Healthcare provider person-centred practice: relationships between prerequisites, care environment and care processes using structural equation modelling

Healthcare systems worldwide are investing in effective approach to enhance care experience and quality care. Efforts are underway to address imbalanced and fragmented care, shifting care from medically-dominated and disease-orientated towards one that is relationship-focused, collaborative, and comprehensive [1‐3]. This long-standing movement of ‘what a person requires’ was defined by Kitwood’s person-centredness as ‘a standing or status that is bestowed upon one human being by other, in the context of relationship and social being, implying recognition, respect and trust’ [4]. McCormack’s four concepts was elaborated in person-centred practice as being in relation, social world, place and self [5]. These concepts defined person-centred care to be ‘an approach to practice that is established through the formation and fostering of therapeutic relationships between all care providers, service users, and others significant to them, underpinned by values of respect for persons, individual right to self-determination, mutual respect, and understanding’ [6].

Respecting individuals as persons and acknowledging their right to care partnership appears to be consistently mentioned concepts across various person-centred definitions, as does the formation of healthy relationships between parties involved [7]. Nolan and colleagues argued the focus should also shift from trying to meet individual needs alone, to interacting with all parties involved in care whose needs should be taken account of [8]. Lastly, it is also often confused as to ‘who’ the person should be. McCormack and McCance clarified that ‘person’ refers to all involved in a caring interaction and therefore encompasses service users, families/carers, healthcare providers, and other members of the multidisciplinary team [1].

There are many benefits of person-centred practice. For example, person centred practices can help foster healthy relationships, improve self-management support and shared decision making. These all lead to an increase in patient satisfaction, self-efficacy and empowerment, leading to a change in self-care behaviours including better medication and treatment adherence [9‐12]. In addition, through indirect relationship, person-centred practice also improves health-related quality of life indicators such as physical functioning [13, 14], and better healthcare utilisation such as reduction in emergency cases, hospitalisations and cost of utilisations [10, 15, 16].

In Malaysia, primary care services are provided both by the public and private sector. The public sector, which has an extensive network of health clinics, community and mobile clinics, are spread throughout the country and provides almost two-thirds of outpatient care. While recognising this access to primary care settings, prevalent non-communicable diseases, growing public expectations and ambitious health goals continued to highlight the pressing need for action on quality of care [17]. The call to reform healthcare system towards person-centredness was mentioned formerly [18‐20]. At primary care level, the Family Doctor Concept initiated in 2014 was aimed to empanel the population to dedicated health teams, ensuring continuity and coordination of care [21]. The Enhanced Primary Healthcare programme in 2018 introduced screening, early illness detection, effective referral and multi-disciplinary teamwork to achieve an integrated network of person-centred care services [22]. Studies that examined delivery of person-centred care included aspects of unvoiced care needs among service users [23], and areas for improvements in shared decision making [24‐26].

Reformation allows health care providers and organizations to adopt a person-centred culture to reciprocate to service users who will then benefit from person-centred health outcomes [27]. However, the challenge remains in effectively translating the principles of person-centredness into practice. Developing person-centred culture requires a sustained commitment across organisations to facilitate changes.

The domains based on the Person-centred Practice Framework were investigated through the hypotheses that test the relationships between the constructs. Structural equation modelling (SEM) was applied to identify the relationships through a path diagram. SEM is a multivariate statistical analysis that is increasingly used in healthcare. It allows assessment of reliability and validity of multi-items constructs measures [38, 39], followed by analyses of structural relationship between measured variables and latent constructs by combining factor analysis and multiple regression analysis. Additionally, the variance explained in the dependent variables accounts for both direct and indirect effects; hence it is larger with SEM than in multiple regression [40]. The protocol describing the study methods and the first part of the instrument’s validation are described elsewhere [37, 41].

Overall, the validity and reliability of the instrument were acceptable. However, there were some low AVE across a few sub-constructs, suggesting suboptimal convergent validity. This is most likely due to differing interpretation of person-centred practice among Malaysian healthcare providers, influencing the factoring of items, as shown and discussed in the first part of the instrument’s validation [37]. It should be noted that no items were dropped due to its significant contribution to the overall model. These results are in line with previous studies in Norway and Germany where six and four items not achieving acceptable factor loading value were all retained [35, 36]. The model goodness-of-fit were positive, in concordance with the previous studies confirming the model fit [34‐36]. Correlation of errors were allowed in the final model - suggesting the possibility of item misinterpretation, given the influence of culture, context, language and local practice, therefore affecting the relationship between items and their latent constructs, as shown previously [37].

The overall model substantiated the order of the Person-centred Practice Framework. Indeed, significant relationship was found in strengthening person-centred prerequisite to establish a person-centred working environment and finally promote delivery of person-centred processes. Previous studies have also shown importance of healthcare providers’ attributes and work culture in improving healthcare delivery and quality of care [50‐53]. When work culture is supported, healthcare providers’ motivation to work increased and level of stress reduced [54]. Presence of excellent teamwork was also an indicator of staff’s intrinsic motivation and implied a high-functioning organisation in terms of communication, support and meeting staff expectations [50‐52].

The provision of a person-centred practice and formulation of a supportive work culture, however, is not without challenges. Manley suggested work culture to be the culture at workplace that service users, residents, and staff experience every day. It extends beyond ‘organisational artefacts’ of visible products such as language, technology and forms of address, and covers values such as shared ideas, effective teamwork, continuous learning environment, and transformational leadership, among others [55]. McCormack et al. described what healthcare providers usually experienced was mere ‘person-centred moments’, that is when things seem to come together and was rewarding, when in reality it depends solely on good traits of individuals and leaders, hence rarely repeatable on a daily basis [7]. It is therefore crucial to understand that person-centred care is not bound, or measured by the quality of health service received by service users, neither by their health outcomes alone, rather by how persons are viewed and treated while receiving care. Moreover, the values of mutuality, collegiality, and care are not necessarily transformed into practice despite being embedded in the mission statements and organizational frameworks. Similarly, team work and team effectiveness were always thought to be commonly in place, but dysfunctional team relationships and discrepancy between envisioned and practiced healthcare continue to exist [56, 57].

This finding emphasises the importance of establishing a supportive and effective working environment and work culture in promoting delivery of person-centred processes, whereby it does not only need to be present to allow the process to happen, it also need to be in place in mediating the person-centred values held by healthcare providers. Developing person-centred cultures therefore need persistent effort and commitment from all parties involved [27].

While the Person-centred Practice Framework outlines all the components and criteria that need to be present, how can they be transformed into practice? Studies utilising practice development methodology demonstrated how the transformation took place [27, 58]. In order to motivate staff to adopt PCC values and attributes, enabling factors must be in place. This includes individual factors such as having transformational leadership skills, offering skilled facilitations to staff, and clarifying roles of all staff. At organisational level, factors enabling the change include effective management, enabling approach to leadership and decision-making, organisational preparedness, and supportive human resource department [59]. Transformational programme proposed, based and prioritised on issues identified by staff, and tailored to the need of the staff and community could then be rolled out, over a period deemed required for the changes to happen. Along the process, evaluation and feedback should be gathered to improve implementation and resolve conflicts [27, 58, 59].

One of the major strengths of the study was exploration of person-centred concepts in a theoretical framework based on established theories. It helps strengthen existing knowledge in the wide PCC field. To our knowledge, this was the first study that investigated the relationship among all domains of PCPI-S questionnaire in a primary care context, extending the instrument applicability into a wider healthcare setting. Nonetheless, since the study only focused on healthcare providers working in public primary care settings, the findings were heavily influenced by the work culture of this setting, and might not necessarily be applicable to a different setting. The model should be validated in multiple samples from various healthcare settings in future studies. Since this study was cross-sectional in nature, the direction of causality for some factors could not be established. Future studies should adopt a longitudinal research design to prove causality. As with all structural models, one disadvantage of using SEM is that the model represents approximations that may omit variables implicated in causal processes or other features [60]. Therefore, future studies are encouraged to investigate the inclusion of other relevant variables in the model.

The findings of this work support the original framework in establishing the pathway that show person-centred prerequisite is needed to form a person-centred care environment, which then needed to allow delivery of person-centred care processes. It is shown that a person-centred care environment also acts as partial mediator between prerequisite and care processes. Therefore, in order to successfully move towards delivering person-centred practice, it is imperative to equip our healthcare providers with person-centred values and beliefs, while at the same time transform current work culture to align with person-centred care.