Paradoxes of person-centred care: A discussion paper

Lebanese nursing students' perceptions of barriers to the implementation of person-centered care in clinical settings: A qualitative study

AIM

This study aims to investigate how Lebanese nursing students perceive the challenges of implementing person-centered care in clinical settings.

DESIGN

A qualitative descriptive design was adopted for this study.

METHODS

At one of Lebanon's top universities, a qualitative descriptive study design was used with 18 nursing students from various academic levels. Content analysis was used to generate the results after three focus group discussions. The Consolidated Criteria for Reporting Qualitative Research were used to report this study.

RESULTS

The content analysis gave rise to four main themes, namely, "overload", "challenges with education", "unawareness", "establishing connection", and "lack of initiatives related to policy". The results showed a number of obstacles that Lebanese nursing students believed were in the path of providing person-centered care. These obstacles included organisational issues like time restraints and an intense workload, as well as interaction difficulties with patients and healthcare teams, and educational issues like insufficient instruction in person-centered care concepts during nursing programs.

The impact of need-based care on formal caregivers' wellbeing in nursing homes: A cluster randomized controlled trial

BACKGROUND

Need-based care is a structured and standardized model that supports formal caregivers in nursing homes in delivering person-centered care by responding with tailored non-pharmacological interventions on residents' unmet needs as well as having positive effects on behavioral and psychological symptoms on residents with dementia. However, limited resources as well as the shortage of caregivers in nursing homes make the implementation of need-based care challenging, especially when it comes to finding ways to spend more time with residents. The aim of this study is to evaluate the impact of the implementation of need-based care in nursing homes on formal caregivers' wellbeing.

METHODS

A three-arm cluster randomized controlled trial was set up in 24 Belgian nursing homes: formal caregivers in the 'need-based care' group (intervention; n = 195) spent time twice a week with residents who had behavioral and psychological symptoms according to the principles of need-based care while formal caregivers in the 'time' group (n = 257) filled in the way they spent time twice a week; a third group delivered standard care (n = 299). An implementation strategy was built upon the Implementation Quality Framework and used in the 'need-based care group'. A total of 741 formal caregivers completed the digital questionnaire at one or more of the five time points (every nine weeks) between November 2021 and July 2022; they rated their sense of competence in dementia care, level of burnout, and, level of engagement. Moments of time were registered in a printed registration book.

RESULTS

Only formal caregivers from the 'need-based care' group experienced a higher sense of competence in dementia care at time points three (p = 0.010) and four (p = 0.001) compared with baseline with an increase of respectively 1.5 (95 % confidence interval [0.25, 2.84]) and 2.4 (95 % confidence interval [0.77, 4.04]) points. No differences in scores on burnout and engagement were found.

CONCLUSION

Despite challenging workforce circumstances in nursing homes, caregivers in the need-based care group as well as in the time group were able to spend time twice a week with residents with behavioral and psychological symptoms. No negative effects were found on formal caregivers' wellbeing after the implementation of need-based care in nursing homes. However, it requires strong leadership and the use of well-considered implementation strategies including reflective practice.

TRIAL REGISTRY

Trial registration number ISRCTN56768265 (10/08/2023).

Patients' experiences of patient-centred care in hospital setting: A systematic review of qualitative studies

BACKGROUND

Patient-centred care (PCC) has been proposed as an appropriate approach for addressing current shifts in healthcare needs. Although the importance of PCC is generally recognised, PCC is poorly understood by patients in the hospital settings.

OBJECTIVES

To identify patients' experiences of PCC in hospital settings.

METHODOLOGICAL DESIGN

This systematic review followed the Joanna Briggs Institute's (JBI) guidance for systematic reviews of qualitative evidence and the PRISMA checklist for reporting systematic reviews. The search strategy included peer-reviewed qualitative studies published after 2010 in English or Finnish. The databases searched were SCOPUS, MEDLINE, CINAHL and Medic. Unpublished studies and grey literature were searched in MedNar. Ten qualitative studies were included, and their quality was assessed by two independent reviewers using JBI quality assessment criteria. The data were analysed using thematic analysis.

SETTING AND PARTICIPANTS

Studies were included if they had explored adult patient experiences of PCC in hospital settings.

RESULTS

A thematic analysis produced 14 subthemes which were grouped into five analytical themes: the presence of the professional, patient involvement in care, receiving information, the patient-professional relationship and being seen as a person.

CONCLUSIONS AND IMPLICATIONS

This review suggests that the implementation and provision of PCC in hospitals is incomplete and patients' involvement in their own care should be in the focus of PCC. The majority of patients experienced receiving PCC, but others did not. The need for improvement of patient involvement was strongly emphasised. Patients highlighted the importance of professionals being present and spending time with patients. Patients felt well-informed about their care but expressed the need for better communication. Meaningful patient-professional relationships were brokered by professionals demonstrating genuine care and respecting the patient as an individual. To improve the implementation of PCC, patient experiences should be considered in the development of relevant hospital care strategies. In addition, more training in PCC and patient-professional communication should be provided to health care professionals.

Healthcare professionals' experiences of job satisfaction when providing person-centred care: a systematic review of qualitative studies

OBJECTIVES

This qualitative systematic review aimed to explore and synthesise healthcare professionals' (HCPs) experiences of job satisfaction when providing person-centred care (PCC) in healthcare settings in Europe.

METHOD

This systematic review of qualitative studies was followed by a thematic synthesis applying an inductive approach. Studies concerning HCPs and different levels of healthcare in Europe were eligible for inclusion. The CINAHL, PubMed and Scopus databases were searched. Study titles, abstracts and full texts were screened for relevance. Included studies were assessed for methodological quality using a quality appraisal checklist. Data were extracted and synthesised via thematic synthesis, generating analytical themes.

RESULTS

Seventeen studies were included in the final thematic synthesis, and eight analytical themes were derived. Most studies were conducted in Sweden and the UK and were performed in hospitals, nursing homes, elderly care and primary care. Thirteen of these studies were qualitative and four used a mixed-method design in which the qualitative part was used for analysis. HCPs experienced challenges adapting to a new remoulded professional role and felt torn and inadequate due to ambiguities between organisational structures, task-oriented care and PCC. Improved job satisfaction was experienced when providing PCC in line with ethical expectations, patients and colleagues expressed appreciation and team collaboration improved, while learning new skills generated motivation.

CONCLUSION

This systematic review found varied experiences among HCPs. Notably, the new professional role was experienced to entail disorientation and uncertainty; importantly, it also entailed experiences of job satisfaction such as meaningfulness, an improved relationship between HCPs and patients, appreciation and collaboration. To facilitate PCC implementation, healthcare organisations should focus on supporting HCPs through collaborational structures, and resources such as time, space and staffing.

PROSPERO REGISTRATION NUMBER

CRD42022304732.

Experiences of older people, healthcare providers and caregivers on implementing person-centered care for community-dwelling older people: a systematic review and qualitative meta-synthesis

BACKGROUND

Person-centered care (PCC) is a critical approach to improving the quality of care for community-dwelling older people. Old-age care services could be provided according to older peoples' choices, needs, and preferences. The purpose of this study was to synthesize research evidence on the experiences of older people, healthcare providers, and caregivers with PCC and to identify the enablers and barriers to implementing PCC for community-dwelling older people.

METHODS

A meta-synthesis of qualitative research design was adopted. Data searches were performed using CINAHL (EBSCOhost), PubMed (OvidSP), Embase (Ovid), Cochrane Database, and PsycINFO (Ovid) in published articles and were reviewed from the earliest date to February 2023. The Qualitative Method Appraisal Tool was used to conduct a quality appraisal on selected articles. Data were extracted based on the capacity, opportunity, and motivation-behavior model (COM-B model), and the findings were synthesized using the meta-aggregative approach.

RESULTS

Twelve included articles were analyzed to identify 122 findings that were organized into 11 categories and combined into three synthesized findings-capacities of older people, healthcare providers, and caregivers; opportunities in the implementation of PCC; motivation in implementing PCC. Capacities consisted of a lack of person-centered knowledge and skills, negative attitudes toward shared decision-making, and a lack of formal training to enhance capabilities among HCPs. Opportunities included a lack of coordination in resource allocation, strengthening multidisciplinary teamwork, establishing a desirable environment, and time constraints. Motivation in implementing PCC included encouraging self-reflection and regulation, respecting the autonomy of older people, lack of clear reward and empowerment mechanisms, and being resilient and optimistic.

CONCLUSIONS

The findings of this research provide a reference for implementing successful PCC in the community. The researchers identified barriers and facilitators of implementing PCC, facilitating through stakeholder's person-centered knowledge and skills being valued and respecting the autonomy of older people. Establishing a positive environment and strengthening multidisciplinary team members also promotes the implementation of PCC. However, additional studies are required to explore the influencing factors and address the barriers.

Impact of the person-centred intervention guided self-determination across healthcare settings-An integrated review

AIM

To review the evidence of the existing literature on the impact of guided self-determination across methodologies in different healthcare settings.

METHODS

An integrated five-stage review.

RESULTS

Forty-five eligible papers were included. Guided self-determination was applied in full- or small-scale, or combined with another intervention or approach in different healthcare settings handling, for example diabetes, stroke survivorship, schizophrenia, attention-deficit hyperactivity disorder and medical disorder, gynaecological and breast cancer, endometriosis, persons with chronic pain, persons in haemodialysis and intensive care survivors. The included studies covered 12 randomised trials, 26 qualitative and seven papers of different methodology. A statistically significant effect was found in three trials. Six main themes describe the qualitative findings across papers on patients: (1) Guided self-determination reduces disease-related loneliness, (2) Insight enables integration of life and disease, (3) Reflection sheets-appreciated but challenging tool to prompt insights and person-specific knowledge, (4) New person-specific knowledge enables person-centred support, (5) Feeling seen and believed in a new and trusted relationship and (6) Exchange of knowledge enables the development of life skills. Four themes describe the healthcare professionals' experience: (1) Change of usual practice-a decision from above, (2) A new role-unlearning previous behaviour and need for support, (3) Reflection sheets as facilitators and barriers and (4) Discovering the benefits of changing to a person-centred approach.

CONCLUSION

Overall, guided self-determination proved to have a great impact on patient important outcomes and was useful and well-accepted by the majority of patients and healthcare professionals. Albeit guided self-determination is not a 'one size fits all' method. Continuous training and supervision of professionals are a necessary mean when implementing guided self-determination to enhance adoption and sustainability in clinical practice.

Fostering globally competent dental students through virtual team-working, problem-solving and person-centred multi-disciplinary care planning

Background/purpose

: Development and acquisition of communication, logical thinking, team-building, critical appraisal, critical thinking and person-centred multi-disciplinary care planning must be considered as skill sets and global core competencies for a dental professional. Therefore, an international online study course to foster undergraduate dental students' skill sets in these areas was established and this study aimed to report the perceptions of participants.

Materials and methods

An international online course consisting of three levels pertaining to the school year was delivered to dental undergraduates of Japan and Thailand from September to December in 2021. An online questionnaire survey was conducted to obtain feedback from the participants and assess the implementation of the course.

Results

In total, 64 responses were obtained from students who participated in all the assigned online sessions and completed the questionnaire (a response rate of 88%). More than 95% of students from each level felt that the programme increased their motivation to study clinical dentistry, and was beneficial for their future and made them appreciate the importance of participating in international exchange. The ratio of favourable respondents was more than 90% with a 95% confidence interval.

Conclusion

Fostering globally competent dental students is important and the acquisition of necessary skill sets could be enhanced through international virtual team-working, problem-solving and person-centred multi-disciplinary care planning activities. These are beneficial for undergraduate dental student training so that they graduate with a broader global perspective and an appreciation of the importance of delivering person-centred culturally sensitive dental care.

Operationalisation of person-centred care in a real-world setting: a case study with six embedded units

Background

Although person-centred care (PCC) is growing globally in popularity it is often vague and lacks conceptual clarity and definition. The ambiguity stretches from PCC’s underlying philosophical principles and definitions of the concept to how it is operationalised and practised on the ground by health care professionals. We explore how the PCC model by the Gothenburg University Centre for Person-centred Care (GPCC) was operationalised in a real-world setting by using a set of recommendations by Fixsen and others that define and structure the core components of innovations in four distinct but interrelated components: philosophical principles and values, contextual factors, structural elements and core practices. Thus, this study aimed to increase knowledge about core practices in PCC in six health care units in real-world circumstances.

Methods

A case study with six embedded health care units was conducted from 2016 to 2019. We collected data from three sources: interviews (n = 12) with change agents, activity logs and written documents. Data were triangulated, and core practices were identified and deductively coded to the PCC model’s structural elements: initiating, working and safeguarding the partnership with patients.

Results

We identified operationalisations of PCC in line with the three structural elements in the GPCC model at all included health care units. A range of both similarities and dissimilarities between units were identified, including the level of detail in describing PCC practices, when these practices were conducted and by whom at the workplace. The recommendations for describing the core components of PCC also helped us identify how some operationalisations of PCC seemed more driven by contextual factors, including a new regulation for planning and documenting care across health care specialities.

Conclusions

Our findings show how PCC is operationalised in different health care units in a real-world setting based on change agents’ understanding of the concept and their unique context. Increased knowledge of PCC and its philosophical principles and values, contextual factors, structural elements and core practices, is necessary to build a common understanding of the PCC-concept. Such knowledge is essential when PCC is operationalised as part of implementation efforts in health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08516-y.

Developing a global practice-based framework of person-centred care from primary data: a cross-national qualitative study with patients, caregivers and healthcare professionals

INTRODUCTION

Person-centred care (PCC) is internationally recognised as a critical component of high-quality healthcare. However, PCC evolved in a few high-income countries and there are limited data exploring this concept across the vast majority of countries which are low- and middle-income. This study aimed to appraise and adapt a PCC model across three serious physical conditions in three middle-income countries and generate an evidence-based framework and recommendations for globally relevant PCC.

METHODS

Cross-national, cross-sectional qualitative study. In depth, semistructured interviews conducted with: advanced cancer patients in Jordan (n=50), their caregivers (n=20) and healthcare professionals (HCPs) (n=20); chronic obstructive pulmonary disease patients in South Africa (n=22), their caregivers (n=19) and HCPs (n=22); heart failure patients in Thailand (n=14), their caregivers (n=10) and HCPs (n=12). Data were analysed using framework analysis. Santana et al's PCC model (2018) and Giusti et al's systematic review (2020) were used to construct an a priori coding frame for deductive analysis, with additional inductive coding for coding that did not fit the frame.

RESULTS

The findings both reveal specific practical actions that contribute towards delivering PCC and highlight new cross-national domains of person-centredness: interdependency and collectivism; bringing care into the home and community; equity and non-discrimination; addressing health and illness within the context of limited resources; and workforce well-being.

CONCLUSION

The data suggest that PCC requires particular structural features of the healthcare system to be in place, such as professional education in PCC values and partnerships with community-based workers. These structures may better enable PCC processes, including tailored information sharing and providing genuine opportunities for patients to do the things that matter to them, such as making informed care decisions and sustaining social relationships. PCC must also accommodate a collectivist perspective and support the well-being of the workforce.

Empowering or addicting? An analysis of the effects of team members–supervisor relationships on job satisfaction in healthcare

Patient-centredness relies on integrated care, which requires teamwork to be effectively implemented. Positive relationships between team members and supervisors are crucial to enhance health professionals’ satisfaction with their job and, consequently, to increase their commitment to organizational excellence. However, the positive effects of team members–supervisor exchange may dilute when the team is endowed with autonomy at work. The article proposes a moderation analysis aimed at collecting evidence of the implications of team members–supervisor relationships on job satisfaction (JS) with team autonomy (TA) as a moderating variable. Results of the study suggest that positive exchanges between team members and supervisors enhance health professionals’ satisfaction with their job. However, TA acts as a negative and statistically significant moderator. Good exchanges between team members and their supervisor seem to lose their positive effects on JS when health professionals are provided with a greater self-determination to accomplish their organizational activities. Tailored management interventions should be designed to sustain teamwork when increased autonomy at work is assigned to health professionals.

What matters to older adults? Exploring person-centred care during and after transitions between hospital and home

AIMS AND OBJECTIVES

To explore person-centred care provided to a group of older adults (65+) by understanding their experiences of care received, their participation in care and what matters to them during and after the transition process between hospital and home.

BACKGROUND

Although facilitating person-centred care (PCC) has gained increasing importance globally over the last few decades, its practical implementation has been challenging. This has caused difficulties in determining its core elements and best practices. Person-centred care aims to deliver healthcare services based on individuals' preferences. Several approaches have been developed to better implement person-centred care practices. The Norwegian transitional and follow-up model, 'Holistic Continuity of Patient Care', chooses the 'What Matters to You?'

APPROACH

Other approaches include 'Shared Decision Making' and 'Continuity of Care'.

DESIGN

This study employed a qualitative design.

METHODS

Individual repeated interviews were conducted among eight participants. A hermeneutic exploratory research method was chosen. The COREQ checklist was followed.

RESULTS

Three main themes related to person-centred care emerged: what matters in meetings with the individual healthcare worker, mobilising health-promoting capabilities and resources and what matters when being in the organisational healthcare system.

CONCLUSION

To participate in their own health issues, older people need to be empowered and better informed about the importance and scope of person-centred care. 'What Matters to You?' is a good focus for the direction of care but can lead to a simplified understanding of individuals' preferences. Increased focus on how care recipients' capabilities and resources affect their responding is needed.

RELEVANCE TO CLINICAL PRACTICE

Ensuring that person-centred aspects are incorporated into the entire healthcare system requires better methods of engaging and empowering older adults in healthcare settings; more focus on PCC competence and skills of healthcare professionals as well as better integration of PCC practices into healthcare administration and policies.

Epistemic injustices in clinical communication: the example of narrative elicitation in person-centred care

The increasing popularity of the term 'person-centred' in the healthcare literature and a wide range of ideals and practices it implies point to the need for a more inclusive and holistic healthcare provision. A framework developed in a Swedish context suggested narrative elicitation as a key practice in transition to person-centred care. Initiating clinical communication by inviting people to tell their stories makes persistent yet often subtle problems in clinical communication visible. By drawing upon an observational study on narrative elicitation and vignette-based focus group interviews with nurses, our aim is to trace 'credibility deficits' (Fricker 2007. Epistemic Injustice. Power and the Ethics of Knowing. Oxford: Oxford University Press) and 'credibility excesses' (Medina 2011, Social Epistemology, 25, 1, 15-35, 2013, The Epistemology of Resistance: Gender and Racial Oppression, Epistemic Injustice, and the Social Imagination. Oxford: Oxford University Press) in narrative elicitation. We argue that narrative elicitation may be one way to tackle epistemic injustices by giving voice to previously silenced groups, yet it is not enough to erase the effects of 'credibility deficits' in clinical communication. Rather than judging individual professionals' success or failure in eliciting narratives, we underline some extrinsic problems of narrative elicitation, namely structural and positional inequalities reflecting on narrative elicitation and the credibility of patients. 'Credibility excesses' can be useful and indicative to better understand where they are missing.