Factor analysis revealed three main viewpoints on PCC. The idealized rankings of statements for these perspectives are presented in Table 3, alongside the results at the department level.
Viewpoint 1: “Treating patients with dignity and respect”
The general view expressed by respondents with viewpoint 1 was that provision of PCC required prioritization of patient preferences. Healthcare professionals with this viewpoint stated that “treating patients with dignity and respect” [statement (st.) 6, scored as +4 within this viewpoint] is a basic condition for healthcare provision and a foundation for every other aspect of care:
“Everybody should be treated with respect no matter what disease they have, what nationality, race or background, or whether they are a homeless person or a VIP, everybody should be treated with dignity and respect.” (Geriatrics Nurse 2)
“If there is no respect or if the patient feels that they are not being treated properly, they are not going to come back to you.” (Geriatrics Fellow 7)
The next most important statement also concerned patient preferences: “healthcare professionals involve patients in decisions regarding their care” (st. 9, +4). Healthcare professionals considered listening to the patient and incorporating their preferences and needs to be important principles of shared decision making. They argued that patients are the actual leaders of their care and should always be involved in the decision-making process:
“It is about engaging the patients, otherwise it is not PCC but completely physician directed. Making sure the patient is able to engage, and it is the healthcare professionals’ responsibility to make sure that the patient is involved.” (Quality Manager 1)
“Unless they are part of the decision, they won’t accept the treatment.” (Geriatrics Nurse 2)
“Patients are supported to set and achieve their own treatment goals” (st. 1, +3) and “healthcare professionals take into account patient preferences” (st. 16, +2) were also distinguishing statements for respondents with this viewpoint. These results further underscore the importance of patients’ preferences and involvement in decision making for PCC:
“Very often patients are not supported to set their own goals; it is the doctor telling them. Especially older patients … they are afraid to question authority and have an honest discussion about what they want and what they need. They are afraid to speak up. I don’t feel that a free and open dialogue is there as much as it should be.” (Quality Manager 1)
The information and education and coordination and communication dimensions were also ranked as important, as shown by the rankings for “patients are well-informed about all aspects of their care” (st. 30, +3), “patients know who is coordinating their care” (st. 27, +3) and “there is open communication between patient and healthcare providers” (st.14, +2):
“I think it will relieve some of their anxiety when they are better informed.” (Intensive Care Manager)
“One of the most important things, especially in the geriatric population with so many comorbidities, is that they know who is in charge so that they have a point person to go to when they are confused or if they have questions.” (Geriatrics Fellow 7)
In the information and education dimension, respondents felt that the main focus should be on communication and informing patients about all aspects of their care, rather than patients’ access to their care records (st. 24, −3).
Family and friends and access to care stood out clearly as the least important dimensions for this viewpoint on PCC. For instance, the relative unimportance of “accommodations for relatives are provided in or near the hospital” (st. 18, −4) was explained as follows:
“It would be great, but I do not think it is a priority. Making sure the patient is okay is our priority and if we find a place close for the family, great, but if not then not.” (Geriatrics Manager)
In addition, healthcare professionals from the geriatrics department argued that the provision of accommodations for relatives was not relevant for an outpatient practice. Respondents also ranked statements about access to care as less important, as shown by the ranking of “clear directions are provided to and inside the hospital” (st. 33, −4), “waiting times for appointments are acceptable” (st. 5, −3), “it is easy to schedule an appointment” (st. 10, −3) and “the hospital is accessible for all patients” (st. 7, −2):
“Most of the people will find their way.” (Geriatrics Physician 3)
“Patients do not mind waiting as long as everyone gets the care he or she needs eventually.” (Intensive Care Nurse 1)
In conclusion, the importance of the patient preferences, coordination, and information and education dimensions of PCC was distinctive for this viewpoint, which we labeled “PCC implies treating patients with dignity and respect.”
Viewpoint 2: “Interdisciplinary approach”
Respondents with this viewpoint stated that healthcare provision using an interdisciplinary approach, in which coordination, patient preferences and information and education are the most important dimensions, is a central issue in PCC. “Healthcare professionals work as a team in care delivery to patients” (st. 3, +4) stood out clearly as the most important statement. Respondents indicated that healthcare professionals must always know what every other professional on a given team is doing at all times in order to provide care of the best quality. Furthermore, they argued that input from different specialties and professions is important and required for a comprehensive overview of a patient’s condition:
“You need all the information about a patient or you may not be aware of what the real problem is or recognize contributing factors to the patient’s condition.” (Quality Manager 3)
“I think patient care needs to be well coordinated between professionals; otherwise you lose the patient in the middle of the lack of coordination.” (Quality Manager 3)
In addition, information and education was considered an important dimension for PCC, evident form the high ranking of “healthcare professionals have good communication skills” (st. 15, +3) and “there is open communication between patient and healthcare professionals” (st. 14, +3):
“Bad communication, not ineffective and miscommunication is probably the most significant reason why errors happen.” (Quality Manager 3)
The patient preferences dimension was also found to be of importance, but in a more indirect, outcome-oriented manner than in viewpoint 1. The statement “healthcare professionals treat patients with dignity and respect” (st. 6, +3) was again ranked highly, but “healthcare is focused on improving the quality of life of patients” (st. 20, +4) was foremost:
“Sometimes we just want to treat the patient, but we are not sure whatever we are doing is going to improve the quality of life in a positive way. I think that this is most important.” (Intensive Care Fellow 4)
Family and friends appeared to be the least important PCC dimension. In accordance with viewpoint 1, “accommodations for relatives are provided in or near the hospital” (st. 18, −4) was ranked as least important for PCC. Additionally, “patients are in charge of their own care” (st. 29, −4) and “healthcare professionals support patients to be in charge of their care” (st. 13, −3) were considered to be among the least important statements:
“The patients are in charge of their care … but they should not be dictating basically what the care is, not knowing everything about the disease or other treatment options that are out there.” (Intensive Care Physician 3)
This perspective was particularly prevalent at the SICU:
“They should be involved, but I think patients here are usually more acute, they are sicker, so it is kind of out their hands at that point … When they are here, in the hospital, that might not be the time that they are dealing with all of that.” (Intensive Care Paramedic 2)
Although most respondents with this viewpoint argued that healthcare professionals should be well informed about a patient’s condition, they ranked “healthcare professionals are well informed; patients need to tell their story only once” (st. 12, −3) as one of the least important statements:
“I think that patients need to tell their story as many times as necessary and I think that different people in the continuum of their care need to hear that story.” (Quality Manager 3)
“When they tell their story to different people, different information comes out.” (Quality Manager 2)
In conclusion, this viewpoint emphasizes the importance of coordination and information exchange among professionals for high-quality care. We labeled this viewpoint “PCC implies an interdisciplinary approach.”
Viewpoint 3: “Equal access and good outcomes”
Respondents representing the third viewpoint stated that equal treatment of all patients is essential for PCC provision. Respondents with this viewpoint emphasized the importance of access to care. “The hospital is accessible for all patients” (st. 7, +4) was ranked as one of the most important statements, which respondents explained by stating that everyone who needs care should be able to receive it, in terms not only of a patient’s physical ability to get to the hospital, but also of a general foundation in society:
“There was a time when a person did not have insurance, sometimes the hospital would turn them away. To me that is just morally incorrect. In a way it is like if you cannot pay, you can die.” (Geriatrics Nurse 5)
Furthermore, “language is not a barrier to access to care” [st. 22] was ranked significantly higher than in the other two viewpoints:
“No language should stop you from going to the doctor and getting the care you need. Because when you do not know what someone is telling you, how can you take care of yourself?” (Geriatrics Nurse 6)
The importance of this issue may reflect the great diversity of the population served by Mount Sinai Hospital, located between the Upper East Side and East Harlem.
The patient preferences dimension was also central in this third viewpoint on PCC. In addition to the statements “healthcare is focused on improving the quality of life of patients” (st. 20, +3) and “patients are well informed about all aspects of their care” (st. 30, +3), “healthcare professionals treat patients with dignity and respect” (st. 6, +4) was ranked highly by respondents with this viewpoint:
“An overall goal in medicine.” (Intensive Care Fellow 5)
“If we do not treat patients with dignity and respect, we are not really doing our job.” (Geriatrics Physician 4)
“Patients’ knowledge is important in their outcomes. If they feel they are in charge of their care and their body and … everything that is being done to them, it will be in their best interest and further their overall health.” (Geriatrics Physician 4)
This perspective resembles the outcome-oriented manner in which patient preferences played a role in viewpoint 2.
The needs of family and friends received low rankings: “accommodations for relatives are provided in or near the hospital” (st. 18, −4) was ranked as least important, followed by “healthcare professionals pay attention to the needs of the patient’s family and friends” (st. 34, −4). Respondents emphasized that although relatives are very important in a patient’s care process, the main focus of healthcare professionals should always be on the patient.
In conclusion, respondents representing this viewpoint emphasized that accessibility of care to any patient and a focus on patient outcomes are important for PCC. We labelled this viewpoint “PCC implies equal access and focus on patient preferences.”
Separate analysis of data from the two departments revealed two main viewpoints in the geriatrics department, represented by all 16 respondents, and three main viewpoints in the SICU, represented by 12 of 15 respondents. The corresponding idealized statement rankings are presented in Table 3. As indicated by the correlations (Table 4), the department viewpoints differed little from those of the overall sample. In the SICU, viewpoint 1 was correlated least with the other viewpoints, but interpretation of the factor provided no new perspective on the study topic. Nonetheless, several remarkable differences between departments regarding specific elements of PCC were evident. For instance, coordination of care appeared to be more important in the geriatrics department. In particular, many professionals in this department ranked “patients have a first point of contact who knows everything about their condition and treatment” (st. 17) as very important, whereas this statement seemed to be fairly unimportant in the SICU:
“I think this is very important for the geriatric population. They are so sick they may not be able to tell me all the details about what they have received or what is actually going on. Now healthcare is so fragmented that you only get bits and pieces. Having somebody that can call to get that information is really important in his or her care.” (Geriatrics Physician 1)
Professionals working at the SICU highlighted the importance of continuity of care, giving fairly high rankings to “when a patient is transferred to another ward, relevant patient information is transferred as well” (st. 35). The information and education and physical comfort dimensions seemed to be less important to SICU professionals, many of whom felt that “patients are in charge of their own care” (st. 29) and “healthcare professionals support patients to be in charge of their care” (st. 13) were least important. The lack of importance of these statements could be explained by SICU patients’ conditions; many are too sick to participate in the decision making process, as described by respondents holding viewpoint 2. Finally, SICU professionals ranked “patients in hospital have privacy” (st. 2) as less important. This could be significant for an ICU as well, as patients at the Mount Sinai Hospital SICU were treated in an open space and did not have private rooms.
These examples show that certain aspects of PCC may be of particular concern for specific departments, in addition to the more general viewpoints distinguished above.