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Deliberate and emergent strategies for implementing person-centred care: a qualitative interview study with researchers, professionals and patients
© The Author(s). 2017
Received: 24 October 2016
Accepted: 24 July 2017
Published: 4 August 2017
The introduction of innovative models of healthcare does not necessarily mean that they become embedded in everyday clinical practice. This study has two aims: first, to analyse deliberate and emergent strategies adopted by healthcare professionals to overcome barriers to normalization of a specific framework of person-centred care (PCC); and secondly, to explore how the recipients of PCC understand these strategies.
This paper is based on a qualitative study of the implementation of PCC in a Swedish context. It draws on semi-structured interviews with 18 researchers and 17 practitioners who adopted a model of PCC on four different wards and 20 patients who were cared for in one of these wards. Data from these interviews were first coded inductively and emerging themes are analysed in relation to normalization process theory (NPT).
In addition to deliberate strategies, we identify emergent strategies to normalize PCC by (i) creating and sustaining coherence in small but continuously communicating groups (ii) interpreting PCC flexibly when it meets specific local situations and (iii) enforcing teamwork between professional groups. These strategies resulted in patients perceiving PCC as bringing about (i) a sense of ease (ii) appreciation of inter-professional congruity (ii) non-hierarchical communication.
NPT is useful to identify and analyse deliberate and emergent strategies relating to mechanisms of normalization. Emergent strategies should be interpreted not as trivial solutions to problems in implementation, but as a possible repertoire of tools, practices and skills developed in situ. As professionals and patients may have different understandings of implementation, it is also crucial to include patients’ perceptions to evaluate outcomes.
As ‘deliberately initiated attempts to introduce new, or modify existing patterns of collective action’ , complex interventions may be ostensibly adopted by practitioners, but they do not necessarily become embedded in everyday clinical practice. The study of implementation strategies as “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” (, p.2) has gained salience in the literature. As these strategies have been rarely defined , there have been significant attempts to avoid inconsistent language use and inadequate descriptions [3–6] and to clarify models and theories used in implementation . As Greenhalgh et al.  argue, implementation is often a nonlinear process characterized by multiple shocks, setbacks, and unanticipated events (, p. 610). Local adaptations are inevitable . In order to change the way healthcare is delivered, it is imperative to take into account the present structures, attitudes and assumptions and how potential and actual challenges are handled by implementers and early adopters. At this point, we want to draw upon deliberate and emergent strategies as they were conceptualised by Mintzberg and Water  not to add to the taxonomy of types of strategies, but rather to highlight the nature of implementation strategies. Deliberate strategies are strategies that are introduced as intended according to a specific agenda set by an organisation, while emergent strategies arise in response to contingencies encountered when pursuing deliberate strategies. In other words, deliberate strategies appear prior to the initiation of a novel type of collective action and offer prescriptions and itineraries based on evidence and intuition (see also ), whereas emergent strategies imply “learning what works–taking one action at a time in search for that viable pattern or consistency” (, p.271). By employing this classification, we want to emphasise that challenges to implementing a complex intervention are collectively and creatively interpreted and handled in practice . Rather than driving a wedge between ‘fidelity’ and ‘flexibility’, this classification may help to explain the dynamic, often corrective and adaptive nature of implementation strategies. For complex interventions, there are often planned responses to expected problems. It is crucial to see how a set of practices are locally interpreted and modified in practice , which is often possible due to emergent strategies.
Over the past half century paternalistic and disease-focused approaches in healthcare have been criticized. There is a growing literature on patient-centred consultations , patient-centredness [14, 15] and person-centred care [16–19] to underline care as “respectful and responsive to individual patient preferences, needs, and values” (, p.49). Even though the terms ‘patient’, ‘client’ and ‘person’ are often used interchangeably in the literature , the idea of attending to the person behind the patient has paved the way for interventions in terms of enabling and encouraging persons to bring their knowledge, preferences and capabilities into decision making and care planning . In this way, person-centredness acknowledges to a higher degree compared to patient-centredness the resources and capacities of the person. The study of strategies for implementing these relatively new models of patient and person-centred care is crucial for better understanding the changes they aim for in preparing, enacting and delivering healthcare.
A recent evidence-based person-centred care (PCC) framework developed by the University of Gothenburg Centre for Person-Centred Care (GPCC) was implemented in different healthcare contexts in Sweden [22, 23]. This framework involves three practices that are intentionally called ‘routines’; collecting the patient’s narrative, establishing partnership by setting goals together and documenting this partnership [22, 24]. These routines require behavioural, technological and organisational changes; hence the model fits in the definition of a complex intervention . The choice of the term ‘routines’ implies that implementation is conceived to embed and sustain certain everyday practices. The GPCC framework has been shown to be effective in clinical studies for people with hip fractures [25, 26], chronic health failure , rheumatoid arthritis  and acute coronary syndrome . However, the implementation of the framework has attracted less scholarly attention [30, 31]. Further research is needed to understand how the framework can be introduced and how and whether it can be sustained.
This study has two aims: first, to explore the deliberate and emergent strategies of key stakeholders to specific contextual challenges encountered when implementing the GPCC framework; and secondly, to explore how the recipients of PCC perceived the effects of these strategies.
Sample and design
Qualitative semi-structured interviews were conducted with three groups. We used a purposive sampling strategy to select researchers and healthcare professionals and a convenience sampling approach for patients. The first group of respondents (n = 18) were researchers in different PCC intervention studies selected to represent different contexts of PCC (see also [11, 24, 32]). The second group (n = 17) were healthcare practitioners who worked in hospital wards enrolled in a larger PCC implementation project at a university hospital in Sweden, or in other healthcare settings used as study sites for GPCC interventions. Hospital wards varied in size, specialisation and patient group. Practitioners took part in a 10-week PCC change management programme, dealing with the ethics of PCC and results from PCC studies. This includes training in developing tools such as care plans and interview techniques. Each ward manager was contacted with information about the study and gave their consent. They were asked to recruit a nurse, an assistant nurse and a physician with experience of working with PCC. Five registered nurses, four assistant nurses, four ward managers and four physicians participated in the study. The third group (n = 20) were patients who had recently been hospitalised, at the time of the interview, to a medical ward where the GPCC framework had been systematically implemented over several years. Patients were eligible for enrolment into the study if they were cognisant and able to communicate in Swedish. A nurse coordinator provided eligible patients with the study information (see also ).
Interviews with researchers were conducted by AW, DL, ME, ÖN. Interviews with practitioners were conducted by AW, DL and a research assistant (MH) and the interviews with patients were conducted by MH. Slightly different topic guides were used for the three different groups (see these guides in ). Questions for researchers and practitioners sought to elicit how PCC related to the everyday work of healthcare practitioners. An additional topic guide was used for the patient interviews . This topic guide was intended to elicit patients’ experiences of care on the ward and their understanding of PCC. Guides were not restricted to questions concerning the implementation of PCC; they rather sought to uncover a wide range of topics about the philosophy, practice and definition of PCC. Interviews lasted between 29 min and 1 h and were audio recorded, transcribed verbatim, anonymised and translated from Swedish into English. Interviews with patients were conducted in their homes, on the hospital ward or by telephone according to their preference. All interviewees were given a pseudonym to maintain anonymity (Researchers represented with R, healthcare practitioners with H and patients with P). All participants prior to their interview were provided written and verbal information and gave informed consent. The study was approved by the regional ethics committee in Gothenburg.
Each transcript was first coded inductively. For the interviews with researchers and practitioners, descriptive codes were created to map different challenges to implementation and the strategies reported by the interviewees. After the initial coding, strategies to overcome reported challenges were divided into two groups as deliberate and emergent . Then, using the framework method , challenges to implementation, deliberate and emergent strategies were grouped and analysed according to four components of Normalization Process Theory [35, 36]. NPT is an influential framework used to understand and assess the implementation of complex interventions in healthcare, especially technological interventions, and has been shown to be useful in several studies [37–40]. Normalization means that an intervention becomes ‘routinely embedded in the matrices of already existing, socially patterned, knowledge and practices’ . This sets normalization apart from a simple adoption or insertion of a new set of ideas and practices into an organisational vacuum.
Mapping of GPCC challenges and strategies against NPT constructs
Constructs of NPT
(2) Communal specification
(3) Individual specification
Conflicting and/or divergent views and expectations about PCC
Translating abstract principles into concrete practices
Education and seminars organized by GPCC
Design of the training programme allowing for contextual adaptations and developments
Lunch seminars, informal meetings, inter-professional discussions in small groups
Invited lectures and seminars
Individual and/or collective ways of relating to professional experiences
Resistance (to change)
Force of habit
Different approaches among professionals (mainly nurses and doctors)
Fatigue from previous implementations
Education and seminars organized by GPCC
Use of research-based evidence (e.g. reduced time of hospitalisation)
Using leading personalities, initiators (“ambassadors”), engaging previous personal relations at work
Convincing and motivating unwilling actors (e.g. doctors with “scientific” evidence)
Interpretation and collective development of routines (e.g. documentation)
(1) Interactional workability
(2) Relational integration
(3) Skill set workability
(4) Contextual integration
Organizational problems (rotation of the staff and the physical environment)
Inter-professional hierarchies (mainly between nurses and doctors)
Different patient groups with specific conditions and needs
Division of workload (e.g. increased documentation)
Funding and extra staff (research nurses)
Transfer of expertise via researchers and experienced implementers
Use of scales and technologies
Commitment and support of managers (e.g. initiating and consolidating teamwork)
Strengthening teamwork by engaging all expertise in the team (the patient included) and empowering nurses to contribute more to decision making
Developing new practices to safeguard continuity (e.g. introduction programmes for new staff
(2) Communal appraisal
(3) Individual appraisal
Increased number of patients and more workload from documentation
Focus on shortening hospitalisation time
Small group discussions, “ethical forums”
Continuous education, evaluation in practice
Evaluation of the workload
First, we will present the barriers to the four mechanisms of normalization, and deliberate and emergent strategies responding to these barriers as reported by researchers and practitioners (see Table 1). In the second part, we will explain three effects of these strategies on patients: they felt a sense of ease and reported inter-professional congruity and non-hierarchical communication.
Barriers and emergent strategies
Ensuring coherence: Small-group and informal meetings
There is obviously the definition we use in GPCC [it] is not, does not need to be the same for everyone. There could be other, and there are other ways of viewing this where you set up other criteria. (R7)
There’s always been person-centred healthcare, but we’ve called it different things throughout the course of history: humanistic nursing and all the possible different angles of approach. (R2)
Some may feel like this is obvious and that we always work in this way. This might create a resistance, like “why should we force an open door or do these obvious things?” But it may not be obvious to everyone, and if you make it more structured it becomes more visible in a different way. (H9)
I’ve always been interested in the patients’ own narratives, and when they had attended this education and passed it onto us, you got to put it into words what you’ve always thought about in a way. (H7)
We did have lunches together with different occupational groups; nurses, assistant nurses and doctors. At least one of each group had attended the education, so we had a little brainstorming and we simply talked about what person-centred care meant for me, what it meant for the assistant nurse and for the doctor. (…) we talk about it from different perspectives and different angles all the time. (H7)
These discussions helped practitioners differentiate PCC from their usual practice. These inter-professional communication groups enabled practitioners to bring their previous experiences and individual concerns to the sense-making work. Some practitioners could link their professional experience and individual techniques to the emphasis on the person and their narratives.
Endorsing cognitive participation: ‘Ambassadors’ and interpreting routines
But there has been a frustration about the structure itself, and of the common understanding about why we’re doing this. This was something you noticed when you started the projects, and the doctor’s unit expressed “How are we going to have the time for this? How can we get the resources?” (H16)
So many old doctors that have been here like a very long time, since the hospital was established, and they think, like ‘Well, what is this innovation? Why should we do it like this?’ And then you need to try to change them, in a way, and show them that this way, in this way we can shorten the care period and we can save in this area or the patients are happier and stuff like that. But it’s time, it all takes time. (H3)
We are currently trying to dedicate two nurses to be ambassadors. (…) My thought is that they can get some time off to be out in the units to support them, to see that they are able to engage this approach and understand and understand the concept, and later on be able to measure and follow up on the number of care plans for example, or be able to interview co-workers and patients about how they have experienced this. (H16)
All workgroups need strong leaders because there is usually a grey, there is a grey mass, which does not want, or do not want change, and they need to be pushed and we need, these strong leaders need to make available the resources and opportunities for this. It’s needed. Then I don’t think one needs anything else. (H5)
So I think it needs more things than just being educated in person-centred care because you can go to the education, Ok, this is how to do it then you will go back to do work, and do like you always do. (R12)
the groups who have worked with this have got together to introduce a proposal for what the care plan would be like, how you would develop it and how you would get the patient to participate in it. (H16)
I think this is the way everyone wants to work but of course you have to find your own PCC-documentation (H6)
When it comes to certain categories of patients, this [PCC] might feel unnecessary, for example, when certain patients aren’t able to speak or might be gravely demented. When you can’t have a discussion with them and you won’t be able to include them in the planning. At times like this the team decisions might tend to get shorter, but we still write them down, and there are often relatives around with whom you can have a dialogue. (H9)
The idea is that it should be written in a simple language, with simple words. I tend to write it in second-person form, which you usually don’t do in the medical record. (H9)
Enabling collective action: Enforcing teamwork
When everyone on the clinic was supposed to work with this [PCC], we did protest quite a lot since we felt that we never would manage to do this, that there only would be paperwork. The deeper understanding for this was definitely missing. (H13)
To be able to succeed and work person-centered you need to have everybody on board. Or at least most of them and the right people I say. Because there are always leading personalities in a ward and if they are with you it’s often a bit easier to get the rest of the staff on board too. They make it happen. But it has to start at the top. I mean, it’s the whole chain down. (H4)
In person-centred care nurses get a new role, actually, in the team, because we have our individual task to perform (…). But we have a different role and we need to work together with the physician, not under the physician. (…) once they get the hang of it, they will like this a lot because today the physicians are responsible for everything, also in areas where they don’t have any training or knowledge at all. (R8)
Person-centred care creates a certain work environment, with a better structure of the work. It facilitates the planning for doctors and nurses, not to make late decisions but rather to have something to work with. This facilitates to make a better work environment. I also think this spreads a certain interest, that it can be exciting to be part of it from the beginning (H16)
You should know that you actually add something and what you see is also important, because it’s a team. (H1)
This is something that you have to keep alive, which is a challenge when you are changing the personnel. This is why we developed the introduction program, to not lose it when we change the personnel, and to introduce to everyone who comes to us to work. (H16)
Aspiring for reflexive monitoring
The disadvantage is the increased workload. We have drastically reduced the time of hospitalization, which means we get a lot more patients than our neighbouring wards, and it is the days when patients arrive or are discharged which are the rough days. (H14)
Another task is to continuously evaluate the work so that feedback can be given on how the work is turning out and what effects it has brought here on the ward, or in the clinic, where it has been introduced. (H9)
We don’t have fixed topics but rather it can be about something that’s happened that has affected the group. It is often ethical dilemmas where you can ventilate your thoughts, and I think by doing this where nothing is right or wrong you establish confidence, which also creates a need to develop these approaches. (H15)
In this study, interviews with patients showed that they were neither explicitly informed about PCC during hospitalisation nor aware of practical changes in the admission, treatment and discharge process. Yet, patients recognised differences. It may be argued that the emergent strategies elaborated in the previous section led patients to perceive PCC as (i) creating a sense of ease (ii) heightening inter-professional congruity and (iii) promoting non-hierarchical communication.
Sense of ease
I have been spending quite a lot of time at hospitals, so I think they have a very positive atmosphere, and it feels like one is not bothering them. It rather feels like they want to take care of you. They want one to be healthy and they want one to feel well, and I think that feels good. So I think they are very positive, yes, caring. (P12)
Then I also thought the personnel who worked together created a quite good atmosphere, and that’s important. Because we get to hear that sometimes down here, that “You seem to have so much fun together.” “Yes, we have.” And many patients find that very pleasant, that we like each other as a work group. […] Nice attitude toward each other and such. Because one notices that very easily as a patient, if someone doesn’t like each other or so, like short answers or something like that. That isn’t very nice. […] Or if one notices that some doctor has an unpleasant attitude and always nags their nurses and there are sighs and so on. Then one isn’t particularly confident as a patient either. (P17)
There’s no hierarchy at all here on this ward. And they are very happy together and nice to each other too. That’s so, it reflects on the whole ward. (P12)
This study combines three key stakeholder groups’ perspectives on the implementation of a specific PCC framework. Drawing upon Minzberg and Water , we demonstrate how deliberate strategies are complemented with emergent strategies seeking to implement and normalize a complex intervention in everyday practice. There have been challenges to the implementation of this framework [31, 32]. The deliberate strategy of introducing PCC via training, seminars and financing proves to be effective in disseminating the philosophy and some techniques for PCC and paving the way for collective negotiation and sense-making within the professional groups. However, although educating and financing as two discrete strategies  may be necessary for the dissemination of information, they are not sufficient to guarantee positive implementation outcomes . Arguably, “the characteristics of environments in which [core components] are worth replicating” (, p.733) should be also subject to discussion before and during the training.
Practitioners, especially doctors, were sceptical about this PCC framework in the introductory phase because they did not think it was innovative or they felt they were already person-centred in their practice. This reaction undermined the coherence of the model in the initial phase and led early adopters and managers to develop strategies to create coherence. Yet, despite the formal educational package, the main learning and developing process happened via informal meetings, where staff discussed how to practice PCC on their specific ward. Early adopters and leaders worked as “purveyors”  to convince unwilling actors of the workability of the framework and increase awareness of its good effects.
The fact that the framework was open to interpretation led practitioners to develop the suggested set of practices, for example, in the case of documentation. Informal meetings also contributed to the development of the framework particularly when practitioners discussed real situations . Therefore, it can be argued that these meetings paved the way for ‘reflecting on action’ and ‘learning in action’ , promoting collective action and reflexive monitoring. Enforcing teamwork and clarifying each team member’s role were emergent strategies in the implementation of PCC, since the hierarchies between different professional cultures and groups , such as between doctors and nurses, had not been explicitly articulated in the framework.
Once these strategies to create coherence, cognitive participation and collective action succeeded during the implementation, practitioners reported better results of co-operation, inter-professional teamwork and communication with patients. This was also reflected in patients’ responses to PCC. Even though patients did not elaborate on the benefits of specific routines of PCC, they felt a sense of ease  and collegial congruity on these wards. This study has shown that the normalization of the framework was experienced by patients in terms of a sense of ease and being listened to, rather than recognized in the specific language of an active partnership between different stakeholders . Patients may not always be attentive to specific PCC routines that are being implemented, yet they perceive changes in the ethics of care found in the reception, environment, attitudes and commitment to collective action.
Changing attitudes among professionals and between professionals and patients has proved to be difficult  and requires effort . Arguably, especially for sustaining complex interventions that aiming to change behavioural and professional attitudes, there must be a systematic approach to the solutions-in-the-making as illustrated for instance with ethical forums. As practitioners made sense of the framework via continuous discussion in informal meetings, they also underlined that it was necessary to create similar platforms to evaluate their PCC practice and embed it into their daily practice. This may have helped professionals to bring their ethical considerations and subjective feelings  as clinicians-as-persons  into PCC.
This study has some limitations. It draws upon a larger study which sought to explore various definitions, practices and challenges in the GPCC framework and was not solely confined to its implementation. The study at hand seeks to narrow the focus to some challenges and strategies as reported by the researchers, practitioners and patients. Therefore, the study is interpretative and not exhaustive in systematically exploring all strategies and difficulties encountered in the implementation; it rather offers important insights about the nature of these strategies and points to some possible directions for future research about the implementation of complex interventions like PCC. Second, as the study took place in a particular institutional context, the findings may not be transferable to other settings. However, it is equally important for the objective of the study to capture strategies as they emerge in specific contexts.
The present study illuminates that emergent strategies not only shed light on problems related to existing conceptions, practices and relations, but they also highlight how normalization is strongly linked with creating a willingness to learn, reflect on action and negotiate division of labour and responsibilities. There is more space for emergent strategies of collective action than deliberate strategies particularly because it is not easy to predict conflicts and tensions in action. It is therefore crucial to open up the implementation of PCC for in-depth discussion to gain a shared understanding between different stakeholders including patients.
Acknowledging PCC as a complex intervention that requires emergent strategies from within to normalize the change process.
Extra resources and support for practitioners dealing with the practicalities of the implementation.
Creation of formal and informal discussion groups for reflexive monitoring.
Evaluation and documentation of emergent practices (for e.g. introduction programs for new staff or ethical forums).
Attentive study of existing hierarchies between professional groups before the implementation.
The authors are grateful to the interviewees for their willingness to participate in the study. A research assistant, Marie Hammer, conducted all patient interviews.
The study was funded by the Centre for Person-Centred Care (GPCC) and LETStudio at the University of Gothenburg, 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. Nicky Britten was partially supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
Availability of data and materials
The data that support the findings of this study are available on reasonable request from the corresponding author [ÖN]. The data are not publicly available due to them containing information that could compromise research participant privacy/consent.
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Authorship of this paper is attributed on the following basis. All authors contributed to the study design, conception and development. ÖN and AW defined the core theoretical components of the manuscript. ÖN drafted the manuscript. AW, ME, DL, LM and NB discussed, revised and confirmed the findings. All authors were responsible for critical revision and finalising the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the Regional Ethical Board Gothenburg, Sweden. All interviewees were provided written and verbal information about the study and gave their consent to be interviewed. Professionals’ consent was verbal and patients’ consent was in a written form. We used a Swedish template for the consent form reviewed by the regional ethical review board.
Consent for publication
NB is a member of the Scientific Advisory Board of GPCC. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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