Define patient-centered care competency
· Identify two issues or trends related to patient-centered care
· Discuss how each issue or trend impacts the role of the professional nurse in the healthcare system.
· Include an Introduction, Conclusion and Reference Page in your paper.
· APA format
The Role of Patient- Centered Care in Nursing
Amanda J. Flagg, PhD, MSN, EdM, RN, ACNS-BC, CNE
� Patient-/family-centered care � Family at bedside � Bedside report � Holistic nursing � Patient satisfaction
� Patient-/family-centered care is key to patient satisfaction. � Inclusion of family and friends is needed for increased quality of care. � Use of a bedside report enhances quality of nursing care delivery.
Nurse Smith, RN is running behind schedule. This is the third 12-hour shift on a 36-bed medical/surgical unit, and the change-of-shift-report has just been received for 7 patients assigned to her care. The night shift nurse has an appointment and needs to get home immediately. There is little time for questions or verifications of proce- dures such as early morning blood draws and catheter care necessities. Patient A is scheduled for surgery and is due to be transported at any moment. Problem: the pro- phylactic antibiotic he was to receive preoperatively has not yet arrived on the unit. Pa- tient B is sleeping, but his glucose reading was 60 at 6:30 AM. Patient C is crying because of poor control of her postsurgical incisional pain, but she is not due for medi- cation for another hour. Nurse Smith’s remaining 4 patients will require her already taxed attention to pull her in several other directions within the hour, and there are 2 admissions waiting in the emergency department. Nurse Smith has been assigned to one of them. And the story continues.
This scenario depicts a multitude of challenges and is played out repeatedly in many acute care inpatient facilities across the nation. Nurses like Nurse Smith bear heavy patient loads with limited support systems and ever-increasing responsibilities in the care of patients, particularly those with chronic illness. Health care has become
Disclosure Statement: The author has nothing to disclose. School of Nursing, Middle Tennessee State University, Box 81, Murfreesboro, TN 37132, USA E-mail address: Amanda.Flagg@mtsu.edu
Nurs Clin N Am 50 (2015) 75–86 http://dx.doi.org/10.1016/j.cnur.2014.10.006 nursing.theclinics.com 0029-6465/15/$ – see front matter � 2015 Elsevier Inc. All rights reserved.
progressively more complicated and highly technical and is perceived by many patients to be an impersonal and highly complex system.1 So where is the patient in all the chaos? How satisfied are patients with nursing care today? What aspects of patient care can be considered in improving the quality of that care that will allow the patient to be seen, heard, and cared for amidst all the noise?
The effects of changes in the field of health care are reverberating in nursing, which requires the need for increased efficiency in the provision of care. This environment pushes even the most experienced nurse to become more task oriented and less patient focused in a sea of constant admissions and discharges with expectations that patients are to do most of their recovery either in a long-term rehabilitation unit or at home.2,3 The mantra “doing more with less and less” seems to be the quote of the day, every day. One form of response to these challenges has echoed in the literature of nursing and
other health care professions for several decades; the concept of patient-centered care (PCC). In fact, the Institute of Medicine has placed PCC as 1 of 6 objectives in the improvement of health care quality for the 21st century.4 So what is PCC and how does it involve nursing care?
Defining Patient-Centered Care
PCC has been depicted as a philosophy, a process, a model, a concept, and a part- nership that involves both the patient and health care provider (to include the nurse) arriving at some form of conclusion about the care and treatment of the patient’s condition.5–7 Although there are no definitive definitions of PCC, several attempts have been made to operationalize this concept. A summary of these efforts describing PCC are outlined in Box 1. Kjeldmand and colleagues12 acknowledged Mead and Bower’s13 early attempts to
describe PCC but suggested that the term patient-centeredness is central to
Brief history of patient-centered care
Balint first described PCC in the mid-1950s as a concept of understanding patients as unique beings.8
There have been many references to PCC as a philosophy.9
a. Mead and Bower (2002) began to form a preliminary framework of patient centeredness as a method of delivering health care to patients by describing 5 distinct dimensions of PCC.10,11
1. Bio psychosocial perspective that takes into account the impact of social and psychological factors of illness
2. Patient as a unique individual that considers the patient’s personal understanding and meaning of illness
3. Sharing of power and responsibility that considers patients’ preferences for information and their participation in decision making
4. The therapeutic alliance that takes into account the development of common goals and the enhancement of a bond shared between patient and provider
5. Doctor/nurse as person aspect that addresses the awareness of personal qualities and subjective experiences of the provider within his or her practice setting.
Patient-Centered Care 77
relationship-centered care by acknowledging an ultimate synthesis of both the biomedical and real-world perspectives of both the patient and health care provider. So what is nursing’s stand on PCC?
Domains of Patient-Centered Care
Competencies for nursing were analyzed and redefined in 2007 by the Quality and Safety Education for Nurses (QSEN) project that redirected how nurses approach their profession.1 In this QSEN project, PCC was defined as a competency that recognizes the patient or designee as the source of control and full partner in providing compas- sionate and coordinated care. This care was based on respect for patients’ prefer- ences, values, and needs.1 Table 1 outlines additional key dimensions of PCC as it relates to nursing.1,4,14,15
Key Factors of a Patient-Centered Care Environment
There are 7 key factors that are imperative to the engagement, support, implementa- tion, and sustainment of PCC.16,17
� Leadership involvement, support, and buy-in � Strategic vision that is clearly defined and operationalized � Involvement of patients and their families and other support systems � Involvement of employees to include all health care providers � Evaluation of and feedback regarding process in place � Design of the physical environment to be supportive of patients, families, and staff
� Availability of technology that supports communication between patients and health care providers
Barriers to Patient-Centered Care
Although PCC is seen as a positive movement in the future of health care delivery, there are barriers that need to be recognized. Potential barriers include the following.
� No clear definition of PCC � Lack of educational programs supporting PCC for all health care providers � Fragmentation of care that focuses on the disease instead of the whole individual � Staff who are overworked experiencing shortages
Table 1 Sample of dimensions of patient-centered care and nursing
Gerteis et al,14 1993 Respect for patients, values, preferences, coordination and integration of care, information, communication, education, comfort, emotional support of family/friends, transition and continuity of care
Institute of Medicine,4 2001 Safety, effectiveness, timeliness, equity, and efficiency of care
Watson’s ten principles of human science and care15
Person-centered nursing conceptual framework: characteristics and attributes of the nurse, context in which care is provided, how care is given, outcomes of care.
QSEN Project, 20071 Patient as source of control, full partner in provision of compassionate care, respect for patient preference, values, and needs.
� Continued dominance of the biomedical mode of practice (doctor and nurse know best)
� Financial costs of educating and recruiting adequate numbers of health care pro- viders in support of PCC
APPLICATION OF PATIENT-CENTERED CARE TO NURSING: HOLISTIC CARE
The philosophy of holistic nursing supports the tenants of PCC that are derived in part from Florence Nightingale who believed in the importance of her patients’ conditions through the interaction of their respective environment.18 Holistic nursing places emphasis on both the environment and treatment of the patient to include patients’ uniqueness as human beings along with their cultural views, values, and beliefs.18,19
Shared Similarities of Holistic Nursing and Patient-Centered Care
Holistic nursing also encourages nurses to reflect on their own self-care and to engage in PCC that includes the use of such skills as listening and questioning. Takase and Teraoka20 developed a competency scale to assess and measure Japanese nurses’ abilities to cope with ever-increasing complex scenarios similar to the scenario described earlier.20 The initial testing of this instrument found that 1 of the 5 themes was in full support of adopting ethically oriented practice to include the need for PCC nursing. The 5 themes identified shared similarities between nursing as a philos- ophy and principles of PCC. These similarities are summarized in Box 2. Holistic nursing values and beliefs are also reflecting of PCC philosophies. They are
summarized in Box 3. The combination of PCC and holistic nursing can benefit patients and nurses; how-
ever, the inclusion of patients and their families and friends is also considered a positive aspect of these philosophies based on the patients’ needs and desires to include them.
PATIENT-CENTERED CARE AND FAMILY-CENTERED CARE
Patient- and family-centered care (PFCC) extends the partnership of patients and health care providers to include families (and friends) at the discretion of the patient involved.21 The involvement of families encourages the sharing of knowledge and experience in the planning of nursing care for the enhancement and well being of the patient.22,23 Acute care facilities are engaging in PFCC in several ways to include the provision of the items listed in Box 4.
Shared nursing interactions using holistic care and PCC
1. Listening to patients’ questions, needs, and views
2. Communicating with patients to ensure understanding of their questions, needs, and views
3. Sharing questions, needs, and views with other members of health care teams
4. Establishment of therapeutic relationships with patients and significant others such as families and friends
5. Providing patients and families with needed education regarding their disease processes
6. Evaluating goals of care in accordance with patients’ and families’ wishes and abilities
7. Providing the best care possible using up-to-date knowledge, competencies, and empathic nursing practice
Holistic nursing beliefs and PCC philosophies
1. Maintain up-to-date knowledge and competencies
2. Identify gaps in learning and knowledge
3. Reflect on practice
4. Observe objectively, yet compassionately
5. Promote health and well-being of self and others
6. Maintain balance both physically and mentally
Patient-Centered Care 79
PFCC is also mirrored in the practice of decreasing the limitations placed on visiting hours in many facilities. Based on patient and family preference and ability, family members are encouraged to stay with patients overnight and are invited to be involved in some aspects of patient care. Even acutely ill patients are afforded less-restrictive visitation hours in such areas as the emergency department and intensive care units.24,25 Alternatively, with extended family visiting, consequences that require consideration include the potential of patient exhaustion, unrealistic expectations for perceived needs of patient and family members, and the potential overall effects of such visits on the progress of patient recovery.
FAMILY PRESENCE AT THE BEDSIDE AND BEYOND
Family presence within the PFCC model extends to include not just presence in patient rooms during set visiting hours but during procedures that occur in inpatient and outpatient areas. Depending on the invasiveness of the procedure and patient and family preferences, several research studies have found positive aspects of such practice.26
One such procedure is the changing of dressings for severe burn injuries. Because of concerns of increased infection rates and the perception of family members’ inability to tolerate observing their loved ones in times of duress, family members are usually not allowed to be present. This often leads to dissatisfaction of care and misperceptions of nursing and medical staff in the eyes of the patient and their loved ones. A study by Bishop and colleagues,27 found that family presence during a burn wound debridement actually had the opposite effect. In selected cases, patients experienced decreased levels of apprehension and pain. Conversely, another aspect of including family participation includes pediatric
patients. Under the auspices of PFCC, pediatric patients are included in this partner- ship, particularly in decision-making processes, regardless of their age, based on the extent of their ability and desire to be part of the planning of their care. The same invi- tation can be extended to the elderly, particularly those patients who have limited cognitive function yet are able to share in basic decision making.
Patient- and family-centered care provisions
1. Family information packs concerning location and cafeteria hours
2. Posted photos of all staff members on each inpatient and outpatient unit
3. Resources assisting in the care of the patient at discharge
FAMILY PRESENCE DURING CHANGE-OF-SHIFT REPORT
The presence of family during patient roundsmay conjure images of gross violations of Health Insurance Portability and Accountability Act (HIPAA); however, if PFCC is to be respected, the inclusion of patient rounds requires that family presence be not only invited but encouraged. The following tenants are suggestions to consider.28–36
� Give patients and families a choice in engaging in rounds. � Have nurses provide introductions (eg, night shift introduces the day shift nurse and staff).
� Use a circle formation if possible during a report to allow for eye contact to occur. � Use terminology that all parties can understand.
Benefits of Patient- and Family-Centered Care Rounds
� Increased patient and family satisfaction of care � Increased communication between patients and nurses � Decreased confusion regarding discharge planning and teaching � Opportunities for patient and family education � Opportunities for discussion and planning of patient care
Barriers to Patient- and Family-Centered Care Rounds
� Limited physical space based on patients’ room size and available areas for discreet conversations
� Nursing units’ buy-in and use of rounds (eg, are rounds audio-taped? Do nurses round together?)
� Time constraints with change-of-shift report � Potential for HIPAA violations of patient information
FAMILY PRESENCE DURING CODES
PFCC seems well suited in many health care situations but remains controversial in extreme interactions during lifesaving, resuscitative efforts. Hung and Pang24 studied family members who were present during successful resuscitative efforts of their loved ones using an interpretive phenomenological approach.24 Table 2 summarizes 10 themes that emerged from thedataand familymembercomments reflecting the themes.
Barriers to Family Presence During Codes
Itzhaki and colleagues37 noted that, in general, lay individuals tended to be more positive toward family presence in a code situation than clinical, staff particularly when the patient survived. Women, both family and clinicians, tended to reflect more negatively in situations in which profuse bleeding was present and resuscitative efforts failed. Box 5 summarizes barriers that could prevent families from witnessing resuscitation efforts of their family members.
Interventions Used to Embrace and Sustain Patient- and Family-Centered Care
A core competency identified in several studies that supports PFCC is that of commu- nication.38,39 The following communication strategies are recommended by the Mas- sachusetts Department of Higher Education Nurse of the Future Competency Committee.40
� Verbal, written, and electronic versions should be clear and concise. � Auditory, visual, and tactile forms are important components.
Table 2 Ten themes with examples of participants’ responses
1. Emotional connectedness to the patient “I was allowed to hold his/her hand”
2. Provision of support to the patient “I could talk to him/her”
3 Maintaining relationship with patient “I was allowed to hold his/her hand”
4 Knowing the patient and health conditions “I could relate aspects of his/her health”
5. Keeping informed of what was going on “I knew what was being done to save this life”
6. Being engaged in what was going on “Watching reassured me the right things were being done”
7. Providing information to the resuscitation team
“Could provide the names of medications he/she was taking”
8. Perceived (in)appropriateness “I was not allowed in the ICU, I felt helpless, alone, discarded”
9. Perceived inconvenience “I might be in the way of the doctors and nurses—should I be here?”
10. Perceived prohibition “The door said no entry unless given permission—I just wanted to be there but I don’t break rules”
Adapted from Hung M, Pang, MC. Family presence preferences when patients are receiving resus- citation in an accident and emergency department. J Adv Nurs 2010;67(1):56–7.
A i g
Patient-Centered Care 81
� Nurses’ own communication styles have an impact on the receivers’ end of the message.
� Effects of communication can evoke many forms of influence to include spiritual, emotional, and cultural characteristics.
� The right time and setting are imperative considerations. � The receiver, often the patient or family, should be assessed regarding their abil- ity and readiness to communicate.
arriers to family presence during codes
he patient prefers that family not be present during code situations.
amily members prefer not to or are afraid to observe.
amily members may be concerned or lose control by becoming inconsolable or physically or erbally challenging.
amily members require attention that would detract from patient care.
here is limited physical space in acute care units.
taff feels family presence is not appropriate.
taff feels anxious, judged, or concerned with family reactions to their responses under ressure of code situations.
imited staff is available to allow for adequate support of family witnesses.
dapted from Itzhaki M, Bar-Tal Y, Barnoy S. Reactions of staff members and lay people to fam- ly presence during resuscitation: the effect of visible bleeding, resuscitation outcome and ender. J Adv Nurs 2011;68(9):1967–77.
� Barriers should be observed and considered. � Rapport should be established between parties. � Opportunities for questions should be provided. � Assessment of both verbal and nonverbal behavior should be noted. Building communication competence leads to PFCC delivery models that increase
patient care satisfaction and staff retention and recruitment, decrease length of stay and ED visits, and decrease medication errors.41 PFCC delivery model components are listed in Box 6. A few facilities are engaging in the concept of PFCC by participating in the Planet-
ree’s PCC Hospital Designation Program. Under this model, facilities must adhere to 50 criteria placed under 11 categories to receive such recognition.42 The 11 categories facilities must meet are as follows.
� Structures and functions needed for development, implementation, and mainte- nance of PCC
� Human interactions � Patient education and access to information � Family involvement � Nutrition program � Healing environment � Arts program to include animal visitation � Spirituality and diversity � Integrative therapies to include alternative therapies � Healthy communities—a plan geared toward the needs of the community at large � Measurement—use of patient/family satisfaction scores as examples
Components of Patient- and family-centered care delivery models
1. Coordination of care conference—meeting with all specialties to include patient and family to discuss plan of care initiating discharge planning
2. Hourly rounding (once per hour)—includes pain, elimination, and positioning needs along with other patient/family concerns
3. Bedside report—completed at the bedside with family and friends present at discretion of patient or patient advocate
4. Initializing and use of patient care partner (when available)—a family member, friend, or volunteer in full support of patient’s needs and desires
5. Individualized care—Established at admission, to include preferred name, priority of care, learning style, and care partner selection
6. Open medical record policy—allowing patients to document their views at their discretion
7. Opening visiting restrictions—driven by patient or family as applicable in a variety of settings
8. Family presence during resuscitation and other procedures—at discretion of patient as applicable
9. Silence and healing—inviting the patient and family to assess noise level in their environment and to report any discomfort of such to the nurse
Adapted from Hunter R, Carlson E. Finding the fit: patient centered care. Nurs Manage 2014;45:39–43.
Table 3 Sample of studies centered on patient satisfaction
Improving patient satisfaction with nursing communication using bedside shift report33
Patient satisfaction rate increased from 75% to 87.6%
Patients’ perspective on person-centered participation in healthcare: a framework analysis5
General attention and interest was felt by patient
Patients felt respected Patients felt trust
Efficacy of person-centered care as an intervention in controlled trials—a systematic review43
Many studies included the concept of PCC but only a few were actually practicing the model
Effects of patient-centered care on patient outcomes: an evaluation44
Patients are demanding more active roles in their care
Implementation of PCC increased pt. satisfaction with care
Patient satisfaction as an outcome of individualized nursing care30
Positive correlations were found between individualized care and patient satisfaction.
Patient-Centered Care 83
EVALUATION—THE ULTIMATE SCORING CARD
A trend is emerging in the literature associating patient satisfaction of care scores to the delivery of PFCC. Although there are multitudes of variables associated with these forms of measurement, several studies are emerging with such reports, and nursing is helping pave the way for such findings. A small sample of studies is provided in Table 3. Although these articles represent studies exploring concepts of PFCC and patient
satisfaction scores in the inpatient setting, outpatient areas are now being included in PFCC models. Most outpatient clinics have associated the reduction of clinic wait times to patient satisfaction scores. Michael and colleagues,45 also studied the effect of wait times patients experienced in the examination room on satisfaction of overall care.45 These aspects of care have been identified as key points of interest for patients and clinicians but there are many other variables that require further study within this context of health care delivery. Wolff and Roter31 suggested that older patients suffering with chronic illness are
more likely to be accompanied to an outpatient visit by either family or friends. They hypothesized that the addition of family members invokes a positive aspect of care by aiding the patient-provider partnership, the exchange of information regarding patient status, and by including family in the decision-making processes. Their study, a meta-analytical review, found that the presence of family should be further studied in hopes of isolating those factors that facilitate decision-making processes. Care of patients with acute and chronic illnesses can be enhanced by understanding the communication processes deemed central to changing health care delivery systems toward a more patient/family focus.
Now that PCC, holistic nursing, PFCC, bedside rounds, and patient satisfaction scores have been addressed, let’s return to the scenario depicting Nurse Smith and
her third day of duty to see how these concepts might benefit both the patients placed in Nurse Smith’s care and Nurse Smith’s practice. Using PFCC:
� Nurse Smith and the night shift nurse would be rounding together, exchanging reports at each patient’s bedside.28–36
� Any concerns or questions Nurse Smith would have could be efficiently addressed by the night shift nurse, the patient, and a family member if present (based on patient permission).
� Patients’ concerns could also be more fully acknowledged, such as patient B’s glucose level, and patient C’s pain control.
� Nurse Smith’s other patients will hear the report on their situations and be given reassurances that Nurse Smith will return after attending to the immediate needs of her first 3 patients. Any requests from these less-critical patients can be answered by appropriately trained delegated personnel.
� A communication board located in each patient room can be updated to include Nurse Smith’s name and contact information.46
� Hourly rounds will minimally include the checking of patients’ pain, elimination, and position changes particularly for those requiring complete, high-level care. Nurse Smith will always ask if there are other concerns or questions.47
� Nurse Smith also has the right to ask for additional assistance if the patient load does not allow for all other competencies of nursing care to be carried out according to such examples as QSEN standards, facility policies and proce- dures, and her Professional Nurse Practice Act.1
PFCC does not occur in a vacuum. To function, all health care members from administration to environmental services are part of a team whose central focus is the patient. Nurse Smith is part of a team inclusive of not only health care providers but also the patient, his or her family, and other support systems. Drawing on all parties’ experiences to provide care to the patient can only enhance the quality and safety of care that is so critical and so needed yet continues to be so challenging.
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The Role of Patient-Centered Care in Nursing
Defining Patient-Centered Care
Domains of Patient-Centered Care
Key Factors of a Patient-Centered Care Environment
Barriers to Patient-Centered Care
Application of patient-centered care to nursing: holistic care
Shared Similarities of Holistic Nursing and Patient-Centered Care
Patient-centered care and family-centered care
Family presence at the bedside and beyond
Family presence during change-of-shift report
Benefits of Patient- and Family-Centered Care Rounds
Barriers to Patient- and Family-Centered Care Rounds
Family presence during codes
Barriers to Family Presence During Codes
Interventions Used to Embrace and Sustain Patient- and Family-Centered Care
Evaluation—the ultimate scoring card
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University, Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered Care
L eaders of the U.S. Depart -ment of Health & HumanServices (2011) urge providers to improve the overall quality of health care by making it more patient centered. Patient-centered care (or person-centered care) refers to the therapeutic relationship between health care providers and recipients of health care services, with emphasis on meeting the needs of individual patients. Al – though the term has been used widely in recent years, it remains a poorly defined and conceptualized phenomenon (Hobbs, 2009).
Patient-centered care is believed to be holistic nursing care. It pro- vides a mechanism for nurses to engage patients as active partici- pants in every aspect of their health (Scott, 2010). Patient shadowing and care flow mapping were used to create a sense of empathy and urgency among clinicians by clarify- ing the patient and family experi- ence. These two approaches, which were meant to promote patient-cen- tered care, can improve patient sat- isfaction scores without increasing costs (DiGioia, Lorenz, Greenhouse, Bertoty, & Rocks, 2010). A better under standing of attributes of patient-centered care and areas for improvement is needed in order to develop nursing policies that in – crease the use of this model in health care settings.
The purpose of this discussion is to clarify the concept of patient-cen- tered care for consistency with the common understanding about pa – tient satisfaction and the quality of care delivered from nurses to patients. Attributes from a customer service model, the Gap Model of
Service Quality, are used in a focus on the perspective of the patient as the driver and evaluator of service quality. Relevant literature and the Gap Model of Service Quality (Parasuraman, Zeithaml, & Leonard, 1985) are reviewed. Four gaps in patient-centered care are identified, with discussion of nursing implica- tions.
Background and Brief Literature Review
Patient-Centered Care The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011) identified patient-centeredness as one of the areas for improvement in health care quality. The IOM (2001b) defined patient-centeredness as
…health care that establishes a partnership among practition- ers, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the edu- cation and support they require to make decisions and partici- pate in their own care… (p. 7)
Charmel and Frampton (2008) defined patient-centered care as
…a healthcare setting in which patients are encouraged to be actively involved in their care, with a physical environment that promotes patient comfort and staff who are dedicated to meeting the physical, emotion- al, and spiritual needs of patients… (p. 80)
In a concept analysis of person- centered care, Morgan and Yoder (2011) defined it as
…a holistic (bio-psychosocial- spiritual) approach to delivering care that is respectful and indi- vidualized, allowing negotiation of care, and offering choice through a therapeutic relation- ship where persons are empow- ered to be involved in health decisions at whatever level is desired by that individual who is receiving the care. (p. 3)
Of significance in various defini- tions of patient-centered care is the focus on the patient’s needs, patient control, and the interaction between the patient and health care provider. Being patient-centered suggests health care providers adapt their
Beverly Waller Dabney Huey-Ming Tzeng
The Gap Model of Service Quality is used to clarify the concept of patient-centered care. Four possible patient-centered care service qual- ity gaps were identified. Nurse administrators may use these gaps to identify and develop appropriate outcome measures.
Instructions for Continuing Nursing Education Contact Hours appear on page 363.
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services to reflect the goals, needs, and values of the individual patient.
The Joint Commission (2010) expected hospital leaders to develop standards to advance effective com- munication, cultural competence, and patient- and family-centered care. Gerteis, Edgman-Levitan, Daley, and Delbanco (1993) identified seven dimensions of patient-cen- tered care needed to improve health care quality: (a) respect for patients’ values, preferences, and expecta- tions; (b) coordination and integra- tion of care; (c) information, com- munication, and education; (d) physical comfort; (e) emotional sup- port and alleviation of fear and anx- iety; (f) involvement of family and friends; and (g) transition and conti- nuity. Communication with pa – tients, which is essential to the appli- cation of patient-centered care, facil- itates patient involvement in the planning of treatment (Hunt, 2009).
Patient-centered care can influ- ence patient satisfaction, the quality of health care, and possibly a patient’s desire to return to a health care provider for future services (Andrews, 2009; Charmel & Frampton, 2008). Patients are ex pected to accept more financial responsibility for their health care, and they expect value in their health care purchases as they would with any other major pur- chase (Charmel & Frampton, 2008). McCormack, Manley, and Walsh (2008) emphasized the significant role played by health care policy in developing systems and processes in health care institutions that are per- son-centered. The recommendations of the IOM (2001b) and the Agency for Healthcare Research and Quality (2009) to adopt a philosophy of patient-centeredness have encour- aged many institutions across the United States to implement patient- centered models. A comprehensive report on patient-centered care was developed by the Institute for Family-Centered Care and the Institute for Health Care Im prove – ment, from which four key concepts emerged: (a) respect and dignity, (b) information sharing, (c) participa- tion, and (d) collaboration (Johnson et al., 2008). Charmel and Frampton (2008) indicated the attributes of
patient-centered care need to be clar- ified to facilitate understanding of their inter-relatedness. As part of the promotion of patient-centeredness for quality improvement, clarifica- tion of the concept of patient-cen- tered care is needed (McCormack et al., 2008).
Communication The interaction between nurses
and patients is central for the effec- tive application of patient-centered care (Hobbs, 2009). Levinson, Lesser, and Epstein (2010) noted communi- cation is fundamental to the delivery of patient-centered care. Nurse- patient communication seeks to increase the nurse’s understanding of the patient’s needs, perspectives, and values. Nurse-patient communi- cation also provides patients with information needed to participate in their care and assists in correcting unrealistic expectations. Patient-cen- tered communication is not simply agreeing to provide information per patients’ requests, nor is it throwing information at patients and leaving them to sort it out (Epstein, Fiscella, Lesser, & Stange, 2010). Skillful com- munication with patients helps to build trust and understanding, and may require the clinician to engage in further questioning to explore fully what the patient hopes to achieve.
The Joint Commission (2010) emphasized identification of patient communication needs as an issue to be addressed by health care leaders. Patient communication needs may include not only language or hearing barriers, but also emotional or fatigue barriers. In a qualitative study of patients with cancer, Montgomery and Little (2011) found some patients may be unable or even unwilling to express their preferences in regard to treatment during the debilitating stages of health. They suggested patients be assessed indi- vidually for their ability to engage in such communication; some individ- uals may need the health profession- al to assume a greater facilitative role. The quality of relationships and interactions between patients and nurses is of great importance to the achievement of patient-centered
care. In addition to adequate infor- mation sharing, structures and processes are needed to enhance the delivery of patient-centered care.
Delivery of Patient-Centered Care
Luxford, Safran, and Delbanco (2011) interviewed senior staff and patient representatives in a qualita- tive study. Several organizational attributes and processes that facili- tate patient-centered care emerged, including the following: (a) strong, committed senior leaders; (b) clear communication of strategic vision; (c) active engagement of patients and families; (d) sustained focus on staff satisfaction; (e) active measure- ment and feedback reporting of patient experiences; (f) adequate resourcing of care delivery redesign; (g) staff capacity building; (h) accountability and incentives; and (i) a culture supportive of change and learning. Barriers included the need to change the organizational culture from a provider-focus orien- tation to a patient-focus one, and the length of time needed for the transi- tion to take place.
Patient-centered care delivery can appear superficial and unconvincing if confusion exists about the mean- ing of patient-centered care (Epstein & Street, 2011). Patient-centered behaviors, such as respecting pa – tients’ preferences, should be justifi- able on moral grounds alone and independent of their relationship to health outcomes. Berwick (2009) claimed health system design may affirm patient-centered care as a dimension of quality in its own right. Patient-centered care should not be confirmed just through its effect on patient or organizational outcomes. Evidence-base literature about identifying interventions for improved outcomes in patient-cen- tered care is lacking, partially due to unclear conceptual models and gold- standard measures (Groene, 2011).
Brief Overview of the Gap Model of Service Quality
The Gap Model of Service Quality (Parasuraman et al., 1985) (the Model) is a widely used business model that focuses on the perspectives of cus-
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tomers to determine quality and pro- vides an integrated view of the cus- tomer-company relationship. The Model is useful for evaluating patient-centeredness in nursing care because of its focus on the customer’s perspective as a measurement of serv- ice quality. In addition, it facilitates the derivation of statements of patient-centered care as an indicator of quality health care. The Model included five unique gaps in service quality that can influence quality as experienced by the customer. Based on earlier reports (Charmel & Frampton, 2008; IOM, 2001a), gaps number 1, 2, 3, and 5 in the Gap Model of Service Quality had similar- ities to the concept of patient-cen- tered care. A brief description of these four gaps follows.
Gap 1. Customer expectation vs. management perception gap. This gap, also identified as the knowledge gap, reveals discrepancies between man- agers’ perceptions of customer expectations and the actual expecta- tions of the customers. This gap in service quality occurs because man- agers fail to identify customer expec- tations accurately. The size of the gap depends on upward communication from customer to top management (Parasuraman et al., 1985).
Gap 2. Management perceptions vs. service standards gap. This gap, also known as the design gap, measures how well the managers’ perceptions of customer expectations are translat- ed into service design standards. Service design standards are policies and expectations of the way service is to be provided. This gap depends on managers’ belief service quality is important and possibly dependent on the resources available for the pro- vision of the service. However, if managers’ initial understanding of customer expectations is flawed, inef- ficient service standards inevitably will be produced (Parasuraman et al., 1985).
Gap 3. Service standards vs. service delivery gap. This gap, also referred to as the performance gap, represents discrepancies between service design and service delivery. This gap occurs when the specified policies are not followed in service delivery. The quality of delivered service can be
affected by numerous factors, such as skill level, type of training received, deficiencies of human resource policies, failure to match supply and demand, degree of role congruity or conflict, and job fit (Parasuraman et al., 1985).
Gap 5. Perceived service vs. expected service gap. This is the gap between customers’ service expectations and their perceptions of the service received. According to Parasuraman and colleagues (1985), customer expectations are based on word-of- mouth communications, personal needs, and past experiences.
These four gaps described three key provider abilities and one cus- tomer ability: (a) the ability of man- agers to identify the expectations of their customers correctly, (b) the abil- ity to transfer the identified expecta- tions of their customers into the stan- dards of service, (c) the ability to transform these standards of service into the actual service delivery, and (d) customers’ perception of how the delivered service met their expecta- tions (Parasuraman et al., 1985).
Gaps in Patient-Centered Care
Based on the Gap Model of Service Quality (Parasuraman et al., 1985), four gaps in patient-centered care were identified (see Figure 1). Each gap depicted in the model of patient-centered care quality in nurs- ing practice is described below.
Gap A. Patient expectation vs. nurse perception gap was derived from Gap 1 in the Gap Model of Service Quality. This gap occurs when dis- crepancies arise between nurses’ and nursing administrators’ perceptions of what the patient expects and the patient’s actual expectations. The health care provider fails to identify the patient’s expectations accurately. Lack of communication with the patient and an insufficient relation- ship focus are key contributors to this gap.
To close this gap, nurses must com- municate with the patient in a way that gathers his or her expectations and needs. Epstein and co-authors (2010) noted the communication goes beyond facts and figures. The cli- nician must frame and tailor informa-
tion in response to an understanding of the patient’s concerns, beliefs, and experiences. Aspects of the patient’s culture, past experiences, his or her perceptions from comments made by others, and immediate personal needs all shape what the patient desires and expects from health care services. The key to closing this gap is to reach consensus about an approach to care which is achieved through shared deliberation.
Gap B. Nurse and nursing adminis- trator perceptions vs. patient-centered care standards gap was derived from Gap 2 in the Gap Model of Service Quality. This gap depends on the health care provider’s and adminis- trator’s beliefs that patient-centered care is important to quality of care and it is possible to provide patient- centered care. This gap is measured by how well the health care delivery design matches the health care provider’s perceptions of the pa – tient’s expectations or needs. Indi – vidual nurses have their own sets of values and service standards based on their backgrounds and what they perceive the patient’s expectations to be. This gap is measured by how well the health care delivery design matches the health care provider’s perceptions of the patient’s expecta- tions or needs.
To close this gap, nurse administra- tors must decide that meeting the needs of individual patients is a prior- ity, set organizational standards, and provide resources necessary to meet those standards. Individual nurses must decide if the provision of patient-centered care is a priority. The infrastructure of patient-centered care is supported through the senior nurs- ing team’s commitment to the princi- ples of patient-centered care. How – ever, development of appropriate standards is contingent on identify- ing patient needs correctly.
Gap C. Patient-centered care stan- dards vs. delivery of patient-centered care gap was derived from Gap 3 in the Gap Model of Service Quality. This gap represents variations in service design and service delivery. The service standards are to be derived from the perceived expecta- tions of patients. Service standards are based on the principles of
Service Quality and Patient-Centered Care
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patient-centered care, and need to be translated to actual delivery of care. Nurses can have great impact on closing this gap.
In practice, patient-centered care is not offered consistently due to nursing factors, such as poor staffing, fatigue, burnout, and lack of educa- tion on the delivery of patient-cen- tered care. A qualitative meta-syn- thesis of four studies found evidence of sustained high commitment nec- essary to the development of person- centered cultures in clinical settings (McCormack, Karlsson, Dewing, & Lerdal, 2010). However, other cultur- al characteristics (e.g., the level of
staff support) may determine the extent to which that commitment could be sustained.
Gap D. Patient expectation of health care service vs. patient perception of actual health care service received gap was derived from Gap 4 in the Gap Model of Service Quality. This gap occurs when the patient’s expecta- tions, which are molded by past experiences, culture, personal needs, and word of mouth, are not met or are lacking in some way (Hunt, 2009; Parasuraman et al., 1985). In other words, when care is not patient-centered, patient expecta- tions cannot be met because they are
not identified. McCormack and co- authors (2008) suggested a direct relationship between patients’ expe- riences of daily care and their percep- tions of service effectiveness.
To close this gap and understand patient preferences, nursing adminis- trators need to promote an interac- tive feedback loop that provides health care providers with a mecha- nism to view care through the eyes of patients and families as well as to link the patients and nursing staff togeth- er (DiGioia et al., 2010). A collabora- tive relationship between health care providers and patients can assist in shaping realistic patient expectations
FIGURE 1. The Four-Gap Model of Patient-Centered Care Quality in Nursing Practice
Patient-Centered Care in Nursing
Patient perceived service
Delivery of patient-centered
Nurse and nursing
administrator perception of patient
Nurse and nursing administrator transla-
tion of perceptions into patient-centered care
Gap B: Nurse and nursing
administrator perceptions vs. patient-centered care
Gap D: Patient expectation of health care service vs. patient
perception of actual health care service received gap
Gap A: Patient expectation
vs. nurse perception gap
Gap C: Patient-centered care
standards vs. delivery of patient- centered care gap
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related to patients’ individual health care needs, and minimize false per- ceptions due to lack of understand- ing. A complex series of interactions between nurses and patients elicit trust and understanding. Nurses need to use the knowledge gathered from these interactions to adapt a plan of care that reflects individual patient needs.
Nursing Implications Nurses may use the four-gap
model of patient-centered care qual- ity (see Figure 1) to examine their practice. This approach will provide opportunity to identify gaps as well as develop nursing practice interven- tions to close the gaps indicated in this new model. For example, nurse executives and managers may devel- op appropriate outcome measures to monitor the closeness of each corre- sponding gap (e.g., patient satisfac- tion measures; patient-centered out- comes such as survival, function, symptoms, and health-related quali- ty of life; clinical outcomes such as injurious fall occurrences, nurses’ job satisfaction measures, and intention to quit) (DiGioia et al., 2010, Patient- Centered Outcomes Research, 2013).
Future Research The four-gap model of patient-cen-
tered care quality in nursing practice needs to be tested. Understanding the nurse-patient relationship and the aspects of communication needed for successful outcomes is essential. A focus on patient perspectives assists in capturing cultural, spiritual, and emo- tional needs that otherwise may be missed or overlooked. Future research that captures the degrees of similarity or difference between patient per- spectives and provider perspectives will help identify areas of strengths and weaknesses for improvement. Future research also may explore the links between system issues, such as the effects of nurse staffing on the ability to deliver patient-centered care, and the developmental process of standards and policy for delivery of patient-centered care.
Conclusion Four patient-centered care serv-
ice quality gaps were identified. Individual patient needs influence expectations, and accurate nurse perceptions of these needs require communication with the patient. Collaboration between nurses and patients is essential to provide bet- ter understanding of patient needs and helps patients understand what to expect realistically from their health care experience. Once pa tient needs have been assessed accurately and understood, poli- cies relevant to the characteristics of the clinical settings can be estab- lished to promote patient-centered care. McClelland (2010) claimed understanding the patient perspec- tive of health care services is piv- otal to the development of patient- centered, quality services. The shift of health care from a clinician-cen- tric orientation to a patient-centric one can be challenging to the entire health care team. However, to realize fully the benefits of patient-centered care, nurses must focus on achieving gains in the quality of relationships and inter- actions with patients (Epstein et al., 2010).
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(2009). National healthcare quality report. Retrieved from http://ahrq.gov/ qual/qrdr09.htm
Andrews, S.M. (2009). Patient family-centered care in ambulatory surgery setting. Journal of PeriAnesthesia Nursing, 24(4), 244-246. doi:10.1016/j.jopan. 2009.05.100
Berwick, D. (2009). What ‘patient-centered’ should mean: Confessions of an extrem- ist. Health Affairs, 28(4), w555-w565.
Charmel, P.A., & Frampton, S.B. (2008). Building the business case for patient- centered care. Healthcare Financial Management, 62(3), 80-85.
DiGioia, A., III, Lorenz, H., Greenhouse, P.K., Bertoty, D.A., & Rocks, S.D. (2010). A patient-centered model to improve met- rics without cost increase: Viewing all care through the eyes of patients and families. Journal of Nursing Admini – stration, 40(12), 540-546.
Epstein, R.M., & Street, R.L. (2011). The val- ues and value of patient-centered care. Annals of Family Medicine, 9(2), 100- 103.
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Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T.L. (1993). Introduction:
Service Quality and Patient-Centered Care
Instructions For Continuing Nursing
Education Contact Hours Service Quality and Patient-
Deadline for Submission: December 31, 2015
To Obtain CNE Contact Hours 1. For those wishing to obtain CNE con-
tact hours, you must read the article and complete the evaluation through AMSN’s Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library
2. Evaluations must be completed online by December 31, 2015. Upon comple- tion of the evaluation, a certificate for 1.3 contact hour(s) may be printed.
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Objectives This continuing nursing educational (CNE) activity is designed for nurses and other health care professionals who are interest- ed in service quality and patient-centered care. After studying the information pre- sented in this article, the nurse will be able to: 1. Describe patient-centered care. 2. Discuss gaps in patient-centered care. 3. Explain the nursing implications of using
the Gap Model of Service Quality to clar- ify patient-centered care.
Note: The authors, editor, and education direc tor reported no actual or potential conflict of interest in relation to this continuing nursing education article.
This educational activity has been co-provided by AMSN and Anthony J. Jannetti, Inc.
Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of CA must retain this certificate for four years after the CNE activity is completed.
Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses’ Credentialing Center’s Commission on Accreditation.
This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director. Accreditation status does not imply endorsement by the provider or ANCC of any commercial product.
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Groene, O. (2011). Patient centeredness and quality improvement efforts in hospitals: Rationale, measurement, implementa- tion. International Journal for Quality in Health Care, 23(5), 531-537.
Hobbs, J.L. (2009). A dimensional analysis of patient-centered care. Nursing Re – search, 58(1), 52-62.
Hunt, M.R. (2009). Patient-centered care and cultural practices: Process and criteria for evaluating adaptations of norms and standards in health care institutions. HEC Forum, 21(4), 327-339.
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Levinson, W., Lesser, C.S., & Epstein, R.M. (2010). Developing physician communi- cation skills for patient-centered care. Health Affairs, 29(7), 1310-1318.
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McClelland, H. (2010). Service improvement and patient experience. International Emergency Nursing, 18(4), 175-176.
McCormack, B., Karlsson, B., Dewing, J., & Lerdal, A. (2010). Exploring person-cen- teredness: A qualitative meta-synthesis of four studies. Scandinavian Journal of Caring Sciences, 24(3), 620-634.
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Montgomery, K., & Little, M. (2011). Enriching patient-centered care in serious illness: A focus on patients’ experiences of agency. The Milbank Quarterly, 89(3), 381-398.
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