Introduction: Person-Centered Care

“Providing healthcare services that respect and meet patients’ and their caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thus constituting patient-centered care” (Kwame & Petrucka, 2021). Person-centered care emphasizes treating each patient as a unique individual rather than as a diagnosis or condition. It requires nurses to acknowledge patients’ lived experiences and personal knowledge, and to integrate their values, preferences, and needs into all aspects of care. By actively engaging patients in their care planning and decision-making, nurses foster collaboration, trust, and shared responsibility for health outcomes (Johnsson et al., 2018).

Communication plays a central role in achieving person-centered care. Effective communication is both  “personal” and “explanatory” (Johnsson et al., 2018). This allows nurses to connect authentically with patients while ensuring that information is conveyed clearly and meaningfully. Through open-ended questions and empathetic listening, nurses invite patients to share their thoughts, feelings, and concerns. When nurses take time to explain health conditions, care routines, and treatment plans in plain language and adapt communication methods as needed, they strengthen the therapeutic relationship (Kwame & Petrucka, 2021).

Achieving person-centered care begins with understanding and addressing communication barriers, as well as implementing strategies to minimize them (Kwame & Petrucka, 2021). Factors such as bias, cultural differences, sensory impairments, and language discordance can interfere with understanding and connection. Nurses must therefore employ evidence-based strategies to identify, minimize, and overcome these barriers in order to deliver person-centered, compassionate, and safe care.

This chapter explores the foundations of person-centered care and the communication practices that support it. It will examine the influence of bias, culture, and developmental factors, among others, on nurse-to-patient interactions. Strategies for adapting communication across social identities and populations will also be explored.

Implicit Bias

Unconscious attitudes that can precipitate unintentional discrimination are referred to as implicit bias. When nurses and healthcare providers harbor biases, it can contribute to health disparities. There are strategies that can be used to recognize bias that we may have, and with knowledge comes the possibility of overcoming those biases (Narayan, 2019). “Bias” is an unreasonable judgment that is not based on facts (Merriam-Webster, 2021).  “Implicit Bias,” or unconscious bias, refers to deeply ingrained attitudes and stereotypes that influence human thoughts and actions (Gordon, 2017).

Implicit bias is an inherent aspect of the human experience. From an early age, humans naturally develop preferences for what is familiar. Even infants can distinguish between “my family” and “others,” perceiving their families as safe and unfamiliar people as potentially threatening. As individuals grow and develop, they are exposed to massive amounts of data about people and the world around them. To manage this information, the human brain unconsciously categorizes and assigns judgments, often with positive or negative associations. For example, a child may learn to view one group as trustworthy or pleasant and another as dangerous or unkind. When encountering new individuals who appear to belong to these groups, responses are often automatic and shaped by these prior judgments. Stereotypes, which are generalized beliefs about groups of people, frequently arise from limited experiences or poor sources of information, such as our parents, our environment, media and film portrayals, or anecdotes. Over time, these judgments and stereotypes may become unconsciously internalized, influencing attitudes and behaviors without deliberate awareness (Narayan, 2019) and leading to negative outcomes.

Narayan (2019) explains that the attitudes and feelings of the unconscious mind are quite powerful, yet people are unaware of how these attitudes and feelings can impact behavior. Implicit bias impacts our thinking, communication, and healthcare delivery. Significant gaps in cardiovascular care exist based on gender (Shaw et al., 2017). Studies have shown that when women present at emergency rooms with chest pain, they receive different care than men. Men are often given immediate attention and receive quick interventional cardiology. In contrast, females are asked about stress levels and given medications. Wright and Merritt (2020) found healthcare disparities with African-Americans related to COVID-19, and Gaddam and Singh (2020) found that those who live in poverty have a statistically significantly lower rate of return of spontaneous circulation than those who are not poverty-stricken in out-of-hospital cardiac arrests. Healthcare provider biases influence diagnoses, treatment recommendations, the thoroughness of patient histories, and the number of tests ordered (FitzGerald & Hurst, 2017).

Implicit bias is most often directed toward people who have a higher weight, older people, and people who identify as LGBTQIA+ (Gopal et al., 2021). However, bias can have an impact on those who use illegal drugs, are mentally ill, or are of a different race or religion. “Nurses with implicit biases may demonstrate less compassion for certain patients and invest less time and effort in the therapeutic relationship with them, adversely affecting assessment and care” (Narayan, 2019). Rebar & Heimgartner (2021) found that nurses may provide different levels of care based on their own biases without being aware of their behavior.

The Nurse’s Role in Promoting Person-Centered Care

The American Nurses Association (ANA) states, “The art of nursing is demonstrated by unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care” (ANA, 2021). Nurses provide person-centered care by incorporating their clients’ physical, mental, spiritual, and social needs, among others, into their healthcare.

Nurses enhance the quality of healthcare by understanding, respecting, and incorporating their patients’ values, beliefs, and preferences, which can ultimately help reduce health disparities (U.S. Department of Health and Human Services [USDHHS], n.d.). Nurses interact with people with different social identities and lifestyles every day, and these differences can significantly impact how patients perceive, accept, and respond to healthcare.

Social identity refers to an individual’s sense of self, based on their membership in social groups. Social group examples include those defined by race, ethnicity, gender, religion, socioeconomic status, sexual orientation, and other characteristics. Unlike personal identity, which encompasses unique individual characteristics, values, and life experiences, social identities are shaped by shared group affiliations and the meanings society attaches to those groups. Social identities influence how individuals perceive themselves and how others perceive and interact with them. Recognizing and respecting patients’ social identities enables nurses to communicate more effectively, reduce health disparities, and deliver person-centered care.

Social identities can be expressed in a multitude of ways, including the following:

• • Language(s) spoken
  • Religion and spiritual beliefs
  • Gender identity
  • Socioeconomic status
  • Age
  • Sexual orientation
  • Nationality
  • Ethnicity
  • Geography
  • Educational background
  • Life experiences
  • Living situation
  • Employment status
  • Immigration status
  • Ability/Disability

People typically have more than one social identity. These identities overlap, intersect, and are woven together. In other words, the many ways in which a person expresses their social identity are not separated but are closely intertwined.

The ADDRESSING framework is a model used to recognize the different social identities that patients align with. These identities influence individuals’ experiences, perspectives, and interactions. This framework encourages healthcare providers to reflect on both their own identities and those of their patients. In this week’s assignment, you will review the framework and then reflect on how social identities can influence communication strategies.

Communication Adaptation Based on Social Identity

As a nurse, you will encounter different populations, social identities, and situations that require thoughtful consideration of how to communicate effectively, respectfully, and therapeutically. You may not even realize when you are caring for certain populations or social identities, as it may not be immediately apparent. For example, it is not necessarily readily apparent when a language discordance exists, or when a person is experiencing intense emotions, or when a person has a disability.

When communicating with patients and their family members, take note of your audience’s social identities and adapt your approach accordingly, considering their age, developmental level, cognitive abilities, communication disorders, and language differences. Providing person-centered care integrates an individual’s social identities, values, and beliefs into their health care. Begin by demonstrating sensitivity to patients and their family members with the following suggestions (Brooks et al., 2019).

• • Set the stage by introducing yourself by name and role when meeting the patient and their family for the first time. Until you are informed otherwise, address the patient formally by using their title and last name. Ask the patient how they wish to be addressed and record this in the chart. Respectfully acknowledge any family members and visitors at the bedside.
  • Begin by standing or sitting at least arm’s length from the patient.
  • Observe the patient and family members regarding eye contact, space orientation, touch, and other nonverbal communication behaviors, and follow their lead.
  • Note the patient’s preferred language and record it in the patient’s chart. If the patient’s primary language is not English, use a medical interpreter before proceeding with interview questions.
  • Use language that is sensitive and appropriate to the patient’s social identity. For example, do not refer to someone as “wheelchair bound”; instead, say “a person who uses a wheelchair” (UK Office for Disability Issues, 2018).
  • Be open and honest about the extent of your knowledge of the social identity/identities. It is acceptable to politely ask questions about their beliefs and seek clarification to avoid misunderstandings.
  • Adopt a nonjudgmental approach and show respect for the patient’s expressions related to beliefs, values, and practices. It is possible that you may not agree, but it is imperative that the patient’s rights are upheld. As long as the expressions are not unsafe, the nurse should attempt to integrate them into care.
  • Assure the client that social identity considerations are a priority in their care.

Strategies for Communicating with Patients who have Specific Needs

Nurses need to overcome communication barriers and address patient-specific special needs, which is key to person-centered care and also helps patients avoid poor health outcomes. Effective communication with individuals who have specific needs or belong to certain social identities, especially when conducting patient education, enables patients to understand and apply the concepts being taught, ultimately leading to more positive health outcomes. Nurses who educate without considering communication barriers, social identity, or special needs will provide ineffective instruction, which can lead to poor health outcomes for patients because they cannot understand what the nurse is trying to impart.

Medical Interpretation

There will be times when you, the client, and/or family do not speak the same language. In this case, you need to carefully assess and evaluate their understanding.  When caring for clients whose primary language is not English and who have a limited ability to speak, read, write, or understand the English language, it is essential to seek the services of a trained medical interpreter. Healthcare facilities are mandated by The Joint Commission to provide qualified medical interpreters. The use of a trained medical interpreter is associated with fewer communication errors, shorter hospital stays, lower 30-day readmission rates, and enhanced client satisfaction.

Refrain from asking a family member to act as an interpreter. Family members should not be used because they may not be familiar with medical terminology, which can lead to incorrect translations, misunderstandings, and errors. The patient may also withhold sensitive information from them, or family members may possibly edit or change the information provided.

Nurses should seek out healthcare interpreters who are certified by the National Board of Certification for Medical Interpreters. The legal requirements for medical interpreters (Title VI of the Civil Rights Act) require organizations that receive federal funds, including Medicare, Medicaid, and the Affordable Care Act, to provide a professional medical interpreter (Patient Engagement Hit, 2022). Medical interpreters may be on-site or available by videoconferencing or telephone. The nurse should also consider coordinating conversations between patients and family members with other healthcare team members to streamline communication. When possible, obtain a medical interpreter of the same gender as the client to prevent potential embarrassment if a sensitive matter is being discussed.

Impaired Vision or Hearing

You can inquire about the presence of any hearing or visual impairment and what is best for the patient in terms of communication. For people with hearing and visual impairment, begin by minimizing any background noises or distractions. Speak in a clear, slightly louder voice with a steady tone and a deeper pitch. Avoid shouting and using a high pitch, as this can distort sounds and make your words more difficult to hear. You should face the patient directly and clearly articulate your words so that they can read your lips and attend to non-verbal cues as necessary. If the patient uses an assistive device (e.g., glasses or a hearing aid), ensure they have access to it.

Impaired Speech

Patients with communication disorders require additional strategies to ensure effective communication. For example, aphasia is a communication disorder that results from damage to areas of the brain responsible for language. Aphasia usually occurs suddenly, often following a stroke or head injury, and impairs the patient’s expression and understanding of language. Expressive aphasia refers to difficulty putting thoughts into words. The patient may cognitively know what they want to say, but are unable to express their thoughts. Receptive aphasia refers to difficulty in understanding what is being communicated to them. The patient may be able to verbalize their thoughts and feelings, but does not understand what is spoken to them. Global aphasia is caused by injuries to multiple areas of the brain that are involved in language processing, including Wernicke’s and Broca’s areas. These brain areas are particularly crucial for comprehending spoken language, accessing vocabulary, applying grammar, and forming words and sentences. Individuals with global aphasia may be unable to say even a few words or may repeat the same words or phrases over and over again. They may also struggle to understand even simple words and sentences (National Institute on Deafness and Other Communication Disorders, 2017).

The most common type of aphasia is Broca’s aphasia. People with Broca’s aphasia often understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead, the words “Bathroom, Go” are expressed. They are often aware of their difficulties and can become easily frustrated.

Cognitive Impairments

Some of your patients will have intellectual or cognitive impairments that may result in disabilities affecting their ability to learn and reason (e.g., Down syndrome, fetal alcohol syndrome). You should consider how each patient can best participate in communication (e.g., listening, talking, understanding, and processing information). You should engage in active listening and determine what is important to the client. Speak clearly and ask simple questions. Speak in a positive tone with a steady pace, and avoid speaking too slowly, as this can come across as patronizing. You may encourage them to bring someone they trust, such as a family member; while still focusing your attention on the patient, also create space for their family to be involved.

Substance Impairment

A patient under the influence of drugs and substances (alcohol, cannabis, prescribed medications, and/or illegal street drugs) can have an altered capacity to think, reason, and communicate. Although some of these substances may be illegal and non-prescribed, it is important to maintain a non-judgmental attitude and convey unconditional positive regard. As a nurse, it is not your job to judge a patient. Rather, you should use a relational inquiry approach to understand the circumstances that have influenced their choices, respecting that each patient has agency and self-determination.

While the patient is under the influence of a substance, use communication strategies that facilitate their capacity to understand what you are saying and communicate with you while maintaining safety. Thus, you should speak clearly and in short, simple sentences. Focus on the reason for seeking care or the priority issue. There will be time for a collaborative discussion and health promotion after the effects of the substances have dissipated.

Emotional Distress, Violence, and Trauma

Emotional Distress

Patients commonly experience sadness, anger, fear, anxiety, embarrassment, and other emotional responses in the context of health and illness. It is essential to create a therapeutic environment where patients feel at ease and open up about their emotions. Open-ended questions, such as “Tell me about how you are feeling,” can facilitate discussions about a patient’s emotional response. Additionally, you might consider using permission statements (See Chapter 9) to help normalize how the patient is feeling and provide an opportunity for them to discuss their emotions. For example, “Patients often experience sadness or anger when they are diagnosed. How are you feeling?”

It is essential to acknowledge the patient’s emotions and provide them with space to experience them. Avoid changing topics. Give the patient time to voice their emotions or even cry. Using silence and active listening are effective communication strategies during these circumstances.

Violence and Trauma

Many patients will have experienced violence and trauma in their lives, such as abuse, bullying, grief or loss of a loved one, or natural disasters or war. You will often not even be aware that they have experienced violence or trauma, so it’s best to use a trauma-informed approach with all patients. Approach all patients with the assumption that they may have experienced violence and trauma at some point in their lives. Reflect on how to best help them feel safe and provide them with as much choice and control as possible during the clinical encounter.

Some communication strategies that are consistent with a trauma-informed approach include:

• • Introducing who you are and why you are there.
  • Explaining each step of what you are doing.
  • Asking permission to touch.
  • Provide the client with options for the first topic to discuss.

Communicating with patients about violence and trauma requires knowledge, skill, and experience. This field of study is vast and deep. As you develop foundational communication skills, you will have opportunities to expand your knowledge of trauma-informed communication. For now, recognize that there is much more to learn about trauma-informed approaches, and an in-depth understanding is necessary to provide the best care for these patients.

Sexual Orientation and Gender Identity

Sexual orientation refers to a person’s physical and emotional interest or desire for others. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors (Brydum, 2015). The acronym LGBTQAI+ stands for Lesbian, Gay, Bisexual, Transgender, Queer, Asexual, and Intersex. The “+” stands for other identities not encompassed in this abbreviated acronym, which is often used to refer to the community as a whole. Historically, individuals within the LGBTQAI+ community have experienced discrimination and prejudice from health care providers and avoided or delayed health care due to these negative experiences. Despite increased recognition of this community in recent years, members of the LGBTQAI+ community continue to experience significant health disparities. Persistent bias and stigmatization of LGBTQAI+ people have been shown to contribute to higher rates of substance abuse and death by suicide in this population (Cole, 2018; USDHHS, 2020).

Gender identity refers to a person’s inner sense of themselves as a man, a woman, or perhaps neither. To the extent that a person’s gender identity does not conform with the sex assigned to them at birth, they may identify as transgender or as nonbinary. Nonbinary means they don’t fall simply into one of two categories, male or female. Transgender and nonbinary people may be sexually oriented toward men, women, both sexes, or neither sex (Meerwijk & Sevelius, 2020). Gender expression refers to a person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms (Keuroghlian et al., 2017).

Discussing Sexuality

It is common for nurses to encounter clients who wish to have discussions pertaining to their sexuality. Sexuality encompasses sex, sexual orientation, gender identity, and gender roles, among other topics. The need for sexuality discussions may be a result of medication sexual side effects, disease processes that may affect a person’s sexuality, surgical procedures affecting sexuality, sexually transmitted infections, sexual trauma, or other health needs of LGBTQAI+ and straight clients. Sexual topics can be uncomfortable for both the nurse and the client. The client may feel embarrassed or as if they cannot initiate the conversation due to social stigmas about certain topics. For this reason, nurses should let clients know they can talk about sexual concerns in a non-judgmental environment by using the following guidelines.

Developmental Considerations

A person’s age and developmental stage should be taken into account when caring for and communicating with them. Developmental stage does not always align with a patient’s chronological age. Regarding communication, a focus on the developmental stage encompasses attention to areas such as language, cognitive, and socio-emotional development. At times, you may need to modify your communication so that you are appropriately engaging with the patient at a level they understand.

When communicating with patients, it is essential for the nurse to assess the receiver’s preferred method of communication and individual characteristics that may influence the communication, and subsequently adapt the communication to meet the receiver’s needs. For example, the nurse may adapt postsurgical verbal instruction for a pediatric versus an adult patient. Although the information requirements regarding signs of infection, pain management, etc., may be similar, the way in which information is provided can be quite different based on the developmental level. Regardless of the individual adaptations made, the nurse must always verify the patient’s understanding.

There are many ways to construct chronological age categories. Broadly speaking, children are defined as anyone under 18, and adults are defined as anyone 18 and older. More specifically, you could consider the categories used in this resource:

• • Newborns: Birth to 24 hours old
  • Neonate: 24 hours to 28 days old
  • Young children: Patients who are 5 years and younger, including infants (28 days to 1 year), toddlers (1–2 years), and preschoolers (3–5 years).
  • Older children and adolescents: Patients who are 6–17 years, including older children/school-age children (6–12 years) and adolescents (13–17 years).
  • Adults and older adults: Patients who are 18 years and older, including adults (18 years and older) and older adults (65 years and older).

The following sections provide tips on broad chronological age categories, including young children, older children and adolescents, adults, and older adults.

Young Children

When interacting with infants, use a combination of verbal and nonverbal communication. Be constantly aware and adapt your use and choice of communication strategies based on the infant’s response.

Most infants enjoy hearing the human voice, and this is how they learn and make sense of language. You should talk to them in a relaxed and pleasant tone of voice, even though they cannot verbally respond. It’s also okay to use baby talk with infants, as it can help with language development: Baby talk is a type of speaking where you use enhanced vocal intonation and hyperarticulation of sounds such as vowels and consonants.

In terms of non-verbal communication, maintain a relaxed body posture, smile, use appropriate eye contact, and employ gestures with your hands. These techniques are particularly important with all children, as non-verbal language can help facilitate their sense of safety.

When communicating with children, adapt your approach to their developmental stage. Tailor your language to a level that children will understand, avoiding long, complex sentences and instead using short sentences with simple words. As children get older, they enjoy receiving compliments and encouragement to connect with them (e.g., “look how much you have grown” or “great job!”).

Because parents are usually present with young children, it’s important to involve them so that the child feels safe. Here are some points to consider with parents:

• • While communicating with a parent, the infant or toddler may sit on their parent’s lap and/or play with a toy. This introductory communication can help the child get familiar and comfortable with you, particularly at the first meeting.
  • To establish trust, try drawing pictures or playing with the patient.
  • It is often helpful to demonstrate procedures on a doll or stuffed animal. Performing a physical assessment on parents before the child is also effective. This strategy helps the child know that you are trustworthy and that you will not hurt them.
  • Children may behave differently because they are afraid or not feeling well. For example, they may hide behind the parent, refuse care from the healthcare provider, or cry or scream. These behaviours can create stress for parents, so it’s important to be patient and demonstrate unconditional positive regard.
  • Some or all of the patient history will be conducted with the parent when the child is unable to speak or fully articulate. Because parents are considered a secondary source of data, you should ask them to clarify and elaborate on how they know what they are sharing with you. For example, if they say that their baby is in pain, ask how they know this.
  • At times during the interview, it may be appropriate to interview the parent without the child present, particularly when talking about sensitive topics.

Older children and adolescents are usually at a stage where they can participate in the client interview in a more active way and articulate their experiences, emotions, and needs. Thus, it is essential to address them as the client first, rather than as their parent(s). Patents are often still involved, but you should offer the child/adolescent the opportunity to speak with you privately at times. For example, you might say to the patient: “At this age, I often like to provide time to speak with you alone. Are you okay if I ask your mom or your dad to step out for a few minutes?”

You should continue to use a combination of nonverbal and verbal communication strategies. In terms of nonverbal communication, make eye contact with a relaxed and open posture that demonstrates interest in what they are saying. Smiling may be appropriate depending on the topic. You should also facilitate the interview using strategies such as nodding and statements that encourage the client to continue sharing (e.g., “uh-huh” and “tell me more”). Be aware of your facial expression and vocal intonation to ensure you are conveying empathy, acceptance, and a non-judgmental attitude. You may want to include fun objects or games, or include the child in the assessment process (e.g., “Would you like to try tapping on your own knee with this reflex hammer?”).

Adolescents are in a transitional stage where they are still children but are moving closer to adulthood. It is important to recognize and respect their self-determination. Additionally, emotional and cognitive capacity will vary from adolescent to adolescent and from situation to situation. Therefore, your communication strategies will need to shift based on the adolescent and the situation. Overall, you should convey acceptance, honesty, and respect. Avoid talking to them as if you were a child, as this is often perceived as demeaning. Additionally, when communicating with adolescents, give them the freedom to make choices within established limits.

When discussing sensitive and intimate topics, it is essential to acknowledge that adolescents often feel self-conscious, embarrassed, and fearful of being judged. Your communication strategies should convey acceptance and understanding of what they are experiencing. Maintain an open and non-judgmental attitude to cultivate a trusting relationship with the client. “Permission statements,” one of the therapeutic communication strategies, can be particularly useful as they can help normalize what an adolescent may be experiencing.

Adulthood is a broad age category encompassing everyone 18 years and older, but there is significant diversity within this group. Some adults will have had minimal encounters with nurses, and others will have had extensive encounters. Younger adults in their late teenage years and early twenties may share characteristics with adolescents, so you may use many of the same communication strategies. You should also examine and acknowledge your own biases and tendencies to stereotype older adults and constantly reassess your own assumptions so that they do not negatively affect your communication.

With older adults, it is important to give them time to process and answer questions, as they may have a slower response time. Avoid making assumptions about their hearing, vision, or cognitive capacity. Rather, speak in a clear voice and face them while you speak, as you would with all clients. It can be helpful to write down instructions or educational information for older adults, as they are often dealing with substantial quantities of health information.

Some older adults may have a caregiver present with them because they are managing multiple illnesses and may have cognitive or physical impairments that cause disabilities. When a caregiver is present, it is essential to include them in the conversation. After engaging in the introductory phase with the client, ask about the person with whom the patient is associated. If appropriate, consider the patient and caregiver as a dyad, in which both are recipients of care, but prioritize the patient as your main focus during the assessment. Avoid assuming that caregivers can better answer questions for older patients. For example, direct your questions to the patient, even if the caregiver may help answer some of them.

Conclusion

Providing person-centered care requires more than clinical expertise; it demands empathy and an intentional commitment to understanding the whole person behind the patient. Communication serves as the foundation of this approach, allowing nurses to recognize and respond to the unique needs, values, and social identities that shape each individual’s experience of health and illness. By developing awareness of implicit bias, adapting communication, and implementing evidence-based strategies to overcome barriers, nurses promote person-centered care. Whether navigating language differences, sensory impairments, emotional distress, or patients in different developmental stages, effective communication transforms care encounters into opportunities for partnership and healing. Ultimately, person-centered communication is both an ethical responsibility and a professional skill that lies at the heart of nursing practice. Every patient should be heard, respected, and supported in achieving their optimal health outcomes.

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