Patient‐centred care is a way of doing things: How healthcare employees conceptualize patient‐centred care

Abstract Background Patient‐centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient‐centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient‐centred care, conceptualize what they are implementing. Objective To examine how hospital employees conceptualize patient‐centred care. Research Design We conducted qualitative interviews about patient‐centred care during site four visits, from January to April 2013. Subjects We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient‐centred care transformation. Measures Data were analysed using grounded thematic analysis. Findings were then mapped to established patient‐centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient‐as‐person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor‐as‐person. Results We identified three distinct conceptualizations: (i) those that were well aligned with established patient‐centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient‐centred care into the organizational culture, encompassing the entire patient‐experience; and (iii) still others that were poorly aligned with patient‐centred care constructs, reflecting more traditional patient care practices. Conclusions Patient‐centred care ideals have permeated into healthcare systems. Additionally, patient‐centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient‐centred care so broadly, it encompasses on‐going hospital initiatives, while others consider patient‐centred care as inherent to specific positions. These latter conceptualizations risk undermining patient‐centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.


| INTRODUCTION
Patient-centred care (PCC) is growing in prominence. Balint first described PCC as "understanding the patient as a unique human being." 1 During the 20th century, PCC became a focus of healthcare systems with its promise to increase patient satisfaction and improve outcomes. 2 A growing body of evidence has linked PCC practices with improvements in a variety of health conditions 3 , increased adherence 4 , decreased healthcare utilization 5 , better ratings of care 6 and improved quality of care. 7 By 2001, The Institute of Medicine identified PCC as a key aspect of high-quality care. 8 PCC is now ubiquitous internationally 9 and extends beyond the provision of health care into medical education, law and quality improvement. 10,11 Moreover, PCC has increasingly become part of the research lexicon. A PubMed search (2016) for "PCC" produces over 20 000 results, with over 2000 publications annually. [12][13][14] While the term PCC has become pervasive, consensus is lacking on what constitutes PCC. [15][16][17][18][19] Most providers, policymakers and researchers agree that PCC represents a shift from a traditional, paternalistic, provider-driven and disease-focused approach towards one that fully integrates the patient's perceptions, needs and experiences, into every phase of medical consultation, treatment and follow-up. 19 In their oft-cited literature review, Mead and Bower describe PCC as encompassing five conceptual dimensions: the biopsychosocial perspective; patient-as-person; sharing power and responsibility; therapeutic alliance; and doctor-as-person. 20 Presently, there is limited research on hospital employee perceptions of PCC. [21][22][23][24][25] To date, this research has been limited to studies with nurses or providers outside of the US 23,24 or focused on only a small subset of employee perceptions of patient-centred care 22,25 . As the research community continues to examine PCC 15,17,18 , healthcare systems are actively implementing initiatives. 26,27 Substantial efforts are underway, for example, to transform the US Veteran Health Administration (VHA) to a patient-centred healthcare system. Several system-wide policies are in place which emphasize the delivery of "personalized, proactive, and patient-driven" care. 28 To facilitate advancement of these PCC initiatives, VHA established the Office of PCC and Cultural Transformation (OPCC&CT), in 2010, to help facilities transform. 29 While researchers and policymakers may be invested in PCC, it is up to hospital employees to enact it in practice. Their conceptualizations of what constitutes PCC shape how initiatives are developed, implemented and enacted. Therefore, we sought to understand how hospital employees conceptualize PCC.

| Setting
We conducted a qualitative study in the US's largest integrated healthcare system, as they embarked on implementing PCC. The VHA provides care to US military Veterans at over 150 medical centres across the US. As part of a larger study examining PCC implementation, we visited four VHA facilities designated as PCC "Centers of Innovation" (COIs). The COI designation was awarded to these four centres based on the facility's prior leadership and support for PCC development, innovation and implementation. The data were collected for quality improvement purposes to inform the field about best practices for PCC implementation. The Institutional Review Board (IRB) reviewed our work and designated our evaluation as IRB-exempt. No formal consent was required; however, we provided verbal and written descriptions of the goal and scope of our evaluation work.

| Participants
We worked closely with medical centre leadership, including the medical centre director or associate director and PCC coordinators, to identify individuals they considered critical to the implementation of PCC innovation. In addition to participating in interviews themselves, they identified a broad range of clinical and non-clinical employees such as middle managers and front line staff for interviews. Potential participants were contacted via email explaining the purpose of the site visit and inviting participation. Interested participants were interviewed during the site visit.

| Data collection
The interviews covered a range of topics. Two central questions that guided our analysis were as follows: "What do you think about when you hear the term PCC?" and "What are the key elements for care to be patient-centered, from your perspective?" Our interview guide was designed to be used flexibly, depending on the participants' unique background and course of the conversation.
We audio-recorded interviews with each participant's consent, between January and April 2013. Although most interviews were conducted individually, group interviews were conducted when the key informant brought others he/she felt were important to answering questions outlined in the email invitation. For example, at one site the integrative medicine lead invited other staff involved in the programme. Interviews lasted approximately one hour. We audiorecorded interviews with participants' consent; when participants declined audio-recording, we took detailed fieldnotes. Audio-recordings were transcribed. 30,31 Transcripts and fieldnotes were entered into NVivo. 32

| Analysis
Data were initially coded using grounded thematic methods. 33 Through group discussion, we examined how the PCC findings mapped to Mead and Bowers' 5 constructs: the biopsychosocial perspective K E Y W O R D S healthcare workers, organizational change, patient-centred care, qualitative research (broadening beyond a disease state to include the psychological and social domains); patient-as-person (understanding an individual's particular illness experience, in the light of the his/her individual life context); sharing power and responsibility (egalitarian doctor-patient relationship); therapeutic alliance (a professional doctor-patient relationship, which entails empathy, congruence and unconditional positive regard); and doctor-as-person (views the doctor as an integral part of a two person relationship). 20 These definitions provided an a priori framework to organize our findings and to determine how employee conceptualizations aligned with the existing PCC literature.
We categorized coded segments according to Mead and Bower and developed grounded codes for data that did not fit. We developed the codebook iteratively until consensus. GF led categorization, which was reviewed with the full team to come to agreement.

| RESULTS
We conducted 77 interviews with 107 employees across the four medical centres (Table 1) Table 2, exemplars are provided.
Several participants began their descriptions by stating that patientcentred means the patient is at the centre. They used this metaphor to discuss patients as a focal point for understanding an aspect of PCC.
For example, after noting that health care should be approached with "the patient at the center," a Chief of Staff described the importance of learning about patient goals and context "with the patient, from their perspective" instead of what is being "done to the patient." At the organizational level, a Member of Leadership noted "historically… we've really designed healthcare not around the patient, we designed it around 'What do the physicians need? What do the nurses need?'"

| Well aligned
In this first category, the participant's description of PCC mapped on to one of Mead and Bower's five conceptual domains below.

| Biopsychosocial perspective
For this domain, participants' described PCC as broadening beyond a patient's disease to include psychological and social domains, and as being "focused more on the patient as a whole person," Nurse Manager. Participants' characterizations recognized patients as more than just a disease, broadening care practices to include patients' life contexts, social support, personality and spirituality "because we see the patient as more than just a patient, [but as] a human being with different facets of their personality," Health Psychologist.

| Patient-as-person
Participants described seeing the patient as a person and needing to understand patients' illness experiences, within the patients' unique lifeworld. Several interviewees describe specific instances where employees took into account a patient's unique circumstances. A Nurse

| Sharing power and responsibility
In this domain, participants describe an egalitarian relationship between patients and providers, in contrast to traditional, paternalistic relation-

| Therapeutic alliance
Descriptions of PCC mapping to this domain described focusing on the interpersonal relationship between the patient and provider, emphasizing empathy and respect. An Integrative Medicine Manager characterized PCC as, "not just a matter of [clinical] tasks, but rather, a matter of relationships." She went on to describe how the patient-provider relationship could serve as a foundation for individualized care. "Patient-centered should be expanded to include 'Staff-centered.'"

| Doctor-as-person
A Patient-Centered Care Coordinator expressed concern that staff would "walk with their feet" and leave the organization and went on to explain that the facility had a responsibility to take care of employees too. Employees were seen as important because it was believed they could not provide PCC unless they were also treated in comparable ways: "My philosophy is, if you take care of the employees, they care of the patients," Patient-Centered Care Coordinator.

Many of our participants broadened their descriptions of PCC beyond
Mead and Bower's focus on the patient-provider dyad, to the organizational level (see model). These descriptions were seen as supporting PCC, and included having a welcoming, conducive facility with a strong PCC culture.

| Atmosphere enhances patient-centred care
Another component of this extension into the organization entailed having a welcoming and healing facility. A Patient-Centered Care Coordinator explained that PCC entailed the entire experience of getting health care, "finding a parking place, getting into the building, finding where they're going…" She went on to explain how this should extend into the patient's appointment, where "all their concerns are addressed and that they're provided education and resources…that can help them." A Service Chief linked a patient's experience upon entering the facility to good customer service: "when you ask for directions, the person you ask will walk you where you need to go. In low-end places, the person will simply point and walk away…Training employees in customer service will make a big difference to how the facility is perceived." Likewise, several other participants likened this positive experience to good customer service: "It's really just being nice and adding that extra touch," Recreational Therapist.
Moreover, some interviewees noted that while physical change was part of their PCC transformation, it had to extend beyond remodelling. A Director of Nursing stated that PCC is "Not just warm and fluffy, the smell of cookies and cinnamon buns," suggesting that PCC must go beyond the easy, feel good initiatives. She went on to describe how PCC could improve patient satisfaction and clinical outcomes, but to do this, PCC needs to be culturally ingrained.

| Cultural shift
Leadership, in particular, linked PCC to a cultural shift. A Director of Nursing said, "The crux of patient-centered care is that it's a cultural shift for every single staff member." She went on to explain that, "implementing and spreading patient-centered care, [is a] huge process, and involves all of us living and breathing it, not just going to committee meetings." A member of a Senior Management Team at another site noted, "It will be truly patient-centered when it's not called patient-centered care," implying that PCC needs to be part of everyday practice instead of something distinct.

| Deviations from patient-centred care constructs
In this final category, conceptualizations of PCC poorly aligned with Mead and Bower. In these descriptions, participants conceptualized PCC as part of their existing care practices or as being so nebulous that it encompassed everything.

| Multifaceted
Some participants, particularly those in leadership, had difficulty articulating PCC as a single construct, "patient-centered care is so multifaceted," Director of Nursing. Similarly, a Member of Leadership at another facility said PCC was "not definable. It's a feeling." Having multiple components made PCC difficult to reduce to a single description: "There is not one definition of patient-centered care, but many." This Member of Leadership added that he would "never try to define patient-centered care because it will always evolve into something else." Moreover, other participants extended the definition of PCC to into all aspects of healthcare service. In one interview, an engineer described infrastructure changes, including purchasing a new, efficient boiler, and then said that these activities were patient-centred because the hospital can save money that can then be used for the patients.

| DISCUSSION
Transforming care to being more patient-centred is a complex task for healthcare organizations. We found that while the term "patient- Transformation offers an ideal setting in which to examine employee conceptualizations of PCC. 29 In the four medical centres in our study, many employees discussed PCC in terms that were consistent with Mead and Bower's core concepts (biopsychosocial perspective; patient-as-person; sharing power and responsibility; therapeutic alliance; and doctor-as-person). Employees also extended PCC beyond the patient-provider dyad, yet, these were still consistent with the broader PCC literature. 8,17,27,34 This tells us that key PCC constructs are understood by those implementing PCC. The leadership, managers and front line staff we spoke with are trying to create a healthcare organization that subscribes to the ideals of PCC.
We found many employees' PCC conceptualizations extended beyond the traditional patient-provider dyad, into the organization (See Figure 1). As Scholl's recent review of patient-centredness found, policy-level conceptualizations are lacking in the literature. 17 However, the policymakers and front line providers we spoke with were clearly thinking about systems-level implications of PCC. Our participants broadened the traditional definition by describing PCC as a cultural shift, imbued into care practices and organizational initiatives. Implementing discrete PCC programmes may not be effective at culture change, without a system-level, multipronged approach 26 .
Participants discussed how physical surroundings can make patients feel comfortable, which while not reflective of current PCC literature, is highly aligned with organizational trends. 35 40 We also found PCC being likened to good customer service. Linking PCC to customer service conflates the key differences between PCC and customer service oriented care. 34  In this paper, we focused on examining the perceptions of what constitutes PCC at the facility level because these conceptualizations shape how PCC initiatives are developed, implemented and enacted in a healthcare organization. Differing conceptualizations and scattered efforts will not serve to systematically advance PCC. In order to embed patient-centredness in an organization's culture one needs to make it a systems property, which requires a clear understanding of the full range of factors that promote or impede PCC. 45 As organizations move ahead with PCC implementation, they will need to consider if they are going to simply task specific disciplines with PCC practices or instead offer a more comprehensive, transformational organizational plan to infuse PCC throughout the facility. As Gillespie et al 21 also note, there is a tendency to take the easy path and simply reframe existing work structures. Organizations that have succeeded in advancing PCC have adopted a comprehensive, organization-wide approach linked to organizational strategy. 46,47 Communicating a strategic vision clearly and consistently to every member of the organization, with leadership engagement and support, is essential to developing an organizational approach to PCC. 46,47 Organizational change strategies that move beyond a shared vision, and engage staff and middle managers in developing work processes and interactions that implement that vision, are critical. It is the shared uptake of this vision that is most likely to result in synchronized efforts to transform the organizational culture to one where patients truly drive care.