What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing

Patient-centred professionalism in pharmacy: values and behaviours

PURPOSE

Research on patient-centred professionalism in pharmacy is scarce compared with other health professions and in particular with pharmacists early in their careers. The purpose of this paper is to explore patient-centred professionalism in early career pharmacists and to describe reported behaviours. DESIGN/METHODOLOGY/APPROACH - This study explored patient-centred professional values and reported behaviours, taking a qualitative approach. In all, 53 early-career pharmacists, pharmacy tutors and pharmacy support staff, practising in community and hospital pharmacy in England took part; the concept of patient-centred professionalism was explored through focus group interviews and the critical incident technique was used to elicit real-life examples of professionalism in practice.

FINDINGS

Triangulation of the data revealed three constructs of pharmacy patient-centred professionalism: being professionally competent, having ethical values and being a good communicator.

RESEARCH LIMITATIONS/IMPLICATIONS

It is not known whether our participants' perspectives reflect those of all pharmacists in the early stages of their careers. The data provide meaning for the concept of patient-centred professionalism. The work could be extended by developing a framework for wider application. Patient-centred professionalism in pharmacy needs further investigation from the patient perspective.

PRACTICAL IMPLICATIONS

The findings have implications for pharmacy practice and education, particularly around increased interaction with patients.

SOCIAL IMPLICATIONS

The data contribute to a topic of importance to patients and in relation to UK health policy, which allocates more directly clinical roles to pharmacists, which go beyond the dispensing and supply of medicines.

ORIGINALITY/VALUE

The methods included a novel application of the critical incident technique, which generated empirical evidence on a previously under-researched topic.

The Development of the Recovery Assessments by Phone Points (RAPP): A Mobile Phone App for Postoperative Recovery Monitoring and Assessment

BACKGROUND

In Sweden, day surgery is performed in almost 2 million patients per year. Patient satisfaction is closely related to potential adverse events during the recovery process. A way to empower patients and give them the opportunity to affect care delivery is to let them evaluate their recovery process. The most common evaluation method is a follow-up telephone call by a nurse one or two days after surgery. In recent years, mHealth apps have been used to evaluate the nurse-patient relationship for self-management in chronic diseases or to evaluate pain after surgery. To the best of our knowledge, no previous research has explored the recovery process after day surgery via mobile phone in a Swedish cohort.

OBJECTIVE

The objective of the study is to describe the process of developing a mobile phone app using a Swedish Web-based Quality of Recovery (SwQoR) questionnaire to evaluate postoperative recovery after day surgery.

METHODS

The development process included five steps: (1) setting up an interdisciplinary task force, (2) evaluating the potential needs of app users, (3) developing the Swedish Web version of a QoR questionnaire, (4) constructing a mobile phone app, and (5) evaluating the interface and design by staff working in a day-surgery department and patients undergoing day surgery. A task force including specialists in information and communication technology, eHealth, and nursing care worked closely together to develop a Web-based app. Modifications to the QoR questionnaire were inspired by instruments used in the field of recovery for both children and adults. The Web-based app, Recovery Assessment by Phone Points (RAPP) consists of two parts: (1) a mobile app installed on the patient's private mobile phone, and (2) an administrator interface for the researchers.

RESULTS

The final version of the SwQoR questionnaire, which includes 31 items, was successfully installed in RAPP. The interface and the design were evaluated by asking for user opinions about the design and usefulness of the app with 10 day surgery patients. Some minor adjustments were made concerning text size and screen color.

CONCLUSIONS

Taking advantage of joint expertise, a useable Web-based app adaptable to different technical platforms was constructed. In addition, the SwQoR was successfully transferred into digital format for use on mobile phones.

Client Centeredness and Health Reform: Key Issues for Occupational Therapy

Health reform promotes the delivery of patient-centered care. Occupational therapy's rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapy's perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapy's research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process

Inappropriate use of medication is widespread, especially in older people, and is associated with risks, including adverse drug reactions, hospitalization and increased mortality. Optimization of appropriate medication use to minimize these harms is an ongoing challenge in healthcare. The term 'deprescribing' has been used to describe the complex process that is required for safe and effective cessation of medication. Patients play an important role in their own health and, while they may complain about the number of medications they have to take, they may also be reluctant to cease a medication when given the opportunity to do so. A review of previously proposed deprescribing processes and relevant literature was used to develop the patient-centred deprescribing process, which is a five-step cycle that encompasses gaining a comprehensive medication history, identifying potentially inappropriate medications, determining whether the potentially inappropriate medication can be ceased, planning the withdrawal regimen (e.g. tapering where necessary) and provision of monitoring, support and documentation. This is the first deprescribing process developed using knowledge of the patients' views of medication cessation; it focuses on engaging patients throughout the process, with the aim of improving long-term health outcomes. Despite a comprehensive review of the literature, there is still a lack in the evidence base on which to conduct deprescribing. The next step in broadening the evidence to support deprescribing will be to test the developed process to determine feasibility in the clinical setting.

Examining the effect of patient-centred care on outcomes

Within patient-centered care (PCC), the individual is viewed as an active member of the healthcare team. While there has been recent interest in conducting systematic reviews to examine the effectiveness of PCC interventions, various studies fall short in explaining the type of intervention most effective in producing significant changes to desired outcomes. The purpose of this systematic review was to determine the characteristics of PCC interventions that have demonstrated effectiveness in enhancing the quality of care and performance of self-care behaviours. A systematic review of 40 studies that addressed PCC interventions, included samples over the age of 18 years, and were published between 1995 and 2014 was performed. Descriptive statistics were used to delineate study, participant, and intervention characteristics. Results suggest PCC-based interventions are not effective when delivered to individuals living with chronic illnesses.

Exploring views on what is important for patient-centred care in end-stage renal disease using Q methodology

BACKGROUND

This study aimed to explore views on what is considered important for Patient-Centred Care (PCC) among patients and the healthcare professionals treating them in a haemodialysis department.

METHODS

Interviews were conducted among 14 patients with end-stage renal disease receiving dialysis and 12 healthcare professionals (i.e. 2 doctors, 4 staff members, and 6 nurses) working at a haemodialysis department. Participants were asked to rank-order 35 statements representing eight dimensions of PCC previously discussed in the literature. Views on PCC, and communalities and differences between them, were explored using by-person factor analysis.

RESULTS

Four views on what is important for PCC in end-stage renal disease were identified. In viewpoint 1, listening to patients and taking account of their preferences in treatment decisions is considered central to PCC. In viewpoint 2, providing comprehensible information and education to patients so that they can take charge of their own care is considered important. In viewpoint 3, several aspects related to the atmosphere at the department were put forward as important for PCC. In viewpoint 4, having a professional or acquaintance that acts as care coordinator, making treatment decisions with or for them, was considered particularly beneficial. All views agreed about the relative importance of certain PCC dimensions; the patient preferences and information and education dimensions were generally considered most important, while the family and friends and the access to care dimensions were considered least important.

CONCLUSIONS

The four views on PCC among patients in a haemodialysis department and the professionals treating them suggest that there is no one size fits all strategy for providing PCC to patients with end-stage renal disease. Some patients may benefit from educational interventions to improve their self-management skills and place them in charge of their own care, whereas other patients may benefit more from the availability of a care coordinator to make decisions for them, or with them. Furthermore, our results suggest that not all eight dimensions of PCC need to be given equal consideration in the care for patients with end-stage renal disease in order to improve patient outcomes.

Exploring the practice of patient centered care: The role of ethnography and reflexivity

Patient centered care (PCC) is an essential dimension of healthcare systems' mission worldwide and is recognized as an important condition for ensuring the quality of care. Nonetheless, it is also acknowledged that various care providers perceive patient centeredness differently and that there remain several unanswered questions about the aspects of healthcare delivery that are linked to an actual achievement of PCC. In the paper, we categorize the current research on PCC into two streams ("dyadic" and "organizational") and we discuss the strengths and weaknesses of each. Despite their important contributions to healthcare services research, these approaches to PCC do not fully capture the network of practices and relationships constituting patients and providers' experiences within healthcare contexts. Therefore, we propose an alternative interpretation of PCC that integrates insights from "practice theories" and emphasizes the negotiated and local nature of patient centeredness, which is accomplished through the engagement of providers and patients in everyday care practices. To develop such interpretation, we propose a research approach combining ethnographic and reflexive methods. Ethnography can help achieve more nuanced descriptions of what PCC truly encapsulates in the care process by drawing attention to the social and material reality of healthcare contexts. Reflexivity can help disentangle and bring to surface the tacit knowledge spread in everyday care practices and transform it into actionable knowledge, a type of knowledge that may support services improvement toward PCC. We anticipate that such improvement is far from straightforward: an actual achievement of PCC may challenge the interests of different stakeholders and unsettle consolidated habits, hierarchies and power dynamics. This unsettlement, however, can also serve as a necessary condition for engaging in a participative process of internal development. We discuss the outcomes, limitations and benefits of our approach through a hospital case study.

Relatives of patients with amyotrophic lateral sclerosis: Their experience of care and support

Objective:

The purpose of this study was to describe relatives' experience of patient care and the support they themselves received during the course of disease progression.

Method:

A total of 15 relatives were included from two neurology clinics in Sweden: 7 wives, 4 husbands, and 4 daughters. Data were collected through qualitative interviews 6 to 12 months after the patient had died. Content analysis was performed to analyze the interviews.

Result:

The results showed that patient care was experienced as positive and as being based on the patient's needs and desires. Treatment from the staff, support and help, knowledge, availability, and continuity among the team were important reasons for the relations to feel secure. In addition, support for relatives was available, but different factors influenced its use. Most relatives did not think about their own needs but focused on the patient.

Significance of Results:

It is important that care and support for both patients and relatives be based on individual needs. The staff members responsible for providing this care and support must have knowledge and experience of the disease and its specific care. If they do not belong to an ALS (amyotrophic lateral sclerosis) team, they may require further education and support. The relatives focus on the patient's situation and do not think of their own needs. It is therefore important that health professionals be observant of the relatives and offer them help and support to better manage their situation.

A concept analysis of patient-centred nursing in the intensive care unit

AIM

To report an analysis of the concept of patient-centred nursing in the context of intensive care.

BACKGROUND

Clarification of patient-centred nursing in the intensive care unit is important because consensus definition of this concept is lacking. The severely compromised physiological state of these people and the sequelae of this differentiate patient-centred nursing in intensive care from that occurring in other hospital settings. While the broad concept has been analysed, it has not been examined in the context of intensive care.

DESIGN

Concept analysis.

DATA SOURCES

CINAHL, PsycINFO, Medline and PubMed databases (2000-2014) were searched. Peer-reviewed papers were identified and reference lists of relevant articles searched.

METHODS

Walker and Avant's eight-stage approach was used.

RESULTS

Patient-centred nursing in the intensive care unit incorporates antecedents of a physiologically compromised patient requiring biomedical intervention, a professional and competent nurse and organizational support. The concept's defining attributes entail maintenance of patient identity by a compassionate and professional nurse exercising biomedical expertise. Consequences include patient satisfaction, positive patient experience, nurse job satisfaction and better nurse workforce retention.

CONCLUSION

Patient-centred nursing in intensive care is differentiated from other healthcare areas by the particular characteristics of critically ill patients, the critical care environment and the challenging bio-psycho-social demands made on intensive care nurses. Effective patient-centred nursing in this environment promotes beneficial outcomes for patients, nurses and healthcare service. Decision-makers and policymakers should support critical care nurses in this challenging role, to maintain delivery of patient-centred nursing and grow an effective nursing workforce.

Patient participation in nursing care on medical wards: An integrative review

BACKGROUND

Patient participation is a way for patients to engage in their nursing care. In view of the possible link between patient participation and safety, there is a need for an updated review to assess patient participation in nursing care.

OBJECTIVES

To investigate patients' and nurses' perceptions of and behaviours towards patient participation in nursing care in the context of hospital medical wards.

DESIGN

Integrative review.

DATA SOURCES

Three search strategies were employed in August 2013; a computerised database search of Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Medline and PsychINFO; reference lists were hand-searched; and forward citation searching was executed.

REVIEW METHODS

After reviewing the studies, extracting study data and completing summary tables the methodological quality was assessed using the Mixed-Methods Assessment Tool by two reviewers. Reviewers met then to discuss discrepancies as well as the overall strengths and limitations of the studies. Discrepancies were overcome through consensus or a third reviewer adjudicated the issue. Within and across study analysis and synthesis of the findings sections was undertaken using thematic synthesis.

RESULTS

Eight studies met inclusion criteria. Four themes were identified - enacting participation, challenges to participation, promoting participation and types of participation. Most studies included were conducted in Europe. The majority of studies used qualitative methodologies, with all studies sampling patients; nurses were included in three studies. Data were largely collected using self-reported perceptions; two studies included observational data. Methodological issues included a lack of reflexivity, un-validated data collection tools, sampling issues and low response rates.

CONCLUSIONS

On medical wards, patients and nurses desire, perceive or enact patient participation passively. Challenging factors for patient participation include patients' willingness, nurses' approach and confusion around expectations and roles. Information-sharing was identified as an activity that promotes patient participation, suggesting nurses encourage active communication with patients in practice. Involving patients in assessment and care planning may also enhance patient participation. For education, enhancing nurses' understanding of the attributes of patient participation, as well as patient-centred care approaches may be beneficial for medical ward nurses. From here, researchers need to examine ways to overcome the barriers to patient participation; further nurse participants and observational data is required on medical wards.

Cardiac patients' perception of patient-centred care: a qualitative study

AIM

The aim of this study was to explore cardiac patients' perception of patient-centred care.

BACKGROUND

Despite patient's importance in the process of care, less attention has been paid to experiences and expectations of patients in definitions of patient-centred care. As patients are an important element in process of patient-centred care, organizing care programs according to their perceptions and expectations will lead to enhanced quality of care and greater patient satisfaction.

DESIGN

This study is a descriptive qualitative study.

METHODS

Content analysis approach was performed for data analysis. Participants were 18 cardiac patients (10 women and 8 men) hospitalized in coronary care units of teaching hospitals affiliated to Tehran University of Medical Sciences. We collected the study data through conducting personal face-to-face semi-structured interviews.

FINDINGS

The participants' perceptions of patient-centred care fell into three main themes including managing patients uncertainty, providing care with more flexibility and establishing a therapeutic communication. The second theme consisted of two sub-themes: empathizing with patients and having the right to make independent decisions.

CONCLUSIONS

Receiving patient-centred care is essential for cardiac patients. Attention to priorities and preferences of cardiac patients and making decisions accordingly is among effective strategies for achieving patient-centred care.

IMPLICATIONS FOR PRACTICE

Cardiac care unit nurses ought to be aware that in spite of technological developments and advances, it is still important to pay attention to patients' needs and expectations in order to achieve patient satisfaction. In planning care programs, they should consider accountability towards patients' needs, flexibility in process of care and establishing medical interactions as an effective strategy for improving quality of care.

Managing Everyday Life: A Qualitative Study of Patients' Experiences of a Web-Based Ulcer Record for Home-Based Treatment

Chronic skin ulcers are a significant challenge for patients and health service resources, and ulcer treatment often requires the competence of a specialist. Although e-health interventions are increasingly valued for ulcer care by giving access to specialists at a distance, there is limited research on patients’ use of e-health services for home-based ulcer treatment. This article reports an exploratory qualitative study of the first Norwegian web-based counselling service for home-based ulcer treatment, established in 2011 by the University Hospital of North Norway (UNN). Community nurses, general practitioners (GPs) and patients are offered access to a web-based record system to optimize ulcer care. The web-based ulcer record enables the exchange and storage of digital photos and clinical information, by the use of which, an ulcer team at UNN, consisting of specialized nurses and dermatologists, is accessible within 24 h. This article explores patients’ experiences of using the web-based record for their home-based ulcer treatment without assistance from community nurses. Semi-structured interviews were conducted with a total of four patients who had used the record. The main outcomes identified were: autonomy and flexibility; safety and trust; involvement and control; and motivation and hope. These aspects improved the patients’ everyday life during long-term ulcer care and can be understood as stimulating patient empowerment.

Chronotope disruption as a sensitizing concept for understanding chronic illness narratives

Objectives: This article aims to elaborate chronotope disruption —a changed relation to time and space— as a sensitizing concept for understanding chronic illness narratives. Methods: Sixteen men and 16 women with Type 2 diabetes were purposefully sampled. Each was interviewed about his or her experience of diabetes self-management using the biographical-narrative interview method. Transcripts were inspected for key moments defined as emotionally laden stories relevant to the purpose of the research. We present dialogically inflected discursive analysis of exemplar extracts. Results: The analysis demonstrates how the concept of chronotope disruption helps identify, and understand, important aspects of patients’ chronic illness narratives. First, we investigate how medical advice can conflict with embodied experience and how progressive bodily deterioration can provoke a reevaluation of past illness (self-mis)management. Second, the increasing temporal and spatial intrusion of chronic illness into participants’ lives is examined. Finally, we focus on the masquerade of health as an attempt to manage, hide, or deny that one is physically challenged. Conclusions: Chronotope disruption offers a useful sensitizing concept for approaching chronic illness narratives and around which to organize analytical insights and to develop practice. Chronotope analysis fills an important gap in the science through compensating current health sciences’ focus on rationality, cognition, and prospective time (prediction) with a patient-oriented focus on emotionality, embodiment, and retrospective time (nostalgia). Chronotope disruption could be used to develop practice by gaining empathic understanding of patients’ life-worlds and provides a tool to examine how new technologies change the way in which the chronically ill have “being” in the world.

Interprofessional patient-centred practice in oncology teams: utopia or reality?

Studies on interprofessional practice usually report professionals' viewpoints and document organizational, procedural and relational factors influencing that practice. Considering the importance of interprofessional patient-centred (IPPC) practice, it seems necessary to describe it in detail in an actual context of care, from the perspective of patients, their families and health-care professionals. The goal of this study was to describe IPPC practice throughout the continuum of cancer care. A qualitative multiple case study was completed with two interprofessional teams from a Canadian teaching hospital. Interviews were conducted with patients, their families and professionals, and observation was carried out. Three themes were illustrated by current team practice: welcoming the person as a unique individual, but still requiring the patient to comply; the paradoxical coexistence of patient-centred discourse and professional-centred practice; and triggering team collaboration with the culmination of the patient's situation. Several influential factors were described, including the way the team works; the physical environment; professionals' and patients'/family members' stance on the collaboration; professionals' stance on patients and their families; and patients' stance on professionals. Finally, themes describing the desired IPPC practice reflect the wish of most participants to be more involved. They were: providing support in line with the patient's experience and involvement; respecting patients by not imposing professionals' values and goals; and consistency and regularity in the collaboration of all members.

Critical care nurses' understanding of the concept of patient-centered care in Iran: a qualitative study

This study explores the perception of nurses working in critical care units about the patient-centered care, which is a crucial factor in attaining quality in nursing care. A qualitative exploratory study with conventional content analysis was used. Three main themes were extracted from the data: from accepting to understanding the patient; improved care as the result of skill and expertise; and adherence to patients' rights charter.

Patient-centred care in general dental practice--a systematic review of the literature

Background

Delivering improvements in quality is a key objective within most healthcare systems, and a view which has been widely embraced within the NHS in the United Kingdom. Within the NHS, quality is evaluated across three key dimensions: clinical effectiveness, safety and patient experience, with the latter modelled on the Picker Principles of Patient-Centred Care (PCC). Quality improvement is an important feature of the current dental contract reforms in England, with “patient experience” likely to have a central role in the evaluation of quality. An understanding and appreciation of the evidence underpinning PCC within dentistry is highly relevant if we are to use this as a measure of quality in general dental practice.

Methods

A systematic review of the literature was undertaken to identify the features of PCC relevant to dentistry and ascertain the current research evidence base underpinning its use as a measure of quality within general dental practice.

Results

Three papers were identified which met the inclusion criteria and demonstrated the use of primary research to provide an understanding of the key features of PCC within dentistry. None of the papers identified were based in general dental practice and none of the three studies sought the views of patients. Some distinct differences were noted between the key features of PCC reported within the dental literature and those developed within the NHS Patient Experience Framework.

Conclusions

This systematic review reveals a lack of understanding of PCC within dentistry, and in particular general dental practice. There is currently a poor evidence base to support the use of the current patient reported outcome measures as indicators of patient-centredness. Further research is necessary to understand the important features of PCC in dentistry and patients’ views should be central to this research.

The effect of heart failure nurse consultations on heart failure patients' illness beliefs, mood and quality of life over a six-month period

AIMS AND OBJECTIVES

To explore the effect contact with a heart failure nurse can have on patients' illness beliefs, mood and quality of life.

BACKGROUND

There is growing interest in patients' illness beliefs and the part they play in a patients understanding of chronic disease.

DESIGN

Secondary analysis on two independent datasets. Patients were recruited from five UK hospitals, four in London and one in Sussex. Patients were recruited from an inpatient and outpatient setting. The first dataset recruited 174 patients with newly diagnosed heart failure, whilst the second dataset recruited 88 patients with an existing diagnosis of heart failure.

METHODS

Patients completed the Minnesota Living with Heart Failure Questionnaire, Hospital Anxiety and Depression Scale, Illness Perception Questionnaire and the Treatment Representations Inventory at baseline and six months. We used a linear regression model to assess the association that contact with a heart failure nurse had on mood, illness beliefs and quality of life over a six-month period.

RESULTS

Patients who had contact with a heart failure nurse were more satisfied with their treatment and more likely to believe that their heart failure was treatable. Contact with a heart failure nurse did not make a statistically significant difference to mood or quality of life.

CONCLUSIONS

This study has shown that contact with a heart failure nurse can improve patient satisfaction with treatment decisions but has less influence on a patient's beliefs about their personal control, treatment control and treatment concerns. With appropriate support, skills and training, heart failure nurses could play an important role in addressing individual patient's beliefs. There is a need to further investigate this.

RELEVANCE TO CLINICAL PRACTICE

Exploring patients' illness beliefs and mood could help to enhance person-centred care. Heart failure nurses would need additional training in the techniques used.

Fostering person-centered care among nursing students: creative pedagogical approaches to developing personal knowing

Person-centered care (PCC) is grounded in principles of respect, autonomy, and empowerment and requires the development of interpersonal relationships. For nursing students to engage in PCC, they need to intentionally develop personal knowing, which is an essential attribute of therapeutic relationships. Developing personal knowing, as well as professional knowledge, positions students to enact PCC in their practice. Faculty members play a vital role in fostering the development of personal knowing by creating opportunities for students in which genuine and respectful dialogue, reflection, self-awareness, and critical thinking can take place. This article explores several creative approaches faculty have used to actualize these qualities in their teaching-learning encounters with nursing students at various stages of their students' professional development. These approaches offer experiential teaching-learning opportunities that foster the development of personal knowing, as well as constructive and respectful relationships between faculty and students, therefore laying the groundwork for PCC in practice settings.

Nurses’ Experiences of Providing Care to Dementia Patients Through Home Health Care

Most Western countries aim to enable dementia sufferers to live at home for as long as possible. Person centeredness, continuity of care, and competence level are all important for the quality of home health care (HHC). The aim of this qualitative study is to describe staff’s experiences of providing care to home-dwelling dementia clients through HHC services. The study used a phenomenological-hermeneutic interpretation of focus group interviews. This study supports the value of continuous interpersonal relationships in HHC services. The findings show that specialized teams facilitate continuity and person-centered care, and that after training, staff become more holistically oriented, involve clients in daily care, and experience greater job confidence.

Anything but basic: Nursing's challenge in meeting patients' fundamental care needs

PURPOSE

Nursing has not explored the fundamental aspects of patient care in a systematic, conceptually coherent, scientific way, and this has created a number of ongoing challenges.

ORGANIZING CONSTRUCT

Each challenge is identified and addressed in the form of a proposition, with evidence provided to support the arguments put forward and defend the proposed actions.

FINDINGS

The challenges include: the need for an integrated way of thinking about the fundamentals of care from a conceptual, methodological, and practical perspective; the ongoing and unresolved tension in nursing practice between a depersonalized and mechanistic approach (termed a "task and time" driven culture) and the need for consistency around understanding and managing the dynamics of the nurse-patient relationship or encounter (termed a "thinking and linking" approach); and the need for a systematic approach to the fundamentals or basics of care that combines the physical, psychosocial, and relational dimensions of the care encounter within the wider context of the care environment. Pragmatic and practical frameworks are needed to ensure that the basic physical and psychosocial needs of patients are embedded not only in the practice but also in the thinking, reflection, and assessment processes of the nurse.

CONCLUSIONS

Nursing's challenge to meet patients' basic or fundamental needs is complex. Developing a knowledge base will include identifying researchable questions, using rigorous methodologies, ensuring the relational dimensions are not lost, and ensuring the new knowledge is applied in practice. This requires collaboration on an international scale to achieve improvements in care.

CLINICAL RELEVANCE

To work collaboratively to generate, test, and implement meaningful ways of capturing nursing practice around basic or fundamental care in order to ensure more integrated, holistic patient care nursing practices.

Getting past widgets and digits: the fundamental transformation of the foundations of nursing practice

Health reform and transformation now call for the creation of a new landscape for nursing practice based on intentional translation application of value-driven measures of service, quality, and price. Nursing is a central driver in the effective recalibration of health care within the rubric of health transformation under the aegis of the Patient Protection and Affordable Care Act. Increasingly relying on a growing digital infrastructure, the nursing profession must now reframe both its practice foundations and patterns of practice to reflect emerging value-driven, health-grounded service requisites. Specific nursing responses are suggested, which position nursing to best coordinate, integrate, and facilitate health delivery in the emerging value-driven service environment.

Patient-centered care: clarification of its specific elements to facilitate interprofessional care

Patient-centered care (PCC) has been described as a vague concept, which yields an inconsistent operationalization and implementation of this approach to care. This integrative review of the literature, guided by the conceptualization of PCC as a complex intervention, aimed to identify the specific elements of PCC. Conceptual, empirical and clinical literature in different health professions (n = 178 articles) was critically analyzed. Comparing and contrasting the definitions and descriptions of PCC revealed three specific elements that were represented in these components: holistic, collaborative and responsive care. Activities that constitute each component were specified. The implementation of PCC components is facilitated by a non-specific element: the therapeutic relationship. The results inform the development of protocols that can be used to promote the fidelity with which PCC is delivered by different professionals in a variety of healthcare settings.

What is meant by patient-centredness being value-based?

OBJECTIVE

To examine whether it is possible to further specify what is meant when we maintain that patient-centredness as a communication skill is a value-based clinical procedure.

DESIGN AND MAIN OUTCOME MEASURES

Since a core element in patient-centredness is associated with patients feeling respected, a study regarding encounters where patients felt respected was analysed.

RESULTS

Similarities were found between the core elements of patient-centredness in terms of inviting, listening, and summarizing, and patients feeling respected in terms of listening, having their questions answered, and believing in what they tell their GP.

CONCLUSION

Even though what is respected cannot be specified, the authors' analysis indicates that feeling respected is frequently and strongly associated with encounters reflecting core aspects of patient-centredness. In this sense, patient-centredness might be considered value-based. Future research might shed light on what is actually respected: is it the patient's autonomy, integrity, dignity, or honour?

Patient participation in care and rehabilitation from the perspective of patients with spinal cord injury

STUDY DESIGN

Qualitative method, semi-structured interviews.

OBJECTIVES

The aim of the study was to explore the meaning of patient participation in care and rehabilitation from the perspective of patients with spinal cord injury (SCI).

SETTING

Post discharge community setting.

METHODS

Semi-structured interviews were performed with 10 persons with SCI representing different ages, gender and levels of injury. All interviews were conducted individually and lasted 40-120 min. The interviews were verbally transcribed and the data were analyzed by means of content analysis.

RESULTS

All informants stressed the importance of patient participation as a necessary prerequisite for successful care and rehabilitation, but emphasized that participation must be tailored to each patient's own preferences, capacities and needs. They also underscored that the staff should be sensitive and responsive to the fact that desired levels and kinds of participation may vary from patient to patient, as well as for the same patient during the course of the rehabilitation. Five themes reflecting central aspects of participation emerged: respect and integrity, planning and decision-making, information and knowledge, motivation and encouragement, and involvement of family.

CONCLUSIONS

Patient participation is a critical component of successful SCI rehabilitation and must be facilitated, promoted and tailored to each patient by the staff. Based on the finding from this study a questionnaire has been developed for assessing patient experiences of five domains of participation in rehabilitation to serve as a tool to help in evaluating provided care and in identifying patients' preferences for participation.

Cultural health capital and the interactional dynamics of patient-centered care

As intuitive and inviting as it may appear, the concept of patient-centered care has been difficult to conceptualize, institutionalize and operationalize. Informed by Bourdieu's concepts of cultural capital and habitus, we employ the framework of cultural health capital to uncover the ways in which both patients' and providers' cultural resources, assets, and interactional styles influence their abilities to mutually achieve patient-centered care. Cultural health capital is defined as a specialized collection of cultural skills, attitudes, behaviors and interactional styles that are valued, leveraged, and exchanged by both patients and providers during clinical interactions. In this paper, we report the findings of a qualitative study conducted from 2010 to 2011 in the Western United States. We investigated the various elements of cultural health capital, how patients and providers used cultural health capital to engage with each other, and how this process shaped the patient-centeredness of interactions. We find that the accomplishment of patient-centered care is highly dependent upon habitus and the cultural health capital that both patients and providers bring to health care interactions. Not only are some cultural resources more highly valued than others, their differential mobilization can facilitate or impede engagement and communication between patients and their providers. The focus of cultural health capital on the ways fundamental social inequalities are manifest in clinical interactions enables providers, patients, and health care organizations to consider how such inequalities can confound patient-centered care.

Pressure ulcer knowledge of registered nurses, assistant nurses and student nurses: a descriptive, comparative multicentre study in Sweden

The aim of this study was to describe and compare the knowledge of registered nurses (RNs), assistant nurses (ANs) and student nurses (SNs) about preventing pressure ulcers (PUs). PU prevention behaviours in the clinical practice of RNs and ANs were also explored. A descriptive, comparative multicentre study was performed. Hospital wards and universities from four Swedish county councils participated. In total, 415 participants (RN, AN and SN) completed the Pressure Ulcer Knowledge Assessment Tool. The mean knowledge score for the sample was 58·9%. The highest scores were found in the themes 'nutrition' (83·1%) and 'risk assessment' (75·7%). The lowest scores were found in the themes 'reduction in the amount of pressure and shear' (47·5%) and 'classification and observation' (55·5%). RNs and SNs had higher scores than ANs on 'aetiology and causes'. SNs had higher scores than RNs and ANs on 'nutrition'. It has been concluded that there is a knowledge deficit in PU prevention among nursing staff in Sweden. A major educational campaign needs to be undertaken both in hospital settings and in nursing education.

Development and preliminary testing of a framework to evaluate patients' experiences of the fundamentals of care: a secondary analysis of three stroke survivor narratives

Aim. To develop and test a framework describing the interrelationship of three key dimensions (physical, psychosocial, and relational) in the provision of the fundamentals of care to patients. Background. There are few conceptual frameworks to help healthcare staff, particularly nurses, know how to provide direct care around fundamental needs such as eating, drinking, and going to the toilet. Design. Deductive development of a conceptual framework and qualitative analysis of secondary interview data. Method. Framework development followed by a secondary in-depth analysis of primary narrative interview data from three stroke survivors. Results. Using the physical, psychosocial and relational dimensions to develop a conceptual framework, it was possible to identify a number of "archetypes" or scenarios that could explain stroke survivors' positive experiences of their care. Factors contributing to suboptimal care were also identified. Conclusions. This way of thinking about how the fundamentals of care are experienced by patients may help to elucidate the complex processes involved around providing high quality fundamentals of care. This analysis illustrates the multiple dimensions at play. However, more systematic investigation is required with further refining and testing with wider healthcare user groups. The framework has potential to be used as a predictive, evaluative, and explanatory tool.

The care delivery experience of hospitalized patients with complex chronic disease

OBJECTIVE

This study investigated what is important in care delivery from the perspective of hospital inpatients with complex chronic disease, a currently understudied population.

PARTICIPANTS AND SETTING

One-on-one semi-structured interviews were conducted with inpatients at a continuing care/rehabilitation hospital (n = 116) in Canada between February and July 2011.

DESIGN

The study design was mixed methods and reports on patient characteristics and care delivery experiences. Basic descriptive statistics were run using SPSS version 17, and thematic analysis on the transcripts was conducted using NVivo9 software.

RESULTS

Patients had an average of 5 morbidities and several illness symptoms including activity of daily living impairments, physical pain and emotional disturbance. Three broad themes (each with one or more subthemes) were generated from the data representing important components of care delivery: components of the care plan (a comprehensive assessment, supported transitions and a bio-psycho-social care package); care capacity and quality (optimal staff to patient ratios, quicker response times, better patient-provider communication and consistency between providers) and the patient-provider relationships (characterized by respect and dignity).

CONCLUSIONS

As health systems throughout the industrialized world move to sustain health budgets while optimizing quality of care, it is critical to better understand this population, so that appropriate metrics, services and policies can be developed. The study has generated a body of evidence on the important components of care delivery from the perspectives of a diverse group of chronically ill individuals who have spent a considerable amount of time in the health-care system. Moving forward, exploration around the appropriate funding models and skill mix is needed to move the evidence into changed practice.