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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 inperson-centred careInternational Journal of Nursing Studies, 109: 103634https://doi.org/10.1016/j.ijnurstu.2020.103634

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International Journal of Nursing Studies 109 (2020) 103634

Contents lists available at ScienceDirect

International Journal of Nursing Studies

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / i j n s

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

a r t i c l e i n f o

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

a b s t r a c t

Background: Direct observation is a common assessment strategy in health education and training, in

which trainees are observed and assessed while undertaking authentic patient care and clinical activities.

A variety of direct observation tools have been developed for assessing competency in delivering person-

centred care (PCC), yet to our knowledge no review of such tools exists.

Objective: To review and evaluate direct observation tools developed to assess health professionals’ com-

petency in delivering PCC.

Design: State-of-the-art review

Data sources: Electronic literature searches were conducted in PubMed, ERIC, CINAHL, and Web of Sci-

ence for English-language articles describing the development and testing of direct observation tools for

assessing PCC published until March 2017.

Review methods: Three authors independently assessed the records for eligibility. Duplicates were re-

moved and articles were excluded that were irrelevant based on title and/or abstract. All remaining arti-

cles were read in full text. A data extraction form was developed to cover and extract information about

the tools. The articles were examined for any conceptual or theoretical frameworks underlying tool de-

velopment and coverage of recognized PCC dimensions was evaluated against a standard framework. The

psychometric performance of the tools was obtained directly from the original articles.

Result: 16 tools were identified: five assessed PCC holistically and 11 assessed PCC within specific skill

domains. Conceptual/theoretical underpinnings of the tools were generally unclear. Coverage of PCC do-

mains varied markedly between tools. Most tools reported assessments of inter-rater reliability, internal

consistency reliability and concurrent validity; however, intra-rater reliability, content and construct va-

lidity were rarely reported. Predictive and discriminant validity were not assessed.

Conclusion: Differences in scope, coverage and content of the tools likely reflect the complexity of PCC

and lack of consensus in defining this concept. Although all may serve formative purposes, evidence sup-

porting their use in summative evaluations is limited. Patients were not involved in the development of

any tool, which seems intrinsically paradoxical given the aims of PCC. The tools may be useful for pro-

viding trainee feedback; however, rigorously tested and patient-derived tools are needed for high-stakes

use.

© 2020 The Authors. Published by Elsevier Ltd.

This is an open access article under the CC BY-NC-ND license.

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

A

h

0

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

cademy, University of Gothenburg, Sweden. Box 457, 405 30 Gothenburg, Sweden.

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

020-7489/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article u

E-mail address: [email protected] (N. Ekman).

nder the CC BY-NC-ND license. ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

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

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What is already known about the topic?

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

by professional bodies as a core competency needed for health

professionals. • Numerous direct observation tools have been developed for use

specifically in assessing skills in delivering PCC. • To our knowledge, no review has been conducted of direct ob-

servation tools for use in assessing PCC competency.

What this paper adds

• This state-of-the-art review identified 16 tools and found differ-

ences in their scope, coverage and content as well as a lack of

consensus in defining PCC. • Although all may serve formative purposes, evidence support-

ing their use in summative evaluations is limited. • Paradoxically, given the aims of PCC, patients were not involved

in the development of any of the tools.

1. Background

Widely acknowledged as an essential element of high qual-

ity care (( Institute of Medicine, 2001 ; World Health Organization,

20 06 ; World Health Organization, 20 08 ; Australian Commission

on Safety and Quality in Health Care (ACSQHC), 2011 ; Goodrich

and Cornwell, 2008 ; Agency for Healthcare Research and Qual-

ity (AHRQ), 2003 ; International Alliance of Patient’s Organizations,

2007 ; Socialstyrelsen, 2016 )), person-centred care ¹ (PCC) has been

designated and endorsed by professional bodies as one of a set

of five core competencies needed for health professionals to meet

the evolving challenges facing health care (( Institute of Medicine

(US) 2003 ; World Health Organization 2005 ; World Health Organi-

zation 2003 ; Accreditation Council for Pharmacy Education (ACPE)

2015 )). The particular importance of PCC competency was under-

scored when, in a follow-up report to their landmark Crossing the

Quality Chasm , the US Institute of Medicine (IOM) positioned PCC

as the central, overarching competency, recommending that All

health professionals should be educated to deliver patient-centred care

as members of an interdisciplinary team, emphasizing evidence-based

practice, quality improvement approaches, and informatics. (9, chap-

ter 3) Reflecting its importance for quality care, PCC is increasingly

incorporated into education and training programs for health pro-

fessionals ( Dwamena et al., 2012 ).

Direct observation is a common assessment strategy in health

education and training, in which trainees are observed and as-

sessed while undertaking authentic patient care and clinical ac-

tivities. Historically, such assessments have been implicit, unstan-

dardized, and based on global, subjective judgments ( Van der

Vleuten, 1996 ); however, today a variety of checklists, rating scales

and coding systems are available to guide, delineate and struc-

ture assessments of clinical competencies ( Kogan et al., 2009 ).

Likewise, numerous direct observation tools have been developed

for use specifically in assessing skills in delivering PCC. As little

agreement exists within and across professions on PCC nomencla-

ture ( Håkansson Eklund et al., 2018 ), definitions ( Socialstyrelsen,

2016 ; Constand et al., 2014 ) and theoretical or conceptual frame-

works ( Mead and Bower, 20 0 0 ; Lawrence and Kinn, 2012 ; Cronin,

2004 ; Scholl et al., 2014 ), it seems reasonable to assume that such

tools differ significantly in their definitions and coverage of be-

haviours and behavioural domains indicative of PCC competency.

To our knowledge no state-of-the-art review has been conducted

of direct observation tools for use in assessing PCC competency.

Given the increasing importance of PCC in healthcare education

and training there is a need for guidance in selecting among ex-

isting direct observation tools for assessing trainees’ competency

in delivering PCC. This review therefore aims to identify available

ools and evaluate them with respect to: assessed competency do-

ain or domains; existence of underlying theoretical or concep-

ual frameworks; coverage of recognized components of PCC; types

f behavioural indicators; psychometric performance; and format

checklist, rating scale, coding system).

¹ Although differences exist in the definitions of person-centred

are and patient-centred care, the terms are frequently used inter-

hangeably in the literature. For the sake of parsimony, the term

erson-centred care has systematically been used in this review.

. Method

.1. Search strategies for identification of studies

The search was performed in March 2017 using the databases

ubMed, CINAHL and Scopus to identify relevant studies. Cen-

red and centeredness (both UK and US spelling) and the follow-

ng terms were identified and used in the search-string: (care OR

ealthcare) AND ("patient-centred" OR "patient centred" OR "person

entred" OR "person centred" OR "patient centeredness" OR "patient

entredness " OR "person centeredness " OR "person centredness")

ND (observ ∗ OR video OR audio) AND (Humans[Mesh] AND (Dan-

sh[lang] OR Norwegian[lang] OR Swedish[lang] OR English[lang])).

.2. Selection of studies

EndNote X7 software was used. Duplicates were removed and

learly irrelevant articles were excluded. Criteria for inclusion

ere: (i) direct observation tool (ii) reports and/or descriptions of

ny development or evaluation of an instrument that measures

atient-centred care, PCC or person centredness (iii) not clinical

ncounters. The selection process started with examining the ti-

les. After inclusion of relevant titles, the same procedure was per-

ormed with the abstracts. Abstracts that clearly did not match the

nclusion criteria were removed. The articles with potential to be

ncluded were read in full text in order to determine whether to

nclude or exclude. Snowballing was used to identify other poten-

ially relevant records. Three authors (NE, CT and AF) indepen-

ently assessed the records for eligibility and recorded the rea-

ons for either inclusion or exclusion, which was documented in

PRISMA flowchart.

.3. Data extraction

A data extraction form was developed to cover, identify and ex-

ract information about the direct observation tool including name

f tool, main concept assessed, characteristics of the development

ample, assessment format, assessed domains of person-centred,

onceptual framework underpinning the tools, type of psychomet-

ic assessments performed (reliability and validity), and developer

dentified limitations.

. Analyses

Each tool was examined against a standard framework for cov-

rage of PCC dimensions. For this purpose the framework endorsed

y the IOM ( Institute of Medicine, 2001 ) was used. The frame-

ork includes six dimensions: Respect for patients’ values, pref-

rences, and expressed needs, Coordination and integration of care,

nformation, communication, and education, Physical comfort, Emo-

ional support—relieving fear and anxiety and Involvement of family

nd friends ( Institute of Medicine, 2001 ) . Articles were examined

or evidence of theoretical or conceptual frameworks underpinning

he development of the tools. If the articles referred to one specific

ramework and used phrases such as: “we operationalized PCC…” or

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

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person-centred care using the framework of…” or “building on pre-

ious conceptual basis we developed…”it was judged to have a the-

retical or conceptual framework; those referring to several differ-

nt frameworks were classified as unclear. Information about psy-

hometric performance of the tools was obtained directly from the

riginal articles and supplemented by a review of references from

rticle bibliographies.

. Result

.1. Search results

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

fter screening by titles, 91 abstracts were read. After excluding ar-

icles based on abstracts, 42 articles were read in full text. Thirteen

ull-texts met inclusion criteria and six additional articles were

dentified by snowballing and found to be eligible. In total, 19 pa-

ers describing 16 different direct observation tools for assessing

CC or a specific aspect of PCC were identified ( Fig. 1 ).

.2. Characteristics of the direct observation tools

Eleven of the 16 direct observation tools were coding systems

Bertakis and Azari, 2011 ; Henbest and Stewart, 1989 ; Zandbelt

t al., 2005 ; Paul-Savoie et al., 2015 ; Braddock et al., 1997 ; Clayman

t al., 2012 ; Dong et al., 2014 ; Sabee et al., 2020 ; Mjaaland and

inset, 2009 ; Krupat et al., 2006 ; D’Agostino and Bylund, 2014 ),

hree were rating scales ( Elwyn et al., 2003 ; Shields et al., 2005 ;

allagher et al., 2001 ) and two were checklists ( Gaugler et al.,

013 ; Chesser et al., 2013 ) ( Table 1 ). Eleven tools focused on spe-

ific aspects of PCC, namely communication and shared decision-

aking, whereas five tools purported to assess the general

oncepts PCC or person-centredness. Various conceptual frame-

orks were presented as starting points for developing the tools.

framework was clearly identified in seven tools ( Henbest and

tewart, 1989 ; Zandbelt et al., 2005 ; Clayman et al., 2012 ; Elwyn

t al., 2003 ; Chesser et al., 2013 ; Sabee et al., 2020 ; D’Agostino

nd Bylund, 2014 ), while the others referred to different definitions

nd concepts and no specific framework could be distinguished.

he tools varied in their coverage of the six IOM domains ( Table

) from a single domain ( D’Agostino and Bylund, 2011 October ;

allagher et al., 2001 ) to all six domains ( Bertakis and Azari, 2011 ;

hesser et al., 2013 ), with an average of three domains per tools

Gaugler et al., 2013 ; Henbest and Stewart, 1989 ; Braddock et al.,

997 ; Clayman et al., 2012 ; Elwyn et al., 2003 ; Mjaaland and Fin-

et, 2009 ; Krupat et al., 2006 ).

Inter-rater reliability was reported for all tools except two

Bertakis and Azari, 2011 ; Clayman et al., 2012 ) ( Table 2 ). Reliabil-

ty was estimated using a variety of methods, where the intra-class

orrelation (ICC) and Cohen s kappa were most common. ICC coef-

cients were fair to excellent ( Hallgren, 2012 ) ranging from 0.53

PBCI subscale inhibiting behaviour) to 0.93 (PBCI subscale facil-

tating behaviour and SOS-PCC). Kappa coefficients reflected gen-

rally moderate to substantial agreement ( Hallgren, 2012 ), ranging

etween 0.46 (PISCH subscale enabling self-management) and 0.72

PISCH subscale fostering relationships). Intra-rater reliability was

eported for three tools, where stability in codings was high to per-

ect for the NAAS subcategories ( r = 0.82–1.0) and satisfactory for

PTION ( r = 0.66).

Most of the tools (12 of 16) reported some evaluation of va-

idity, where construct and content validity were most frequently

ssessed. About half of the tools were developed and evaluated in

rimary care settings ( Bertakis and Azari, 2011 ; Henbest and Stew-

rt, 1989 ; Braddock et al., 1997 ; Elwyn et al., 2003 ; Shields et al.,

0 05 ; Mjaaland and Finset, 20 09 ; Krupat et al., 20 06 ; Gallagher

t al., 2001 ) and all but two ( Zandbelt et al., 2005 ; Mjaaland and

inset, 2009 ) were developed in English speaking countries.

.3. Description of the direct observation tools

The following section provides a brief overview of informa-

ion about the included observation tools regarding their for-

at, coverage, scoring, conceptual framework and psychome-

ric evaluations/ performance as reported in the original ar-

icles. The tools are organized in accordance with Table 1 ,

.e. tools for assessing global PCC/ person centredness, shared-

ecision making, person-centred communication and nonverbal

erson-centred communication, and alphabetically within each

ategory.

.3.1. Global person-centred care/ person centredness

COT is a 16-item checklist for assessing global PCC. The check-

ist assesses if the staff performs behaviours indicative of PCC,

or example “speaks to a resident at least a total of 15 s during

are interaction”. Items are scored as 1 if the behaviour is ob-

erved and 0 if not observed and scores are summed, where 16

epresents maximum PCC. Inter-rater reliability, assessed across

ve raters (interdisciplinary reviewers) was satisfactory (ICC of all

appa coefficients = 0.77. Face validity included verbal and writ-

en feedback from scientific experts on earlier versions to refine

nd revise the tool. Content validity was assessed based on feed-

ack from nine interdisciplinary scientific experts regarding 31 care

orker-dementia patient interactions and open-ended feedback on

tems ( Gaugler et al., 2013 ).

Modified version of DOC is a coding system for assessing

lobal person-centred practice style and includes six different clus-

ers (e.g. , technical and health behaviour ) of physician practice be-

aviours among the 20 DOC codes (e.g., structuring interaction,

ealth education and health knowledge ). For each DOC code, the

umber of intervals during which the associated behaviour is ob-

erved is recorded and is expressed as a percentage of the total

f all DOC-coded behaviours noted during the visit. A total of 509

ideotaped encounters between patients and family physicians or

eneral internists were used for the development of the modified

ersion of DOC. Reliability and validity are documented for the

riginal DOC but have not been assessed for the modified version

Bertakis and Azari, 2011 ).

Henbest and Stewart instrument is a coding system assessing

octors’ global person-centred behaviour in primary care consul-

ations. The method involves identifying patients’ offers, defined

s any symptom, complaint, thought, feeling, expectation or obser-

ation expressed by the patient. The assessor then rates the doc-

ors’ responses to these offers on a four-point scale (0–3). The to-

al score for a consultation divided by the number of offers as-

essed gives the person-centredness score for that consultation.

his tool showed high inter-rater (18 tapes analyzed) and intra-

ater reliability after two weeks (two tapes analyzed) (Spearman

orrelation = 0.91 and 0.88, respectively). After six weeks (12 tapes

nalyzed) the intra-rater coefficient decreased to 0.63. The tool

as sensitive to differences among physicians and among physi-

ians responses to different patient offers. Analysis of 12 tapes with

wo raters comparing this tool with that of Brown and colleagues

howed moderate to high criterion validity (Spearman correlation

.51–0.89) ( Henbest and Stewart, 1989 ).

PBCI is a coding system assessing global person-centredness in

wo dimensions. The first dimension, Facilitating behaviours, has

1 categories ( e.g. , open and closed questions) . The second dimen-

ion, Inhibiting behaviours, includes 8 categories (e.g. , changing fo-

us ). These two dimensions are coded in relation to content ( medi-

al, psycho-social and other ). Reliability and validity were evaluated

n a sample of 323 videotaped appointments between residents

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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 ³Development

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)

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Table 1 ( Continued ).

Direct observation

tool ¹Competency 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


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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Direct observation


basis


setting



comfort

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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7


Direct observation


basis


setting



comfort

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.


reliability:


N interactions: 186

N raters: 2

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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al. / In

terna

tion

al Jo

urn

al o

f N

ursin

g Stu

dies

109 (2

02

0) 10

36

34


Direct observation


basis


setting



comfort

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 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,

USA

Physicians-

patients


ICC = 0.72

N interactions: 193

N raters: NR

Concurrent

validity:

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).


N. E

km

an

, C

. Ta

ft a

nd P.

Mo

on

s et

al. / In

terna

tion

al Jo

urn

al o

f N

ursin

g Stu

dies

109 (2

02

0) 10

36

34

9


Direct observation


basis


setting



comfort

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 α for

process categories = 0.86.


reliability: Cronbach‘s

alpha = 0.48

N interactions: 56

N raters: NR

Content validity:

Panel of radiation

therapists and PCC

researchers.

Concurrent

validity:

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

communica-

tion

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



N interactions: 13

N raters: 4

Validity: NR


10

N. E

km

an

, C

. Ta

ft a

nd P.

Mo

on

s et

al. / In

terna

tion

al Jo

urn

al o

f N

ursin

g Stu

dies

109 (2

02

0) 10

36

34


Direct observation


basis


setting



comfort

Emotional

support

Involvement

of family

The Process of

Interactional

Sensitivity Coding

in Healthcare

(PISCH)

( Sabee et al., 2020 )

Person-

centred

communica-

tion

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 )

Person-

centred

communica-

tion

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

Concurrent

validity:

correlation with

other measure

(RIAS). No

misclassification

between RIAS

codes and ARCS

codes.


N. E

km

an

, C

. Ta

ft a

nd P.

Mo

on

s et

al. / In

terna

tion

al Jo

urn

al o

f N

ursin

g Stu

dies

109 (2

02

0) 10

36

34

11


Direct observation


basis


setting



comfort

Emotional

support

Involvement

of family

Four Habits Coding

Scheme (4HCS)

( Krupat et al.,

2006 ; Frankel and

Stein, 2001 )

Person-

centred

communica-

tion

Coding system

• Habit 1: Invest in the

Beginning • Habit 2: Patient’s

Perspective • Habit 3: demonstrate

Empathy • Habit 4: Invest in the

End


USA

Physicians-

patients


(Pearson correlation):

Habit 1 = 0.70, Habit

2 = 0.80, Habit 3 = 0.71,

Habit 4 = 0.69, Overall

0.72


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

Concurrent

validity:

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

communica-

tion

Coding system, 10 codes

Paraverbal and Non-verbal

Yes X Oncology

consultations,

USA

Physicians-

patients



paraverbal = 0.81–0.96;

nonverbal = 0.85–0.93

Intra-rater reliability


paraverbal = 0.82–1.0;

non-verbal = 0.89–0.94

N interactions: 10

N raters: 2

Concurrent

validity:

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

communica-

tion

Rating scale, 34 items, 6

categories:

• Immediacy/affection • Similarity/depth • Receptivity/trust • Composure • Formality • Dominance

Unclear X Primary care,

USA

Physicians-

patients

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


(Cronbach s alpha):




Composure = 0.98;

Formality = 0.92;

Dominance = 0.60

Inter-rater-agreement

(within group agreement

coefficient):

Immediacy/affection =

0.65;



Composure = 0.74;

Formality = 0.58

Dominance = 0.78

N interactions: 20

N raters: 3

Concurrent

validity:

correlation with

other measure

(Interview Rating

Scale):




Composure = 0.62;

Formality = −0.31;

Dominance = −0.26

1 Refers to several different frameworks.


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.

i

t

w

m

r

c

a

and specialists in general medicine, internal medicine, rheuma-

tology and gastro-enterology. Four raters (social scientists) coded

the sessions. High inter-rater reliability was noted for the Facili-

tating behaviour dimension (relative agreement, ICC = 0.93 and ab-

solute agreement ICC = 0.92) while it was moderate for the In-

hibiting behaviour dimension (ICC = 0.53 and ICC = 0.53, respectively)

( D’Agostino and Bylund, 2014 ). Internal consistency was assessed

by Cronbach s alpha (Facilitating behaviour dimension = 0.64 and

nhibiting behaviour dimension = 0.50). Convergent validity was

ested against the Eurocommunication scale where all correlations

here in the expected directions (positive for the facilitating di-

ension ( r = 0.28) and negative for the inhibiting dimension

= −0.29) ( Zandbelt et al., 2005 ).

SOS-PCC is a 9-item coding system assessing global person-

entred care in four dimensions (i.e. biological aspects, establish

therapeutic relationship and provides a treatment plan in col-


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√ √

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ha

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ak

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IDM ( B

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√ D

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difi

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√ √

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CS ( K

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mu

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NA

AS ( D

’Ag

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ylu

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√ √

√ √

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( G

all

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√ √

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t

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aboration with the patient). Items are scored on a four-step Lik-

rt scale ranging from 1 (not demonstrated) to 4 (strongly demon-

trated). An expert panel developed 5 videos and the SOS-PCC was

ested in a sample of 21 registered nurses and 21 physicians work-

ng with chronic pain patients. The inter-rater reliability between

hree observers (one registered nurse, a resident in psychiatry

nd a PhD student in the health care field) was good (ICC = 0.93).

ontent validity was considered to be satisfactory by a panel of

even interdisciplinary experts in the health care field and internal

onsistency reliability was high (Cronbach s alpha = 0.88) ( Paul-

avoie et al., 2015 ).

.3.2. Shared decision-making

IDM is a coding system assessing shared decision making and

nformed consent. It has six key elements (e.g., discussion of risks

nd benefits) and scores are determined for each consultation de-

ision. Each decision is rated on each element from 0 to 2 and then

ggregated over the six elements to a total score. Inter-rater relia-

ility was assessed in a sample of 20 audiotaped encounters rated

y three coders (one physician and two graduate students in med-

cal ethics) and the complete agreement percentage on a given de-

ision was 77%. The developers have reported that although pre-

iminarily analyses indicate good validity, it needs further exami-

ation ( Braddock et al., 1997 ).

DEEP-SDM is a coding system with ten coding frames (e.g.,

efinition of option, patient preferences and values, and plan for

ollow-up) for assessing essential elements of shared decision mak-

ng. Decision making is coded from 1 (doctor led) to 9 (patient

ed) for each decision. Coding was conducted by two research as-

istants using a sample of 20 video-recordings of 20 women at vis-

ts with their medical oncologist. Validity and reliability were not

resented ( Clayman et al., 2012 ).

OPTION is a 12-item checklist assessing how well clinicians in-

olve patients in decision making. An example item is “The clini-

ian identifies a problem(s) needing a decision making process ”. Items

re rated against a 5-point scale (strongly agree-disagree). Inter-

ater reliability was acceptable in a random sample of 21 consul-

ations rated by two non-clinical raters (inter-rater generalisability

oefficient = 0.68; cohen s kappa = 0.71; intra-class coefficient = 0.62),

s was intra-rater reliability (0.66) ( D’Agostino and Bylund, 2011

ctober ). Content validity was based on literature reviews, quali-

ative studies and consultations with patients and clinicians. Con-

truct validity was supported by showing that OPTION was sen-

itive to differences in clinician age, sex, qualification and clinical

opic ( Elwyn et al., 2003 ).

RPAD is a 9-item rating scale assessing patient-physician col-

aborative decision making. Example items include “Physician’s

edical language matches patient’s level of understanding” and

Physician gives patient opportunity to ask questions and checks pa-

ients understanding of the treatment plan”. Items are rated against

3-point Likert scale and item ratings are summed to a total score.

onstruct validity was tested against another measure (MPCC) re-

ulting in a modest correlation ( r = 0.19). RPAD correlated with

tandardized patient’s perceptions of the physician-patient rela-

ionship ( r = 0.32–0.36) but less with the patient survey mea-

ures ( r = 0.06 to 0.07). Inter-rater reliability was shown to be

ood (ICC = 0.72) in comparisons of ratings of 193 recordings from

hysician-patient encounters ( Shields et al., 2005 ).

.3.3. Person-centred communication

The modified version of MPCC is a coding system assess-

ng person-centred communication. The tool comprises compo-

ents and subcomponents which categorises physicians’ provision

f information and responses to patients’ verbal ‘offers’ regarding

ymptoms, ideas, expectations, feelings and side effects of treat-

ent and effect on function. The first subcomponent consists of


t

l

a

s

2

c

i

w

a

o

i

c

0

a

t

(

B

a

r

t

s

p

i

(

b

d

i

r

c

(

l

t

f

d

m

r

s

c

e

5

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s

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six items which are rated on a 6-point scale for depth of dis-

cussion and the second subcomponent consists of nine items. Re-

liability and validity were examined in 56 recorded radiother-

apy consultations. Ten percent of the consultations were dual-

coded and inter-coder reliability was high (Krippendorffs α= 0.86).

Internal consistency reliability was also good (Cronbach s alpha

0.48). The MPCC correlated weakly with patient-perceived person-

centeredness (PPPC) ( r = 0.01) ( Dong et al., 2014 ).

PCOF is a 13-item checklist assessing person-centred commu-

nication in 13 different categories with three different options

reflecting person-centred behaviours. For example the category

Gathering Information has 3 options: uses open-ended questions, uses

reflecting statement, uses summary/clarifying statement). Scores rep-

resent the total number of options endorsed. Four raters (two

physicians and two PhD social science researchers) observed 13

encounters in a family medicine residency centre resulting in an

overall inter-rater reliability of 0.67 (Cronbach’s alpha). Reliabil-

ity estimates also differed by discipline. Validity was not reported

( Chesser et al., 2013 ; Schirmer et al., 2005 ).

PISCH is a coding system assessing interactional sensitivity in

person-centred communication. It comprises 7 interaction units in-

cluding multiple codes. Scores are expressed as a percentage of

the units. Inter-coder reliability was assessed using a sample of 50

transcripts of conversations between physicians and patients with

type 2 diabetes. Reliability for the PISCH units was estimated to

0.46–0.72 (Cohens kappa) and 0.44–0.72 (Scotts’s pi). Four of the

categories (exchanging information, fostering relationships, man-

aging uncertainty and meta-communication) reached acceptable

inter-coder reliability. A panel of experts (health communication

and/or discourse analysis) reviewed the coding scheme to test the

face validity of the instrument ( Sabee et al., 2020 ).

A modified version of RIAS, ARCS is a coding system assess-

ing person-centred communication. The RIAS includes 10 cate-

gories (e.g. social talk, biomedical questions and empathy) and the

ARCS supplements these with four additional person-centred cat-

egories: Attribution, Resources, Coping and Solution-focused tech-

niques (ARCS). Verbal ‘utterances’ by both the doctor and patient

are coded into each category. Scores represent the frequencies of

utterances in the different 10 categories. The inter-rater reliabil-

ity was fair (Cohens kappa = 0.52) between the five coders (re-

searchers experienced in the communication skills training) us-

ing 145 video-recorded consultations with 24 general practitioners

( Arora, 2003 ). Construct validity was assessed by a correlation with

the RIAS measure where no misclassifications across the general

RIAS and ARCS codes were identified ( Mjaaland and Finset, 2009 ).

4HCS is a coding system assessing clinicians’ communication

skills. The 4HCS identifies 23 behaviours, each associated with one

of the four habits: Invest in the beginning, (six items); Patient’s

perspective (three items); Demonstrate empathy (four items) and

Invest in the end (10 items). Items are rated on a 5-point scale.

Construct validity was tested against other available measures.

Inter-coder reliability was assessed in13 videotaped visits in pri-

mary care that were rated independently by two coders (health

professions students). Reliability estimates were satisfactory (0.69–

0.80 for the four habits (overall 0.72)). Internal consistency reliabil-

ity assessed using Cronbach’s alpha was satisfactory for two habits

(Habit 1 = 0.71 and Habit 3 = 0.81) and unsatisfactory for the

other two (Habit 2 = 0.51 and Habit 4 = 0.61) Evidence for con-

struct validity was provided by correlations between 4HCS ratings,

RIAS, back channel responses, and non-verbal measures ( Krupat

et al., 2006 ; Frankel and Stein, 2001 ).

4.3.4. Nonverbal person-centred communication

NAAS is a coding system assessing nonverbal communication.

The tool consists of two codes (paraverbal and non-verbal) which

include ten behaviour categories (e.g., talk-time, smiling, eye con-

act). NAAS categories are coded in one-minute segments. A base-

ine score is first calculated as ( Institute of Medicine, 2001 ) an

verage of the physician’s NAAS behaviours during the first two

egments in the consultation; and ( World Health Organization,

006 ) an average of the patient’s NAAS behaviours during the

orresponding segments. Subsequent segments are compared with

nitial segments to reveal if the physician and patient changed

ithin each NAAS behaviour and, if so, in what direction. Inter-

nd intra-rater reliability was assessed in ten randomly selected

ncology consultations coded by two raters. Inter-rater reliabil-

ty for the ten NAAS categories in the paraverbal and non-verbal

odes was satisfactory (Pearson correlation = 0.81–0.96 and 0.85–

.93, respectively). Intra-rater reliability was 0.82–1.0 (paraverbal)

nd 0.89–0.94 (non-verbal). Construct validity was assessed with

he MIPS measure showing correlations with physician eye contact

r = 0.447) and patient eye contact ( r = 0.623) ( D’Agostino and

ylund, 2011 October ; D’Agostino and Bylund, 2014 ).

This adapted version of the RCS-O is a 34-item rating scale

ssessing six dimensions of nonverbal communication. Items are

ated on a 7-point Likert scale ranging from “strongly disagree”

o “strongly agree” and item ratings are summed to dimension

cores. Inter-rater reliability was assessed using a random sam-

le of 20 videotaped interactions of medical students interview-

ng patients. Interactions were rated by three trained observers

social and behavioural scientists) at two time points separated

y eight weeks. At time one, four of the six dimensions (imme-

iacy/affection, similarity/depth, receptivity/trust and composure)

ndicated fair to excellent internal consistency (0.84–0.98), inter-

ater reliability (0.51–0.72), inter-rater agreement (0.65–0.86) and

onstruct validity (correlation with the interview rating scale (IRS))

0.50–0.76). The estimates were similar at time two (eight weeks

ater), except that the inter-rater reliability for receptivity/trust

hen was low (0.19). Internal consistency was also strong for the

ormality dimension (0.91–0.92) but moderate for the dominance

imension (0.60–0.66). Inter-rater reliability was low for both for-

ality ( −0.11–0.02) and dominance (0.34–0.50) and even if inter-

ater agreement was good (0.58–0.86) these two dimensions were

uggested to be dropped or revised. Formality and dominance both

orrelated negatively with the IRS ( −0.26 to −0.31) ( Gallagher

t al., 2001 ).

. Discussion and conclusion

This review identified a manifold of direct-observation methods

or use in assessing PCC, varying in assessed main constructs; as-

essment formats; conceptual frameworks underpinning their de-

elopment; coverage of core PCC dimensions; and psychometric

valuations and performance.

Given the multitude and variation in existing PCC frameworks

nd concepts, it is important that developers of assessment tools

arefully articulate the conceptual underpinnings of their tool

Hallgren, 2012 ). Although clear descriptions were provided for

ome methods, in 9 of the 16 tools we were nevertheless un-

ble to ascertain with any certainty what conceptual framework(s)

as applied or developed to guide their construction. Furthermore,

ontent analyses were seldom performed to affirm if the content

f the methods adequately represents the construct(s) intended to

e assessed. Similar shortcomings have previously been reported

n quantitative measures for assessing patient-centred communi-

ation ( Epstein et al., 2005 ). In the absence of information about

he assumptions underlying a tool and theoretical and/or empirical

upport for those assumptions, its validity and utility as a measure

or assessing PCC may be questioned.

Given that PCC assessment tools often embody different con-

epts, apply different nomenclature to designate often similar con-

epts ( Arora, 2003 ; Mead and Bower, 20 0 0 Jan ) or seemingly sim-


i

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lar concepts that are operationalized differently ( Epstein et al.,

005 ), we examined the content of each tool in relation to a

tandard framework in order to identify conceptual commonalities

nd differences between the tools. For this purpose we chose the

ix IOM-endorsed dimensions covering aspects of PCC ( Institute of

edicine 2001 ). We found that only two tools, the DOC ( Bertakis

nd Azari, 2011 ) and PCOF ( Chesser et al., 2013 ), appeared to cover

ll six dimensions, whereas coverage by the remaining tools varied

rom as few as one to a maximum of four dimensions. Interestingly

he DOC was the only tool of the five purporting to measure the

olistic concept PCC or patient-centeredness to tap all IOM dimen-

ions. The other four holistic tools were judged to include between

hree and four dimensions, indicating both notable conceptual dif-

erences between methods and significant gaps in assessment do-

ains. This is in line with findings by Mead & Bower ( Mead and

ower, 20 0 0 Jan ) showing that PCC assessed by means of three

ifferent direct-observation tools (an adapted RIAS, Eurocommuni-

ation and Henbest & Stewart instrument) ( Mead and Bower, 20 0 0

an ) correlated poorly, which the authors suggested indicate that

hey tap distinct aspects of doctor-patient interactions.

Similarly, dimension coverage varied in the four tools (each tool

ncluded between two and three dimensions) designed specifically

o assess shared decision making. For example, IDM ( Braddock

t al., 1997 ) was judged to tap Involvement of family and friends ,

hereas OPTION ( Elwyn et al., 2003 ) instead covered Emotional

upport . This difference may in part account for weak correlations

eported between these measures ( Weiss and Peters, 2008 ). On a

imilar note, the five tools assessing patient-centred verbal com-

unication also appeared to differ somewhat in dimension cover-

ge, although commonalities in coverage were apparent. PCOF ap-

eared to tap all six IOM dimensions and the others between three

nd four dimensions. With content suggesting three common un-

erlying concepts, substantial agreement between these communi-

ation assessment tools may be expected; however, to our knowl-

dge the only head-on-head evaluation of these methods has been

ade between the MPCC and the 4HCS, where weak correlations

ere found ( Clayton et al., 2011 ). The two identified tools for as-

essing nonverbal communication (NAAS ( D’Agostino and Bylund,

014 ) and RSC

–O ( Gallagher et al., 2001 ) were unsurprisingly, given

heir focus on behavioural aspects doctor-patient interactions, both

udged to tap a single IOM dimension, namely Respect for patients’

alues, preferences, and expressed needs.

Few of the tools appeared to cover the IOM dimensions Physi-

al comfort ( n = 4) or Involvement of family and friends ( n = 3). It

s noteworthy that these two dimensions have also been shown to

e the least frequently covered IOM domains in patient-reported

CC measures ( Tzelepis et al., 2015 ). This suggests that their im-

ortance as independent core elements of PCC may either be over-

tated in the IOM framework or undervalued in assessment tools.

or example, providing patients with physical comfort may be seen

o lie within the realm of standard professional ethics and good

edical practice rather than as a component distinctly characteriz-

ng PCC. On the other hand, involving family and friends in patient

are may serve to further the aims of PCC in that they may facil-

tate patient-clinician communication, provide emotional support

o the patient during consultations and at home and help to ne-

otiate medical decision making ( Rosland et al., 2011 ). Despite its

elatively meagre representation in the methods included in this

eview, involvement of family and friends has also been identified

s one of the six most frequently recurring domains found in nine

rominent PCC frameworks ( Cronin, 2004 ).

The comprehensiveness of reported psychometric evaluations

aried substantially between tools. No evaluations were reported

or two tools (DEEP-SDM ( Clayman et al., 2012 ) and DOC ( Bertakis

nd Azari, 2011 ), whereas relatively rigorous reliability and va-

idity evaluations were performed for the OPTION, MPCC and

AAS. Reliability was evaluated in terms of inter-observer reliabil-

ty (IOR) for 12 of the 16 tools, all of which reported IOR estimates

eeting conventional cutoffs for moderate to high agreement be-

ween/among raters. Cases of moderate IOR associated with the

odified RIAS, PISCH and RSC

–O were attributed to shortfalls in

he tool related to ambiguities in concept definitions or inade-

uacies in defining target behaviours, or inclusion of behaviours

hat are not readily observable ( Sabee et al., 2020 ; Mjaaland and

inset, 2009 ; Gallagher et al., 2001 ). Although IOR is often un-

erstood to be a characteristic inherent to an assessment tool, it

ay be influenced by a number of methodological factors unre-

ated to the observation tool per se, such as sample homogeneity,

nit of analysis ( Hallgren, 2012 ), extent of rater training ( Mead and

ower, 20 0 0 Jan ), raters’ professional background ( Chesser et al.,

013 ) and other rater characteristics/ idiosyncrasies ( Kogan et al.,

017 ), etc. For example, although checklists are assumed to im-

rove IOR because they provide relatively unambiguous behavioral

efinitions ( Regehr et al., 1998 ) we noted that some of the cod-

ng systems, e.g., Henbest & Stewart and SOS-PCC actually outper-

ormed the two checklists PCOF and COT. It is conceivable that in

hese cases extensive rater training in using the coding schemes

ay have offset the effect of greater clarity in target behaviour

efinitions.

It is noteworthy that other important types of reliability were

ess frequently reported for the various tools. For example, test-

etest reliability, reflecting the stability of ratings over time, was

eported for only 3 of the 16 tools, and homogeneity, as measured

ith e.g. Cronbach’s alpha, was reported for 7 of them. In the ab-

ence of comprehensive evaluations of reliability it is not possi-

le to fully appraise the precision to be expected of codings. Also

oteworthy is that power calculations for estimating samples sizes

sed in testing reliability (and validity) were reported for only one

ool, the SOC-PCC, undermining confidence in the estimates.

Validity assessments were reported for all tools except DOC,

DM, DEEP-SDM and PCOF ( Bertakis and Azari, 2011 ; Braddock

t al., 1997 ; Clayman et al., 2012 ; Chesser et al., 2013 ). Concur-

ent validity was most commonly evaluated but notably many cor-

elations were very low. Content validity was evaluated by and

arge by panels of experts; however, the experts’ areas of exper-

ise were often not specified. Paradoxically, we found no mention

f patients taking part in the evaluation process. Moreover, it is

oteworthy that other measurement characteristics that are criti-

al for appraising and interpreting outcomes, such as responsive-

ess and sensitivity were conspicuously absent in evaluations of

he various methods. Likewise, predictive validity was not assessed

or any method.

All of the identified methods have their own particular

trengths and weaknesses and decisions about which one to use

ill invariably involve some amount of tradeoff. Ultimately, the

hoice of tool will depend on the purpose for which it is to be

sed. For formative use to guide learning by providing bench-

arks to orient and give feedback to reinforce learners, all of the

ools may in some way be useful. However, at a minimum evi-

ence supporting content validity of the tool should be available

o ensure that the sampled behaviours comprehensively and accu-

ately represent the construct (s) of interest. On the other hand, for

igh stakes, summative use, tools with clear conceptual base and

emonstrated strong validity and reliability are needed. We can-

ot recommend any of the tools without some reservations; how-

ver, of the tools assessing holistic PCC the Henbest & Stewart in-

trument ( Henbest and Stewart, 1989 ) appears promising given its

ell-defined conceptual core and relatively good psychometric per-

ormance. It has not, however, been evaluated for content validity

nd only three IOM dimensions were covered. Of the tools for as-

essing shared decision making, OPTION ( Elwyn et al., 2003 ) is one

f the two with a defined conceptual framework and stands out as


C

C

C

C

D

D

D

E

E

F

G

G

G

H

H

I

I

K

K

K

L

M

M

P

R

R

the most rigorously tested tool. Nevertheless, inter-rater reliabil-

ity estimates were moderate and only three IOM dimensions were

covered. Of the patient-centred communication tools, the MPCC

( Dong et al., 2014 ) performed best in terms of inter-rater relia-

bility and content validity was evaluated; however, its conceptual

framework was unclear and concurrent validity was not supported.

Finally, of the two tools intended to measure nonverbal patient-

centred communication, the NAAS ( D’Agostino and Bylund, 2014 )

clearly outperformed the RCS-O ( Gallagher et al., 2001 ) on every

count.

5.1. Limitations

There are limitations to this review. The eligibility of tools for

inclusion and their coverage of the IOM domains were subjectively

judged but were thoroughly discussed by co-authors until agree-

ment was reached. Our main search was limited principally to ar-

ticles identified through the search string, subsequent evaluations

of the included tools were not sought and no attempt was made

to contact developers for additional information about their tools.

On the other hand, after a tool was identified in the search, we

searched the literature for earlier articles describing the develop-

ment of the tools.

6. Conclusions

Differences in the scope, coverage and content of the identi-

fied direct observation tools likely reflect the complexity of PCC

and lack of consensus in defining this concept. Greater clarity and

transparency are needed in describing conceptualizations and as-

sumptions underpinning of the tools to enable potential users to

make informed decisions when selecting tools. Although all of the

tools may serve formative purposes, evidence supporting their use

in summative evaluations is scarce. Patients were not involved in

the development of any of the assessment tools, which seems in-

trinsically paradoxical given the aims of PCC. All of the tools may

be useful for providing trainee feedback; however, rigorously tested

and patient-derived tools are needed for high-stakes use.

Funding sources

This work was supported by the centre for Person-centred Care

at the University of Gothenburg (GPCC), Sweden. GPCC is funded

by the Swedish Government’s grant for Strategic Research Areas,

Care Sciences (Application to Swedish Research Council no. 2009-

1088) and co-funded by the University of Gothenburg, Sweden.

Declaration of Competing Interest

None.

References

Agency for Healthcare Research and Quality (AHRQ), 2003. National HealthcareQuality Report .

Accreditation Council for Pharmacy Education (ACPE) (2015). Accreditation stan-

dards and key elements for the professional program in pharmacy lead-ing to the doctor of pharmacy degree. https://www.acpe-accredit.org/pdf/

Standards2016FINAL.pdf Arora, N.K., 2003. Interacting with cancer patients: the significance of physi-

cians’ communication behaviour. Soc. Sci. Med. 57, 791–806. doi: 10.1016/S0277- 9536(02)00449- 5 .

Australian Commission on Safety and Quality in Health Care (ACSQHC)., 2011. Pa-tient Centred care: Improving quality and Safety Through Partnership With Pa-

tients and Consumers. ACSQHC, Sydney, Australia .

Bertakis, K.D. , Azari, R. , 2011. Determinants and outcomes of patient-centred care.Patient Educ. Couns. 85, 46–52 .

Braddock, C.H. , Fihn, S.D. , Levinson, W. , Jonsen, A.R. , Robert, A. , Pearlman, R.A. , 1997.How doctors and patients discuss routine clinical decisions. informed decision

making in the outpatient setting. J. Gen. Intern. Med. 12, 339–345 .

hesser, A. , Reyes, J. , Woods, N.K. , Williams, K. , Kraft, R. , 2013. Reliability in patien-t-centred observations of family physicians. Fam. Med. 45 (6), 428–432 .

layman, M.L. , Makoul, G. , Harper, M.M. , Koby, D.G. , Williams, A.R. , 2012. Develop-ment of a shared decision making coding system for analysis of patient-health-

care provider encounters. Patient Educ. Couns. 88, 367–372 . Clayton, M.F. , Latimer, S. , Dunn, T.W. , Haas, L. , 2011. Assessing patient-centred com-

munication in a family practice setting: how do we measure it, and whose opin-ion matters? Patient Educ. Counc. 84, 294–302 .

onstand, M.K. , MacDermid, J.C. , Bello-Haas, V.D. , Law, M , 2014. Scoping review of

patient-centred care approaches in healthcare. BMC Health Serv. Res. 19 (14),271 .

ronin, C., “Patient-Centered Care: An Overview of Definitions and Concepts,” pre-pared for the National Health Council, 2004.

’Agostino, T.A. , Bylund, C.L. , 2011 October. The nonverbal Accomodation AnalysisSystem (NAAS): initial application and evaluation. Patient Educ. Couns. 85 (1),

33–39 .

’Agostino, T.A. , Bylund, C.L. , 2014. Nonverbal accommodation in healthcare com-munication. Health Commun. 29 (6), 563–573 .

ong, S. , Butow, P.N. , Costa, D.S. , Dhillon, H.M. , Shields, C.G. , 2014. The influenceof patient-centred communication during radiotherapy education sessions on

post-consultation patient outcomes. Patient Educ. Couns. 95, 305–312 . Dwamena, F. , Holmes-Rovner, M. , Gaulden, C.M. , Jorgenson, S. , Sadigh, G. , Siko-

rskii, A. , Lewin, S. , Smith, R.C. , Coffey, J. , Olomu, A. , Beasley, M , 2012. Interven-

tions for providers to promote a patient-centred approach in clinical consulta-tions. Cochrane Datab. System. Rev. Issue 12 .

lwyn, G. , Edwards, A. , Wensing, M. , Hood, K. , Atwell, C. , Grol, R. , 2003. Shared de-cision making: developing the OPTION scale for measuring patient involvement.

Qual. Saf. Health Care 12, 93–99 . pstein, R.M. , Franks, P. , Fiscella, K. , Shields, C.G. , Meldrum, S.C. , Kravitz, R.L. , Duber-

stein, P.R. , 2005. Measuring patient-centred communication in Patient-Physician

consultations: theoretical and practical issues. Soc. Sci. Med. 61, 1516–1528 . rankel, R.M. , Stein, T. , 2001. Getting the most out of the clinical encounter: the four

habits model. J. Med. Pract. Manag. 16 (4), 184–191 . allagher, T.J. , Hartung, P.J. , Gregory, S.W. , 2001. Assessment of a measure of re-

lational communication for doctor-patient interactions. Patient Educ. Counc. 3(45), 211–218 .

augler, J.E. , Hobday, J.V. , Savik, K. , 2013. The CARES(R) Observational Tool: a valid

and reliable instrument to assess person-centred dementia care. Geriatr. Nurs.(Minneap) 34, 194–198 .

oodrich, J. , Cornwell, J. , 2008. Seeing the Person in the Patient. The Point of CareReview Paper. King’s Fund, London .

åkansson Eklund, J , et al. , 2018. "Same same or different?"; A review of reviews ofperson-centred and patient-centred care.". Patient Educ. Couns. Published on-

line .

allgren, K. , 2012. Computing inter-rater reliability for observational data: anoverview and tutorial. Tutor. Quant. Methods Psychol. 8 (1), 23–34 .

Henbest, R.J. , Stewart, M.A. , 1989. Patient-centredness in the consultation. 1: amethod for measurement. Fam. Pract. 6 (4), 249–253 .

ICN Framework of Competencies for the Generalist Nurse. International Council ofNurses, Geneva 2003.

Institute of Medicine, 2001. Committee On Quality of Health Care in America. Cross-ing the Quality chasm: a New Health System For the 21st Century. National

Academy Press .

nstitute of Medicine (US), 2003. Committee on the health professions educationsummit. In: Greiner, AC, Knebel, E (Eds.), Health Professions Education: A Bridge

to Quality. National Academies Press (US), Washington (DC) . nternational Alliance of Patient s Organizations – A global voice for patients

(2007). What is Patient-centred healthcare? A review of definitions and prin-ciples IAPO http://iapo.org.uk/sites/default/files/files/IAPO%20Patient-Centred%

20Healthcare%20Review%202nd%20edition.pdf accessed Sept 2018;

ogan, J.R. , Hatala, R. , Hauer, K.E. , Holmboe, E. , 2017. Guidelines: the do’s, don’tsand don’t knows of direct observation of clinical skills in medical education.

Perspect. Med. Educ. 6, 286–305 . ogan, J.R. , Holmboe, E.S. , Hauer, K.E , 2009. Tools for direct observation and as-

sessment of clinical skills of medical trainees: a systematic review. JAMA 302,1316–1326 .

rupat, E. , Frankel, R. , Stein, T. , Irish, J. , 2006. The Four Habits Coding

Scheme:validation of an instrument to assess clinicians communication be-haviour. Patient Educ. Couns. 26, 38–45 .

awrence, M. , Kinn, S , 2012. Defining and measuring patient-centred care: an ex-ample from a mixed-methods systematic review of the stroke literature. Health

Expect 15, 295–326 . ead, N. , Bower, P , 20 0 0. Measuring patient-centredness: a comparison of three

observation-based instruments. Patient Educ. Couns. 39 (1), 71–80 .

Mead, N. , Bower, P , 20 0 0. Patient-centredness: a conceptual framework and reviewof the empirical literature. Soc. Sci. Med. 51 (7), 1087–1110 .

jaaland, T.A. , Finset, A. , 2009. Frequency of GP communication addressing the pa-tient’s resources and coping strategies in medical interviews: a video-based.

BMC Fam. Pract. 10 (49), 1–9 . aul-Savoie, E. , Bourgault, P. , Gosselin, E. , Potvin, S. , Lafrenaye, S. , 2015. Assessing

patient-centred care for chronic pain: validation of a new research paradigm.

Pain Res. Manag. 20 (4), 183–188 . egehr, G. , et al. , 1998. Comparing the psychometric properties of checklists and

global rating scales for assessing performance on an OSCE-format examination.Acad. Med. 73 (9), 993–997 .

osland, A.-.N. , Piette, J.D. , Choi, H.J. , Heisler, M. , 2011. Family and friend par-

http://refhub.elsevier.com/S0020-7489(20)30118-8/sbref0002

https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf

https://doi.org/10.1016/S0277-9536(02)00449-5

































































































http://iapo.org.uk/sites/default/files/files/IAPO%20Patient-Centred%20Healthcare%20Review%202nd%20edition.pdf










































S

S

S

S

S

T

V

W

W

W

W

Z

ticipation in primary care visits of patients with diabetes or heart failure:patient and physician determinants and experiences. Med. Care 49 (1), 37–

45 . abee, C.M. Koenig, C.J. Wingard, L. Foster, J. Chivers, N. Olsher, D. Vandergriff, I.

The process of interactional sensitivity coding in health care: conceptually andoperationally defining patient-centred communication. J. Health Commun., 20:7,

773–782. chirmer, J.M. , Mauksch, L. , Lang, F. , Marvel, K. , Zoppi, K. , Epstein, R.M. , Brock, D. ,

Pryzbylski, M. , 2005. Assessing Communication competence: a review of current

tools. Fam. Med. 37 (3), 184–192 . choll, I. , Zill, J.M. , Harter, M. , Dirmaier, J. , 2014. An integrative model of patient-cen-

teredness – a systematic review and concept analysis. PLoS ONE 9 (9), e107828 .hields, C.G. , Franks, P. , Fiscella, K. , Meldrum, S. , Epstein, R.M. , 2005. Rochester Par-

ticipatory Decision-Making Scale (RPAD): reliability and validity. Ann. Fam. Med.3, 436–442 .

ocialstyrelsen. En mer tillgänglig och patientcentrerad vård, 2016. Sammanfat-

tning Och Analys Av Landstingens Och Regionernas Handlingsplaner-Delrapport.Swedish National Board of Health and Welfare https://www.socialstyrelsen.se/

Lists/Artikelkatalog/Attachments/20115/2016- 3- 22.pdf .

zelepis, F. , Sanson-Fisher, R.W. , Zucca, A.C. , Fradgley, E.A. , 2015. Measuring thequality of patient-centred care: why patient-reported measures are critical to

reliable assessment. Patient Prefer Adher. 9, 831–835 . an der Vleuten, C.P.M. , 1996. The assessment of professional competence: devel-

opment, research and practical implications. Adv. Health Sci. Educ. 1, 41–67 . eiss, M.C. , Peters, T.J. , 2008. Measuring shared decision making in the consulta-

tion: a comparison of the OPTION and Informed Decision Making instruments.Patient Educ. Counc. 70, 79–86 .

orld Health Organization. (2005). The challenge of chronic conditions: preparing

a health care workforce for the 21st century. orld Health Organization. (2006). Quality of care: a process for making strate-

gic choices in health systems. http://apps.who.int/iris/bitstream/handle/10665/ 43470/9241563249 _ eng.pdf?sequence=1&isAllowed=y

orld Health Organization. (2008). The world health report 2008: primary healthcare now more than ever: introduction and overview. Retrieved from: www.

who.int/whr/2008/en/index.html .

andbelt, L.C. , Smets, E.M. , Oort, F.J. , de Haes, H.C. , 2005. Coding patient-centredbehaviour in the medical encounter. Soc. Sci. Med. 61, 661–671 .






















https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/20115/2016-3-22.pdf











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