Background

Patient-centered care (PCC) is a method of forming trusting relationships between patients and care providers. It is widely defined as a holistic approach to providing care that includes patient involvement, communication, access to services, well-trained staff, and an environment that meets patients’ psychosocial, physical, and cultural needs [1]. It has previously been explored in many fields of healthcare including, but not limited to nursing [2], cancer care [3], pediatrics [4], long-term care [5], mental health [6], primary care [7], and related areas such as social work [8]. PCC requires efforts on all levels including the patient, the provider, and the healthcare system [9] to ensure it is meaningfully practiced.

Effective PCC should help patients and physicians to communicate in a respectful way that both parties understand within an environment that is conducive to appropriate care processes. Previous research demonstrates that when there is dissonance between patients’ expectations and the services rendered, there are often components of patient-centeredness missing [10,11,12]. PCC and its many components can make a huge impact on patients’ experiences when performed properly.

PCC is an emerging priority in many healthcare settings, yet it has not been incorporated into ED practice in a standard way. Traditional ED quality improvement initiatives often focus on structures, processes, and outcomes—for example, how long a patient waits, the percentage of patients that leave without being seen by a physician, and the volume of patients during the intervention [13, 14]. Although these variables should be considered to create a better ED that benefits the health system, the way in which patients perceive their experience is essential to acknowledge. The quality and personalization of services sought out by patients in the ED are critical, and it is highly important to ensure patients leave feeling satisfied with the care they receive. Despite the growing literature on interventions that can be used to make the ED more efficient [15,16,17,18], there are currently no systematic reviews on how EDs include PCC. Thus, it is of interest to know what is most important to patients to better their experience, and how PCC can encompass those elements.

The goal of this review is to examine PCC in the ED to better understand how EDs undertake this method. The objectives are to determine (1) what the components of PCC are in the ED and (2) what the challenges and benefits of PCC in the ED are, as perceived by staff and patients.

Methodology

This study follows the strategy of review outlined in the protocol available on PROSPERO, updated in November 2021 [19]. As stated in the protocol, our phenomenon of interest included PCC in the context of the ED, and our main outcomes of interest are components or methods of PCC, challenges and benefits to PCC for staff, and challenges and benefits to PCC for patients. Secondary outcomes of interest included any evidence on the impacts of PCC, e.g., ED wait times or length of stay, patient satisfaction, and patients leaving without being seen.

Patient and public involvement

To better understand current and previous experiences of patients in the ED, we undertook patient engagement initiatives [20]. By involving patient partners, the research in question becomes more patient-centered [21]. We discussed issues and needs with local advocacy groups to gain perspective from those with lived experience and included patient partners on the research team. Figure 1 depicts the process of patient involvement throughout the study from research question development to dissemination.

Fig. 1
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Pathway of patient and public involvement in the study

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Search strategy

Search terms were identified and search strategies were developed by a medical librarian. The primary strategy (PubMed, MEDLINE) was peer-reviewed using PRESS and translated to search Embase (Elsevier), CINAHLPlus (EBSCO), PsycINFO (EBSCO), and Cochrane (Wiley) (Additional file 1: Appendix A). The reference sections of relevant studies were also examined for any additional references. The original searches were completed on June 6, 2020, and rerun on December 2, 2020.

Study selection

The titles and abstracts of all articles identified by the database searches were examined by two independent reviewers after duplicates were removed. Inclusion and exclusion criteria can be found in the protocol [19]. Reviewers completed a calibration exercise with the first ten articles and reached agreement on inclusion criteria. All full texts were then reviewed. A third reviewer was invited to mitigate any dispute.

Quality appraisal

The quality of each study was assessed using the scoring system for mixed studies reviews [22]. Studies 75% and above were good quality, 50–74% were fair, and below 50% were low. All studies that met the criteria were included, despite the quality score.

Synthesis of results and analysis

Two approaches were used for data synthesis and integration. The Joanna Briggs Institute (JBI) convergence-integrated approach for mixed-methods studies [23] was used to “qualitize” quantitative studies into textual descriptions to allow integration with qualitative data. “Qualitized” findings from quantitative studies are assembled into categories with qualitative findings based on similarity of meaning. To best determine the categories once all data was “qualitized”, we used a meta-ethnographic approach. Meta-ethnographic synthesis is suitable for understanding conceptual or theoretical underpinnings of a particular phenomenon [24]. This approach was selected to help understand what the various components of PCC were and what common components were used across all included studies. It was also used to compile information regarding challenges and benefits of PCC and determine commonalities across the literature. For the purposes of this study, “concepts” are defined as information extracted from the studies that include either direct quotes from study participants or authors’ interpretations of their own results. “Key concepts” are the groupings of similarities and differences across concepts from the included studies after the studies are translated into one another, and “themes” are the third-order constructs that are re-interpretations of the concepts and key concepts determined by the reviewers of this study.

The concepts were separated based on the viewpoint, being staff or patient/family. To address each population, healthcare providers, and patients and families, two separate reciprocal translations were conducted. All concepts were compared to one another using a line of argument synthesis [24] to identify key concepts reflected in both populations that described PCC activities, challenges, and benefits. Theme interpretation was completed by one reviewer (AW), based on the independent data extractions from both reviewers. All themes were discussed during weekly meetings between members of the research team, including a PCC expert and clinician, patient engagement expert, and methodologist, to reduce bias and ensure consensus was reached. Finally, the synthesis is expressed through tables and narrative format [25].

Results

Study characteristics

Three thousand eight hundred thirty-eight studies were imported for screening. 3136 total articles were screened in the title and abstract phase, 69 were assessed for eligibility in the full-text phase, and 14 studies were included in the data extraction phase. Reasons for exclusion were no patient-centered care (n=48), setting of intervention outside of the ED (n=7), and full-text article was not available (n=1). One study was removed during the extraction phase because the focus of the article was social services rather than healthcare, despite being in the ED setting, leaving 13 articles for the final data extraction and quality appraisal (Fig. 2).

Fig. 2
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PRISMA diagram

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Table 1 demonstrates all study characteristics. Countries of study included the USA (n=4), Canada (n=2), UK (n=2), Sweden (n=2), Australia (n=2), and Taiwan (n=1). All studies included patient and/or healthcare professional populations that had experience in the ED. Eleven studies included populations related to adult ED care and two studies included populations related to pediatric ED care. While most studies were directly related to the ED setting (n=10), three studies investigated settings that were specialized units adjoined to or having direct impacts on EDs (n=3). The quality scores varied. Six studies (n=6) were considered good quality, six (n=6) were fair, and one (n=1) low.

Table 1 Characteristics of included studies
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Defining components of patient-centered care

Descriptions and definitions of PCC were extracted from all included articles (Table 2). Five articles had directly stated definitions or descriptions of patient-centered, person-centered, and family-centered care. The other nine articles did not describe their activities using PCC-related terminology but were still included due to the presence of PCC components. The most cited components of PCC in the literature, and thus, the themes of PCC, were comfort of environment (n=8), communication (n=7), education (n=7), involvement of patient/family in information sharing and decision making (n=7), respect and trust (n=7), continuity and transition of care (n=7), and emotional support (n=5) (Table 3).

Table 2 Definitions of PCC and key findings as identified by the included articles
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Table 3 Components of PCC as identified within the included articles
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Challenges and benefits of PCC as perceived by ED staff

Challenges and benefits of providing PCC were noted in four articles (n=4). Noted concepts of difficulties in providing components of PCC from the ED staff perspective were a lack of training or experience (n=2), communication barriers by having multiple care providers (n=1), complex patient needs (n=1), the design of the ED space being set up for efficiency rather than communication (n=2), patient frustration and negative attitudes (n=1), work demands impacting providers’ ability to form relationships with patients and families (n=1), and professional conflicts impacting trust between patients and providers (n=1). However, components of PCC that were applied successfully saw beneficial results. ED staff reported that keeping patients informed helps to avoid emotional distress and uncertainty (n=2), patient placement in close proximity to ED staff with clear lines of sight allows staff to offer their presence (n=1), and encouraging patient participation (n=1) and treating patients and families as experts in their own care (n=1) brings about patient-provider collaboration.

Challenges and benefits of PCC as perceived by patients

Patient experiences were described in six articles (n=6) demonstrating evidence of barriers to and benefits of receiving PCC. Concepts and key concepts of patient concerns included overwhelming waiting rooms (n=1), difficulty of navigation (n=1), and untrained or inexperienced staff (n=2). Further barriers to a positive care experience were lack of frequent updates from staff (n=1), limited access to information on ED care processes (n=1), dismissive attitudes from ED staff towards patients’ and families’ input (n=2), difficulty establishing communication with ED staff (n=1), and the use of language by staff that patients cannot understand thus limiting their ability to participate in decision making (n=1). Patient satisfaction was often achieved when components of PCC were present, for example, having frequent contact with staff (n=1), when patients felt listened to and valued as experts in their own health (n=2), when interacting with trained staff (n=1), when respected by ED staff (n=2), and being treated courteously without scepticism (n=1). When they were able to establish relationships, patients were able to share more information with providers (n=1) and place their trust in care providers to make good medical decisions on their behalf (n=1). Furthermore, having a patient-focused environment with accessible features allows patients to be comfortable in the ED (n=1) and having continuity of care via follow-up clinics helped patients to make changes to their lifestyles and attitudes (n=1) that in turn better their health.

Impacts of PCC on outcomes

Four studies (n=4) assessed the impacts of PCC components on various outcomes in the ED. Examples of quantitative impacts measured included patient length of stay (n=3), number of patients who left without being seen (n=1), and patient satisfaction (n=1). Results of these studies demonstrated decreased length of stay (n=3), reduced number of patients who left without being seen (n=1), and greater patient satisfaction (n=1) with the implementation of PCC-related interventions. Further qualitative findings support the idea that the patient experience is bettered by the presence of PCC components both individually and altogether.

Contribution of patient engagement

The results of this study were shared with patient partners for feedback. There was an agreement on the components of PCC in the ED that were identified, but it was noted that “building trust between patients and providers” might be another important component to consider. Inclusivity and ethnic representation among physicians were identified by patient partners as foundations to building better relationships as it helps patients feel like they can better relate to their care providers. Although these were not components identified in the literature, this may represent another gap in the knowledge of providing PCC in the ED when trying to meet patients’ cultural and psychosocial needs.

Discussion

PCC can be a valuable contribution to emergency medicine practices. PCC in the ED includes aspects of communication, education, involvement of the patient/family in information sharing and decision making, comfort of environment, respect and trust, emotional support, continuity, and transition of care. However, there is not yet an operational definition for how PCC should be implemented in the ED. Though all the included studies shared common components, most of the studies did not include each component of PCC that was identified. This finding demonstrates there is no agreed-upon framework for PCC in the ED setting. This is echoed throughout the literature and identifies a concern that there is currently a lack of consistency in PCC models throughout the broader healthcare system. Where some studies lack multiple components of PCC, it is possible that they could have had better outcomes had they included the other aspects.

The PCC in the reviewed articles also varied greatly depending on what roles staff had, patients’ illnesses, and the care process involved, e.g., to move them quickly to a specialized unit for appropriate care or to make them more comfortable in the ED waiting room. The variations in perspective likely contributed to the resulting differences across the studies regarding what PCC was practiced and what patients or staff found to be beneficial or lacking. Additionally, there were many identified challenges echoed from both the staff and patient perspectives. For example, staff education was seen as a barrier and communication as an enabler to PCC by both the patients and the staff across multiple studies. This indicates that there is agreement and that the impact of PCC reverberates both positively and negatively throughout the healthcare system. This overlap may suggest a few key starting points to creating a unique definition for PCC in the ED.

Compared to models of PCC in different healthcare settings, there is an overlap of pillars that support patient-centered practices. In a review of over 900 studies on PCC across various healthcare settings [1], a few of the most common principles included taking a holistic approach, seeing the patient as an expert in their own care, recognizing autonomy and sharing responsibility in decision making, ensuring services are accessible, and having supportive, well-trained staff who can communicate and engage with patients. Further frameworks [39, 40] outline that concepts related to the patient-centered environment include advocacy, values, and empowerment as well as staff being partners in care through collaboration, communication, and health promotion. Although five of the included articles in the current review examined populations with mental health emergencies, we did not identify any new themes through analysis and comparison between mental health and non-mental health populations. This contributes to the evidence that different healthcare settings may put emphasis on the components that are more relevant to their context, but the broad ideas of PCC are aligned with the current findings and support the notion that PCC in the ED does not need major adaptations to be integrated. It should also be recognized that components of PCC were practiced before evolving into what is known as PCC today [41]. Therefore, the conception of new PCC pillars throughout different healthcare settings is to be expected. Although the ED environment presents unique challenges, including patient-centeredness can help to create a better environment for providers and patients.

Until now, the components that should go into PCC in the ED have not all been recognized. Rather, they were accounted for piece by piece and not as a whole. One could argue that providing any one component of PCC is better than none; however, it is important to consider all components in a holistic, well-rounded patient-centered practice.

This review can be useful as a foundation to understanding the components of PCC that will improve the ED experience. It can also be used to assist in the development of PCC training modules for ED staff or implementation of better PCC practices in the ED. By using the outlined components of PCC and implementing some of the suggested methods and examples from the literature, it is possible to develop a comprehensive list of actionable PCC practices.

Limitations

The results of this review are limited by the evidence from the retrieved studies and by the quality of the information reported in those studies. In the quantitative articles, neither the effect sizes nor significance levels were provided in some cases, so we were unable to report this information. The data also did not support meta-analysis, which would have made our results stronger, due to the lack of quantitative evidence. Articles that are aligned with the current evidence are more likely to get published; therefore, it is possible that evidence opposing the included studies was not available due to publication bias. Our search was limited to only English language, peer-reviewed articles; therefore, it is possible articles in other languages or non-peer-reviewed articles were missed. Finally, because some of the included studies had small sample sizes, it is possible that the evidence from those EDs would not be generalizable to another population. In future, should more quantitative evidence become available, it would be beneficial to do quantitative analysis to get a better understanding of the effect of PCC on patient outcomes. The strength of the evidence produced through this review should also be evaluated as new information becomes available surrounding PCC in the ED.

Conclusion

Despite the challenges faced by staff, patients, and families, PCC overall has a beneficial impact. Some of the many downfalls of ED care identified by its users can be mitigated by implementing PCC. This study contributes to the literature on how we can address PCC in the ED and how it can be used to improve the ED environment. PCC has been identified by patients as essential to improving the patient experience and should be prioritized as an evidence-based method of providing care that meets the patients’ needs.