Culturally Competent
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NURS OUTLOOK 64 (20r6) 352-366
NURSING
OUTLOOK
-www.nursingoutlook.org
A proposed model of person-, family-, and culture-centered nursing care
Maichou Lor, MS, RN*, Natasha Crooks, BSN, RN, Audrey Tluczek, PhD, RN, FAAN
ARTICLE INFO
Article history: Received 28 May 2015 Revised 6 January 2016 Accepted 28 February 2016 Available online 8 March 2016
Keywords: Concept analysis Cultural competency Family centered Patient centered Person centered
University of Wisconsin-Madison, School of Nursing, Madison, WI
ABSTRACT
Background: For decades person-, patient-, family-centered, and culturally competent care models have been evolving and conceptualized in the literature as separate. To our knowledge, there has not been a systematic approach to comparing all four of these conceptual models of care. Purpose: To explicate and compare four conceptual care models: person-, patient-, family-centered, and culturally competent care. Methods: A comparative concept analysis informed by Rogers' evolutionary concept analysis was used to compare 32 nursing research on person-, patient-, family-centered care, and culturally-competent care published between 2009 and 2013. Results: Collective results of analyses of 32 nursing research articles found 12 attributes: collaborative relationship, effective communication, respectful care, holistic perspective, individualized care, inter-professional coordination, self-awareness, empowerment, family as unit of care, interpersonal relation- ships, cultural knowledge, and cultural skills. Antecedents included: lack of empirical evidence, poor patient outcomes, implementation problems, knowledge deficits, patient/parent emotional distress, poor patient-provider relationships, and health disparities. Consequences included: improved health-related outcomes, increased satisfaction, enhanced patient/family- provider relationships, reduced hospitalization, improved quality of life, improved quality of parent-child relationships, increased trust, enrollment in research, insights about biases, and appreciation for cultural differences. So- cial justice, advocated by scholars and national organizations, was absent from all studies. Conclusions: Findings informed the proposed blended conceptual care framework that embraces the attributes of each care model and includes social justice. Cite this article: Lor, M., Crooks, N., & Tluczek, A. (2016, AUGUST). A proposed model of person-, family-, and culture-centered nursing care. Nursing Outlook, 64(4), 352-366. http://dx.doi.org!10.1016/ j.outlook.2016.02.006.
A clear understanding and articulation of concepts is essential to advance nursing knowledge and to effec- tively communicate within nursing research, educa- tion, and practice as well as across disciplines, (Bonis,
2013). Over the past few decades, four conceptualiza- tions of health care delivery have emerged that reflect a shift in the health care delivery paradigm from a paternalistic, disease-focused perspective to care
* ~,;;;~~~onding author: Maichou Lor, School of Nursing, U~iversity of Wisconsin, Signe Skott Cooper Hall, 701 Highland Ave., Madison, address: [email protected] (M. Lor).
nt matter © 2016 EI' . sevIer Inc. All nghts reserved. <4U"'OK.LU16.02.0()6
NURS OUTLOOK 64 (20r6) 352 366 353
models that focuses on the needs, preferences, and cultural values of the constituents of health care: person-centered, patient-centered, family-centered, and culturally competent care. Application of these four conceptual care models tends to vary based on the patient population or the environment in which care is delivered. The term "patient centered" is typically used in regard to recipients of services in tertiary care set- tings (Morgan & Yoder, 2012), whereas "person centered" is used in reference to nursing home resi- dents (Brooker, 2007). "Family-centered" care is generally preferred in interventions for pediatric pop- ulations (American Academy of Pediatrics, 2012). "Culturally competent" care is a term that calls for customizing care for patient populations that share one or more demographic characteristics, usually race, ethnicity, language, or country of origin (Office of Minority Health, U.S. Department of Health and Human Services, 2015).
Many professional organizations and government agencies advocate for institutional implementation of these conceptual care models (American Academy of Pediatrics, 2012; American Association of Colleges of Nursing, 2008; American Nurses Association, 2015; Bloom, 2002; Chao, Anderson, & Hernandez, 2009; The Joint Commission, 2010). These concep- tual care models are also recommended for inclusion in undergraduate and graduate nursing curricula (American Association of Colleges of Nursing, 2008; American Nurses Association, 2015). Therefore, the purpose of this article was to (a) describe the histor- ical separate evolution of these four conceptual care models, (b) report results of a concept analysis that offers conceptual clarity about the use of each model in current empirical nursing literature, (c) compare models to identify conceptual similarities and dif- ferences, and (d) discuss implications for blending the models.
Historical Evolution of Models
Table 1 provides an overview of the historical evolution of the four models. In summary, multiple disciplines have contributed to the parallel evolution of each of these four conceptual care models. Although the models share several attributes, for example, unique- ness of the "patient," importance of patient-provider relationship, and emphasis on individualized care, they remain mutually exclusive within the research literature. In addition, person-, patient-, or family- centered care models do not address power, privilege, historical oppression, or cross-cultural patient-nurse relationships. To our knowledge, there has been no systematic approach to comparing these four care models as conceptualized by nurse researchers. Therefore, we conducted a comparative concept anal- ysis to explicate the current state of these concepts within nursing research and explore how similar or different the models might be.
Methods
InclusionlExclusion Criteria and Data Sources
Table 2 details the search criteria, search terms, data- bases, and article selection for each concept. Our search included articles published by nursing re- searchers, documented by authorship, reporting pri- mary data, and published between 2009 and 2013. We chose this time frame because previous concept ana- lyses had been completed before 2009. We chose arti- cles with nurse authors because our aim was to explicate how the four conceptual care models have been conceptualized in nursing science. The most common reason for exclusion was that nurses were not authors.
Analytic Procedures
The research team was comprised of content and methodology experts. We followed the procedures of Rodgers (2000) in the conduct of a separate concept analysis for each of the four conceptual care models, beginning with person-centered care, followed sequentially by patient-centered care, family-centered care, and culturally competent care. We selected con- cepts significant to nursing, that is, four conceptual care models, and performed database searches using specific inclusion and exclusion criteria. Each researcher independently identified the surrogate terms, antecedents, attributes, and consequences in each article. The team met weekly to discuss the codes and reach group consensus about results. During our analysis, we found that in the family-centered and cultural competency articles, researchers identified barriers to implementing care models. Therefore, we added "barriers" as a category. Findings were entered into matrices. We modified and refined codes and matrices as new findings emerged from the analysis. On completion of the analysis of the four conceptual care models, we compared the results across the models to identify distinguishing and overlapping characteristics as recommended by Haase, Leidy, Coward, Britt, and Penn (2000). Finally, we assimi- lated the findings into a proposed blended model that also included social justice.
Results
Sample Characteristics
Our sample consisted of 32 articles published from 2009 to 2013. Most of the 10 person-centered care studies originated in Europe. The rest were from the United States and Australia. Most of the patient- centered care studies were performed in the United States. Only one study of patient-centered care was
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NURS OUTLOOK 64 (20r6) 352-366 355
performed in Israel. Half of the family-centered care studies were conducted in European countries; the rest were from the United States, Canada, several African countries, and Australia. Most culturally competent care studies originated in the United States, one study was from Spain, and one was from South Africa.
Study Designs
Most study designs were qualitative, particularly in the family-centered care research (Bolster & Manias, 2010; Coyne, O'Neill, Murphy, Costello, & O'Shea, 2011; Coyne, 2013; Ho, 2009; Jomfeldt, Rask, Brunt, & Svedberg, 2012; McLauglin et al., 2013; Mitchell, Chaboyer, Burmeister, & Foster, 2009; Roets, Rowe-Rowe, & Nel, 2012; Staniszewska et al., 2012; Trajkovski, Schmied, Vickers, & Jackson, 2012). Three researchers in patient-centered and culturally compe- tent care used a mix of qualitative and quantitative methods (Collins-McNeil et al., 2012; Haigh & Ormandy, 2011; Walton, 2011). Studies across all con- cepts involved quasiexperimental designs (Ailinger, Martyn, Lasus, & Lima Garcia, 2010; Dudas et al., 2013; Ekman et aI., 2012; Mitchell et al., 2009). Re- searchers of person- and family-centered care used cross-sectional designs (Edvardsson, Petersson, Sjogren, Lindkvist, & Sandman, 2013; McCormack et al., 2010; Sjogren, Lindkvist, Sandman, Zingmark, & Edvardsson, 2012; Soury-Lavergne et al., 2011; Wil- liams, Boyle, Herman, Coleman, & Hummert, 2012).
Surrogate Terms and Attributes
Surrogate terms are words considered synonymously for the concept (Tofthagen & Fagerstrom, 2010). The surrogate terms identified for the four concepts are listed in Table 3. The term "family centered" was uni- versally applied to that concept of family-centered care, whereas the terms used to describe culturally competent care were quite varied.
Attributes define or characterize the concept under study (Tofthagen & Fagerstrom, 2010). The following 12 attributes were found across all four concepts. Table 3 lists the attributes by conceptual care model.
Collaborative relationship was the central attribute endorsed by all four models of care. Such relationships consisted of individual health care providers and interprofessional care teams working in partnership with the identified patient and his/her family in plan- ning and implementing their care (Glass, Moss, & Ogle, 2012). Collaborative relationships are achieved by providing patients/families "honest information" about the patients' condition and related care (Mitchell et al., 2009). In pediatric settings, collaboration also meant including parents in their children's care (Mitchell et al., 2009; Staniszewska et al., 2012; Trajkovski et al., 2012). These relationships also required nurturing partnerships with key community stakeholders (Walton, 2011). Ekman et al. (2012)
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described three phases of partnerships: initiating, working, and safeguarding.
Effective communication was described as a contin- uous process involving verbal or nonverbal exchanges of information between all health care providers and patients (Coyne et al., 2011; McLaughlin, Melby, & Coates, 2013). Ho (2009) suggested that effective communication requires reflective listening with a sense of empathy, recognizing, and understanding nonverbal cues of communication, such as eye contact, gestures, and facial expressions and feelings. Kelley (2011) described effective communication as requiring clinicians to establish trust with patients, actively listen, use simple language, adopt an unhurried demeanor, and assess the patient's beliefs, fears, tone of voice, and style of speech. Kelley (2011) suggested that matching the provider race and gender to that of the patient improves communication. In addition, written materials need to be understandable to those with low literacy levels, visually appealing, and un- cluttered (Ho, 2009).
Respectful care was characterized as being responsive to and accepting of the person's beliefs and values, acting in a caring, sympathetic manner (McCormack et al., 2010), and being polite and affirming (Williams et al., 2012). Respectful interactions with patients and their families were characterized as sensitive and compassionate (Staniszewska et al., 2012). Respectful care required being open-minded about patient or family beliefs, values, or practices that are different from one's own (Hawala-Druy & Hill, 2012; Kelley, 2011).
A holistic perspective referred to planning and deliv- ering care based on knowledge of the multiple facets of the person and their family (Kennedy, 2012; McLaughlin et al., 2013; Roets et al., 2012; Trajkovski et al., 2012). These facets include social, cultural, psy- chological, and spiritual as well as physical needs. A holistic perspective also involved recognizing the in- dividual's wishes and attending to individual stressors (Roets et al., 2012; Trajkovski et al., 2012).
Individualized care consisted of tailoring care plans and care delivery to the needs and wishes of patients and/or their families. Such care included providing psychosocial support to the family and physical care to the patient (Mitchell et al., 2009; Staniszewska et al., 2012). In pediatric settings, individualized care required "getting to know" parents and their prefer- ences (Bolster & Manias, 2010; Trajkovski et al., 2012) and involving parents in their children's physical care, for example, bathing and combing hair (Mitchell et al., 2009; Staniszewska et al., 2012). In residential settings for the elderly, it involved residents taking part in normative activities, for example, making coffee, tak- ing outdoor walks, playing games, or attending reli- gious services (Edvardsson et al., 2013). Coyne et al. (2011) described "negotiated care" that involved an iterative exchange of information between families and nurses to reach mutually agreeable goals and related care. This process required nurses to remain
358 NURS OUTLOOK 64 (20r6) 352-366
flexible and nonjudgmental. Individualized care was associated with patients having a sense of well-being and trust; "responsive care" was associated with pa- tients having trust in nurses (Radwin, Cabral, & Wilkes, 2009).
Interprofessional coordination required mUltiple disci- plines to work together as a synergistic team and to comprehensively address patient and family needs (Coyne et aI., 2011). Bolster and Manias (2010) noted that effective communication among team members is critical for optimal teamwork.
Self-awareness required self-reflection to gain an understanding of one's own assumptions and become open to beliefs and values different than one's own (Abdelhadi & Drach-Zahavy, 2012; Bolster & Manias, 2010; Coleman & Medvene, 2013; Edvardsson et aI., 2013; Hawala-Druy & Hill, 2012; Walton, 2011). In describing self-awareness, Hawala-Druy and Hill (2012) recommended that nurses also gain an under- standing of how intersecting patient identities and institutionalized social injustices contribute to health inequities.
Empowerment of patients and families was accom- plished by providing patients or their caregivers important health information and encouraging them to participate in the patient's care, for example, medi- cation administration, to assure that they had acquired the competence and confidence to successfully perform the task at home (Bolster & Manias, 2010). Empowerment was also associated with assuring ac- cess to care, providing adequate health information, and involving patients, families, and communities in care (Coyne, 2013; Coyne et aI., 2011; Soury-Lavergne et aI., 2011; Walton, 2011).
Viewing the family as a unit of care meant considering the psychosocial needs of the entire family and the identified patient. This attribute was especially important in pediatric or culturally diverse populations (Ailinger et aI., 2010; Anderson & Friedemann, 2010; Coyne, 2013; Coyne et aI., 2011; McLaughlin et aI., 2013; Roets et aI., 2012; Staniszewska et aI., 2012; Trajkovski et aI., 2012).
Interpersonal relationship involved establishing trust, listening to family life stories, and coming to know the family within the social context of their lives beyond the health care setting (Bolster & Manias, 2010; Trajkovski et aI., 2012). Such relationships were said to evolve over time with repeated contacts (Bolster & Manias, 2010).
Cultural knowledge meant gaining an understanding and appreciation for culturally specific beliefs and health care practices as well as factors contributing to cultural values (Ailinger et aI., 2010; Anderson & Friedemann, 2010; Collins-McNeil et aI., 2012; Hawala-Druy & Hill, 2012; Ho, 2009; Kelley, 2011; ~alton, 2011). An example was knowledge about reli- gIous practices (Ho, 2009). Some authors also advo- cate~ for considering multiple intersecting identities as
Important component of cultural knowledge & Hill, 2012; Walton, 2011).
Cultural skills involved incorporating cultural knowledge and self-awareness into clinical practice (Walton, 2011). These skills require effective cross- cultural communication and capacities for building partnerships at the individual and community levels (Walton, 2011).
As noted in Table 3, the concepts ofperson-, patient-, and family-centered care as well as culturally compe- tent care shared the attributes of collaborating in part- nership with patient and/or family, communicating effectively, and acting in a respectful and caring way. Person-, patient-, and family-centered care included viewing patients holistically, individualizing care, and coordinating interprofessional care as attributes. Person-centered, patient-centered, and culturally competent care recognized developing self-awareness as an attribute. Empowering patients, families, and/or communities and viewing family as a unit of care were attributes espoused by family-centered and culturally competent care. Forming interpersonal relationships was shared by person-centered, patient-centered, and culturally competent care. Gaining cultural knowledge and developing culturally congruent, responsive behavioral skills were unique to culturally competent care.
Antecedents
Antecedents are events or phenomena that have been previously associated with the concept (Tofthagen & Fagerstrom, 2010). In this analysis, antecedents included factors researchers cited as a rationale for conducting their studies.
Person- and Patient-Centered Care The most common reasons for person- and patient- centered care were poor patient health outcomes (Ekman et aI., 2012; Edvardsson, Fetherstonhaugh, & Nay, 2010; Edvardsson et aI., 2013; Glass et aI., 2012; }omfeldt et aI., 2012; Williams et aI., 2012; Radwin et aI., 2009; Dudas et aI., 2013) and paternalistic patient-provider relationships (Coleman & Medvene, 2013; Jomfeldt et aI., 2012; Williams et aI., 2012; Slatore et aI., 2012). Conditions that preceded and prompted person- or patient-centered care studies included lack of empirical support (Edvardsson et aI., 2010; Bolster & Manias, 2010; Ekman et aI., 2012; Haigh & Ormandy, 2011; Abdelhadi & Drach-Zahavy, 2012; McCormack et aI., 2010; McKeown, Clarke, Ingleton, Ryan, & Repper, 2010). Other reasons for initiating person-centered care included concerns about quality of life (Edvardsson et aI., 2013), incon- gruence between person-centered philosophy and task-oriented patient care (Bolster & Manias, 2010), nurse-patient interaction is not person-centered based (Bolster & Manias, 2010; Coleman & Medvene, 2013), and need for more creative ways to embrace a person-centered framework (McKeown, Clarke, Ingleton, Ryan, & Repper, 2010). Other reasons for
• conducting studies of patient-centered care included
NURS OUTLOOK 64 (2016) 352-366 359
high cost of care services, for example, intensive care services at the end of life (Radwin, Ananian, Cabral, Keeley, & Currier, 2011), poor organization and de- livery of care (Haigh & Ormandy, 2011), and inconsis- tent findings of relationships between experience and adverse nurse-sensitive events (Radwin et al., 2009).
Family-Centered Care The three most common antecedents for family- centered care research included (a) lack of empirical evidence in particular settings (Coyne, 2013; Coyne et al., 2011; Kennedy, 2012; McLaughlin et al., 2013; Soury-Lavergne et al., 2011; Trajkovski et al., 2012), (b) unmet psychological needs of family members (McLaughlin et al., 2013; Mitchell et al., 2009; Roets et al., 2012), and (c) professionals having difficulty integrating family-centered care into practice (Coyne, 2013; Coyne et al., 2011; McLaughlin et al., 2013; Mitchell et al., 2009; Staniszewsk et al., 2012; Trajkovski et al., 2012). Other reasons for implement- ing the study included the high incidence of emotional distress associated with having loved ones requiring intensive critical care (Roets et al., 2012; Soury- Lavergne et al., 2011; Trajkovski et al., 2012), parent reports of being marginalized during their children's hospitalizations (Mitchell et al., 2009; Staniszewsk et al., 2012), and controversies surrounding family- witnessed resuscitation (McLaughlin et al., 2013).
Culturally Competent Care The most common antecedents for culturally compe- tent care research were (a) health disparities (Ailinger et al., 2010; Anderson & Friedemann, 2010; Collins- McNeil et al., 2012; Hawala-Druy & Hill, 2012; Kelley, 2011; Walton, 2011), (b) lack of empirical evidence demonstrating the importance of culturally competent care (Ailinger et al., 2010; Anderson & Friedemann, 2010; Walton, 2011), (c) insufficiency of culturally competent education leading to potential bias or in- justices in care (Hawala-Druy & Hill, 2012; Walton, 2011), (d) limited availability of interpreters or bilin- gual nurses (Ailinger et al., 2010; Ho, 2009), and (e) inadequate knowledge of diseases in minority pop- ulations (Ailinger et al., 2010; Collins-McNeil et al., 2012). The objectives of Healthy People 2020 and the objectives of Institute of Medicine were mentioned as antecedents (Ailinger et al., 2010; Hawala-Druy & Hill, 2012). Other antecedents included the growing need for culturally competent education because of the increasingly diverse and growing U.S. population (Hawala-Druy & Hill, 2012) and the growing need for family health education worldwide (Anderson & Friedemann, 2010).
In summary, the literature on all four conceptual care models identified lack of empirical evidence as an antecedent. The person- and family-centered care re- searchers noted poor patient outcomes or unmet needs of patients as antecedents. Culturally competent and family-centered care research was associated with difficulty integrating care models and providers'
insufficient education about these concepts. Culturally competent care researchers also mentioned the growing need for family health education as an ante- cedent, which is connected to family-centered care. Patient's emotional distress was an antecedent unique to the family-centered care literature. The quality of patient-provider relationships was only mentioned as an antecedent in person-centered research. Cultural competency researchers frequently identified health disparities and language barriers as antecedents that were not mentioned in the studied involving the other three care models.
Consequences
Consequences are what happen as a result of the phenomena under study (Tofthagen & Fagerstrom, 2010). In this analysis, consequences were the find- ings associated with the implementation of the care model.
Person- and Patient-Centered Care Person-centered interventions were associated with improved health-related outcomes, for example, pa- tient self-care, health goal attainment, and lifestyle (Glass et al., 2012), and less ambiguity and uncertainty in illness (Dudas et al., 2013). Person-centered care was also associated with shorter hospital stays, improved functionality, and reduced hospital readmission in pa- tients (Ekman et al., 2012). One study reported residents who reported higher person-centered scores had significantly higher quality of life and cognitive scores than those who had not (Edvardsson et al., 2013; McKeown et al., 2010). Studies also revealed that person-centered care increased communication, satis- faction, and improved relationships between providers and patients (Coleman & Medvene, 2013; Williams et al., 2012; Jomfeldt et al., 2012). Of the five patient-centered studies, only one study reported consequences (Radwin et al., 2009). Radwin et al. (2009) reported that patient-centered interventions were positively related to subsequent desired health outcomes, defined as sense of well-being. For example, responsiveness and proficiency of nurses were positively related to patients' trust in nurses, and individualization was positively associated to subsequently authentic self- representation, optimism, and a sense of well-being.
Family-Centered Care Reports from family members and nurses showed that family-centered care was associated with a high qual- ity of care (Coyne, 2013; Coyne et al., 2011; Mitchell et al., 2009). Several studies highlighted facilitators of family-centered care. Kennedy (2012) noted that get- ting to know the child/patient results in effective communication, trust, informed decision-making, and collaborative teamwork. In another study, neonatal intensive care unit nurses reported that family- centered care helps parents become confident and competent caretakers which promotes bonding with
360 NURS OUTLOOK 64 (2016) 352-366
Societal Factors
-Community resources -Social services -Health insurance -Public policy -Social justice
Institutional Factors
-Philosophy -Policies -Staff education -Staffing model -Social justice
Figure 1 - Person-, family-, and culture-centered nursing care model.
their sick newborns (Trajkovski et al., 2012). One study showed that 24-hr family-friendly visitation policies and family member participation in patient care ten- ded to be more common in pediatric than those in adult intensive care units (Soury-Lavergne et al., 2011). Staff education and training in family-centered principles and practices were associated with significantly greater family satisfaction with care than a control group (Mitchell et al., 2009). Acute intensive care settings posed unique challenges to the delivery of family- centered care. Roets et al. (2012) identified 15 specific family stressors that need to be addressed in pediatric intensive care units: child's medical procedures, child's appearance, inadequate overwhelming conflicting in- formation about child, role ambiguity, child's pain and discomfort, medical equipment, fear for child's life, sense of helplessness, changes in child's behavior, physical and emotional separation from child, sudden, unexpected changes or seriousness of child's condi- tion, complexity of health care system, separation from family, and support when a child in the unit dies. Neonatal intensive care unit nurses expressed a need for institutional guidelines in support of family- centered care (Trajkovski et al., 2012). Emergency nurses identified a need for more education to competently address the emotional needs of families during and after the resuscitation of a loved one (McLaughlin et al., 2013).
Culturally Competent Care ~onsequences of culturally competent care included mcreased enrollment of African Americans in studies
2011), improved medication adherence et ~1" 2010), and increased acceptable and
mterventions in minority populations'
(CollinS-McNeil et al., 2012). Ho (2009) found that pre- dominantly white health care providers and culturally diverse patients differed in communication style, beliefs, values, and cultural customs which can contribute to cross-cultural misunderstanding. Stu- dents who received education in cultural competence developed increased self-awareness, open-minded- ness, appreciation for cultural differences, problem- solving skills, appreciation for the role of families in holistic patient care, skills in interprofessional collab- oration, and a repertoire of family interventions (Anderson & Friedemann, 2010; Walton, 2011). Cultural competence education helped students broaden their perspectives, heightened their awareness of their own culture, including biases and stereotypes, and increased their appreciation of team collaboration and mutual respect of professional roles (Hawala-Druy & Hill, 2012).
In summary, collectively, results showed improved health-related outcomes including self-management and mental health, for example, reduction of stress, patient and family satisfaction, and patient- and family-provider relationships. Person-centered care also reduced the length of patient hospitalizations or readmissions and improved patient functioning and quality of life. Family-centered care was believed to improve the quality of care and parent-child re- lationships. Culturally competent care implemented with members of historically oppressed racial/ethnic groups increased their trust of health researchers and Willingness to participate in research. Cultural competence education helped students gain insights about their socially constructed biases and an appre- ciation for cultural differences. This review also amplified certain prerequisites for successful
NURS OUTLOOK 64 (2or6) 352-366 361
Table 4 - Intersecting Identities on Continuum of Privilege-Disadvantage
Identity
Age Sex Gender Sexual orientation Race/ ethnicity Historical factors Abilities Education Language
Health literacy Income Religion/spirituality
Adult Male
Privileged
Congruent gender Heterosexual White/European descent Historical privilege Abled body and mind High English
High High JudeO-Christian
implementation of these models. Most notable were institutional support and staff education.
A Proposed Person-, Family-, and Culture-Centered Nursing Care Model
Given our findings of favorable outcomes associated with each conceptual care model, similar attributes among the models, and the importance of the nonoverlapping attributes, we assert that merging these models into a blended care model that in- corporates social justice could potentially (a) foster scientific discourse and collaboration across spe- cialties, for example, geriatrics and pediatrics, acute and residential care, majority and underrepresented populations; (b) exert a synergistic benefit on patient, family, and community health outcomes; and (c) take the guesswork out of which model to apply to which patient population under which circumstances. Although the literature reveals several blended care models, for example, Tucker's patient-centered culturally sensitive health care model (Tucker, Marsiske, Rice, Jones, & Herman, 2011), there are no known nursing care models that blend all four con- ceptual models of care. Therefore, we propose a blended nursing model of person-, family-, and culture-centered care that could be universally applied to all people across all settings. The following discus- sion describes the components and philosophical un- derpinning of this blended model.
As illustrated in Figure 1, the proposed model builds on existing models of care to include the person receiving care, their family, and their culture, comprised on intersecting identities. We chose "per- son" rather than "patient" to emphasize the person- hood of those for whom we serve within health care systems. The term "patient" is setting bound, tYEically used in hospitals or clinics, whereas the goal of health care is to address individual and family health care needs across settings. The term "person" encompasses all the unique attributes of a human being that contribute to his/her personhood (McCormack, 2004). Cassel (1982) describes the different facets of a person ,
Disadvantaged
Children and elderly Female Nonconforming or transgender Lesbian/gaylbisexual/questioning (LGBQ) Underrepresented groups Historical trauma Disability/cognitive impairment/mental illness Low Limited English proficiency or first language is not
English Low Low Non-Western religions
as having a personal history, cultural background, so- cial roles, interpersonal relationships, political views, personal life, perceived future, and a transcendental or spiritual self.
Individuals tend to live within social units that they consider to be their family. Families are char- acterized as interdependent social systems that serve to meet the affective, sociocultural, economic, developmental, and physical needs of members (Friedman, Bowden, & Jones, 2003). We agree with Wright and Leahey (2013) that "the family is who they say they are" (p. 55). Families mayor may not include biologically or legally related members, multiple generations, or individuals who reside together. We contend that, regardless of the age of the identified patient, his/her family should be considered in the assessment and intervention plan. Including the family in care can help providers: (a) understand the person's proximal social context, (b) enlist support in meeting the patient's care needs, (c) gage the impact of the patient's health on the family's functioning, and (d) identify other family members in need of services (Friedman et aI., 2003).
The concept of holistic perspective espoused by person-, patient-, and family-centered care models suggests that nurses need to consider various aspects of a person's identity in assessment, care planning, and care delivery. Therefore, the proposed blended model draws from theories of intersectionality with the supposition that mUltiple aspects of one's identi- ties contribute to one's personal sense of culture (Crenshaw, 1991; Davis, 2008; Hancock, 2007). Culture reflects patterns of beliefs, values, behavior, knowl- edge, and experience that are collectively held by a particular group in response to the sociopolitical context and passed from one generation to the next (Hofstede, 1980; Lederach, 1995). Put simply, culture is "a way of life" (Griswold, 2012; Long, 1997). Each in- dividual's worldview is shaped by his/her affiliation with various intersecting sociocultural groups and internalized identities (Viruell-Fuentes, Miranda, & Abdulrahim, 2012). Thus, individuals self-define the meaning of culture.
362 NURS OUTLOOK 64 (2016) 352-366
Recent research (Bauer, 2014; Veenstra, 2013) has documented relationships between intersecting iden- tities and health outcomes. Intersectionality is defined as coexisting identities, categories, and experiences that include, but are not limited to race, gender, class, and sexual orientation (Hancock, 2007). The interaction of underrepresented identities has been associated with limited access to care, health inequality, and power differentials in patient-provider relationships (Davis, 2008; Hancock, 2007). Determining which identities are most salient to the person's health needs to be performed in partnership with the patient and/or family. These identities can fall anywhere along a continuum of privilege-disadvantage that is grounded in a social justice perspective illustrated in Table 4. Our Western health care system is based on the beliefs, values, and practices of the privileged majority culture of the United States. Therefore, the more identities that a person has at the disadvantaged end of the contin- uum, the more nursing support and advocacy that person and family will likely require within the health care system and the community. Assessment of individual and family needs relative to privilege- disadvantage facilitates tailored interventions and so- cially just care that can promote health equity. Nurses need to assess the impact of these interesting identities to optimize the quality of care.
Nurse and Interprofessional Team Attributes
The blended model incorporates the 12 attributes identified in the concept analysis. These attributes are essential to establishing and maintaining the core attribute, collaborative relationships. In accordance with the American Association of Colleges of Nursing (2008) and the American Nurses Association Code of Ethics (2015), we added social justice. Social justice is based on the following principles: (a) the fair and equitable access to and delivery of services, (b) recog- nition and reduction of power differentials, (c) atten- tion to social determinants of health, (d) creation of institutions policies and procedures that promote health equity, (e) protection of human rights, and (f) support of human development and self-actualization (Buettner-Schmidt & Lobo, 2011). We contend that so- cial justice is a prerequisite for quality nursing care and essential to advancing health equity. Socially just public policies are critical to making health resources equitably available to all communities. Institutional policies that reflect a philosophy of social justice are likely to support staffing models, practitioners' skills, and programming that address health disparities. A major deficit in person-, patient-, and family-centered care models is the absence of social justice: There- fore, we positioned social justice as an important component of the proposed blended model at the so- cietal, institutional, and individual levels. In so doing, this model offers a framework for examining new and innovative ways to incorporate social justice in nursing science, education, and practice.
Collaborative Relationship
Within the blended model, attammg an accurate diagnosis and prescribing appropriate treatment are predicated on the premise that nurses nurture collab- orative relationships based on mutual trust. Collabo- rative relationships involve reciprocal interpersonal connections among all parties (the provider, individ- ual, and family) and are essential to successful imple- mentation of person-, family-, and culture-centered nursing care (PFCC). Nurses need to engage in a continuous process of developing the attributes of PFCC. The person and family must feel comfortable communicating their concerns and preferences to nurses who are sensitive to their needs. Nurses need to partner with the person and their family in working toward mutually shared health goals. This reciprocal relationship is a continuous process of learning about the person's intersecting identities. Such relationship building can involve trial and error and not always knowing what to say or what to do. Cross-cultural re- lationships are not prescriptive; they are about getting to know the person over time through open and honest exchanges. This ongoing therapeutic relationship is the channel through which centered care is adminis- tered and desired health outcomes are attained.
Institutional Factors
Within this blended model, we acknowledge institu- tional factors that are prerequisites for the capacity to implement the person-, family-, and culture-centered care. Several studies reviewed in this analysis pointed to organizational support as essential to successful implementation of person-centered, patient-centered, family-centered, and culturally competent care. Such support included adopting policies, procedures, and staffing models that facilitate centered care; providing formal training for entire teams of providers; and designing physical facilities to accommodate a holistic inclusive care model that meets the needs of identified patients and their families (Abdelhadi & Drach- Zahavy, 2012; Coyne et al., 2011). Nursing staff educa- tion needs to include family theory, communication skill building, and patient teaching methods (Coyne et al., 2011). We advocate that institutional policies and staff development initiatives reflect philosophies that promote socially just care and attain health equity.
Societal Factors
Societal factors can affect patients' and families' ca- pacities to access, engage in, and follow through with prescribed treatment, thus affecting health outcomes. In the blended model of care, societal factors include health insurance, public policy, social services, com- munity resources, and transportation (Dixon, 2000; Marmot & Wilkinson, 2005; World Health Organization Commission on Social Determinants of
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Health, 2008). When social and cultural environments are altered for better or worse, disease rates also change accordingly (Marmot & Wilkinson, 2005). Thus, to promote socially just care and attain health equity for all persons, health programs must incorporate ecological approaches to individual and community assessments and interventions.
Based on our concept analysis, several conditions were found to impede implementation of several care models. In one study, parents of hospitalized children reported lack of clarity about their roles, whereas nurses reported short staffing which precluded offer- ing families choices. Thus, barriers to family-centered care included poor nurse-parent communication and staffing problems that led to over-reliance on parents for children's care (Coyne, 2013; Coyne et aI., 2011). The most commonly identified barrier to culturally competent care was differences between patients' and health care providers' cultural values and customs, language, or communication styles (Ailinger et aI., 2010; Ho, 2009). Other factors included mistrust of research by minority populations due to historical factors and socioeconomic conditions, for example, transportation problems and patient work schedules (Kelley, 2011). The most commonly identified barriers to patient-centered care were related to organization and delivery of care staffing levels, for example short staff, disruptive duties including telephone calls and multidisciplinary team meetings, communication barriers, and poor layout of the ward (Haigh & Ormandy, 2011).
Evaluation of the Proposed Model
The application of the proposed model to research, education, and clinical practice warrants empirical evaluation.
Research Although empirical evidence continues to support the efficacy of each conceptual care model analyzed in this study, additional research is needed to validate the proposed blended person-, family-, and culture- centered nursing care framework. Specifically, in- struments are needed to operationalize the constructs of the proposed model in ways that will provide clarity and consistency across studies and health disciplines. Process research (e.g., video-taped observations of patient-providers interactions) could help identify and describe nursing activities in this care model that are typically invisible (e.g., culturally respectful care). The results of this comparative concept analysis revEFaled a lack of nurse researchers and the use proximal health- related outcomes that reflected subjective opinions of patients, family members, or providers rather than actual patient health outcomes. Therefore, future nursing research needs to examine clinical outcomes that resulted from the proposed care model.
Clinical The proposed model is designed to be relevant to various popUlations regardless of their age, racial! ethnic/cultural background, health status, and care environment. Quality improvement initiatives could be developed to evaluate institutional readiness and possible barriers to implementation of this care model. For example, clinicians and researchers can collaborate in the development of measures to assess practitioners' knowledge of and attitudes toward adopting evidence-based practices that involve deliv- ering person-, family-, and culture-centered nursing care. In addition, clinicians could also assess their or- ganization's level of readiness (e.g., institutional re- sources, staff attributes, and organizational climate) to fully implement the proposed blended model.
Education The proposed model could be incorporated into un- dergraduate- and graduate-level curricula. This model is currently being integrated into the concept-based undergraduate programming in our school of nursing. At the graduate level, the concepts and attributes of this care model could easily lend themselves to doctoral studies. For example, the first author of this article is currently testing the relationship component of this model among older adult Hmong as a part of her doctoral study.
Limitations and Implications for Research
We acknowledge several limitations of our compara- tive concept analysis. First, the number of the articles reviewed was small, and there were only five articles on patient-centered care. However, we summarized seminal work published before 2009 in the Historical Evolution of Models section. Second, some articles, for example, family-centered care and cultural competency care, focused on provider perceptions of outcomes, rather than patient outcomes. Finally, we acknowledge that there are other conceptual care models not reviewed for this article. We limited our focus to four conceptual models that seem to have been most enduring over time.
Goals of Healthy People 2020 (Office of Disease Prevention and Health Promotion, u.S. Department of Health and Human Services, 2015) call for improve- ment in the quality of health care, access to health care, health-related quality of life, health communi- cation, and achievement of health equity. The report emphasizes the importance of addressing the social determinants of health and modalities of social justice to accomplish these goals. Although professional or- ganizations and scholars advocate for social justice within the context of health care, this concept is noticeably absent from the research related to models of health care delivery. Furthermore, there is no clear evidence that these models actually advance health equity. Additional nursing research is vital to clearly
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operationalize the implementation of social justice at multiple levels including, but not limited to social policy, institutional procedures, and individual clinical practices. It is of paramount importance that such research evaluates the impact of existing and new care models, for example, proposed blended models, on population-based health equity.
Conclusion
Our findings showed that a very small portion of recent person-centered, patient-centered, family-centered, or culturally competent research was conducted by nurses. Most of the outcomes measured were proximal to the care delivery, for example, patient satisfaction, rather than health outcomes per say or health equity. Although person-centered, patient-centered, family- centered, and culturally competent care are concep- tualized in the research literature as distinctly different models, this comparative concept analysis suggests these models have evolved to become more alike than different. However, social justice remains conspicu- ously absent from the research on all four care models. Therefore, we advocate for merging these care models into a single-blended conceptual framework that in- corporates social justice at the societal, institutional, and individual levels. This framework can be univer- sally applied to all recipients of health care across all settings. Given that empirical evidence continues to support the efficacy of each conceptual care model analyzed, the proposed blended person-, family-, and culture-centered framework holds promise for improving health care outcomes and achieving health equity. Additional research is needed to validate that premise.
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