Healthcare organizations are constantly aiming to improve the performance of the health services provided for chronically ill people. This is done via the implementation of several models of care. In recent years, the concept of patient-centered care has received increasing attention. Although several definitions of patient-centered care exist in the literature, the conceptualization of this concept for people with diabetes mellitus is poorly understood. This research was conducted to explore and clarify current definitions of patient-centered diabetes care in the context of nursing practice. Rodgers’ evolutionary model of concept analysis method was used to guide this inquiry. Results indicate that, patient-centered care has a holistic perspective: an approach that is vital in the delivery of nursing services that support patients’ choices and autonomy in their healthcare decisions. Findings suggest that, for patients with diabetes mellitus, this approach to care increased efficacy, achieved positive patient outcomes, and resulted in better interactions between patients and their professional teams.

DM: Diabetes Mellitus

PCC: Patient-Centered Care 

WHO: World Health Organization

RNAO: Registered Nurses’ Association of Ontario

IOM: Institute of Medicine

Diabetes mellitus (DM) has been identified as a significant health issue, which the World Health Organization (WHO) has declared an epidemic (WHO, 2021). DM is a global health concern due to its high prevalence, accompanied by premature morbidity and mortality, its influence on the quality of patients’ lives, and its impact on healthcare systems (International Diabetes Federation [IDF], 2020). Despite the growth in knowledge about DM and its treatment options, many diabetic people do not meet evidence-based goals and continue to experience preventable complications (Wisnewski, 2019). This ambivalence between optimal condition control and actual control can be attributed to numerous variables, among which are the clinician, the patient, and the health care system. Fundamental to all of these is the concept of patient-centered care (PCC). Managing the diabetic patient’s condition is a complex process that needs consistent self-care behaviors from the patient, such as attention to medication, diet, and exercise. It also requires the support of healthcare providers in encouraging patients to participate in their care plans (Wisnewski, 2019). Involving patients throughout the care and service process allows them to increase their self‐management, knowledge, and skills, thereby building confidence in their ability to control their condition and to improve their health-related outcomes (Wisnewski, 2019). Globally, healthcare organizations are intent on improving the performance of the healthcare services provided to chronically ill people through the implementation of various models of care (Rutten et al., 2018). In 2010, the Registered Nurses’ Association of Ontario (RNAO) declared that patients with chronic illness, such as DM, need to receive care that promotes their independence and self-management. Among chronic diseases, DM particularly exemplifies the direct relationship between patient behaviors and clinical outcomes. For chronic health conditions to be successfully managed, it is necessary to alter the way in which care is currently provided and to move toward PCC (RNAO, 2010). For the PCC model for diabetes to be correctly implemented, the components of that approach to care must be known and understood, while attention must also be paid to patient-specific factors that may influence outcomes (RNAO, 2010). In recent years, the concept of PCC has received increasing attention, and it is widely considered an essential prerequisite to quality health care (Boström et al., 2014; Burman et al., 2013; Rutten et al., 2018; Santana et al., 2018). Although several definitions of PCC exist in the literature, the conceptualization and implementation of PCC with diabetes are poorly understood among healthcare providers due to a lack of clarity in its definition. This paper therefore aims to conduct a concept analysis of patient-centered diabetes care in the context of nursing practice. Clarification of the concept of PCC is needed to assist healthcare providers, and particularly nurses, to understand this evolving concept better.

The purposes of this concept analysis are twofold:

To explore and clarify current definitions of patient-centered diabetes care in the context of nursing practice.

To identify the constructs that are antecedents, defining attributes, and consequences of patient-centered diabetes care in the context of nursing practice.

This study used Rodgers’ evolutionary concept analysis approach. The term “concept” is accepted as a method for labelling an observed phenomenon. Concepts are defined as the building blocks of theories or as a cluster of attributes that contribute significantly to the evolution of theories (Tofthagen & Fagerstrøm, 2010). Concept analysis is a dynamic, objective process through which one is able to clarify the current understanding of a concept in diverse disciplines, refine the concept to reduce ambiguity, identify all aspects of the concept, and provide a foundation for further development (Tofthagen & Fagerstrøm, 2010). Concept analysis is the foundational phase in any scientific research in all disciplines, including nursing. Thus, the findings of concept analysis are beneficial in making an understanding of a concept more concrete and comprehensible. They assist in the developing of research instruments, in developing theories to reflect the relationships between concepts, and therefore, the appropriate application of the concept. Understanding key concepts in nursing practice will help nurses to identify strategic interventions that can benefit patients. Of the numerous methods of conducting concept analysis, Rodgers’ evolutionary concept analysis model (1989) was selected because this model is considered to be an inductive method of analysis that develops over time with attention paid to methodological rigor, where the aspects of meaning and application are the main drivers of the concept development (Tofthagen & Fagerstrøm, 2010). The following activities, as proposed by Rodgers (1989), were used to guide the concept analysis: (1) identify the concept of interest, (2) identify surrogate terms for the concept, (3) identify and select an appropriate setting and realm (sample) for data collection, (4) collect data relevant to identifying the attributes and contextual bases of the concept, (5) analyze data to identify the attributes or characteristics of the concept, (6) identify the antecedents, consequences, and references of the concept, where possible, (7) identify concepts that are related to the term of interest, and (8) identify a model case for the concept.

Data Sources

The data were collected on the basis of Rodgers’ (1989) eight-step method. First, we identified the concept of PCC and sought its surrogate expressions, including the defining attributes, antecedents, consequences, and contexts, and including terms frequently utilized to depict PCC in the nursing, medical, and healthcare education literature. We explored surrogate or related terminology, such as “individualized-care,” “centered care,” and “person-centered care.” Our inclusion criteria specified that articles for consideration needed to include the concept of PCC in nursing practice and involve adults with chronic illness, and specifically, DM. In addition, articles needed to be in peer-reviewed journals, have abstracts, and be published in the English language. Articles about children were excluded. The articles all involved professional education within the nursing, medical, and healthcare disciplines. A 10-year time window was considered sufficient to identify the most recent perspectives. Brief, unreferenced editorials and commentaries on cultural competence were excluded from the search, as was literature on professional education from outside the disciplines of medicine, nursing and health care.

The Search Process

The following online databases were systematically searched: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID, PUBMED, and MEDLINE. The keywords used were patient-centered care, individualized-care, client-centered care, and person-centered care. To limit the search results, a Boolean advanced search was also employed, using the keywords “diabetes mellitus” and “nursing care” with the operator “AND”. The initial search produced 157 articles. After reading through the abstracts and skimming the articles, 52 were selected as meeting the inclusion criteria. These 52 articles were read by the two authors. The articles were accepted if some form of PCC was discussed in the article, and if its antecedents, attributes, and consequences could all be identified from the article. Duplicate articles were eliminated, and of the original 52 articles, 26 were included in the analysis.

The two authors carefully and objectively read all 26 articles selected for inclusion, in their entirety. As each article was read, relevant quotes were extracted. These quotes were then coded and identified as either antecedents, attributes, consequences, or related concepts. Next, each article was re-read and reviewed several times to evaluate for additional data that may have been missed during the initial review. Inductive thematic analysis of information relating to the concept was then carried out using the texts selected from the articles, and paying greater attention to frequently recurring themes. Finally, the themes were identified as the antecedents, attributes, or consequences of the concept and clustered accordingly.

Surrogates

The terms “patient-centered model” (Burman et al., 2013; Moore et al., 2017; Novikov et al., 2016; Ratner et al., 2017; Wisnewski, 2019), “patient-centered care” (Boström et al., 2014; Burman et al., 2013; Moore et al., 2017; Novikov et al., 2016; Ortiz, 2021; Ratner et al., 2017; Wisnewski, 2019), “person-centred care” (Moore et al., 2017; van Leeuwen & Jukema, 2018), “patient-focused care” (Boström et al., 2014; Wildeboer et al., 2018), “patient-centered transition of care” (Ortiz, 2021), and “patient-centered diabetes care” (Hamm et al., 2017; Kim et al., 2019) were all used in the literature as surrogate terms, and were often used interchangeably with “patient-centered diabetes care.”

Attributes

The defining attributes of a concept are the key characteristics that appear repeatedly in the literature, as these constitute the real definition of the concept (Tofthagen & Fagerstrøm, 2010). The analysis of patient-centered diabetes care in the context of nursing practice resulted in the following defining attributes: individualized care (understanding the patient’s particular disease (DM) journey in the light of the patient’s life context), sharing power and responsibility (egalitarian nurse-patient relationship), therapeutic alliance (a professional nurse-patient relationship, which entails listening, empathy, motivation, compassion, and unconditional positive regard), engaging (an important tool in empowering self-care in patient with DM and a significant tool in planning and implementing person-centered care), and unique (a consideration of the whole person’s needs and a valuing of the patient’s perspective and his/her unique characteristics) (Boström et al., 2014; Burman et al., 2013; Fix, et al., 2018; Greene, Tuzzio, & Cherkin, 2012; Hebblethwaite, 2013; Kelly et al., 2019; Moore et al., 2017; Novikov et al., 2016; Ortiz, 2021; Ratner et al., 2017; Santana et al., 2018; Thompson, 2019; Wisnewski, 2019).

Antecedents

Rodgers (1989) described antecedents as the phenomena, conditions, or events that must be in place prior to the manifestation of the concept (Tofthagen & Fagerstrøm, 2010). Three antecedents of patient-centered diabetes care in the context of nursing practice were identified in the literature: organization and leadership, professional training and education, and professional attitudes. Successful implementation of PCC requires changes in service delivery at both staff and organizational levels. The context of the healthcare environment is key in influencing others, whether through direct patient care or through executive practice that makes it possible to implement PCC successfully (Burman et al., 2013; Stenov et al., 2019). Having an organization’s vision, mission, and philosophy of care statement align with the principles of PCC is paramount in influencing the behaviors, actions, and interactions of the staff providing the care (Burman et al., 2013; Fix et al., 2018; Moore et al., 2017). To create and sustain a PCC climate, it is necessary to have policies and procedures that balance the values of respect, empowerment, and choice for the patients with organizational values in care delivery (Burman et al., 2013; Fix et al., 2018; Hwang et al., 2019; Santana et al., 2018). Establishing patient-centered diabetes care requires long-term commitment and support from the healthcare organization’s leaders at all levels (Boström et al., 2014; Fix et al., 2018). It is significant when nurse leaders, who serve as role models, conform consistently with the PCC approach (Moore et al., 2017; Stenov et al., 2019). A lack of support by nurse leaders for creating a PCC culture, engaging in PCC values, and maintaining a PCC approach prevents the nurses under them incorporating PCC into their daily working practice (Burman et al., 2013). Providing sufficient resources, support, education, and training are critical determining factors that influence the ability of nurses to provide care that is centered on the patient (Boström et al., 2014; Fix et al., 2018; Stenov et al., 2019; van Leeuwen & Jukema, 2018). Thus, nurses will not engage in activities relating to PCC at the bedside unless they have sufficient time to participate in training courses and educational sessions that equip them with PCC competency (Boström et al., 2014; Moore et al., 2017). In addition, it is essential for nurses to possess the skills and personal traits needed to implement PCC successfully in their duties. This will require them to integrate multiple elements, including the knowledge, techniques, attitude, thinking ability, and values that are required for PCC (Moore et al., 2017; van Leeuwen & Jukema, 2018). Nurses need to be motivated to actually want to become more knowledgeable and skillful in the successful implementation of PCC. Therefore, a lack of interest, knowledge, commitment, and professional attitude are all barriers to the successful implementation of PCC. In addition, having insufficient staffing, high staff workloads, and a lack of communication skills in nurses can all lead to a reduction in the practice of PCC (Boström et al., 2014; Fix et al., 2018; Greene et al., 2012; Hwang et al., 2019; Moore et al., 2017; Santana et al., 2018; Stenov et al., 2019).

Consequences 

Consequences are the outcomes that result from the occurrence or use of the concept of interest, and they may be positive or negative (Tofthagen & Fagerstrøm, 2010). The review of the literature indicates that the consequences of patient-centered diabetes care in the context of nursing practice are all positive. Practicing PCC leads to nurses respecting the values, beliefs, and unique needs of each patient when providing care (Burman et al., 2013; Oreofe & Oyenike, 2018; Ortiz, 2021). Nurses who provide PCC contribute to the increased satisfaction of diabetic patients with the care process. PCC helps patients to cope with their DM disease, increases their ability to adhere to their treatment regimens, to change their lifestyles appropriately, and to perform self-care activities correctly. It increase their feelings of well-being, improves the quality of their lives, and decreases their utilization of healthcare services (Ortiz, 202; Ratner et al., 2017; Slingerland et al., 2013; Stock et al., 2014). Additionally, care that is more person-centered improves safety in nursing practice, for example, by reducing medication errors, and it enhances rapport between patients and nurses, thereby building therapeutic relationships that result in improved quality-of-care and patient outcomes (Burman et al., 2013; Oreofe & Oyenike, 2018; Ortiz, 2021).

Related Concepts

Related concepts are concepts that have some relationship to the concept of interest but do not share the same set of attributes (Tofthagen & Fagerstrøm, 2010). Communication is related to patient-centered diabetes care in the context of nursing practice (Boström et al., 2014; Janes & Titchener, 2014; Kelly et al., 2019; Thompson, 2019; Wildeboer et al., 2018; Wisnewski, 2019). The term “communication” is defined as transmitting or exchanging information through words and behaviors between patients and healthcare providers to enable the latter to understand the patients’ health problems and needs over time and to provide appropriate care for these needs in the context of their other needs (Kelly et al., 2019). According to Kelly et al. (2019), poor patient outcomes are caused by gaps in communication between care providers and patients. With effective communication, positive patient outcomes increase and are indicated through patient satisfaction and adherence to therapy (Kelly et al., 2019). Wisnewski (2019) emphasizes that good communication skills are an important prerequisite for good care, and because of that, all healthcare providers need communication skills training. Gathering information through active listening to patients and discussing care plans with patients are critical components of communication, which healthcare providers need if they are to facilitate patient-centered care and enhance patient care (Kelly et al., 2019; Thompson, 2019; Wisnewski, 2019). In this analysis, there was a close relationship between the concept of PCC and the term “respect,” which refers to considering each patient’s voice to deliver responsible care based on their needs, preferences, cultures, beliefs, and personal values, including the nonmedical dimensions and their social circumstances (Boström et al., 2014; Janes & Titchener, 2014; Wildeboer et al., 2018; Wisnewski, 2019). According to Wisnewski (2019), all patients should be treated with dignity, with an acknowledgment of their value as unique individuals. Boström et al. (2014) emphasize that respect is a core component of caring that allows healthcare providers, including nurses, to be immersed in the entirety of the patient’s situation, seeing beyond the moment of care, knowing what will work, delving into the patient’s values, and being present with the patient to meet their greatest needs. Paying attention to the patients’ concerns, explaining their care plans, and protecting their privacy are all direct reflections of the healthcare providers’ respect for their patients (Janes & Titchener, 2014).

Model Case

Rodgers (1989) described how the next stage of the process was to identify model cases that illustrate the defining attributes and improve understanding of the concept (Tofthagen & Fagerstrøm, 2010). The case below is an example of such a model case. Mrs. Sara is a 54-year-old, married, and Middle Eastern woman who was diagnosed with type 2 diabetes several years ago. She was hospitalized with a hyperglycemic episode. During the initial assessment, the nurse assessed the patient’s previous experiences of treatment, and also her cultural, religious, social, and personal preferences. During that time, Mrs. Sara claimed that she was afraid of the future and expressed her frustration due to her loss of control of her blood glucose levels, and she then suddenly broke down and cried. She explained that she had lost her husband due to Covid-19, which made her feel that life was worthless, and this was the end of the world for her. The nurse realized that Mrs. Sara was suffering from emotional distress and needed help. So the nurse allowed Mrs. Sara to cry and then gently asked her if she would consider seeing a psychotherapist. She also tried to help Mrs. Sara to get on with her life by reinforcing the meaning of life for her and by encouraging her to participate in a support group and to keep in touch with her family, friends, and community. The nurse also encouraged her to make lifestyle changes, such as attempting to walk and spending time outdoors. The nurse also gave her the facts about DM and its treatment, and proceeded to provide empathic care to reduce Mrs. Sara’s emotional distress. During that time, the patient explained that she needed to pray, and she said it was a prayer time for her. Not being a Muslim, the nurse asked Mrs. Sara to explain what was needed. Mrs. Sara asked if she could change the gown provided by the hospital for her prayer clothes, and if possible, be given time, privacy, and a place to pray, and that interruptions should be avoided while she was praying. The nurse responded to the patient’s needs and approached Mrs. Sara’s concerns from a holistic and individualized perspective. Over the entire care period, the nurse provided Mrs. Sara with the necessary health knowledge that prompted her active participation in the treatment decisions (encouraged her autonomy). The nurse also listened carefully to all the patient’s concerns, preferences, and needs (a caring attitude), discussing the goals for her care, and allowing time for the patient to carefully consider her options before making a decision (individualization of care). In doing all this, the nurse was responding to Mrs. Sara’s needs, respecting her values, communicating, and treating her as a unique individual. All these behaviors support the defining attributes of PCC.

Definition of Patient-Centered Diabetes Care

The conceptual definition of patient-centered diabetes care that is specific to nursing practices, and as proposed in this concept analysis, is based on attributes identified from the literature. As such, patient-centered diabetes care in the context of nursing practices is defined as a standard of practice that considers patients with DM as whole persons with biological, psychological, and social needs, preferences, values, and wishes, which guide all nursing activities, interactions, and decision-making processes. This type of care goes far beyond simply setting nursing care goals for the patient, and requires of the nurse the integration of advocacy, communication skills, ethics, competency, and engagement in professional interactions and collaborations. In this way, the nurse is able to guide the patient with DM into wholistic health care activities and empower the patient by expanding their role in their own health care.

This concept analysis has attempted to provide a clearer definition of patient-centered diabetes care based on an identification of the terms and surrogate expressions used to describe and explain the concept. A comprehensive literature review was undertaken, and Rodgers’ (1989) evolutionary method was used for the analysis. When providing patient-centered diabetes care in the context of nursing practice, it is important to recognize and address the identified antecedents and attributes if the positive consequences of PCC are to be obtained. Our analysis revealed that shifting the treatment of DM away from a disease-focused approach and toward PCC is necessary to enhance the quality of care in healthcare systems. It is important to shift the focus away from the interests of the healthcare providers to thinking more about what matters to the patients, and to encourage patients with DM to play the major role in the management of their condition (Kelly et al., 2019; Ratner et al., 2017; Wisnewski, 2019). PCC is a promising approach to care that is particularly well suited to supporting patients’ self-management of DM. A growing body of evidence has linked PCC in DM with increased patient satisfaction, enhanced patient well-being, decreased symptom burden, improved patient-provider communication, decreased healthcare utilization, and increased efficiency of care (Burman et al., 2013; Fix et al., 2018; Oreofe & Oyenike, 2018; Ortiz, 2021; Ratner et al., 2017; Slingerland et al., 2013; Stock et al., 2014). In the course of this concept analysis, several definitions of PCC were identified. The IOM (2001) defined PCC as “care that is respectful and responsive to individual patient preferences, needs, and values, and ensures that patient values guide all clinical decisions” (p. 49). By 2010, the IOM defined PCC as a model of clinical practice aimed at providing care that respects patients’ needs and preferences, involving the patient in shared decision-making, advocating, and coordinating care. Ortiz (2021) goes further in his definition of PCC in the nursing context as being a holistic (bio-psychosocial-spiritual) approach to delivering care that is organized around the patient, where providers partner with patients and their families to identify and meet the patients’ needs and preferences. Similarly, Slingerland et al. (2013) describe PCC in the context of diabetes as a comprehensive treatment strategy that meets each patient’s physical, psychological, and social needs. Oreofe and Oyenike (2018) also identify PCC in the nursing context as a complex approach to care that involves various interactions between the patient, the nurse, and the environment, with the ultimate goal of meeting each patient’s physical, psychological, and social needs. According to Hwang et al. (2019), PCC is a multidimensional concept with a strong emphasis on patient participation in treatment decisions and care management, recognizing that this is a context in which patients’ values, needs, and preferences can easily be neglected. Although patient participation in healthcare decisions is recognized as being a core element of patient-centered care, implementing and maintaining this approach to care is not easy. A cross-sectional study was conducted with a sample of 479 nurses at two general hospitals in Korea. This revealed that patient participation in clinical decisions was not easily achieved, and the degree of patient participation was low (Hwang et al., 2019). Interestingly, the study also revealed that patients preferred to participate passively in healthcare encounters and to comply with medical instructions without asking about care plans or the purpose of their medication (Hwang et al., 2019). Another aspect that emerged from the results of this study was that nurses who had a high level of competency in patient-centered care experienced greater patient participation in the care process. There is therefore a need to enhance nurses’ competency in patient-centered care to promote patient participation and ultimately safer health care (Hwang et al., 2019). In this paper, PCC has been analyzed in the nursing context, specifically as addressed by Burman et al. (2013) and Kelly et al. (2019), as a concept that places patients at the center of their own care and develops good services that ensure that the patient’s values guide all clinical decisions and that patients are treated in a dignified and supportive manner. Kelly et al. (2019) emphasizes that hospitality, safety, welcoming, and everydayness are crucial dimensions of a person-centered environment. In their discussion of PCC, these researchers highlight that nurses need to pay greater attention to patients’ needs and help them to make choices about their day-to-day lives (Kelly et al., 2019). The researchers state that considering the psychosocial aspects of care for patients with long-term chronic conditions is fundamental to providing a more person-centered care environment (Kelly et al., 2019). Boström et al. (2014) and Henschen et al. (2019) explored PCC in the context of DM and both point out that achieving PCC requires healthcare providers to offer well-coordinated and integrated services that consciously adopt the patient’s perspective. These researchers emphasize that PCC is an approach involving care that reinforces patient–provider communication, and that this includes listening, discussing, and interacting with patients rather than just giving information.

PCC is a dynamic concept that is still evolving within the practice of nursing. Foundational behaviors of PCC include providing holistic care, delivering comprehensive care, individualizing patient care plans, responding to patients’ needs, respecting patients’ values, communicating and listening, encouraging patient autonomy, empowering self-care, tailoring care, treating the patient as a unique individual, collaborating with the patient, engaging patients in their care, and providing integrated care and whole-person care. These behaviors are foundational to nursing practice and are the basic dimensions of quality nursing care. In 2010, the IOM recommended in The Future of Nursing: Leading Change, Advancing Health that, as nurses represent the largest segment of the healthcare workforce, there is a need to expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Importantly, it says, “Producing a health care system that delivers the right care—quality care that is patient centered, accessible, evidence based, and sustainable—at the right time will require transforming the work environment, scope of practice, education, and numbers of America’s nurses” (IOM, 2010, p. 4). Thus, healthcare organizations should support and help nurses to link their nursing to high quality patient care, which includes protecting patient safety and meeting defined (organizational or professional society) standards of practice, so that nurses can act as partners with physicians and other health professionals. Higher levels of education and training are needed if nurses are to value PCC as the preferred way of caring and to adopt new roles quickly in response to rapid changes in healthcare settings and in an evolving health care system. PCC is thus a key responsibility of nurses in the provision of health care today. Proper implementation of PCC in diabetes care requires knowledge of the components of that standard of care as well as attention to patient-specific factors that may influence outcomes. Further research is needed to explore the impact of technology on patient-centered care, how the nursing shortage affects the practice of patient-centered care, and what resources should be developed to assist nurses in delivering patient-centered care. Research is also needed to identify additional variables that have an impact on PCC within the practice of nursing and the consequences of PCC in specific nursing situations.

Ibtesam Alqahtani and Jawhrah Alqahtani contributed to conceptualisation, writing, critical review, commentary and revision. "We also, would like to acknowledge King Saud University for their unwavering support of researchers and commitment to academic development."

No conflict of interest has been declared by the authors. All authors reviewed, edited and approved the final version.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.