Patient-centered care—A new focus on a time-honored concept

I am struck by how many time-honored pillars of nursing are only recently entering the mainstream of professional and public consciousness. In the last issue, I commented on care coordination, resurrected as the medical home. In this issue I will focus on patient-centered care—a concept that has gained new cachet as a focus of the healthcare home and as a component of the Institute of Medicine (IOM) quality chasm series.1

Patient-centered care has been a central concept in nursing for a very long time. Elements of patient preferences and self-care management are evident in Florence Nightingale's Notes on Nursing, first published in 1860.2 Elizabeth Inga Hansen wrote a paper about the “personal and impersonal nurse” in 1816,3 and Sister John Gabriel's book Through the Patient's Eyes4 presaged the book of the same name from the Picker/Commonwealth program5 by nearly 60 years. The human relations movement in the 1950s and 1960s certainly informed the emphasis in nursing education on assessing and meeting patient needs and on incorporating the family into the care. The works of Peplau, Orlando, and Wiedenbach,6, 7, 8 among others, come to mind in this respect. The studies from the Yale School of Nursing in this era established the centrality of patient-expressed needs and preferences to improved care outcomes.9, 10

As a nursing student during this era, I firmly believed that nursing had invented patient-centered care. However, participation in a recent invitational forum convened by the American Board of Internal Medicine Foundation (ABIMF) suggested that the term was actually coined by the social psychologist Enid Balint, focusing on patient-centeredness for physicians.11 Tracing this citation back to its source, as well as several of the more than 7000 one finds using the term “patient-centered care,” convinces me that medicine and nursing have been living in parallel universes regarding clinician–patient relationships and person-centered care since at least the 1960s. We each have a rich literature regarding interpersonal relationships between provider and patient, whole-person regard as the basis for therapeutic care, the need and means to incorporate families and significant others into care of the ill,12 and patient-centered intervention studies (see for example Lauver et al13). Yet, we rarely come together in forums such as that sponsored by ABIMF to see what we have each learned and how to move forward together to improve care. Nurse researchers are only recently learning how important it is to publish their work in interdisciplinary journals to bring it to the attention of physicians and other health professionals.

The IOM series of reports on improving the quality of care in America has provided a strong impetus as well as some new focus on person-centered care that should guide the way for us to come together across the professions. Crossing the Quality Chasm identified “new rules” for health care in this century. Among these are:

Most of these are time-honored elements of patient-centered care—except number 3 (bold and italicized above): the patient (or person or family) as the source of control is truly a new emphasis. This completely flips the old provider-centered care on its head.

Making this truly person-centered care a reality requires new knowledge, skills, and attitudes for most of us. A Robert Wood Johnson–sponsored initiative called Quality Safety Education in Nursing (QSEN) has developed an inventory of knowledge, skills, and attitude sets for nursing education organized around the IOM competencies for health professionals. First and foremost is patient-centered care, defined as “Recogniz[ing] the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.”15 The entire May/June 2007 issue of Nursing Outlook is devoted to this project, which incorporates competencies for numerous aspects of patient-centered care.

Medicine is also developing competencies for both prelicensure education and certification of continuing competence in practice.16 There is great opportunity and interest in working jointly in this dynamic time. One might even say we are creating new wine for the old skins.