Patient-centered care (PCC) is defined by the Quality and Safety Education for Nurses (QSEN) model as “the recognition of the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patients’ preferences, values, and needs” (QSEN, 2005). PCC assumed prominence with the publication of Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine [IOM], 2001), which affirms that a great quality chasm exists between the ideology of good care and the reality of the patient experience. However, nursing has long been a proponent of this concept, and many of the basic questions addressed in this IOM report are vestiges of Florence Nightingale’s pioneering work.
The IOM (2001) report defined patient centeredness as essential for quality and patient safety, and emphasized that the way care is given is as important as the care itself. Six goals are specified for the provision of health care: care should be safe, effective, timely, efficient, equitable, and, above all, patient- and family-centered. These tenets are foundational to nursing practice, so why does a quality chasm exist?
Let’s examine one scenario. New parents visiting the neonatal intensive care unit are assailed by the clamor of machines and innumerable overhead pages. A nurse approaches, introduces herself, and proceeds to manipulate both their infant and the machinery at the bedside while providing a running commentary on the infant’s condition. The nurse then becomes engaged in documentation and pays little attention to the parents. It is 1900 hours and the mother’s still unverbalized desire to touch or hold her infant is overridden by the standing rule that parents must leave the unit during shift change. The nurse feels the need to connect with the family, but there is no time. It is the end of a long, exhausting day. The parents speak limited English, and their apparent grief makes it clear that they are in no state to listen or make important decisions about the infant’s care. As the parents reluctantly step outside the unit, the overhead pages are endless and the many machines continue making noise. They distantly hear the nurse talking about arranging a care conference for the next day.
Several issues that must be resolved to improve the quality of the patient/family experience become immediately apparent in this scenario: the anonymity of the patient/parents; the lack of sensitivity to the parents’ experience (i.e., their anxieties and fears are not addressed); the demonstration of violence toward the parents by separating them from their infant at what was, for them, an arduous time; the lack of “partnership” with the parents; the nurse’s/system’s needs and wants being satisfied with little regard for the needs and wants of the parents; and the system’s power over patient/parent wishes. PCC requires that systems change.
Why Teach PCC?
PCC will improve both the patient experience and health outcomes. Evidence shows that involving patients and families in care promotes safety, helps avoid errors, saves time, and builds relationships (Agency for Healthcare Research and Quality, 2002). The Joint Commission (TJC) also addresses the need to embed PCC practices in the core of health care delivery systems (TJC, 2010). According to Press Ganey (2012) surveys, patient satisfaction is evident in PCC environments and positively impacts the development of trust between families and caregivers. Patient satisfaction influences staff productivity and efficiency and strengthens patient loyalty to the institution.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) promotes patient centeredness as a business imperative, and recommends linking PCC to hospital reimbursement (Planetree & Picker Institute, 2008). HCAHPS also advises that institutional cleanliness; low noise levels; pain control; communication with nurses and physicians; and quality discharge and medication information are aspects of the health care experience most valued by patients and families. Moreover, the IOM (2003) confirms that health professionals have not been adequately prepared to meet the nation’s health needs, including PCC. Pre-licensure nursing programs, nurse residency programs, hospital orientation, and ongoing staff development programs must advance the practice of PCC as a standard of care.
Strategies for Teaching PCC
PCC empowers patients and families to negotiate the complex health care environment. Educators must create learning environments that allow students and new nurses to make meaning of PCC by using all learning domains. Several strategies can bring this concept to life.
Action-based role-play can engage students in simulation laboratories. Role-play promotes affective domain skills, refines communication, enhances problem solving, improves students’ clinical judgment, and promotes active and reflective learning (Billings, 2010). Role-play can augment students’ listening skills. With role-play, learning occurs from within the group as learners discover what they need to know. Feedback must promote the patient/family perspective.
Unfolding case scenarios are effective in clinical simulations, leading to improved interpersonal interactions, leadership, and team work and facilitating connections between concepts. Simulation helps learners develop confidence and clinical imagination and begin their socialization as professionals (Day, 2011). Debriefing, which facilitates learning through examination and correction of fledgling thought processes that impact clinical judgment, is critical.
Clinical journaling is often used as a reflective teaching strategy. It promotes personal growth and professional development of students and new nurses (Kuo, Thurton, Cheng, & Lee-Hsieh, 2011). Journaling should be guided by reflecting on what could have been done better.
Problem-based learning (PBL) provides a cognitive approach to clinical problem solving (Onyon, 2012). PBL promotes responsiveness and focuses on content and problem solving.
The QSEN Knowledge, Skills, Attitude (KSA) PCC module outlines strategies for preparing nurses to meet the challenges posed by multiple dimensions of care (QSEN, 2012). QSEN’s Clinical Assessment Tool facilitates easy monitoring of care delivery and safety and delineates responsibility for KSA in patient management (Girdley, 2009).
PCC is evidence of the nursing process at work. Translating PCC into practice and understanding its importance in daily caregiving gives purpose to the learning experience. Nurse educators must champion the renewed movement toward PCC as it defines nursing’s goals.
- Agency for Healthcare Research and Quality. (2002). Expanding patient-centered care to empower patients and assist providers. Washington, DC: U.S. Government Printing Office.
- Billings, D. (2010). Role-play revisited. The Journal of Continuing Education in Nursing, 43(5), 201–202. doi:10.3928/00220124-20120424-04 [CrossRef]
- Day, L. (2011). Using unfolding case studies in a subject-centered classroom. Journal of Nursing Education, 50, 447–452. doi:10.3928/01484834-20110517-03 [CrossRef]
- Girdley, D. (2009, April20). Clinical assessment tool: Teaching strategy for safety and patient centered care. Retrieved from www.qsen.org/teachingstrategy.php?id=72
- Institute for Patient- and Family-Centered Care. (2010). What is patient- and family-centered health care? Retrieved from www.ipfcc.org/index.html
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
- Institute of Medicine. (2003, April18). Health professions education: A bridge to quality. Retrieved from www.iom.edu/Reports/2003/Health-Professions-Education-A-Bridge-to-Quality.aspx
- Kuo, C. L., Thurton, M., Cheng, S. F. & Lee-Hsieh, J. (2011, June). Using clinical caring journaling: Nursing student and instructor experiences. Journal of Nursing Research, 19(2), 141–149. doi:10.1097/JNR.0b013e31821aa1a7 [CrossRef]
- Onyon, C. (2012, January). Problem-based learning: A review of the educational and psychological theory. The Clinical Teacher, 9(1), 22–26. doi:10.1111/j.1743-498X.2011.00501.x [CrossRef]
- Planetree & Picker Institute. (2008). Patient-centered care improvement guide: Introduction. Retrieved from www.patient-centeredcare.org/chapters/introduction.pdf
- Press Ganey. (2012). Inpatient insights: Delivering superior clinical care. Retrieved from www.pressganey.com/ourSolutions/hospitalSettings/satisfactionPerformanceSuite/inpatientInsights.aspx
- Quality and Safety Education for Nurses. (2005). Patient centered care competencies/definition. Retrieved from www.qsen.org/qualityandsafety/definition.php
- Quality and Safety Education for Nurses. (2012). Competency KSAs (pre-licensure). Retrieved from www.qsen.org/ksas_prelicensure.php#patient-centered_care
- The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals. Retrieved from www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727