1. Shuss, Stacy ASN, RN
  2. Lockhart, Lisa MHA, MSN, RN, NE-BC
  3. Kelton, Diane BSN, RN
  4. Davis, Charlotte BSN, RN, CCRN

Article Content

Nurses have the most interaction with patients, which means that we have the biggest impact on cultivating a positive patient experience and ensuring that the healthcare team provides skilled patient-centered care (PCC). To truly embrace the PCC approach to healthcare delivery, the healthcare team must share power and decisions with the patient. After we provide the patient with education on the benefits and risks associated with a diagnosis, treatment, or procedure, the healthcare team works jointly with the patient to establish a care plan that's based on the patient's holistic needs.

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In PCC, the patient is considered a vital member of the healthcare team. In the past, a treatment plan was driven solely by the patient's diagnosis with minimal input from the patient. In today's healthcare environment, the treatment plan incorporates the diagnosis as a component; however, the focus is on decisions made by the patient. PCC is a partnership in which the patient and healthcare team jointly work together to optimize the patient's health.


Get to the center

PCC is a priority identified by the American Association of Critical-Care Nurses (AACN), and adopting a conceptual framework that includes both a PCC and family-centered care approach to healthcare delivery is a requirement of Magnet(R) recognition. When providing PCC, consider incorporating the following elements from Mountain States Healthcare Alliance, a 13-hospital integrated healthcare delivery system based in Johnson City, Tenn.


1. Every member of the healthcare team plays an important role in providing PCC. All members of the healthcare team, ranging from the clinical nurse, physician, chaplain, social worker, housekeeping staff, and administrative team, play a vital role in the patient's healthcare experience. They all share a common goal of placing the patient's holistic needs as a shared priority.


2. PCC is the foundation of a continuous therapeutic relationship that follows the patient during illness and health. This allows for a more comprehensive individualized care plan to be developed based on the healthcare team's detailed knowledge of the patient's clinical history.


3. PCC is personalized to reflect the patient's holistic needs, personal values, and life choices. This requires the healthcare team to customize the care plan by incorporating the patient's preferences, as well as his or her emotional, spiritual, and physical needs.


4. Information is openly shared between the patient and healthcare team members. This open and honest dialogue conveys to the patient and his or her caregivers that they're a vital and valued member of the healthcare team. When patients and caregivers feel that their insight and concerns are being addressed and incorporated into the care plan, they have increased trust and satisfaction with the care received.


5. A safe, calm, peaceful, and supportive environment is maintained to optimize comfort and healing. Many healthcare facilities are incorporating soothing color schemes and decor into all of their patient care areas. Caregivers are provided comfortable areas to rest in the patient rooms to encourage them to stay with the patient during their healthcare experience. Music is often integrated into patient rooms, hallways, and waiting areas. Pet therapy animals are increasingly welcomed as research continues to prove that their presence has a soothing effect on patients by lowering their stress hormone levels.


6. The patient's family, friends, and caregivers are encouraged to be part of the healthcare team. In many situations, the patient may rely heavily on loved ones to help him or her make healthcare decisions. They can also be an incredible asset to reinforce or explain the healthcare team's instructions and rationales to the patient in a way that fosters optimal patient comprehension and compliance with the treatment plan. This can result in both reduced readmission rates and increased patient satisfaction.


7. PCC begins with maintaining a safe and therapeutic environment. The Joint Commission's 2015 National Patient Safety Goals provide a foundation that healthcare facilities should include in all patient care areas, such as:


* using at least two patient identifiers to ensure that they're providing care to the correct patient


* labeling all medications correctly to prevent the wrong medication being administered to the wrong patient


* ensuring that important test results are communicated to the correct staff member and patient without delay; this reduces care delivery delays, decreases patient anxiety, and improves trust between the patient and healthcare team


* using preventive techniques to reduce healthcare-associated infections, such as maintaining good hand hygiene and utilizing evidence-based practice interventions to minimize invasive line and urinary catheter associated infections


* identifying patients who are at risk for falls on admission and communicating this to all healthcare team members


* explaining to the patient and his or her family why we use patient alarms.



8. Be honest and forthcoming when a medical error has been made. Real PCC begins with being honest and accountable with the patient, family, and your fellow team members when a medical or nursing error occurs. Most healthcare facilities have a specific protocol for how the error is conveyed to the patient and who conveys that information. Remember to follow your facility's guidelines and seek your executive nursing leadership's opinion and approval before divulging information.


9. Be a cooperative team player to your peers and volunteer your assistance. Nurses should remain focused on assisting their team members to meet each patient's holistic healthcare needs. This may require you to assist peers in activities ranging from direct patient care to coordinating a specific religious clergy member of the patient's faith to visit to ease the patient's anxiety and provide emotional comfort. Some patients may want specific religious ceremonies conducted during their stay and as long as it doesn't place the patient at physical risk, we should accommodate these requests.


10. Never forget the patient is the final healthcare decision maker! As nurses, we must provide all of the information necessary for the patient to make the decision that best meets his or her healthcare needs, cultural beliefs, and life plans, including any potentially negative consequences of the decision. We may not always agree with the patient's ultimate decision, but we must honor it.


The healthcare team should incorporate the patient's spiritual and religious beliefs into his or her care when appropriate. It's vital that we ask patients on admission what their religious or cultural beliefs are so that we can ensure we're providing culturally-sensitive care. Ask patients if they have a religious preference and if they do, offer to have a clergy member visit with them. Some specific religions have unique rituals that must be performed at birth or death. You should also ask if the patient has any specific dietary needs; many religions observe specific dietary restrictions. Dietary choices should be offered unless medically contraindicated to conform to the specific religious or cultural needs of the patient.


Tailor your work area

PCC can be tailored to the nurse's clinical environment and work area (see What does PCC look like?). This requires you to be accepting and embrace new ways of providing care to patients and their families.


For example, most inpatient hospital settings now have open visitation, even in ICUs. Open visitation is among the defining elements of a PCC approach and allows for family and friends to visit with the patient at any time unless the patient is experiencing a rapid hemodynamic decline or an emergent procedure to stabilize him or her. It also allows the healthcare team to incorporate the patient's cultural traditions, personal preferences, and lifestyle into the care plan. Restricted ICU visitation traditions cultivated the false belief that visitors obstruct nursing and medical care, physically exhaust patients, interfere with healing, and potentially cause negative clinical patient outcomes. However, recent research studies have shown that open family visitation contributes to improved physiologic outcomes and lower stress for patients, and increased job satisfaction for nurses.


Hospice care units should encourage family and friends to visit or stay with the patient when possible. Many hospitals, such as Veterans Affairs medical centers, are providing family care units for the family to sleep, bathe, and even prepare meals. The Fisher House Foundation provides military families with lodging close to a loved one during hospitalization for an illness, disease, or injury. This allows the family to spend quality time with the patient during his or her acute care illness or end of life in a home-like environment.


It's recommended that long-term-care units ensure that the patient environment is as home-like as possible. This includes personalizing the resident's room with medical beds that resemble furniture, photos, and decorations that he or she would have at home, and bathrooms that resemble a home bathroom or spa.


Address barriers

Barriers to PCC may include:


* nurse resistance. It may be difficult to change the way we think as we shift from a diagnosis-driven care plan to one that's directed by the patient's holistic healthcare needs. It may also be hard to embrace a customer service approach. That's why nurses must receive adequate training on effective communication skills, as well as the benefits of providing extensive patient education so that patients can make informed decisions that are directed by their values, beliefs, and goals. We must be supportive of change initiatives that are research-based with clinical outcomes that reveal increased workplace efficiency or improved patient or family satisfaction scores associated with the healthcare services we provide.


* cost. Whenever organizational policy and care delivery are changed, cost is a factor. As the healthcare industry has changed, we must ensure that the services we deliver are cost-effective. This often requires us to think outside of the box for interventions that can effectively meet the patient's healthcare needs at a low or nominal cost to the patient or insurance payer. Many patients may become noncompliant with a treatment plan if it places a financial burden on them or their family. When we find that new products have been released that are equally effective, safe, and cost less, we should present the new product to our nursing management team members for consideration. This demonstrates our dedication to meeting our organization's needs, as well as adhering to our focus of providing safe patient care.


* physician buy-in. Changing the way physicians interact with patients and families is vital. For some providers, this means changing the way they provide care from a system in which decisions are made by the healthcare team to one where decisions are made jointly with the patient and family when appropriate. We must share vital information, such as patient satisfaction scores, with our physician colleagues.



How can we address these barriers?


* Education on crucial conversations. Healthcare teams should be mindful that sensitive conversations with the patient and family should occur in a private area where they can have their questions or concerns directly addressed. This is vital when a new diagnosis is made or concerning test results are shared. By providing privacy and adequate time for patients to process information, we can ensure that they have full comprehension of the information provided and how it may impact their current or future health.


* Education on multidisciplinary teams. The healthcare team should be provided information on the benefits of grand rounds-a healthcare approach in which multiple members of the healthcare team round daily at the bedside. Grand rounds are directly linked to decreased complication rates, lower mortality, and increased care plan adherence. They're also directly linked to reduced miscommunication errors.


* Culture change that allows and promotes inclusion rather than exclusion of patients and their caregivers. We must shift our concept of healthcare delivery from one in which the patient is receiving care in our work environment to one where we work in the patient's environment. One way to ensure this is by providing bedside shift report so that the patient can interject vital information and feel that he or she is truly a member of the healthcare team. We can also increase our visitation policy when it's safe for the patient.



The beating heart of care

At the heart of PCC is the belief that healthcare team members and the patient and family are partners, working together to best meet their needs. We must be dedicated to listening to and honoring our patients' and their families' ideas and choices, and use their concerns, knowledge, values, beliefs, and cultural backgrounds to improve care planning and delivery. We must understand that patients' personalities, life experiences, values, beliefs, education levels, and religious and cultural backgrounds are all vital components that can impact their healthcare decisions.


Ultimately, our patients are our healthcare customers. We must provide optimal customer service that's tailored to patients' healthcare needs so that we can improve their health and increase their trust and satisfaction in the healthcare services that we provide. As nurses, we have to create a culture that accepts the patient as a valued member of our healthcare community.


key points

Common ways to improve your delivery of PCC

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* Be considerate of your patient's time. When possible, group your patient's follow-up appointments, tests, and procedures in one visit to your healthcare facility.


* Ensure that your patient knows a point of contact name and phone number for follow-up visits before he or she is discharged.


* Inform your patient that your goal is to provide excellent care during his or her stay at your healthcare facility.


* Perform your job duties with a smile, unhurried movements, and caring attitude. Patients can sense if you're rushed and this can increase their anxiety if they're worried that you won't have time to meet their needs.


* Provide good customer service. Avoid phrases like "that's not my job." It's everyone's job to provide good service to our patients from the CNO to the security officer. Remember that your patients have choices for where they receive their healthcare services, and you want them to continue to choose your facility.


* Watch your verbal and nonverbal communication. Make eye contact and ensure that your vocal tone and body language convey respect for your patient and his or her visitors.


* Share your clinical insight and suggestions for improving care delivery systems with your healthcare and administrative team members. As nurses, we have invaluable insight on how to improve the efficiency of healthcare delivery.



cheat sheet

Culture change


* Starts at the top


* Includes all staff


* Must be reflected in organizational policy


* Requires support and education


What does PCC look like?

PCC in the ICU

In the past, visiting hours in the ICU were limited to a few specific hours a day. The current trend incorporates a PCC approach of allowing open visitation that's only limited if an emergent life-threatening event is occurring with a patient. According to the AACN, the presence of a patient's loved one improves the patient's communication and understanding, decreases anxiety, and improves staff satisfaction.


Patients and families are encouraged to listen to and participate in grand rounds with the healthcare team during which they discuss the patient's current health problems and progress toward returning to an optimal level of health. This allows patients and families to voice their questions and receive timely, accurate, and comprehensive information that will allow them to make the best healthcare decisions.


If patients aren't awake or families aren't present for rounding, most ICUs have incorporated useful tools to convey daily goals. A common tool used is a wall-mounted dry erase board that lists the nurse's name for that shift and the primary goal for the patient that day. This can ease the patient's and family's anxiety by providing a measurable daily goal such as oxygen level will remain above 92%.


PCC in the long-term-care setting

In the long-term-care environment, patients are referred to as residents. There's a paradigm shift in both the resident living environment and also in the manner in which care is delivered to reflect PCC. The current trend is to make the resident's living environment as home-like as possible. Residents and families are encouraged to decorate their loved one's bedroom to reflect their personal style with pictures, photos, mementos, and personal furniture when possible. The resident can even have his or her own personal bedding set that reflects his or her personal decorating taste. This allows residents to truly feel like their long-term-care center room is home.


Long-term-care staff members are reminded that they work in the resident's home. Common areas are decorated tastefully with soothing colors and comfortable chairs that encourage the resident to socialize with other residents and staff members.


Many long-term-care centers even have a pet therapy animal that resides at or frequently visits the home. Most long-term-care facilities offer routine social outings outside of the long-term-care center for residents who are able to travel. They also have frequent social events, such as dances, ice cream events, birthday dinners, holiday parties, bingo, and movies.


Residents and families are interviewed by the dietician on admission to assess their specific dietary likes and dislikes so that their meals will be tailored to their dietary choices. Residents who require assistance with bathing are offered choices as to what of type bath they would prefer (bath or shower) and what their preference is for bathing assistance (day or night).


PCC in the outpatient setting

PCC in the outpatient environment can take several directions. This is typically where the medical home relationship with the patient begins. In this environment, the RN becomes a case manager. This role is essential to the long-term management of the patient's care and, more importantly, the maintenance of health. In this environment, the focus is on keeping the patient at the most optimal state of health that he or she can achieve and supporting the patient and his or her caregiver in achieving and maintaining that state. Interviewing the patient and caregiver is vital to collaboratively develop a mutually agreed on care plan and set goals to achieve it.


The nurse case manager also assists the patient and caregiver in healthcare navigation, keeping the patient's goals at the forefront and collaborating with him or her in goal development and evaluation. Case management tasks may include setting up appointments, assisting the patient to arrange travel to and from the appointments, locating specialists, finding support and education in the community, and guiding the patient on his or her journey.


on the web


* Agency for Healthcare Research and Quality: Patient-Centered Medical Home Resource Center:


* Commonwealth Fund: A 2020 Vision of Patient-Centered Primary Care:


* Institute for Patient- and Family-Centered Care:


* Patient-Centered Primary Care Collaborative:


* Picker Institute: Patient-Centered Care Improvement Guide:


* The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and-Family-Centered Care:




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