The contribution of person-centred cultures to the aetiology and management of depression among older adults in nursing homes: a realist review protocol

Introduction

Depression (which could refer to depressive disorder or depressive symptoms)¹ is common among older adults^2,3. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) depressive symptoms among older adults include inability to sleep and concentrate, tiredness, desire to die, pain, weight loss, constipation, feeling of worthlessness, psychomotor retardation, depressed mood and loss of interest in activities that used to give pleasure, with the predominance of somatic symptoms⁴. Globally, depression among older adults is recognised as a public health concern, encompassing major depressive disorder and depressive symptoms^1,5. The prevalence and incidence of depression among older adults in nursing homes are significantly higher than they are among community-dwelling older adults^6,7. See Table 1 for comparison of incidence and prevalence of depression among older adults in nursing homes and in the community.

Depression among older adults in nursing homes

There are different types of residential care facilities that exist in different countries depending on the needs of the older adults. A nursing home is a type of residential care facility. Many definitions and terms for a nursing home exist in the literature (Table 2) such as skilled nursing facility, subacute care facility, care home, geriatric hospital⁸. The definition of a nursing home that aligns with this study is that of long-term care facility where an older adult receives nursing care in addition to assistance with activities of daily living for twenty hours a day for an indefinite period (). An end-of-life care may also be provided.

A recent observational longitudinal cohort study⁹ with a sample size of over 1200 older adults found that the rate of admission to a long-term care facility was not associated with severe disability or co-morbidity but rather with moderate disability and a lack of social support. This is in contrast to the belief that all the older adults in nursing homes live with severe disability.

Depression among older adults in nursing homes is associated with poor well-being, poor quality of life, high mortality rates, increased use of acute care services, cognitive and functional declines and poor recovery from other morbidities^10–12. The higher prevalence and incidence are concerning given the projected increase in older adults needing nursing home care globally^18,19. In addition, pharmacotherapy is effective only for a subset of depressed older adults, particularly those with mild to moderate depression and those with dementia do not respond well to pharmacotherapy^20–23.

Depression in nursing homes has multifaceted causes including social, psychological, and biological factors. Though no single factor is solely responsible for depression^1,2, Staff training, organisational culture, and quality of care in nursing homes significantly influence depression among older adults^15,24–26. The American Geriatric Society and the American Association for Geriatric Psychiatry stress the importance of nursing home culture in fostering good mental health care²⁶. Given these prevalence and incidence rates of depressive symptoms and major depressive disorder among older adults in nursing homes^3,8,13, exploring effective care strategies becomes imperative. The World Health Organization advocates for person-centred approaches to care, emphasising individual needs and preferences²⁷.

Person-centredness and person-centred cultures

Recognised as a multidimensional concept²⁸, person-centredness is considered a gold standard approach to care for older adults globally^27,29, influencing international health policies^30,31. It is distinct from patient-centredness, which focuses on medical decision-making, by placing emphasis on organisational cultures in nursing homes that promote independence, social engagement, and respect for older adults' dignity, preferences, and choices^32,33.

Person-centredness in care refers to an approach that prioritises the individuality and personhood of older adults^32,34. It emphasises building relationships based on strengths and values, respecting individuals’ preferences and promoting their well-being^35,36. Kitwood's seminal work in dementia care laid the foundation for models such as the VIPS Model³⁷ and the person-centred nursing framework³⁶, which advocate for personalised care and improvements in the physical and social environment of nursing homes^38,39.

Person-centred cultures are beliefs, values and concepts that foster the personhood of a service user in a healthcare setting⁴⁰ and are necessary for delivery of person-centred care^28,40. Person-centred cultures are cultures that promote the independence of older adults, demonstrate respect for the choices, preferences and autonomy of the older persons, their social engagement and a culture of staff training and development^34–36.

Use of realist review

Studying healthcare policies or interventions is challenging due to their complexity and impact on different aspects of the health system⁴⁹. Realist review, a theory-driven and explanatory form of systematic review grounded in critical realism, is useful for exploring such interventions^49,51. Critical realism posits that reality exists independently of human knowledge, not all aspects are visible, reality is layered, causality is multidirectional, and multiple methodologies and scientific theories are needed to understand it^52–55. It holds that the interconnectedness of social elements allows for theory development about social phenomena⁵⁶.

Realist review begins and ends with theory, aiming to develop, test, and refine theories by explaining the relationship among contexts (C), mechanisms (M), and outcomes (O) of an intervention^49,50. It thus provides insights to foster policy or intervention implementation through mechanism transfer^49,50. According to Pawson⁵⁷, context refers to conditions enabling or hindering an intervention's mechanism, including personal, interpersonal, organisational, institutional, and infrastructural factors. Mechanism denotes the resources provided by an intervention and stakeholder responses, while outcome represents the intended or unintended consequences⁵⁷. Realist review answers "what works, how, why, and in what contexts?" by being cyclical, involving stakeholders, using diverse evidence sources, and being theory-driven⁵⁸. Stakeholder involvement ensures relevance and transferability of findings. Realist review has been applied widely in healthcare research^59,60.

Protocol

The aim of the realist review outlined in this protocol is to identify from available evidence (both published and unpublished, and grey literature) if person-centred cultures contribute to the aetiology and management of depression among older adults in nursing homes, how, for who, why and in what contexts?

The research questions guiding this review are:

Methods

The development of candidate programme theories (CPTs) in a realist review involves constructing frameworks to analyse the causal mechanisms through which interventions produce outcomes in specific contexts⁵⁹. This process entails mapping out potential mechanisms that explain how the intervention works, drawing on insights from a scoping review of existing literature, expert knowledge, and preliminary data to form hypotheses about these mechanisms⁶¹. This review will be reported using RAMESES (Realist and Meta-narrative Evidence Synthesis: Evolving Standards) standards⁵⁰ and the framework to be followed for the design of this review is the four-step framework⁶²:

1. Define the scope of the review

2. Search for and appraise the evidence

3. Extract and synthesize findings

4. Develop narrative

2. Search for and appraise the evidence

The search for evidence will be guided by the research question and the developed IPTs, with an iterative and ongoing process throughout the review^50,67. Any alterations will be documented for transparency. Search methods will include the snowball approach and forward and backward citation tracking⁵⁰. A search strategy (please, see additional file 2), developed using the PICO framework with support from a university information specialist, will be adapted across databases. In the PICO framework, P stands for the population (older adults), I for the intervention (person-centred cultures), C for comparison, and O for outcome (development or amelioration of depression).

The following electronic databases will be used: CINAHL, PubMed/Medline, EMBASE, PsycINFO, Scopus, Cochrane databases and repositories, andWeb of Science.. These databases index articles on health and social care. Grey literature sources will include Google, Health Service Executive, and National Health Service guidelines on person-centredness, and hand-searching of references.

Search terms will be derived from key literature on person-centredness and depression and the initial programme theories. Using various data sources, including unpublished data, is beneficial in realist reviews⁵⁰. Only studies involving older adults (age 60 and above) in nursing homes from 1990 (the approximate start of the person-centred movement) will be included³⁹. Inclusion and exclusion criteria are detailed in Table 3

Table 3. Inclusion and Exclusion Criteria.

Item	Inclusion	Exclusion
Population	Older adults (60 years and above) living in nursing homes (nursing homes as described before)	Any study population different from nursing home, i.e. hostels
Language	Written in English	Any other language different from English
Timeframe	From 1990 till September 2024	Outside this time frame
Study design	All study designs that are relevant that have produced findings that can contribute to theory building and testing	Studies whose findings cannot contribute to theory development and testing
Type of evidence	Published and unpublished evidence that can contribute to theory development and testing	Any evidence that cannot contribute to testing development and testing
Geographic location	Any location	None

Search results will be imported into Covidence an online software for managing and screening systematic search results which is freely available to staff and students of the University College Dublin. Rayyan is an alternative that is freely available. Two reviewers (TO and SPT) will first screen titles and abstracts, followed by full-text screening. An additional team member (TF) will act as an arbitrator in case of disagreements. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines⁶⁷ will be used to guide the reporting of the screening and inclusion of documents. Endnote software which is freely available to staff and students of the University College Dublin, will be used to record the references from search results and any additional references included during the review. Zotero is an alternative which is freely available.

In realist reviews, both academic and non-academic data sources are used to build robust theories⁶². Unlike other reviews that use predefined criteria to assess evidence quality, realist reviews focus on whether evidence contributes to theory development and testing^62,68. Evidence quality is assessed based on relevance, richness, and rigour⁶⁹. Relevance refers to data's ability to aid theory building or testing, while richness pertains to the explanatory power of the data.

A distinction has been made between conceptual richness and contextual thickness of an evidence⁶⁹. The conceptual richness pertains to theoretical explanations of how an intervention works, and contextual thickness, which describes the relationship of the intervention to the broader context. Thus, data can be relevant without being rich, and assessing data for relevance and richness helps manage data during realist reviews⁷⁰. Rigour pertains to the methodological approach used to generate the data⁶² Pawson and Wong advise that realist reviewers should not be overly rigid about rigour, as even methodologically weak data can provide valuable insights^62,68. This review will use the framework by Dada and colleagues⁷⁰ to guide the assessment of relevance, richness, and rigour (Please, see Figure 1) and relevance, richness and rigor criteria are listed in Table 4.

Figure 1. Framework of applying relevance, richness and rigor in realist review⁶⁹, reproduced with permission, license number 5880420875929.

Table 4. Criteria for relevance, richness and rigor.

Relevance	Richness	Rigor
Include:    1.  Population: include any study involving older adults (60 years and above) living in nursing homes (nursing homes as described before).    2.  Language: include any study written in English.    3.  Time frame: any study from 1990 till December 2024    4.  Study designs: All study designs that are relevant that have produced findings that can contribute to theory building and testing except reviews or metanalysis.    5.  Type of evidence: published and unpublished evidence that can contribute to theory development and testing.    6.  Location: any location. Exclude:    1.  Any study population different from nursing home, i.e. hostels.    2.  Studies whose findings cannot contribute to theory development and testing.    3.  Any other language different from English    4.  Outside this time frame	High: any document that can make many contributions to theory refinement in terms of mechanisms, contexts and outcomes. There is a rich description of the mechanism and or the contexts to develop, refine and refute the PTs Moderate: Makes 1 0r 2 contributions to theory development. Regardless of rigor, there is a contribution to PTs development. Low: Makes a little contribution to theory development. There is a little description of potential contexts, mechanisms and outcomes that result to theory development. None: though relevant to the review, the document makes no contributions to theory development. No description of the mechanism, context or outcome relevant to theory development.	The rigor or trustworthiness of the data source and the coherence of the theory will be considered to contextualise the contributions of the evidence by asking the following questions: Are the methods used credible? If not, use other data to support the data. At the level of the PTs, are the theories coherent and simple? The advice from the expert panel will also be used to assess the rigor of the data and the coherence of the PTs. No document will be excluded based on rigor.

Adapted from 70

Dissemination of findings and next steps

The outcomes of the realist review will follow RAMESES reporting guidelines⁴⁹, and will be disseminated through peer-reviewed journal publication, conference presentations to healthcare and academic audiences, and engagement with key stakeholders. Additionally, findings will be integrated into a PhD thesis. This review sets the foundation for a subsequent realist evaluation involving healthcare staff working in nursing homes, who will contribute to the further development of IPT relating to the contribution of person-centred cultures to the aetiology and management of depression among older adults in nursing homes. This realist review protocol has been registered by PROSPERO (registration number is CRD42024568251)

Conclusion

Findings from this realist review will give understanding on the implementation of person-centredness and the embedding of person-centred cultures in nursing homes and provide explanation on the mechanisms through which person-centred cultures contribute to aetiology and management of depression among olde adults in nursing homes. To the best of our knowledge, this is the first realist review to look at the contributions of person-centred cultures to the aetiology and management of depression among older adults in nursing homes. It is anticipated that findings from the review detailed in this protocol will contribute to knowledge on how to improve the wellbeing and mental health of older adults in alignment with World Health Organisation’s Decade of Healthy Ageing 2021–2030⁷⁵ and comprehensive mental health action plan 2013–2030⁷⁶.

Systematic review registration

This realist review protocol has been registered by PROSPERO (registration number is CRD42024568251).

Ethics

Ethical approval is not needed because this study is a review of published literature and no data collection will take place.

Consent to participate

This is a protocol paper, so consent is not applicable.