Tanya McCance, DPhil, MSc, BSc (Hons.) RGN
Brendan McCormack, D.Phil (Oxon.), BSC (Hons.) Nursing, PGCEA, RNT, RGN, RMN
Jan Dewing, MPhD, MN, BSc, RGN, RNT
‘Person-centredness’ is a term that is becoming increasingly familiar within health and social care at a global level; it is being used to describe a standard of care that ensures the patient/client is at the centre of care delivery. In this article we explore the relevance of person-centredness in the context of nursing, taking account of the ongoing critical debate and dialogue regarding developments in this field. Person-centredness is recognised as a multidimensional concept. The complexity of the concept contributes to the challenge of articulating its shared meaning and describing how it can be applied in practice. The aim of this paper is to explore some of the issues pertaining to language and conceptual clarity, with a view to making connections and increasing our shared understanding of person-centred care in a way that can impact nursing practice. We begin by describing the development of the concept of person-centredness, after which we discuss the synergies with patient-centredness and other related terms, and consider how nurses can operationalise person-centredness in their practice.
Citation: McCance, T., McCormack, B., Dewing, J., (May 31, 2011) "An Exploration of Person-Centredness in Practice" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 1.
Key words: Person-centredness, person-centred care, nursing, practice development.
In this article we aim to explore the concept of person-centredness and how it relates to the practice of nursing. We will begin by describing the development of person-centredness as a concept of relevance to healthcare generally, and nursing specifically. Next we will explore the relevance of person-centredness in the context of nursing. Finally we will offer a Framework that enables practitioners to operationalise person-centred care in practice and provide examples of how the Framework can be used as a tool to improve care.
Development of the Concept of Person-Centredness
‘Person-centredness’ is a term that is becoming increasingly familiar within health and social care at a global level. It is being used to describe a standard of care that ensures that the patient/client is at the centre of care delivery. It is therefore not surprising that the body of literature relating to person-centred care is growing, along with the academic debate and critical dialogue regarding the development of this concept. Person-centredness is not a new concept, having its roots in humanistic psychology through the work of, for example, Rogers (1980) and Heron (1992). In the healthcare literature we have seen for some time the use of a related term which appears to refer to a similar idea; specifically the term patient-centred care which has been used in American nursing since the 1970s (See Table).
Table: Definitions of Related Terms
“an approach to practice established through the formation and fostering of therapeutic relationships between all care providers...patients and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development” (McCormack, Dewing, Breslin, Tobin et al., 2010, p.13).
“...understanding the personal meaning of the illness for the patient by eliciting their concerns, ideas, expectations, needs, feelings and functioning; promoting the understanding of the patient within their unique psychosocial context; sharing power and responsibility, and developing common therapeutic goals that are concordant with the patient’s values” (Drach-Zahavy, 2009, p.1465).
“a way of caring for children and their families within health services which ensures that care is planned around the whole family, not just the individual child/person and in which all the family members are recognised as care recipients” (Shields, Pratt, & Hunter, 2006, p.1318).
“… all parties involved in caring (the older person, family carers, and paid or voluntary carers) should experience relationships that promote a sense of:
• security – to feel safe within relationships;
• belonging – to feel ‘part’ of things;
• continuity – to experience links and consistency;
• purpose – to have a personally valuable goal or goals;
• achievement – to make progress towards a desired goal or goals;
• significance – to feel that ‘you’ matter”
(Nolan et al., 2004, p.49).
“Focuses on the woman’s individual needs, aspirations and expectations, rather than the needs of the institution or professionals” (Leap, 2009, p.12).
A review of the existing literature indicates that to date, research in this area has mainly focused on attempting to clarify the meaning of the terms ‘personhood’ and ‘person-centredness’ (Edvardsson et al., 2010; Slater, 2006), exploring the implications of the term in practice (Dewing, 2004), and determining the cultural and contextual challenges to implementing a person-centred approach (Binnie & Titchen, 1999; McCormack et al., 2008; McCormack & McCance, 2010; McMillan et al., 2010). There has also been significant conceptual and theoretical advancement in the area of person-centredness as evidenced by the development of frameworks, such as the Authentic Consciousness Framework (McCormack, 2003), the Senses Framework (Nolan et al., 2004), and the Person-Centred Nursing Framework (McCormack & McCance, 2006, 2010), along with the application and testing of these frameworks in practice (McCance et al., 2010; McCormack, Dewing, Breslin, Coyne-Nevin et al., 2010; Ryan et al., 2008). This work has contributed some to our understanding of how we can effectively operationalise person-centredness in practice. We have also seen an increased focus on outcome evaluation and the development of a range of tools that enable the evaluation of the relationship between a person-centred approach to nursing and the resulting outcomes for patients and nurses (Slater et al., 2009; Smith et al., 2010). There is, however, still much to be achieved in the area of outcome evaluation which requires “a different orientation in-order-to capture the complexities of person-centred nursing in practice” (McCormack & Heath, 2010, p. 81).
Despite the notable advancements in the area of person-centred care, there are aspects that still require attention. There has been considerable debate about the specific concepts that underpin person-centredness (Australian Commission on Safety and Quality in Healthcare, 2010; Dewing, 2008) and the appropriateness of person-centred models and their implementation (Australian Commission on Safety and Quality in Healthcare, 2010; McMillan et al., 2010; Nolan et al., 2004). Indeed it has been suggested that “current understandings of the concept largely rest on abstractions, conceptual synergies and personal opinions” (Edvardsson et al., 2010, p. 2612). Furthermore, it is acknowledged that much of the debate about person-centredness and person-centred practice is currently found within the field of gerontology, initially due to the influences of early writers/researchers such as Tom Kitwood (Kitwood, 1997; Kitwood & Bredin, 1992). The limitations of conducting research within a specific field of practice that has a narrow focus on the related literature (a good example being dementia care) have been discussed by McCormack, Karlsson et al. (2010). They have suggested these limitations lead to development activity happening in ‘silos,’ with little sharing across teams, specialties, systems, and organisations, resulting in a lack of common and shared meaning. This becomes very evident when we reflect on the use of language and the interchangeable use of terms such as ‘patient-centred,’ ‘relationship centred,’ and ‘woman-centred’ care. The aim of this paper is to explore some of the issues pertaining to language and conceptual clarity, with a view to making connections and increasing our shared understanding of person-centred care in a way that can impact nursing practice.
Synergies With Patient-Centredness and Other Related Terms
At a fundamental level the word ‘person’ captures those attributes that represent our humanness and the way in which we construct our life. Although person-centredness is recognised as a multidimensional concept, what we understand about being a person has been central to its development. Exploring the concept of ‘person’ can lead us to raise questions, such as:
- What distinguishes persons from non-persons?
- What makes us unique as humans? and
- How do we engage with the world?
At a fundamental level, however, the word ‘person’ captures those attributes that represent our humanness and the way in which we construct our life. ‘Constructions’ such as how we think about moral values; how we express political, spiritual, or religious beliefs; how we engage emotionally in our relationships; and the kind of life we want to live, are all shaped by our attributes as persons. We encourage readers to hold these constructions at the forefront of their mind as they continue to engage with the ideas presented in this article.
...‘person-centredness’ is used freely within health and social care [but] some argue that the use of this term is an example of tokenism by those using it, because they use it without any real sense of what the term actually means. The term ‘person-centredness’ is used freely within health and social care. Yet some argue that the use of this term is an example of tokenism by those using it, because they use it without any real sense of what the term actually means. Whilst several analyses have been conducted in an attempt to define core attributes of person-centredness (Dewing, 2008; Leplege et al., 2007; Slater, 2006), the early definition provided by Kitwood (1997) or variations of it, continue to be widely used. Kitwood defined person-centredness as “… a standing or status that is bestowed upon one human being by others, in the context of relationship and social being. It implies recognition, respect and trust” (p.8). Furthermore, based on a review of the literature, and using the definition provided by Kitwood, McCormack has argued that there are four core concepts at the heart of person-centred nursing: being in relation, being in a social world, being in place, and being with self. Being in relation emphasises the importance of relationships and the interpersonal processes that enable the development of relationships that have therapeutic benefit. Being in a social world considers persons to be interconnected with their social world, creating and recreating meaning through their being in the world. Closely linked to being in a social world is being with self, which emphasises the importance of persons ‘knowing self’ and the values they hold about their life and how they make sense of what is happening to them. Being in place encourages us to pay attention to ‘place’ recognising the impact of the ‘milieu of care’ on the care experience.
In the healthcare literature we see a proliferation of terms being used to reflect person-centredness, such as personhood, person-centred, patient-centred, people-centred, client-centred, woman-centred, and relationship-centred care. These terms are often used interchangeably to express the idea of being person-centred (Leplege et al., 2007; Slater, 2006). The nursing literature is consistent in the view that being person-centred requires the formation of particular relationships (often described as therapeutic) between professionals, patients, and others significant to them in their lives, and that these relationships are built on mutual trust, understanding, and a sharing of collective knowledge (Binnie & Titchen, 1999; Dewing, 2004; McCormack, 2004; Nolan et al., 2004). The question, however, remains as to whether all these terms are describing the same thing or whether there are actual differences between terms. The Table presents a sample of definitions drawn from the literature.
As nurses, our understanding of person-centredness is as applicable to our colleagues as it is to the patients and clients we care for... If we apply our understanding of person-centredness at a basic level, we can start to tease out the similarities and differences between these terms. Respecting individuals as persons and acknowledging their place in the care partnership appears to be the most consistently applied idea across definitions, as does the focus on building relationships. It could be argued that ‘patient-centred’ and ‘women-centred’ are the two terms that focus primarily on the recipient of care, whilst the terms ‘person-centred’ and ‘relationship-centred’ tend to reflect a broader orientation that takes account of context and other relationships that may exist in that environment, for example, relationships between professionals. Nolan and colleagues have argued for a move away from what they perceive as a focus on meeting individual needs, to a focus on interactions among all parties involved in care whose needs should be taken account of if good care is to result (Nolan et al., 2004). This would also be consistent with the views of McCormack and McCance (2010) who clarify that person in their work refers to “all those involved in a caring interaction and therefore encompasses patients, clients, families/carers, nursing colleagues, and other members of the multidisciplinary team” (p. 4). As nurses, our understanding of person-centredness is as applicable to our colleagues as it is to the patients and clients we care for; it reflects the potential impact of staff relationships and team effectiveness on creating a therapeutic environment. Such a shared understanding, however, has implications for the appropriate use of terms such as woman-centred and patient-centred, which are of course central components of person-centred practice.
Operationalising Person-Centredness in Practice
The current focus on person-centredness in practice illustrates society’s drive to redress the current imbalance in care, moving away from an ethos that is medically dominated, disease orientated, and often fragmented toward one that is relationship focused, collaborative, and holistic. The current focus on person-centredness in practice illustrates society’s drive to redress the current imbalance in care, moving away from an ethos that is medically dominated, disease orientated, and often fragmented toward one that is relationship focused, collaborative, and holistic. The challenge of delivering effective, person-centred care, however, is often in the translation. Although the idea of person-centredness is well understood at a basic level, the challenge is often recognising it in practice. We might think we are delivering care that looks like one thing, but in reality it is quite another. To overcome this gap between the concept and the reality of person-centred care we have developed the Person-Centred Nursing Framework, a tool that enables nurses to explore person-centred care in their practice. We would argue this Framework can provide a lens that enables the operationalisation of person-centred care and can be used to evaluate developments in practice and hence demonstrate outcomes.
The Person-Centred Nursing (PCN) Framework, developed by McCormack and McCance (2006, 2010) was derived from previous empirical research focusing on person-centred practice with older people (McCormack, 2003) and the experience of caring in nursing (McCance, 2003). In summary, the Framework comprises four constructs. Prerequisites focus on the attributes of the nurses and include: being professionally competent; having developed interpersonal skills; being committed to the job; being able to demonstrate clarity of beliefs and values; and knowing self. The care environment focuses on the context in which care is delivered and includes: appropriate skill mix, systems that facilitate shared decision making, effective staff relationships, organisational systems that are supportive, the sharing of power, the potential for innovation and risk taking, and the physical environment. Person-centred processes focus on delivering care through a range of activities and include: working with patient’s beliefs and values, To overcome this gap between the concept and the reality of person-centred care we have developed the Person-Centred Nursing Framework... engagement, having sympathetic presence, sharing decision making, and providing holistic care. Outcomes, the central component of the Framework, are the results of effective, person-centred nursing and include: satisfaction with care, involvement in care, feeling of well being, and creating a therapeutic environment.
The relationship between the constructs of the Framework is indicated by the pictorial representation displayed in Figure 1. To reach the centre of the Framework (the outcomes), the prerequisites must first be in place in order to work with the care environment, to enable the delivery of effective care through the care processes. We acknowledge that there are relationships both within and across constructs, some of which are currently being tested through further research.
The Framework was first published in 2006 by McCormack and McCance. Since then it has been tested in several different contexts and in several different countries. We view the Framework as flexible and dynamic; and indeed there have been changes made to the Framework as a result of engaging in critical debate and dialogue (McCormack & McCance, 2010). The Person-Centred Nursing Framework, as a tool to enable the operationalisation of person-centred care, has been utilised in many different ways. It has been used to promote an increased understanding of person-centred care with the aim of enabling practitioners to recognise key elements in their practice, and by service managers to better ensure person-centredness is a concrete aspect of service organisation and delivery. It has also been used as an analytical framework to generate meaning from practice-derived data that can inform the development of person-centred practice. Most importantly, however, it has been used as a tool that can assist practitioners to identify barriers to change and to focus the implementation and evaluation of developments in practice. Two examples are provided below to illustrate the use of this Framework. The first is an example of a large-scale programme in Australia and the second is an example of an organisational programme developed for delivery of person-centred practice within an acute care setting in the UK.
Large Scale Programme in Australia
...it is the depth to which implementation takes place that can either result in a superficial and surface behavioural response or a deeper and longer lasting, values-based transformation. Uniting Care Ageing (South Eastern Region) in Australia provides a range of care services for more than 14,000 people, making it the single largest provider of aged-care services in New South Wales and the Australian Central Territory. This region is using the Framework in several ways during their three-year, region-wide practice development and research programme. The Framework is one of two key models underpinning their work. Specifically, it is being used to give a shape and structure to an organisational-wide strategy known as Inspired Care (United Care Ageing, n.d.).
Inspired Care aims to embody person-centred care by nurturing and sustaining vibrant relationships, engagement, honouring the individual, and providing holistic care. However, as with any strategy it is the depth to which implementation takes place that can either result in a superficial and surface behavioural response or a deeper and longer lasting, values-based transformation. Having found, with past initiatives, the former approach disappointing in terms of developing person-centred cultures, the region decided to explore the latter approach. In Year 1 the development focused on the pre-requisites of the workers providing care and on some aspects of the care environment, such as power, effective relationships, and risk taking in work. This was achieved by introducing three sets of complex interventions. The first set focused on developing skilled facilitators across the organisation who would influence from within; the second set focused on introducing creative, work-based learning; and the third set on the collection, learning from, and use of evidence collected by the care teams from their own work and workplaces. As of this writing (Year 3), a comprehensive work plan is being used to further embed the values and principles of person-centredness and the Inspired Care strategy across the region of this organisation (See Figure 2). The outcomes from this programme are currently being evaluated through research.
Detailed examination of the Person-Centred Framework with ‘everyday’ organisational practices, such as induction, corporate meetings, telephone interaction from support services, and even incident reporting, have created multiple opportunities to transform these practices to be more person-centred whether for workers or for the older people and families receiving services. For example, recent work to revisit the principles and processes underpinning the reporting of incidents has enabled the regional team to see how learning takes place and how care teams relate their experiences both to the Framework and the values of person-centredness.
Incident reporting across the region has now been recast as ‘Continuous Improvement Opportunities’ and a learning-oriented process has been devised around the constructs of the Person-Centred Framework, along with a practice development, action-planning process. The documentation clearly includes the Framework to make it highly visible and to encourage those who are reporting incidents to look at the incident within the Person-Centred Framework (Dewing et al., 2010). Furthermore, the documentation invites the comments and suggestions, complaints and praise from services users to elicit suggestions of what could be changed or improved. The Framework is then used to help teams establish what areas of person-centredness the incident has touched on (See Figure 3). Over time it will be possible to identify patterns within each service and across the region to see if certain aspects of person-centredness, as portrayed by the Person-Centred Nursing Framework, reappear. This evidence can then be used to support workplace facilitation and management, as well as planning for learning and development, and even for the statutory inspection process.
Person-Centered Practice in Acute Care
A key element within this work has been the use of patient stories, both as a means of obtaining user feedback for the participating areas, and also as a data collection method within the overall programme evaluation. The Belfast Health and Social Care Trust, the largest provider of health and care within Northern Ireland, used the Framework to underpin a practice development programme of work (McCance et al., 2010). The aim of this programme was to support nursing teams to explore the concept of person-centredness within their own setting in-order-to improve care delivery. The Person-Centred Nursing Framework has underpinned the delivery of the programme and is being used in a variety of ways to facilitate engagement of participants with the concept of person-centredness as it relates to their practice. Examples include: using the Framework to raise awareness of the concept; using the Framework ‘in action’ within the workplace as a tool to evaluate care during handovers or during analysis of critical events, both positive or negative; and using the Framework to assess the experience of patients being cared for in each site. A key element within this work has been the use of patient stories, both as a means of obtaining user feedback for the participating areas, and also as a data collection method within the overall programme evaluation. The Framework was used to help make sense of feedback received from patient stories. An example of a story collected from a patient is presented in the Box; Figure 4 illustrates how this feedback was mapped onto the Person-Centred Nursing Framework. In this example important elements relating to ‘attributes of the nurse’ are identified. They can be summarised as follows:
- professional competence reflected in the description of the more experienced nurses
- developed interpersonal skills evidenced through the description of both verbal and non-verbal communication displayed by the nurses
- clarity of beliefs and values demonstrated by the more junior nurse who clearly held the position that she wanted to be open, honest, and transparent about her own developing competence
Box: Example of a Patient Story
“Some of the more experienced nurses, their ability to remain calm even though we were asking awkward questions, especially my brother who wanted to hear everything .... the nurses that stood out were those who were very experienced so (nurse named) was excellent. .... She had a very soft voice, she didn’t raise her voice at all, she just kept her voice very calm and at ease. There is another girl on the other side of that, a wee girl called ….and she was only qualified in September and what she lacked in experience she more than made up for in her manner. She was very friendly, always smiling, anything you asked her, she would say ok lets look at the chart, if she didn’t know she would tell us she didn’t know and she would go away and find out. She didn’t try and pretend that she knew something that she didn’t. She would show us the chart, if she doesn’t know she will say she doesn’t know, she is not trying to fob anybody off, she will find out” (Patient Story, McCance et al., 2010).
This account implicitly leads us to make judgements on relationships within this team and in relation to levels of skill mix (care environment), as noted when the junior nurse is confident that she can approach another more senior member of staff if she needs additional information or support. This feedback process provides an opportunity to celebrate what is good about practice; it also provides the opportunity to identify areas for practice change. Working with the Framework in this way increase practitioners’ understanding of how person-centredness presents in practice. Within a practice development approach it encourages staff to critically reflect and learn from the valuable feedback provided by both patients and their families.
...we have provided an example of how we can move from discussing core elements of nursing practice at a basic level to engaging in activities that can get to the heart of person-centred practice. In this article we have presented and discussed person-centredness as a concept in the context of nursing and aged care, taking account of the ongoing critical debate and dialogue regarding developments in this field. The complexity of person-centredness inevitably contributes to difficulties experienced in articulating how these concepts apply in practice. This complexity is further reinforced by the use of terms that may, or may not, be describing the same thing, ultimately influencing the development of shared understandings. We have presented one tool that aims to generate a greater understanding of how person-centred principles are operationalised in practice; we have illustrated its potential use. In summary, we have provided an example of how we can move from discussing core elements of nursing practice at a basic level to engaging in activities that can get to the heart of person-centred practice.
Tanya McCance, DPhil, MSc, BSc (Hons.) RGN
Professor McCance holds a joint appointment between the University of Ulster and the Belfast Health and Social Care Trust (Northern Ireland) as Professor of Research and Development (R&D). She has been a registered nurse since 1990 and throughout her career has held several joint posts demonstrating her commitment to practice, education, and research. Dr. McCance currently leads a number of projects that are practice based and collaborative in nature. These projects contribute to a programme of work that focuses on person-centred care. Tanya’s primary interest is in developing research in practice settings. She currently sits on a number of editorial boards, committees, and working groups and is recognised for her contributions to the strategic development of nursing and midwifery R&D. She has over 20 publications and has delivered many regional, national, and international conference presentations. Her most recent work focuses on the identification of a relevant and appropriate set of key performance indicators for nursing and midwifery that are indicative of person-centred care and on the development of methodologies that will demonstrate the unique contribution of nursing to the patient experience.
Brendan McCormack, D.Phil (Oxon.), BSC (Hons.) Nursing, PGCEA, RNT, RGN, RMN
Professor McCormack is Director of the Institute of Nursing Research and Head of the Person-Centred Practice Research Centre at the University of Ulster (Northern Ireland). He leads a number of practice development and research projects in Ireland, the United Kingdom, Europe, and Australia that develop person-centered practice. His writing and research focus on gerontological nursing, person-centered nursing, and practice development. Dr. McCormack serves on a number of editorial boards, policy committees, and development groups in these areas. He has a particular interest in the use of arts and creativity in healthcare research and development. Brendan serves as Editor of the International Journal of Older People Nursing; he has published more than 110 peer-reviewed publications in addition to 5 books.His most recent book, Person-Centered Nursing, co-authored with Professor Tanya McCance, was published in July, 2010. Brendan has been appointed as a standing member of Sigma Theta Tau’s Global Health Advisory Council, President of the All-Ireland Gerontological Nurses Association, and Chairman of the 'Age NI’ Charity.
Jan Dewing, MPhD, MN, BSc, RGN, RNT
Professor Dewing works jointly with East Sussex Health Care National Health Service (NHS) Trust and Canterbury Christchurch University Kent England.She is a Registered Nurse and has worked in nursing for many years building a portfolio as a clinical academic. Her previous experiences include working with clinical nursing and practice development units and serving in lecturer-practitioner roles, senior management roles, educational roles, and research roles. Most of Jan's posts have been joint posts between health service providers and academic organisations.In her current role she works between the NHS Trust and Canterbury Christchurch University, focusing on mutually beneficially ways of working that bring desired outcomes for both organisations and ultimately for the patient 's experience of care and safety. Professor Dewing's areas of research interest are in person-centred practice, effective workplaces, teams and leaders, skilled facilitation, evaluation, and workplace learning.She also has expertise in re-enablement and gerontological practice, including dementia care. Jan is widely published and presents at a variety of national and international conferences. She is Editor of a new e-journal, The International Journal of Practice Development, published by the Foundation of Nursing Studies, and of the International Practice Development Collaborative journal: The International Journal of Practice Development.
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© 2011 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2011
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