Quality care for individuals facing chronic illnesses, functional limitations, or a combination of both has risen to the forefront as a primary goal within medical and care services. Person-centered care (PCC) stands as a cornerstone not only in achieving this objective but also in delivering superior health maintenance and medical attention [1,2,3]. Beyond upholding fundamental human rights, PCC offers significant advantages to both care recipients and providers [4, 5]. Moreover, the effective implementation of person-centered care necessitates a specific skill set among healthcare professionals to navigate the complexities of this approach [6]. Key components of PCC include [7]: personalized, goal-oriented care plans tailored to individual preferences; continuous review of these plans and goals; support from a multidisciplinary team; robust coordination among all involved healthcare and support providers; ongoing education and information sharing for professionals; and quality enhancement through feedback from individuals and their caregivers.
The body of research dedicated to the practical application of PCC is steadily expanding. A notable example is McCormack’s widely recognized mid-range theory [8], a globally respected framework that outlines PCC and its implementation. This framework serves as a practical guide for healthcare practitioners and researchers, particularly within hospital environments. PCC, in this context, is defined as “an approach to practice that is developed through the establishment and nurturing of therapeutic relationships among all care providers, service users, and their significant others, grounded in values of respect for individuals, their inherent right to self-determination, mutual respect, and understanding” [9].
As highlighted by the principles of PCC, it is crucial to recognize that “person” in the context of care extends beyond just the recipient to include all participants in the care process [10, 11]. PCC necessitates that professionals receive training in relevant methodologies and skills, as caregivers significantly influence the quality of life for those under their care [12,13,14]. Furthermore, acknowledging the substantial demands placed on caregivers, their well-being is paramount. Emerging research suggests that implementing PCC can yield considerable benefits for both care recipients and their caregivers [15].
Despite extensive literature and frequent mentions in healthcare policy and research [16], PCC implementation faces several hurdles. A universal definition of PCC remains elusive [17], causing issues in areas like effectiveness evaluation [18, 19]. The challenge of quantifying the subjective aspects of PCC dimensions and the infrequent use of standardized assessment tools are significant concerns [20]. These challenges led to the development of the Person-Centered Care Assessment Tool (P-CAT) [21]. The P-CAT was conceived as a concise, cost-effective, user-friendly, adaptable, and thorough instrument for reliably and validly measuring PCC in research settings [21].
Understanding the Person-Centered Care Assessment Tool (P-CAT)
While numerous tools are available to evaluate PCC from various angles (caregiver or recipient perspectives) and across different environments (hospitals, nursing homes), the P-CAT stands out for its brevity and simplicity, encompassing all core elements of PCC identified in the literature. Originally designed in Australia for long-term care settings for older adults with dementia, its application is expanding into other healthcare domains, including oncology [22] and psychiatric facilities [23].
The P-CAT’s appeal lies in its conciseness, ease of use, adaptability to diverse medical and care settings, and its potential for emic applicability (cross-culturally relevant constructs with consistent structure and interpretation [24]). Consequently, it is a favored tool among professionals for PCC measurement [25, 26], extending across numerous countries with varied linguistic and cultural backgrounds. Since its inception, the P-CAT has been adapted and validated in countries with significant cultural and linguistic differences, including Norway [27], Sweden [28], China [29], South Korea [30], Spain [25], and Italy [31].
The P-CAT consists of 13 items scored on a 5-point scale (ranging from “strongly disagree” to “strongly agree”), where higher scores reflect greater person-centeredness. It is structured around three dimensions: person-centered care (7 items), organizational support (4 items), and environmental accessibility (2 items). The original validation study (n = 220; [21]) demonstrated satisfactory internal consistency for the total scale (α = 0.84) and good test-retest reliability (r =.66) over a one-week period. A 2021 reliability generalization study [32] assessing the P-CAT’s internal consistency across 25 meta-analysis samples (including some validation studies mentioned above) reported a mean α value of 0.81. The mean age of the sample was identified as the only variable significantly impacting the reliability coefficient. Factor analysis revealed three factors, accounting for 56% of the total variance, while content validity was affirmed through expert reviews, literature analysis, and stakeholder input [33].
While not explicitly stated, validation studies across different language versions of the P-CAT may be implicitly guided by a long-standing validity framework distinguishing content, construct, and criterion validity [34, 35]. However, a modern validity framework-based re-evaluation of the P-CAT, offering a refined definition of validity, has yet to be undertaken.
Scale Validity and Modern Frameworks
Traditionally, validation has been viewed as a process focused on the psychometric attributes of a measurement instrument [36]. In the early 20th century, the increased use of standardized tests in education and psychology led to two validity definitions: one defining validity as the extent to which a test measures its intended construct, and another describing it as the correlation of an instrument with a specific variable [35].
Over the last century, validity theory has evolved, shifting towards an understanding that validity should be grounded in specific interpretations for a defined purpose. It should not solely rely on empirically derived psychometric properties but also be supported by the theoretical underpinnings of the measured construct. The distinction between classical and modern validity theory highlights this evolution in understanding. Classical Test Theory (CTT) represents the traditional approach, while modern approaches emphasize (a) a unified view of validity and (b) validity judgments based on inferences and interpretations of measure scores [37, 38]. This advancement led to the creation of frameworks for gathering evidence to support the interpretation and application of instrument scores [39].
The Standards for Educational and Psychological Testing (“Standards”), published by the American Educational Research Association (AERA), the American Psychological Association (APA), and the National Council on Measurement in Education (NCME) in 2014, serve this purpose. These standards offer guidelines for evaluating the validity of score interpretations based on their intended use. Two key concepts in this modern view are: first, validity is a unified concept focused on the construct; second, validity is “the degree to which evidence and theory support the interpretations of test scores for proposed uses of tests” [37]. The “Standards” propose five sources of validity evidence [37]: test content, response processes, internal structure, relations to other variables, and consequences of testing. Test content validity relates to the relevance of test administration, subject matter, item wording, and format to the intended construct, primarily assessed using qualitative methods, though quantitative approaches can be included. Response process validity examines the cognitive processes and item interpretation by respondents, using qualitative methods. Internal structure validity focuses on the interrelationships between items and the construct, assessed quantitatively. Validity concerning relationships with other variables compares the measured construct with theoretically relevant external variables, using quantitative methods. Lastly, validity based on testing consequences analyzes both intended and unintended outcomes that might stem from invalidity, mainly through qualitative methods.
Despite the crucial role of validity in establishing a strong scientific basis for score interpretations, health field validation studies have often prioritized content, criterion, and construct validity, neglecting the interpretation and application of scores [34].
The “Standards” framework is considered appropriate for reviewing questionnaire validity due to its capacity to analyze validity sources using both qualitative and quantitative methods and its evidence-based approach [35]. However, due to limited awareness or lack of systematic protocols, few instruments have been evaluated using the “Standards” framework to date [39].
Current Research and the P-CAT
Despite the widespread use of the Person-Centered Care Assessment Tool (P-CAT) and its seven validations [25, 27,28,29,30,31, 40], a validity analysis within the “Standards” framework is lacking. Empirical evidence supporting the P-CAT’s validity has not been synthesized to form a comprehensive judgment based on available data.
Such a review is essential due to unresolved methodological issues with the P-CAT. For instance, while its multidimensionality was identified in the original study, Bru-Luna et al. [32] noted that subsequent adaptations [25, 27,28,29,30, 40] often utilize the total score for interpretation, neglecting its multidimensional structure. The original multidimensionality, therefore, appears not to be consistently replicated. Bru-Luna et al. [32] also pointed out that the internal structure validity of the P-CAT is frequently underreported due to a lack of robust methods for definitively establishing score calculations.
The validity of the P-CAT, particularly its internal structure, remains uncertain. Nevertheless, both research and professional practice highlight the relevance of this tool in assessing PCC. This perception, however, may be subjective and insufficient for a comprehensive validity assessment based on prior validation studies. A proper validity evaluation necessitates a model for conceptualizing validity, followed by a review of existing P-CAT validity studies using this model.
Consequently, this study aimed to systematically review the evidence from P-CAT validation studies, employing the “Standards” as a guiding framework.
References
[1] Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy; 2001.
[2] International Alliance of Patients’ Organizations. What is patient-centred healthcare? A review of definitions and principles. 2nd ed. London, UK: International Alliance of Patients’ Organizations; 2007.
[3] World Health Organization. WHO global strategy on people-centred and integrated health services: interim report. Geneva, Switzerland: World Health Organization; 2015.
[4] Britten N, Ekman I, Naldemirci Ö, Javinger M, Hedman H, Wolf A. Learning from Gothenburg model of person centred healthcare. BMJ. 2020;370:m2738.
[5] Van Diepen C, Fors A, Ekman I, Hensing G. Association between person-centred care and healthcare providers’ job satisfaction and work-related health: a scoping review. BMJ Open. 2020;10:e042658.
[6] Ekman N, Taft C, Moons P, Mäkitalo Å, Boström E, Fors A. A state-of-the-art review of direct observation tools for assessing competency in person-centred care. Int J Nurs Stud. 2020;109:103634.
[7] American Geriatrics Society Expert Panel on Person-Centered Care. Person-centered care: a definition and essential elements. J Am Geriatr Soc. 2016;64:15–8.
[8] McCormack B, McCance TV. Development of a framework for person-centred nursing. J Adv Nurs. 2006;56:472–9.
[9] McCormack B, McCance T. Person-centred practice in nursing and health care: theory and practice. Chichester, England: Wiley; 2016.
[10] Nolan MR, Davies S, Brown J, Keady J, Nolan J. Beyond person-centred care: a new vision for gerontological nursing. J Clin Nurs. 2004;13:45–53.
[11] McCormack B, McCance T. Person-centred nursing: theory, models and methods. Oxford, UK: Wiley-Blackwell; 2010.
[12] Abraha I, Rimland JM, Trotta FM, Dell’Aquila G, Cruz-Jentoft A, Petrovic M, et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open. 2017;7:e012759.
[13] Anderson K, Blair A. Why we need to care about the care: a longitudinal study linking the quality of residential dementia care to residents’ quality of life. Arch Gerontol Geriatr. 2020;91:104226.
[14] Bauer M, Fetherstonhaugh D, Haesler E, Beattie E, Hill KD, Poulos CJ. The impact of nurse and care staff education on the functional ability and quality of life of people living with dementia in aged care: a systematic review. Nurse Educ Today. 2018;67:27–45.
[15] Smythe A, Jenkins C, Galant-Miecznikowska M, Dyer J, Downs M, Bentham P, et al. A qualitative study exploring nursing home nurses’ experiences of training in person centred dementia care on burnout. Nurse Educ Pract. 2020;44:102745.
[16] McCormack B, Borg M, Cardiff S, Dewing J, Jacobs G, Janes N, et al. Person-centredness– the ‘state’ of the art. Int Pract Dev J. 2015;5:1–15.
[17] Wilberforce M, Challis D, Davies L, Kelly MP, Roberts C, Loynes N. Person-centredness in the care of older adults: a systematic review of questionnaire-based scales and their measurement properties. BMC Geriatr. 2016;16:63.
[18] Rathert C, Wyrwich MD, Boren SA. Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev. 2013;70:351–79.
[19] Sharma T, Bamford M, Dodman D. Person-centred care: an overview of reviews. Contemp Nurse. 2016;51:107–20.
[20] Ahmed S, Djurkovic A, Manalili K, Sahota B, Santana MJ. A qualitative study on measuring patient-centered care: perspectives from clinician-scientists and quality improvement experts. Health Sci Rep. 2019;2:e140.
[21] Edvardsson D, Fetherstonhaugh D, Nay R, Gibson S. Development and initial testing of the person-centered Care Assessment Tool (P-CAT). Int Psychogeriatr. 2010;22:101–8.
[22] Tamagawa R, Groff S, Anderson J, Champ S, Deiure A, Looyis J, et al. Effects of a provincial-wide implementation of screening for distress on healthcare professionals’ confidence and understanding of person-centered care in oncology. J Natl Compr Canc Netw. 2016;14:1259–66.
[23] Degl’ Innocenti A, Wijk H, Kullgren A, Alexiou E. The influence of evidence-based design on staff perceptions of a supportive environment for person-centered care in forensic psychiatry. J Forensic Nurs. 2020;16:E23–30.
[24] Hulin CL. A psychometric theory of evaluations of item and scale translations: fidelity across languages. J Cross Cult Psychol. 1987;18:115–42.
[25] Martínez T, Suárez-Álvarez J, Yanguas J, Muñiz J. Spanish validation of the person-centered Care Assessment Tool (P-CAT). Aging Ment Health. 2016;20:550–8.
[26] Martínez T, Martínez-Loredo V, Cuesta M, Muñiz J. Assessment of person-centered care in gerontology services: a new tool for healthcare professionals. Int J Clin Health Psychol. 2020;20:62–70.
[27] Rokstad AM, Engedal K, Edvardsson D, Selbaek G. Psychometric evaluation of the Norwegian version of the person-centred Care Assessment Tool. Int J Nurs Pract. 2012;18:99–105.
[28] Sjögren K, Lindkvist M, Sandman PO, Zingmark K, Edvardsson D. Psychometric evaluation of the Swedish version of the person-centered Care Assessment Tool (P-CAT). Int Psychogeriatr. 2012;24:406–15.
[29] Zhong XB, Lou VW. Person-centered care in Chinese residential care facilities: a preliminary measure. Aging Ment Health. 2013;17:952–8.
[30] Tak YR, Woo HY, You SY, Kim JH. Validity and reliability of the person-centered Care Assessment Tool in long-term care facilities in Korea. J Korean Acad Nurs. 2015;45:412–9.
[31] Brugnolli A, Debiasi M, Zenere A, Zanolin ME, Baggia M. The person-centered Care Assessment Tool in nursing homes: psychometric evaluation of the Italian version. J Nurs Meas. 2020;28:555–63.
[32] Bru-Luna LM, Martí-Vilar M, Merino-Soto C, Livia J. Reliability generalization study of the person-centered Care Assessment Tool. Front Psychol. 2021;12:712582.
[33] Edvardsson D, Innes A. Measuring person-centered care: a critical comparative review of published tools. Gerontologist. 2010;50:834–46.
[34] Hawkins M, Elsworth GR, Nolte S, Osborne RH. Validity arguments for patient-reported outcomes: justifying the intended interpretation and use of data. J Patient Rep Outcomes. 2021;5:64.
[35] Sireci SG. On the validity of useless tests. Assess Educ Princ Policy Pract. 2016;23:226–35.
[36] Hawkins M, Elsworth GR, Osborne RH. Questionnaire validation practice: a protocol for a systematic descriptive literature review of health literacy assessments. BMJ Open. 2019;9:e030753.
[37] American Educational Research Association, American Psychological Association. National Council on Measurement in Education. Standards for educational and psychological testing. Washington, DC: American Educational Research Association; 2014.
[38] Padilla JL, Benítez I. Validity evidence based on response processes. Psicothema. 2014;26:136–44.
[39] Hawkins M, Elsworth GR, Hoban E, Osborne RH. Questionnaire validation practice within a theoretical framework: a systematic descriptive literature review of health literacy assessments. BMJ Open. 2020;10:e035974.
[40] Le C, Ma K, Tang P, Edvardsson D, Behm L, Zhang J, et al. Psychometric evaluation of the Chinese version of the person-centred Care Assessment Tool. BMJ Open. 2020;10:e031580.
