Advocates of the Person-Centered Healthcare (PCH) approach say that PCH is a response to a failure of caring for patients as persons. Nevertheless, there are many human subjects falling to fulfill the requirements of a traditional philosophical definition of personhood. Hence, if we take, PCH seriously, a greater clarification of the key terminology of PCH is urgently needed. It seems necessary, for instance, that the concept of the person should be extended in order to include those (...) individuals with insipient or immature levels of consciousness, as well as those who are severely and permanently mentally handicapped. In this article, we will depart from some well-known philosophical concepts of what it means to be a person and try to offer a broader and more inclusive meaning. We suggest that persons are human beings with a socially recognized biography, which implies to recognize as persons individuals with necessities, but also with narratives about their interests and claims, expressed sometimes by other people related to them. This is particularly the case of individuals that suffer from severe disorders of consciousness. For those, is not only care that matters; respect matters too. Caregivers should therefore not only sympathetically care for the well-being of these people; they should also be concerned to respect their interests and claims by interpreting them empathetically, in the light of their biographical story. Our conclusion is that, in order to be coherent, PCH must consider individuals with severe disorders of consciousness as persons and we think that our revised concept of personhood fits with this requirement. (shrink)

Engagement with the historical and theoretical underpinnings of measuring quality of life (QoL) and patient‐reported outcomes (PROs) in healthcare is important. Ideas and values that shape such practices—and in the endgame, people's lives—might otherwise remain unexamined, be taken for granted or even essentialized. Our aim is to explicate and theoretically discuss the philosophical tenets underlying the practices of QoL assessment and PRO measurement in relation to the notion of person‐centredness. First, we engage with the late‐modern history of the (...) concept of QoL and the act of assessing and measuring it. Working with the historical method of genealogy, we describe the development of both QoL assessments and PRO measures (PROMs) within healthcare by accounting for the contextual conditions for their possibility. In this way, the historical and philosophical underpinnings of these measurement practices are highlighted. We move on to analyse theoretical and philosophical underpinnings regarding the use of PROMs and QoL assessments in clinical practice, as demonstrated in review studies thereof. Finally, we offer a critical analysis regarding the state of theory in the literature and conclude that, although improved person‐centredness is an implied driver of QoL assessments and PROMs in clinical practice, enhanced theoretical underpinning of the development of QoL assessments is called for. (shrink)

Evidence based medicine (EBM) is under critical debate, and person centered healthcare (PCH) has been proposed as an improvement. But is PCH offered as a supplement or as a replacement of EBM? Prima facie PCH only concerns the practice of medicine, while the contended features of EBM also include methods and medical model. I here argue that there are good philosophical reasons to see PCH as a radical alternative to the existing medical paradigm of EBM, since the (...) two seem committed to conflicting ontologies. This paper aims to make explicit some of the most fundamental assumptions that motivate EBM and PCH, respectively, in order to show that the choice between them ultimately comes down to ontological preference. While EBM has a solid foundation in positivism, or what I here call Humeanism, PCH is more consistent with causal dispositionalism. I conclude that if there is a paradigmatic revolution on the way in medicine, it is first of all one of ontology. (shrink)

Despite the growing interest and supporting evidence for person-centered care, there is still a fundamental disagreement about what makes healthcare person-centered. In this article, we define PCC as operating with three fundamental conditions: personal, participatory and holistic. To further understand these concepts, we develop a framework based on the theory of affordances, which we apply to the healthcare case of rehabilitation and a concrete experiment on social interactions between persons with cerebral palsy and physio- (...) and occupational therapists. Based on the application of the theory, we argue that in order for healthcare to be considered as PCC, professionals need to adopt a personalistic attitude in their care, defined in terms of mutual affordances: how the professional and the person of care acknowledges each other as a person in an interaction. In opposition, we define the functionalistic attitude in terms of object affordances, those related to a concrete goal. We show that PCC requires a balance of personalistic and functionalistic attitudes, since this contributes to a participatory and holistic conception of, and interaction with, the person of care. (shrink)

This book focuses on two important, interlinked themes in psychiatry, i.e., the relation between self (or: person), context and psychopathology; and the intrinsic value-ladenness of psychiatry as a practice. -/- Written against the background of scientistic tendencies in today’s psychiatry, it is argued in Part I that psychiatry needs a clinical conception of psychopathology alongside more traditional scientific conceptions; that this clinical conception of psychopathology must be based on a fundamental rethinking of the interaction between illness manifestations, contextual influences (...) and the patient as person, such that psychopathology is conceived as the product of this interaction rather than as the outward manifestation of a broken mechanism within the patient. -/- In Part II, it is shown that self- and context-related factors have a large impact on who one is as a professional. I argue that an analysis is needed of the normative aspects of the relations that sustain and frame professional role-fulfilment. This analysis culminates into a so-called normative practice model (NPM) which distinguishes between qualifying, conditioning and foundational principles (or: rules, norms). The normative practice model helps to locate and resist scientistic defenses of the legitimacy of psychiatry and to replace them by a positive account that provides clinicians (and scientists) the conceptual tools they need to justify what they do in broader contexts. The main thrust of the argument is to show that psychiatry needs a value-sensitive account of its legitimacy, in which other normative dimensions are recognized than those that sustain the expert role. Psychiatrists should in other words not defend the legitimacy of their profession by referring to the expert role solely but provide a broader account in which justice is done to the broader social, legal, and economic contexts of professional activity. The analysis of this inherent normativity begins within clinical practice, it extends to the concept of disease as well as to wider domains of psychiatric care and the sociology of professions, and, finally, amounts into an analysis of the value-ladenness of interactions between healthcare institutions, the government, professional organizations and patient groups. (shrink)

Policy reforms implemented in Saudi Arabia in recent years aim to modernize the culture and infrastructure of healthcare delivery and are expected to integrate person‐ and patient‐centered care principles throughout the national healthcare system. However, in a complex multicultural environment where most nurses are international migrant workers, unique challenges emerge that frame the delivery of care. Better understanding is needed about what nurses perceive to be high‐quality, person‐centered care in Saudi Arabia and how they (...) manage to enact it in practice. Semi‐structured interviews were conducted with 21 nurses working in two tertiary hospitals in Riyadh, the capital city. Participants included Saudi citizens (n = 9) and expatriates (n = 12) who were asked to describe their perceptions of quality nursing care and explain the obstacles that they encounter in providing such care. Nurses reported extensive efforts to achieve individualized, empathetic, developmentally appropriate care. Their descriptions of care aligned with principles of patient‐centeredness in care but were not separable from challenges at the patient, organizational, and regional levels, including staffing and supplies shortages, gaps in regional care coordination, inadequate language translation services, variability in cultural beliefs about healthcare communication, and overt discrimination against expatriate workers. Nurses reported creative strategies to achieve professional nursing values while navigating a dynamic landscape of constraints. The findings add to literature suggesting that person‐centeredness in care cannot be understood outside the social and organizational conditions that shape it. (shrink)

Practical and evidence-based, this unique book is the first comprehensive text focused on person-centered approaches to people with serious mental illness such as schizophrenia and bipolar disorder. It reflects a range of views and findings regarding assessment, treatment, rehabilitation, self-help, policy-making, education and research. It is highly recommended for all healthcare professionals, students, researchers and educators involved in general practice, psychiatry, nursing, social work, clinical psychology and therapy. Healthcare service providers, and policy makers and shapers, will (...) find the book's wide-ranging, multi-professional approach enlightening. 'Serious Mental Illness reflects a continued distancing from the outmoded and unsubstantiated belief that people with severe mental illnesses could not recover, and that they would respond positively only to goals and treatment plans chosen, designed and implemented by providers in order to prevent their further deterioration. Anyone with an interest in the concept of person-centered approaches will discover new ideas in this book. Indeed, anyone with an interest in person-centered approaches has to read this book. Not only is it the first such book on person-centered approaches, but it will serve as the gold standard in this topic area for years to come.' William A Anthony, in the Foreword. (shrink)

UK maternity policy makes great fanfare about providing person-centered care, built around what the pregnant woman or birthing person needs. Maternity Voices Partnerships involving healthcare professionals and women are supposed to guide policy and practice at the local level. UK consent law prioritizes the pregnant person's own conception of the risks and factors that are material to her care. The COVID-19 pandemic has shown how tenuous a hold these laudable principles actually have when the going (...) gets tough. (shrink)

An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease, involving dialysis or conservative care. Shared decision-making is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A (...) shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD. (shrink)

Person Centred Medicine is a substantial and contentious view of healthcare that carries both ontological and epistemological presuppositions. This chapter examines two key aspects: that the person is a central, basic irreducible element in ontology and that person-level knowledge is both important and possible. Some reasons for holding both of these are sketched.

Clinical Ethics, Ahead of Print. It could hardly be denied that healthcare should be patient-centred. However, some of the practices commonly described as patient-centred care may have ethically problematic consequences. This article identifies and discusses twelve ethical conflicts that may arise in the application of person-centred care. The conflicts concern e.g. privacy, autonomous decision-making, safeguarding medical quality, and maintaining professional egalitarianism as well as equality in care. Awareness of these potential conflicts can be helpful in finding the best (...) way to ensure that healthcare has its focus on the needs and interests of the patients. Patient-centred care may have to take different forms, depending of the nature of the disease, the patient’s life situation, and the economic, organizational and technological resources available to the healthcare unit. (shrink)

There is a critical need to establish a space to engage in careful deliberation amid exciting, important, necessary, and groundbreaking technological and clinical advances in pediatric medicine. Extracorporeal membrane oxygenation (ECMO) is one such technology that began in pediatric settings nearly 50 years ago. And while not void of medical and ethical examination, both the symbolic progression of medicine that ECMO embodies and its multidimensional challenges to patient care require more than an intellectual exercise. What we illustrate, then, is a (...) person-centered framework that incorporates the philosophy and practice of palliative care and care-based ethical approaches. This person-centered framework is valuable for identifying and understanding challenges central to ECMO, guides collaborative decision-making, and recognizes the value of relationships within and between patients, families, healthcare teams, and others who impact and are impacted by ECMO. Specifically, this person-centered approach enables caregivers to provide compassionate and effective support in critical, and often urgent, situations where conflicts may emerge among healthcare team members, families, and other decision makers. By reflecting on three cases based on actual situations, we apply our person-centered framework and identify those aspects that were utilized in and informed this project. We aim to fill a current gap in the pediatric ECMO literature by presenting a person-centered framework that promotes caregiving relationships among hospitalized critically ill children, families, and the healthcare team and is supported through the philosophy and practice of palliative care and clinical ethics. (shrink)

Background In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. (...) Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined.Methods Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes.Results Approximately, 95% of physicians were patient-centered in explaining the patient’s severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient’s wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions.Conclusions In relatively low-conflict situations, such as the announcement of a patient’s medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice. (shrink)

Since the 1970’s epidemiological measures focusing on “health-related quality of life” or simply “quality of life” have figured increasingly as endpoints in clinical trials. Before the 1970’s these measures were known, generically, as performance measures or health status measures. Relabeled as “quality of life measures” they were first used in cancer trials. In the early 2000’s they were relabeled again as “patient-reported outcome measures” or PROMs, in their service to the FDA to support drug labeling claims. To the limited degree (...) that the philosophical literature addresses these measures, it tends to associate them with two major theories of well-being: subjective well-being and the capabilities approach. In this paper, I argue that philosophers ought to treat quality of life measures/proms as a distinct from these theories. I argue that quality of life/proms serve healthcare as vehicles for patient-centered care and this has important consequences for how we theorize these measures. To this end, two requirements set them apart from measures of subjective well-being and the capabilities approach: quality of life/proms need to be patient-directed and inclusive. (shrink)

Background In an effort to improve the quality of medical care, the philosophy of patient-centered care has become integrated into almost every aspect of the medical community. Despite its widespread acceptance, among patients and practitioners, there are concerns that rapid advancements in artificial intelligence may threaten elements of patient-centered care, such as personal relationships with care providers and patient-driven choices. This study explores the extent to which patients are confident in and comfortable with the use of these technologies (...) when it comes to their own individual care and identifies areas that may align with or threaten elements of patient-centered care. Methods An exploratory, mixed-method approach was used to analyze survey data from 600 US-based adults in the State of Florida. The survey was administered through a leading market research provider (August 10–21, 2023), and responses were collected to be representative of the state’s population based on age, gender, race/ethnicity, and political affiliation. Results Respondents were more comfortable with the use of AI in health-related tasks that were not associated with doctor-patient relationships, such as scheduling patient appointments or follow-ups (84.2%). Fear of losing the ‘human touch’ associated with doctors was a common theme within qualitative coding, suggesting a potential conflict between the implementation of AI and patient-centered care. In addition, decision self-efficacy was associated with higher levels of comfort with AI, but there were also concerns about losing decision-making control, workforce changes, and cost concerns. A small majority of participants mentioned that AI could be useful for doctors and lead to more equitable care but only when used within limits. Conclusion The application of AI in medical care is rapidly advancing, but oversight, regulation, and guidance addressing critical aspects of patient-centered care are lacking. While there is no evidence that AI will undermine patient-physician relationships at this time, there is concern on the part of patients regarding the application of AI within medical care and specifically as it relates to their interaction with physicians. Medical guidance on incorporating AI while adhering to the principles of patient-centered care is needed to clarify how AI will augment medical care. (shrink)

Person-centred care is a cornerstone of contemporary health policy, research and practice. However, many researchers and practitioners worry that it lacks a 'clear definition and method of measurement,' and that this creates problems for the implementation of person-centred care and limits understanding of its benefits. In this paper we urge caution about this concern and resist calls for a clear, settled definition and measurement approach. We develop a philosophical and conceptual analysis which is grounded in the body of (...) literature concerning the theory and practice of person-centred care. We consider a range of influential definitional frameworks of person-centred care, highlighting their differences and showing that they do not correspond to a clearly circumscribed and consistent underlying concept. We argue that a degree of indeterminacy and vagueness should not be seen as a problem with the concept of person-centred care; these are features of a rich and contested concept which exists prior to and outside of practical and technical operational definitions and applications. We defend the value of operating with multiple accounts of person-centred care, arguing that what counts as being person-centred can vary across different care contexts, in relation to different patient groups, and as a reflection of different, defensible ethical perspectives. Although the idea of a single, agreed definition is attractive and may seem to be a practical or even necessary step towards meaningful and coordinated action, we argue that this is only the case in a qualified sense. Comprehensive attempts to narrow down the concept in this way should be resisted, as they risk undermining what it is that makes person-centredness a valuable concept in healthcare. (shrink)

Digital technologies have become a crucial factor in nursing. Given the fact that many tasks could also be done by robots or AI systems, the place for the nurse in this scenario is unclear. In what way and to what extent will the implementation of ever more sophisticated technology affect nursing practice? It is the aim of this paper to analyse the potential challenges of nursing practice in the digital age. The analysis is conducted through the lens of new materialism, (...) a set of theoretical models that understand the relationship between humans and technology as dynamic and performative. According to this view, there is no prefixed essence of technology. Rather, the meaning of technology is enacted in concrete practice. The analysis shows that in past debates on technology use in nursing, the nurses’ role has been defined as guardians of humanity, defending the patient against the dehumanizing effects of technology. This role has been transferred to the digital age, where it is the duty of nurses to cushion the negative effects of digital technology. As an alternative to this outdated role, nurses should be included in processes of technology design and policymaking. Enabling nursing professionals to shape the circumstances of a digitally enhanced holistic practice may empower their status within the healthcare system and also benefit the patient by contributing to a more person‐centred care. (shrink)

SCHOFIELD I, TOLSON D and FLEMING V. Nursing Inquiry 2012; 19: 165–176 [Epub ahead of print]How nurses understand and care for older people with delirium in the acute hospital: a Critical Discourse AnalysisDelirium is a common presentation of deteriorating health in older people. It is potentially deleterious in terms of patient experience and clinical outcomes. Much of what is known about delirium is through positivist research, which forms the evidence base for disease‐based classification systems and clinical guidelines. There is little (...) systematic study of nurses’ day‐to‐day practice of nursing patients with delirium. The aim was to uncover the kinds of knowledge that informs nurses’ care and to explicate the basis of that knowledge. Critical Discourse Analysis is underpinned by the premise that powerful interests within society mediate how social practices are constructed. Links were made between the grammatical and lexical features of nurses’ language about care in interviews and naturalistic settings, and the healthcare context. Care focused on the continuous surveillance of patients with delirium by nurses themselves or vicariously through other patients, and containment. Nurses influenced by major discourses of risk reduction and safety, constructed patients with delirium as risk objects. The philosophy of person‐centred and dignified care advocated in nursing literature and government policy is an emerging discourse, though little evident in the data. The current dominant discourses on safety must give space to discourses of dignity and compassion. (shrink)

Nursing practice occurs in the context of conversations with healthcare users, other healthcare professionals, and healthcare institutions. This discussion paper draws on symbolic interactionism and Fairclough's method of critical discourse analysis to examine language that nurses use to describe the people in their care and their practice. We discuss how nurses’ use of language constructs meaning about healthcare users and their own work. Through language, nurses are articulating what they believe about healthcare users and nursing (...) practice. We argue that the language nurses use can contribute to viewing their practice as tasks on bodies that must be accomplished efficiently and objectively within the biomedical model, rather than relational and person‐centered. Moreover, the language nurses use can perpetuate a sense of powerlessness within healthcare systems yet paradoxically they are in a position of power over healthcare users. Nurses’ compliance with the efficiency and biomedical model results in a lack of emphasis on the full breadth of nursing work, which could be enacted in relational rather than power‐laden practices. We conclude by positing that careful use of language among nurses in all settings is essential, if we are to begin to articulate what nursing is to ourselves and to others. (shrink)

This discussion paper aims to explore potential ethical and moral implications of (patient) centredness in nursing and healthcare. Healthcare is experiencing a philosophical shift from a perspective where the health professional is positioned as the expert to one that re‐centres care and service provision central to the needs and desires of the persons served. This centred approach to healthcare delivery has gained a moral authority as the right thing to do. However, little attention has been given to (...) its moral and ethical theoretical grounding and potential implications for nurses, persons served and the healthcare system. Based upon a review of academic and grey literature, centredness is proposed as a value‐laden concept in nursing inquiry. Potential moral and ethical implications of centredness on nurses/healthcare providers, persons served and the healthcare system are discussed. These challenges are then considered within the context of normative and relational ethical theories. These perspectives may offer guidance relative to how one should act in those circumstances as well as an understanding as to how interdependency and engagement with the other person(s) can help navigate the challenges of a centred care approach. Viewing centredness through an ethical theoretical lens provides a valuable discourse to nursing in efforts to expand the knowledge base and integrate centred approaches into practice and policy. (shrink)

Although spiritual practices such as prayer are engaged by many to support well‐being and coping, little research has addressed nurses and prayer, whether for themselves or facilitating patients' use of prayer. We conducted a qualitative study to explore how prayer (as a proxy for spirituality and religion) is manifest—whether embraced, tolerated, or resisted—in healthcare, and how institutional and social contexts shape how prayer is understood and enacted. This paper analyzes interviews with 21 nurses in Vancouver and London as a (...) subset of the larger study. Findings show that nurses' kindness can buffer the loneliness and exclusion of ill health and in this way support the “spirit” of those in their care. Spiritual support for patients rarely incorporated prayer, in part because of ambiguities about permission and professional boundaries. Nurses' engagement with prayer and spiritual support could become a politicized site of religious accommodation, where imposition, religious illiteracy, and racism could derail person‐centered care and consequently enact social exclusion. Spiritual support (including prayer) sustained nurses themselves. We propose that nursing's equity‐oriented knowledge encompass spirituality and religion as sites of exclusion and inclusion. Nurses must be supported to move past religious illiteracy to provide culturally and spiritually sensitive care with clarity about professional boundaries and collaborative models of spiritual care. (shrink)

In this paper we use the concept of the person to examine person‐centred dialogue and show how person‐centred dialogue is different from and significantly more than transfer of information, which is the dominant notion in health care. A further motivation for the study is that although person‐centredness as an idea has a strong heritage in nursing and the broader healthcare discourse, person‐centred conversation is usually discussed as a distinct and unitary approach to communication, primarily (...) related to the philosophy of dialogue—the philosophy of Martin Buber. In this paper we start with the concept of person to critically reflect on theoretical perspectives on communication to understand person‐centred conversations in the context of nursing and health. We position the concept of the person through the use of Paul Ricoeur's philosophy and follow by distinguishing four theoretical perspectives on communication before reflecting on the relevance of each of these for person‐centred communication. These perspectives are: a linear view of communication as transfer of information, communication as a relation in the sense of philosophy of dialogue, practice‐based communication on constructionist grounds, and communication as a practice to create social community. In relation to the concept of the person, we do not find transfer of information relevant as a theoretical underpinning for person‐centred conversations. From the other three perspectives that are relevant we distinguish five types of person‐centred conversations pertinent to nursing and health: problem identifying conversations, instructive conversations, guiding and supportive conversations, caring and existential conversations, and therapeutic conversations. Through this analysis it is argued that person‐centred communication and conversations are substantially different to transfer of information. We also discuss the significance of communication adjusted to specific situations, including emphasis on how we speak in relation to the aim or topic of a conversation. (shrink)

This paper presents a systematic account of ethical issues actualised in different areas, as well as at different levels and stages of health care, by introducing organisational and other procedures that embody a shift towards person centred care and shared decision-making (PCC/SDM). The analysis builds on general ethical theory and earlier work on aspects of PCC/SDM relevant from an ethics perspective. This account leads up to a number of theoretical as well as empirical and practice oriented issues that, in (...) view of broad advancements towards PCC/SDM, need to be considered by health care ethics researchers. Given a PCC/SDM-based reorientation of health care practice, such ethics research is essential from a quality assurance perspective. (shrink)

The legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity. In response to the increased interest in social justice, medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations. This paper aims to explore decolonising ideas of healing within medical education following recent events including the University College London Medical School’s Decolonising the Medical Curriculum public engagement event, the Wellcome Collection ’s (...) Ayurvedic Man: Encounters with Indian Medicine exhibition and its symposium on Decolonising Health, SOAS University of London’s Applying a Decolonial Lens to Research Structures, Norms and Practices in Higher Education Institutions and University College London Anthropology Department’s Flourishing Diversity Series. We investigate implications of ‘recentring’ displaced indigenous healing systems, medical pluralism and highlight the concept of cultural humility in medical training, which while challenging, may benefit patients. From a global health perspective, climate change debates and associated civil protests around the issues resonate with indigenous ideas of planetary health, which focus on the harmonious interconnection of the planet, the environment and human beings. Finally, we look further at its implications in clinical practice, addressing the background of inequality in healthcare among the BAME populations, intersectionality and an increasing recognition of the role of inter-generational trauma originating from the legacy of slavery. By analysing these theories and conversations that challenge the biomedical view of health, we conclude that encouraging healthcare educators and professionals to adopt a ‘ decolonising attitude ’ can address the complex power imbalances in health and further improve person-centred care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Microaggressions among Healthcare Providers Facilitate Microaggressions toward PatientsH. Rhodes Hambrick (bio) and Sonya Tang Girdwood (bio)In the conclusion of Freeman and Stewart's (2024) book, Microaggressions in Medicine, the authors specifically recognize the existence of microaggressions among healthcare professionals but have chosen not to focus on these microaggressions in the book. However, it is imperative to acknowledge that microaggressions committed among healthcare professionals can perpetuate microaggressions toward (...) patients by creating a permissive culture wherein microaggressions are committed and accepted as the norm.Microaggressions among healthcare professionals, especially when there are hierarchal differences, often masquerade as concerns regarding "professionalism" (Miller et al. 2023). While we recognize that establishing standards of professional behavior (e.g., thorough and timely communication with patients and healthcare staff, commitment to providing safe and effective care) is crucial to the ethical practice of medicine, the precise definition of professionalism in medicine is nebulous. Therefore, individuals in power within medicine can overlay their personal opinions about what constitutes "professional" behavior. This subjectivity and the lack of a consensus definition can lead to the policing of trainees both within the walls of the hospital and within their personal lives.Given that microaggressions are often centered on aspects of a person's behavior, dress, or personality that may pertain to a particular identity, these are also coined by Freeman and Stewart as self-identity microaggressions (chapter 6) and are distressingly common in medicine. Enforcing dress codes is an example of policing trainees under the guise of professionalism that may simultaneously constitute microaggressions toward people of certain demographics, specifically those who are nonwhite and nonmale. For example, women are often given advice to wear dark-colored, conservative suits for interviews and instructed that dresses and skirts must be long in clinical settings to avoid distracting men. Black trainees may be told that their natural hairstyles are [End Page 157] "unprofessional" and are given advice on how to appear more "presentable" in interviews and on rotations. To cite a recent example of a self-identity microaggression, it made news when a Latina student had points deducted during her practical exam with a standardized patient for wearing large hoop earrings, a type of jewelry she has worn her whole life and represents her cultural heritage (Hatzipanagos 2021).Disappointingly, this policing even extends beyond clinical and "professional" settings. One surgical residency searched the social media profiles of their residents to investigate how many "unprofessional" photos trainees posted, and the results were published in a journal prior to retraction of the publication (Hardouin et al. 2020). Among the list of "unprofessional photos" were those of residents in "inappropriate attire," which included bikinis and swimsuits being worn in non-clinical settings. Fortunately, when the findings were published, the journal received severe backlash on social media. Physicians, both men and women, posted pictures of themselves in swimsuits on social media under the hashtag "#medbikini," arguing that what we wear, especially in our private lives, does not affect our abilities as physicians. While the article was retracted, it was made clear that trainees are judged by their appearance by their superiors and that microaggressions can even be published in reputable journals. Conducting and publishing research like this constitute a type of self-identity microaggression, in which trainees are made to feel that part of their identity outside of work, such as their choice of swimwear, which, in the case of a bikini, may be tied to their gender identity, is fundamentally "unprofessional," even when it has no bearing on their ability to function as doctors.Microaggressions can also be committed when trainees are policed on their behaviors, speech patterns, or mannerisms. They may be reprimanded for using certain vocabulary or speaking with subculture-specific idioms because they will be seen as "unprofessional," when in reality, these forms of speech may simply reflect a cultural or personality difference. Superiors may express their preferences or dislike of certain behaviors by using the threat of labeling them "unprofessional." For example, using bright colors or personal touches on presentations might be given as feedback of "looking unprofessional." Expressing preferences and labeling them as opinions are encouraged, but tagging on the term unprofessional carries a weight that removes any choice from... (shrink)

Person‐centred care is founded on ethics as a basis for organizing care. In spite of healthcare systems claiming that they have implemented person‐centred care, patients report less satisfaction with care. These contrasting results require clarification of how to practice person‐centred ethics using Paul Ricoeur's ‘Little ethics’, summarized as: ‘aiming for the good life, with and for others in just institutions’. In this ethic Kantian morality is at once subordinate and complementary to Aristotelian ethics because the ethical (...) goal needs to be critically assessed and passed through the examination of the norm in each care situation. This paper presents examples that describes a person‐centred care practice that balance a critical review of care activities based on a conviction of aiming for patients' wellbeing. In contrast to patients' experiences of person‐centred care in real life, research projects have shown that if the clinical performers comprehend and apply the practice of person‐centred ethics, patients report positive outcomes. The implementation of person‐centred care therefore demands that stakeholders and managers enables and requires that healthcare staff study ethics in the same way as studying for example pharmacology is required when handling patients' medicines. (shrink)

Person‐centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person‐centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to (...) reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person‐centred. In this article, we explore key concepts of neo‐liberal thought which forms an important back‐story to the articles. Economic concepts, “efficiency” and “freedom” are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo‐liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power. (shrink)

Background: Patients and their caregivers are expected to take joint responsibility for reporting symptoms and seeking medical assistance, for example, by calling oncology emergency telephones or other helplines during a cancer trajectory. Research objective: The aim was to explore the meaning of responsibility as it appeared in patients’ or caregivers’ experiences of calling an oncological emergency telephone. Design, participants and context: Inspired by qualitative description and qualitative content analysis, a secondary analysis of data from interviews with 12 participants calling the (...) oncological emergency telephone at a Danish university hospital was performed. Ethical considerations: The project observes demands for safekeeping data and all regulations concerning research ethics in agreement with the Nordic Nurses Federation and the Danish Health Act. Findings: Two main themes emerged: (1) to act responsibly as a patient or caregiver was to ‘be watchful and alert’, ‘report symptoms the right way’ and ‘do crosschecking’ and (2) to deal with the burden of responsibility was to ‘feel safe when dealing with the burden of responsibility’ and ‘be relieved from the burden of responsibility’. Discussion: Too much responsibility and a potential imbalance between healthcare professionals’ expectations and callers’ knowledge and capacity to act may place additional burdens on the callers, which may be eased by person-centred care. Conclusion: The meaning of responsibility appeared in the participants’ capacity to act, where they observed, assessed and reported symptoms and controlled prescribed treatments as well as shared or handed over the responsibility to the healthcare providers. Thus, the analysis provided essential knowledge for healthcare professionals on how patients and caregivers handle this responsibility when faced with a cancer disease that is treated on an outpatient basis. (shrink)

Receiving a diagnosis of cancer can be devastating. Cancer continues to be one of the most feared diagnoses, and experiencing pain is a major fear for people diagnosed with cancer. Cancer pain is complex in aetiology and can be acute or chronic and can be caused by various compression, ischaemic, neuropathic or inflammatory processes. Many people with cancer will experience excruciating pain, which is often underreported and undertreated. The reasons for this are complex and include various factors including fears and (...) beliefs held by patients. Cognitive factors are important modulators of pain and the appraisals, meanings and beliefs that people have in relation to illness, cancer, and pain, have implications in regard to help-seeking behaviours and the coping strategies people adopt. Cancer pain can impact a range of psycho-social factors across its course. Cancer pain relates to higher rates of psychological distress, anxiety and low mood, and the perception of pain intensity is, in turn, influenced by psychological factors. Cancer pain can negatively affect psychological health, and psycho-social factors can affect the pain experience. It has been suggested that people with a life-limiting illness experience ‘total pain’, and this can encompass psychological, social, practical, spiritual domains. Research demonstrates that cancer is predominantly an illness affecting older people, yet there is a higher risk of under-treated pain in this age group and there is a paucity of research into the subjective experiences of older people managing their cancer pain. Many older people are required to self-manage cancer pain at home as outpatients, due to drivers to keep people out of inpatient care, such as the high healthcare costs of inpatient treatment, and patients wanting to manage their illness, and die, at home. Our own research into this area found that the self-management of cancer pain involves a sequential and temporal process, which centres on perceptions of control. We describe how the older people in our study experienced a perceived loss of control, followed by a sense of gaining control over pain through various experience of certain internal and external factors. The assessment and treatment of physical pain should be done in combination with assessment and treatment of psycho-social and spiritual pain, and interventions for cancer pain need to focus on increasing positive affect and reducing helplessness. No person should suffer with poorly controlled pain and we argue for the need for further research in this area to ensure adequate treatment for all.Clinical Implications: Assessment and treatment of physical pain in people with cancer needs to be conducted in combination with assessment and treatment of psycho-social issues and spiritual pain. Psychological and behavioural approaches have strong evidence supporting their efficacy for reducing cancer pain. Interventions should target helplessness and focus on increasing positive affect through positive psychological states including fighting spirit and resilience. Person-centred interventions that focus on helping people with the search for meaning may help those with cancer pain derive positive benefits. (shrink)

Communicating an unfavourable prognosis while maintaining patient hope represents a critical challenge for healthcare professionals. Duty requires respect for the right to patient autonomy while at the same time not doing harm by causing hopelessness and demoralisation. In some cases, the need for therapeutic privilege is discussed. The primary objectives of this study were to explore HPs’ perceptions of hope in the prognosis communication and investigate how they interpret and operationalise key ethical principles. Sixteen qualitative semistructured interviews with HPs (...) from different positions and experience, including doctors and nurses in four different departments, were conducted in the Ticino Cantonal Hospital, Switzerland. The interviews were recorded, transcribed verbatim and analysed using thematic analysis. HPs defined prognosis and patient hope as interdependent concepts related to future perspectives for subjective quality of life. Two main factors allow HPs to maximise the benefits and minimise the harm of their communication: respecting the patient’s timing and sharing the patient’s wishes. Time is required to reframe needs and expectations. Furthermore, communication needs to be shared by HPs, patients and their relatives to build common awareness and promote a person-centred approach to prognosis. In this process, interprofessional collaboration is key: doctors and nurses are complementary and can together guarantee that patients and relatives receive information in the most appropriate form when they need it. Organisational aspects and the HPs’ emotional difficulties, particularly in coping with their own despair, are barriers to effective communication that need further investigation. (shrink)

About one-third of Australians use the services of complementary and alternative medicine (CAM); but debate about the role of CAM in public healthcare is vociferous. Despite this, the mechanisms driving CAM healthcare choices are not well understood, especially in rural Australia. From 2016 to 2018, 2,679 persons from the Goulburn Valley, northern Victoria, were surveyed, 28% (755) of whom reporting visiting CAM practitioners. A Generalized Linear Mixed Model was used to assess associations between various socio-demographic variables and the (...) use of CAM services. The strongest significant inverse (p < 0.05) association with CAM use overall was being unemployed, with markedly lower odds of using CAM than those employed full-time (OR 0.22 [0.12, 0.41]). The next strongest inverse relationship was being retired (OR 0.44 [0.30, 0.65]). The strongest positive associations were with English spoken at home (OR 2.38 [1.34, 4.24]), private health insurance (hospital cover) (1.57 [1.28, 1.91]), being Australian born (OR 1.61 [1.14, 2.28]), and female sex (1.25 [1.02, 1.52])). Females had significantly higher odds of using osteopathy than males (OR 1.98 [1.33, 2.96]) but there were no significant sex differences for chiropractic or massage. This is the first such study conducted solely for a rural Australian population. The drivers of CAM use differed from previous nation-wide studies and they varied across modalities. The factors identified here as being associated with CAM use could be used by CAM practitioners in developing person-centred services. Similarly, the findings are relevant to primary-care services in understanding what sectors of society might eschew conventional health care for CAM in rural regions, where health services are often limited. (shrink)

The global COVID‐19 pandemic challenged the world—how it functions, how people move in the social worlds and how government/government services and people interact. Health services, operating under the principles of new public management, have undertaken rapid changes to service delivery and models of care. What has become apparent is the mechanisms within which contemporary health services operate and how services are not prioritising the person at the centre of care. Person‐centred care (PCC) is the philosophical premise upon which (...) models of health care are developed and implemented. Given the strain that COVID‐19 has placed on the health services and the people who deliver the care, it is essential to explore the tensions that exist in this space. This article suggests that before the pandemic, PCC was largely rhetoric, and rendered invisible during the pandemic. The paper presents an investigation into the role of PCC in these challenging times, adopting a Foucauldian lens, specifically governmentality and biopolitics, to examine the policies, priorities and practical implications as health services pivoted and adapted to changing and acute demands. Specifically, this paper draws on the Australian experience, including shifting nursing workforce priorities and additional challenges resulting from public health directives such as lockdowns and limitations. The findings from this exploration open a space for discussion around the rhetoric of PCC, the status of nurses and that which has been lost to the pandemic. (shrink)

Burnout among physicians, nurses, and students is a serious problem in U.S. healthcare that reflects inattentive management practices, outmoded images of the “good” provider as selflessly ignoring the care of the self, and an overarching rubric of Patient Centered Care that leaves professional self-care out of the equation. We ask herein if expanding PCC to Patient and Professional Centered Care would be a useful idea to make provider self-care an explicit part of mission statements, a major part (...) of management strategies and institutional goal setting, and of educational programs. We offer several practical suggestions for PPCC implementation, including structuring healthcare systems so as to nurture professional meaning, integrity, and inter-personal reflective emotional processing as a buffer against burnout and as a key to better patient care. It should not bring into question the primacy of practitioner commitment to the good of patients, nor should it be taken to suggest in any way a shift in focus away from patients’ values and respect for patient autonomy. PPCC asserts that the respect for patient’s values and autonomous choices properly remains the ethical benchmark of modern healthcare systems, along with altruistic professional commitment to the optimal care of patients. However, it enunciates an explicit commitment to structuring systems that allow for and actively encourage the professional well-being and wellness upon which good patient care depends. (shrink)

Over the past decade or so, the predominant patient-centered ethos in American bioethics has come under attack by critics who claim that it is morally deficient in certain respects, particularly when viewed in the context of acute-care decisionmaking. One line of criticism has been that the current ethic of patient autonomy gives an individual competent patient far too much decisional authority over the terms of his own treatment so that the patient is at complete liberty to neglect the ways (...) in which his medical decisions can drastically and negatively affect the lives of other family members. Given that family members must help shoulder the financial, emotional, and rehabilitative burdens involved in the patient's care, it has been argued that they too have a legitimate interest in choosing what sort of medical treatment the patient eventually receives. Another closely related line of criticism is that the prevailing focus on patient autonomy gives short shrift to the moral significance of the family as a genuine community. Echoing a view of the person advanced by most communitarian political theorists, some commentators have argued that the patient comes to the clinic so thoroughly embedded in a complex web of familial relationships and obligations that it does not make sense to identify him as the only person in the family to make decisions about treatment. (shrink)

Palliative care is provided at a certain timepoint, both in a person's life and in a societal context. What is considered to be a good death can therefore vary over time depending on prevailing social values and norms, and the person's own view and interpretation of life. This means that there are many interpretations of what a good death can actually mean for an individual. On a more general level, research in palliative care shows that individuals have basic (...) common needs, for example physical, mental, social and spiritual well‐being. Therefore, in today's pluralistic Western society, it becomes important that palliative care is person centred to enable individuals to receive, as far as can be achieved, care that promotes as good a life as possible based on the person's own needs and preferences, and in accordance with evidence and current laws. For many years a research group, consisting nurse researchers together with nurses working in palliative care, has developed a model for person‐centred palliative care, the 6S‐model. The model's central concept is Self‐image, where the starting point is the patient as a person and their own experience of the situation. The other concepts: Self‐determination, Symptom relief, Social relationships, Synthesis and Strategies are all related to the patient's self‐image, and often to each other. The model's development, value base and starting assumptions are reported here, as are examples of how the model is applied in palliative care in Sweden. The model has been, and still is, constantly evolving in a collaboration between researchers and clinically active nurses, and in recent years also with patients and close relatives. (shrink)

The ageing population is increasing worldwide with an increase in chronic disorders. At the same time, person‐centred care has become a policy within both health and social care. To facilitate coordination and collaboration and integrate the older adult's perspective in the decision‐making process the collaborative care planning process with the development of a written care plan can be used. In this study, the result of an interpreted analysis of four empirical studies of the collaborative care planning as a (...) class='Hi'>person‐centred practice will be discussed and reflected on. A framework based on the French philosopher Paul Ricoeur's little ethics was used in the synthesis of the studies. The findings revealed two common threads: personhood and power asymmetry. Both challenges in achieving a person‐centred collaborative care planning. Ricoeur's dialogical thinking and description of a person served as an underpinning in discussing and reflecting upon the findings of the interpreted synthesis. Collaborative care planning is a complex process. However, Ricoeur's philosophy contributed to a greater understanding of the collaborative care planning as a person‐centred practice and accentuated that ethics, human values, and the older adults and care partners perspectives need to be given the same importance and considerations as the medical and social sciences perspectives for the collaborative care planning process to truly become person‐centred. (shrink)

The aim of this analysis was to examine the concept of time to rejuvenate and extend existing narratives of time within the nursing literature. In particular, we hope to promote a new trajectory in nursing research and practice which focuses on time and person‐centred care, specifically of older people with cognitive impairment hospitalized in the acute care setting. We consider the explanatory power of concepts such as clock time, process time, fast care, slow care and time debt for elucidating (...) the relationship between ‘good care’ and ‘time use’. We conclude by offering two additional concepts of time, plurotemporality and person‐centred time (PCT) which we propose will help advance of nursing knowledge and practice. Nurse clinicians and researchers can use these alternative concepts of time to explore and describe different temporal structures that honour the patient's values and preferences using experiential, observation‐based nursing research approaches. (shrink)

In this article, we sought reconciliation between the “body‐as‐representation” and the “body‐as‐experience,” that is, how the body is represented in discourse and how the body of older people with cognitive impairment is experienced. We identified four contemporary “technologies” and gave examples of these to show how they influence how older people with cognitive impairment are often represented in acute care settings. We argued that these technologies may be mediated further by discourses of ageism and ableism which can potentiate either the (...) repressive or productive tendencies of these technologies resulting in either positive or negative care experiences for the older person and/or their carer, including nurses. We then provided examples from research of embodied experiences of older people with dementia and of how nurses and other professionals utilized their inter‐bodily experiences to inform acts of caring. The specificity and individuality of these experiences were more conducive to positive care experiences. We conclude the article by proposing that the act of caring is one way nurses seek to reconcile the “body‐as‐representation” with the “body‐as‐experience” to mitigate the repressive effects of negative ageism and ableism. The act of caring, we argue, is the essence of caring enacted through the provision of person‐centred care which evokes nurses to respond appropriately to the older person's “otherness,” their “variation of being” while enabling them to enact a continuation of themselves and their own version of normality. (shrink)

Relationships are central to enacting person‐centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person‐centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long‐term care. The acute (...) care setting is characterized by archetypal constraints which differentiate it from long‐term care, in terms of acuity and haste, task‐orientated work patterns and influence from “the rule of medicine,” all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re‐interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re‐presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person‐centred care versus relationship‐centred care by arguing that these are complementary rather than mutually exclusive and can be brought together in one theoretical framework acknowledging personhood as relational in essence. (shrink)

Rationale: Patients with advanced dementia experience multifaceted vulnerabilities because of their diminished capacities for decision making. The dominant versions of person-centred care (PCC) emphasise patient preferences and autonomy, which often undermines a recognition of their distinct unfulfilled needs. Determining whether an individual autonomy conception of personhood applies to patients with advanced dementia is morally problematic from various theoretical perspectives and leads to the one-approach-fits-all problem when caring for this patient population. -/- Aims and Objectives: The availability of patients' advanced (...) directives varies depending on their cultural backgrounds. The goal of the study is to argue that PCC, with a focus on relational autonomy, should be the first step for caring for patients with advanced dementia. -/- Method: The study engages in a critical exploration of inclusivity and diversity in ethical thinking within a framework of PCC and uses philosophical argumentation to assess the viability of a relational autonomy conception of PCC. -/- Results and Conclusion: By taking relationality seriously, especially in caring for patients with advanced dementia in a multicultural society, and by considering the moral nexus of unmet needs through the perspective of PCC, we can resolve the problem of one-approach-fits-all in dementia care. (shrink)

Key commentators on person‐centred care have described it as a “new ethic of care” which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person‐centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person‐centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their (...) practice tend to comply more often with prevailing norms than those championed by person‐centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses’ ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person‐centred care. We argue that nurses’ responses to the ethical demand by way of parrhêsia can be an important feature of intra‐organizational reflexivity and its transformation towards the delivery care that is more person‐centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research. (shrink)

Background: According to ethical guidelines, healthcare professionals should be able to provide care that allows for the patients’ values, customs and beliefs, and the existential issues that are communicated through them. One widely discussed issue is existential loneliness. However, much of the debate dealing with existential loneliness concludes that both the phenomenon and the concept are quite vague. Aim: To clarify what constitutes existential loneliness, and to describe its lived experiences. A further aim was to provide a definition of (...) existential loneliness that can function as a tool for identifying the phenomenon and for differentiating it from other kinds of loneliness. Method: A literature review including theoretical and empirical studies. Different search strategies were used to gather the articles included in the study. The analysis of the empirical studies had an interpretative approach. The articles were also analysed with the aim of providing a definition of existential loneliness. This was done by means of criteria such as language, uniqueness, theory and usefulness. This study is not empirical and does therefore not require an ethics review. Results: The analysis resulted in two main characteristics. The first one was perceiving oneself as inherently separated (disconnected) from others and from the universe. The second one brings out emotional aspects of EL, such as isolation, alienation, emptiness and a feeling of being abandoned. The empirical findings were divided into two categories: experiences of EL and circumstances in which EL arises. A definition of EL is also suggested, based on the two main characteristics identified. Conclusion: In order to meet patients’ needs, it is an ethical duty for healthcare staff to be able to recognise experiences of EL, that is, to communicate with the patients about these experiences in an appropriate manner. This in turn demands knowledge about existential issues and skills to deal with them. (shrink)

Those giving birth within modern maternity systems are recognised as facing a number of barriers to person-centred care. In this paper, I argue that in order to best facilitate the conditions for positive change, work needs to be done to provide a more granular articulation of the specific barriers. I then offer a nuanced and contextually aware articulation of one key component of the overall failure to ensure person-centred care: medical authority and the expectation of conformity. Articulating these (...) barriers with increased specificity is valuable, as it creates a stronger foundation from which to challenge existing problems which serve to constrain the autonomy of birthing individuals. The analysis offered in this paper also underscores the need for change at an institutional, rather than individual, level. (shrink)