The study introduces the ACTION programme, a person-centred communication educational intervention for nurse assistants (NAs) in home care for older adults. Home Care Services (HCS) differ internationally in structure, organisation, and funding. There is a global trend towards supporting ageing at home, due to rising institutional costs, the older adults’ preference for familiar environments, and demographic shifts [1]. A gap exists, however, between the theoretical understanding and practical implementation of person-centred care (PCC), largely due to organisational barriers such as low staffing levels, low caregiver motivation, limited recognition of efforts, and insufficient opportunities for continuous professional development [2].

In Sweden, NAs play a crucial role in the provision of HCS, particularly for older adults. Home care is an essential component of the Swedish welfare system, allowing older adults to continue living in their homes while receiving the health and social support they need. NAs form one of the largest occupational groups in Sweden’s healthcare sector, responsible for providing most of the direct health care and social services in home settings [3]. They perform a variety of tasks that require not only practical nursing skills but also interpersonal and communication competencies. NAs assist with daily living activities such as personal hygiene, dressing, and mobility, and also administer basic medical care, such as medication management and wound dressing. They are also expected to respect each older adult’s dignity and individuality while supporting their emotional and psychological well-being. However, NAs report facing challenges due to time constraints, rigid schedules, and lack of training [4]. Older adults have diverse needs, including physical, emotional, and existential concerns. These needs may be subtly expressed [5], requiring NAs to have communication skills to identify and address them. Their role is complex because older adults often present with frailty, cognitive decline, and chronic illnesses, all of which complicate communication and care. Additionally, nursing staff face conflicting demands from the healthcare system, organisational constraints, patients, and relatives, and struggle to balance personal values with professional obligations under time pressure [6]. These aspects further highlight the complexity of implementing interventions in healthcare settings, particularly in dynamic environments such as home care. Educational interventions on communication have demonstrated positive outcomes, including increased knowledge, improved communication skills, and enhanced job satisfaction among healthcare professionals [7, 8]. However, the success of these programmes often depends on the implementation strategies employed and the contextual factors influencing them. The Medical Research Council’s guidance emphasises the importance of systematically planning, implementing, and evaluating complex interventions. This involves understanding the multifaceted nature of such programmes and their interaction with the local context [9]. Web-based and blended learning methods enhance flexibility and accessibility in training, and improve healthcare professionals' behaviours, patient outcomes, and adoption of new practices [10–13]. Education, whether individual or group-based, is described in a review as positively influencing nurses' attitudes, knowledge, perceived control, skills, and social norms, allowing them to adopt multifaceted strategies showing slight but non-significant advantages over single approaches in clinical practice [14]. Key enablers include management support, resource availability, and structured facilitation during the training process. Conversely, challenges such as high workloads, limited time for training, and variability in participants’ educational backgrounds and attitudes can hinder participation and programme completion [15, 16].

The ACTION programme is a web-based educational intervention designed by parts of this research group to enhance the competence of NAs in person-centred communication while providing home care for older adults. It has been pilot-tested and evaluated in studies that provide insights into its implementation, feasibility, and outcomes [4, 15, 17]. The programme includes modules and in-person group supervision, and focuses on developing empathy, active listening, and tailored communication. It supports self-directed and reflective learning, allowing NAs to access content online through various devices. The programme encourages integrating personal experiences into learning and applying knowledge daily. Evaluations show it enhances NAs' communication skills and job satisfaction by fostering accomplishment and connection with older adults [4, 15, 17]. To gain a deeper insight into the significance of competence development in communication, this study aimed to evaluate an educational intervention focused on person-centred communication for NAs providing home care for older adults.

Fourteen home care team managers in Mid-Sweden were contacted by one of the co-authors regarding participation in the ACTION program. Eleven teams agreed to participate. Each team was randomly assigned to either an intervention or a control group.

A total of 132 NAs agreed to participate, resulting in 79 NAs in the intervention group (70 women, nine men) and 53 in the control group (43 women, 10 men). However, not all enrolled NAs completed the education programme or the surveys, citing reasons such as challenging working conditions, stress, and heavy workloads. In the intervention group, approximately half (n = 43) completed all educational modules and the evaluation form. Among these, 35 NAs completed both the pre- and post-surveys. In the control group, 44 NAs completed both the pre- and post-surveys (see Fig. 1). A description of the sample is presented in Table 1.

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To evaluate the effect of the intervention on NAs’ communication, data were collected through surveys using validated instruments, as well as responses from an evaluation of the education programme. The validated instruments included questions related to PCC [19], empathy [20], job satisfaction [21], and self-efficacy communication skills [22]. Furthermore, the surveys included demographic questions about sex, age, native language, and work experience in the care of older adults. The intervention group completed a baseline survey before the intervention and another survey six to eight weeks later. The control group completed the same pre- and post-surveys as the intervention group [18]. At the end of the education programme, the intervention group completed an evaluation. This evaluation consisted of open-ended questions and was administered as a final assignment in the last education module. The questions included were: 1) What do you think has been important and interesting about the communication education programme? 2) What new knowledge and ideas have you gained? 3) How do you think your way of communicating might have been affected after the education programme? and 4) Is there anything you felt was missing or that could be improved in the education programme?

All data collection and participation in the ACTION programme took place during the NAs’ regular work hours, with time specifically allocated within their schedules to participate.

Job satisfaction measures to what extent staff rate job satisfaction, with 37 items on a five-point Likert-type scale ranging from 1 (Very displeased) to 5 (Very pleased), with scores from 1 to 185, where higher values indicate a higher degree of job satisfaction. Cronbach’s alpha was .833 for survey 1, and .835 for survey 2. The question My clinical grading was excluded from the survey because it was not relevant to this group. The scale consists of five factors: I Personal satisfaction (ten items) (Cronbach’s alpha was .405 for survey 1, and .346 for survey 2), II: Satisfaction with workload (seven items) (Cronbach’s alpha was .358 for survey 1, and .137 for survey 2), III: Satisfaction with professional Support (nine items) (Cronbach’s alpha was .690 for survey 1, and .675 for survey 2), IV: Satisfaction with pay and prospects (eight items) (Cronbach’s alpha was .582 for survey 1, and .792 for survey 2), and V; Satisfaction with training (three items) (Cronbach’s alpha was .332 for survey 1, and .681 for survey 2).

The Self-Efficacy Questionnaire (SE-12) measures the clinical communication skills of healthcare professionals [22]. The 12 items are on a 10-point Likert-type scale ranging from 1 (very uncertain) to 10 (very certain), with scores from 12 to 120, where higher values indicate a higher degree of self-scored clinical communication skills. Cronbach’s alpha was .862 and .878 across the two measurements.

The results were divided into two main sections: statistical answers from the surveys and answers from the evaluation forms.

This study investigated the effects of a person-centred communication intervention on NAs working with older adults in home care settings. While the quantitative findings did not show significant differences between the intervention and control groups, the qualitative insights provided meaningful reflections on participants’ experiences and perceptions. The lack of changes in survey outcomes brings the study’s design into question. Overestimation by the intervention group could be a factor, as participants might have initially rated their communication skills highly, leading to a ceiling effect. Many NAs believed they had strong communication skills before the education programme, and this could explain the high baseline scores and the lack of significant post-intervention changes. Research participation has consequences for behaviours being investigated, although little can be known about the conditions under which NAs operate, their mechanisms of effects, or their magnitudes [26]. Similarly, the timing of the post-measurements might not have been optimal. It is plausible that the true benefits of such interventions require a longer time frame to manifest.

Contextual factors such as staff shortages and time constraints may complicate the implementation of educational interventions. These challenges can create a work environment that might hinder NAs from effectively using communication techniques such as person-centred communication. The gap between PCC practices and theoretical knowledge often arises due to organisational issues, including insufficient staff ratios, lack of caregiver motivation and team cohesion, limited managerial recognition, and inadequate ongoing training and support [2]. Such barriers can reduce the quality of care for older individuals and limit NAs attention to the older adults. It is important to implement a tailored personal health plan and facilitate inter-professional teamwork and collaboration with older adults and their relatives, establishing a person-centred approach [27].

Though the quantitative results were inconclusive, the qualitative findings revealed improved self-awareness among NAs regarding communication techniques. The participants valued tools like mirroring, managing silence, and calmness, praising their practicality. The intervention fostered reflection on non-verbal cues and strengthened trusting relationships, enhancing interactions with older adults through mindful and effective communication practices. The participants noted that the education programme made them more aware of their expressions, body language, and tone when interacting with the older adults. They valued the reminder to ask questions, even if uncomfortable, to better understand the older adults’ needs. This aligns with previous research emphasising reflective practices in improving healthcare communication [7, 8].

Interestingly, the intervention seemed to enhance NAs' ability to clearly articulate their understanding of effective communication. After the training, their responses to qualitative questions became more detailed and descriptive, indicating improved reflection and expression regarding communication practices. Qualitative methods can capture subtle changes of interventions that might not be immediately apparent in quantitative data, highlighting the value of subjective evaluations in understanding intervention impacts [28]. The fidelity of the intervention remains vital, as inconsistent attendance or lack of follow-up may affect practical implementation.

Additionally, the participants noted challenges with navigating the digital platform used for the training, particularly for those with limited technological skills. This highlights the need for technological support and simplified instructions in future implementations to ensure accessibility for all staff members. This is in line with a review describing that technology is reshaping education by expanding the traditional learning environment and encouraging the development of digital programmes for cognitive growth [29]. Operational challenges, such as staff shortages and time constraints, were also mentioned as obstacles to fully integrating the new strategies into daily workflows. These factors not only influence the effectiveness of interventions but also underscore the complexities of working in care environments. The participants also emphasised the importance of extending access to the education programme to newly hired staff and substitutes. Providing training early in their careers could significantly enhance their communicative abilities and interactions with older individuals.

The link between job competency and the intention to stay in the workplace was found to be significantly influenced by intrinsic and extrinsic job satisfaction. Considering the challenges of staff shortages and retention in long-term care settings, organisations should focus on strategies to boost employees’ intention to remain. One way to achieve this is by enhancing employees’ competency, as higher competency leads to improved care quality and increased extrinsic job satisfaction. Strengthening competency fosters both intrinsic and extrinsic job satisfaction, improving care standards, affirmation, personal achievement, and willingness to stay in long-term care roles [30].

Our results could help build a more robust foundation for PCC. The positive reflections from the participants demonstrate that even if measurable improvements were absent, the intervention contributed to meaningful shifts in self-awareness and communication practices.

In conclusion, while the intervention did not produce significant quantitative changes, it facilitated meaningful qualitative reflections and shifts in the participants' communication practices. The study highlights the importance of addressing contextual factors, providing ongoing support, and tailoring interventions to the unique challenges of care settings. By doing so, future initiatives can better equip NAs with the skills and confidence needed to provide high-quality, PCC. The findings also suggest a need for better adjustments in scheduling to reduce stress and improve workflow. Ensuring that NAs have the time and resources to practice new communication techniques is essential for their successful implementation. Moreover, future studies should explore the integration of tailored personal health plans, inter-professional teamwork, and collaboration with older adults and their relatives. Additionally, ongoing education and support for newly hired staff and substitutes could help bridge gaps in experience and enhance the overall quality of care. Future studies should also investigate the experiences of older adults and their relatives regarding communication and person-centredness in interactions with nursing staff.