Examining the theoretical relationships between constructs in the person-centred practice framework: a structural equation model


 Background Research relating to Person-centred practice continues to expand and currently there is a dearth of statistical evidence that tests the validity of an accepted model of person-centred practice. The Person-centred Practice Framework is a leading model of practice and this study aims to examine it statistically.Methods A cross sectional survey design using a standardized tool was used to assess a purposive sample (n=1283, 31.8%) of multi-disciplinary health professionals across both Northern and Southern Ireland. Survey items scores were summed to provide construct scores and included in a structural model to examine the theoretical model of person-centred practice. Full ethical approval was gained. Results The results were drawn from a multi-disciplinary sample, and representing a broad range of clinical settings. The model explains 60.5% of the total variance. Factor loadings on to the second order latent construct, and fit statistics confirm the acceptability of the measurement model. Statistically significant factor loadings were acceptable. A positive and statistically significant relationship was observed between prerequisites and care environment as well as care processes.Conclusions The study provides statistical evidence to support the Person-centred Practice Framework, with a multidisciplinary sample. The findings help confirm the effectiveness of the PCPI-S and an instrument to measure an internationally renowned model of Person-centred practice.


Introduction
The value placed on person-centredness as the preferred approach in health and social care is uncontested, as evidenced in policy and strategy development globally [1,2,3]. The knowledge base underpinning person-centredness continues to expand, with greater clarity on person-centredness as a concept relevant to international healthcare, and an increased understanding of the key components that need to be considered for effective implementation of person-centred practice [4,5,6]. This has led to the development of conceptual frameworks and models depicting the components of person-centredness (e.g. [7,8]), alongside the development of tools to enable measurement [9]. This paper presents the outcomes from a programme of work that has focused on the development of a conceptual framework for implementing person-centred practice [10,11], and development of a tool aligned to the framework that can offer a valid and reliable standardised measure [12].

Background
It is generally accepted that the principles underpinning person-centredness as an approach focuses on: treating people as individuals; respecting their rights as a person; building mutual trust and understanding; and developing positive relationships.
Furthermore, these principles re ect a standard of care that practitioners aspire to in their professional practice. The challenge, however, continues to be how these principles are translated into everyday practice to enable multiprofessional teams to deliver this standard of care consistently over time [13,14].
The Person-centred Practice Framework (PCPF) was originally born out of a desire to operationalise person-centredness in a way that would illuminate practice, and provide practitioners with a language that would enable them to name components of personcentredness and the barriers and enablers that in uence its development in the workplace.
The PCPF comprises four domains which are brie y described below.
1. Prerequisites, which focus on the attributes of the nurse and include: professionally competent, developed interpersonal skills, commitment to the job, clarity of beliefs and values, and knowing self.
2. Care environment, which focuses on the context in which care is delivered and includes: appropriate skill mix; shared decision-making systems; effective staff relationships; supportive organisational systems; power sharing; potential for innovation and risk-taking; and the physical environment.
3. Person-centred processes, which focus on delivering care to the patient through a range of activities and include: working with patient's beliefs and values; being engaged, having sympathetic presence, sharing decision-making and providing holistic care. 4. Outcomes, which are the results of effective person-centred practice and include: experience of good care; involvement with care; feeling of well-being; and existence of a healthful culture.
In the most recent version of the PCPF an additional element has been added to take account of the macro context. This re ects the factors that are strategic and political in nature that in uence the development of person-centred cultures and include: health and social care policy; strategic frameworks; workforce developments; and strategic leadership.
The relationship between the four main constructs of the PCPF is represented pictorially, that being, to reach the centre of the framework, the attributes of staff must rst be considered, as a prerequisite to managing the care environment, in order to provide effective care through the care processes. This ordering, ultimately leads to the achievement of the outcomes -the central component of the framework (refer to Figure 1). It is also acknowledged that there are relationships between the constructs. The original Person-centred Nursing Framework was described as a mid-range theory [15]. It's place on the continuum of theory development was made explicit by McCormack & McCance [10,11] drawing on the seminal work of Fawcett [16]. Fawcett argues that mid-range theories articulate one or more relatively concrete and speci c concepts that are derived from a conceptual model.
Furthermore, the propositions that describe these concepts propose speci c relationships between them, and empirical indicators provide the means of measuring concepts within a mid-range theory. The Person-Centred Practice Framework meets the criteria for a mid-range theory, in that it has been derived from two abstract conceptual frameworks [17,18], comprises concepts that are relatively speci c, and outlines relationships between the concepts.
Please insert Figure 1 here.
Furthermore, recent advancements have been made to develop empirical indicators to measure concepts within the PCPF. The development of the Person-centred Practice Inventory -Staff (PCPI-S) provides a measure that effectively maps directly onto the constructs of the PCPF. De Silva [9] conducted a review of existing tools to measure person-centred practice and reported that of the 114 instruments identi ed, none provided direct measurement of the concepts of person-centred practice. Many quantitative tools relied on statistical techniques that draw heavily on a posteriori classi cation of constructs that emerge from reductionist techniques such as exploratory factor analysis.
The PCPI-S holds to the concept of theory driven instrument development [12]. Instrument items map directly to accepted de nitions that make up the model: factors onto items and second order latent variables onto rst order factors. It provides quantitative data to allow testing of the theoretical model that underpins it. The comprehensiveness of the PCPF and as a consequence its complexity, gives the model an advantage over other simplistic models that reduce person-centred practice to measurements of broad, ill-de ned concepts. These use, at best, proxy measures and add little to advance understanding of how to effectively measure and move toward person centred outcomes.

Methods
A quantitative cross sectional survey research design using the PCPI-S was used to generate su cient data to adequately test the measurement model. The PCPI-S is a 59-itemed instrument that measures 17 constructs aligned to the Person-centred Practice Framework [11]. All items of the PCPI-S are measured on a ve point scoring range (1-Strongly Disagree to 5 -Strongly Agree), with higher scores indicating higher levels of agreement. Demographic details of participants were also collected. Factor structure and psychometric properties of the PCPI-S are reported by Slater et al [12] and Bing-Jonsson et al [19] and are acceptable.

Sample
The PCPI-S was tested with a sample of health professionals drawn from 6 organisations representing 14  were selected so as to obtain a good representation of views on person-centred practice for health professionals across the participating organisations. A gatekeeper in each clinical unit randomly distributed questionnaire packs to all health professionals working within the unit. The following inclusion criteria was applied: (i) working full time' (ii) have worked in the clinical setting for at least 6 months; and (iii) willing to participate.

Ethical Approval
Full ethical approval was sought and gained from the relevant organisational and ethical bodies in line with research governance requirements. The main ethical issues related to informed consent and assuring con dentiality and anonymity for all participants.

Procedure
Questionnaires were distributed to the gatekeeper in each clinical setting with the consent of the unit nurse manager/clinical nurse manager who provided a list of the total population of health professionals in the settings. A total of 4039 questionnaire packs were distributed across clinical settings. Participants were asked to complete the questionnaire and return it in the envelope provided for collection by a researcher (Data collected Mar -Dec 2015). The process of implied consent was made explicit in the Participant Information Sheet and sought whereby a completed questionnaire implies consent to participate. This ensured the con dentiality and anonymity of returned questionnaires. A deadline of two weeks was given for the return of questionnaires and a week of follow-up visits to retrieve them. Questionnaires collected were collated and categorised for data analysis by construct and clinical setting. A response rate of 31.8% (n=1283) was achieved (refer to Table 1).

Measurement Model
Construction of the measurement model for testing was based on the PCPF (refer to Figure 1). The 59 items of the PCPI-S map onto the 17 constructs of the framework, and the constructs onto second order latent factors. The relationship between the items and their unobserved rst order latent variables assumes the rst order latent variables drives the indicators (i.e. these indicators are assumed to be observable instances or manifestations of their unobserved latent variables, and thus changes in the unobserved latent variables are 'indicated' by observable changes in the items in its measure [20]. The relationship between item and rst order unobserved latent variable psychometric properties has been previously presented [12,13]. Similarly, a second order latent variable assumes the rst order latent variables to be 'driven' by the second order latent variable and its subsequent lter down to the items. Wang and Wang [20] suggest that the aggregation of items, to rst order and eventually to broad second order latent variables allows for complex models to be simpli ed and interaction effects between the second order variables examined. In this paper, structural modelling using actual scores for each construct will be used to t the second order latent variable measurement model and the relationship between the second order variables. The PCPF model postulates a direct relationship between second order latent variables Prerequisites and the Care Environment and subsequently Care Processes. This measurement model (see Figure 2) was tested as the initial model. Given the relative newness of the PCPI-S and the lack of comparative ndings relating to the testing and tting of the PCPF, a pragmatic approach to the speci cation of the model was applied.

Statistical Analysis
The data were prepared in line with descriptive and measures of dispersion statistics were generated for all items to help inform subsequent analysis. Inter-item correlations were generated to examine for collinearity prior to full analysis. Con rmatory factor analysis was used to examine the theoretical measurement model. Examination of the data indicates skewness and kurtosis on many of the items. Therefore, the data were analysed using Maximum Likelihood Robust (MLR) as relevant with continuous and skewed data.
The model was re-speci ed using the modi cation indices provided in the statistical output until acceptable and a statistically signi cant relationship identi ed. All re-speci cations of the model were guided by principles of meaningfulness (a clear theoretical rationale); Transitivity (if A is correlated to B, and B correlated to C, then A should correlate with C); Generality rule if there is a reason for correlating the errors between one pair of errors, then all pairs for which that reason applies should also be correlated [21].
Acceptance modi cation criteria included the following: 1. within factors inter-item correlated errors were permitted and based on criteria of being theoretically relevant introduced one at a time and selected on highest score rst (exceeding scores of 3.98).
2. across factors inter-item correlated errors were permitted and based on criteria of being theoretically relevant introduced one at a time and selected on highest score rst (exceeding scores of 3.98) 3. only statistically signi cant relationship retained to help produce as parsimonious a model as possible.
Acceptable t statistics were set at Root Mean Square Estimations of Approximation (RMSEA) of 0.08 or below; 90% RMSEA higher bracket below 0.08; and Comparative Fit Indices (CFI) of 0.90 or higher and TFI below 0.05 [20,22]. Hair et al [23] advocate a factor loading of 0.30 for a sample size of greater than n=350.

Results
A breakdown of the demographic details is outlined in Table 1. There was a good spread of responses across banding and experience. There was an uneven distribution across healthcare setting in the total sample as the organisations requested different samples to be surveyed. The correlation matrix scores (see table 3) indicate a positive correlation between the 17 measures at a low to moderate size.
There were no issues of collinearity between construct scores.    A standard unit change in Prerequisites will produce a 0.685 unit change in Care Environment; a 1 unit change in Prerequisites will produce a .875 unit change in Care Processes (See Figure 2). There was no signi cant relationship between care environment and care process.
Insert Figure 2 here.
'Shared Decision-making' was the most signi cant predictor of 'Care Environment' and all seven constructs contributed signi cantly to Care Environment. All ve constructs contributed signi cantly to 'Care Processes' but 'Sympathetic Presence' was the main contributor.

Discussion
Person-centred practice provides a central tenet underpinning health and social care internationally [1,2]. The Person-centred Practice Framework [11] is internationally recognised and is being implemented globally [24]. This paper provides for the rst time, statistical evidence of the relationships between the theoretical constructs of the framework and what these might mean for developing our understanding of person-centredness and its operationalisation in healthcare practice. Whilst the data reinforces the importance of the constructs of the framework and their relevance to person-centred healthcare, a number of issues are raised by the ndings of the study.
The signi cance of interpersonal skills as a core component of person-centred practice is reinforced by the nding that the constructs 'Developed Interpersonal Skills' and 'Being committed to the job' offer the largest contribution to 'the 'Prerequisites' domain. The prerequisites of the Person-centred Practice Framework focus on the qualities of the practitioner that need to be in place in order for person-centred practice to be realised. The fact that interpersonal skills and commitment to the job emerge as the most signi cant qualities that need to be in place for person-centred practice to happen is an illuminating nding. In their writing, McCormack and McCance [10] argue that person-centredness is essentially a relational practice that is dependent on wellestablished interpersonal skills that can be operationalised in different practice contexts. The signi cance of interpersonal relationships also reinforces the idea that person-centredness is more than the 'doing' of particular practices, but is much more about a way of 'being' as a practitioner. The dominant focus in healthcare developments and innovations on doing personcentredness is one of the reasons why despite more than 10 years of quality improvements focusing on person-centred practices, we continue to see problems in practice and the existence of what Laird et al [25] have described as 'person-centred moments' at best. Commitment to the job further reinforces the being of person-centredness. McCance & McCormack [11] de ne commitment to the job as 'the dedication of practitioners demonstrated to patients, families, and communities through intentional engagement that focuses on achieving the best possible outcomes' (pp55). Dedication implies presence and being in the moment with patients, families and communities and through such presence enables engagement. The ndings of this study reinforce the need for practitioners to have well-developed interpersonal skills that will enable them to be present with patients and families.
The fact that 'clarity of values and beliefs' had the least signi cance in explaining the theory, raises important issues about how person-centred practice cultures are developed. The data shows that values and beliefs are important and of course are essential to the being of the person-centred practitioner. However, the data also suggests that having clear beliefs and values is not enough in itself for person-centred healthcare. In contemporary healthcare there is signi cant emphasis placed on values and beliefs among healthcare teams through programmes such as 'Values in Action' https://www.hse.ie/eng/about/our-healthservice/values-in-action/valuesinactionblog/how-the-nine-values-in-action-behaviours-were-developed.html that reinforce the importance of particular values being evident in healthcare practice behaviours. What such programmes fail to recognise, however, are the complex factors that have to be addressed on a continuous basis for such values to be translated into everyday practice. Emancipatory and transformational practice development [5] methodologies however have played a signi cant role in demonstrating the need for continuous facilitated meaningful engagement to develop person-centred health cultures. Evidence from practice development programmes show how clarity of beliefs and values acts as a foundation for culture change, leadership development, team effectiveness and consistency in patient care [26,27]. Notably, such programmes also depend on long-term engagement for the development and embedding of culture change in healthcare settings -it is not a quick-x solution. This is both a strength and a weakness of practice development as in a fast-moving healthcare context, quick-x solutions that are the artefacts of person-centredness will always be favoured. Furthermore, the ndings from this study suggest that this focus needs to be questioned and challenged if we are to see a large-scale shift towards person-centred cultures becoming a norm in healthcare organisations.
The data also suggests that the 'shared decision-making systems' construct of the care environment domain was the most likely predictor of a person-centred culture. This nding reinforces the importance of interdisciplinarity and service-user participation in healthcare practice. An organisational commitment to collaborative, inclusive and participative ways of engaging within and between teams is essential for person-centred practice [11] (McCormack & McCance 2017). Shared decision-making among team members is the foundation of interdisciplinary practice [28] and the essence of person-centred healthcare. Ensuring that serviceusers play a key role in shaping their care plans is fundamental to person-centred practice and something that has been demonstrated to person-centred outcomes [29,30]. Research by Ekman and colleagues shows that when patients are active agents in the development of a care plan, when healthcare teams collaborate to ensure the implementation of the plan and when evaluation of the impact of the plan is undertaken from the perspective of the patient, then patient and team outcomes can be demonstrated. The ndings from the research reported in this paper reinforce the importance of this collaborative working and illustrate engagement in action and negotiation being achieved.
From the perspective of the 'person-centred processes', it is illuminating that the data suggests that being sympathetically present is core to all of the other person-centred processes -thus suggesting that being sympathetically present is a core person-centred practice. McCance & McCormack [11] (pp.57) de ne being sympathetically present as -"An engagement that recognises the uniqueness and value of the patient by appropriately responding to cues that maximise coping resources through the recognition of important agendas in the person's life". The statistical signi cance of sympathetic presence in this research further highlights the need for the professional development of healthcare practitioners to focus as much on helping them develop their 'ways of being' as much as it does focus on the competence of what they do. Being sympathetically present is a phenomenological process that reinforces the individuality of persons. As Callaghan [31] (pp.21) asserts: One of the di culties in dealing with anything related to human experience is caused by no two people being exactly alike. There is so much that we have in common that we are inclined to imagine everyone is the same. Everybody is not. That which has meaning for one person may have none for another. Something of immense signi cance for one will mean little or nothing to another. The basic axiom is that each person is an individual and as such, a unique entity. This must never be forgotten in our attempts at self awareness or in our dealings with others" Recognising this individuality is core to person-centred practice and the evidence from the research reported here reinforces that it is not something that person-centred practitioners do as a 'practice' but that it is an essence of being person-centred and underpins all practices. This is a signi cant nding from this research as it begins to surface issues that healthcare organisations may need to address for person-centred cultures to become a norm, including the reorganisation of services, challenging the standardisation agenda and protocolised care, as well as support systems for practitioners to enable them to sustain such individualised and engaged ways of being.
The ndings from the study provide new and innovative data relating to the realisation of person-centredness in healthcare and redress issues relating to the translation of person-centred principles into practice as identi ed by Moore et al [13] and Sharp and colleagues [14]. The evidence suggests that all the theoretical constructs make a statistical signi cant contribution to the overall understanding of person-centred practice and with varying degree of signi cance. Importantly, the ndings highlight the focus on speci c aspects of the framework to identify areas for change, facilitate change and evaluate it, so that the development of person-centred cultures can be sustained as a continuous focus in quality improvement programmes.
The ndings add to a growing evidence base for a psychometrically sound tool [12,19], that maps onto an established theoretical framework, redressing De Silva's [9] critique of tools to measure person-centred practice and relate the ndings to an acceptable theoretical framework. The PCPI-S has shown its value in measuring person-centred practice [32]. The ndings from this study continue to demonstrate that the PCPI-S has acceptable psychometric properties and displays the usefulness of the instrument as a means of informing how a theoretically driven approach to developing person-centredness in healthcare can be systematically developed through targeted interventions. The ndings show the role that 'prerequisites' (practitioner qualities) play in shaping the 'care environment' and engaging in 'person-centred processes'. This is as expected in McCormack and McCance's [11] theoretical framework and indicates that a focus on 'prerequisites' can produce signi cant changes in shaping the overall approach to realising person-centred healthcare cultures.

Limitations
Only minor modi cations (correlated errors) were required to the model to provide acceptable t statistics. The presence of correlated errors indicates the presence of in uential and as yet unmeasured elements. However, the Person-centred Practice Framework [11] contains elements (e.g. the macro context) that are not measured by the PCPI-S and should be included in modi cations to the instrument. This would provide a comprehensive assessment of person-centred practice and further help with the translational process. The theoretical framework requires further testing with varying samples, to further explore its potential and psychometric properties.

Conclusions
Person-centred practice is an internationally recognised indicator of good practice and the Person-centred Practice Framework is a strong theoretical model for realising this in everyday practice. This paper provides statistical evidence to support the Personcentred Practice Framework and uses an instrument that appears to effectively measure the relationships between the constructs underpinning the theory. This is the rst study that has attempted to articulate the relationship between person-centred constructs informed by an established theory. Ongoing research is needed to further test these relationships and build a reputable model of quality improvement that is theoretically driven and informs the development of targeted interventions that ful l the need to be context-speci c, but replicable across organisations and international contexts. Full ethical approval for the study was gained from the relevant institutions (Ulster University Nursing Filter Committee, Letterkenny University Hospital and Sligo University Hospital Ethics Committee). All ethical guidelines were adhered to during the study. Informed consent for use of the data was gained from all participants using implied consent. This ensured the anonymity of each submission. Participants received a participant information sheet explaining that the completion and return for the questionnaire implied consent to use the data.

Consent for Publication
Not applicable

Availability of Data and Materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.