person centred care nursing essay

The Person-Centred Nursing Framework

• First Online: 27 April 2021

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• Brendan McCormack 4 &
• Tanya McCance 5  

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In this chapter, the Person-centred Nursing Framework developed by McCormack and McCance [1, 2] will be described, and an updated framework will be presented. This will be placed in the context of the origins of the framework, which are founded on the concepts of caring and person-centredness. The evolution of the framework will be discussed, highlighting the changes over time that have characterised its development. The position of the Person-centred Nursing Framework as a middle-range theory will be explored and placed in the context of nursing theory development as a basis for practice. Finally, we will illustrate the centrally of the framework to knowledge generation that demonstrates a strong relationship between the theory, practice and research of person-centred practice.

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McCormack, B., McCance, T. (2021). The Person-Centred Nursing Framework. In: Dewing, J., McCormack, B., McCance, T. (eds) Person-centred Nursing Research: Methodology, Methods and Outcomes. Springer, Cham. https://doi.org/10.1007/978-3-030-27868-7_2

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• Published: 03 September 2021

A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward

• Abukari Kwame 1 &
• Pammla M. Petrucka 2  

BMC Nursing volume  20 , Article number:  158 ( 2021 ) Cite this article

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Providing healthcare services that respect and meet patients’ and caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thereby fulfilling a significant aspect of patient-centered care requirement. Effective communication between patients and healthcare providers is crucial for the provision of patient care and recovery. Hence, patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns, beliefs, and contextual variables. Achieving patient-centered care and communication in nurse-patient clinical interactions is complex as there are always institutional, communication, environmental, and personal/behavioural related barriers. To promote patient-centered care, healthcare professionals must identify these barriers and facitators of both patient-centered care and communication, given their interconnections in clinical interactions. A person-centered care and communication continuum (PC4 Model) is thus proposed to orient healthcare professionals to care practices, discourse contexts, and communication contents and forms that can enhance or impede the acheivement of patient-centered care in clinical practice.

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Providing healthcare services that respect and meet patients’ and their caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thus constituting patient-centered care. Care is “a feeling of concern for, or an interest in, a person or object which necessitates looking after them/it” [ 1 ]. The Institute of Medicine (IOM) noted that to provide patient-centered care means respecting and responding to individual patient’s care needs, preferences, and values in all clinical decisions [ 2 ]. In nursing care, patient-centered care or person-centered care must acknowledge patients’ experiences, stories, and knowledge and provide care that focuses on and respects patients’ values, preferences, and needs by engaging the patient more in the care process [ 3 ]. Healthcare providers and professionals are thus required to fully engage patients and their families in the care process in meaningful ways. The IOM, in its 2003 report on Health Professions Education , recognized the values of patient-centered care and emphasized that providing patient-centered care is the first core competency that health professionals’ education must focus on [ 4 ]. This emphasis underscored the value of delivering healthcare services according to patients’ needs and preferences.

Research has shown that effective communication between patients and healthcare providers is essential for the provision of patient care and recovery [ 5 , 6 , 7 , 8 ]. Madula et al. [ 6 ], in a study on maternal care in Malawi, noted that patients reported being happy when the nurses and midwives communicated well and treated them with warmth, empathy, and respect. However, other patients said poor communication by nurses and midwives, including verbal abuse, disrespect, or denial from asking questions, affected their perceptions of the services offered [ 6 ]. Similarly, Joolaee et al. [ 9 ] explored patients’ experiences of caring relationships in an Iranian hospital where they found that good communication between nurses and patients was regarded as “more significant than physical care” among patients.

According to Boykins [ 10 ], effective communication is a two-way dialogue between patients and care providers. In that dialogue, both parties speak and are listened to without interrupting; they ask questions for clarity, express their opinions, exchange information, and grasp entirely and understand what the others mean. Also, Henly [ 11 ] argued that effective communication is imperative in clinical interactions. He observed that health and illness affect the quality of life, thereby making health communication critical and that the “intimate and sometimes overwhelming nature of health concerns can make communicating with nurses and other healthcare providers very challenging” [ 11 ]. Furthermore, Henly [ 11 ] added that patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns. Given the prevalence of face-to-face and device-mediated communications and interactions in healthcare settings, we must explore and clarify who, what, where, when, why, and how interactions with individuals, families, and communities are receiving care and health services [ 11 ].

The value of effective communication in nurse-patient clinical interactions cannot be overemphasized, as “research has shown that communication processes are essential to more accurate patient reporting and disclosure” [ 12 ]. Respectful communication between nurses and patients can reduce uncertainty, enhance greater patient engagement in decision making, improve patient adherence to medication and treatment plans, increase social support, safety, and patient satisfaction in care [ 12 , 13 ]. Thus, effective nurse-patient clinical communication is essential to enhancing patient-centered care and positive care outcomes.

Patient-centered communication, also known as person-centered communication or client-centered communication, is defined as a process that invites and encourages patients and their families to actively participate and negotiate in decision-making about their care needs, as cited in [ 7 ]. Patient-centered communication is crucial in promoting patient-centered care and requires that patients and their caregivers engage in the care process. As McLean [ 14 ] observed, patient-centered care can be enhanced through patient-centered communication by valuing patients’ dignity and rights. Through open communication and collaboration, where information and care plans are shared among care providers, patients, and their families, care provision becomes patient-centered [ 14 ].

Given the interconnected nature of patient-centered care and communication, we must identify the barriers and enablers of patient-centered care and communication and proposed efficient ways to enhance that because patient-centered communication is essential in achieving patient-centered care. Our aim in this paper is to identify the barriers and facilitators of patient-centered care and communication and propose and present a patient-centered care and communication continuum (PC4) Model to explain how patient-centered care can be enhanced in nurse-patient clinical interactions. As Grant and Booth argued, critical reviews are often used to present, analyse, and synthesized research evidence from diverse sources, the outcome of which is a hypothesis or a model as an interpretation of existing data to enhance evidence-based practice [ 15 ]. Thus, this critical literature review study explores the questions: what are the barriers and facilitators of patient-centered care and how can patient-centered care be enhanced through effective clinical communication?

An earlier version of this study was submitted as part of author AK’s doctoral comprehensive exams in February 2021. An interdisciplinary doctoral committee recommended many of the included literature and the questions explored in this study based on the current discourse of patient-centered care advocated for in many healthcare facilities and in recognition of the universal healthcare access objective of the health sustainable development goal. Additional searches for literature were conducted between September and November 2020 using keywords such as barriers and facilitators of nurse-patient interaction, patient-centered care, patient-centered communication , and nurse-patient communication . Databases searched included CINAHL, PubMed, Medline, and Google Scholar. Included studies in this critical review were empirical research on nurse-patient interactions in different care settings published in English and open access. All relevant articles were read, and their main findings relevant to our review questions were identified and organized into themes and subthemes discussed in this paper. Other published studies were read, and together with those that addressed the review question, a model was developed regarding how to enhance patient-centered care through effective communication.

Barriers to Patient-Centered Care and Communication

Nurses constitute a significant workforce of care providers whose practices can severely impact care outcomes (both positive and negative). Nurses spend much time with patients and their caregivers. As a result, positive nurse-patient and caregiver relationships are therapeutic and constitute a core component of care [ 9 , 13 ]. In many instances, nurses serve as translators or patients’ advocates, in addition to performing their primary care duties. Although good nurse-patient relationships positively impact nurse-patient communication and interaction, studies have shown that several factors impede these relationships with significant consequences on care outcomes and quality [ 6 , 16 , 17 ]. Thus, these barriers limit nurses’ and other care providers’ efforts to provide healthcare that meets patients’ and caregivers’ needs. We categorize the barriers to patient-centered care and communication into four kinds: institutional and healthcare system-related, communication-related, environment-related, and personal and behaviour-related barriers. Although these barriers are discussed in separate subheadings, they are interlinked in complex ways during clinical practice.

Institutional and Healthcare System Related Barriers

Many barriers to providing patient-centered care and communication during nurse-patient interactions emanate from healthcare institutional practices or the healthcare system itself. Some of these factors are implicated in healthcare policy or through management styles and strategies.

Shortage of nursing staff, high workload, burnout, and limited-time constituted one complex institutional and healthcare system-level barrier to effective care delivery [ 18 , 19 ]. For instance, Loghmani et al. [ 20 ] found that staffing shortages prevented nurses from having adequate time with patients and their caregivers in an Iranian intensive care unit. Limitations in nursing staff, coupled with a high workload, led to fewer interactions between nurses, patients, and caregivers. Similarly, Anoosheh et al. [ 16 ] found that heavy nursing workload was ranked highest as a limiting factor to therapeutic communication in nurse-patient interactions in Iran.

In a study on communication barriers in two hospitals affiliated with Alborz University of Medical Sciences, Norouzinia et al. [ 21 ] found that shortage of nurses, work overload, and insufficient time to interact with patients were significant barriers to effective nurse-patient interactions. Similar factors are identified as barriers to nurse-patient communication and interactions in other studies [ 13 , 16 , 18 ]. For instance, Amoah et al. [ 16 ] reported that nursing staff shortage and high workload were barriers to patient-centered care and therapeutic communication among Ghanaian nurses and patients. Amoah and colleagues reported a patient’s statement that:

[B]ecause there are few nurses at the ward, sometimes you would want a nurse to attend to you, but he or she might be working on another patient, so in such case, the nurse cannot divide him or herself into two to attend to you both [ 16 ].

Nurses and patients and their caregivers have noted that limited time affects nurse-patient interactions, communication, and care quality. Besides, Yoo et al. [ 22 ] reported that limited visiting hours affected communications between caregivers and nurses in a tertiary hospital in Seoul, Korea. Since the caregivers had limited time to spend with patients, they had little knowledge about the intensive care unit and distrusted the nurses.

Although nursing staff shortage is a significant barrier to patient-centered care and communication that healthcare institutions and managers must know, some healthcare scholars have critique nurses’ complaints of time limitation. For instance, McCabe [ 7 ] argued that the quality of nurse-patient interactions is what matters and not the quantity of time spent with patients and their caregivers. McCabe maintained that “spending long periods with patients does not always result in positive nurse-patient relationships” [ 7 ]. He argued that implementing patient-centered care does not require additional time; hence, nurses’ perceptions of being too busy cannot excuse poor therapeutic communication during clinical interactions. Instead, nurses are encouraged to develop self-awareness, self-reflection, and a commitment to ensuring that patients receive the needed care.

Another institution-related barrier to patient-centered care and communication is the healthcare system’s emphasis on task-centered care. Care providers are more focused on completing care procedures than satisfying patients’ and caregivers’ needs and preferences. This barrier to patient-centered care and communication is acknowledged in several studies [ 7 , 14 , 20 , 22 , 23 ]. For example, McLean [ 14 ] studied dementia care in nursing homes in the United States. She found that patient-centered care and communication in one nursing home (Snow I) were severely affected when nurses, physicians, and care managers focused on completing tasks or observing care and institutional routines to the detriment of satisfying patients’ care needs. However, in the other care home (Snow II), patient-centered care was enhanced as nurses, physicians, and the care home managers focused on addressing patients’ needs and values rather than completing care routines and tasks.

Similarly, Yoo and colleagues [ 22 ] observed that nurse-patient communication was affected when the ICU nurses placed urgency on completing tasks linked directly to patients’ health (e.g., stabilizing vital signs) than communicating to addressed patients’ specific needs. This evidence shows that when nurses are more task-focused, patients and caregivers are treated as bodies and objects, on which medical and care practices must be performed to restore health. Research has shown that when nurses focus on task-oriented care, it becomes hard to provide holistic care to patients or teach and communicate with patients even when nurses are less busy [ 20 ].

Nursing managers and their management styles can affect patient-centered care and communication. Studies have revealed that the management styles that nursing managers implement can either facilitate or impede patient-centered care [ 14 , 22 ]. When nurse managers orient their nursing staff towards task-centered care practices, it affects nurse-patient interaction and communication. Moreover, when nurse managers fail to address their staff’s mental health needs and personal challenges, it influences how nurses attend to patients’ care needs. For example, nurses have indicated that nurse-patient communication is affected when nurse managers are unsupportive or unresponsive to their needs [ 20 ].

In a study exploring nursing and midwifery managers’ perspectives on obstacles to compassion giving and therapeutic care across 17 countries, Papadopoulos et al. [ 24 ] discovered that nurses and midwifery managers’ characteristics and experiences could facilitate or impede compassion and therapeutic interactions in nursing care. Negative personal attitudes, including selfishness, arrogance, self-centeredness, rudeness, lack of leadership skills, the desire for power, and feelings of superiority among nurses and midwifery managers, were obstacles to compassion building. The study further showed that managers who emphasize rules, tasks, and results do not prioritize relationship-building and see their staff as workers rather than team members [ 24 ]. Therefore, nurse managers and care administrators must monitor nurse-patient interaction and communication to address nurses’ concerns and support them, especially in resource-constrained and high patient turnover contexts [ 25 , 26 ].

Communication-Related Barriers

Effective communication is essential to providing patient-centered care. Studies have shown that poor communication between care providers and patients and their caregivers affects care outcomes and perceptions of care quality [ 7 , 16 , 27 , 28 ]. A consistent communication-related barrier in nurse-patient interaction is miscommunication, which often leads to misunderstandings between nurses, patients, and their families [ 20 ]. Other communication-related barriers include language differences between patients and healthcare providers [ 6 , 16 , 27 ], poor communication skills, and patients’ inability to communicate due to their health state, especially in ICU, dementia, or end-of-life care contexts [ 13 , 22 ]. For instance, in their maternity care study, Madula et al. [ 6 ] noted that language barriers significantly affected effective communication between nurses/midwives and expectant mothers. A patient in their study indicated that although many nurses were polite and communicated well, some nurses had challenges communicating with patients in the Chitumbuka language, which affected those nurses’ ability to interact effectively with patients [ 6 ].

Furthermore, Norouzinia et al. [ 21 ] asserted that effective communication could not be established when nurses and patients have a language difference. Moreover, the meanings of certain non-verbal communication acts (e.g., head nodding, eye gaze, touch) can invoke different interpretations across different cultures, which could impede the interactions between patients and nurses. Even in healthcare contexts where nurses and patients speak the same language, “differences in vocabulary, rate of speaking, age, background, familiarity with medical technology, education, physical capability, and experience can create a huge cultural and communication chasm” between nurses and patients [ 12 ]. In ICU and other similar care settings, nurses find it difficult to effectively communicate with patients because the mechanical ventilators made it hard for patients to talk [ 22 ].

To overcome the communication-related barriers, healthcare institutions must make it a responsibility to engage translators and interpreters to facilitate nurse-patient interactions where a language barrier exists. Moreover, nurses working in ICU and other similar settings should learn and employ alternative forms of communication to interact with patients.

Environment-Related Barriers

The environment of the care setting can impact nurse-patient communication and the resulting care. Thus, “good health care experiences start with a welcoming environment” [ 29 ]. Mastors believed that even though good medicine and the hands working to provide care and healing to the sick and wounded are essential, we must not “forget the small things: a warm smile, an ice chip, a warm blanket, a cool washcloth. A pillow flipped to the other side and a boost in bed” [ 29 ]. The environment-related barriers are obstacles within the care setting that inhibit nurse-patient interaction and communication and may include a noisy surrounding, unkept wards, and beds, difficulties in locating places, and navigating care services. Noisy surroundings, lack of privacy, improper ventilation, heating, cooling, and lighting in specific healthcare units can affect nurse-patient communication. These can prevent patients from genuinely expressing their healthcare needs to nurses, which can subsequently affect patient disclosure or make nursing diagnoses less accurate [ 13 , 18 , 21 ]. For instance, Amoah et al. [ 16 ] revealed that an unconducive care environment, including noisy surroundings and poor ward conditions, affected patients’ psychological states, impeding nurse-patient relationships and communication. Moreover, when care services are not well-coordinated, new patients and their caregivers find it hard to navigate the care system (e.g., locating offices for medical tests and consultations), which can constrain patient-centered care and communication.

Reducing the environment-related barriers will require making the care setting tidy/clean, less noisy, and coordinating care services in ways that make it easy for patients and caregivers to access. Coordinating and integrating care services, making care services accessible, and promoting physical comfort are crucial in promoting patient-centered care, according to Picker’s Eight Principles of Patient-Centered Care [ 30 ].

Personal and Behaviour Related Barriers

The kind of nurse-patient relationships established between nurses and patients and their caregivers will affect how they communicate. Since nurses and patients may have different demographic characteristics, cultural and linguistic backgrounds, beliefs, and worldviews about health and illnesses, nurses’, patients’, and caregivers’ attitudes can affect nurse-patient communication and care outcomes. For instance, differences in nurses’ and patients’ cultural backgrounds and belief systems have been identified as barriers to therapeutic communication and care [ 12 , 13 , 21 ]. Research shows that patients’ beliefs and cultural backgrounds affected their communication with nurses in Ghana [ 16 ]. These scholars found that some patients refused a blood transfusion, and Muslim patients refused female nurses to attend to them because of their religious beliefs [ 16 ]. Further, when nurses, patients, or their caregivers have misconceptions about one another due to past experiences, dissatisfaction about the care provided, or patients’ relatives and caregivers unduly interfere in the care process, nurse-patient communication and patient-centered care were affected [ 16 , 21 ].

Similarly, nurse-patient communication was affected when patients or caregivers failed to observe nurses’ recommendations or abuse nurses due to misunderstanding [ 20 ], while patients’ bad attitudes or disrespectful behaviours towards nurses can inhibit nurses’ ability to provide person-centered care [ 31 ]. The above-reviewed studies provided evidence on how patients’ and caregivers’ behaviours can affect nurses’ ability to communicate and deliver patient-centered care.

On the other hand, nurses’ behaviours can also profoundly affect communication and care outcomes in the nurse-patient dyad. When nurses disrespect, verbally abuse (e.g., shouting at or scolding), and discriminate against patients based on their social status, it affects nurse-patient communication, care outcomes, and patient disclosure [ 6 , 32 ]. For instance, Al-Kalaldeh et al. [ 18 ] believe that nurse-patient communication is challenged when nurses become reluctant to hear patients’ feelings and expressions of anxiety. When nurses ignore patients’ rights to share ideas and participate in their care planning, such denials may induce stress, discomfort, lack of trust in nurses, thereby leading to less satisfaction of care [ 18 ].

Furthermore, when nurses fail to listen to patients’ and caregivers’ concerns, coerce patients to obey their rules and instructions [ 16 , 17 , 20 ], or fail to provide patients with the needed information, nurse-patient communication and patient-centered care practices suffer. To illustrate, in Ddumba-Nyanzia et al.‘s study on communication between HIV care providers and patients, a patient remarked that: “I realized no matter how much I talked to the counselor, she was not listening. She was only hearing her point of view and nothing else, [and] I was very upset” [ 17 ]. This quote indicates how care provider attitudes can constrain care outcomes. Due to high workload, limited time, poor remunerations, and shortage of personnel, some nurses can develop feelings of despair, emotional detachment, and apathy towards their job, which can lead to low self-esteem or poor self-image, with negative consequences on nurse-patient interactions [ 13 , 18 ].

Given the significance of effective communication on care, overcoming the above personal and behaviour related barriers to patient-centered care and communication is crucial. Nurses, patients, and caregivers need to reflect on the consequences of their behaviours on the care process. Thus, overcoming these barriers begins with embracing the facilitators of patient-centered care and communication, which we turn to in the next section.

Facilitators of patient-centered care and communication

Patient-centered care and communication can be facilitated in several ways, including building solid nurse-patient relationships.

First, an essential facilitator of patient-centered care and communication is overcoming practical communication barriers in the nurse-patient dyad. Given the importance of communication in healthcare delivery, nurses, patients, caregivers, nursing managers, and healthcare administrators need to ensure that effective therapeutic communication is realized in the care process and becomes part of the care itself. Studies have shown that active listening among care providers is essential to addressing many barriers to patient-centered care and communication [ 7 , 13 ]. Although handling medical tasks promptly in the care process is crucial, the power of active listening is critical, meaningful, and therapeutic [ 22 ]. By listening to patients’ concerns, nurses can identify patients’ care needs and preferences and address their fears and frustrations.

Another facilitator of patient-centered care is by understanding patients and their unique needs [ 25 ], showing empathy and attending attitudes [ 7 , 13 ], expressing warmth and respect [ 22 ], and treating patients and caregivers with dignity and compassion as humans. For instance, McCabe [ 7 ] noted that attending, which obligates nurses to demonstrate that they are accessible and ready to listen to patients, is a patient-centered care process; a fundamental requirement for nurses to show genuineness and empathy, despite the high workload. Showing empathy, active listening, respect, and treating patients with dignity are core to nursing and care, and recognized in the Code of Ethics for Nurses [ 33 ], and further emphasized in the ongoing revision of the Code of Ethics for nurses [ 34 ].

Besides, engaging patients and caregivers in the care process through sharing information, inviting their opinion, and collaborating with them constitutes another facilitator of patient-centered care and communication. When patients and caregivers are engaged in the care process, misunderstandings and misconceptions are minimized. When information is shared, patients and caregivers learn more about their health conditions and the care needed. As McLean [ 14 ] argued, ensuring open communication between care providers and patients and their families is essential to enhancing patient-centered care. Conflicts ensue when patients or their families are denied information or involvement in the care process. As a result, the Harvard Medical School [ 30 ] identified patient engagement, information sharing, and nurse-patient collaboration during care as essential patient-centered care principles.

Finally, health policy must be oriented towards healthcare practices and management to facilitate patient-centered care and communication. These policies, at a minimum, can involve changes in management styles within healthcare institutions, where nurse managers and healthcare administrators reflect on nursing and care practices to ensure that the Code of Ethics of Nurses and patients’ rights are fully implemented. Resource constraints, staff shortages, and ethical dilemmas mainly affect care practices and decision-making. Nonetheless, if patients are placed at the center of care and treated with dignity and respect, most of the challenges and barriers of patient-centered care will diminish. Empowering practicing nurses, equipping them with interpersonal communication skills through regular in-service training, supporting them to overcome their emotional challenges, and setting boundaries during nurse-patient interactions will enhance patient-centered care practices.

In line with the above discussion, Camara et al. [ 25 ] identify three core dimensions that nurses, patients, and caregivers must observe to enhance patient-centered care: treating the patient as a person and seeing the care provider as a person and a confidant. Regarding the first dimension, care providers must welcome patients, listen to them, share information with them, seek their consent, and show them respect when providing care. The second dimension requires that the healthcare provider be seen and respected as a person, and negative perceptions about care providers must be demystified. According to Camara et al. [ 25 ], care providers must not overemphasize their identities as experts but rather establish good relationships with patients to understand patients’ personal needs and problems. Lastly, patients and caregivers must regard care providers as confidants who build and maintain patients’ trust and encourage patients’ participation in care conversations. With this dimension, patients and caregivers must know that nurses and other care providers have the patient at heart and work to meet their care needs and recovery process.

Camara et al.‘s [ 25 ] three dimensions are essential and position patients, their caregivers, and nurses as partners who must engage in dialogic communication to promote patient-centered care. As a result, effective communication, education, and increased health literacy among patients and caregivers will be crucial in that direction.

Enhancing Patient-Centered Care and Communication: A Proposed Model

Nursing care practices that promote patient-centered communication will directly enhance patient-centered care, as patients and their caregivers will actively engage in the care process. To enhance patient-centered communication, we propose person-centered care and communication continuum (PC4) as a guiding model to understand patient-centered communication, its pathways, and what communication and care practices healthcare professionals must implement to achieve person-centered care. In this PC4 Model, we emphasize the person instead of the patient because they are a person before becoming a patient. Moreover, the PC4 Model is supposed to apply to all persons associated with patient care; thus, respect for the dignity of their personhood is crucial.

Although much is written about patient-centered communication in the healthcare literature, there is a gap regarding its trajectory and what communication content enhances patient-centered communication. Also, little is known about how different clinical discourse spaces influence communication and its content during nurse-patient clinical interactions. Using evidence from Johnsson et al. [ 3 ], Murira et al. [ 23 ], and Liu et al. [ 35 ], among other studies, we outline the components of the PC4 Model and how different discourse spaces in the clinical setting and the content of communication impact patient-centered care and communication.

The proposed PC4 Model in this paper has three unbounded components based on the purpose of and how communication is performed among care providers, patients, and their caregivers. Figure  1 illustrates the PC4 Model, its features, and trajectory.

A Person-Centered Care and Communication Continuum (PC4 Model)

Task-Centered Communication

At the lowest end of the PC4 Model is task-centered communication. Here, the care provider’s role is to complete medical tasks as fast as possible with little or no communication with the patient and their caregivers. Patients and caregivers are treated as bodies or objects whose disease symptoms need to be studied, identified, recorded, treated, or cured. As Johnsson et al. [ 3 ] observed, communication content at this stage is mainly biomedically oriented, where nurses and other healthcare professionals focus on the precise medical information (e.g., history taking, medical examination, test results, medication, etc.) about the patient. With a task-centered orientation, nurses make journal entries about their patients’ disease state and ensure that treatment plans, diagnostic tests, and medical prescriptions are completed. Communication at this stage is often impersonal or rigid (see [ 23 ] for details). Care providers may address patients and their caregivers by using informal attributes (e.g., bed 12, the woman in the red shirt, card 8, etc.), thereby ignoring patients’ and caregivers’ personal and unique identities. Patients’ and caregivers’ nonverbal communication signs are mostly overlooked.

Motivations for task-centered communication can be attributed to time limitation, high workload, and staff shortage, thereby pushing nurses and other care providers to reach as many patients as possible. Moreover, the healthcare system’s orientation towards and preference for biomedically-focused care seems to favour task-centered communication [ 7 , 14 ].

Depending on the clinical discourse space under which patient-provider interactions occur, different forms of communication are employed. Clinical discourse spaces can be public (e.g., in the ward, patient bedside), private (e.g., consulting rooms, medical test labs, nurse staff station, etc.), or semi-private (e.g., along the corridor) [ 35 ]. In these clinical discourse spaces, nurse-patient communication can be uninformed (patients or caregivers are not informed about patients’ care conditions or why specific data and routines are performed). It can be non-private (others can hear what the nurse and patient are talking about) or authoritative (care providers demonstrate power and control and position themselves as experts) [ 23 ]. Finally, in task-centered communication, healthcare providers often use medical jargon or terminologies [ 3 ] since the goal of communication is not to engage the patient in the process. Usually, patients or their caregivers are not allowed to ask questions, or their questions get ignored or receive superficial, incomprehensible responses.

Process-Centered Communication

Process-centered communication is an intermediate stage on the continuum, which could slip back into the task-centered or leap forward into person-centered communication. Through process-centered communication, care providers make an effort to know patients and their caregivers as they perform care routines. Care providers ask patients or their caregivers questions to understand the care conditions but may not encourage patients or caregivers to express their thoughts about their care needs. Patients and caregivers are recognized as persons with uniques care needs but may not have the agency to influence the care process. Care providers may chit-chat with patients or their caregivers to pass the time as they record patients’ medical records or provide care. Unlike task-centered communication, there is informative and less authoritative communication between nurses and patients and their caregivers. The goal of process-centered communication could be a mixture of instrumental and relational, with less display of power and control by nurses.

Person-Centered Communication

This is the highest point of the PC4 Model, where patient-centered care is actualized. At this stage of the communication continuum, patients and caregivers are treated as unique persons with specific care needs and are seen as collaborators in the care process. As McLean [ 14 ] observed, caregiving becomes a transactional relationship between the care provider and receiver at the person-centered stage of the continuum. The care itself becomes intersubjective, a mutual relational practice, and an ongoing negotiation for care providers and receivers [ 14 ].

The content of communication at this stage of the continuum is both “personal” and “explanatory” [ 3 ]. Nurses and other healthcare providers create meaningful relationships with patients and their caregivers, understand patients’ concerns, needs, and problems, use open-ended questions to encourage patients or caregivers to express their thoughts and feelings about the care situation. Nurses and other healthcare professionals explain care routines, patients’ health conditions, and management plans in lay language to patients and caregivers through person-centered communication. Accomplishing this level includes employing alternative forms of communication to meet the needs of intensive care unit patients, deaf patients, and ventilated and intubated patients. For instance, it has been shown that “deaf people […] frequently do not have access to clear and efficient communication in the healthcare system, which deprives them of critical health information and qualified health care” [ 36 ]. Empathetic communication practices, including active listening, showing genuine interest in patients’ care, and respect and warmth, become a significant part of nursing care [ 3 , 7 , 14 , 22 ].

Different communication strategies are employed based on the care situation and context. Chit-chatting, as a form of personal communication [ 3 ], use of humor as a communication strategy [ 7 , 8 ], and even maintaining silence [ 28 ] are essential in enhancing person-centered care and communication. Both care providers and patients or their caregivers use relationship-building and -protecting humor (see [ 28 ] for details) to address difficult situations in the care process.

Implications of the PC4 Model for Nursing Practice

Given the values of effective communication in nurse-patient interactions and care outcomes, nurses and other healthcare providers must ensure that they develop therapeutic relationships with patients, their families, and caregivers to promote person-centered care and communication. Achieving that begins with knowing and reflecting on the barriers of therapeutic communication and ways to minimize them. The PC4 Model draws nurses and all healthcare providers’ attention to patient-centered care pathways and how effective communication is necessary. Healthcare professionals, including nurses, must be aware of how their communication orientation–––either oriented toward completing tasks, following care processes or toward addressing patients’ and their caregivers’ needs––can impact patient-centered care. Healthcare providers must observe the care context, patients’ unique situations, their non-verbal language and action, and whether they belong to historically marginalized groups or cultures.

Mastors [ 29 ] has offered healthcare providers some guidance to reflect on as they communicate and interact with patients and caregivers. Thus, (a) instead of asking patients, “What’s the matter?“ care providers must consider asking them, “What’s important to you?“ With this question, the patient is given a voice and empowered to contribute to their own care needs. Care providers should (b) check with patients in the waiting room to update patients whose waiting time has been longer than usual, based on the care context. They should also (c) try to remember their conversations with patients to build on them during subsequent interactions. This continuity can be enhanced by nurse managers reexamining how they deploy care providers to patients. The same nurse can be assigned to the same patients for the duration of the patient’s stay to help patients feel valued and visible [ 29 ].

Knowledge of cultural competence, sensitivity, humility, and interpersonal communication skills will help achieve and implement the PC4 Model. As Cuellar [ 37 ] argues, “[h]umility is about understanding and caring for all people [and] being empathetic.“ Cultural competence is a “dynamic process of acquiring the ability to provide effective, safe, and quality care to the patients through considering their different cultural aspects” [ 38 ]. The concept of cultural competence entails “cultural openness, awareness, desire, knowledge and sensitivity” during care [ 39 ]. It demands that care providers respect and tailor care to align with patients’ and caregivers’ values, needs, practices, and expectations, based on care and moral ethics and understanding [ 39 ]. Active listening and showing compassion as therapeutic relationship-building skills are essential, and continuous education and mentorship will be crucial to developing these skills among healthcare providers.

We invite qualitative and quantitative studies, especially on language use and communication strategies, to explore and evaluate the PC4 Model. Providing in-depth and experiential data on ways to increase its effectiveness as a tool to guide healthcare providers is highly desired. More knowledge can support healthcare providers in offering evidence-based patient-centered care in different healthcare settings and units.

Conclusions

Effective communication is an essential factor in nurse-patient interactions and a core component of nursing care. When communication in the nurse-patient dyad is patient-centered, it becomes therapeutic. It allows for trust and mutual respect in the care process, thereby promoting care practices that address patients’ and caregivers’ needs, concerns, and preferences. We have identified the barriers and facilitators of patient-centered care and communication and proposed a person-centered care and communication continuum (PC4 Model) to demonstrate how patient-centered communication intersects with patient-centered care.

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Abbreviations

Intensive Care Unit

Institution of Medicine

Person-Centered Care and Communication Continuum

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Acknowledgments

We express our gratitude to the first author’s doctoral committee members for their valuable comments, suggestions, and critique of an earlier version of this paper. We are also grateful to the anonymous reviewers for the insightful comments and suggestions that have helped us improve the study’s quality.

Authors' information

Abukari Kwame is a Ph.D. candidate in Interdisciplinary Studies in the College of Graduate and Postdoctoral Studies, University of Saskatchewan, interested in patients' rights in nurse-patient clinical communications and interactions in the hospital setting. He holds two Master of Philosophy degrees in Indigenous Studies and English Linguistics. Abukari's research interests include language use in social interaction, health communication, First/Second language acquisition, African traditional medical knowledge, and Indigenous and qualitative research methodologies.

Pammla M. Petrucka is a professor in Nursing and has international research experience with many of her graduate students from Africa, Asia, and the Caribbean. Pammla has published extensively in the field of nursing. Her research interests are vast, including child and maternal health, Indigenous peoples' health, global health, and vulnerable populations, with extensive experiences in qualitative research and indigenous research methodologies. Pammla is co-editor of the BMC Nursing journal and a reviewer for many other academic journals.

The authors have not received any funding for the conduct, preparation, and publication of this paper.

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Kwame, A., Petrucka, P.M. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs 20 , 158 (2021). https://doi.org/10.1186/s12912-021-00684-2

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Domain 2: Person-Centered Care

Descriptor: Person-centered care focuses on the individual within multiple complicated contexts, including family and/or important others. Person-centered care is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate. Person-centered care builds on a scientific body of knowledge that guides nursing practice regardless of specialty or functional area.

Contextual Statement: Person-centered care is the core purpose of nursing as a discipline. This purpose intertwines with any functional area of nursing practice, from the point of care where the hands of those that give and receive care meet, to the point of systems-level nursing leadership. Foundational to person-centered care is respect for diversity, differences, preferences, values, needs, resources, and the determinants of health unique to the individual. The person is a full partner and the source of control in team-based care. Person-centered care requires the intentional presence of the nurse seeking to know the totality of the individual’s lived experiences and connections to others (family, important others, community). As a scientific and practice discipline, nurses employ a relational lens that fosters mutuality, active participation, and individual empowerment. This focus is foundational to educational preparation from entry to advanced levels irrespective of practice areas.

With an emphasis on diversity, equity, and inclusion, person-centered care is based on best evidence and clinical judgment in the planning and delivery of care across time, spheres of care, and developmental levels. Contributing to or making diagnoses is one essential aspect of nursing practice and critical to an informed plan of care and improving outcomes of care (Olson et al., 2019). Diagnoses at the system-level are equally as relevant, affecting operations that impact care for individuals. Person-centered care results in shared meaning with the healthcare team, recipient of care, and the healthcare system, thus creating humanization of wellness and healing from birth to death.

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Entry-Level Domain 2 Competencies

2.1 Engage with the Individual in establishing a caring relationship.

2.1a Demonstrate qualities of empathy.

2.1b Demonstrate compassionate care.

2.1c Establish mutual respect with the individual and family.

2.2 Communicate effectively with individuals.

2.2a Demonstrate relationship-centered care.

2.2b Consider individual beliefs, values, and personalized information in communications.

2.2c Use a variety of communication modes appropriate for the context.

2.2d Demonstrate the ability to conduct sensitive or difficult conversations.

2.2e Use evidence-based patient teaching materials, considering health literacy, vision, hearing, and cultural sensitivity.

2.2f Demonstrate emotional intelligence in communications.

2.3 Integrate assessment skills in practice.

2.3a Create an environment during assessment that promotes a dynamic interactive experience.

2.3b Obtain a complete and accurate history in a systematic manner.

2.3c Perform a clinically relevant, holistic health assessment.

2.3d Perform point of care screening/diagnostic testing (e.g. blood glucose, PO2, EKG).

2.3e Distinguish between normal and abnormal health findings.

2.3f Apply nursing knowledge to gain a holistic perspective of the person, family, community, and population.

2.3g Communicate findings of a comprehensive assessment.

2.4 Diagnose actual or potential health problems and needs.

2.4a Synthesize assessment data in the context of the individual’s current preferences, situation, and experience.

2.4b Create a list of problems/health concerns.

2.4c Prioritize problems/health concerns.

2.4d Understand and apply the results of social screening, psychological testing, laboratory data, imaging studies, and other diagnostic tests in actions and plans of care.

2.4e Contribute as a team member to the formation and improvement of diagnoses.

2.5 Develop a plan of care.

2.5a Engage the individual and the team in plan development.

2.5b Organize care based on mutual health goals.

2.5c Prioritize care based on best evidence.

2.5d Incorporate evidence-based intervention to improve outcomes and safety.

2.5e Anticipate outcomes of care (expected, unexpected, and potentially adverse).

2.5f Demonstrate rationale for plan.

2.5g Address individuals’ experiences and perspectives in designing plans of care.

2.6 Demonstrate accountability for care delivery.

2.6a Implement individualized plan of care using established protocols.

2.6b Communicate care delivery through multiple modalities.

2.6c Delegate appropriately to team members.

2.6d Monitor the implementation of the plan of care.

2.7 Evaluate outcomes of care.

2.7a Reassess the individual to evaluate health outcomes/goals.

2.7b Modify plan of care as needed.

2.7c Recognize the need for modifications to standard practice.

2.8 Promote self-care management.

2.8a Assist the individual to engage in self-care management.

2.8b Employ individualized educational strategies based on learning theories, methodologies, and health literacy.

2.8c Educate individuals and families regarding self-care for health promotion, illness prevention, and illness management.

2.8d Respect individuals and families’ self-determination in their healthcare decisions.

2.8e Identify personal, system, and community resources available to support self-care management.

2.9 Provide care coordination.

2.9a Facilitate continuity of care based on assessment of assets and needs. 

2.9b Communicate with relevant stakeholders across health systems.

2.9c Promote collaboration by clarifying responsibilities among individual, family, and team members.

2.9d Recognize when additional expertise and knowledge is needed to manage the patient.

2.9e Provide coordination of care of individuals and families in collaboration with care team.

Advanced-Level Domain 2 Competencies

2.1d Promote caring relationships to effect positive outcomes.

2.1e Foster caring relationships.

2.2g Demonstrate advanced communication skills and techniques using a variety of modalities with diverse audiences.

2.2h Design evidence-based, person-centered engagement materials.

2.2i Apply individualized information, such as genetic/genomic, pharmacogenetic, and environmental exposure information in the delivery of personalized health care.

2.2j Facilitate difficult conversations and disclosure of sensitive information.

2.3h Demonstrate that one’s practice is informed by a comprehensive assessment appropriate to the functional area of advanced nursing practice.

2.4f Employ context driven, advanced reasoning to the diagnostic and decision-making process.

2.4g Integrate advanced scientific knowledge to guide decision making.

2.5h Lead and collaborate with an interprofessional team to develop a comprehensive plan of care.

2.5i Prioritize risk mitigation strategies to prevent or reduce adverse outcomes.

2.5j Develop evidence-based interventions to improve outcomes and safety.

2.5k Incorporate innovations into practice when evidence is not available.

2.6e Model best care practices to the team.

2.6f Monitor aggregate metrics to assure accountability for care outcomes.

2.6g Promote delivery of care that supports practice at the full scope of education.

2.6h Contribute to the development of policies and processes that promote transparency and accountability.

2.6i Apply current and emerging evidence to the development of care guidelines/tools.

2.6j Ensure accountability throughout transitions of care across the health continuum.

2.7d Analyze data to identify gaps and inequities in care and monitor trends in outcomes.

2.7e Monitor epidemiological and system-level aggregate data to determine healthcare outcomes and trends.

2.7f Synthesize outcome data to inform evidence-based practice, guidelines, and policies.

2.8f Develop strategies that promote self-care management.

2.8g Incorporate the use of current and emerging technologies to support self-care management.

2.8h Employ counseling techniques, including motivational interviewing, to advance wellness and self-care management.

2.8i Evaluate adequacy of resources available to support self-care management.

2.8j Foster partnerships with community organizations to support self-care management.

2.9f Evaluate communication pathways among providers and others across settings, systems, and communities.

2.9g Develop strategies to optimize care coordination and transitions of care.

2.9h Guide the coordination of care across health systems.

2.9i Analyze system-level and public policy influence on care coordination.

2.9j Participate in system-level change to improve care coordination across settings.

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The person-centred nursing and person-centred practice frameworks: from conceptual development to programmatic impact, brendan mccormack dphil(oxon), frcn, faan, professor and head of the divisions of nursing, occupational therapy and art therapies; associate director, centre for person-centred practice research, queen margaret university, edinburgh, scotland.

The development of the Person-centred Nursing and Person-centred Practice Frameworks has spanned over 20 years of research, practice development and evaluation activities. The original framework published in 2006, was developed for use in the intervention stage of a large quasi-experimental project that focused on measuring the effectiveness of the implementation of person-centred nursing in a tertiary hospital setting ( McCormack and McCance 2006 ).

Nursing Standard . 35, 10, 86-89. doi: 10.7748/ns.35.10.86.s40

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30 September 2020 / Vol 35 issue 10

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• Volume 5, Issue 12
• The empirical evidence underpinning the concept and practice of person-centred care for serious illness: a systematic review
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• http://orcid.org/0000-0003-2667-1665 Alessandra Giusti 1 , 2 ,
• http://orcid.org/0000-0002-2991-8160 Kennedy Nkhoma 1 ,
• Ruwayda Petrus 3 ,
• Inge Petersen 3 ,
• Liz Gwyther 4 ,
• Lindsay Farrant 4 ,
• http://orcid.org/0000-0003-3076-0783 Sridhar Venkatapuram 2 ,
• http://orcid.org/0000-0001-9653-8689 Richard Harding 1
• 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
• 2 King's Global Health Institute , King's College London , London , UK
• 3 School of Applied Human Sciences , University of KwaZulu-Natal College of Humanities , Durban , South Africa
• 4 School of Public Health and Family Medicine , University of Cape Town Faculty of Health Sciences , Cape Town , Western Cape , South Africa
• Correspondence to Alessandra Giusti; alessandra.giusti{at}kcl.ac.uk

Introduction Person-centred care has become internationally recognised as a critical attribute of high-quality healthcare. However, the concept has been criticised for being poorly theorised and operationalised. Serious illness is especially aligned with the need for person-centredness, usually necessitating involvement of significant others, management of clinical uncertainty, high-quality communication and joint decision-making to deliver care concordant with patient preferences. This review aimed to identify and appraise the empirical evidence underpinning conceptualisations of ‘person-centredness’ for serious illness.

Methods Search strategy conducted in May 2020. Databases: CINAHL, Embase, PubMed, Ovid Global Health, MEDLINE and PsycINFO. Free text search terms related to (1) person-centredness, (2) serious illness and (3) concept/practice. Tabulation, textual description and narrative synthesis were performed, and quality appraisal conducted using QualSyst tools. Santana et al ’s person-centred care model (2018) was used to structure analysis.

Results PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow data: n=12,446 studies screened by title/abstract, n=144 full articles assessed for eligibility, n=18 studies retained. All studies (n=18) are from high-income countries, and are largely of high quality (median score 0.82). The findings suggest that person-centred care encompasses the patient and family being respected, given complete information, involved in decision-making and supported in their physical, psychological, social and existential needs. The studies highlight the importance of involving and supporting family/friends, promoting continuation of normality and self-identity, and structuring service organisation to enable care continuity.

Conclusion Person-centred healthcare must value the social network of patients, promote quality of life and reform structurally to improve patients’ experience interacting with the healthcare system. Staff must be supported to flexibly adapt skills, communication, routines or environments for individual patients. There remains a need for primary data investigating the meaning and practice of PCC in a greater diversity of diagnostic groups and settings, and a need to ground potential components of PCC within broader universal values and ethical theory.

• systematic review
• health services research
• health systems
• health policy

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjgh-2020-003330

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Key questions

What is already known.

Person-centred care has become internationally recognised as a dimension of high-quality healthcare, promoted as a core competency of health workers, a key component of primary care and essential to achieving the Universal Health Coverage goals.

Ongoing conceptual debates are attempting to determine what constitutes ‘person-centredness’ and how this concept can be understood and implemented in a variety of settings.

Serious illness is especially aligned with the need for PCC; the complex clinical scenarios surrounding serious illness usually necessitate the involvement of significant others and depend on high-quality communication and joint decision-making to deliver care concordant with patient preferences, with recognition and management of clinical uncertainty.

What are the new findings?

Included studies largely support the Santana et al model of PCC and suggest that additional domains should be given visibility: family and friend involvement and support; promoting continuation of normality and self-identity; structuring service organisation to enable continuity of care and patient navigation.

The empirical data stresses the importance of patients and families being respected, listened to, understood, given honest, complete and comprehendible information and being engaged in all decisions that affect their daily life, care and treatment. Patients must be supported in their physical, psychological, social and spiritual needs.

All retained studies were conducted in high-income, Western countries.

Empirical studies present invaluable data on the meaning and practice of PCC, however none develop this evidence into a theorised framework for implementation of PCC for serious illnesses.

What do the new findings imply?

Person-centred healthcare must value the social network of each patient, promote quality of life and personal goals not only health status improvement, and implement structural reforms to improve patients’ experience of interacting with the healthcare system.

Health systems must be structured to enable sufficient availability and accessibility of health workers, and support staff to be able and willing to flexibly adapt skills, communication, routines or environments for individual patients.

There is a need for primary data investigating the meaning and practice of PCC in a greater diversity of diagnostic groups and settings, particularly non-Western, low- and middle-income settings.

There is a need to consider the theoretical underpinnings of PCC and to ground potential components within broader universal values and ethical theory.

Introduction

Person-centred care has become internationally recognised as a dimension of high-quality healthcare. 1 The Institute of Medicine describes quality care as that which is: “safe, effective, patient-centred, efficient, timely and equitable”. 2 WHO policy on people‐centred healthcare highlights person‐centredness as a core competency of health workers, a key component of primary care, and essential to achieving the Universal Health Coverage goals. 3–6

A variety of terms have been used to denote person-centred approaches. ‘ Patient -centredness’ was first to gain prominence and aimed to challenge the reductionism of the biomedical model and stress the importance of psychosocial factors. 2 3 Many moved towards use of the term ‘ person -centredness’, suggesting this better articulates the holism of the ‘whole person’ and a broader conception of well-being. 7 8 In recent years, the term ‘ people -centredness’ has also gained prominence, emphasising a focus on “the whole person in their specific familial and community contexts”. 9 Person-centred, patient-centred and people-centred care (PCC) all embody an approach that consciously adopts the perspectives of individuals, families and communities, respects and responds to their needs, values and preferences and sees them as participants in their own healthcare rather than just beneficiaries. 2 10

Conceptual clarity is critical to the design, delivery and replication of successful innovations in care. 11 Despite the global prominence of PCC as a goal of health systems, the approach suffers from a lack of clarity. Ongoing conceptual debates are attempting to determine what constitutes ‘person-centredness’ and how this concept can be understood and applied in a variety of contexts. 7 12–14 While numerous conceptualisations of PCC are presented in existing literature, 8 15–21 most do not appear to offer empirical origins or practical guidance on the implementation of PCC. The WHO Global strategy on people-centred and integrated health services recognises that there is not a single model of PCC to be proposed, but rather that it should be context-specific and that each country should generate its own evidence to enable appropriate, acceptable, feasible practice of PCC. 10 It is currently unclear what evidence is available to model contextually-appropriate and culturally-appropriate PCC.

The need for a person-centred approach is particularly important in the context of serious illness. The complex clinical scenarios surrounding serious illness usually necessitate the involvement of significant others, high-quality communication and joint decision-making to deliver care concordant with patient preferences, with recognition and management of clinical uncertainty. 22–24 As populations age, as infectious disease is better managed, and multimorbidity becomes more prevalent, serious health-related suffering associated with conditions such as cancer, chronic lung disease and dementia is rising fastest in low- and middle-income countries (LMICs). 25 Serious illness is also a context in which delivering PCC can be more complex and may require more dimensions to a greater degree than for non-serious illness. Focussing specifically on serious illness is therefore a means of ‘stress testing’ generalist PCC theory and ensuring it captures ‘what matters’ in all diagnostic cases. A better understanding of PCC in the context of serious illness would have health-system-wide relevance for other less complex clinical scenarios.

This systematic review aims to aggregate and appraise the empirical evidence underpinning the concept and practice of PCC in the context of serious illness. Specifically, the objectives of the review are to answer the following questions:

What is the primary data underpinning conceptualisations and practice-based frameworks of ‘person-centredness’ in the context of serious illness?

What is the quality of this data?

What are the key constructs of PCC according to this data?

This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. 26 The review protocol was registered prospectively with PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139259 (registration number 139259).

Definition of terms

To structure this review, literature was considered in line with two frequently cited definitions of PCC, one policy-led (using the term ‘ people -centredness’) and one patient-led (using the term ‘ patient -centredness’):

“An approach to care that consciously adopts the perspectives of individuals, families and communities and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways.” (WHO, 2015) 10

“Care that is focussed and organised around people, rather than disease. Within this approach disease prevention and management are important but not enough to address the needs of person, family and community.” (International Alliance of Patients Organisations, 2007) 27

These definitions informed the broad review search strategy.

Numerous terms exist relating to person-centred care, including patient-centred, people-centred, patient-directed and so forth. We acknowledge that these various terms have differences in their origins and connotations. 28 However, as they overlap significantly and are often used interchangeably we chose to include all terms in the search strategy and analysis. When referring to this approach we chose to use the term ‘person-centred’. In agreement with Ekman et al 8 and The Health Foundation, 29 we take that view that the word ‘person’ avoids reducing the individual to a mere recipient of services and better highlights the whole human being with reason, preferences, needs and a social and cultural background.

The review focuses on serious illnesses in line with the following definition: “Serious illness carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments or caregiver stress. This includes conditions not advanced or high dependency/low function that carry a degree of clinical uncertainty” (Kelley et al , 2016). 30

According to Kelley et al ’s broadest definition of serious illness, serious medical conditions include: cancer (metastatic or hematological), renal failure, dementia, advanced liver disease or cirrhosis, diabetes with severe complications, amyotrophic lateral sclerosis, acquired immune deficiency syndrome, hip fracture, chronic obstructive pulmonary disease or interstitial lung disease if using home oxygen or hospitalised, and congestive heart failure if hospitalised for the condition. 30

Search strategy

The full search strategy is reported in online supplemental appendix A . The following databases were searched on 18 May 2020 with no date restrictions: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, MEDLINE, Ovid Global Health, PsycINFO and PubMed. Forward and backward reference chaining of included articles was performed.

Supplemental material

We included free text search terms (title, abstract and keyword search) related to (1) person-centred care/patient-centred care, (2) serious illness and (3) concept or practice (the meaning of PCC or way in which PCC is enacted). Search terms were adapted to each database subject headings and ‘exploded’ terms. The specific serious conditions included were those listed by Kelley et al 30 within their broad, operationalised definition of serious illness. Please see online supplemental appendix A for full list of search terms and example search strategy.

Data collection and extraction

All potential references identified were exported to EndNote reference manager and deduplicated. The primary reviewer (AG) assessed the titles and abstracts against the inclusion and exclusion criteria (detailed in online supplemental appendix A ). The full texts of remaining references were then similarly screened. Any reference for which inclusion was unclear was agreed through discussion with the secondary reviewer (KN) or adjudicated by a third reviewer (RH) if consensus was not reached. The following variables were extracted from retained studies into a common table: authors, year of publication, country, setting, aim and objectives, study design and methods, sample and main findings.

Quality assessment

We applied Kmet et al ’s Standard Quality Criteria 31 to the primary data. The checklists (quantitative data n=14-items, qualitative data 10-items) score each criterion ‘yes’=2, ‘partial’=1 and ‘no’=0. Items deemed not applicable are excluded from the summary score, which ranges from 1 (highest) to 0 (lowest). Online supplemental appendix A further details the method to calculate scores. We did not exclude studies based on quality score. The primary reviewer (AG) assessed the quality of each study. The secondary reviewer (KN) also assessed the quality of n=5 of the studies and met with the primary reviewer thereafter to compare assessments, resolve any discrepancies and enable reflections to be applied to all other studies’ quality assessments.

For quantitative studies, Kmet et al propose a cut-off score of 0.75 as the threshold for including a paper in a review. 31 As our goal was to assess data quality rather than exclude data failing to meet a quality threshold, we used Lee et al ’s 32 definitions for Kmet et al ’s quality scores; strong (summary score of >0.80), good (summary score of 0.71 to 0.79), adequate (summary score of 0.50 to 0.70) and limited (summary score of <0.50). For qualitative studies, Kmet et al use a threshold of 0.55 for inclusion of a study into their systematic review, 31 therefore we defined qualitative papers with scores of ≥0.55 as ‘adequate quality’ and ≤0.54 as ‘low quality’.

Data analysis

Retained studies were analysed using narrative synthesis in line with Guidance on the Conduct of Narrative Synthesis in Systematic reviews. 33 The preliminary synthesis was performed by tabulation, grouping and clustering.

To synthesise the extracted data the authors adopted a PCC model developed by Santana and colleagues 34 (hereafter referred to as Santana model). The Santana model was selected to structure the analysis of retained studies as it provides comprehensive, practical guidance for implementation of PCC, explicitly linking this guidance to the Donabedian model for assessing healthcare quality. 35 Santana et al ’s model was generated through a narrative review and synthesis of evidence, recommendations and best practice from implementation case studies, as well as existing frameworks. However, besides the consultation of a patient representative, there is limited voice of patients and families informing the model. The model’s authors suggest validation of the framework with additional diverse patient perspectives and to identify any necessary revisions or additions. 34

The components of the Santana model were used to construct an a priori coding frame for deductive analysis of the study findings retained in this systematic review (see online supplemental figure 1 for a priori coding frame). Findings that did not fit into the a priori frame were inductively coded into new codes. The primary reviewer (AG) coded the data using NVivo V.12 software, coding data that did not fit into the a priori frame into additional ‘Other’ nodes. The primary reviewer reviewed the contents of these ‘Other’ nodes throughout the analysis, generating new inductive codes where new themes appeared and revising or adding to these as more data was coded. New inductive codes were reviewed by the second and third reviewers (KN and RH), and discussed until consensus on new code meanings and labels was reached.

Patient and public involvement

Patient and public involvement was not conducted as part of this review.

The search summary flowchart following PRISMA guidelines is presented in figure 1 . The search yielded 12,446 references following deduplication, and 18 studies/n=19 papers 36–54 were retained and synthesised in this review. The characteristics of included studies are summarised in box 1 . Further detailed characteristics of each included study are presented in online supplemental table 1 , with Kmet et al ’s 31 data quality score.

Characteristics of included studies

Countries and settings.

All retained studies (n=18/18) reported data from high-income, Western countries.

The Netherlands (n=5/18) 36–40

Canada (n=3/18) 41–43

Australia (n=3/18) 44 45 49

USA (n=2/18) 46 50

UK (n=1/18) 47

Ireland (n=1/18) 53

Norway (n=1/18) 48

Sweden (n=1/18) 54

Germany (n=1/18 study reported in n=2/18 papers) 51 52

Healthcare settings

Hospital wards (n=5/18) 37 38 41 47 48

Residential aged care facilities (n=3/18) 44 45 54

Outpatient clinics (n=2/18) 36 50

Nursing homes (n=1/18) 53

Cancer centre (n=1/18) 42

Academic cancer institution (n=1/18) 43

Unknown/combination (n=5/18 studies reported in n=6/19 papers) 39 40 46 49 51 52

Diagnostic groups and healthcare professionals

Cancer (n=10/18 studies reported in n=11/17 papers) 36 38 39 41–43 48–52

Dementia (n=4/18) 44 45 53 54

End-stage renal disease (n=1/18) 37

Palliative or end-of-life care (n=2/18) 40 46

Mixed diagnostic groups experiencing acute care (n=1/18) 47

Participant groups included

Healthcare professionals (n=14/18 studies reported in n=15/18 papers) 37 39–47 49 51–54

Patients (n=10/18) 36–39 42 44 48–50 54

Caregivers (n=3/18) studies included 42 44 49

Volunteers working in palliative care (n=1/18) 40

Study designs

Qualitative designs (n=13/18):

Semi-structured interviews (n=11/18 studies reported in n=12/19 papers) 36 38 43–49 51–53

Focus groups (n=2/18) 43 47 50

Case studies (interview and observation) (n=1/18) 41

Mixed qualitative methods (posters and interviews, n=1/18) 42 interviews and focus groups, (n=1/18) 49

Quantitative design (n=1/18):

Survey (n=1/18) 54

Mixed-methodology designs (n=4/18):

Q methodology (n=2/18) 37 40

Questionnaire (n=1/18) 38

Delphi method (n=1/18) 39

Term used to refer to the PCC approach

Patient-centred care (n=8/18) 36–40 48–50

Person-centred care (n=7/18) 42 44 45 47 49 53 54

Patient-centred and family-centred care (n=1/18) 43

Client-centred care (n=1/18) 46

Individualised integrative care (n=1/18 reported in n=2/18 papers) 51 52

Interprofessional patient-centred care (n=1/18) 41

Kmet Data Quality Scores

Range=0.35 to 0.95 (possible range: 0 to 1)

Median=0.82

Qualitative studies and qualitative component of mixed-methods studies (n=17/18):

n=17 scored ≥0.55 (adequate quality)

n=1 scored ≤0.54 (low quality).

Quantitative studies and quantitative component of mixed-methods studies (n=5/18):

n=4 scored >0.80 (strong)

n=1 scored 0.71–0.79 (good)

Summary of aims and research questions of studies retained in this review

n=8/18 studies included an objective to investigate what is understood by the term PCC or what PCC should consist of in practice. 37 40 42 44–48

n=3/18 studies focused on patients’ experiences and expectations of care in relation to predetermined ideas of PCC components. 36 49 50

n=2/18 studies aimed to develop PCC indicators. 38 39

n=2/18 studies (reported in n=3/17 papers) aimed to investigate how teams that identify as providing PCC practice their care. 41 51 52

n=2/18 studies aimed to investigate clinicians’ knowledge and attitudes towards PCC. 43 53

n=1/18 study aimed to identify the organisational, environmental, resident and staff variables associated with aged care units with higher perceived levels of PCC. 54

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PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 flow diagram.

Synthesis of included studies’ findings

Patient-family-provider relationship.

Overall, the findings suggest that PCC encompasses empowerment of both the patient and their family by being respected, 40 41 48 50 53 listened to, 36 37 47 48 understood, 47 given honest, complete and comprehendible information 36 37 39–41 43 48 49 and by being engaged in treatment decisions and all decisions that affect their daily life and care. 36 37 42 46 48 50 51 This requires collaborative, trusting relationships to be developed between patients, families and clinicians, 40 47 49–51 which rely on clinicians’ communication skills, 39 43 49 attitude 41 and demonstrable compassion, 42 for example, by comforting nervous patients. 36 The studies highlighted specific patient information needs, for example, using diagrams or drawings to aid comprehension, using accessible language, providing information about the possible course of the disease and information about the treatment option of ‘no active therapy’. 38 49 It was also raised that patients should be given the necessary information, education and support to enable self-management. 39

A further dominant theme was the importance of involving and supporting the patient’s family, friends or significant others, 36 44 46 47 49 although some patients may deem this a lesser priority. 37 40

In addition to physical symptom control, the studies suggest patients must also be supported in their psychological, social and spiritual needs, 39 40 45 49 51 52 with great attention to all needs and aspects of care that are important to the person. 36 42 46 47 Sufficient time 51 52 and availability of staff 41 was identified as crucial to address these needs. 54 This also requires flexibility and willingness to adapt skills, routines or environments for individual patients. 44 46

Several studies’ findings placed weight on promoting autonomy, continuation of self and normality and enabling patients to participate in life. 44 45 52 53 This was particularly highlighted in studies focussed on dementia patients and nursing homes, 44 53 where a dementia-friendly physical environment was also deemed important. 54

Organisational level requirements

On an organisational level, PCC was reported to demand a shared philosophy of care, 54 satisfactory leadership, support from colleagues and continuing education and mentorship of staff. 54 PCC was seen as requiring interdisciplinary collaboration, 51 54 and consistency and regularity in collaboration of all members of a care team. 41 Furthermore, all staff (not only front-line) were deemed responsible for providing person-centred care. 42 Included studies highlighted the importance of the coordination and continuity of patient care 44 49 and of streamlining care delivery, 43 for example, by having nursing staff provide additional teaching following the physician visit, 43 or appointing each patient a care coordinator. 37 39 49 Studies also indicated the importance of enhancing accessibility of healthcare services and considering logistical barriers, such as lack of transport or financial resources. 49

Complementary findings across participant groups, across countries and across PCC terms

There were no clear discrepancies between the findings of studies incorporating patient participants, caregiver participants or healthcare professional participants. The heterogeneity of studies did not permit analysis to determine difference between countries or regions. However, the study conducted with indigenous Australian populations reported study-specific findings such as the high financial burden of accessing care and the importance of feeling ‘culturally safe’ within the healthcare system. 49 There was also no evidence of consistent differences between findings from studies using different terms within the PCC consortium, that is, patient-centred care, patient-centred and family-centred care, client-centred care and so on. Based on the WHO definition of ‘people-centredness’, we hypothesised that this term has conceptual differences to person-centredness and patient-centredness and wished to investigate what these may be. However, as none of the retained empirical studies used this term we did not have the opportunity to investigate this.

Domains of Santana model supported by included studies’ data

The data from included studies largely supported the Santana model components ( online supplemental table 2 ), providing more detail about the specific meanings of subdomains, and suggesting relationships between concepts. This is particularly the case for many of the model’s Process dimensions which saw numerous corresponding data codes, for example, Being responsive to preferences, needs and values; Sensitivity to emotional or psychosocial needs; Sharing information; Shared decision-making .

Understanding patient within his or her unique psychosocial or cultural context is an example of a Santana model domain that is better specified through the included studies’ findings. Findings related to this domain suggest that clinicians should show interest in the person as a whole and gain an understanding of their psychological and emotional health, spiritual and existential issues, living conditions, financial situation, social support system, culture, personal identity and daily routines and activities. This knowledge should then be translated into tailored care, perhaps providing emotional support from nurses, referring to appropriate specialists, considering patient convenience and resource availability when ordering investigations and initiating conversations and activities that may be meaningful to a particular patient. 36 38 39 42–47 49 51 52

Domains of Santana model left unpopulated by included studies’ data

Table 1 presents domains of the Santana model for which no corresponding study data was found. Predominantly, the Structure components of the Santana model were unpopulated by findings from the 16 studies. This includes domains such as “S3. Co-designing the development and implementation of health promotion and prevention programs”, and “Spiritual and religious spaces”. “P2b. Providing resources” was the only Process domain to be left unpopulated by the data. Outcome dimensions “O2b Patient-Reported Experiences (PREMs)” and “O2c. Patient-Reported Adverse Outcomes (PRAOs)” were left with no corresponding findings from included studies.

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Santana model domains with no assigned codes from included studies:

Model adaptation: evidence additional to Santana model domains

Additional units of meaning arose from the included studies that are currently lacking in the Santana model: Family and friend involvement and support, Promoting continuation of normality and self-identity and Structuring service organisation to enable continuity of care and patient navigation . Table 2 presents these inductively-identified additional themes with examples of corresponding codes from supporting studies. Table 3 presents an adapted version of the Santana framework incorporating these additional themes.

Inductively-identified themes additional to Santana model with corresponding codes(see online supplemental table 2 for full table of studies’ findings deductively mapped onto Santana model and inductively mapped onto additional themes)

Adapted Santana framework incorporating additional themes from the empirical evidence (presented in bold text)

Specifically, Family and friend involvement and support was described as: inviting the patient to bring someone to appointments, 39 establishing conversation with family/friends; 42 involving family/friends in information-sharing and decisions regarding the patient’s care; 37 providing family/friends with opportunities to ask specialists and nurses questions; 38 respecting the opinions and worries of friends/family; 36 acknowledging family/friends in their role as carer for the patient; 37 44 and involving family/friends at all stages including long-term care, treatment and follow-up. 38 Being involved was deemed to avoid feelings of anxiety among family 44 49 and aid the patient emotionally, practically and in understanding and reflecting on information provided by clinicians. 49 51 This domain of PCC also requires healthcare professionals to pay attention to the needs of family/friends of the patient, 37 46 49 including providing accommodations in or near the hospital during treatment if possible, 37 49 and gathering information on the emotional health of family/friends and referring to specialists as appropriate. 39 It is worth noting that some patients and professionals may place this need as a low priority compared with other PCC domains. 37 40

Promoting continuation of normality and self-identity was discussed as requiring encouragement and enablement of persons with serious illness to participate in life despite the disease, and to regain a sense of control and self-efficacy. 51 52 This requires the clinician to consider a patient’s life goals and self-identity when discussing care and treatment options. 51 For long-term inpatients, particularly those with dementia, arranging and enabling meaningful activities was also viewed as a critical part of PCC. Creating individually targeted activities were described not only as providing a meaningful content to the day, but also as a means in reaffirming the residents as individual persons who were able to do the things they enjoyed. 44

Structuring service organisation to enable continuity of care and patient navigation encapsulates a collection of studies’ findings highlighting the importance of streamlining and easing patient navigation, ensuring continuity of care and simplifying the process of multi-specialist care. Suggestions for enabling this included appointing each patient a care coordinator or liaison officer, 37 41 49 ensuring patients see the same professionals over time 36 41 44 using multidisciplinary clinics to decrease wait times and patient anxiety between specialist referrals, 43 and arranging for nursing staff to provide additional information or education following a physician visit. 43

This review has revealed that a number of different constructs underpin the meaning and practice of PCC in the research evidence. These include patient and family empowerment and autonomy through respectful communication, appropriate information sharing and shared decision-making, addressing psychological, social, spiritual and cultural needs and enhancing coordination and continuity of care. The findings of this review indicate that person-centred healthcare must value the social network of each patient, and should promote quality of life and personal goals, not only health status improvement. This implies that person-centred health systems should be structured with flexible health workforce capacity and support staff to adapt skills, communication, routines or environments for individual patients and their families.

The studies’ findings largely validate the domains of the Santana framework of PCC, supporting their importance and providing more detail about specific meanings and subcomponents. The empirical findings of included studies also highlight new PCC themes additional to the Santana model. In focussing on serious illness, this review provides insights into the meaning of PCC that other, less severe conditions may not draw attention to.

The additional theme from included studies’ findings : Family and friend involvement and support , is in line with several other prominent conceptualisations of PCC. 2 16 55 It particularly aligns with conceptualisations that focus on ‘ people -centred’ care, such as that by the WHO, bringing attention to the health of people within their full social circles and communities. 56 57 The vast majority of everyday care is often undertaken by patient’s families and social networks. Enabling families and friends to be active participants in a patient’s healthcare should therefore rightly be a key goal of person-centred health systems reform.

Included studies also indicate PCC as enabling patients to continue to participate in daily life and meaningful activities, promoting continuation of self, personal identity and normality. This finding emphasises that patients’ highly value quality of life and continuation of their normal lives, not only health status improvement. This supports the idea that PCC involves striving to avoid damage to personal identities that the person values, 58 and ties into findings from research with frail populations showing patients value care that supports ‘getting back to normal’ or ‘finding a new normal’. 59 This finding also overlaps with a dimension of Mead and Bower’s patient-centredness framework: the ‘patient-as-person’, which places focus on the individual’s experience of illness and the impact of illness on the individual’s life or sense of self. 15

The third additional theme : Structuring service organisation to enable continuity of care and patient navigation, places particular weight on the organisational and structural reforms that are needed to enable person-centred, care-continuity processes. It highlights that PCC requires not only aspects of the clinician–patient interaction to reform, but also the experience the patient has in interacting with the wider healthcare system. Continuity of care has been presented within other prominent conceptualisations of PCC 17 17 18 55 55 however the specific structural features needed to enable this are rarely discussed. This review’s findings point towards some practical steps for achieving this, such as appointing each patient a care coordinator or arranging for nursing staff to provide additional teaching following a physician visit.

Strengths and limitations

The literature search conducted was comprehensive, considered numerous synonyms for PCC and involved no country or year of publication restrictions. This review also benefitted from interdisciplinary, multinational co-authors, allowing a range of perspectives and cultural viewpoints to inform the analysis and discussion. However, the review does suffer some limitations. First, only peer-reviewed studies published in English were included. Second, the review research questions and search strategy relating to ‘practice’ may have contributed to the lack of supporting data for structure and outcome domains of the Santana model. Third, only publications that included the term ‘person-centred’ (or synonym) were included. Research has certainly been conducted in non-Western LMICs that could inform models of PCC, for example, studies investigating ‘good communication skills’ or ‘empathetic care’. However, searching terms related to, in addition to near synonyms of, PCC would have deemed this review unfeasible. Our aim was to understand PCC as it is currently described.

Conclusions; implications for PCC research, policy and practice

This review indicates that there is a stark absence of theoretical models of PCC for serious illness that are grounded in empirical data. Future research should aim to generate theoretically-underpinned empirical frameworks for clinicians and policy makers on how to implement PCC through relevant, appropriate healthcare delivery.

It would also be insightful for future studies to further investigate the aforementioned PCC domains additional to the Satana model to validate whether these domains should constitute PCC components, and if so, what the specific, operationalisable actions within those components should be. One particular additional theme, Involving and supporting the patient’s family and friends , unsurprisingly surfaced most clearly in studies that included caregivers as participants (n=3). This highlights the importance of including this participant group in further empirical studies.

The included studies add depth and detail to existing Santana model domains, such as: Understanding patient within his or her unique psychosocial or cultural context . The findings related to this domain recognise that much of health is determined outside the clinic by social situations beyond the patient–clinician interaction, such as education, employment, income, housing, social support and gender. 60 Acknowledging and addressing these social determinants of health are critical to delivering PCC. Healthcare professionals must be given the support, tools and structures to actively engage with these social determinants of a person’s health and illness. However, this finding also raises the wider question of where the responsibility of PCC lies and how much of this rests with the individual clinic and clinician. Certain socially determined aspects of patient health can be positively influenced by a healthcare professional, others cannot. Consideration is needed about how and when clinicians should go beyond the clinic, and how to involve any external actors in contributing towards better patient health outcomes. 61 We must reflect on how a practice-based theory of PCC should sit within the broader socio-economic and cultural environment in which a health system operates.

Included studies also strongly support Santana model domains revolving around information sharing, shared decision-making and clinicians taking the time to properly understand each patient’s needs. This reaffirms the importance of in-depth holistic assessment of the patient and the need to empower patients and families through health literacy, equipping them with the knowledge to make informed decisions. 62

Several Outcome and Structure components of the Santana model were left unsupported by findings from the studies. This is not to say that those subdomains are unimportant, but that evidence to support them is lacking, and that patients, caregivers and professionals are most immediately exposed to, and concerned with, discussing processes. Future primary research with healthcare managers or policy makers should specify important structural and outcome domains. However, we could also perhaps infer that patients and caregivers facing serious illness are as, or even more, concerned with the quality of processes than with the outcomes which are most often the focus of healthcare improvement efforts. This suggests we should value process improvements as we value outcome improvements and should value the processes of person-centred care in and of themselves rather than just as a means to a series of outcomes. This supports ethical arguments that we should recognise the intrinsic, not just instrumental, value of PCC, and should pursue it as a valued quality and ethical domain in its own right. 13 58

The lack of study findings corresponding to some Structure components of the Santana model may also be a result of the lack of diversity in settings and diagnostic groups of included studies. The components left unpopulated by the studies’ findings appear to be those less relevant among the diagnostic groups and high-income settings of included studies. For example, Facility that prioritises the safety and security of its patients and staff is less likely to be voiced as a concern in high-income settings with lower rates of violent crime and civil unrest. Health promotion is an element of PCC that seems less poignant in cases of patients with end-of-life cancer and dementia; this topic may be of greater relevance in other serious conditions that are more responsive to lifestyle factors, such as chronic obstructive pulmonary disease. More empirical work is needed to confirm whether these components are of importance, what these components consist of and how they should be operationalised in day-to-day practice. This empirical investigation would be most insightful if conducted in a diverse range of contexts within which these components are likely to be more relevant.

PCC is an approach that evolved from high-income countries, and African theorists have questioned the relevance of Eurocentric conceptualisations and noted the absence of data to understand the meaning, feasibility and acceptability of PCC in non-Western LMICs. 63 This is unsurprising given existing biasses in healthcare research towards high-income countries, and limited resources and platforms for LMICs to conduct and promote this research. In the context of fewer resources, PCC may also be mistakenly perceived as a ‘nice-to-have luxury’ rather than a ‘need-to-have necessity’ and may be challenging to promote in settings with a history of disease-specific, vertical programmes. However, the lack of diversity in study countries raises questions about how both Santana model domains and additional themes could be conceptualised and operationalised globally, in a diversity of settings. Successful enactment of person-centred care would require a multitude of contextual and cultural factors to be considered and accommodated. For example, as Markus and Kitayama 64 discuss, the dominant construal of self differs between Western and other contexts. Western notions of the ‘self’ are that of an individual independent agent, while in most non-Western societies the ‘individual’ is more integrated with significant others. A patient with more interdependent views of self may be highly concerned with harmonising relationships and views. This has very real implications for the clinician–patient interaction and how to best practice involvement and support of a patient’s family and wider social network. Data from more individualistic cultures, such as that from the included Galekop et al study, 40 may suggest that ‘ there are some meetings involving the whole family, but ultimately, it is the patient who decides and not the family ’ . In a more collectivist culture, however, great importance may be placed on collective decision-making and the impacts of illness on a person’s network, 65 and thus, person-centred care would need to enable this. We must carefully consider the underlying values and determinants of culture in order to ensure cultural sensitivity in PCC theory. 58 66 A global theory of PCC and resulting policy would need to accommodate different beliefs and worldviews and centre around a common set of human values.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3

Handling editor Seye Abimbola

Twitter @KennedyNkhoma6, @sridhartweet

Contributors AG planned, conducted, reported and submitted this systematic review, and is responsible for the overall content as guarantor. KN assessed the quality of a subselection of included studies and compared assessments with AG. KN and RH reviewed the work as required. RP, IP, LG, LF and SV contributed to design and interpretation. KN, RH, SV, RP, IP, LG and LF approved the manuscript.

Funding This research was partly funded by the National Institute of Health Research (NIHR) Global Health Research Unit on Health System Strengthening in sub-Saharan Africa, King’s College London (GHRU 16/136/54) using UK aid from the UK Government to support global health research.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. This paper is a systematic review and does not report novel primary data.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• v.3(2); 2016 Jun

Person-centred care: what is it and how do we get there?

Angela coulter.

A Nuffield Department of Population Health, University of Oxford, Oxford, UK

John Oldham

B Royal College of Physicians, London, UK

This edition of Future Hospital Journal has a focus on person-centred care and explores the dimensions to partnership working at three different levels – consultation, service and system levels. In this introduction, the authors explain what they consider to be the essential components of person-­centred care and what needs to be done to embed it at all levels of healthcare delivery. The changing attitudes of patients and the desire of most of them to receive personalised care based on their individual needs, preferences and lifestyles are explored. It is argued that a culture change is needed to make person-centred care the norm and that patients can help deliver this through a more meaningful involvement in medical research, training and education, service reconfiguration and commissioning.

Definitions

Hippocrates said ‘it is more important to know what sort of person has a disease than to know what sort of disease a person has’. It is, therefore, surprising that we have only recently started to question the meaning of person-centred care and how treatment and care programmes could be tailored to meet the individual needs of patients and carers. When the NHS was founded nearly 70 years ago, people were delighted to receive free care for conditions they may have tolerated for many years because of their inability to pay for medical treatment. People were grateful recipients of healthcare and the prevailing attitude was that doctors knew best. Patients expected to be told what treatment they were going to be given and it was not the ‘done thing’ to challenge the doctor. Today, attitudes are very different. Health information is abundant, patients expect excellent care, and they are much more likely to complain if it falls short of expectations. More importantly, they want to be treated as individuals whose knowledge, values, preferences, family and social circumstances are acknowledged as being of crucial importance when deciding how to manage their medical care.

Person-centred care means treating patients as individuals and as equal partners in the business of healing; it is personalised, coordinated and enabling. 1 It is not a medical model and should be regarded as multidisciplinary, recognising that a person may need more than one professional to support them. Working in this way means recognising people’s capabilities and potential to manage and improve their own health, not seeing them simply as victims of disease or passive recipients of care. Most people want to help themselves, so the health system should be geared to ensuring they acquire the knowledge, skills and confidence to do so. Unfortunately, the way care is delivered sometimes has the opposite effect. Overly directive or paternalistic approaches create dependency and undermine people’s confidence to protect their health, prevent illness and manage their own care. 2 Paternalistic practice styles risk providing inappropriate care that patients would not have wanted if they had been well-informed. 3 Professionals often underestimate the extent to which patients are able to take responsibility for their health. Many patients would be willing and indeed eager to do so if their capabilities were recognised, supported and strengthened, instead of being ignored and undermined. For those people with limited or no mental capacity to assume greater responsibility for their care, we should ensure relatives, carers and trained advocates are fully involved in the care planning process.

The good news is that policymakers have recognised the need to promote person-centred care and there are now concerted efforts under way to empower patients by informing, involving and empowering them. This includes strategies to build health literacy, to promote shared decision making, to support self-care, and to encourage co-creation of services. This special issue includes articles describing some of these initiatives in more detail. Here, we discuss some underpinning themes.

Information

Nowadays most people expect to play an active part in decisions that affect them, including healthcare decisions. There is huge public interest in health and healthcare, generating strong demand for information about diseases, symptoms, treatments and care packages. The government-funded NHS Choices website, www.nhs.uk , received 23.4 million unique visitors in 2014, the vast majority of whom were looking for information about their or their family’s health problems. 4 Professionals sometimes see this thirst for health information as a threat, blaming ‘Dr Google’ for confusing their patients, but it makes much more sense to welcome it as an opportunity to inform and educate. Of course, it is not just about having information available but about explanation and re-enforcement of support to achieve person-centred care.

When patients come in brandishing documents downloaded from websites, it is a signal that consultation styles need to adapt. Increasingly, patients want to be informed about available treatment options and to be fully involved in deliberations about the best way to treat or manage their condition. Not all health information is reliable or useful; people need help to sort out the wheat from the chaff. Quality standards and certification schemes, like NHS England’s Information Standard, are available to help with this task ( www.england.nhs.uk/tis ). However, help from clinicians committed to working in partnership with patients is even more important, together with access to the right type of information in the right way and at the right time.

Evidence-based patient decision aids can be very useful for helping patients understand the choices available to them ( https://decisionaid.ohri.ca ). Similar to clinical guidelines but written specifically for patients, these decision aids give basic information about conditions, treatment options, likely outcomes and uncertainties. There is good evidence that they can be very effective if used in the right way. 5 Many such tools are now available on publicly accessible websites and some are even integrated into electronic medical record systems, making them readily available for use during consultations at the touch of a button. 6

The importance of ensuring that patients have access to reliable information is often underplayed, but this is set to change because of a groundbreaking decision by the UK Supreme Court. 7 Following their ruling in the case of Montgomery v Lanarkshire Health Board, the legal requirement to ensure that patients understand their treatment choices and are given information about the risks as well as the benefits of all reasonable options is now much clearer. The courts have taken the view that patients should be helped to make informed choices, so simply providing information about a treatment that the doctor has chosen and obtaining a signature on a consent form is not sufficient. Shared decision making, where clinicians and patients work together to select tests, treatments or support packages, based on clinical evidence and the patient’s informed preferences, is now the legally accepted standard and doctors ignore this at their peril.

Personalisation

All patients want to be listened to and treated with respect and empathy, but this is especially important for people with long-term conditions. Personalised care planning aims to provide support from health professionals that is tailored to the needs of individual patients. It involves a conversation, or series of conversations, between a patient and a clinician when they jointly agree on goals and actions for managing the patient’s health problems. Patients’ goals in managing their condition may differ from those of professionals, but both are important. 8 Instead of giving instructions and advice, this approach encourages patients to clarify their own goals, working together with the clinician to identify the help they need to achieve these. Both parties in the conversation need to have a good understanding of each other’s priorities. Before talking about symptoms, many patients want the doctor to ask ‘what do I need to know about you before we discuss how to manage your illness?’ Studies have shown that this type of collaborative approach can lead to improvements in physical and psychological health and strengthen patients’ confidence and skills to manage their health. 9 The NHS Mandate promised that everyone with a long-term condition would be involved in a personalised care planning process ‘that reflects their preferences and agreed decisions’, 10 but, to date, progress has been slow, with relatively few patients experiencing proactive, well-coordinated, systematic support. 11

Other policy developments designed to support a more collaborative, personalised approach include facilitating patient record access and integrated personal commissioning. Enabling access to their electronic medical records and sending patients copies of referral letters and other important communications are seen as ways to empower patients. It is now a contractual obligation for GPs to offer patients online access to their summary records and by May 2015 almost every GP surgery in England (97%) offered this service, a huge increase from only 32% in April 2014. 12 The ability for patients to review their medical records has not been well publicised and take-up of the offer has been slow, but opening up inter-professional communications to patients is an important symbolic step towards greater empowerment.

The Integrated Personal Commissioning scheme (IPC) goes further in this direction. IPC gives people with complex needs the option of holding an individual budget, which they can use to purchase relevant support. The model, which assumes close involvement of voluntary organisations, includes personalised care and support planning, independent advocacy, peer support and brokerage. 13 The budget can be directly managed by the service users themselves or managed on their behalf by an independent agency. This scheme, currently being piloted in nine sites around England, is intended to provide better integration of care for people whose multiple needs mean they have to rely on a large number of service providers. The hope is that this form of personal control will lead to improvements in their quality of life, help to prevent crises and reduce the likelihood that they will experience unplanned admissions to hospitals or other institutions.

Skills and attitudes

Working with patients in a more person-centred manner places new demands on health professionals. It requires excellent listening, communication and negotiation skills and the capacity to respond flexibly to people’s individual needs. Effective evidence-based medicine is central to what most patients want, but person-centred care cannot be reduced to technical cookbooks. Guidelines and protocols have their place, but they must not be allowed to squeeze out the crucial human qualities of caring and compassion, which are highly valued by patients.

Making person-centred care the norm not only requires a culture shift in the way patients and doctors work together, it also requires the NHS to succeed with its many initiatives aimed at ensuring nurses and doctors deliver care with compassion, dignity and respect. Too often patients complain about a lack of information and difficulty in getting the doctor or senior nurse to sit down and have a conversation with them. Patients are made to feel they are taking up the doctor’s time unnecessarily or that staff are too busy for a discussion. When things go wrong, health professionals often seem defensive and unwilling to admit mistakes may have been made. These scenarios, which are well documented in the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 14 may be indicative of resource pressures or weak leadership, but they certainly inhibit progress towards a more person-centred system.

Moving forward

The real world challenges faced by clinicians and healthcare systems in delivering person-centred care should not be underestimated. The greatest barrier to change is probably culture. Clinicians may need to acquire new skills and indeed many need to recognise that new skills are needed. The NHS will continue to struggle with huge financial pressures, often resulting in the rationing of expensive treatments. Integration of health and social care and good coordination between medical specialists is a real challenge for many organisations, yet this is vital for delivering a good patient experience. A whole systems approach to commissioning and a payment system to hospitals that encourages new ways of working, in settings valued by patients, are also of immense importance. And let’s not forget the pressures in the system caused by a serious shortage of doctors.

So what is needed to make person-centred care a reality? Firstly, the concept needs to be embedded at all levels of the healthcare system, from government policy to delivery of care by individual clinicians. Initiatives to promote better integration of care should start from an understanding of the patient’s perspective, focusing on personalised care planning and care coordination rather than organisational integration. Patients should be invited to help redesign these systems. Professional training is important too; the way doctors and patients interact and negotiate treatment plans should be a core element of undergraduate and postgraduate training for all medical disciplines. From service reconfiguration to medical research, commissioning, training and education, patients can make a valued contribution and help deliver the culture change that is needed to make person-centred care the norm.

‘Being’ person-centred: a reflection from a personal and professional experience

In this week’s Evidence Based Nursing Blog, Andrew Cassidy (@mrandycassidy) brings his own personal lived experiences and professional thoughts from his years working in the NHS and other sectors on what being person-centred looks like. 

I’ve worked in the healthcare for nearly fifteen years, in the NHS, the third sector, and for a social enterprise. In spite of the differences in these roles, a main focus of each of them has been on the provision of person-centred care. But what is person-centred care, and how can one person be expected to say what is and what isn’t person centred for someone else? This question was brought into sharp relief in the early days of the pandemic. I have Crohn’s Disease, and take immunosuppressant medication to keep it under control. This placed me in the shielding group, and led to one of the most challenging conversations that I have ever had with my healthcare team. Early in the morning of March 23rd, my GP called to ask me how I would feel about having a DNR placed on my medical records. I have a good relationship with my GP, and her manner was sensitive and, I felt, pitched at a level I would respond to. We’ve always been candid in our conversations, and I appreciated this candour in our conversation, but it made me think. My conversation with my GP was structured around my level of understanding and my “expertise” of my own condition. However, I appreciate how difficult that conversation would have been for my GP to instigate, and I began to wonder how the conversations she had with other patients in my position were positioned. Were they all as “person-centred” as the conversation I had?

This made me think about my professional life, and the roles of my clinical colleagues. As nurses, they are expected to provide person-centred care in all circumstances. But how can “person-centred-ness” be quantified? Two people could look at the same interaction, and arrive at two polar opinions as to whether or not it was person-centred. Is there a universal definition, or is it nebulous and does that definition differ from person to person? Further, if there is no definitive definition – and, if the notion of what is and is not “person-centred” varies from person to person, then surely there cannot be? – how can we reasonably expect professionals themselves to determine whether their interactions are person-centred or not?  I decided to examine my own experiences of care, and to try to determine what factors were important in my appraisal of whether or not they were person-centred. My first thoughts ran to health literacy. For me, the first step of a person-centred approach is communicating at a level people are comfortable with. I’ve had Crohn’s for over twenty years, and conversations about antiemetics, 5-ASA’s, and terminal ilea do not faze me, but I can imagine the confusion these conversations would give rise to someone who has been newly diagnosed. But here’s the rub; that’s precisely what makes it person-centred for me. The very aspect that makes it person-centred to me could have completely the opposite effect on someone else. This leaves a very obvious question; can we truly expect professionals to know at first glance or interaction the approach that would suit every patient and pitch their interactions accordingly? And, if so, how can policies be made at Trust / Health Board / National levels when we have a virtual smorgasbord of opinions on what person-centred is and isn’t. For me, the essence of person-centred care comes down to ascertaining what is important to the person themselves. Recent initiatives have led the way on this, notably the Scottish Government’s What Matters to You , have shone a light on a way forward.  A system simply cannot decide what being person-centred looks like, but getting to the heart of what is important to the person can provide a starting point. What matters to the person should influence everything in a healthcare environment, from communications to potential treatment options and long-term support and care. Only once what matters to someone is identified and valued can systems begin to design a package of care that truly puts people at the centre.

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• Last updated: 17/12/2020

• Open access
• Published: 29 May 2024

The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada

• Samina Idrees 1 ,
• Gillian Young 1 ,
• Brian Dunne 2 ,
• Donnie Antony 2 ,
• Leslie Meredith 1 &
• Maria Mathews 1  

BMC Health Services Research volume  24 , Article number:  680 ( 2024 ) Cite this article

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Person-centred planning refers to a model of care in which programs and services are developed in collaboration with persons receiving care (i.e., persons-supported) and tailored to their unique needs and goals. In recent decades, governments around the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery. Although regional mandates provide a framework for directing care, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. This study aims to address a gap in the literature by describing how person-centred care plans are implemented in community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Ontario, Canada. We asked participants about their organization’s approach to developing and updating person-centred care plans, including relevant supports and barriers. We analyzed the data thematically using a pragmatic, qualitative, descriptive approach.

We interviewed administrators from 12 community-care organizations. We identified three overarching categories or processes related to organizational characteristics and person-centred planning: (1) organizational context, (2) organizational culture, and (3) the design and delivery of person-centred care plans. The context of care and the types of services offered by the organization were directly informed by the needs and characteristics of the population served. The culture of the organization (e.g., their values, attitudes and beliefs surrounding persons-supported) was a key influence in the development and implementation of person-centred care plans. Participants described the person-centred planning process as being iterative and collaborative, involving initial and continued consultations with persons-supported and their close family and friends, while also citing implementation challenges in cases where persons had difficulty communicating, and in cases where they preferred not to have a formal plan in place.

Conclusions

The person-centred planning process is largely informed by organizational context and culture. There are ongoing challenges in the implementation of person-centred care plans, highlighting a gap between policy and practice and suggesting a need for comprehensive guidance and enhanced adaptability in current regulations. Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Peer Review reports

The community-care sector facilitates the coordination and administration of in-home and community-based health and social services. Community-care services include supports for independent living, residential services, complex medical care, and community-participation services to support personal and professional goals (e.g., education, employment, and recreation-based supports) [ 1 ]. There is substantial heterogeneity in the clinical and demographic characteristics of the community-care population, including individuals with physical and developmental disabilities, and complex medical needs [ 2 ]. We refer to the individuals served by these organizations as ‘persons-supported’ in line with person-first language conventions [ 3 , 4 ].

In recent decades, governments across the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery [ 5 , 6 , 7 , 8 ]. Person-centred care encompasses a broad framework designed to direct care delivery, as opposed to a singular standardized process. In the context of community-care, person-centred planning refers to a model of care provision in which programs and services are developed in collaboration with persons-supported and tailored to their unique needs and desired outcomes [ 9 , 10 ].

In Ontario, Canada, community-care services are funded by the Ministry of Health (MOH) and the Ministry of Children, Community and Social Services (MCCSS). Service agreements between these ministries and individual agencies can be complex and contingent on different factors including compliance with a number of regulatory items and policies [ 7 , 11 ]. MOH provides funding for health-based services including in-home physiotherapy, respiratory therapy, and personal support services, among several others. MOH funds Home and Community Care Support Services (HCCSS), a network of organizations responsible for coordinating the delivery of in-home and community-based care in the province. MCCSS funds social service agencies including those providing community participation and residential support for people with intellectual and developmental disabilities (IDDs).

Several tools and resources have been developed to aid organizations in providing person-centred care and organizations may differ in their use of these tools and their specific approach. Although regional mandates provide a framework for directing care delivery, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. In addition, as noted by a recent scoping review, there is limited literature on the implementation process and impact of person-centred planning on individual outcomes [ 12 ]. Using a pragmatic, qualitative, descriptive approach [ 13 ], we outline how community-care organizations enact a person-centred approach to care and the factors that shape their enactment. By describing existing practices in the context of the community-care sector, we aim to provide insight on how to optimize care delivery to improve outcomes and inform current policy. This study is part of a larger, multi-methods project examining the implementation of person-centred care plans in the community-care sector. This project encompasses qualitative interviews with representatives from different community-care organizations, as well as staff and persons-supported at a partner community-care organization. This paper focuses on analyzing data from interviews with representatives from different community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Southwestern Ontario (roughly the Ontario Health West Region) between October 2022 and January 2023. We included community-care organizations funded by MOH or MCCSS. We excluded organizations that did not provide services in Southwestern Ontario. We identified eligible organizations and participants by searching online databases, including community resource lists, as well as through consultation with members of the research team.

We used maximum variation sampling [ 14 ], to recruit participants from organizations with a wide range of characteristics including location (i.e., urban, rural), organization type (i.e., for-profit, not-for-profit), and types of services provided (e.g., residential, recreation, transportation, etc.) We contacted eligible organizations via email, providing them with study information and inviting them to participate. We recruited until the data reached saturation, defined as the point at which there was sufficient data to enable rigorous analysis [ 14 , 15 ].

In each interview, we asked participants about their organization’s approach to developing and updating individual service agreements or person-centred care plans, and the supports and barriers (e.g., organizational, funding, staffing, etc.) that facilitate or hinder the implementation of these plans (Supplementary Material 1 : Interview Guide). We also collected information on relevant participant and organizational characteristics, including participant gender, position, years of experience, organization location, type (i.e., for-profit, not-for-profit), services offered, years in operation, and client load. The interviews were approximately one hour in length and conducted virtually via Zoom (Zoom Video Communications Inc.) or by telephone. The interviews were audio-recorded and transcribed verbatim. Interviewer field notes were also used in data analysis.

We analyzed the data thematically [ 16 ]. The coding process followed a collaborative and multi-step approach. Initially, three members of the research team independently reviewed and coded a selection of transcripts to identify key ideas and patterns in the data, and form a preliminary coding template. We then met to consolidate individual coding efforts. We compared coding of each transcript, resolving conflicts through discussion and consensus. In coding subsequent transcripts and through a series of meetings, we worked together to finalize the codebook to reflect more analytic codes. We used the finalized template to code all interview transcripts in NVivo (QSR International), a software designed to facilitate qualitative data analysis. We refined the codebook on an as-needed basis by incorporating novel insights gleaned from the coding of additional transcripts, reflecting the iterative nature of the analysis.

We increased the robustness of our methodology by pre-testing interview questions, documenting interview and transcription protocols, using experienced interviewers, and confirming meaning with participants in interviews [ 14 , 15 , 16 ]. We kept detailed records of interviews, field notes, and drafts of the coding template. We made efforts to identify negative cases and provided rich descriptions and illustrative quotes [ 17 ]. We included individuals directly involved in the administration of community-care services on our research team. These individuals provided important context and feedback at each stage of the research process.

This study was approved by the research ethics board at Western University. We obtained informed consent from participants prior to the onset of interviews. We maintained confidentiality through secure storage of interview data (e.g., audio recordings), password-protection of sensitive documents, and the de-identification of transcripts.

Positionality

The authors represent a multidisciplinary team of researchers, clinicians, and community-care leaders. The community-care leaders and clinicians on our team provided key practical expertise to inform the development of interview questions and the analysis of study findings.

We interviewed administrators across 12 community-care organizations in Southwestern Ontario. The sample included representatives from seven organizations that received funding from MCCSS, three organizations that received funding from MOH, and two organizations that received funding from both MCCSS and MOH (Table  1 ). Eleven organizations were not-for-profit, one was a for-profit agency. The organizations provided care in rural ( n =  3), urban ( n =  4), or both rural and urban populations ( n =  5). Seven of the 12 participants were women, nine had been working with their organization for more than 11 years, and all had been working in the community-care sector for more than 12 years (Table  2 ).

We identified three key categories or processes relating to organizational characteristics and their impact on the design and delivery of person-centred care plans: (1) organizational context, (2) organizational culture, and (3) the development and implementation of person-centred care plans.

Organizational context

Organizational context refers to the characteristics of persons-supported, and the nature of services provided. Organizational context accounts for the considerable heterogeneity across organizations in the community-care sector and their approach to person-centred care plans.

Populations served

The majority of organizations included in the study supported individuals with IDDs: “all of the people have been identified as having a developmental disability. That’s part of the eligibility criteria for any funded developmental service in Ontario.” [P10]. Participants described how eligibility was ascertained through the referral process: “ the DSO [Developmental Services Ontario] figures all of that out and then refers them to us .” [P08]. These descriptions highlighted a common access point for publicly-funded adult developmental services in the province. Accordingly, these organizations were primarily funded by MCCSS. Other organizations focused on medically complex individuals including those with acquired brain injuries or those unable to access out-patient services due to physical disabilities: “the typical reason for referral is going to be around a physical impairment… But, with this medically complex population, you’re often seeing comorbidities where there may be some cognitive impairment, early dementia.” [P04]. In these organizations, eligibility and referral were usually coordinated by HCCSS. These insights highlighted the diverse characteristics of community-care populations, emphasizing the need to consider both physical and cognitive health challenges in care provision approaches.

Services offered

The characteristics of persons-supported informed the context of care and the type of services offered by the organization. The different dimensions of services offered within this sector include social and medical care, short and long-term care provision, in-home and community-care, and full and part-time care.

Nature of care: social vs. medical

Many organizations serving individuals with IDDs employed a holistic, psychosocial model of care, designed to support all areas of an individual’s life including supports for independent-living, and community-based education, employment, and recreation services to support personal and professional goals: “we support people in their homes, so residential supports. We also support people in the community, to be a part of the community, participate in the community and also to work in the community.” [P06]. These descriptions reflect a comprehensive approach to care, aiming to address needs within and beyond residential settings to promote active participation within the broader community. In contrast, some organizations followed a biomedical model of care, designed to support specific health needs: “We provide all five therapies… physiotherapy, occupational therapy, speech, social work, and nutrition. In some locations we provide visiting nursing, at some locations shift nursing. We have some clinic-nursing… and we provide personal support and home-making services in a number of locations as well.” [P04]. These organizations adopted a more clinically-focused approach to care. In either instance, the care model and the nature of services offered were largely determined by an organization’s mandate including which gaps they aimed to fill within the community. Many organizations described providing a mixture of social and medical care for individuals with complex needs. However, the implementation of care plans could be impacted by the lack of integration between social and medical care sectors, as some participants spoke to the importance of “[integrating] all of the different healthcare sector services… [including] acute care and public health and home and community care and primary care, and mental health and addictions.” [P04].

Duration of care: short-term vs. long-term

The duration of care also varied based on the needs of persons-supported. Organizations serving individuals with IDDs usually offered support across the lifespan: “We support adults with developmental disabilities and we support them from 18 [years] up until the end of their life.” [P06]. Some organizations provided temporary supports aimed at addressing specific health needs: “For therapies – these are all short-term interventions and typically they’re very specific and focused on certain goals. And so, you may get a referral for physiotherapy that is authorized for three visits or five visits” [P04], or crisis situations (e.g., homelessness): “Our services are then brought in to help provide some level of support, guidance, stabilization resource, and once essentially sustainability and positive outcomes are achieved—then our services are immediately withdrawn.” [P12]. One organization employed a model of care with two service streams, an initial rehabilitation stream that was intended to be short-term and an ongoing service stream for individuals requiring continuing support.

In-home vs. community-based care

Many organizations provided in-home care and community-based supports, where residential supports were designed to help individuals lead independent lives, and community-based supports encouraged participation in community activities to further inclusion and address personal and professional goals. One participant spoke about the range of services offered in the home and community:

“There’s probably two big categories of [services we offer]: community support services—so that includes things like adult day programs, assisted living, meals on wheels, transportation, friendly visiting … and things like blood pressure clinics, exercise programs… and then on the other side we do home care services. In the home care basket, we provide personal support, and we also provide social work support.” [P05].

Likewise, another participant spoke in further detail on the types of services that allow individuals to live independently within their homes, or in community-based residential settings (e.g., long-term care facilities):

“We provide accommodation supports to about 100 people living in our community—which means that we will provide support to them in their own homes. So, anywhere from an hour a week to 24 hours a day. And that service can include things from personal care to home management to money management, cooking, cleaning, and being out and about in communities—so community participation. We also provide supports for about 50 people living in long-term care facilities and that is all community participation support. So, minus the last 2 and a half years because of the pandemic, what that means is that a person living in a long-term care facility with a developmental disability can have our support to get out and about for 2 or 3 hours a week, on average.” [P10].

Full-time vs. part-time support

The person-supported’s needs also determined whether they would receive care within their homes and if they would be supported on a full-time (i.e., 24 h a day, 7 days a week) or part-time basis:

“ It really does range from that intensive 24- hour/7 day a week support, which we actually do provide that level of intense support in the family home, if that’s needed. And then, all the way through to just occasional advocacy support and phone check-in.” [P01].

Organizational Culture

Organizational culture was described as a key influence in the development and implementation of person-centred care plans. The culture of the organization includes their perceptions, attitudes and beliefs surrounding persons-supported; their model of care provision; as well as their willingness to evolve and adapt service provision to optimize care delivery.

Perceptions, attitudes, and beliefs regarding persons-supported

Participants described their organization’s view of persons-supported, with many organizations adopting an inclusionary framework where persons-supported were afforded the same rights and dignities as others in the community. This organizational philosophy was described as being deeply intertwined with an organization’s approach to personalizing programs and services:

“…an organization needs to be able to listen to the people who are receiving the service… and support them, to learn more, figure out, articulate, whatever it is, the service or the supports that they need in order to get and move forward with their life.” [P10].

The focus on the person-supported, their needs, likes, and dislikes, was echoed across organizations, with an emphasis on the impact of “culture and trying to embed for each person who delivers service the importance of understanding the individual.” [P05]. Participants also described their organization’s approach to allowing persons-supported to take risks, make mistakes, and live life on their own terms:

“You have to go and venture out and take some [risks]… We try to exercise that philosophy - people with disabilities should have the same rights and responsibilities as other people in the community. Whether that’s birthing or education, getting a job, having a house they can be proud of, accessing community supports, whether that be [a] library or community centre, or service club, whatever that is.” [P03].

Model of care provision

The model of care provision was heavily influenced by the organization’s values and philosophy. Several organizations employed a flexible model of care where supports were developed around the needs, preferences, and desired outcomes of the person-supported:

“…if we don’t offer [the program they want], we certainly build it. Honestly, most of our programs were either created or built by someone coming to us [and] saying ‘I want to do this with my life,’ or …‘my son would like to do art.’” [P02].

Although there were similarities in models across the different organizations, one participant noted that flexibility can be limited in the congregate care setting as staff must tend to the needs of a group as opposed to an individual:

“Our typical plan of operation outside of the congregate setting is we design services around the needs of the person. We don’t ask them to fit into what we need, we build services for what they need. Within the congregate care setting, we have a specific set of rules and regulations for safety and well-being of the other people that are here.” [P11].

Evolving service orientation

In organizations serving individuals with IDDs, many described shifting from program-based services to more individualized and community-based supports: “The goal was always to get people involved in their community and build in some of those natural supports … [we] are looking to support people in their own communities based on their individual plans.” [P07]. One participant described this model as a person-directed approach as opposed to person-centred, citing the limitations of program-based services in meeting individual needs:

“[Persons-supported] couldn’t [do] what they wanted because they were part of a bigger group. We would listen to the bigger group, but if one person didn’t want to go bowling … we couldn’t support them because everybody had to go bowling.” [P06].

The focus on individualized support could potentially lead to increased inclusion for persons-supported in their communities:

“… people go to Tim Horton’s, and if they go every day at 9 they probably, eventually will meet other people that go at 9 o’clock and maybe strike up a conversation and get to know somebody and join a table … and meet people in the community.” [P02].

By creating routines centred on individual preferences, the person-supported becomes a part of a community with shared interests and values.

Person-centred care plans

Community-care organizations enacted a person-centred approach by creating person-centred care plans for each person-supported. Although all participants said their organization provided person-centred services, there was considerable variation in the specific processes for developing, implementing, and updating care plans.

Developing a person-centred care plan

The development of a care plan includes assessment, consultation, and prioritization. The initial development of the care plan usually involved an assessment of an individual’s needs and goals. Participants described agency-specific assessment processes that often incorporated information from service referrals: “ In addition to the material we get from the DSO [Disability Services Ontario] we facilitate the delivery of an intake package specifically for our services. And that intake package helps to further understand the nature and needs of an individual.” [P12]. Agency-specific assessment processes differed by the nature of services provided and the characteristics of the population. However, most organizations included assessments of “not only physical functioning capabilities, but also cognitive.” [P01]. Assessment also included an appraisal of the suitability of the organization’s services. In instances where persons-supported were seeking residential placements or independent-living support, organizations assessed their ability to carry out the activities of daily living:

“[Our internal assessment] is an overview of all areas of their life. From, ‘do they need assistance with baking, cooking, groceries, cleaning, laundry? Is there going to be day program opportunities included in that residential request for placement? What the medical needs are?’” [P02].

In contrast, the person-supported’s community-based activities were primarily informed by their interests and desired outcomes: “We talk about what kinds of goals they want to work on. What kind of outcomes we’re looking for…” [P06].

The development of the care plan also included a consultation phase, involving conversations with the person-supported, their family members, and potentially external care providers: “We would use the application information, we’d use the supports intensity scale, but we’d also spend time with the person and their connections, their family and friends, in their home to figure out what are the kinds of things that this person needs assistance with.” [P10]. Participants described the person-supported’s view as taking precedence in these meetings: “We definitely include the family or [alternate] decision-maker in that plan, but the person-supported ultimately has the final stamp of approval.” [P08]. Many participants also acknowledged the difficulty of identifying and incorporating the person-supported’s view in cases where opinions clash and the person-supported has difficulty communicating and/or is non-verbal: “Some of the people we support are very good at expressing what they want. Some people are not. Some of our staff are really strong in expressing what they support. …And some of the family members are very strong. So you have to be very careful that the [person-supported] is not being lost in the middle of it.” [P06].

Participants also noted that some persons-supported preferred not to have a care plan:

“Some of the people say ‘I hate [the plans] I don’t want to do them’…. we look at it in a different way then. We’ll use graphic art, we’ll use video, we’ll think outside the box to get them to somehow—because at the end of the day when we’re audited by MCCSS every [person-supported] either has to have [a plan]… or there has to be [an approval of] why it wasn’t completed.” [P02].

Plan development may also include a prioritization process, particularly in cases where resources are limited. A person-supported’s goals could be prioritized using different schemas. One participant noted that “the support coordinator takes the cue from the person-supported - … what they’ve identified as ‘have to have’ and ‘nice to have’. … because the ‘have to haves’ are prioritized.” [P09]. Likewise, the person-supported’s preference could also be identified through “[an] exercise, called ‘what’s important for and what’s important to .’” [P06]. This model, based on a Helen Sanderson approach [ 18 ], was described as being helpful in highlighting what is important to the person-supported, as opposed to what others (i.e., friends, family, staff, etc.) feel is important for them.

Several organizations updated care plans throughout the year, to document progress towards goals, adapt to changing needs and plan for future goals: “We revisit the plan periodically through the year. And if they say the goal is done, we may set another goal.” [P06]. Organizations may also change plans to adapt to the person-supported’s changing health status or personal capacity.

Implementing a person-centred care plan

The implementation of care plans differed based on the nature of services provided by the organization. The delivery of health-based or personal support services often involved matching the length and intensity of care with the individual’s needs and capacity:

“Sometimes that is a long time, sometimes it’s a short time, sometimes it’s an intervention that’s needed for a bit, and then the person is able to function.” [P05].

In contrast, the delivery of community-based services involved matching activities and staff by interests: “[if] a person-supported wants to go out and be involved in the music community, then we pull the staff pool in and match them up according to interest.” [P06].

Broad personal goals were broken down into smaller, specific activities. For example, one participant described their organization’s plan in helping a person-supported achieve his professional goal of securing employment:

“[The person-supported] said ‘Okay, I want a job.’ So for three weeks he was matched up with a facilitator. They came up with an action plan in terms of how to get a job, what kind of job he’s looking for, where he wants to go, where he wants to apply, how to conduct an interview. And after three weeks he got a job.” [P09].

Organizations that provided residential services focused on developing independent-living skills. One participant described their organization’s plan to empowering persons-supported by allowing them to make their own financial decisions:

“If one month they’re looking after their own finances, and they’ve overspent. Well, maybe we help them out with a grocery card or something and say ‘okay, next month how are you going to do this?’ [The person-supported may say], ‘well, maybe I’ll put so much money aside each week rather than doing a big grocery shop the first week and not having enough money left at the end of the month.’” [P03].

The participant noted that “a tremendous amount of learning [happens] when a person is allowed to [take] risks and make their own decisions.” [P03].

Likewise, participants representing organizations that provided residential services described tailoring care to the persons-supported’s sleeping schedule and daily routine:

“We develop a plan and tweak it as we go. With [the person-supported] coming to the home, what worked well was, we found that he wanted to sleep in, so we adjusted the [staff] time. We took a look at his [medication] times in the morning… and [changed] his [medication] times. We found that he wanted to sleep [until] later in the day, so he would get up at 10 o’clock, so then instead of having breakfast, lunch, and supper he would just have a bigger brunch. Just really tailoring the plan around the person-supported, and it’s worked out well.” [P08].

These examples highlight how organizational context and culture influence how organizations operationalize person-centred care plans; the same individual may experience different approaches to care and engage in different activities depending on the organization they receive services from.

In this paper, we described key elements of the person-centred planning process across different community-care organizations in Southwestern Ontario. We also identified that the context and culture of an organization play a central role in informing the process by which services are personalized to an individual’s needs. These findings shed light on the diversity of factors that influence the implementation of person-centred care plans and the degree to which organizations are able to address medical and social needs in an integrated fashion. They also inform future evaluations of person and system-related outcomes of person-centred planning.

There are regulations around individualizing services delivered by community-care organizations, whereby care providers must allow persons-supported to participate in the development and evaluation of their care plans. HCCSS or MOH-funded services are largely focused on in-home rehabilitation or medical care. In contrast, MCCSS-funded organizations often focus on developing independent living skills or promoting community participation, thus highlighting the role of the funding agency in determining organizational context as well as the nature of services and personalization of care plans.

We also identified organizational culture as a key influence in the person-centred planning process. In previous reports, organizational culture, and specifically the way in which staff perceive and view persons-supported and their decision-making capabilities can impact the effective delivery of person-centred care [ 19 ]. Staff support, including their commitment to persons-supported and the person-centred process, has been regarded as one of the most powerful predictors of positive outcomes and goal attainment in the developmental services sector [ 20 , 21 ]. Moreover, in order to be successful, commitment to this process should extend across all levels of the organization, be fully integrated into organizational service delivery, and be reflected in organizational philosophy, values and views of persons-supported [ 22 , 23 , 24 ].

MCCSS mandates that agencies serving individuals with IDDs develop an individual service plan (ISP) for each person-supported, one “that address[es] the person’s goals, preferences and needs.” [ 7 ]. We reference ISPs as person-centred care plans, as is in line with the view of participants in interviews. There are a series of checklists designed to measure compliance with these policies, and the process is iterative, with mandated annual reviews of care plans and active participation by the person-supported [ 25 ]. In our study, the agencies funded by MCCSS adhered to the general framework outlined by these regulations and informed service delivery accordingly. However, participants also described areas for improvement with respect to the implementation of these policies in practice. These policies, while well-intentioned, may imply a one-size-fits-all approach and appear more as an administrative exercise as opposed to a meaningful endeavor designed to optimize care. Participants spoke about individuals who preferred not to have an ISP, and how that in and of itself is a person-centred approach, respecting the person’s wishes. Additionally, we heard about how the goal-setting process may not be realistic as it can be perceived as unnatural to have goals at each point in one’s life. Moreover, participants noted challenges in implementing person-centred care in shared residential settings (e.g., group homes) or in cases where persons-supported had difficulty communicating.

Prior research indicates that individuals living in semi-independent settings fare better across several quality-of-life measures relative to individuals living in group homes, including decreased social dissatisfaction, increased community participation, increased participation in activities of daily living, and increased empowerment [ 26 ]. Furthermore, a recent study by İsvan et al. (2023) found that individuals living in the community (e.g., own home, family home, or foster home) exhibit greater autonomy in making everyday and life decisions, and greater satisfaction with their inclusion in the community [ 27 ]. These findings may be indicative of a reduced focus on person-centred care plan development and implementation in congregate care settings, where limited staff capacity can make it difficult to tend to the needs of everyone in the home. However, poor outcomes may also be explained by potentially more complex health challenges or more severe disability in persons-supported living in congregate care settings. The challenges described in our study are consistent with calls to improve the quality of care provided in residential group home settings [ 28 , 29 ].

In line with our findings, previous literature also describes challenges in implementing person-centred planning for individuals who have difficulty communicating or are non-verbal [ 19 , 30 , 31 , 32 ]. Communication has also been identified as a barrier to patient-centred care for adults with IDDs in healthcare settings [ 33 , 34 ]. Other reports have identified a need for increased training and awareness of diverse communication styles (including careful observation of non-verbal cues) to aid staff in including persons-supported in the development of care plans [ 35 , 36 , 37 ]. Importantly, these methods take substantial time which is often limited, and compounded by staffing shortages that are widespread across the sector [ 38 ]. Similar barriers were identified in interviews with staff and persons-supported at a partner community-care agency within our larger project [ 39 ]; other papers from the project examine strategies used by the organization to overcome these barriers.

Limitations

The findings from this study should be interpreted in the context of the following limitations. There is a risk for social desirability bias, whereby participants may feel pressure to present their care plan process in a more positive light due to societal norms and expectations [ 40 ]. Additionally, the experiences and views of community-care organizations may vary by region and organization type (i.e., for-profit vs. not-for-profit). In this study, we limited participation to agencies providing services in Southwestern Ontario and we were only able to interview one for-profit agency, despite concerted recruitment efforts. Consequently, we may not have fully captured how financial pressures, or different contextual and cultural components of an organization impact their implementation of care plans.

The person-centred planning process in community-care organizations is largely informed by the characteristics of the population served and the nature of services offered (i.e., organizational context). This process usually involves initial and continued consultations with persons-supported to tailor plans to their specific needs and desired outcomes. There are ongoing challenges in the implementation of person-centred planning, including a need for increased adaptability and clarity in current regulations. In some areas, there may be benefit to incorporating nuance in the application of policies (e.g., in cases where a person-supported does not want to have a formal plan in place). In other areas, it may be helpful to have increased guidance on how to optimize care delivery to improve outcomes (e.g., in cases where a person-supported has difficulty communicating, or is residing in a group home). Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Data availability

The datasets generated and analyzed in the current study are not publicly available to maintain participant confidentiality, however access may be granted by the corresponding author upon reasonable request.

Abbreviations

Acquired Brain Injury

Disability Services Ontario

Home and Community Care Support Services

Intellectual and Developmental Disabilities

Individual Service Plan

Ministry of Children, Community and Social Services

Ministry of Health

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Acknowledgements

The authors thank Ruth Armstrong, from PHSS - Medical & Complex Care in Community, for her valuable feedback and support throughout the research process.

This research was funded by the Canadian Institutes of Health Research. The funding agency had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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S.I. conducted the interviews, developed the coding template, coded the data, thematically analyzed the data, and prepared the manuscript. G.Y. helped develop the coding template, and reviewed and approved the final manuscript. B.D. and D.A. helped conceptualize the study, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. L.M. coordinated research activities, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. M.M. conceptualized the study, supervised its implementation, and was a major contributor in reviewing and editing the manuscript. All authors have read and approved the final manuscript.

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Idrees, S., Young, G., Dunne, B. et al. The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada. BMC Health Serv Res 24 , 680 (2024). https://doi.org/10.1186/s12913-024-11089-7

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King’s Conceptual System Theory in Nursing Research Paper

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Introduction

Conceptual systems, goal attainment, clinical quality problem, practice quality improvement initiative, quality committee employment of king’s theory, additional theory.

Various evidence-nursing theories are implemented in practice to define the nursing scope. King’s Conceptual System theory is one correlating to achieving set goals. Namely, the framework highlights that setting and achieving goals requires communication and a mutual objective between the nurse and the patient. Through interactions and communication, the care provider and the patient can find a common denominator regarding treatment objectives and put efforts toward obtaining the said goal. However, for the plans to coincide between those defined by the nurse and the patient, communication is critical. This will facilitate a better understanding of the factors that impact how the care receiver operates and what motivates them. In this paper, King’s Conceptual System Theory will be discussed from the perspective of its systems, its influence on goal attainment, employment in clinical quality circumstances, and additional theories to improve the quality of practice.

King’s theory implies the presence of a set of systems that impact behavior. Namely, the framework developed by Imogene King is based on the influences of the personal, interpersonal, and social systems (Smith & Parker, 2020). The personal system comprises the notions of perception, self, development, body image, learning, time, personal space, and coping. Perception defines how the patient interprets the given information. Self, on the other hand, relates to the definition the patient uses to define themselves as individuals. Development is the action that leads to self-perception. Body image highlights one’s reaction to their physical appearance, and learning is linked to the conceptualization of a state. Time and space correlate with duration and a comfortable distance, respectively. Last but not least, coping is the strategy for dealing with stress.

The interpersonal system goes beyond the “self” and comprises interactions with other people. Namely, the term highlights how the person communicates with other individuals, interacts in a social situation, the role that the care provider takes during said interaction, potential stress following the communication, and the interactive process in which the person connects with the environment (Song & Kim, 2023). Furthermore, the social system exceeds personal perceptions and interactions with others. The term is applied to exemplify the larger group linked to the patient or the goal. Namely, it comprises workplaces as well as healthcare, religious, or educational systems and authorities. Thus, the theory implies that goal attainment relates to one’s personal system, for example, one’s perception of self, interpersonal – comprised of family members, and social – comprised of coworkers.

King’s theory highlights the relationship between the care provider and the patient concerning achieving objectives. Namely, the framework is built with the consideration of the interconnection between the nurse and the individual requiring assistance (Fronczek, 2021). Namely, the nurse participates in the patient’s assessment, diagnosis, and evaluation of whether the health goals will be attained based on the previous analysis. Specifically, goal attainment starts during the assessment when the nurse uses communicative skills to inquire and learn about the patient’s personal, interpersonal, and social systems. Furthermore, the theory implies that nursing diagnosing is the following step in which the healthcare provider determines the challenges that the patient is willing to solve. Last but not least, the evaluation is the stage in which it is determined which goals will be attained by the patient and to what extent. The theory implies that the nurse is focused on providing patient-centered care as the goals of each individual patient are different and require an individualistic approach.

Various clinical quality problems can be identified as issues that negatively impact patient safety as well as the goals and values of the institution responsible for said patient. One of them is a high rate of occurrence of bed sores. Pressure ulcers are skin impairments that are linked to the patient’s limited mobility. However, through effective nursing diagnosis, which is one of the steps highlighted in King’s theory, injuries can be prevented (Wood et al., 2019). For example, the nurse communicates with the patient and determines that they lack physical activity, have had an injury that prevents them from being active, or have a sedentary lifestyle. As a result of said communication, the nurse can set a goal of presenting pressure ulcers both by monitoring the patient and providing care as well as by motivating the individual to be physically active if possible. Moreover, the goal correlates with the hospital’s objectives, as pressure ulcers are unsafe and lead to prolonged hospital stays (Wood et al., 2019). Thus, the goals of the nurse, which is to improve patient well-being, align with the goals of the patient who wants to avoid pain and correlate with the objective of the facility, which is to shorten hospital stays. As a result, it can be highlighted that King’s theory can, indeed, be applied when defining a clinical quality problem, such as a lack of safety mechanisms for pressure ulcer prevention and treatment.

Within the personal clinical practice, King’s theory can, indeed, be applied to improve specific quality improvement initiatives. Specifically, it appears that the goal attainment framework can be employed during the provision of discharge instructions. According to researchers, patients who have not been provided with enough information that they can retain and adhere to in regard to their conditions and prevention measures encounter more negative health outcomes (DeSai et al., 2021). The framework allows for the determination of the patient’s influences and, as a result, the goals that are more likely to be achieved. Thus, in care, the individual is to increase physical activity, and the nurse can determine in which ways said objective could be approached. Under the circumstances that the patient is, for example, a member of a church group, the nurse can provide instructions on the benefits of volunteering while walking or joining an activity with fellow church members. A patient who is more likely to be isolated may follow online exercises and workouts depending on the condition that is to be prevented or addressed. Similarly, a patient with body image issues may be motivated by physical activity linked to weight loss, which would similarly lead to goal attainment. On the other hand, discharge instructions may be provided to a spouse or caretaker in case the patient is more likely to be motivated by people close to them. This highlights that the theory aligns with patient-centered care as it accounts for individual cases and motivations that differ from person to person. A nurse would, therefore, be aware of the best possible measures that can be applied when preparing the patient for discharge.

The quality committee is responsible for monitoring both organizational processes and outcomes. One of the elements that are linked to the quality of care is patient-centered care (Oldland et al., 2020). Namely, the committee ensures that each patient is being approached based on personal wishes, cultural preferences, and needs. As highlighted prior, King’s goal attainment theory is, indeed, one of the approaches correlating with the principles of patient-centered care as it emphasizes the importance of communication (Park, 2021). The quality committee may exercise an assessment by seeking feedback on communication with nurses. For example, the circumstances that can be examined are whether the health goal was achieved. Since the facility’s goals are to ensure patient safety, be financially efficient, and establish regulatory measures that generate success, patient goal attainment aligns with all of the aforementioned values. Thus, the quality committee can align the outcomes with King’s Conceptual Model simply by determining whether the patient’s targets were reached as a result of treatment.

A variety of additional nursing theories can be applied to improve the quality of practice initiatives. Namely, the initiative mentioned previously, which is improved discharge instruction provision, can be addressed through Orem’s Self-Care Deficit Theory. The framework highlights that in order for a patient’s recovery to be successful, the patients themselves are to participate in it and have a level of independence over their efforts toward improved well-being (Smith & Parker, 2020). Thus, a patient who is able to perform certain tasks, such as hygiene or mobility actions, does not require the assistance of a nurse and would likely succeed without the involvement of care providers in each step of the recovery.

King’s Conceptual System Theory is the nursing theory in which the patient’s goals are exemplified based on the systems influencing them. Namely, each individual is bound to personal, interpersonal, and social circumstances that can either maximize or minimize health goal attainment. The goal of the nurse, on the other hand, is patient well-being, and it can be achieved by communicating and understanding the elements that lead to behavioral changes in said individual. The model can be applied to improve the quality of care as well as practice initiatives as it correlates with the value of patient-centered care and considers the differences between people’s needs and preferences. A framework that likewise can be applied to quality improvement is Orem’s Self-Care Deficit Theory which emphasizes the importance of patient participation in care.

DeSai, C., Janowiak, K., Secheli, B., Phelps, E., McDonald, S., Reed, G., & Blomkalns, A. (2021). Empowering patients: Simplifying discharge instructions . BMJ Open Quality , 10 (3). Web.

Fronczek, A. E. (2021). Ushering in a new era for King’s conceptual system and theory of goal attainment . Nursing Science Quarterly , 35 (1), 89–91. Web.

Oldland, E., Botti, M., Hutchinson, A. M., & Redley, B. (2020). A framework of nurses’ responsibilities for Quality Healthcare — exploration of content validity . Collegian , 27 (2), 150–163. Web.

Park, B. M. (2021). Effects of nurse-led intervention programs based on goal attainment theory: A systematic review and meta-analysis . Healthcare , 9 (6), 699. Web.

Smith, M. C., & Parker, M. E. (2020). Nursing theories and nursing practice (5th ed.). F.A. Davis.

Song, M. O., & Kim, S. (2023). The experience of patient safety error for nursing students in covid-19: Focusing on King’s conceptual system theory . International Journal of Environmental Research and Public Health , 20 (3), 2741. Web.

Wood, J., Brown, B., Bartley, A., Margarida Batista Custódio Cavaco, A., Roberts, A. P., Santon, K., & Cook, S. (2019). Reducing pressure ulcers across multiple care settings using a collaborative approach . BMJ Open Quality , 8 (3). Web.

• Essential Nursing Skills in a Patient-Centered Care Approach
• Family/Patient-Centered Care: A Letter
• The Patient-Centered Nursing: Application of Theory
• Change in Nursing Practice: Communicating with Stakeholders
• The Nurse-to-Patient Ratios in Acute Care Setting
• A Change Acton Plan: BayCare Case
• Organizational Change at BayCare Health System
• Discussion: Leadership in Nursing
• Chicago (A-D)
• Chicago (N-B)

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IvyPanda . "King’s Conceptual System Theory in Nursing." June 2, 2024. https://ivypanda.com/essays/kings-conceptual-system-theory-in-nursing/.