has been applied. It considers both staff and residents, which is crucial, as they greatly influence one another, and should therefore be viewed together.

A limitation of this paper is that the Social Determinants of Health that apply specifically to residents in NHs are unknown; therefore, the Integrated Model of Population Health and HP framework had to be adapted. Another limitation is that, due to the study’s broad focus and chosen methodology, this paper serves as an overview. Less focus was placed on the quality of the included publications, and expert opinions and pilot projects were also included, in order to provide an comprehensive overview of the literature. Additionally, it included English publications and those in German with English abstracts, which could be viewed as a potential limitation.

Challenges specific to the nursing home setting

The underlying aim of the five main approaches which were extracted from this study, was to improve the living conditions for NH residents and/or the working conditions for staff. It is well-known that the working conditions in NHs are sub-optimal due to staff shortages, inadequate levels of registered nurses, high workload, and a high rate of dementia among the residents (80), along with staff retention and turnover issues (81). Older persons are frequently afflicted with chronic diseases and cognitive challenges, which can trigger admission to a NH (4). Staff must have adequate medical knowledge, along with expertise, regarding how to best care for residents with such health challenges in order to provide optimal care. Working in a NH setting is considered by some staff to be more stressful than in the acute care setting (5).

Other challenges are also prevalent in the NH setting. Front-line workers such as certified nursing assistants and other care-aides, consist of over half of the workforce (70). Issues present for care-workers in the NH environment include heavy workload, psychological stress due to high demand and low control (73;74), being undervalued by management and a shortage of necessary resources (82). Health problems such as poor mental health, musculoskeletal dysfunctions along with cardiovascular disease, can then occur (71). These issues also contribute to the well-documented high turnover rate (71). The factors most associated with strong job satisfaction in Swiss NH care-workers were reported as: “NH leadership, teamwork and safety climate, the resonance of the NH administrator, workers’ perceptions of staffing adequacy, (less) workplace conflicts and (fewer) health complaints” (83). Leadership at both the supervisor and executive administrator level was viewed as being the most important factor for job satisfaction (83).

Registered nurses along with team/middle managers also face particular challenges in the nursing home environment. Besides the medical knowledge necessary to care for complex residents, the following themes an expert nurse requires in the NH setting were proposed as: context of the NH, knowing the NH resident, transitions, moral agency, saliency, holistic knowledge, and skills/know-how (84). Further, due to the effect management has on employees’ health and well-being, leadership development is viewed as being especially important in NHs (71). Leadership style along with supportive management, through increasing care-worker participation, empowerment, and influence, can increase the quality of care that is provided to residents (85).

The studies analysed, in general, did not direct their focus on the discussion of these challenges; rather they were mostly focused on strategies to alleviate them. However, it is important to place emphasis on these challenges when examining how HP could be systematically utilized, in order to improve the living conditions for NH residents and the working conditions for staff. Many aspects of a medical model remain vital in ensuring that residents’ often complex physical and psychological requirements can be met. Strong leadership is also necessary to support the team in the meeting of residents’ needs.

Why health promotion in the nursing home setting… and how?

As discussed in the previous section, there are many issues present in NHs. HP practice often focuses on the workplace setting, and as such, can have a major impact upon the workers’ well-being (14). This study reveals that a variety of approaches and practices do exist which at least partially apply HP in the NH setting, and that more recognition is recently being given to HP for both residents and staff. For example, in the past five years in Germany, a federal directive has been given to develop a quality concept focusing on improving the effectiveness and sustainability of HP and prevention in long-term care settings (67). Some Workplace HP programs are also tackling the complexity of the NH setting, by moving beyond behavioral changes with the staff, to integrating organizational-level changes (73;74). Evaluation has also recently become more evident in the research, as with the first national US study assessing the adoption of Culture Change in NHs (37). More specific implementation evaluation has also occurred with Person-Centered Care approach (36). However, with the exception of some recent advancements as well as examples in the Offering Person-Centered Care, many initiatives are lacking a systematic approach. This is especially evident in regard to the systematic application of HP. Therefore, an important research implication regarding these findings, is that more studies are necessary which focus on the implementation and evaluation of systematic HP approaches in NHs.

In order to promote more sustainable and efficient use of resources among NHs, we recommend the development of a framework depicting how to systematically utilize HP in the NH setting. It is important that the Ottawa Charter action strategies and the Social Determinants of Health be components in this framework, as they are key to the comprehensive and systematic guiding of HP practice. The development of such a HP framework for the NH setting could be supported by examples of HP initiatives which already exist in other settings (e.g. health promoting schools, health promoting hospitals, etc.) (86). Additionally, our study identified that the Ecological Settings Approach has been specifically applied to the NH setting via the development of a framework (7). In Austria, a comprehensive HP pilot project was also implemented (5). Additionally, the WHO Active Aging Determinants offer valuable recommendations for the NH setting (9). These resources, together with initiatives from other settings, could assist in the development of a framework focusing on the implemention of systematic HP specifically for NHs.

Conclusions

Complementary approaches which meet the needs of both the residents and the nursing staff are needed in NHs. This scoping review provided a new way of viewing HP in the NH setting. Through the systematic use of key HP concepts (a combination of the Ottawa Charter action strategies, the targeted Population Health Levels and the Social Determinants of Health), it was revealed how HP has most often been applied in NHs. It is now more apparent where progress has been made and where gaps still exist, in the implementation of HP in this setting. As an additional step, it is proposed that HP be used more systematically in order to continue to improve the well-being for both the residents and the staff in NHs. Importantly, HP is ideal for connecting resources and settings together, for example, by linking NHs together and facilitating in the sharing of resources and knowledge within a city or a region. At local levels as well as at national and international levels, more sustainable and effective ways of delivering care in the NH setting are needed, especially with the ever-increasing number of older persons in society. Systematically applied HP offers much potiential for improving the well-being of both residents and staff, and could greatly contribute to the ongoing progress being made in this setting.

Acknowledgements

Financial support from the Bern University of Applied Sciences, Department of Health Professions, Applied Research & Development in Nursing, is kindly acknowledged.

Contributors: Conception and design of the study: TH, KS. Acquisition of data: TH, KS. Analysis and interpretation data: TH, KS, SH. Drafting the article: TH, KS, SH, JMGAS. Revisions and final approval of the article: TH, KS, SH, JMGAS.

Competing interests: None declared.

Funding: This research was financed by the Bern University of Applied Sciences, Department of Health Professions, Division of Nursing, Switzerland.

Patient content: Not applicable.

Ethics approval: Not applicable.

Availability of data and materials: All data generated or analysed during this study are included in this published article.

References

(1) Katz PR. An International Perspective on Long Term Care: Focus on Nursing Homes. J Am Med Dir Assoc. 2011;12:487-492.e1. doi:10.1016/j.jamda.2011.01.017.

(2) Kane RL, Rockwood T, Hyer K, et al. Rating the Importance of Nursing Home Residents’ Quality of Life. J Am Geriatr Soc. 2005;53:2076-82. doi:10.1111/j.1532-5415.2005.00493.x.

(3) Brownie S, Horstmanshof L. Creating the Conditions for Self-Fulfilment for Aged Care Residents. Nurs Ethics. 2012;19:777-86. doi:10.1177/0969733011423292.

(4) Abumaria IM, Hastings-Tolsma M, Sakraida TJ. Levine’s Conservation Model: A Framework for Advanced Gerontology Nursing Practice. Nurs Forum. 2015;50:179-88. doi:10.1111/nuf.12077.

(5) Krajic K, Cichocki M, Quehenberger V. Health-Promoting Residential Aged Care: A Pilot Project in Austria. Health Promot Int. 2015;30:769-81. doi:10.1093/heapro/dau012.

(6) Government of Canada. Ottawa Charter for Health Promotion: An International Conference on Health Promotion 2012.09.14. [Available from: https://www.canada.ca/en/public-health/services/health-promotion/population-health/ottawa-charter-health-promotion-international-conference-on-health-promotion.html].

(7) Harris N, Grootjans J. The Application of Ecological Thinking to Better Understand the Needs of Communities of Older People. Australas J Ageing. 2012;31:17-21. doi:10.1111/j.1741-6612.2010.00501.x

(8) WHO. Active Ageing: A Policy Framework. 2002. [Available from: https://www.who.int/ageing/publications/active_ageing/en/].

(9) Van Malderen L, Mets T, De Vriendt P, Gorus E. The Active Ageing–Concept Translated to the Residential Long-Term Care. Qual Life Res. 2013;22:929-37. doi:10.1007/s11136-012-0216-5.

(10) Arksey H, O’Malley L. Scoping Studies: Towards a Methodological Framework. Int. J. Soc. Res. Methodol. 2005;8:19-32. doi:10.1080/1364557032000119616.

(11) Levac D, Colquhoun H, O’Brien K. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. doi:10.1186/1748-5908-5-69.

(12) The Joanna Briggs Institute. The Joanna Briggs Institute Reviewers’ Manual 2015 Methodology for JBI Scoping Reviews. The University of Adelaide, South Australia: The Joanna Briggs Institute 2015.

(13) Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6:e1000097. doi:10.1371/journal.pmed.1000097.

(14) Public Health Agency of Canada. Population Health Promotion: An Integrated Model of Population Health and Health Promotion. 1996. [Available from: https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-promotion-integrated-model-population-health-health-promotion.html].

(15) Harris N, Grootjans J, Wenham K. Ecological Aging: The Settings Approach in Aged Living and Care Accommodation. EcoHealth. 2008;5:196-204. doi:10.1007/s10393-008-0176-y.

(16) Wahl H-W, Iwarsson S, Oswald F. Aging Well and the Environment: Toward an Integrative Model and Research Agenda for the Future. Gerontologist. 2012;52:306-16. doi:10.1093/geront/gnr154.

(17) Bradshaw SA, Playfore ED, Riazi A. Living Well in Care Homes: A Systematic Review of Qualitative Studies. Age Ageing. 2012;41:429-40. doi:10.1093/ageing/afs069.

(18) Kane RA, Kling KC, Bershadsky B, et al. Quality of Life Measures for Nursing Home Residents. J Gerontol A Biol Sci Med Sci. 2003;58:240-8. doi:10.1093/gerona/58.3.m240.

(19) Gerritsen DL, Steverink N, Ooms ME, Ribbe MW. Finding a Useful Conceptual Basis for Enhancing the Quality of Life of Nursing Home Residents. Qual Life Res. 2004;13:611-24. doi:10.1023/B:QURE.0000021314.17605.40.

(20) Van Malderen L, Mets T, Gorus E. Interventions to Enhance the Quality of Life of Older People in Residential Long-Term Care: A Systematic Review. Ageing Res Rev. 2013;12:141-50. doi:10.1016/j.arr.2012.03.007.

(21) Zubritsky C, Abbott KM, Hirschman KB, Bowles KH, Foust JB, Naylor MD. Health-Related Quality of Life: Expanding a Conceptual Framework to Include Older Adults Who Receive Long-Term Services and Supports. Gerontologist. 2013;53:205-10. doi:10.1093/geront/gns093.

(22) Rinnan E, Andre B, Drageset J, Garasen H, Espnes GA, Haugan G. Joy of Life in Nursing Homes: A Qualitative Study of What Constitutes the Essence of Joy of Life in Elderly Individuals Living in Norwegian Nursing Homes. Scand J Caring Sci. 2018;32:1468-76. doi:10.1111/scs.12598.

(23) Haugan G, Moksnes UK, Lohre A. Intrapersonal Self-Transcendence, Meaning-in-Life and Nurse-Patient Interaction: Powerful Assets for Quality of Life in Cognitively Intact Nursing-Home Patients. Scand J Caring Sci. 2016;30:790-801. doi:10.1111/scs.12307.

(24) Vassbø TK, Kirkevold M, Edvardsson D, Sjögren K, Lood Q, Bergland Å. The Meaning of Working in a Person-Centred Way in Nursing Homes: A Phenomenological-Hermeneutical Study. BMC Nurs. 2019;18:45. doi:10.1186/s12912-019-0372-9.

(25) McCormack B, Roberts T, Meyer J, Morgan D, Boscart V. Appreciating the ‘Person’ in Long-Term Care. Int J Older People Nurs. 2012;7:284-94. doi:10.1111/j.1748-3743.2012.00342.x.

(26) McCormack B. Person-Centredness in Gerontological Nursing: An Overview of the Literature. J Clin Nurs. 2004;13:31-8. doi:10.1111/j.1365-2702.2004.00924.x.

(27) McCormack B, Dewing J, Breslin L, et al. Developing Person-Centred Practice: Nursing Outcomes Arising From Changes to the Care Environment in Residential Settings for Older People. Int J Older People Nurs. 2010;5:93-107. doi:10.1111/j.1748-3743.2010.00216.x.

(28) Boscart VM, Sidani S, Ploeg J, et al. Neighbourhood Team Development to Promote Resident Centred Approaches in Nursing Homes: A Protocol for a Multi Component Intervention. BMC Health Serv Res. 2019;19:922. doi:10.1186/s12913-019-4747-0.

(29) Sjogren K, Lindkvist M, Sandman PO, Zingmark K, Edvardsson D. To What Extent Is the Work Environment of Staff Related to Person-Centred Care? a Cross-Sectional Study of Residential Aged Care. J Clin Nurs. 2014;24:1310-9. doi:10.1111/jocn.12734.

(30) Siegel EO. Supporting and Promoting Personhood in Long Term Care Settings: Contextual Factors. Int J Older People Nurs. 2012;7:295-302. doi:10.1111/opn.12009.

(31) Mueller C, Burger S, Rader J, Carter D. Nurse Competencies for Person-Directed Care in Nursing Homes. Geriatr Nurs. 2012;34:101-4. doi:10.1016/j.gerinurse.2012.09.009.

(32) Coleman CK, Medvene LJ, Van Haitsma K. A Person-Centered Care Intervention for Geriatric Certified Nursing Assistants. Gerontologist. 2013;53:687-98. doi:10.1093/geront/gns135.

(33) Shura R, Siders RA, Dannefer D. Culture Change in Long-Term Care: Participatory Action Research and the Role of the Resident. Gerontologist. 2011;51:212-25. doi:10.1093/geront/gnq099.

(34) Perry L, Bellchambers H, Howie A, et al. Examination of the Utility of the Promoting Action on Research Implementation in Health Services Framework for Implementation of Evidence Based Practice in Residential Aged Care Settings. J Adv Nurs. 2011;67:2139-50. doi:10.1111/j.1365-2648.2011.05655.x.

(35) Brownie S, Nancarrow S. Effects of Person-Centered Care on Residents and Staff in Aged-Care Facilities: A Systematic Review. Clin Interv Aging. 2013;8:1-10. doi:10.2147/CIA.S38589.

(36) Cornelison LJ, Hermer L, Syme ML, Doll G. Initiating Aha Moments When Implementing Person-Centered Care in Nursing Homes: A Multi-Arm, Pre-Post Intervention. BMC Geriatr. 2019;19:115. doi:10.1186/s12877-019-1121-3.

(37) Lima JC, Schwartz ML, Clark MA, Miller SC. The Changing Adoption of Culture Change Practices in U.S. Nursing Homes. Innov Aging. 2020;4:igaa012. doi:10.1093/geroni/igaa012.

(38) Edvardsson D, Backman A, Bergland Å, et al. The Umeå Ageing and Health Research Programme (U-Age): Exploring Person-Centred Care and Health-Promoting Living Conditions for an Ageing Population. Nord J Nurs Res. 2016;36:168-74. doi:10.1177/2057158516645705.

(39) White DL, Newton-Curtis L, Lyons KS. Development and Initial Testing of a Measure of Person-Directed Care. Gerontologist. 2008;48:114-23. doi:10.1093/geront/48.supplement_1.114.

(40) Edvardsson D, Innes A. Measuring Person-Centered Care: A Critical Comparative Review of Published Tools. Gerontologist. 2010;50:834-46. doi:10.1093/geront/gnq047.

(41) Pomeroy SH, Scherer Y, Runkawatt V, Iamsumang W, Lindemann J, Resnick B. Person-Environment Fit and Functioning Among Older Adults in a Long-Term Care Setting. Geriatr Nurs. 2011;32:368-78. doi: 10.1016/j.gerinurse.2011.07.002.

(42) Brune K. Culture Change in Long Term Care Services: Eden-Greenhouse-Aging in the Community. Educ Gerontol. 2011;37:506-25. doi:10.1080/03601277.2011.570206.

(43) Hartmann CW, Snow AL, Allen RS, Parmelee PA, Palmer JA, Berlowitz D. A Conceptual Model for Culture Change Evaluation in Nursing Homes. Geriatr Nurs. 2013;34:388-94. doi:10.1016/j.gerinurse.2013.05.008.

(44) White-Chu EF, Graves WJ, Godfrey SM, Bonner A, Sloane P. Beyond the Medical Model: The Culture Change Revolution in Long-Term Care. J Am Med Dir Assoc. 2009;10:370-8. doi:10.1016/j.jamda.2009.04.004.

(45) Rahman AN, Schnelle JF. The Nursing Home Culture-Change Movement: Recent Past, Present, and Future Directions for Research. Gerontologist. 2008;48:142-8. doi:10.1093/geront/48.2.142.

(46) Hill NL, Kolanowski AM, Milone-Nuzzo P, Yevchak A. Culture Change Models and Resident Health Outcomes in Long-Term Care. J Nurs Scholarsh. 2011;43:30-40. doi:10.1111/j.1547-5069.2010.01379.x.

(47) Miller SC, Miller EA, Jung HY, Sterns S, Clark M, Mor V. Nursing Home Organizational Change: The ”Culture Change” Movement as Viewed by Long-Term Care Specialists. Med Care Res Rev. 2010;67:65S-81S. doi:10.1177/1077558710366862.

(48) Koren MJ. Person-Centered Care for Nursing Home Residents: The Culture-Change Movement. Health Aff (Millwood). 2010;29:312-7. doi:10.1377/hlthaff.2009.0966.

(49) Jones CS. Person-Centered Care. The Heart of Culture Change. J Gerontol Nurs. 2011;37:18-23. doi:10.3928/00989134-20110302-04.

(50) Petersen M, Warbuton J. The Eden Model: Innovation in Australian Aged Care? Australas J Ageing. 2010;29:126-9. doi:10.1111/j.1741-6612.2010.00419.x.

(51) Monkhouse C. Beyond the Medical Model - the Eden Alternative in Practice: A Swiss Experience. Journal of Social Work in Long-Term Care. 2003;2:339-53. doi:10.1300/J181v02n03_11.

(52) Ragsdale V, McDougall GJ, Jr. The Changing Face of Long-Term Care: Looking at the Past Decade. Issues Ment Health Nurs. 2008;29:992-1001. doi:10.1080/01612840802274818.

(53) Zimmerman S, Bowers BJ, Cohen LW, Grabowski DC, Horn SD, Kemper P. New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research. Health Serv Res. 2016;51:475-96. doi:10.1111/1475-6773.12430.

(54) Rabig J, Thomas W, Kane RA, Cutler LJ, McAlilly S. Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi. Gerontologist. 2006;46:533-9. doi:10.1093/geront/46.4.533.

(55) Kehoe MA, Van Heesch B. Culture Change in Long Term Care: The Wellspring Model. Journal of Social Work in Long-Term Care. 2003;2:159-73. doi:org/10.1300/J181v02n01_11.

(56) Barkan B. The Live Oak Regenerative Community: Championing a Culture of Hope and Meaning. Journal of Social Work in Long-Term Care. 2003;2:197-221. doi:10.1300/J181v02n01_14.

(57) Nolan MR, Davies S, Brown J, Keady J, Nolan J. Beyond Person-Centred Care: A New Vision for Gerontological Nursing. J Clin Nurs. 2004;13:45-53. doi: 10.1111/j.1365-2702.2004.00926.x.

(58) Wilson CB, Davies S. Developing Relationships in Long Term Care Environments: The Contribution of Staff. J Clin Nurs. 2008;18:1746–55. doi:10.1111/j.1365-2702.2008.02748.x.

(59) Wilson CB. Developing Community in Care Homes Through a Relationship-Centred Approach. Health Soc Care Community. 2009;17:177-86. doi:10.1111/j.1365-2524.2008.00815.x.

(60) Jeon YH, Simpson JM, Chenoweth L, Cunich M, Kendig H. The Effectiveness of an Aged Care Specific Leadership and Management Program on Workforce, Work Environment, and Care Quality Outcomes: Design of a Cluster Randomised Controlled Trial. Implement Sci. 2013;8:126. doi:10.1186/1748-5908-8-126.

(61) Tellis-Nayak V. A Person-Centered Workplace: The Foundation for Person-Centered Caregiving in Long-Term Care. J Am Med Dir Assoc. 2007;8:46-54. doi:10.1016/j.jamda.2006.09.009.

(62) Toles M, Anderson RA. State of the Science: Relationship-Oriented Management Practices in Nursing Homes. Nurs Outlook. 2011;59:221-7. doi:10.1016/j.outlook.2011.05.001.

(63) Engström M, Wadensten B, Häggström E. Caregivers’ Job Satisfaction and Empowerment Before and After an Intervention Focused on Caregiver Empowerment. J Nurs Manag. 2010;18:14-23. doi:10.1111/j.1365-2834.2009.01047.x.

(64) Barry T, Brannon D, Mor V. Nurse Aide Empowerment Strategies and Staff Stability: Effects on Nursing Home Resident Outcomes. Gerontologist. 2005;45:309-17. doi:10.1093/geront/45.3.309.

(65) Petterson IL, Donnersvärd HÅ, Lagerström M, Toomingas A. Evaluation of an Intervention Programme Based on Empowerment for Eldercare Nursing Staff. Work & Stress. 2006;20:353-69. doi:10.1080/02678370601070489.

(66) Zimber A, Gregersen S, Kuhnert S, Nienhaus A. Betriebliche Gesundheitsförderung durch Personalentwicklung Teil I: Entwicklung und Evaluation eines Qualifizierungsprogramms zur Prävention psychischer Belastungen. Gesundheitswesen. 2010;72:209-15. doi: 10.1055/s-0029-1214403.

(67) Tempelmann A, Kolpatzik K, Ehrenreich H, Stroing M, Hans C. Quality Prevention and Health Promotion Programming in Long-Termcare: The Qualipep Project. Bundesgesundheitsblatt-Gesund. 2019;62:296-303. doi: 10.1007/s00103-019-02910-4.

(68) Rosen J, Mittal V, Degenholtz H, et al. Organizational Change and Quality Improvement in Nursing Homes: Approaching Success. J Healthc Qual. 2005;27:6-14. doi: 10.1111/j.1945-1474.2005.tb00583.x.

(69) Gregersen S, Zimber A, Kuhnert S, Nienhaus A. Betriebliche Gesundheitsförderung durch Personalentwicklung Teil II: Praxistransfer eines Qualifizierungsprogramms zur Prävention psychischer Belastungen. Gesundheitswesen. 2010;72:216-21. doi:10.1055/s-0029-1215559.

(70) Miranda H, Gore RJ, Boyer J, Nobrega S, Punnett L. Health Behaviors and Overweight in Nursing Home Employees: Contribution of Workplace Stressors and Implications for Worksite Health Promotion. ScientificWorldJournal. 2015. doi:10.1155/2015/915359.

(71) Zhang Y, Flum M, Kotejoshyer R, Fleishman J, Henning R, Punnett L. Workplace Participatory Occupational Health/Health Promotion Program: Facilitators and Barriers Observed in Three Nursing Homes. J Gerontol Nurs. 2016;42:34-42. doi: 10.3928/00989134-20160308-03.

(72) Otto AK, Pietschmann J, Appelles LM, et al. Physical Activity and Health Promotion for Nursing Staff in Elderly Care: A Study Protocol for a Randomised Controlled Trial. BMJ Open. 2020;10:e038202. doi:10.1136/bmjopen-2020-038202.

(73) Syed IUB. Diet, Physical Activity, and Emotional Health: What Works, What Doesn’t, and Why We Need Integrated Solutions for Total Worker Health. BMC Public Health. 2020;20:152. doi: 10.1186/s12889-020-8288-6.

(74) Kernan G, Cifuentes M, Gore R, Kriebel D, Punnett L. A Corporate Wellness Program and Nursing Home Employees’ Health. Front Public Health. 2020;8 :531116. doi:10.3389/fpubh.2020.531116.

(75) WHO. Governance for health in the 21st century. 2012. [Available from: https://www.euro.who.int/en/publications/abstracts/governance-for-health-in-the-21st-century].

(76) WHO. Strategy and action plan for healthy ageing in Europe, 2012–2020. 2012. Report No.: EUR/RC62/10 Rev.1 Sixty-second session + EUR/RC62/Conf.Doc./4 Malta, 10–13 September 2012.

(77) WHO. Health 2020: a European policy framework supporting action across government and society for health and well-being. 2013.

(78) United Nations - Principles for Older Persons, Stat. Adopted by General Assembly resolution 46/91 (16 December 1991, 1991). [Available from: https://www.ohchr.org/EN/ProfessionalInterest/Pages/OlderPersons.aspx].

(79) Leedahl SN, Chapin RK, Little TD. Multilevel Examination of Facility Characteristics, Social Integration, and Health for Older Adults Living in Nursing Homes. J Gerontol B Psychol Sci Soc Sci. 2015;70:111-22. doi: 10.1093/geronb/gbu112.

(80) Zuniga F, Ausserhofer D, Hamers JP, Engberg S, Simon M, Schwendimann R. Are Staffing, Work Environment, Work Stressors, and Rationing of Care Related to Care Workers’ Perception of Quality of Care? a Cross-Sectional Study. J Am Med Dir Assoc. 2015;16:860-6. doi: 10.1016/j.jamda.2015.04.012.

(81) Zhang Y, Punnett L, Gore R, CPH-NEW Research Team. Relationships Among Employees’ Working Conditions, Mental Health, and Intention to Leave in Nursing Homes. J Appl Gerontol. 2014;33:6-23. doi: 10.1177/0733464812443085.

(82) Zhang Y, Flum M, Nobrega S, Blais L, Qamili S, Punnett L. Work Organization and Health Issues in Long-Term Care Centers - Comparison of Perceptions Between Caregivers and Management. J Gerontol Nurs. 2011;37:32-40. doi:10.3928/00989134-20110106-01.

(83) Schwendimann R, Dhaini S, Ausserhofer D, Engberg S, Zuniga F. Factors Associated With High Job Satisfaction Among Care Workers in Swiss Nursing Homes - a Cross Sectional Survey Study. BMC Nurs. 2016;15:37. doi:10.1186/s12912-016-0160-8.

(84) Phelan A, McCormack B. Exploring Nursing Expertise in Residential Care for Older People: A Mixed Method Study. J Adv Nurs. 2016;72:2524-35. doi:10.1111/jan.13001.

(85) Andre B, Sjøvold E, Rannestad T, Ringdal GI. The Impact of Work Culture on Quality of Care in Nursing Homes - a Review Study. Scand J Caring Sci. 2014;28:449-57. doi:10.1111/scs.12086.

(86) WHO. World report on Ageing and Health. Geneva, Switzerland: World Health Organization 2015. Contract No.: ISBN 978 92 4 069481 1 (PDF).