A state-of-the-art review of direct observation tools for assessing competency in person-centred care

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This is the published version of a paper published in International Journal of Nursing Studies.

Citation for the original published paper (version of record):

Ekman, N., Taft, C., Moons, P., Mäkitalo, Å., Boström, E. et al. (2020)

A state-of-the-art review of direct observation tools for assessing competency in person-centred care

International Journal of Nursing Studies, 109: 103634 https://doi.org/10.1016/j.ijnurstu.2020.103634

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International Journal of Nursing Studies 109 (2020) 103634

ContentslistsavailableatScienceDirect

International Journal of Nursing Studies

journalhomepage:www.elsevier.com/ijns

A state-of-the-art review of direct observation tools for assessing competency in person-centred care

Nina Ekman

^a^,^b^,^c^,^∗

, Charles Taft

^a^,^b

, Philip Moons

^a^,^b^,^c

, ˚Asa Mäkitalo

^d

, Eva Boström

^e

, Andreas Fors

^a^,^b^,^f

a Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden

b Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden

c Academic Centre for Nursing and Midwifery, Faculty of Medicine, KU Leuven, Leuven, Belgium

d Department of Education, Communication and Learning, University of Gothenburg, Gothenburg, Sweden

e Department of Nursing, University of Umeå, Umeå, Sweden

f Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Sweden

article info

Article history:

Received 19 September 2019

Received in revised form 21 January 2020 Accepted 22 April 2020

Keywords:

Observation-based methods Patient-centred care Person-centred care State-of-the-art review

abstract

Background: Directobservation is acommonassessmentstrategy inhealth education and training,in whichtraineesareobservedandassessedwhileundertakingauthenticpatientcareandclinicalactivities.

Avarietyofdirectobservationtoolshavebeendevelopedforassessingcompetencyindeliveringperson- centredcare(PCC),yettoourknowledgenoreviewofsuchtoolsexists.

Objective:Toreviewandevaluatedirectobservationtoolsdevelopedtoassesshealthprofessionals’com- petencyindeliveringPCC.

Design:State-of-the-artreview

Datasources:Electronicliterature searcheswereconductedinPubMed, ERIC,CINAHL, andWebofSci- enceforEnglish-languagearticlesdescribingthedevelopmentandtestingofdirectobservationtoolsfor assessingPCCpublisheduntilMarch2017.

Reviewmethods: Three authorsindependently assessedthe records for eligibility.Duplicates were re- movedandarticleswereexcludedthatwereirrelevantbasedontitleand/orabstract.Allremainingarti- cleswerereadinfulltext.Adataextractionformwasdevelopedtocoverandextractinformationabout thetools.Thearticleswereexaminedforanyconceptualortheoreticalframeworksunderlyingtoolde- velopmentandcoverageofrecognizedPCCdimensionswasevaluatedagainstastandardframework.The psychometricperformanceofthetoolswasobtaineddirectlyfromtheoriginalarticles.

Result:16tools wereidentified:fiveassessedPCCholisticallyand 11assessedPCCwithinspecific skill domains.Conceptual/theoreticalunderpinningsofthetoolsweregenerallyunclear.CoverageofPCCdo- mainsvariedmarkedlybetweentools.Mosttoolsreportedassessmentsofinter-raterreliability,internal consistencyreliabilityandconcurrentvalidity;however,intra-raterreliability,contentandconstructva- liditywererarelyreported.Predictiveanddiscriminantvaliditywerenotassessed.

Conclusion:Differencesinscope,coverageandcontentofthe toolslikelyreﬂectthecomplexityofPCC andlackofconsensusindeﬁningthisconcept.Althoughallmayserveformativepurposes,evidencesup- portingtheiruseinsummativeevaluationsislimited.Patientswerenotinvolvedinthedevelopmentof anytool,whichseemsintrinsicallyparadoxicalgiventheaimsofPCC.Thetoolsmaybeusefulforpro- vidingtraineefeedback;however,rigorouslytestedandpatient-derivedtoolsareneededforhigh-stakes use.

ThisisanopenaccessarticleundertheCCBY-NC-NDlicense.

(http://creativecommons.org/licenses/by-nc-nd/4.0/)

∗ Corresponding author at: Institute of Health and Care Sciences, Sahlgrenska

Academy, University of Gothenburg, Sweden. Box 457, 405 30 Gothenburg, Sweden. E-mail address: nina.ekman@gu.se (N. Ekman).

https://doi.org/10.1016/j.ijnurstu.2020.103634

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• Person-centred care (PCC) has been designated and endorsed byprofessionalbodiesasacorecompetencyneededforhealth professionals.

• Numerousdirectobservationtoolshavebeendevelopedforuse speciﬁcallyinassessingskillsindeliveringPCC.

• Toourknowledge,noreviewhasbeenconductedofdirectob- servationtoolsforuseinassessingPCCcompetency.

Whatthispaperadds

• Thisstate-of-the-artreviewidentiﬁed16toolsandfounddiffer- encesintheirscope,coverage andcontentaswellasalackof consensusindeﬁningPCC.

• Althoughall mayserve formative purposes,evidencesupport- ingtheiruseinsummativeevaluationsislimited.

• Paradoxically,giventheaimsofPCC,patientswerenotinvolved inthedevelopmentofanyofthetools.

1. Background

Widely acknowledged as an essential element of high qual- itycare ((Instituteof Medicine,2001;World HealthOrganization, 2006; World Health Organization, 2008; Australian Commission on Safety and Quality in Health Care (ACSQHC), 2011; Goodrich and Cornwell, 2008; Agency for Healthcare Research and Qual- ity(AHRQ),2003;InternationalAllianceofPatient’sOrganizations, 2007; Socialstyrelsen,2016)),person-centredcare¹ (PCC)hasbeen designated and endorsed by professional bodies as one of a set ofﬁvecorecompetenciesneededforhealthprofessionalstomeet theevolving challengesfacing health care ((Institute ofMedicine (US)2003;WorldHealthOrganization2005;WorldHealthOrgani- zation2003;AccreditationCouncilforPharmacyEducation(ACPE) 2015)).The particularimportance ofPCC competency wasunder- scoredwhen,inafollow-upreporttotheir landmarkCrossingthe QualityChasm,theUSInstitute ofMedicine(IOM) positionedPCC as the central, overarching competency, recommending that All healthprofessionalsshouldbeeducatedtodeliverpatient-centredcare asmembersofaninterdisciplinaryteam,emphasizingevidence-based practice,qualityimprovementapproaches,and informatics.(9,chap- ter3)Reﬂectingitsimportanceforqualitycare,PCCisincreasingly incorporatedintoeducationandtrainingprograms forhealthpro- fessionals(Dwamenaetal.,2012).

Direct observation isa commonassessmentstrategy inhealth education and training, in which trainees are observed and assessed while undertaking authentic patient care and clinical ac- tivities.Historically, suchassessments havebeenimplicit, unstan- dardized, and based on global, subjective judgments (Van der Vleuten,1996);however,todayavarietyofchecklists,ratingscales and coding systems are available to guide, delineate and struc- ture assessments of clinical competencies (Kogan et al., 2009).

Likewise,numerous directobservationtoolshavebeendeveloped foruse specifically in assessing skills in delivering PCC. As little agreementexists withinandacrossprofessionsonPCCnomencla- ture(Håkansson Eklund et al., 2018), definitions (Socialstyrelsen, 2016; Constand etal.,2014) andtheoretical orconceptualframe- works(MeadandBower,2000;Lawrence andKinn,2012;Cronin, 2004;Scholletal.,2014),itseemsreasonabletoassumethatsuch tools differ significantly in their definitions and coverage of behaviours andbehavioural domains indicativeof PCC competency.

Toourknowledge no state-of-the-artreview hasbeen conducted of direct observation tools foruse in assessing PCC competency.

Given the increasing importance of PCC in healthcare education andtrainingthereis a needforguidance inselecting amongex- istingdirect observation tools forassessing trainees’ competency indeliveringPCC.Thisreview thereforeaims toidentifyavailable

main or domains; existence of underlying theoretical or concep- tualframeworks;coverageofrecognizedcomponentsofPCC;types of behaviouralindicators; psychometric performance; andformat (checklist,ratingscale,codingsystem).

¹ Althoughdifferences existin the deﬁnitionsof person-centred careandpatient-centredcare,thetermsarefrequentlyusedinter- changeably inthe literature.For thesake of parsimony,theterm person-centredcarehassystematicallybeenusedinthisreview.

2. Method

2.1. Searchstrategiesforidentiﬁcationofstudies

The search wasperformedinMarch2017 usingthe databases PubMed, CINAHL and Scopus to identify relevant studies. Cen- tredandcenteredness (bothUK andUSspelling)andthe following termswere identiﬁedandused inthesearch-string: (careOR healthcare)AND ("patient-centred" OR "patient centred" OR "person centred" OR "person centred" OR"patient centeredness" OR"patient centredness " OR "person centeredness " OR "person centredness") AND (observ^∗ OR video OR audio) AND (Humans[Mesh]AND (Dan- ish[lang]ORNorwegian[lang]ORSwedish[lang]OREnglish[lang])).

2.2. Selectionofstudies

EndNoteX7 softwarewasused. Duplicateswere removedand clearly irrelevant articles were excluded. Criteria for inclusion were:(i)directobservationtool (ii)reportsand/or descriptionsof any development or evaluation of an instrument that measures patient-centred care, PCC or person centredness (iii) not clinical encounters. The selection process started with examining the ti- tles.Afterinclusionofrelevanttitles,thesameprocedurewasper- formedwiththeabstracts.Abstractsthatclearlydidnotmatchthe inclusion criteriawereremoved. The articleswithpotential to be includedwere read infull text inorder todetermine whetherto includeorexclude.Snowballingwasusedtoidentifyotherpoten- tially relevant records. Three authors (NE, CT and AF) indepen- dently assessed the records for eligibility and recorded the rea- sonsfor eitherinclusion or exclusion,which wasdocumented in aPRISMAﬂowchart.

2.3. Dataextraction

Adataextractionformwasdevelopedtocover,identifyandex- tractinformationaboutthedirectobservationtoolincludingname oftool,mainconceptassessed,characteristics ofthedevelopment sample, assessment format, assessed domains of person-centred, conceptualframeworkunderpinningthetools,typeofpsychomet- ricassessmentsperformed(reliabilityandvalidity), anddeveloper identiﬁedlimitations.

3. Analyses

Eachtool wasexaminedagainstastandardframeworkforcov- erageofPCCdimensions.Forthispurposetheframeworkendorsed by the IOM (Institute of Medicine, 2001) was used. The framework includes six dimensions: Respect for patients’ values, pref- erences, and expressed needs, Coordination and integration of care, Information, communication, and education, Physical comfort, Emo- tionalsupport—relievingfear andanxiety andInvolvementof family and friends (Institute ofMedicine, 2001). Articleswere examined forevidenceoftheoreticalorconceptualframeworksunderpinning thedevelopmentofthetools.Ifthearticlesreferredtoonespeciﬁc frameworkandusedphrasessuchas:“weoperationalizedPCC…” or

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N. Ekman, C. Taft and P. Moons et al. / International Journal of Nursing Studies 109 (2020) 103634 3

“person-centred careusingtheframework of…” or“building onpre- viousconceptualbasiswedeveloped…”itwasjudgedtohaveathe- oreticalorconceptualframework;thosereferringtoseveraldiffer- entframeworkswereclassiﬁedasunclear.Informationaboutpsy- chometricperformanceofthetoolswasobtaineddirectlyfromthe originalarticlesandsupplementedbyareviewofreferencesfrom articlebibliographies.

4. Result 4.1. Searchresults

An initial search yielded 2371non-duplicatedrecords (Fig. 1).

Afterscreeningbytitles,91abstractswereread.Afterexcludingar- ticlesbasedonabstracts,42articleswerereadinfulltext.Thirteen full-texts met inclusion criteria and six additional articles were identifiedbysnowballingandfoundtobeeligible.Intotal,19pa- pers describing16 differentdirect observationtools forassessing PCCoraspecificaspectofPCCwereidentified(Fig.1).

4.2. Characteristicsofthedirectobservationtools

Eleven ofthe 16direct observationtoolswere codingsystems (Bertakis and Azari, 2011; Henbest and Stewart, 1989; Zandbelt etal.,2005;Paul-Savoieetal.,2015;Braddocketal.,1997;Clayman et al., 2012; Dong et al., 2014; Sabee et al., 2020; Mjaaland and Finset, 2009; Krupat et al., 2006; D’Agostino and Bylund, 2014), three were ratingscales (Elwyn etal., 2003; Shields etal., 2005; Gallagher et al., 2001) and two were checklists (Gaugler et al., 2013;Chesseretal., 2013) (Table 1). Eleventoolsfocused onspe- ciﬁcaspects ofPCC, namelycommunicationandshared decision- making, whereas ﬁve tools purported to assess the general concepts PCC or person-centredness. Various conceptual frame- workswere presentedasstartingpointsfordevelopingthe tools.

A framework was clearly identified in seven tools (Henbest and Stewart, 1989;Zandbeltet al.,2005;Clayman etal., 2012; Elwyn et al., 2003; Chesser etal., 2013; Sabee et al., 2020; D’Agostino andBylund,2014),whiletheothersreferredtodifferentdefinitions and concepts and no specific framework could be distinguished.

The toolsvaried in their coverage ofthe sixIOM domains (Table 2) from a single domain (D’Agostino and Bylund, 2011 October; Gallagheretal.,2001)toallsixdomains(BertakisandAzari,2011; Chesseret al., 2013), withan average ofthree domains per tools (Gaugleretal., 2013; Henbest andStewart,1989;Braddock etal., 1997;Claymanetal.,2012;Elwynetal.,2003; MjaalandandFin- set,2009;Krupatetal.,2006).

Inter-rater reliability was reported for all tools except two (BertakisandAzari,2011;Claymanetal., 2012)(Table2).Reliabil- itywasestimatedusingavarietyofmethods,wheretheintra-class correlation(ICC)andCohen´s kappaweremostcommon.ICCcoef- ficients were fair to excellent (Hallgren,2012) ranging from 0.53 (PBCI subscaleinhibiting behaviour) to 0.93 (PBCI subscalefacil- itating behaviour andSOS-PCC). Kappa coefficientsreflected gen- erallymoderatetosubstantialagreement(Hallgren,2012),ranging between0.46(PISCHsubscaleenablingself-management)and0.72 (PISCH subscalefosteringrelationships). Intra-raterreliability was reportedforthreetools,wherestabilityincodingswashightoper- fect fortheNAASsubcategories(r= 0.82–1.0)andsatisfactory for OPTION(r=0.66).

Most of the tools (12 of16) reported some evaluation of validity, whereconstructandcontent validitywere mostfrequently assessed.Abouthalfofthetoolsweredevelopedandevaluatedin primarycaresettings(BertakisandAzari,2011;HenbestandStew- art, 1989;Braddocketal., 1997; Elwynetal.,2003; Shieldsetal., 2005; Mjaaland and Finset, 2009; Krupat et al., 2006; Gallagher

etal.,2001)andall buttwo (Zandbeltetal.,2005; Mjaalandand Finset,2009)weredevelopedinEnglishspeakingcountries.

4.3.Descriptionofthedirectobservationtools

The following section provides a brief overview of information about the included observation tools regarding their format, coverage, scoring, conceptual framework and psychometric evaluations/ performance as reported in the original articles. The tools are organized in accordance with Table 1, i.e. tools for assessing global PCC/ person centredness, shareddecision making, person-centred communication and nonverbal person-centred communication, and alphabetically within each category.

4.3.1. Globalperson-centredcare/personcentredness

COTisa16-itemchecklist forassessingglobalPCC.Thecheck- list assesses if the staff performs behaviours indicative of PCC, for example “speaks to a resident at least a total of 15 s during care interaction”. Items are scored as 1 if the behaviour is observed and 0 ifnot observed andscores are summed, where 16 represents maximum PCC. Inter-rater reliability, assessed across fiveraters(interdisciplinary reviewers)wassatisfactory (ICCofall Kappa coefficients=0.77. Face validity included verbal and writ- ten feedback fromscientific experts on earlier versionsto refine andrevisethetool.Contentvalidity wasassessedbased onfeed- backfromnineinterdisciplinaryscientificexpertsregarding31care worker-dementiapatientinteractionsandopen-endedfeedbackon items(Gaugleretal.,2013).

Modified version of DOC is a coding system for assessing globalperson-centredpracticestyleandincludessixdifferentclus- ters(e.g.,technicaland healthbehaviour) ofphysicianpracticebe- haviours among the 20 DOC codes (e.g., structuring interaction, health education and health knowledge). For each DOC code, the numberofintervalsduringwhichtheassociatedbehaviour isob- served is recorded and isexpressed as a percentage of the total ofallDOC-coded behavioursnotedduringthevisit.Atotalof509 videotapedencounters betweenpatientsandfamilyphysicians or generalinternists wereusedforthedevelopmentofthemodified version of DOC. Reliability and validity are documented for the originalDOCbuthavenotbeenassessedforthemodifiedversion (BertakisandAzari,2011).

HenbestandStewartinstrumentisacodingsystemassessing doctors’global person-centredbehaviour in primary care consultations. The method involves identifying patients’ offers, deﬁned asanysymptom,complaint,thought,feeling,expectationorobser- vation expressedby thepatient. Theassessor then ratesthedoc- tors’responsestotheseoffersonafour-pointscale(0–3). Theto- tal score for a consultationdivided by the number of offers assessed gives the person-centredness score for that consultation.

This tool showed highinter-rater (18 tapes analyzed) and intra- rater reliability after two weeks (twotapes analyzed) (Spearman correlation=0.91and0.88,respectively).After sixweeks(12tapes analyzed) the intra-rater coeﬃcient decreased to 0.63. The tool wassensitive to differences among physicians and amongphysi- cians´responsestodifferentpatientoffers.Analysisof12tapeswith tworaterscomparingthistoolwiththatofBrownandcolleagues showedmoderatetohighcriterion validity(Spearmancorrelation 0.51–0.89)(HenbestandStewart,1989).

PBCIisacodingsystemassessingglobalperson-centrednessin two dimensions. The ﬁrst dimension, Facilitating behaviours, has 11categories(e.g.,openand closedquestions).The second dimension,Inhibitingbehaviours, includes 8categories(e.g.,changingfo- cus).Thesetwodimensionsarecodedinrelationtocontent(medi- cal,psycho-socialandother).Reliabilityandvaliditywereevaluated in a sample of 323 videotaped appointments between residents

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N. Ekman, C. Taft and P. Moons et al. / International Journal of Nursing Studies 109 (2020) 103634 Table 1

Summary table of studies included in this state-of-the-art review.

Direct observation

tool ¹ Competency Format/ content

Conceptual

basis IOM domains ³

Development

setting Reliability Validity

Respect Coordination Information Physical

comfort Emotional

support Involvement of family The CARES

Observational tool (COT)

( Gaugler et al.,

2013 )

Person- centred Care

Checklist, 16 items

• Greet

• Introduce

• Use name

• Smile/Eye

• Physical Contact

• Approach

• Eye level

• Calm

• Ask/Discuss/Assess

• 15 s

• Explain

• Involve in care/Activity

• Resident’s Life

• Comfort

• Share

• Write

Unclear ¹ X X X Dementia

home care, USA, Care workers- patients

Inter-rater reliability:

Intraclass correlation coeﬃcient (ICC) = 0.77 N interactions: 5 N raters: 5

Face validity: PI with input from scientiﬁc advisors reviewed Content validity:

panel of several interdisciplinary experts

Modiﬁed version of the Davis Observation Code (DOC)

( Bertakis and

Azari, 2011 )

Person- centred care

Coding system, 6 categories

• Technical cluster

• Health behaviour cluster

• Addiction cluster

• Patient activation cluster

• Preventive service cluster

• counselling cluster

Unclear X X X X X X Primary care,

USA, Physicians- patients

Not reported (NR) NR

Henbest and Stewart instrument

( Henbest and

Stewart, 1989 )

Person- centredness

Coding systemidentifying patients’ offers deﬁned as:

• Symptoms

• Thoughts

• Feelings

• Expectations

• Prompts

• Non-speciﬁc cues

Yes X X X Primary care,:

UK, Physicians- patients

Spearman correlation = 0.91 Intra-rater reliability:

Spearman correlation = 0.88 (after 2 weeks) and 0.63 (after 6 weeks).

N interactions:18 (inter-rater); 8 (intra-rater, 2 weeks); 12 (intra-rater, 12 weeks)

N raters: 2

Criterion validity:

Correlation with other measure (Patient-Centered Clinical Method) rs = 0.51 and 0.89 (2 raters, 12 interactions)

( Continued on next page )

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N. Ekman, C. Taft and P. Moons et al. / International Journal of Nursing Studies 109 (2020) 1036345 Table 1 ( Continued ).

Direct observation tool ¹

Competency Format/ content Conceptual basis

IOM domains ³ Development

setting

Reliability Validity

Respect Coordination Information Physical comfort

Emotional support

Involvement of family The

patient-centred behaviour coding instrument (PBCI)

( Zandbelt et al.,

2005 )

Person-

centredness Coding system Facilitating behaviours Inhibiting behaviours

Yes X X X X Residents and

specialist in general internal medicine, rheumatology and gastro- enterology, Netherlands Physicians- patients

Inter-rater reliability (ICC);

Relative agreement facilitating = 0.93, inhibiting = 0.53;

Absolute agreement Facilitating = 0.92, inhibiting = 0.53 Internal consistency reliability (Cronbach ´s alpha):

: Facilitating = 0.64, inhibiting = 0.50.

N interactions: 323 N raters: 4

Concurrent validity:

Correlation with other measure (Eu- rocommunication):

facilitating ( r = 0.28 and inhibiting ( r = −0.29)

The Sherbrooke Observation Scale of Patient-Centered Care (SOS-PCC)

( Paul-Savoie et al.,

2015 )

Person- centred care

Coding system

• Considers biological aspects

• Considers life projects

• Considers

psychological aspects

• Considers the impact of the current conditions on the patient’s life

• Considers past experiences

• Wishes to establish a therapeutic relationship

• Shows an open mind, without prejudice

• Provides a treatment plan in collaboration with the patient

• Inquires about the patient’s understanding of his/her current medical condition

Unclear X X X X Chronic pain

consultations, Canada Physicians- Nurses- patients

ICC = 0.93 Internal consistency reliability:

Cronbach ´s alpha = 0.88 N interactions: 42 N raters: 3

Content validity:

7 interdisciplinary experts in the health care ﬁeld

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setting

Emotional support

Involvement of family Informed Decision

Making instrument (IDM)

( Braddock et al.,

1997 )

Shared decision making

Coding system

• Eliciting patient ´s preference

• Assessment of understanding

• Discussion of uncertainty

• Discussion of pros/cons

• Discussion of alternatives

• Discussion of issue/decision

Unclear X X X Primary care,

USA Physicians- patients

Agreement = 77%.

N interactions: 20 N raters: 3

NR

Detail of Essential Elements and Participants in Shared Decision Making (DEEP-SDM)

( Clayman et al.,

2012 )

Shared Decision Making

Coding system, 10 categories

• Rationale for option

• Deﬁnition of option

• Process or procedure

• Risk/cons

• Beneﬁts/pros

• Patient self-eﬃcacy

• Patient preference and values

• Patients outcome expectations

• Patient understanding conﬁrmed

• Plan for follow-up

Yes X X X Oncology

consultations, USA Physicians- patients

Reliability: NR NR

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setting

Emotional support

Involvement of family The OPTION

(observing patient involvement)

( Elwyn et al.,

2003 )

Shared decision

making ^• Rating scale, 12 items

• The clinician:

• identiﬁes a problem(s)

…

• states that there is more than one way…

• lists “options” …

• explains the pros and cons…

• checks the patient’s preferred information…

• explores the patient’s expectations…

• explores the patient’s concerns…

• the patient has understood…

• provides opportunities…

• preferred level…

• An opportunity …

• Arrangements are made…

Yes X X X Primary care,

United Kingdom Physicians- patients

ICC = 0.62; Cohen ´s kappa = 0.71;

Generalisability coeﬃcient = 0.68 Intra-rater reliability:

Generalisability coeﬃcient = 0.66.

Internal consistency reliability:

Content validity:

items formulated from existing literature Known groups validity: scores inﬂuenced by patient age (negative); sex of clinician (positive in favour of female);

qualiﬁcation of clinician (positive), and clinical equipoise (positive).

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setting

Emotional support

Involvement of family The Rochester

Participatory Decision-Making Scale (RPAD) ( Shields et al.,

2005 )

Shared decision making

Rating scale, 9 items

• Explain the clinical issue or nature of the decision

• Discussion of the uncertainties associated with the situation

• Clariﬁcation of agreement

• Examine barriers to follow-through with treatment plan

• Physician gives patient opportunity to ask questions and checks patients understanding of the treatment plan

• Physician asks, “Any questions?”

• Physician asks open-ended questions

• Physician checks his/her understanding of patient’s point of view

Unclear X X Primary care,

ICC = 0.72 N interactions: 193 N raters: NR

correlation with other measure (MPCC, dimension ﬁnding common ground) r = 0.19.

Correlation with standardized patient perceptions ( r = 0.32–0.36) and patient survey measures ( r = 0.06–0.07).

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Direct observation

tool ¹ Competency Format/ content Conceptual

basis IOM domains ³ Development

Emotional support

Involvement of family Modiﬁed version

of The Measure of Patient-Centered Communication (MPCC)

( Dong et al., 2014 )

Person- Centred Communica- tion

Coding system

• Subcomponent 1:

Coping with ideas, feelings and expectations of radiotheraphy

• Subcomponent 2:

Receiving clear information regarding treatment, side effects, and effect on function.

Unclear X X X X Radiotherapy

context, Australia Physicians- patients

Inter-coder reliability:

Krippendorff’s αfor process categories = 0.86.

Internal consistency reliability: Cronbach‘s alpha = 0.48 N interactions: 56 N raters: NR

Content validity:

Panel of radiation therapists and PCC researchers.

Comparison with other measure (Patient-perceived patient- centredness), Pearson correlation = 0.01 The

patient-Centered Observation Form (PCOF)

( Chesser et al.,

2013 ; Schirmer

et al., 2005 )

Person- centred communication

Checklist (form) 13 categories

• Establishes Rapport

• Maintains a Relationship Throughout the Visit

• Collaborative Upfront Agenda Setting

• Maintains Eﬃciency

• Gathering Information

• Assessing Patient’s Perspective on Health

• Electronic Medical Record Use

• Physical Exam

• Sharing Information

• Behaviour Change discussion

• Informed Decision Making

• Shared Decision Making

• Closure and Follow-up

Yes X X X X X X Family

medicine residency centre, USA Physicians- patients

Validity: NR

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setting

Emotional support

Involvement of family The Process of

Interactional Sensitivity Coding in Healthcare (PISCH)

( Sabee et al., 2020 )

Coding system, 7 categories:

• Exchanging information

• Fostering relationships

• Managing uncertainty

• Meta-communication

• Recognizing and responding to emotions

• Making decisions

• Enabling self-management

Yes X X X X Type 2

diabetes consultations, USA Physicians- patients

Cohen ´s kappa = 0.46–0.72;

Scotts ´s pi = 0.44–0.72 N interactions: 50 N raters: NR

Face validity:

review by panel of experts

Modiﬁed version of The Roter Interaction Analysis System (RIAS), ARCS

( Mjaaland and

Finset, 2009 )

Coding system

• Social talk

• Biomedical questions

• Biomedical information

• Questions about lifestyle and psychosocial issues

• Information about lifestyle and psychosocial issues

• Gives orientation

• Facilitation

• Empathy

• Shows disapproval

• Residual, Unintelligible

• Attribution (ARCS)

• Resources (ARCS)

• Coping (ARCS)

• Solution-focused techniques (ARCS)

Norway Physicians- patients

Inter-rater reliability (Cohen ´s kappa): 0.52 N interactions: 145 N raters: 5

correlation with other measure (RIAS). No misclassiﬁcation between RIAS codes and ARCS codes.

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Direct observation

tool ¹ Competency Format/ content Conceptual

basis IOM domains ³ Development

Emotional support

Involvement of family Four Habits Coding

Scheme (4HCS)

( Krupat et al.,

2006 ; Frankel and

Stein, 2001 )

Coding system

• Habit 1: Invest in the Beginning

• Habit 2: Patient’s Perspective

• Habit 3: demonstrate Empathy

• Habit 4: Invest in the End

Inter-rater reliability (Pearson correlation):

Habit 1 = 0.70, Habit 2 = 0.80, Habit 3 = 0.71, Habit 4 = 0.69, Overall 0.72

Internal consistency reliability (Cronbach ´s alpha): Habit 1 = 0.71, Habit 2 = 0.51, Habit 3 = 0.81 and Habit 4 = 0.61 N interactions: 13 N raters: 2

correlation with other measure (RIAS).

Habit 1 = −0.07–0.28 Habit 2 = 0.08–0.37 Habit 3 = −0.01–0.37 Habit 4 = 0.01–0.21 The Nonverbal

Accommodation Analysis System (NAAS)

( D’Agostino and

Bylund, 2011

October ;

D’Agostino and

Bylund, 2014 )

Nonverbal person- centred communication

Coding system, 10 codes Paraverbal and Non-verbal

Yes X Oncology

consultations, USA Physicians- patients

Inter-rater reliability (Pearson correlation):

paraverbal = 0.81–0.96;

nonverbal = 0.85–0.93 Intra-rater reliability (Pearson correlation):

paraverbal = 0.82–1.0;

non-verbal = 0.89–0.94 N interactions: 10 N raters: 2

correlation with other measure (MIPS): physician eye contact = 0.45;

patient eye contact = 0.62.

Adapted version of the Burgoon and Hale Relational communication scale for observational measurement (RCS-O)

( Gallagher et al.,

2001 )

Nonverbal person- centred communication

Rating scale, 34 items, 6 categories:

• Immediacy/affection

• Similarity/depth

• Receptivity/trust

• Composure

• Formality

• Dominance

Unclear X Primary care,

Inter-rater-reliability (Cronbach ´s alpha):

Immediacy/affection = 0.62;

Similarity/depth = 0.51;

Receptivity/trust = 0.72;

Composure = 0.69;

Formality = 0.02;

Dominance = 0.34 Internal consistency (Cronbach ´s alpha):

Composure = 0.98;

Formality = 0.92;

Dominance = 0.60 Inter-rater-agreement (within group agreement coeﬃcient):

Composure = 0.74;

Formality = 0.58 Dominance = 0.78 N interactions: 20 N raters: 3

correlation with other measure (Interview Rating Scale):

Composure = 0.62;

Formality = −0.31;

Dominance = −0.26

1 Refers to several different frameworks.

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Fig. 1. PRISMA 2009 ﬂow diagram.

1 ) (i) Not a direct observation tool (ii) no reports and/or descriptions of any development or evaluation of an instrument that measures patient-centred care, PCC or person centredness (iii) not clinical encounters.

and specialists in general medicine, internal medicine, rheumatology andgastro-enterology. Four raters(social scientists)coded the sessions. High inter-rater reliability wasnoted for the Facili- tatingbehaviourdimension (relativeagreement,ICC=0.93andab- solute agreement ICC=0.92) while it was moderate for the In- hibitingbehaviourdimension(ICC=0.53andICC=0.53,respectively) (D’Agostinoand Bylund,2014). Internal consistency wasassessed by Cronbach´s alpha (Facilitating behaviour dimension =0.64 and

inhibiting behaviour dimension =0.50). Convergent validity was testedagainsttheEurocommunicationscalewhereallcorrelations where inthe expected directions (positivefor the facilitatingdi- mension (r = 0.28) and negative for the inhibiting dimension r=−0.29)(Zandbeltetal.,2005).

SOS-PCC is a 9-item coding system assessing global person- centred care in four dimensions (i.e. biological aspects, establish a therapeutic relationship and provides a treatment plan in col-

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N. Ekman, C. Taft and P. Moons et al. / International Journal of Nursing Studies 109 (2020) 103634 13

Table 2 Summary table of reliability and validity in the included studies. ReliabilityValidity Direct observation tool ¹Inter-rater Test-retest reliabilityInternal consistencyFaceContentConcurrentKnown groups Person-centred care/centeredness COT ( Gaugler et al., 2013 ) √√√ DOC ( Bertakis and Azari, 2011 ) Henbest and Stewart ( Henbest and Stewart, 1989 ) √√√ PBCI ( Zandbelt et al., 2005 ) √√√ SOS-PCC ( Paul-Savoie et al., 2015 ) √√√ Shared decision-making IDM ( Braddock et al., 1997 ) √ DEEP-SDM ( Clayman et al., 2012 ) OPTION ( Elwyn et al., 2003 ) √√√√√ RPAD ( Shields et al., 2005 ) √√ Person-centred communication MPCC ( Dong et al., 2014 ) √ . √√√ PCOF ( Chesser et al., 2013 ; Schirmer et al., 2005 ) √√ PISCH ( Sabee et al., 2020 ) √√ Modiﬁed RIAS ( Mjaaland and Finset, 2009 ) √√ 4HCS ( Krupat et al., 2006 ; Frankel and Stein, 2001 ) √√√ Nonverbal person-centred communication NAAS ( D’Agostino and Bylund, 2011 October ; D’Agostino and Bylund, 2014 ) √√√√ RCS-O ( Gallagher et al., 2001 ) √√√

laboration withthepatient). Itemsare scoredon a four-stepLik- ertscalerangingfrom1(notdemonstrated)to4(stronglydemon- strated).Anexpertpaneldeveloped5videosandtheSOS-PCCwas testedinasampleof21registerednursesand21physicianswork- ingwith chronicpain patients.The inter-rater reliabilitybetween three observers (one registered nurse, a resident in psychiatry andaPhDstudentin thehealthcare ﬁeld)wasgood(ICC=0.93).

Contentvalidity was considered to be satisfactory by a panel of seveninterdisciplinaryexpertsinthehealthcareﬁeldandinternal consistency reliability was high (Cronbach´s alpha=0.88) (Paul- Savoieetal.,2015).

4.3.2. Shareddecision-making

IDMisa codingsystemassessing shareddecisionmaking and informedconsent.Ithassixkeyelements(e.g.,discussionofrisks andbeneﬁts) andscoresaredeterminedforeachconsultationde- cision.Eachdecisionisratedoneachelementfrom0to2andthen aggregatedoverthesixelementstoatotalscore.Inter-raterrelia- bilitywasassessedinasampleof20audiotapedencountersrated bythreecoders(onephysicianandtwograduatestudentsinmed- icalethics)andthecompleteagreementpercentageonagivende- cision was77%.The developers havereported that although pre- liminarilyanalyses indicate goodvalidity, it needs furtherexami- nation(Braddocketal.,1997).

DEEP-SDM is a coding system with ten coding frames (e.g., deﬁnitionof option,patient preferences andvalues, andplan for follow-up)forassessingessentialelementsofshareddecisionmak- ing. Decision making is coded from 1 (doctor led) to 9 (patient led)foreachdecision. Coding wasconductedbytwo researchas- sistantsusingasampleof20video-recordingsof20womenatvis- itswiththeirmedicaloncologist. Validityandreliabilitywerenot presented(Claymanetal.,2012).

OPTIONisa12-itemchecklistassessinghowwell cliniciansin- volvepatients indecisionmaking. Anexample item is“Theclini- cianidentifiesaproblem(s)needingadecisionmakingprocess”.Items are rated against a 5-point scale (strongly agree-disagree). Inter- raterreliability wasacceptableina randomsampleof21 consul- tationsratedbytwonon-clinicalraters(inter-ratergeneralisability coefficient=0.68;cohen´skappa=0.71;intra-classcoefficient=0.62), aswas intra-rater reliability (0.66)(D’Agostinoand Bylund, 2011 October). Contentvalidity wasbased on literaturereviews, quali- tativestudiesandconsultationswithpatientsandclinicians.Con- struct validity was supported by showing that OPTION was sen- sitiveto differencesinclinician age,sex, qualificationandclinical topic(Elwynetal.,2003).

RPAD is a 9-item ratingscale assessing patient-physician collaborative decision making. Example items include “Physician’s medical language matches patient’s level of understanding” and

“Physiciangivespatientopportunityto ask questionsandchecks pa- tientsunderstanding ofthetreatment plan”.Itemsare ratedagainst a3-pointLikertscaleanditemratingsaresummedtoatotalscore.

Constructvaliditywastestedagainstanothermeasure(MPCC) re- sulting in a modest correlation (r = 0.19). RPAD correlated with standardized patient’s perceptions of the physician-patient relationship (r = 0.32–0.36) but less with the patient survey measures (r = 0.06 to 0.07). Inter-rater reliability was shown to be good(ICC=0.72)incomparisonsofratingsof193recordingsfrom physician-patientencounters(Shieldsetal.,2005).

4.3.3. Person-centredcommunication

The modiﬁed version of MPCC is a coding system assessing person-centred communication. The tool comprises compo- nentsandsubcomponents whichcategorises physicians’provision ofinformationandresponses topatients’ verbal ‘offers’regarding symptoms, ideas, expectations,feelings and side effects of treatment andeffect on function. The ﬁrst subcomponent consists of