This paper aims to analyze assumptions about the central concept of "centering" patients and families in patient- and family-centered care (PFCC) research. It uses a structured problematization method to identify three main areas of assumptions in PFCC intervention research: 1) spatial assumptions that patients and families can be centered through proximity, 2) assumptions that care can be democratized by including patients and families, and 3) assumptions that centering is primarily a problem and accomplishment for nursing. The paper argues for adopting theoretical lenses that de-center individual actors to better account for complex relationships among multiple human and non-human actors in care practices.

1. Nursing Inquiry. 2021;e12448. wileyonlinelibrary.com/journal/nin © 2021 John Wiley & Sons Ltd | 1 of 10
https://doi.org/10.1111/nin.12448
Received: 19 April 2021 | Revised: 10 July 2021 | Accepted: 16 July 2021
DOI: 10.1111/nin.12448
R E V I E W
Problematising assumptions about ‘centredness’ in patient
and family centred care research in acute care settings
Harkeert Judge | Christine Ceci
Faculty of Nursing, University of Alberta,
Edmonton, Alberta, Canada
Correspondence
Harkeert Judge, PhD Candidate, Faculty of
Nursing, University of Alberta, 11405‐87 Ave,
Edmonton, AB T6G 1C9, Canada.
Email: harkeert@ualberta.ca
Abstract
Over the last two decades significant efforts have been made to implement
patient and family ‘centred’ care as both a practical and moral imperative for
adult acute care delivery. Although many resources have been developed and
adopted by institutions, research suggests persistent and diverse barriers to
implementing and achieving patient and family ‘centred’ care in adult acute care
practice settings. These issues in implementation suggest re‐examining the
nature of ‘centredness’ in care may be useful. A structured problematisation
method, as outlined by Alvesson and Sandberg, is utilised to identify and ana-
lyse assumptions about the central notions of ‘centring’ that inform patient and
family centred care intervention research. From our analysis, we highlight three
predominant areas within ‘centring’ intervention research that may benefit from
rethinking: Vitruvian spatiality, democratising care, and ‘centring’ positioned as
primarily a problem and accomplishment for nursing. As a challenge to these
assumptions, we argue for the adoption of theoretical lenses that ‘de‐centre’
individual actors to better account for complex relations among multiple actors,
both human and nonhuman, which work to involve patients and families in care
practices.
K E Y W O R D S
acute care, adult, patient and family centred care, problematisation, sociological critique
The purpose of this paper is to identify and analyse assumptions
about the central notion of ‘centring’ that informs patient and
family centred care (PFCC) intervention research in adult acute
care settings, and to show how these assumptions may be limiting
the effectiveness of knowledge development in this field. We
explore the question of how do researchers come to know and
shape patient and family ‘centred' care as an object of scientific
investigation? A problematisation approach, as outlined by
Alvesson and Sandberg (2011, 2013), is described and used to
explore the growing field of PFCC research.
1 | BACKGROUND TO PATIENT AND
FAMILY ‘CENTRED’ CARE
Significant resources have been committed to developing policies to
promote the implementation of PFCC in hospital settings, and much
research has been undertaken to examine the effects and effec-
tiveness of these policies and PFCC initiatives. A widely adopted
conceptualisation of PFCC offered by the Institute for Patient and
Family Centered Care (2017) foregrounds dignity and respect as
foundational values, and information sharing, participation and

2. collaboration as central strategies for their practical application. This
conceptualisation underpins many initiatives across North America
intended to transform adult hospital care, ranging from organisational
policies and quality improvement strategies to efforts to change in-
dividual health care provider values and behaviours (American As-
sociation of Critical Care Nurses, 2019; Institute for Patient and
Family Centred Care & Canadian Foundation for Healthcare Im-
provement, 2015). Although there is broad uptake of the idea of
centring care on patients and families, it has been difficult to establish
an evidence base to both support PFCC initiatives and improve their
implementation (CADTH, 2015). Arguments for implementing PFCC
initiatives are broad and usually associated with improved quality of
care and safety, and enhanced patient satisfaction and experiences
(Park et al., 2018). These wide‐ranging benefits are described in a
PFCC curriculum developed by Emanuel et al. (2016) in consultation
with a range of patient safety stakeholders across Canada, including
quality assurance councils, hospitals and the American Patient Safety
Education Program. By prioritising patient and family involvement in
their own care, PFCC initiatives are also suggested to improve op-
erational efficiencies of health care by reducing the length of hospital
stays and readmissions, care transitions and discharge planning
(CADTH, 2015). However, it is unclear if these operational trends are
linked to other advances in hospital care, such as enhanced proce-
dural techniques, increased use of health informatics or develop-
ments in community care services.
Alongside these organisational logics, PFCC approaches to care
are justified as simply the ‘right’ thing to do and thus as a moral
obligation for health service providers (Millenson et al., 2016). In the
ethical discourses most often used, ‘centring’ care approaches are
argued for on the grounds that, by partnering and engaging with
families, health care providers will be more likely to respect patient
autonomy and choice (Igel & Lerner, 2016; Sedig, 2016). For example,
PFCC strategies, such as bedside rounding and bedside whiteboards,
are presented as effective means to encourage participation, in-
formation sharing and collaboration, thereby positioning patients as
experts on their lives and as having the right to choose their pre-
ferred health intervention (Emanuel et al., 2016). Additionally, most
stakeholder groups, including managers, physicians, nurses, patients
and family advisory groups support the idea that ‘good’ care is care
that involves the patient and family voice and satisfies their pre-
ferences (Kreindler, 2015). Although care providers and researchers
suggest various benefits, significant challenges are reported when
implementing PFCC initiatives and studying their effects within the
adult acute care setting.
1.1 | Implementation challenges
Research studies reporting barriers to implementing PFCC initiatives
describe challenges across organisational and individual care provider
levels despite decades of research and advocacy work (Lloyd
et al., 2018; Luxford et al., 2011; West et al., 2005). Administrative
hospital staff report barriers to implementing ‘centring’ care
strategies related to individual health care provider's limited experi-
ence and unsupportive attitudes, high workloads and time pressures
and constraints related to environmental resources (Lloyd et al.,
2018). These workload challenges, environmental constraints and
time pressures are also described by health care providers; however,
these are instead framed as issues relating to competing organisa-
tional priorities (Kiwanuka et al., 2019). While some challenges re-
lated to identified barriers are thought to be adequately addressed
through more education, many appear to be outside the control of
individual health care providers at the direct point of care (Bokhour
et al., 2018). For example, many health care providers state more
PFCC infrastructure is necessary to support its implementation
(Emanuel et al., 2016). Such infrastructure includes a variety of
structural and formal hospital processes, such as policies, materials or
technologies to support communication and information sharing,
or physical space for families to visit. Additional barriers, such as
traditional paternalistic care delivery models (Moore et al., 2017), lack
of scientific certainty to support PFCC (Goodridge et al., 2018) and
practices of tokenism where patients and families are present but not
actually engaged in care practices are also reported in the literature
(Kiwanuka et al., 2019).
1.2 | Theoretical challenges of PFCC
Researchers interested in developing solutions to address identified
barriers and challenges in the implementation of PFCC in acute care
are met with additional theoretical challenges, particularly a persis-
tent ambiguity and uncertainty related to describing and classifying
patient and family ‘centred’ care. Contemporary theories describing
the ‘centring’ of patients and families in care use somewhat diffuse
labels, including patient centred care, family centred care, person
centred care and PFCC. And although a number of concept analyses
have been undertaken in an attempt to differentiate and clarify these
‘centring’ care theories and approaches, they have had limited suc-
cess (Coyne et al., 2018; Morgan & Yoder, 2012; Smith, 2018). At the
same time, while many researchers continue to utilise various ‘cen-
tring’ care models interchangeably in their studies, others strongly
assert that there are important differences (Lines et al., 2015;
Starfield, 2011). For example, a literature review by Eklund et al.
(2019) suggests that the goal of patient‐centred care is a functional
life and the goal of person centred care is a meaningful life, and that
therefore these approaches should not be conflated. However,
Kokorelias et al. (2019) also synthesised literature through a scoping
review and recommended researchers consider developing a uni-
versal family centred care model with components from PFCC and
person centred care models to improve care. Although a study by
Hughes et al. (2008) is older, their work provides an informative and
descriptive history of the competing types of centring care ap-
proaches (e.g., family centred, patient centred, client centred). While
highlighting their diverse origins and intentions, Hughes et al. (2008)
suggest that all these approaches to care are linked by ‘an
implicit appeal to psychological or sociological theories of improved
2 of 10 | JUDGE AND CECI

3. interaction as psychosocial and ethical goods’ (p. 456). In this way, it
seems fair to observe that patient and family ‘centred’ care as an idea
has become significant for a range of stakeholders, despite carrying
diverse moral and ideological (e.g., professional or disciplinary) values
and practical meanings.
‘Centredness’ as a goal (if not a practice) is also accepted and
endorsed across many health disciplines, including nursing (Interna-
tional Family Nursing Association, 2018), medicine (Igel &
Lerner, 2016), disability and rehabilitation (Leplege et al., 2007),
physical therapy (Bamm & Rosenbaum, 2008) and psychiatry (Allen &
Petr, 1998). But while these approaches appear to be more or less
similar, Kreindler (2015) demonstrates how self‐evident claims to
practice ‘centred’ care can also create intergroup conflict. For ex-
ample, if all stakeholders claim a version of ‘centredness’ is implicit in
their work, then challenges during implementation are typically
blamed upon other stakeholder groups. Kreindler (2015) suggests this
is in part due to multiple definitions and politics underpinning
‘centred’ care approaches. At the direct point of care, PFCC ap-
proaches by health care providers (e.g., nurses) typically stress
humanistic or shared decision‐making values, whereas health ad-
ministrators at the organisational level typically describe ‘centred’
approaches as policies and interventions that are designed with
consumer input (Kreindler, 2015). Physicians and nurses appear to be
hesitant about this increasingly consumerist patient identity, in part
because it changes the nature of their work from a professional
service highlighting dignity to a type of commercial transaction
(Kreindler, 2015). In summary, what seems most evident is that in-
itiatives aiming to ‘centre’ patients and families in care have laudable
goals and are strongly sought after. However, there are also long-
standing challenges to both implementing and studying the effects of
PFCC initiatives in hospital care. Furthermore, the meanings and
politics attached to the various ‘centring’ discourses remain fluid,
presenting further challenges for those attempting to study its effects
and improve care for patients and families. These concerns necessi-
tate critical scholarship to enhance knowledge development about
those practices that aim to ‘centre’ patients and families in hospital
care. In this context and given that extant research presupposes a set
of assumptions that enable ‘centredness of care’ to be conceptualised
and studied, it seems necessary to re‐examine how we come to know
that patients and families are ‘centred’ in care.
1.3 | History of ‘Centring’ discourse in health care
Researchers exploring the evolution of PFCC concepts commonly
report the idea of ‘centring’ originates from concerns within Western
paediatric hospital care settings. Throughout the early 1900s to mid‐
1950s, severely restricted hospital visitation policies were a point of
contention in American paediatric hospital care (Giganti, 1998).
Renshaw (2009) suggests psychological research describing ‘maternal
deprivation’ among hospitalised children led to early campaigning by
parents to protest visiting restrictions in American hospitals. Similarly,
Jolley and Shields (2009) state family centred discourses were
advocated for alongside the rise of psychoanalytical research after
World War II, which demonstrated the risk of psychological harm to
children and their parents if they were separated for long periods of
time. Psychological research has heavily influenced contemporary
understandings of ‘centred’ care for adult patient populations (e.g.,
see Rogers, 1959 early work on client centred theory).
The Institute for Patient and Family Centred Care (n.d.) also of-
fers a brief history of how PFCC emerged in unique ways across
different hospital settings, including critical care, maternity care, end
of life care, and again with the greatest emphasis on paediatric care.
While PFCC policies for paediatric populations were generally readily
adopted, endorsement of family involvement for adult patient po-
pulations took more time. This seems to be, in part, related to the
greater emphasis on an individualising patient‐centred discourse in
adult care. Ideas of patients as individualised subjects developed
during the latter half of the 20th century arising from concerns that
medical care treated patients as objects or things, rather than whole
persons (May, 1992). Rather than an ‘object’ or biological/patholo-
gical body to be worked on by health experts, the ‘inner or emotional
significance’ of the patient became of interest to health care provi-
ders (Hughes et al., 2008, p. 461). The Institute of Medicine's (2001)
Crossing the Quality Chasm report is also widely cited within PFCC
intervention studies as the turning point in the widespread im-
plementation of PFCC in all care settings. Although it is difficult to
pinpoint a single origin of ‘centring’ discourses, as various disciplines,
advocacy groups and contexts of care were instrumental in its
widespread adoption, concerns related to patient identity, risk and
the nature of hospital care practices influenced the organisation of
care and public desire to encourage greater patient and family in-
volvement or ‘centredness’ in hospital care.
2 | PROBLEMATISATION: A CRITICAL
REVIEW METHOD
A structured problematisation method, as developed by Alvesson and
Sandberg (2011, 2013), is utilised to identify and analyse assumptions
shaping and producing research practices intended to have effects on
the implementation and evaluation of PFCC. These assumptions are
important to examine because they inform how researchers con-
struct their object of inquiry and develop solutions to what are seen
as barriers to ‘centring’ patients and families in acute care settings.
Unlike traditional research review methods, which aim to synthesise
and appraise research findings to determine the ‘state’ of knowledge,
the purpose of the problematisation approach to identify and if ne-
cessary, challenge the assumptions underlying the construction of
research questions and the methods employed to answer them
(Alvesson & Sandberg, 2011). Thus, problematisation differs from
traditional literature syntheses because the review process is in-
tended to raise questions about the way research problems are
constructed within a field of study, particularly when efforts have
produced unsatisfactory results so that alternative research ques-
tions can be created and theorised. This approach is deliberately
JUDGE AND CECI | 3 of 10

4. more philosophical than most review methods, analysing how con-
temporary knowledge guiding PFCC intervention research has
evolved, as well as how PFCC as an object of study is methodolo-
gically and theoretically explored. And, perhaps most importantly, the
problematisation approach also encourages researchers to in-
vestigate the possibility of more effective and innovative con-
ceptualisations to inform future research practices.
Alvesson and Sandberg's (2011, 2013) problematisation method
is informed by Michel Foucault's practice of problematisation, often
described as a ‘movement of critical analysis in which one tries to
see how different solutions to a problem have been constructed’
(Foucault & Lotringer, 1996, p. 422). This iterative movement of
critical analysis is likened to a practice of ‘dialectical interrogation’, a
process of question raising undertaken through exploring the taken‐
for‐granted assumptions of a domain of literature against home and
alternative theoretical stances (Alvesson & Sandberg, 2013). To fur-
ther support critical analysis, Alvesson and Sandberg (2011) provide a
typology of assumptions as ‘heuristic support for identifying and
challenging assumptions’ in existing literature (p. 267). Root‐
metaphor, in‐house and ideological assumptions were utilised as
exploratory techniques in our analysis. These are not all‐
encompassing of this method, rather these types of assumptions
offer a starting point and language to build a structured and in‐depth
analysis. Furthermore, assumptions identified through Alvesson and
Sandberg's typology of assumptions are then examined in relation to
alternative theoretical stances and research approaches in the studies
of health care organisations and management. Alvesson and Sand-
berg's work focuses on improving challenges within organisation and
management studies, and their problematisation method has proven
useful for reconsidering longstanding problems requiring innovation
in health care (Ceci et al., 2018; Egan et al., 2016; Purkis &
Ceci, 2014; Symonds‐Brown et al., 2019).
2.1 | Constructing a search strategy
As described by Alvesson and Sandberg (2011), problematisation calls
for an extensive and methodical literature search, but not an ex-
haustive one. That is, we did not attempt to gather all the ‘centring’
care literature, such as in traditional systematic reviews. Instead, the
aim is to critically explore this broad body of literature and identify a
comprehensive sample of relevant research studies illustrating how
PFCC tends to be studied in adult acute care settings. Due to the
theoretical ambiguity across the ‘centring’ discourses, we use the
term PFCC as an umbrella term to include the following approaches
to ‘centring’ care: patient centred care, family centred care, care,
person centred care, and patient and family centred.
The following search strategy was developed in consultation
with a health sciences librarian: (Patient and family centred care or
FCC or PFCC or person centred care or patient centred care) AND
(adults or adult) AND (hospital or acute setting or inpatient or ward).
The CINAHL and MEDLINE databases were used initially, as their
contributions are predominantly from health disciplines. No date
parameters were applied to develop an understanding of when and
how research concerned with PFCC initiatives has evolved.
2.2 | Establishing boundaries of the PFCC
problematisation
Although we describe the problematisation method in a systematic
way, the actual process of constructing the boundaries of the review
and the analysis was iterative. For example, many studies simply
stated PFCC as an outcome or used ‘centred’ as a descriptor of some
other kind of intervention (e.g., nutrition programme or ventilator
weaning). There was the question of whether studies that used ‘in-
dividualized’ or patient ‘focused’ language should be considered sy-
nonymous with PFCC. We also debated including studies that
implemented tools such as bedside rounding or communication
whiteboards, but did not specifically foreground themselves as PFCC
interventions in our problematisation. While we recognise there are
relevancies across these areas and PFCC as ‘intervention’, they were
excluded from in‐depth reading. From our search strategy, we first
screened the title and abstract of the articles for any mention of
PFCC, person centred care or family centred care. Included texts
focused on acute care settings and adult patient populations. Full‐
text review resulted in the exclusion of those studies that did not
specify PFCC as an intervention in an adult acute care setting.
Google Scholar and Scopus database were used to identify a
sample of highly cited texts (i.e., more than 50 citations) from our
search. Highly cited texts offer key examples of shared assumptions
informing the field of PFCC intervention research. To supplement the
database search strategy for highly cited texts, the bibliographies of
highly cited texts were reviewed to identify historical papers, experts
within this field, and to trace how knowledge has developed. This
review process resulted in a sample of 23 studies for in‐depth ana-
lysis. The texts informing this analysis include empirical studies, re-
views and commentaries on PFCC intervention research. These are
considered dominant or ‘typical’ texts carrying the ‘norms’ and taken‐
for‐granted assumptions related to PFCC.
3 | ASSUMPTIONS UNDERLYING PFCC
INTERVENTION RESEARCH
We highlight three predominant areas within PFCC‐related inter-
vention research for problematising that are unique to the hospital‐
based care research we examined: A reliance on Vitruvian spatiality, a
concern with democratising care and the creation of ‘centring’ as
a problem for nursing. Identification and analysis of assumptions in-
forming research practices as an ‘outcome’ of our work differ
significantly from the outcomes of traditional literature reviews,
which typically present their findings as ‘gaps’ in knowledge. In our
case, we suggest that these sets of assumptions are very much
shaping PFCC intervention research practices and what is thought
possible for improving the care of patients and families in acute care.
4 of 10 | JUDGE AND CECI

5. These assumptions were identified through ongoing reflection, dia-
logic interrogation, and a particular interest in supporting the gen-
eration of more interesting research questions and knowledge
practices related to ‘centring’ patients and families in care. The fol-
lowing questions guided our problematisation and study analysis:
How do researchers come to know and study PFCC in adult acute
care? Are established standardised tools or frameworks used? What
outcomes are described as good? What solutions or paths forwards
are offered?
3.1 | Root‐metaphor: Establishing a ‘Centre’ of care
for patients and families
‘Centredness’ is an influential metaphor with symbolic references
related to the spatial (re)organisation of care for patients and families.
The image of a transcendental centre within care was foregrounded
across all the studies reviewed in this problematisation regardless of
the type of ‘centring’ theory implemented. However, this ‘centre’ is
described as occupied by different and somewhat competing entities,
such as persons (e.g., Edvardsson et al., 2008, 2009), patients (e.g.,
Berghout et al., 2015; Ferguson et al., 2013), or patients and their
families (e.g., Ciufo et al., 2011). Alvesson and Sandberg (2011) de-
scribe root‐metaphor assumptions as the broader images related to a
topic, such as the idea there is a ‘culture’ within organisations. The
idea of an organisational culture, suggesting shared or unified values,
has been critiqued by Alvesson and Spicer (2012) for being overly
rational. Practice‐based theorists, such as Nicolini (2016, 2017) and
Gherardi (2012) have taken the critique of studying ‘culture’ in or-
ganisations further, arguing traditional theoretical framings of orga-
nisational ‘culture’ overlook the sociomaterial practices that
accomplish, stabilise and interfere with organisational work. Nicolini
(2016) describes how abstract entities such as culture are simply
convenient summaries and warns against utilising them as re-
presentations. Instead, Nicolini (2017) recommends we consider the
effects and the technologies that produce abstract generalisations
such as ‘culture’. The metaphor of a ‘centre’ within health care is
similarly insidious, influencing how we discuss, intervene on, and
understand everyday hospital care activities for patients and families.
The word ‘centre’ originates from the Greek term Kentron,
meaning sharp point and can refer to the stationary point on a
compass (Merriam Webster, n.d.). Historically the ‘centre’ of hospital
care has been described as disease or physician/health‐systems
centred (van der Eijk et al., 2013; Taylor, 2008). A ‘centre’ of care
suggests that there is a place from which all hospital care activities
originate or an area that is most important in relation to other hos-
pital actors or care activities. Thus, it appears that PFCC intervention
research presupposes hospital care practices should and can contain
a focal point, a carefully balanced and fixed position available to be
stably occupied and examined—most often this is the patient's body.
This idea of a fixed and stable centre has implications for the way we
think about how care occurs for patients and their families—and
though appealing, there are important limitations that become
apparent when this metaphor is carefully examined. To do this, we
draw on Haraway's (2008) critique of Leonardo da Vinci's Vitruvian
man, a powerful portrayal of the transcendental ‘centred’ body.
Across disciplines of art, science, medicine and sociology re-
searchers tend to view the world through the image of the Vitruvian
man or the ‘Man of Perfect Proportion’ as described by Haraway
(2008, p. 7). Haraway critiques this lens as overtly humanist in her
text, When Species Meet. With light humour, but also with strong
intent, Haraway literally draws a counter image to humanist thinking,
titled Leonardo da Vinci's Dog, as the centre of the universe. Through
this counter image, Haraway raises serious questions about the kinds
of relations we make and account for in the world when framed
through the constraints of anthropocentrism. In PFCC research, the
question becomes what relations or actors are made visible through
‘centring’ interventions and which actors and subjects are made
invisible?
In the PFCC intervention studies analysed here, the Vitruvian
lens creates knowledge that overwhelmingly emphasises in-
dividualisation and psychologisation of care. Many researchers
claimed ‘centring’ care theories would individualise care through the
strategies examined. Examples of such strategies included creating
tailored health care plans (Alharbi et al., 2012), involving patient
preference during discharge (Anthony & Hudson‐Barr, 2004), in-
corporating patient needs during medication administration (Bolster
& Manias, 2010), including patient perspective or voice when eval-
uating centred care (Bechel et al., 2000; Marshall et al., 2012; Rathert
et al., 2015) or developing PFCC education materials (Ferguson
et al., 2013). Efforts to individualise care through such PFCC inter-
ventions rest on a logic of supporting humanised care practices
raising a question of the alternative ethos PFCC interventions are
intended to work against. And it is the case that most PFCC inter-
vention studies commonly report traditional hospital care models as
problematic because they are too standardised (Alharbi et al., 2012),
task‐oriented (Ross et al., 2015), apply a ‘one‐size‐fits all’ approach to
care practices (Sidani, 2008, p. 24), or dehumanise or objectify the
persons receiving care (Coyle & Williams, 2001). These are important
problems to work against; however, the strategies for individualising
or humanising care are vague and limited to consideration of the
uniqueness, desires or personal resources of now ‘centred’ patients.
3.1.1 | Shortcomings of individualising and overly
psychologising care
A ‘centred’ body narrows the theoretical gaze of researchers studying
care, distracting researchers from the networks of social relations,
actors, and activities required to produce care practices. For instance,
the ‘centring’ of patients and families is perhaps most often oper-
ationalised within acute care settings through the creation of flexible
family presence policies (Ciufo et al., 2011). While open visitation
policies are an effective starting point to improve access and increase
human connection, hospital space is limited and highly contested.
PFCC researchers often presuppose that physical space (e.g., hospital
JUDGE AND CECI | 5 of 10

6. rooms or beds) is readily available for patients and families to occupy.
Yet as Rankin (2015) demonstrates through her ethnographic work in
hospital settings, ‘individualized’ space is actually created, monitored
and managed through a network of technologies that work to con-
stitute the character and possibilities of hospital care practices.
Rankin (2015) provides key empirical examples of technologies, in-
cluding bed management software, electronic charting and compu-
terised discharge planning that contribute to the ‘decentring’ of
patients, perhaps more so than events that occur in specific care
provider, patient and family relations and actions.
Rather than investigating the social and material realities of or-
ganising care for patients and families, PFCC research organised by
the Vitruvian lens tends to focus on what patients/families/staff
‘know’ within their minds about individualised or ‘centred’ care. For
example, PFCC research often reflects the assumptions that the pa-
tient's perspective should be the point of departure for hospital care
practices, and that this perspective and thus, the effectiveness of
‘centring’ interventions, can be best known through the use of vali-
dated psychometric tools. In our sample of intervention studies,
psychometric indicators included satisfaction measures (Coyle &
Williams, 2001; Ferguson et al., 2013; Martin et al., 1998;
Poochikian‐Sarkissian et al., 2010; Sidani, 2008), anxiety (Slatore
et al., 2012) and patient opinion surveys (Anthony & Hudson‐
Barr, 2004). While patient perspectives are valuable and high levels
of satisfaction should be sought, reliance on psychometric methods
appear to make invisible the noncognitive factors (e.g., space,
beds and virtual care environments) influencing care. Rankin (2003)
also argues that survey‐type methods commonly employed in PFCC
research can constrain the type of knowledge that can be accessed
because focused questions force specific answers from participants.
By examining the work of Rankin (2003, 2015) and the effects of
psychometric tools utilised to explore PFCC, it becomes evident that
the metaphor of a transcendental or ‘centred’ body makes invisible
the sociomaterial realities shaping ‘good’ care of patients and families.
3.2 | Ideological assumptions: Sharing power and
activating partnerships through PFCC
A key moral and political assumption within PFCC research is that
hospital‐based care decisions should be democratic, or that power
among patients, families and hospital staff should be shared through
activating egalitarian partnerships. Alvesson and Sandberg (2011)
describe ideological assumptions as the ‘various political, moral, and
gender‐related assumptions held about the subject matter’ (Alvesson
& Sandberg, 2011). The image of the Vitruvian man remains effective
in describing and analysing how notions of power within PFCC re-
search are typically attributed to a ‘centred’ body or an autonomous
human actor in care. For example, a patient survey study of person‐
centredness by Coyle and Williams (2001) suggests health care
providers maintain control over how patients are involved in care,
assuming a sovereign notion of power. To overcome concerns of a
transcendental individual controlling care decisions, the idea of
activating partnership is shared as the main solution across many
studies (Anthony & Hudson‐Barr, 2004; Bolster & Manias, 2010;
Rathert et al., 2015). However, empirical examples of how partner-
ships are ‘activated’ are not discussed in detail. The most concrete
example of power‐sharing was noted in Slatore et al's. (2012) diagram
of patient centred care. Slatore et al. (2012) display sharing power
and responsibility as a key tenant influencing patient centred care,
one that can be actualised through encouraging patient and provider
agreement on care plans. Assertions of sharing power with
‘centred’ bodies receiving care appear largely undertheorised in this
field of research and are simply justified as a moral imperative and
underscored by ‘democratic’ ideology.
3.2.1 | Limitations of ‘centredness’ as democratic
ideology
Although these ethical discourses of respecting autonomy and dig-
nity, by actualizing collaborative partnerships and sharing responsi-
bility appear ‘good’, they also obscure and overly simplify our
understanding of why and in what way power is distributed in care.
Armstrong (2014) offers an interesting account of how patients and
their families were not always seen as autonomous or agentic in
health care. Through a sociological lens, Armstrong (2014) shows
how concerns about rising health care costs, as well as behavioural/
psychological research in the 1980s (e.g., development of the Health
Belief Model) contributed to the development of the idea that pa-
tients and families should be active, motivated and responsible for
participating in their health care outcomes. PFCC intervention studies
similarly focus on improving the agential capacity of ‘centred’ bodies.
However, this sovereign notion of power conceals the network of
politics and technologies that promote or interfere with patient and
family involvement. For example, as described by Rankin (2015),
managerial technologies such as those employed to streamline pa-
tient discharge are implemented using the discourses of PFCC, but
these technologies do not necessarily improve the care experiences
of patients and families. Furthermore, while a democratic ideology is
morally persuasive, it conceals how PFCC care models are also clo-
sely tied to advances in ‘consumer’ identities of patients, which are
thought to support patient's rights as autonomous individuals (e.g.,
Bechel et al., 2000; Martin et al., 1998; Sharp et al., 2015). However,
as Rankin (2003) argues, patient satisfaction measures used to eval-
uate PFCC are related to a business model of health care delivery,
one commonly found in privatised health care facilities. Assumptions
related to individualising, psychologising and democratising care ap-
pear to draw upon one another and overlap significantly in PFCC
intervention research.
3.3 | Centring: An in‐house assumption for nursing
Researchers appear to overwhelmingly associate PFCC implementa-
tion as a ‘nursing problem’. This could be a result of our sampling
6 of 10 | JUDGE AND CECI

7. strategy, but most intervention studies were published in nursing
journals and recruited nursing staff as participants for surveys. We
conducted a backward and forward citation chain search on the in-
cluded articles to see how the ‘centring’ intervention research has
evolved. We note that researchers interested in ‘centring’ policies
and interventions frequently tend to evidence their previous research
and cite other like‐minded researchers, which demonstrates a strong
acceptance of in‐house assumptions. For example, recent person‐
centred research made reference to earlier works, such as Tom
Kitwood's (1997) person centred care model for people with
dementia and Gerteis et al. (1993) text, Through the Patient's Eyes:
Understanding and Promoting Patient‐Centred Care. Additionally, stu-
dies foregrounding ‘patient’ and ‘family’ identities frequently referred
to early work from the Picker Institute. During our review of PFCC
initiatives, we also noted many researchers had nursing backgrounds,
so it is not entirely surprising that the role of nurses in relation to
facilitating or improving PFCC is emphasised. McCormack and
McCance (2006) framework for person‐centred nursing was heavily
cited across many of the intervention studies. The creation of
‘centring’ discourses as a nursing problem is interesting, given that
‘centring’ theories foreground a team‐based and collaborative care
model (Esmaeili et al., 2014).
3.3.1 | ‘Centring’ a problem and accomplishment for
nursing
There is some tension between the philosophical emphasis on teamwork
within PFCC and the dominant nursing perspective within research stu-
dies. If we seriously consider patient and family ‘centredness’ as a team‐
based accomplishment, then the implications for PFCC implementation
must be broader than the current empirical focus on psychologising
hospital‐based nursing care of patients and families. May (1992) and May
and Purkis (1995) suggest that individualising care discourses can distract
from other kinds of work that nurses accomplish when providing care for
patients and their families. In a similar line of thinking, Allen (2015) draws
on the work of social scientists in the field of Science and Technology
Studies to explore how nurses accomplish care alongside human and
nonhuman actors. By utilising ethnographic methods that ‘de‐centre’ the
human body, Allen (2015) observes and describes how patient care tra-
jectories require a network of care activities, including documentation,
beds and transfer reports. Her analysis demonstrates that anthropo-
centric or overly humanist notions of nursing caregiving make invisible
other actors that are necessary for organising care for patients and fa-
milies in hospital settings.
4 | DISCUSSION: DECENTRING CARE
PRACTICES
Upon beginning this review, we became aware there is an abundance
of research on this topic, as evidenced by the growing number of
systematic, scoping and literature review type studies synthesising or
appraising the rigour of PFCC intervention research. We also ob-
served few empirical or review‐type studies that critically examine
extant knowledge practices related to ‘centring’ care for patients and
families. By critique we mean there is an overwhelming acceptance
that PFCC is generally a ‘good’ thing to introduce into everyday acute
care practices, despite the challenges and implementation barriers
continually identified in the research literature. Rather than en-
couraging critical research to explore why PFCC interventions are
difficult to implement and why theoretical ambiguity persists, re-
searchers reporting barriers typically call for more evidence‐based
measures and identify repetitive themes (e.g., overlooked populations
or inadequate PFCC theories) that require more precise definitions
and investigation. Alvesson and Sandberg (2011) describe this as
‘gap‐spotting’ research, where researchers create or identify knowl-
edge holes that need to be filled based on the presuppositions in-
forming a field of study. While gap‐spotting can accelerate
knowledge production on a specific topic, this approach to knowl-
edge can simply create more of the same kinds of research. In the
field of PFCC research, we have observed that this results in more
kinds of ‘centring’ theories and further theoretical ambiguity. For
example, Siouta and Olsson (2020) conducted a policy analysis of
patient centredness in Sweden and found ‘that contemporary nar-
ratives about centeredness are neither more, nor less, care seeker‐
centred than the narratives of yesteryear’ (p. 9). These authors, while
problematising current ‘centring’ policies, suggested a different kind
of person‐centred care, which does not particularly inspire more in-
teresting or innovative research in this field.
Supporting the involvement of patients and families in care in
acute care settings is a critical undertaking and responsibility; how-
ever, our analysis of key assumptions informing PFCC research sug-
gests current approaches to knowledge development in this area may
be less effective than hoped for. Knowledge development is con-
strained by the dominance of the Vitruvian lens, a metaphor for
centring practices, which leaves to one side the multiple social and
material realities of hospital care practices that may actually be
shaping the contexts of care. As we described above, theorists with
both nursing (e.g., Janet Rankin and Davina Allen) and sociological
backgrounds (e.g., Carl May and David Armstrong) provide interesting
and alternative theoretical lenses to understand the challenges and
politics of sustaining good hospital care practices for patients
and families. Although not as well cited, a group of researchers
studying the implementation of patient centred care in Italy utilise
ethnographic methods and practice‐based approaches (Liberati
et al., 2015), and in their work seem more able to account for the
social, material and relational networks that centre and decentre
patients and families in hospital‐based care practices. For example, in
an ethnographic study of patient‐centred care on a hospital ward,
Liberati et al. (2013) describe the complexity of sharing power in care
by highlighting inconsistencies between organisational policies and
the everyday practices of care. In another study, Gorli et al. (2017)
utilise the theoretical framing of Actor Network Theory to attend to
the material effects of health care redesign, specifically highlighting
relations between physical space and the capacities engendered for
JUDGE AND CECI | 7 of 10

8. patient ‘centredness’. For example, when hospital space was rear-
ranged to actualise PFCC and centralise care functions, in part to
save costs and create more efficient use of resources, both patients
and clinicians were disoriented—everything looked the same. The
new aesthetics made it harder for patients and families to find their
physicians and vice‐versa. What is significant about these alternative
theoretical approaches is that, by shifting our gaze from the Vitruvian
‘centre’, and from an analysis of care that involves mainly or only
human actors, our understandings of how care is accomplished in
hospital settings are much expanded. Research efforts that try to
account for these heterogeneous actors in care seem more likely to
develop new knowledge that might improve care practices for pa-
tients and families in hospitals.
5 | CONCLUSION AND FUTURE
RESEARCH RECOMMENDATIONS
Meaningful involvement of patients and families in hospital‐based
care is an important goal, one that seems more likely to be achieved if
researchers are able to broaden the theoretical lenses through which
such care practices are studied. Contemporary studies aiming to
‘centre’ patients and families through PFCC initiatives have shown
there are significant and longstanding barriers. While these studies
have been critical in demonstrating that there are significant con-
cerns related to dehumanisation of care and undermining of the
voices of patients and families, research practices that rely on the
assumptions described in this paper appear to constrain knowledge
development in this field and also limit the exploration of potentially
more creative lines of action. Alternative theoretical lenses, such as
those described through reference to Rankin's (2015) and Allen's
(2015) work, are warranted. Practice‐based studies and ethnographic
methods work not so much to decentre care or patients, but to more
accurately locate patients and families in networks of care with
multiple actors—both human and nonhuman—that require critical
attention for their effects.
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
DATA AVAILABILITY STATEMENT
Data available on request from the authors and also available in article
supplementary material (see PRISMA) (Supplementary information).
ORCID
Harkeert Judge http://orcid.org/0000-0003-3147-4244
Christine Ceci https://orcid.org/0000-0002-8503-5928
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How to cite this article: Judge, H., Ceci, C. (2021).
Problematising assumptions about ‘centredness’ in patient
and family centred care research in acute care settings.
Nursing Inquiry, e12448. https://doi.org/10.1111/nin.12448
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