presentation on person centred care

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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Person-Centered Care

The relationship between value-based care and person-centered care.

In a value-based health care system, doctors and other health care providers deliver high-quality care using a person-centered care approach. This differs from a traditional fee-for-service system where patients get their health care from multiple, siloed specialists who focus on a specific health issue rather than patients’ comprehensive, long-term needs.

Person-centered care includes:

• Care that’s guided and informed by patients’ goals, preferences, and values
• Success measured by patient-reported outcomes 
• Integrated and coordinated care across health systems, providers, and care settings
• Managing chronic and complex conditions 
• Relationships built on trust and a commitment to long-term well-being

An example of person-centered care

Tyler meets with his doctor about breathing problems and is diagnosed with asthma. In addition to prescribing Tyler a rescue inhaler to treat the symptoms, his doctor follows up with a telehealth visit to identify contributing factors, including smoking and his current living conditions, and develop a treatment plan. Together they come up with a comprehensive plan that considers Tyler’s related health, behavioral, and social needs. For example, the plan includes connecting Tyler with a smoking cessation program when he is ready to quit. The plan also leverages community partners and public services who can help him understand what in his apartment might contribute to his asthma and where he can get help to improve his living situation. 

For more information about the CMS Innovation Center’s new strategy and the future of value-based care, visit our Strategic Direction webpage .

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Person-centred care made simple What everyone should know about person-centred care

October 2014

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• Person-centred care
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• This seeks to provide a quick overview of person-centred care, offering a clear explanation of the principles, why it is important, how it has developed, and some examples to help those considering putting person-centred care into practice.
• It's written for anyone interested in health and health care, including health care professionals and those who use the NHS.

The challenges facing the NHS are well understood. There are growing numbers of older people and people living with long-term conditions and disabilities. At the same time, health and social care budgets are under increasing pressure.

If we are to provide high-quality care that affords people the best possible quality of life, we need to rethink the relationship between people and the services that provide their care.

In person-centred care, health and social care professionals work collaboratively with people who use services. Person-centred care supports people to develop the knowledge, skills and confidence they need to more effectively manage and make informed decisions about their own health and health care. It is coordinated and tailored to the needs of the individual. And, crucially, it ensures that people are always treated with dignity, compassion and respect.

Cite this publication

Person-centred care made simple. The Health Foundation; 2014 (www.health.org.uk/publications/person-centred-care-made-simple).

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What is Person-Centred Care?

Last updated on 4th April 2023

In this article

Person-centred care is a fundamental principle of the caring profession. It essentially means that any care is focused on the needs of the individual, rather than the organisational needs of the service.

In previous generations, patients and people in care or hospital were content to sit back and accept whatever type of care was given to them, regardless of whether it actually suited their needs or not. Today most people have their own opinions of how they wish to be treated so any caregiver or organisation needs to be flexible and make the system suit the person needing care, rather than the other way around.

Policy makers at the NHS have been working to introduce the principles of patient-centred care for at least the last 20 years. And according to statistics, some areas have seen a marked improvement.

In cancer care, for example, 76% of patients undergoing treatment reported that this was fully explained and they felt involved with decisions and treatment.

However, not all sectors of the caring profession have delivered such positive findings, and with the difficulties of gaining accurate feedback from vulnerable patients, especially from those with mental health issues, it can be hard to evaluate where improvements can be made.

So let’s examine the principles of person-centred care and find out why it is so important to work in a person-centred way.

What is person-centred care?

Person-centred care is one of the fundamental principles and standards of care as laid down by the Care Quality Commission – the independent regulator of health and social care in England.

There are 13 principles in all and they all need to be implemented when working in care or the health profession. They are all equally important and are as follows:

Person-centred care – all treatment or care must be suitable for the patient’s own individual needs and preferences. This should be in their best interests and not be implemented solely to fit in with the structure of the organisation.

Dignity and respect – this is a fundamental human right that ensures that everyone using the service is treated in an equal respectful manner and in ways that does not cause them a loss of dignity. This will include protecting people’s privacy when assisting with dressing or visiting the toilet. It also includes the way that patients are addressed.

Consent – all people undergoing care must give their consent before treatment is carried out. If this is not possible, the patient should have someone who makes these decisions for them, such as a family member or someone working for their best interests.

Safety – healthcare providers have a duty to keep patients in their care safe and free from harm. This means that all staff should be adequately trained and have professional levels of competence, qualifications and training.

Safeguarding – this helps protect the vulnerable from abuse, neglect or degrading treatment. Safeguarding helps ensure that patients or people in care do not have their liberty curtailed any more than strictly necessary. To find out more, check out our article on Deprivation of Liberty Safeguards .

Food and drink – all people in care or undergoing treatment should receive enough food and drink to keep them well and free from hunger or thirst. In some cases, people need assistance to eat and to drink and this should always be provided by staff. There have been cases where food has been left in front of people unable to feed themselves, so simply delivering the food to the patient is not always enough.

Good governance – this covers everything from care plans which must be maintained for all patients or people in care, to the safety and welfare of patients and staff alike. There should be clear governance in place so that the service can function in a consistent way in all areas and improve where necessary.

Complaints – there should be an effective complaints procedure so that if a patient or patient’s representative such as a family member has cause for complaint there is a system in place. The service should take any complaints seriously and be able to investigate the problem, taking action if any problems are highlighted.

Premises and equipment – all care facilities, hospitals, nursing homes and anywhere else that provides care for patients, should be fit for purpose. All equipment needs to be in good order and the premises clean and in good condition.

Suitability of staff – all staff working in the service should be proven to be fit and proper. This means that they should be fully trained to be able to carry out their responsibilities correctly and that they should have a current DBS check to ensure that they are suitable for this type of work.

A strong recruitment policy is crucially important and all applicant backgrounds should be thoroughly checked out before they start working with vulnerable people. See our guide to DBS checks to find out more.

Staff training and legislation – staff need to be fully supported in order to carry out their caring responsibilities. This means that they should be properly trained and supervised. Aspects of care such as moving and handling should conform to all legislation and all staff should be fully trained in safe practices to avoid any injuries to themselves or the patients.

Duty of candour – all aspects of care need to be open and honest. That way, if something does go wrong, and after all sometimes things do happen, you can explain and apologise to the patient and provide support. If there is this candour within the facility, your patients will feel that they are safe and that you are not hushing up or protecting practices or staff which are questionable.

A care facility must display their CQC ratings – all healthcare providers must display their CQC ratings where they can be seen, including in the premises and on the website. The Care Quality Commission carries out inspections of all healthcare facilities.

There are four ratings:

• Outstanding – the service is performing exceptionally well.
• Good – the service is performing well and meets expectations.
• Requires Improvement – the service is not performing as well as expected and has received notifications of how to improve.
• Inadequate – the service is performing badly and action has been taken against the providers.

How do you provide person-centred care?

To provide person-centred care you need to consider the needs of the individual, so how you do this will depend upon each person you deal with. However, the principles are always the same; you have to respect that each person has his or her own views on what is best for them and that they have their own values and priorities that need to be respected.

Working in a person-centred way is rewarding for both you and the person you care for. By getting to know and to understand the person you care for, you can involve them in any decisions. These do not always have to be big decisions, but for the person in care they are certainly life-enhancing.

Small acts like involving your patient in clothes choices for the day instead of laying out your chosen outfit for the day gives them a degree of autonomy. Asking them which of the menu choices they prefer keeps them in control of their own diet.

Person-centred care is important for the daily well-being of the patient. For example, you might know that someone enjoys watching the birds from their window so you might ask them if they would like to sit by it for a while, rather than wheeling them into the TV lounge as a matter of course. Go wild – try filling the bird feeders to encourage the birds to come! These types of small actions may not seem very important to you but they are extremely important for patient well-being.

It is also essential that you always ask the patient beforehand. After all we all have different moods on different days. Your birdwatching patient might like to do this sometimes but other times may prefer to do something else. It is not enough to say, “Alf likes birdwatching so staff should always put him there!” He might not always feel like it, so be mindful before you make assumptions.

When it comes to more serious care decisions, taking time to explain the options will enable the patient to choose what is best for them. After all, being treated like an individual rather than an object or job of work to fit into a busy schedule is very demeaning and undignified and goes against the 13 principles of the Care Quality Commission.

Why is person-centred care important for patients?

The benefits of person-centred care for patients are enormous, so let’s take a look at a few of these:

• The patient will trust you and feel confident in your care: if you treat someone with dignity and respect and help them retain their independence as much as possible, it will make the whole experience far more comfortable and easier for both of you. For example, asking your patient if they are ready to be lifted in the hoist is far less alarming than just raising it suddenly without giving them a warning or asking for their consent. Once your patient trusts that you will not carry out fast unexpected actions without their consent they can relax and trust you with their care.
• Patient-centred care improves quality of life: by meeting the emotional, social and practical needs of your patient you can help them enjoy life. Disabilities, old age, special needs all have their unique challenges but this does not mean that people cannot live rich and fulfilling lives to the best of their abilities. Getting to know your patient and respecting their tastes and preferences greatly improves quality of life in care.
• Getting to know your patients helps you understand them: often people have difficulties in communicating such as with people suffering from dementia, those with learning difficulties or people with communication difficulties such as stroke victims. With person-centred care you can learn to understand their mode of communication as well as knowing what makes them tick, so can help them maximise their quality of care experience. Without taking time to understand, your patient may become frustrated, angry, aggressive or tearful, when all of this could have been so easily avoided if you had just taken the time to understand and get to know the person.
• Person-centred care improves independence and confidence: if your patient is fully involved in decision-making, he or she is far more likely to stick to the care plan and take medication, do exercises or anything else the care plan entails. This is not always possible but if you and the patient are on the same side, it will improve their independence, and it gives them some control over their treatment. It improves confidence too because they feel that any decisions come down to them.

Why is person-centred care important for healthcare workers?

Do you know the old adage, “you can take a horse to water but you can’t make him drink?”

As people, we are all exactly the same when it comes to doing this and most of us find it much easier to do something we want to do, rather than doing something we are told to do without explanation. Let’s take a further look at some of the benefits of person-centred care for healthcare workers.

• Person-centred care makes the whole job much easier –  When you are working in a person-centred way and respect the individual needs and wishes of the patient, your job is much easier because you will be working with the patient rather than against him or her.
• Person-centred care helps people stick to their own care plans –  As outlined above, if your patient is fully involved in decision-making, he or she is far more likely to stick to the care plan and take medication, do exercises or anything else the care plan entails.
• Person-centred care makes for a happier working environment –  If your patients are happy it has a positive effect upon the morale of your healthcare team and the whole environment of the home or care facility.
• Person-centred care save money and time –  Tailoring the care and medication to suit the patient means that they are more likely to stick with the care plan and actually take their medication or use their disability aids. If someone has been involved and has agreed to a care plan they are less likely to go against it. After all, if somebody feels a care package has been foisted upon them without their own permission they are far less likely to stick to it.
• Person-centred care improves the strain on the NHS –  If people feel they are being listened to and are confident in your care they are far less likely to try to admit themselves to hospital via A and E or to turn to costly private treatment.
• It is the right thing to do – Working in healthcare can be rewarding but only if you consider the well-being of the patient before everything else. Put simply, it is the right thing to do. Doing the best job you can do for your patients not only makes them feel happy, you can sleep easy at night knowing that you have made a difference to many people’s lives in a positive way.

Case study of person-centred care

Mary is an elderly woman of 83 who suffers from mild dementia but was happy living at home with care support. Everything was fine until the support team noticed that she began to struggle with the food that was served to her, refusing to eat and drink and spitting things out, sometimes making herself sick. As a result, her health and weight deteriorated and it seemed likely that she would need to move to a nursing home.

The family and care team felt this would be a shame as she was otherwise happy and managing at home with support, so they looked for a solution. They encouraged Mary with the aid of pictures to talk about foods that she liked and the sort of things she ate when younger. And with the assistance of a key worker, Mary was encouraged to make dietary choices and participate in the preparation of the food. Once the new food plan was initiated, Mary stopped refusing food and her weight and health has improved as a result.

What are the principles of person-centred care?

There are four principles of person-centred care which have been outlined by the Health Foundation. These should be adhered to whenever you work to support and care for patients.

1. Always treat people with respect, compassion and dignity

Just because someone is now in the position where they need care and support, this doesn’t mean that they are now irrelevant or without their own thoughts, feelings, ideas or beliefs.

You should always treat your patients with respect, compassion and dignity. It is important for all of us to feel validated, and when people in care feel that they have a voice and are respected as individuals, their physical and emotional health will improve.

2. Provide coordinated support

It is important that person-centred care is delivered on a consistent level and this means keeping records. That way the various agencies and care providers who may be working together to care for the patient can deliver consistent care without interruptions. It means that medication is not disrupted and that carers can share information between themselves. It is important that patient confidentiality is always respected, but communication between professionals should always be open and transparent.

3. Provide personalised care to each person

We are all different. We all have different motivations, requirements, likes and dislikes and the same goes for your patients. This means it is important to treat each patient as an individual. If you offer a standardised approach to all your patients you risk damaging their self-esteem and quality of life.

For example, some nursing homes mistakenly believe that playing World War 2 songs back to back is good for their elderly residents. Yet most people in care are not only too young to remember this time, but they will have their own tastes, and it is unlikely they would all choose to listen to this type of music themselves.

4. Help patients realise their strengths and abilities so they can retain some degree of independence

The importance of person-centred care should help patients keep some control over their decisions and to do as much as they can for themselves. However, this can be a fine line between providing good quality care and with asking too much from your patients.

If you require too much from your patients they may feel that you don’t care and cannot be bothered to help them. Too much help will cause dependence and will erode their abilities.

The answer is good communication. Try and encourage your patients to do as much as possible for themselves but provide support when necessary.

The benefits of person-centred care are far reaching. Not only is it good for the patient to retain as much independence as possible and be treated as an individual, it helps the healthcare professional if the patient or resident is happy and consents to treatment.

If you are an overstretched health worker it can be difficult to think of the well-being of all your charges. But if everyone in your service keeps to the ethos of providing good quality person-centred care, this will make your job easier. Communicating and record keeping is paramount between professionals, and actually taking time to get to know your patients is very rewarding and will help you provide good quality care.

At the end of the day, person-centred care is the right thing to do. It is a fundamental human right to be treated with respect and dignity whatever our circumstances. And as a caregiver or healthcare professional you have the power to make a positive difference to your patients’ lives.

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About the author

Jane Higgins

Jane works with the CPD Online College to produce great articles and has been with us since 2019. Specialising in numerous areas of content, Jane has a vast writing experience and mainly works on our health & safety and mental health posts. Outside work Jane enjoys playing music, learning foreign languages and swimming in the sea even when it is far too cold for comfort!

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MCA: Care planning, involvement and person-centred care

This section explores two key themes that are central to care planning within the MCA framework: involvement, and keeping the wishes of the person at the centre of their care and support. It emphasises that building relationships and good communication are critical to meaningful involvement.

Involving people in decisions about them

Involving people in decisions about their care is intrinsic to the principles of the MCA and should be evident in every care and support plan. Research on mental health and wellbeing demonstrates that involvement leads to improved service outcomes and enhances mental wellbeing. [9] People who use services and their carers are experts by experience. By bringing their knowledge and ideas, they give a fresh perspective on how their particular needs for care and support can best be met.

Providers and commissioners must challenge assumptions about how care plans are developed that limit the level of active involvement by the user. Supporting people to be involved in decisions about their care and treatment should be reflected in the ethos, management, policies and care practice of each service. All services should be able to show how they do this.

Meaningful involvement is based on a sharing of power between the person using the service and the provider. Involving people in designing their care plans means:

• having a conversation among equals who are working together to help one of them make a decision about their care and support
• that the person is considered as a whole in all aspects of their life
• that the plan belongs to the person, keeping them in control
• that the plan is only implemented or shared with others if the person gives consent (where they have capacity to do so).  

These are identified [10] as key elements in person-centred care planning for people with long-term conditions. They are, however, equally applicable to care planning for all adults in need of care and support:

…care planning is a conversation between the person and the healthcare practitioner about the impact their condition has on their life, and how they can be supported to best meet their health and wellbeing needs in a whole-life way. The care plan is owned by the individual, and shared with others with their consent. It is important that a discussion takes place, there is a record of it, and people know they have a plan.

Producing a shared written record of how the person will be cared for tells them (and others whom they wish to involve) what to expect. Giving this information clearly maintains the accountability of the service provider and enables people to raise any concerns about the care plan or its delivery.

What to look for

• The person or their family/friends are able to tell you how they were involved in developing the care and support plan and that they felt (and feel) listened to.
• The person and their chosen representative are aware of the care and support plan and have seen a copy.
• The care and support plan clearly explains how care and support will be delivered.

The next section considers how to create a care and support plan that follows the MCA principles.

Person-centred care and support plans

Each person’s needs and choices will be unique to them. This means that staff must do all they can to help the person convey their personal aspirations and goals, and the support they need. Creating the care plan with the person or their chosen representative will keep the focus on what is important to that individual and will enable their care and support to reflect this.

Designing an MCA-compliant care and support plan requires a cultural shift from ‘traditional’ models of care planning to  person-centred care planning . The key differences between the two are summarised in the table below (Table 1).

Table 1 Key differences between ‘traditional’ and person-centred care

Promoting involvement may mean orientating the person to the decision. For example, helping to orientate a person with dementia to the time and place relevant to the decision and filling in the gaps of their understanding. It might also include orientating a person’s beliefs concerning a decision. For example, helping someone who is depressed to hold onto positive values that were important to them when they were not so depressed. Ongoing work to reduce the effects of mental health conditions and maintain independence and control is vital to maximising a person’s capacity to make a decision.

Actively involving other people who are part of the person’s life will usually improve their care and support. Linking into a person’s existing support network will bring together all the information about them, so that their care and support are tailored to meet their specific needs and preferences. This will help to improve the user’s experience and promote their wellbeing, rather than merely responding to problems as they arise: ‘Being truly person centred is about recognising people within the full context of their lives and how they live them and not just focusing on their health conditions’. [10] The person’s wishes, thoughts and feelings should be routinely prioritised together with input from families and carers. 

What to look for in the care and support plan and other records

• What the person would like to achieve with their care and support, their goals and aspirations for the future.
• What is important to the person about how they live their life now: what they enjoy doing, their interests, likes and dislikes, who is important to them, who they like to see, and their preferred routines (such as when they like to get up and go to bed, whether they like a bath or a shower, etc.).
• Details of key life events and dates to assist with chronological orientation.
• How best to support and involve the person in decision-making.
• Essential information for continuity of care and for use in emergencies.
• Roles and responsibilities so that the person receives coordinated care and support to meet their needs.
• Where a person lacks capacity to express their choices, how their families and others who are interested in their welfare have been consulted.
• What outcome the person wants and any other options considered.
• The associated benefits and risks of each option.

The case of M, [11] from the Court of Protection, clearly illustrates the importance of care planning that takes account of the full context of a person’s life.

Practice example: the case of M

M, a 67-year-old woman, had a mild mental health problem and lacked capacity to decide where to live. She had substantial medical needs including diabetes, which was not well controlled. M was placed in a care home by the clinical commissioning group (CCG).  It considered this to be in her best interests because of the significant risks to her health if she returned home. However, M hated living in the care home and said that she wanted to leave or she would take her own life. While acknowledging these risks, the Court of Protection said that if M remained in the care home, she was entitled to ask, what for? The right to life and the state’s obligation to protect it is not absolute and the Court must have regard to the person’s own assessment of their quality of life. In M’s case, there was little to be said for a solution that attempted to preserve her daily life without meaning or happiness.

Involvement in the cycle of care and support planning

Involvement is not an isolated activity. Ongoing communication between commissioners, providers, users and their families/carers is fundamental to taking the right decisions at the right time. It enables decisions to be altered over time to reflect people’s changing needs.

Services must make sure that their staff have the knowledge and skills to  maximise involvement  as part of an ongoing conversation that takes place at all stages of the care and support planning process. For example:

• at the outset, when developing the plan of care for each person
• as part of the risk management process, including safeguarding
• each and every time care and support are provided
• when carrying out reviews
• through regular feedback about people’s experience of the service they receive.
• Evidence that staff ask people about their preferences each time they provide care or support – for example, whether they want to take their medicines now, whether they would like a cup of tea, coffee or a cold drink.
• Evidence that staff regularly ask the views of people using the service and/or their families about the care and support they receive and listen to what they say.
• Evidence of systems for reviewing care and support plans and obtaining feedback.

Relationships

Involvement in the care and support planning cycle is underpinned by the quality of the relationship between the person using the service and the social care professional: [12] ‘People who use services have emphasized the support that they gain from relationships based on warmth, empathy, reliability and respect’. [13]

Having the right care staff with sufficient time and the right training in communication skills is critical to building effective relationships. [5]

• Care staff talk to people in a respectful way.
• People say that staff are caring towards them and always treat them with respect.

Communication

Assumptions are often made about the capacity of people who have limited communication skills or sensory impairments. Yet we know that it is quite possible to discern what a person feels or wants from their gestures and facial expressions, tone and volume of voice, or body language and behaviours. Care staff may need to observe a person’s responses over a period of time to understand these non-verbal signals.

A  communication chart  is a good example of a person-centred approach that carefully looks for what each individual is trying to communicate, rather than making blanket assumptions. The authors of ‘Person centred thinking with older people’ [14] provide a useful worked example about eating, based on four questions:

• What is happening?  Food is being prepared.
• What is the person doing?  Shutting their lips tightly.
• What do we think this means?  Best guess – the person does not want food at the moment or wants a drink first.
• What should we do?  Offer a drink, gently encourage the person to eat, try shifting their mealtime to later in the day, maintain a record of food consumed and monitor.

Other ways to help a person communicate include the following:

• Making time to listen, to ask enough questions, to create opportunities for the person to tell their story in their own time, in their own way.
• Researching their previous wishes and finding out about their values.
• Providing all the relevant information in an accessible way – for example, in plain English, in clear writing, in Braille, in alternative languages, in pictures or in photographs, or a combination of these.
• Using a translator or other person/professional who understands the person’s communication style best.
• Addressing any sensory needs – does the person use a hearing aid, glasses, dentures; do they understand sign language?
• Involving family, friends or an advocate to provide support and reassurance.
• Choosing the right setting and time of day, considering whether the person may gain or regain capacity at a later date.
• Meeting with the person informally to explain the options and possible outcomes.
• Talking clearly, slowly, using straightforward, jargon-free language.

In order for care staff to successfully support people’s dignity and choices, they must do all they practically can to understand the meaning that users are trying to convey: ‘Having the power to communicate and to be understood is central to older people being able to have choice and control in their life – in fact, to have any quality of life at all’. [14]

• A description of any communication needs and how these will be met.
• Where the person has limited communication ability, other non-verbal communication methods that the person may use.
• How the person was supported to be involved in decisions about their care and support.

What else to look for

• Users have clean spectacles, dentures are fitted and hearing aids are working.
• Staff use different communication tools to meet people’s needs.
• Staff explain what is happening each time they offer care and support.
• Staff take time to listen to what people are trying to convey.

5 – House of Lords (2014) ‘Select Committee on the Mental Capacity Act 2005, 2014: Post-legislative scrutiny’, summary, p 1, London: The Stationery Office.

9 – Mersey Care NHS Trust (2007) ‘Increasing mental health and well-being: Involving service users and carers’, Liverpool: Mersey Care NHS Trust.

10 – Harvey, J. (2010) ‘Key elements of personalised care planning in long term conditions and personal health budgets’, London: HSA Press.

11 – M v The County Council and the Clinical Commissioning Group (CCG) and A. EWHC 3456 (COP) (Jackson, J.) 2013.

12 – Ashead, A., Beresford, P. and Croft, C. (2007) ‘Research findings from palliative care, social work and service users: Making life possible’, London: Jessica Kingsley Publishers.

13 – Beresford, P., Bewley, C., Branfield, F., Croft, S., Fleming, J., Glynn, M. and Postle, K. (2011) ‘Supporting people: Towards a person-centred approach’, Bristol University: Policy Press.

14 – Bowers, H., Bailey, G., Sanderson, H., Easterbrook, L. and Macadam, A. (2007) ‘Person centred thinking with older people’, Cheshire: HSA Press.

The Mental Capacity Act (MCA) and care planning report

Person-centred care

Apr 03, 2019

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Person-centred care. Maggie Eisner, August 2010. Paired discussion. Think about your own experience of a health care episode, or that of someone you’re close to What do you want from a health professional, apart from good clinical knowledge and skill?. What is it?.

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• deep awareness
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• typical physician illness
• professional values

Presentation Transcript

Person-centred care Maggie Eisner, August 2010

Paired discussion • Think about your own experience of a health care episode, or that of someone you’re close to • What do you want from a health professional, apart from good clinical knowledge and skill?

What is it? • One of the RCGP domains of competence • RCGP definition of person-centred approach: • Understand the individual, their aims and expectations in life • Develop a frame of reference to understand their context (family, community, social and cultural dimensions in their attitudes, values, beliefs) • Understand their concepts of health and illness

How’s it different from the triangular approach? • The triangle is the first stage • The triangle helps us conceptualise the patient’s situation • Person centred care includes what we then give out to the patient

Why is it important? To the typical physician my illness is a routine incident in his rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who perceived this incongruity …. I just wish he would …. give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each person is ill in their own way

How do we do it? • RCGP - Using the consultation to create effective doctor-patient relationship: • Aim to integrate the patient’s perspective with the doctor’s agenda, to find common ground and make a mutual plan • Communicate comprehensibly, enabling patient to reflect on their own concepts, finding common ground for further decision making • Agree on decisions which respect patient’s autonomy • Be aware of subjectivity on patient’s side (feelings, values, preferences) and doctor’s (attitudes, values, feelings)

Dignity-conserving careHarvey Chochinov, BMJ 2007;335:184-187 • Everyone deserves kindness, humanity and respect (core professional values of medicine) • ‘How patients perceive themselves to be seen’ is a powerful mediator of their dignity • We can think about this in a structured way: • Attitudes • Behaviours • Compassion • Dialogue

Attitudes • Questions • How would I be feeling in the patient’s position? Why do I think this? Am I right? • How might my attitude be affecting them? Is that to do with my own experience, anxieties or fears? • Actions • Reflect on your attitude in the care of each patient • Discuss and challenge attitudes in case discussions

Behaviours • Behave with respect and kindness - it doesn’t take extra time • Remember that what’s routine for you may not be so for the patient, e g examination or questions they don’t expect to be asked • Pay attention to all aspects of communication, not just your words

Compassion deep awareness of the suffering of others combined with the wish to relieve it • How do you develop it? • Natural to some people • May develop with life experience • Through the Arts - stories, novels, film, theatre, poetry • How do you show it? • Non verbal communication, e g understanding look, touch on shoulder, arm or hand • Saying things which acknowledge the person beyond their illness

DialogueTwo-way communication • Start with empathic communication e g I know this must be frightening for you • In a broad sense, find out who the patient is and ‘where they are coming from’ • What would it be useful for me to know about you? • What is it you are most worried about? • How is this affecting your life? • Who else might be affected by this? • Who have you got to support you? • Who else should we get involved to help?

Case discussions • One when you felt you (or another doctor you observed) were able to perceive the patient as a person and treat them with kindness, humanity and respect • One when these things didn’t happen

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Whose centre is it anyway? Defining person-centred care in nursing: An integrative review

Amy-louise byrne.

Central Queensland University School of Nursing, Midwifery and Social Science, Townsville, Queensland, Australia

Adele Baldwin

Clare harvey, associated data.

All relevant data are within the manuscript and its Supporting Information files.

The aims of this literature review were to better understand the current literature about person-centred care (PCC) and identify a clear definition of the term PCC relevant to nursing practice.

Method/Data sources

An integrative literature review was undertaken using The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus and Pubmed databases. The limitations were English language, full text articles published between 1998 and 2018 within Australian, New Zealand, Canada, USA, Europe, Ireland and UK were included. The international context off PCC is then specifically related to the Australian context.

Review methods

The review adopted a thematic analysis to categorise and summarise themes with reference to the concept of PCC. The review process also adhered to the Preferred Reporting System for Meta-Analysis (PRISMA) and applied the Critical Appraisal Skills Programme (CASP) tools to ensure the quality of the papers included for deeper analysis.

While definitions of PCC do exist, there is no universally used definition within the nursing profession. This review has found three core themes which contribute to how PCC is understood and practiced, these are People , Practice and Power . This review uncovered a malalignment between the concept of PCC and the operationalisation of the term; this misalignment was discovered at both the practice level, and at the micro, meso and micro levels of the healthcare service.

The concept of PCC is well known to nurses, yet ill-defined and operationalised into practice. PCC is potentially hindered by its apparent rhetorical nature, and further investigation of how PCC is valued and operationalised through its measurement and reported outcomes is needed. Investigation of the literature found many definitions of PCC, but no one universally accepted and used definition. Subsequently, PCC remains conceptional in nature, leading to disparity between how it is interpreted and operationalised within the healthcare system and within nursing services.

Introduction

Healthcare is changing, for both providers and recipients of care, with ongoing challenges to traditional roles and power balances. The causative factors of changes to the way healthcare is provided are complex, but one contributing factor is easier access to healthcare information and better-informed populations [ 1 ] whereby people as healthcare consumers have access to healthcare information through multiple media. On the surface, consumers are no longer seen as passive recipients of care, but rather as valuable and active members of the healthcare team. The concept of Person-Centred Care (PCC) is used to describe a certain model for the role of the patient within the healthcare system and the way in which care is provided to the patient [ 2 , 3 ]. Globally, there is continued advocacy for person-centred, individualised care [ 4 ], with the contemporary term for PCC being frequently presented in healthcare discourse, and frequently associated with the safety and quality of healthcare service provision [ 5 , 6 ]. Indeed, partnering with consumers within a person-centred framework is now a fundamental requirement for Australian healthcare services, meaning that they cannot achieve accreditation without demonstration of PCC [ 7 ]. Hence, PCC is now seen in healthcare service strategy and models of care, designed to support the voice of the patient and the role of the healthcare service in engaging with patients [ 6 ]. PCC also forms part of the Australian nursing professional standards [ 8 ] yet is paradoxically described as an ‘extra’ to nursing practice [ 9 ], taking a back seat to nursing tasks and errands that make up the day to day regime of the nurse.

Despite the discourse around PCC, and the requirements of PCC within healthcare, there appears to be no universally accepted definition of the term. This leaves the concept open to interpretation and potential confusion, particularly when personnel, in this case nurses, attempt to operationalise it. This review investigated the meaning of PCC with reference to nurses across different practice settings and specialities. To further facilitate the understanding [ 10 ] and theory development of the concept of PCC, this review adopted an integrative review methodology [ 11 ].

In the late 1950’s and 60’s, PCC, and care for the entire self was first described in the context of psychiatry, such as in Rogers’ ‘On becoming a person’ [ 12 ]. Patient-centred medicine was a term first coined by psychoanalyst Michael Balint. Balint was instrumental in the education of general practitioners around psychodynamic factors of patients and challenged the traditional illness-orientated model [ 13 ]. Balint’s challenge extended beyond the traditional healthcare model to include both the physical and psychosocial as part of the practitioner’s role. Balint explained; “Here , in additional to trying to discover a localized illness or illnesses , the doctor also has to examine the whole person in order to form what we call an ‘overall diagnosis . ’ The patient , in fact , has to be understood as a unique human-being . ” [ 13 p269].

The idea of caring for the whole person, and the divide between traditional medical practice and the psychosocial needs of the patient was discussed by Engle in 1977. He wrote; “The dominant model of disease today is biomedical…It assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables . It leaves no room within its framework for the social , psychological , and behavioural dimensions of illness . ” [ 14 p379]. The biopsychosocial model proposed provided a new basis for care which included care of the mind and body. Over the succeeding years, this model of care and the notion of patient centre care continued to evolve, with many iterations of the term moving with the changing climate of healthcare systems.

PCC gained significant traction through the Institute of Medicines (IOM) 2001 report ‘Crossing the Quality Chasm: A New Health System in the 21 st Century’ [ 15 ] as a key element of quality healthcare. The IOM provided one of the first contemporary definitions, stating that PCC “encompasses qualities of compassion , empathy and responsiveness to the needs , values and expressed preferences of the individual patient” [ 15 p48]. The World Health Organization continues to advocate for integrated care that is in tune with the patient’s wants and needs through the framework on Integrated People-Centred Care. This includes the vision that “all people have equal access to quality health services that are co-produced in a way that meets their life course needs” . [ 5 ] This framework aims to improve engagement of people and communities, strengthen governance and accountability, reorientate the model of healthcare, and coordinate services across sectors [ 5 ], seeing people as important contributors and decision makers over their own care.

More recently, the Australian Commission on Safety and Quality in Health Care (ACSQHC) defines PCC as an “innovative approach to the planning , delivery , and evaluation of health care … [involving] mutually beneficial partnerships among health care providers , patients , and families . ” [ 2 p13]. Thus, PCC has become an integral element of care from a quality, planning and practice level, and therefore appears prominently in Australian healthcare service discourse and associated models of care, often presented as an underpinning philosophy for the way in which nursing care is provided [ 3 ]. The concept of PCC continues to evolve, notably in the change to ‘person’ rather than ‘patient’ in recognition of the whole person, not simply the disease process. Other variables such as Family-centred care are used more in the context of aged care and paediatrics [ 16 , 17 ].

As the term has become more common in healthcare discourse, frameworks have emerged to allow the term to be operationalised into practice. There are several person-centred nursing frameworks including the Senses [ 18 ], VIP [ 19 ], 6 C’s [ 20 ], The Burford Model [ 21 ] and McCormack and McCance’s framework [ 22 ]. These frameworks describe elements such as attributes of staff, methods of interactions, coordination of care and services, the care environment and consideration of outcomes of care. These examples provide insight into attempts to operationalise PCC, into individual practice and healthcare service provision.

Nurses are the healthcare professionals who spend the most time with people and are therefore in a position to act as their advocates, with nursing staff managing the continuity of care [ 23 ]. This review seeks to investigate the meaning of person-centred nursing practice, and acts as a starting point for a wider study into the concept of PCC for people with long term conditions. Consumers of healthcare navigate a complex and fragmented system, with fragmentation leading to patients feeling lost, and a decrease in the quality of services offered [ 24 ]. This places even greater importance on a partnership between provider and receiver, particularly in the face of increasing chronicity/complexity of care. Within this fragmented and complex system, the patient must always remain at the centre of their care. Hence, there is a need for a robust definition to ensure PCC is more clearly operationalised and care delivered is designed around the needs of the patient, rather than trying to make the patient fit within the system.

This review uses the term person rather than patient in recognition of the person as a whole. Where clarity is required, the term healthcare consumer is used; a term frequently used in Australia.

The aim of this literature review was to understand better from the literature how nurses operationalise the definition of PCC.

Search questions

This literature review sought to answer the following questions:

• Is there a commonly/generally accepted definition for PCC that is used by nurses?
• How do nurses operationalise PCC in practice?

Search strategy

An integrative literature review was conducted using the terms Person Cent* Care OR Patient Cent* Care AND Nurs* AND Definition OR Meaning OR understanding OR Concept. The search was expanded to include similar terms and concepts such as patient/person-centredness and personalisation. A major subject heading of ‘patient centred care’ was used within the searches. This review is positioned within the nursing discipline; therefore, articles were included if they were specific to nursing or if they included nursing texts in the review. English language, full text articles published between 1998 and 2018 were included. Publications from Australia and New Zealand, Canada, USA, Europe, UK and Ireland were included to gain an understanding of PCC in the western context. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus and Pubmed databases were searched. This search is registered with PROSPERO (ID number 148778) and was completed in March 2019. While the search strategy includes international literature, this will be related back to the Australian context, in order to understand how PCC operates within Australia.

Data extraction

The framework, from Whittemore and Knafl [ 11 ], describes a comprehensive review, identifying the maximum number of eligible primary sources and requires the researcher to explicitly justify decisions made in the sampling. Using this framework, a total of 1817 articles met the search terms, highlighting the volume of literature available on the concept of PCC. Table 1 provides the scope of inclusions and exclusions. From this, 255 articles were selected for review.

After removal of duplicates, 203 articles were subjected to full review. A further refined strategy excluded Key Performance Indicators (KPI), service measures, assessment tools and validations as the goal was defining the term, rather than to assess how it is measured; these represented a large proportion of the articles within the search. A total of 44 articles were subjected to quality review. To ensure adequate rigour, reliability and relevance, all articles were evaluated against the Critical Appraisal Skills Programme (CASP) systematic and qualitative review checklists [ 25 , 26 ] by the lead author and reviewed by a senior researcher on the team. The relevance of the papers and the quality of the reviews/articles themselves was appraised. All articles were appraised against the aims of this review. Following this, a total of 17 articles were included in the final review. Fig 1 provides the summary for the search process while S1 File provides the PRISMA checklist.

Using the previously identified framework that allowed for data from diverse methods and approaches to be analysed and compared, a constant comparison method was used to convert data from different categories into patterns, themes and relationships. The data is thus displayed below in Table 2 to encompass the full depth of the concept and to provide new understanding, and its implications to practice [ 11 ]. Table 2 demonstrates the characteristics of the articles reviewed including their design methods, populations and findings.

This review set out to investigate if a universal definition of PCC for nursing exists and is used; what was uncovered was a deeper understanding of the concept and operationalisation of PCC, highlighting a malalignment between concept and reality. Three (3) core themes were identified in the review process, each of which is comprised of two (2) sub-themes. These three core themes of People , Practice , and Power , with the respective sub-themes are discussed are summarised in Table 3 .

Theme 1: People

Unsurprisingly, the most common threads in the literature about PCC relate to people and, consistent with the philosophy of PCC, is described as basic, human kindness and respectful behaviour [ 22 , 27 , 28 , 29 ]. The core theme of People comprises two sub-themes: Recognising uniqueness and Partnerships .

Recognising uniqueness

PCC, as the name suggests, is care that is considered and based on the individual person, who is the recipient of care. Prominent in the literature are the concepts of personhood, individuality and uniqueness [ 16 , 28 , 30 ]. Individuality, and the sense of self, understands that each person has their own unique wants, needs and desires [ 16 , 29 ] Personhood reinforces and values the complete person, with an understanding that illness affects the entire person [ 31 ]; an holistic consideration of the person that extends to family interventions and involvement [ 27 , 32 ] described as developing and maintaining trust within the family unit [ 33 , 34 ]. Uniqueness is central to this subtheme as recognition of the person as a unique being leads to unique and tailored care, based on the needs of the whole person [ 16 , 29 ].

Partnership

The literature discusses the need for a relationship between healthcare provider and healthcare receiver as a way of facilitating information, knowledge and decision making. The term ‘relationship’ is prominent in the literature including the terms therapeutic relationship [ 16 ], clinical relationship [ 35 ] and partnership [ 29 , 36 , 37 ]. This is described in the contexts of cohesive, cooperative teams [ 29 , 32 ], mutuality between provider and receiver [ 38 ], and the balance of power and the sharing of knowledge [ 16 ]. These themes are further developed through the practice of the nurse and are thus carried forward to the next theme, Practice.

Theme 2: Practice

PCC is a product of person-centred practice, particularly in the context of nursing. However, the ability to practice PCC is influenced by professional and system factors. The core theme of Practice is comprised of the sub-themes Doing and Space .

‘Doing’ refers to the complex interplay of professional attributes, behaviours and tasks that makes up the daily remit of the nurse; that is, the ‘doing’ of nursing is a combination of these things within the care environment. Personal attributes of nursing staff emerge as a common element in the literature related to PCC. The literature describes attributes such as communication, respect, values, empathy, compassion and non-judgemental behaviour [ 9 , 29 ]. Lusk and Fater [ 7 ] further describe such attributes as caring, faith and hope, trust, relationships, teaching, learning and listening. In describing a framework to facilitate the practice of person-centred care, McCormack and McCance [ 22 ] discussed professional competence, interpersonal skill, job commitment and professional insight. Others have extended this to include understanding vulnerability, fear, the patient identity [ 30 ] and highlight the need to recognise the person as competent to make decisions [ 31 ]. This view, centred on dignity and privacy and the moral and ethical behaviours of the nurse [ 16 , 28 ], facilitates the relationship and balance of power with the person. Delivering whole person care includes elements such as respect for the individual [ 16 ], and planning care that is based on individual needs [ 25 ]. In practice, this is described as the person being valued for their lived experience, life stories [ 9 , 16 ] and the continuation of self [ 34 ]. Kitson et al. [ 35 ] describe this as addressing both the physical and emotional needs of the person and alleviating anxiety.

The existing literature alludes to the idea of opening a space to practice PCC. The literature describes this as being flexible within the care, offering choice [ 9 , 31 ], and creating opportunities for people to engage [ 34 ]. Practicing PCC involves freely giving information to the person [ 36 ] and finding the time to listen and engage with them [ 36 , 39 ], which implies that PCC is a proactive way of delivering nursing care. Gachoud et al. [ 32 ] found that nurses see themselves as most important in delivering PCC, with Doctors playing a lesser role in PCC practice. This understanding creates a concept whereby nurses are pivotal in creating an environment in which the person can truly engage.

While PCC is an individual practice method, the environment within which nurses’ practice must be considerate and supportive of the delivery of PCC as a significant priority; a view supported by McCormack and McCance [ 22 ] in their description of organisational systems and leadership within PCC. Despite competing priorities and the associated tasks of daily practice, nurses must find and open a space to practice PCC as an essential element of the profession. Interestingly, PCC within the literature is often discussed as an addition to nursing tasks. Edvardsson et al. state that promoting PCC in aged care includes doing ‘little extras’ [ 9 p50], such as understanding the patient’s life story, making eye contact and using the person’s name. Marshall et al. found that nurses describe PCC as ‘making the effort’ and ‘going the extra mile’ [ 37 p2667], being helpful and timely with care and attention. Others describe making choices available [ 16 ], ascertaining priorities [ 27 ] and doing the ‘right’ thing [ 31 ].

Theme 3: Power

PCC as a concept is about balancing power between the provider and receiver of care. The notion of PCC is imbued with connotation of power, discussed in relation to all elements of the care and is intertwined in some way with all themes within this review. The sub-themes of Power are the Power over one’s care and the Power to practice PCC .

Power over one’s care

The idea of power balance is discussed in the literature and includes the sharing of knowledge [ 29 ], respect for decision making and individualised care based on these decisions [ 28 , 17 ]. Further to this is the notion of the person having ‘active’ involvement in the care process [ 22 , 35 ]. This is described through identification of the person’s strengths and reinforcing this through the care continuum [ 16 , 38 ]. In addition to this, the literature describes empowerment, promoting the sense of self efficacy [ 31 , 33 , 37 ], supporting the person to be as self-managing as possible [ 36 ] or to have a level of autonomy in their care. Here, the person holds the power in care planning and decision making throughout the care journey and there is a responsibility of knowledge transference and the maintenance of personal autonomy [ 35 ]. This is apparent in the literature through concepts such as control, rights, patient involvement and participation [ 27 , 33 , 35 ]. PCC, however, places importance on a marriage between provider and receiver as a process of sharing knowledge, rather being entirely self-governing, in which the provider (as the custodian of knowledge) has an obligation to impart knowledge.

The power to practice PCC

The need for care systems to be innovative and make a commitment to PCC comes through in the literature [ 22 ], as well as the need for the environment to allow for flexibility and to factor time and space to practice PCC [ 9 , 36 ]. This is a significant shift from the traditional biomedical model, whereby emphasis on personal choice [ 33 ] and partnerships [ 17 ] must be considered within all layers of the healthcare system. Barriers and enablers including workplace culture, leadership [ 22 ], policy and practice, organisational systems, environment [ 28 , 35 ], workload, and ward culture [ 37 ] were identified. The literature also included topics around cost [ 28 ], care coordination [ 28 , 33 ] and of course, outcomes of clinical care provided [ 27 , 29 , 30 ].

Jakimowicz et al. [ 30 ] noted the conflict between system standards, benchmarking and the provision of PCC in a time poor environment. Consistently, the literature discussed the idea of measuring PCC as a method of quantifying this important element of nursing practice amongst the myriad of measurable tasks nursing time is allocated to. The need and ability to measure PCC is cited as crucial for quality improvement of care [ 31 , 38 ]. This review excluded articles related to the measurement of PCC as the primary aim was to find how PCC was defined, however this was still very much a part of the discussion around the meaning and practice of PCC. Morgan and Yoder [ 31 ] discussed several measurement tools, finding them to align more with the effect of care rather than the care directly. Lawrence & Kinn [ 27 ] found that outcome measures used where often in line with the needs and requirements of clinicians, auditors and researchers, or hospital clinical outcomes [ 33 ], rather than with the goals of the patient. Outcomes vary from self-care, patient satisfaction, well-being and improved quality of care [ 28 , 31 , 38 ] to improved adherence and decreased hospitalisation [ 29 ]. This highlights competing priorities within the nursing profession and demonstrates that nursing time is conflicted between what they ‘should’ do and what they ‘must’ do, hence highlighting a nurses limited power to practice PCC in the context of the system standards.

The review demonstrates that the concept of PCC is indeed a method of providing care, or the way in which nurses deliver care. To be person-centred, the nurse must recognise the person as unique, form meaningful partnerships, open a space within the doing of their day to involve and engage with the person, allowing the person control and power of their care.

It is interesting to note that while the existing literature covers a wide variety of clinical areas, and patient and staff perspectives, there were indeed core common themes of PCC. Despite the core concepts associated with PCC taking on more importance within certain clinical areas; for example, continuation of self in aged care [ 9 , 34 ], patient advocacy for intensive care [ 30 ], or communication in stroke care [ 27 ], they are consistent across specialities with the themes building on one another. Perhaps the reason why PCC has been so widely accepted is that the characteristics are simple, kind, human interactions, valuing both the person and the care provider. While definitions of PCC exist, there is no one universally used definition of PCC in nursing practice, potentially compounding a degree of separation between practice and healthcare systems. The findings demonstrate a tension between the theory and the conceptualisation of PCC, and as a result, the operationalisation of the term at both the practice level and a wider healthcare service level.

At the practice level, the theory/practice gap for PCC was evident. The theory/practice gap includes elements of practice failing to reflect theory, perceptions of theory being irrelevant to practice, and ritualistic nursing practice. Consequences of the theory/practice gap can greatly influence nursing practice and collaboration [ 40 ]. In the context of PCC, the theory/practice gap is apparent in the challenge of translating the ideas of PCC into a concrete concept. It is of significance that PCC is seen as ‘extra’ or additional to nursing tasks when these professional behaviours are in line with the Australian Nursing Professional Standards [ 8 ], which requires that they are an intrinsic element of the nursing profession. In fact, to be a registered nurse in Australia one must demonstrate respect for the person as the expert, respect autonomy and “ share knowledge and practice that supports person-centred care” [ 8 ]. This highlights an important matter for consideration; why are core elements of PCC being viewed as ‘going the extra mile’ rather than a core competency for nurses? Certainly, from the perspective of the professional standards, PCC should not be the road less travelled, but rather the daily standard practice of nursing. One answer to this may be the task orientation of the contemporary nursing culture that sees nurses required to meet organisational time allocations for care [ 41 ]. Sharp, McAllister and Broadbent [ 42 ] uncovered a tension between PCC and nursing culture, finding that nurses were increasingly bogged down with tasks and processes, taking them away from the people that they provide nursing care for. These authors found that this led to a feeling of frustration and helplessness in nurses who appear to have accepted the culture of auditable, measurable activities and processes, particularly within the climate of organisational accreditation requirements. This activity-based nursing environment manifests in missed nursing care largely related to patient centred elements, e.g. discharge planning, communication within the healthcare team, absence of adequate patient education on key factors of care such as medication guidance, functional assessment and so on [ 43 , 44 ].

Further, it is apparent that the concept of PCC cannot be isolated from other philosophies of nursing practice and in fact, is embedded in other approaches to nursing care. For example, as outlined by Kim [ 45 ], nursing is defined by dimensions, rather than characteristics. If PCC is considered as a dimension, a complex, interwoven mix of characteristics, then it is possible to gain some concrete understanding of PCC in the context of all clinical areas. The five dimensions proposed by Kim reflect the ‘human’ side of nursing practice, and like the general interpretation of PCC, shows how human interactions, values and knowledge combine to provide care. Kim goes on to say that these dimensions vary with individual nurses and changing clinical situations; which seems to fit with the current confusion about PCC giving choice and decision-making power to patients. As found in this review, PCC attempts to balance the power between providers of care and receivers, giving choice and decision-making power. Yet the focus on nursing tasks and prioritisation of these tasks is evident, demonstrating the malalignment between concept and practice, where research has identified that the current task-oriented system of nursing does fail to meet the care needs of patients [ 46 ].

Nursing practice, however, is only one element of delivering PCC within the healthcare system. This disparity extends between the concept of PCC and its ability to exist within the current healthcare system itself, where time to care is explicitly rationed through budgets that do not allow for individualised person-centred care [ 47 ].

The notion of PCC is one centred on mutuality and a balance of power; a distinct move from the paternalistic biomedical model to a biopsychosocial model that is guided by the person, rather than the disease process. However, in current healthcare services, care is often system centred. That is, care is organised, funded and coordinated in a way that meets the needs of the system or service [ 28 , 33 ]. System fragmentation is understood to have significant influence on people accessing care, whereby people with long-term and complex conditions are most vulnerable to the negative impact from the lack of care coordination and cohesion [ 48 ].

In Australia, complex funding models are central to the concept of system fragmentation which begins at the Commonwealth and State funding levels [ 48 ], making it difficult for patients to navigate the system. System silos remain a significant issue for healthcare services and for the delivery of care, with Medicare models remaining fragmented for specialist services [ 49 ]. The States are the healthcare system managers, yet the federal government holds the responsibility of leading primary healthcare. This presents a challenge in provided collaborative and integrated services, particularly for those with long-term conditions [ 50 ]. The OECD highlight the importance of reducing system fragmentation in order to ‘Improve the co-ordination of patient care .’ [ 50 p1].

Indeed, system fragmentation leads to an increased ‘treatment burden’, whereby poor treatment coordination, ineffective communication and confusion about treatments can contribute to poor health outcomes and greater levels of cost, time, travel and medications for the person [ 51 ] Sav et al. [ 51 ] discuss the need for individualised and coordinated services across specialities as a requirement for reducing treatment burden. In addition to this, the Australian Charter of Healthcare Rights prescribes the rights of those seeking care in any Australian service and includes the right to access, respect, communication and participation [ 52 ]. Accreditation of healthcare services is conditional to evidence of multi-level partnerships with consumers of health. Positive partnerships (PCC) are clearly linked to improved access to care, which in turn leads to reports of positive experiences and better-quality healthcare. Of critical importance at an organisational and government level, the standards also describe this partnership as a mechanism for reducing hospital costs through improved rates of preventable hospitalisation and reducing hospital length of stay [ 7 ].

Potentially Preventable Hospitalisations (PPH) place considerable economic and resource burden on the healthcare system, with approximately 47% of PPH being attributed to long-term conditions [ 53 ]. Thus, reducing preventable hospitalisation is a measurable target for healthcare services under the National Healthcare Agreement as a way of controlling the escalating costs of care and maintaining sound fiscal management of public services [ 54 ]. In line with the ACSQHC standard Partnering with Consumers , PCC has been introduced to some services as a mechanism for improving communication between services and those with long term conditions. What is less clear, is how care tailored to the individuals wants and needs of the patient (PCC), exists within a system predominately focused on reducing variation and the associated costs of care. While the philosophy of PCC naturally fits within the care environment, understanding how effective it is, how the person is included and how outcomes important to the person are captured, take a lower precedent to the measure of reduced hospital costs, self-efficacy and reduced hospitalisation. Capturing what is important for the individual presents a difficult task for services providing population-based care.

These system wide constraints provide a considerable challenge to nurses in their attempts to operationalise the concept of PCC. Nursing, it seems, has become task orientated, a sentiment supported by Foe & Kitson who found that nurses are constrained by a ‘checklist’ mentality, whereby completing and documenting tasks is seen as more important than engaging with the person [ 55 p100]. These tasks and checklists align with the requirements of the National Standards for hospital accreditation. An example of this is the need to collect data on the use of invasive devices or the allocated time intervals in which screening (such as skin inspection and falls risk) must occur; for example within eight (8) hours of admission [ 7 ]. Indeed, policy and procedure for nursing practice reflect that of the need of accreditation and national policy requirements as opposed to the needs of individual people. While partnering with consumers is an important element of the standards [ 7 ], quantifying the way in which healthcare services and indeed nurses engage with patients is less clear. Kitson states ‘ Nursing theory , it would seem , has been limited by the profession’s ability to systematically document the complexity and richness of what happens when nurses and patients (and their careers) interact’ [ 35 p99], an issue it seems stemming from the fact that nursing interventions promoting person-centred, compassionate care are poorly described, with little to no consensus on the term, and interventions that do exist are poorly evaluated [ 56 ]. On top of this, nurses are generally not encouraged, nor enabled to reflect on practice in order to generate new insights and nursing practice [ 35 ]. Molina-Mula et al. [ 23 ], discuss the nursing profession as being the key to professional teamwork models, meeting the needs of patients and thereby increasing their personal decision-making capacity. However, it is possible that PCC is hindered by the level of professional autonomy, time and space afforded to nurses [ 57 ]. Indeed, the malalignment discussed herein, demonstrates that nurses may be hindered at higher levels of system compliance or difficulties in coordinating care services, which permeates nursing culture and ultimately nursing practice, limiting their ability to provide PCC that is individualised to the people seeking care.

Finally, while this review excluded articles related to the measurement and indicators of PCC, this is undoubtedly linked to its perceived meaning and how it is operationalised. This review demonstrates that the understanding of PCC is made up of how and where PCC appears in healthcare discourse and shows that PCC is potentially skewed by how it is(n’t) measured and the outcomes that are(n’t) reported as a product of PCC. This finding presents a framework within which further investigation of the concept of PCC (Meaning, Practice, Measures, Outcomes) within healthcare services could be undertaken. This proposed framework will be applied by the author to conduct further research into the role of PCC within nurse-led service for people with long-term conditions.

Implications for practice

This review highlights the dominant discourse around the concept of PCC yet uncovered the idea of malalignment between the rhetoric and the reality of the concept. Further exploration of the alignment between healthcare services and the goal of PCC may prove beneficial in ensuring the practice of PCC is fostered from all levels of the healthcare service. The above provides a rationale for why the definition of PCC should be provided, given that the concept is currently somewhat nebulous in nature. A consistent definition, with reference to all levels of the healthcare service including practice, will ensure that the concept stays true to the philosophy of compassionate and balanced care. Any definition provided should carefully consider how PCC is measured and prioritised within the healthcare system, which has the potential to move the concept from its current rhetorical nature, to a genuine commitment and priority of nurses and services. Lastly, the review provides a basis for the importance of nursing education and workforce development of the concept and the practice of PCC, given the apparent barriers that nurses may face in delivering PCC.

Limitations

This integrated review was limited to articles relating to the nursing profession and hence has excluded reviews on PCC in relation to other disciplines. Practice related elements such as procedure, service measures and outcomes of PCC were excluded from this review as the aim was to find a generalised way of defining the term. Furthermore, only one framework met the criteria of the search strategy and was included, there are however, several frameworks for PCC in nursing and hence some elements of PCC and their definitions may have been excluded.

This review was performed with published literature only, with no investigation of grey literature undertaken. PCC is often discussed in healthcare service literature, including procedure, service profiles and service strategy. This information will undoubtedly have an impact on how nurses understand and practice PCC within their own area and within their service. This review was designed to investigate a universal definition of PCC as described in the literature and hence chose to limit this to an academic search. The practice of PCC from a policy to practice perspective perpetuates meaning and will be the subject of further research for the author.

This review was conducted as a starting point for the author’s research higher degree (PhD) studies, and hence the search strategy and quality processes were completed by one person. All elements of the review were discussed at length with academic supervisors to ensure adequate rigor and accuracy throughout the search, review and integrative process.

The concept of PCC is well known to nurses, yet ill-defined and operationalised into practice. Healthcare service policy and care provisions, and indeed nursing services, need a clear definition of PCC in order to work toward embedding it into practice and into models of care in a meaningful and genuine way. However, PCC is potentially hindered by its apparent rhetorical nature, and further investigation of how PCC is valued and operationalised through its measurement and reported outcomes will serve the philosophy of PCC well. Investigation of the literature found many definitions of PCC, but no one universally accepted and used definition. Subsequently, PCC remains conceptional in nature, leading to disparity between how it is(n’t)operationalised within the healthcare system and within nursing services. In light of the malalignment discovered within this review, a universal definition of PCC is not provided herein; instead, this review highlights the need for further investigation of PCC between the levels of the healthcare service (at the micro, meso and macro levels) and how this influences the critical work that nurses do in supporting people through their healthcare journey.

Supporting information

Funding statement.

The author(s) received no specific funding for this work. The publication is funded under the first authors Research Higher Degree (PhD) budget.

Data Availability

• PLoS One. 2020; 15(3): e0229923.

Decision Letter 0

PONE-D-19-26103

Whose Centre is it Anyway? Defining Person-Centred Care in Nursing

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Reviewer #2: Yes

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Reviewer #1: Praise to the authors for having written a good review highlighting seminal information on Person-Centered Care (PCC). The methodological approach is clear and appropriate. The approach used in the process of eligibility of studies included is also clear with a supporting table, however, it is not clear how quality appraisal using CASP was applied to the studies included.

Results: The results are presented concisely, clearly and make sense with respect to the aim of the review but could have been longer to elaborate on the characteristics of the papers included in the review.

Discussion: The discussion is good and linked to theory and practice. However, a higher level of discussion was needed here. There could have been a better debate highlighting the linkage or differentiating features of PCC from similar concepts such as patient centered care or patient and family centered care.

Conclusion: Very clear and linked to the study findings. The fact that authors attempted to highlight current literature on person centered care, this could have been more interesting if they could have highlighted the differences in terms of definition by the different scholars or institutions.

Advice for improvement of the manuscript: as this is an integrative review, it could offer more in the way of future direction for defining the concept of PCC.

Reviewer #2: This is an interesting paper that has the potential to inform policy change in the future. The review itself seems quite strong, however, the international/Australian focus needs more clarity. In the literature search strategy you have chosen to include multiple jurisdictions which have important differences in healthcare system functioning. However, in each section when you give examples they are only focused on the Australian context. While I understand that for the definition of PCC the inclusion of more broad context is helpful, consider carefully how the operationalization will be different in different jurisdictions and the policy/practice challenges. I suggest you either make it clear that this global review of definitions is only being applied to the Australian context, or diversify your examples throughout. This will also be important for the corresponding terminology that you use – the term consumer for example is rarely used in the Canadian healthcare context so it will be important early in the paper to define such terms and outline which contexts they are used and comparable terms in each of the other jurisdictions. Also related to terminology in Canada, we would refer only to the ‘healthcare system’, not the ‘health system’ as there is an acknowledgement that it is not about preventative health.

Here are some more minor changes throughout:

Introduction:

Page 3, line 47-49 “The concept of Person-Centred Care (PCC) is used to describe the role of the patient within the health system and the way in which care is provided to the patient [2,3].”

- This is to describe a certain model for the role of the patient – not the role of patients in general – this implies it is a way to describe patients in all care models

Page 3, line 52-58 – accreditation is based on jurisdiction – which jurisdiction are you referring to? Same with nursing professional standards.

Page 4, line 59 – healthcare not health

Page 4, line 63 – is this different nursing contexts as in hospitals vs community or different countries where they practice?

Background:

Page 5, line 84 – when was this report created? What happened between 1977 and 2000? Add a sentence here, likely wasn’t a 20-30 year period without any changes.

Page 5, line 86 – is this the first definition of PCC? It’s the first you mention as far as I can tell for this specific term, might be important to mention this if it is the first attempt to define it.

Line 89 – is this WHO framework? Unclear who’s framework – please specify

Line 94 – awkward “of their own care” consider changing to about their own care or over their own care.

Line 96-97 – this quote is cut a little awkwardly – consider adding a word in square brackets to make it flow better like [involving].

Line 98 – from not form

Again your aim and scope doesn’t specify an Australian context, rather an international application. Either make clear in the introduction that this paragraph about Australia’s ACSQHC is an example from the various jurisdictions. Potentially consider including an example from another country to support the international focus of the paper.

Paragraph starting line 104 seems disconnected from previous paragraph. Consider adding a sentence at the beginning that bridges and waiting until the second sentence to list examples of frameworks. Consider moving the sentence on 110 to this paragraph as it justifies the move from PCC in general to nursing frameworks specifically.

Line 114-116 – combine these 2 short sentences.

- The first aim – to better understand the literature – seems vague, can you be more specific here? Consider combining with the search question – ie the aim could be to understand better from the literature how nurses operationalize the definition.

Line 144 – you don’t specify you use this framework, make this clear

Figure 1 – are you missing the arrow from screening to eligibility?

How many papers are citing the same papers?

Consider creating a figure or table summarizing each of the themes and subthemes to allow a visualization of your results that is easier for readers to refer to.

Line 200 – ‘based’ not ‘base’.

Line 237 – take out the “the” before people.

Line 240 – need to define the term medical officer, either in this paragraph or as a footnote.

Line 281 – access to what?

Line 290 – if measuring PCC is important to the discussion and still part of the papers you reviewed it would be helpful to add a sentence or two here to justify why you didn’t include them.

Discussion:

Lines 302-305 – abrupt switch between these two sentences, consider a sentence in between moving from stating it’s a model of care to what the reader must assume is the definition that emerged from the review.

Line 325 – they are ‘an’ intrinsic element.

Line 330 – core business – consider core competency or another word that is more in line with healthcare and patient centredness.

Line 354 – this sentence seems unfinished – should it say “giving choice and decision-making power to patients”?

Line 360 – again should be healthcare system throughout.

Again this is an Australian example, consider diversifying or adding a second country example to make the argument that your paper has international scope.

Implications for practice:

Again this is another section to clarify the jurisdiction you are talking about and be careful about the suggestions you are making here and in the conclusion about policy and practice. It could be helpful to say that across the western countries included general things need to change and give a couple of specific examples in different countries.

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Reviewer #1: Yes: Frank Kiwanuka

Reviewer #2: No

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Submitted filename: PONE-D-19-26103_review.docx

Author response to Decision Letter 0

Thank you for the comprehensive feedback on the manuscript Whose Centre is it Anyway? Defining Person-Centred Care in Nursing; An Integrative Review. The valuable feedback has been considered and changes have been made as per the table below. Please find attached a revised copy of the manuscript with tracked changes and a complete copy with changes embedded. Once again, we thank you for your time and consideration and we look forward to your consideration of this new version.

Yours sincerely

Amy-Louise Byrne (Corresponding author)

Please see the rebuttal letter for a detail account of the changes made

Submitted filename: Response to Reviewers letter.docx

Decision Letter 1

PONE-D-19-26103R1

Whose Centre is it Anyway? Defining Person-Centred Care in Nursing: An Integrative Review

We would appreciate receiving your revised manuscript by Mar 20 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

2. Is the manuscript technically sound, and do the data support the conclusions?

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: The authors have sufficiently responded to the previous comments and thanks for submitting the revision. However, they could consider expanding on the background by including more literature from other countries which have significantly contributed to literature person-centered care. Some suggestions, there is plenty of literature coming from the University of Gothenburg Center or Person centers care GPCC and Finland on this topic. This will reflect a global picture on the topic. Were there any assumptions that the authors made about including the countries specified?

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Author response to Decision Letter 1

The feedback from the reviewers is appreciated. Please see the rebuttal letter for a response to the reviewers. No changes have been made to the manuscript on this third submission

Submitted filename: Response to Reviewers letter 2.docx

Decision Letter 2

19 Feb 2020

PONE-D-19-26103R2

Dear Dr. Byrne,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/ , click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at gro.solp@gnillibrohtua .

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact gro.solp@sserpeno .

With kind regards,

Additional Editor Comments (optional):

Acceptance letter

25 Feb 2020

Dear Dr. Byrne:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact gro.solp@sserpeno .

For any other questions or concerns, please email gro.solp@enosolp .

Thank you for submitting your work to PLOS ONE.

PLOS ONE Editorial Office Staff

on behalf of

Ms Janhavi Ajit Vaingankar