CLINICAL ISSUES

Using the caring dimensions inventory as an indicator of person-centred nursing

Tanya McCance, Paul Slater and Brendan McCormack

Aims. This paper reports ndings from a large-scale quasi-experimental study that used a measure of caring as a means of evaluating person-centred nursing and aims to illustrate the synergy between the concepts of caring and person-centredness. Background. Evidence would suggest that effective person-centred nursing requires the formation of therapeutic relationships between professionals, patients and others signicant to them in their lives and that these relationships are built on mutual trust, understanding and a sharing of collective knowledge. This correlates with the conceptualisation of caring that is underpinned by humanistic nursing theories. Design. A pretest post-test design was used in this study to evaluate the effect of person-centred nursing on a range of outcomes, one of which was nurses and patients perception of caring. Methods. The Person-Centred Nursing Index was the main data collection tool. The Caring Dimension Inventory and Nursing Dimensions Inventory, were component parts of the Person-Centred Nursing Index and were used to measure nurses and patients perceptions of caring. The Person-Centred Nursing Index was administered at ve points in time over a two-year intervention period. Results. Nurses had a clear idea of what constituted caring in nursing, identifying statements that were reective of personcentredness, which was consistent over time. This was in contrast to patients, whose perceptions were more variable, highlighting incongruencies that have important implications for developing person-centred practice. Conclusion. The ndings conrm the Caring Dimension Inventory/Nursing Dimensions Inventory as an instrument that can be used as an indicator of person-centred practice. Furthermore, the ndings highlight the potential of such instruments to generate data on aspects of nursing practice that are traditionally hard to measure. Relevance to clinical practice. The ndings would suggest that nurses need to be aware of patients perceptions of caring and use this to inuence changes in practice, where the prime goal is to promote person-centredness. Key words: caring, instrument development, nurses, nursing, nursing practice, patients experience
Accepted for publication: 16 April 2008

Introduction
There is an increasing emphasis on the provision of personcentred care within healthcare systems that is broadly interpreted as treating people as individuals. Existing evidence would suggest that to work effectively in this way
Authors: Tanya McCance, MSc, DPhil, RN, Professor, Co-Director for Nursing R&D, Belfast Trust, Mona Grey Professor for Nursing R&D, University of Ulster, Belfast, UK; Paul Slater, MSc, PhD, Research Fellow, Institute of Nursing Research, University of Ulster, Newtownabbey, Co. Antrim, UK; Brendan McCormack, BSc Nursing, DPhil, PGCEA, RN, RNT, Professor of Nursing Research, Institute of Nursing Research/School of Nursing, University of Ulster, Newtownabbey, Co. Antrim, UK

requires the formation of therapeutic relationships between professionals, patients and others signicant to them in their lives and that these relationships are built on mutual trust, understanding and a sharing of collective knowledge (Binnie & Titchen 1999, McCormack 2001, 2004, Dewing 2004, Nolan et al. 2004). This approach is also consistent with
Correspondence: Tanya McCance, Professor, Co-Director for Nursing R&D, Belfast Trust, Mona Grey Professor for Nursing R&D, University of Ulster, Admin Building, Knockbracken Healthcare Park, Sainteld Road, Belfast BT8 8BH. Telephone: 028 9056 4987. E-mail: tanya.mccance@belfasttrust.hscni.net

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previous nursing literature on therapeutic caring, which similarly emphasises the importance of concepts such as relationships, values and caring processes underpinned by humanistic nursing theories (McCance et al. 1999, Dewing 2004). This paper reports ndings from a large-scale quasiexperimental study that used a measure of caring as a means of evaluating person-centred nursing (PCN), illustrating how the two concepts can work together to provide greater insights into the development of person-centred care.

Humanistic caring and person-centredness

While a denitive denition for both caring and personcentredness remains illusive in the literature (Paley 2001, Nolan et al. 2004), there are underpinning principles that drive research, education and practice that focus on both these concepts. Many of the theories on caring are founded on underpinning principles that are consistent with a human science approach. These principles include: a philosophy of human freedom, choice and responsibility; the importance of human relationships; and a belief that persons are nonreducible and connected to others and the environment around them (McCance et al. 1999). The principles of person-centeredness advocated by the authors of this paper include: respect for persons; the rights of individuals as persons; the values and beliefs of individuals; mutual respect and understanding; and the development of therapeutic relationships (McCormack et al. 2008). Comparing these elements at a level of principle draws out important similarities that focus on the person and on the development of relationships. The concepts of person and personhood are central to both caring and person-centredness. The word person captures those attributes that represent our humanness and the factors that we regard as the most important and most challenging in our lives. Persons should always be treated as ends in themselves and not as a means to anothers end a principle that guides ethical, legal and moral frameworks in nursing and healthcare. McCormack (2001) undertook a philosophical analysis of the concept of person. Drawing on the work of Frankfurt (1989) and other philosophers (for example, Hare 1981, Lindley 1986, Dworkin 1991), McCormack concluded that it is the ability to engage in reective evaluation of action that distinguishes persons from other creatures. Through reection, an individual is able to derive a set of principles that guide decision-making throughout life and determine what one does in particular situations. In this way, persons are capable of making choices that are their own. The reective person is capable of change, forming and abandoning relationships, engaging with others or being
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alone and chooses the kind of life he/she wants to live. Although a person may be no longer free to do what he wants to do (because of a disabling illness for example), his will may remain as free as he was before. Although the person cannot turn his desires into actions, he is still free to form those desires and determine possible actions as freely as if his freedom of action had not been impaired (Frankfurt 1989). It is this moral personality that gives persons status and it is this humanity that distinguishes persons from other species, i.e. our personhood. The idea of the reective person can also be seen in the caring literature. Watson (1985), in her Theory of Human Caring, refers to person as a being-in-the-world who possesses three spheres of being mind, body and soul that are inuenced by the concept of self (p. 54). Similarly, Boykin and Schoenhofers (1993) theory of nursing as caring describes personhood as that which implies living out who we are, demonstrating congruence between beliefs and behaviours and living the meaning of ones life (p. 8). The patient-centred, client-centred, person-centred care literature also reects this ideal, generally focusing on what it means to be a person and how that is taken into account in caring interactions (McCormack 2001, Nolan et al. 2004). Fundamental to this way of working is the value placed on the nursepatient relationship. McCormack (2001) suggests that the nursepatient relationship must take into account who the patient is as a person and how this impacts on the understandings and expectations within that particular relationship. Implicit in all of this is the importance of getting to know the person. This is a theme that has characterised the concept of caring and has been identied through concept analysis, as a critical attribute (McCance et al. 1997). The need to understand self and others was also highlighted from a concept analysis undertaken by Brilowski and Wendler (2005), but was identied as an antecedent (needs to be present for caring to occur), as opposed to a critical attribute. Similarly, McCormack (2004), who explored personcentredness and how this applies to gerontological nursing, suggests that knowing what the patient values about his/her life and how he/she makes sense of events (being with self) is one of the core concepts at the heart of PCN. The study described in this paper was underpinned by the PCN framework, which brought together previous empirical research focusing on person-centred practice with older people and the experience of caring in nursing (McCormack & McCance 2006). In summary, the framework comprises four constructs. Prerequisites focus on the attributes of the nurses and include: being professionally competent; having developed interpersonal skills; being committed to the job; being able to demonstrate clarity of beliefs and values; and

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knowing self. The care environment focuses on the context in which care is delivered and include: appropriate skill mix; systems that facilitate shared decision making; effective staff relationships; organisational systems that are supportive; the sharing of power; and the potential for innovation and risk taking. Person-centred processes focus on delivering care through a range of activities and include: working with patients beliefs and values; engagement; having sympathetic presence; sharing decision making; and providing for physical needs. Outcomes, the central component of the framework, are the results of effective PCN and include: satisfaction with care; involvement in care; feeling of well-being; and creating a therapeutic environment. The relationship between the constructs suggest that to deliver positive outcomes for patients and staff account must be taken of the prerequisites and the care environment, which are necessary for providing effective care through person-centred processes. This further reinforces the synergy between caring and person-centredness and to some extent demonstrates that the concept of caring is inherent within a philosophy of person-centredness.

The person-centred nursing index (PCNI; Slater 2006) is an instrument designed to measure constructs related to PCN. It was developed as an integral part of the study described in this paper and was generated from an amalgamation of key ndings from an extensive literature review, focus groups and a pilot study. The tool comprised several outcome measures, one of which was nurses and patients perceptions of caring. The PCNI incorporated the CDI as the measure that would provide data on nurses experience of caring. The patients experience of caring is measured using the Nursing Dimension Inventory (NDI). The NDI (Watson et al. 1999) was developed to assess non-nursing views on what constitutes caring. It was based on Watsons initial work with the CDI and differed in the perspective from which caring was viewed. It has been used to effectively assess non-nursing populations perceptions of caring (Watson et al. 1999).

The study
The overall aim of the Person-Centred Nursing Project was to measure the effectiveness of PCN when introduced into a range of clinical areas within a tertiary hospital setting. This paper focuses on one aspect of this study aimed at addressing the following research question: Does PCN make a difference to patients and nurses perceptions of caring? The PCN framework was used to inform the study design, which results in the adoption of a quasi-experimental approach using a pretest/post-test design. The design comprised three major components: A theoretical framework, in the form of the PCN framework (McCormack & McCance 2006), as previously mentioned; A practice development intervention based on a model developed by Garbett and McCormack (2002); Measurement tools/evaluative approaches used to evaluate differences over time on a range of dependent variables as a result of the practice development intervention, which included the PCNI, of which the CDI was a component part.

Evaluating person-centred practice

It has been recognised that while there is a lot of emphasis on providing care that is person-centred, translating the core concepts into professional practice is challenging, with few research studies reported that evaluate the caring outcomes that may arise from PCN (McCormack & McCance 2006). This has been further compounded by the lack of valid instruments within the literature that go some way to measuring elements of person-centred practice (Traynor & Wade 1993, Adams et al. 1995, Coyle & Williams 2001). The measurement of caring, however, has faired somewhat differently, with a proliferation of instruments reported in the literature that aim to measure caring in nursing. The Caring Dimensions Inventory (CDI) is one such instrument that has been developed within the UK by Watson and colleagues (1999, 2001). It comprises 35 operationalised statements of nursing actions designed to elicit the degree to which participants perceive these actions as representative of caring using a 5-point likert scale. The items included in the instrument have been categorised as psychosocial, technical professional inappropriate and unnecessary activities. The CDI has been used to ascertain perceptions on caring from the perspective of a range of groups, including registered nurses, nursing students and non-nursing students (Watson et al. 1999, 2003a), between different clinical areas and specialities (Lea & Watson 1995, 1999, Walsh & Dolan 1999) and from an international perspective (Watson et al. 2003b).

Sampling
Eight wards and departments were selected for participation in the study. Inclusion was based on a broad set of criteria, which included: effective leadership; nurse management support; evidence of some development work that focused on personcentredness; and voluntary participation. Wards and departments declaring an interest in participating were asked to demonstrate how they met the inclusion criteria. The areas that
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were selected to take part included: intensive care unit; sexual health clinic; older people rehabilitation ward; paediatric infectious diseases ward; medical admissions unit; general surgery ward; cardiology ward; and an operating room. A patient (and where appropriate relative) sample was also recruited from each participating area. Patients/relatives were randomly selected from each participating area, on ve time points corresponding with the administration of the PCNI, with sample sizes ranging from n = 70n = 107 across the ve time points. Each patient was administered the NDI on discharge from the hospital by nurses. Patients were informed of the aims of the study and asked to complete the questionnaire and return it in the SAE provided to a key collection point in the clinical setting. All nurses (excluding bank nurses or temporary staff) who met the following inclusion criteria were also invited to participate in the study: Registered nurses; Employed by the hospital; Working in a clinical setting participating in the study. Each nurse completed the CDI as part of the PCNI and returned it to the researcher in a SAE provided. All information was anonymous and condential. Response rates varied from 7642% (see Table 1).

by the practice development intervention. These included: job satisfaction; stress; staff retention; patients satisfaction with care; patients involvement in care; and nurses and patients perception of caring. As previously mentioned, the CDI and NDI were component parts of the PCNI and were used to measure nurses and patients perceptions of caring. The validity and reliability of the CDI and NDI have been previously tested (Watson & Lea 1997, Watson et al. 2001). The PCNI was administered at ve points in time once prior to the intervention phase (zero months), to obtain an accurate baseline measure, and at four specic time points over the two-year intervention period (4, 8, 12 and 18 months).

Data analysis
Data collected using the PCNI were analysed using the software package MOKKEN SCALING PROCEDURE 3.0 (Groningen, Netherlands) (Molenaar et al. 1994) and SPSS 11.5 (SPSS Inc., Chicago, IL, USA). Mokken scales are ordinal, unidimensional and cumulative scales in which a positive response to one particular item indicates which of the other items have also been responded to positively (Watson 1996). For example, an individual who endorses measuring the vital signs of a patient in the CDI should also endorse all the other items that are more strongly endorsed such as Listening to a patient. The SPSS 11.5 was used to generate graphic presentation of changes in items identied from the Mokken scaling procedure.

Data collection methods

The PCNI (Slater 2006) was the main data collection tool, which comprised several outcome measures identied as dependent variables, which could be potentially inuenced

Table 1 Response rates and demographic details of the sample of nurse and patients Gender Male (%) 107) 77) 71) 70) 75) 58 53 43 61 44 Gender Male (%) 122, 76%) 121, 75%) 67, 42%) 90, 56%) 86, 54%) 11 12 17 13 10 Female (%) 89 88 83 87 90 Female (%) 42 47 57 39 56 Age of the patient Up to 16 (%) 103 39 30 147 19 Nurse grade D (%) 42 45 41 39 41 E (%) 27 27 29 30 28 F (%) 9 10 4 8 7 G (%) 7 8 7 7 7 1625 (%) 112 92 62 162 18 2635 (%) 75 158 92 59 11 3645 (%) 102 53 123 118 5 4655 (%) 15 132 123 118 8 Shift Other (%) 15 10 19 16 16 Day (%) 57 52 54 58 57 Night (%) 8 13 8 7 6 Mixed (%) 35 25 38 35 36 5665 (%) 30 224 215 176 9 65+ (%) 159 303 354 221 30

Data point Time Time Time Time Time 1 2 3 4 5 (n (n (n (n (n = = = = =

Data point Time Time Time Time Time 1 2 3 4 5 (n (n (n (n (n = = = = =

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Ethical considerations
The study was approved by the local research ethics committee. Issues relating to anonymity, condentiality and informed consent were fully addressed. Permission was also formerly sought from the Director of Nursing and the senior nurse managers responsible for the participating sites.

Results
The results reported in this section focus solely on the data pertaining to patients perception of caring using the NDI and nurses perception of caring using the CDI. Table 1 illustrates the response rates within the participating sites for nurses and a demographic prole over the ve time points. Only at data collection point 3 did the participating sites response rate drop below 50%. This represents a consistently high response rate over the period of the study. The nature of the questionnaire distribution for patients meant that it was impossible to keep an accurate record of the number of questionnaires distributed; hence, exact response rates for the patient sample are not available. There was, however, a good spread of respondents according to gender and age groups (Table 1).

005. Scales produced at each data time point were acceptable statistically. At time 1, 19 items were positively scored at a statistically signicant level (H = 038, p < 0001); at time 2, 16 items (H = 040; p < 0001); At time 3, 23 items (H = 041, p < 0001); At time 4, 21 items (H = 040, p < 0001); and at time 5, 18 items (H = 042, p < 0001). All positively scored and statistically signicant items for the ve time points are displayed in Table 2. Nurses had a clear idea of what constituted caring in nursing, with 12 core statements considered caring on all ve data collection points, which are presented in Table 2. These statements related to technical and intimacy aspects of nursing duties, such as listening to a patient or keeping relatives informed about a patient. Interestingly, listening to a patient was scored as the most caring of all nursing tasks on all occasions. Furthermore, there was generally limited movement in the ranking of each of the 12 core statements over the ve occasions as illustrated in Fig. 1. Some items, however, emerged over time as indicative of caring, such as getting to know a patient, which was not ranked in the rst two time points, but was ranked in the nal three time points with a mean score of 430 at time point 5.

Patients perceptions of caring Nurses perception of caring

The Mokken scaling procedure extracts scale items to generate a positively scored list of items and organises the items into a hierarchy. Higher placement in the hierarchy indicates more positive overall scoring by the respondents than lower-placed items. Findings are deemed statistically signicant when Loevingers coefcients scores (H-values) are greater than 03 and probability levels (p-value) are less than A sample of patients (and patient relatives where appropriate) were recruited at ve points in time and asked to complete the NDI. As with the CDI, the list of identied items were statistically signicant if the Loevingers coefcients (H-values) were greater than 03 and probability levels (p-values) less than 005. Examination of the hierarchical list of items identied at each of the ve time points were statistically signicant. At time 1, 22 items were positively

Table 2 Core statements that were considered caring by nurses across all ve time points Ranking/time Statements 1 2 5 6 7 8 10 13 15 16 17 19 Listening to a patient Explaining a clinical procedure to a patient Being with a patient during a clinical procedure Involving a patient in care Measuring the vital signs of a patient Consulting with a doctor Reporting a patients condition to a senior nurse Being honest with a patient Instructing a patient about aspects of self-care Observing the effects of medication on a patient Making a nursing record about a patient Keeping relatives informed about a patient Construct Intimacy Technical Intimacy Intimacy Technical Technical Technical Intimacy Technical Technical Technical Intimacy 1 1 5 8 6 9 11 14 12 7 13 4 15 (466) (452) (444) (451) (443) (441) (431) (439) (447) (437) (452) (430) 2 1 4 5 3 8 10 9 7 11 12 15 13 (467) (455) (452) (457) (447) (441) (446) (449) (439) (427) (414) (419) 3 1 2 5 6 7 8 10 13 15 16 17 19 (460) (452) (437) (437) (435) (434) (434) (429) (417) (415) (412) (406) 4 1 5 10 6 8 7 12 9 14 11 18 16 (467) (454) (451) (454) (453) (453) (438) (452) (430) (441) (416) (425) 5 1 4 6 5 9 8 10 12 11 16 14 17 (464) (453) (447) (449) (445) (446) (445) (442) (442) (429) (433) (428)

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Listerning to a patient Explaining a clinical procedure to a patient Being with a patient during a clinical procedure Involving a patient in care Measuring the vital signs of a patient Consulting with a doctor Reporting a patients condition to a senior nurse Being honest with a patient Instructing a patient about aspects of self-care Observing the effects of medication on a patient Making a nursing record about a patient Keeping relatives informed about a patient

5 48 46 44 42 4 38 36 34 32 3 Time 1 Time 2 Time 3 Time 4 Time 5

Figure 1 Movement of 12 core statements over time.

scored at a statistically signicant level selected (H = 041 p < 0001); at time 2, 19 items (H = 038; p < 0001); at time 3, 14 items selected (H = 039; p < 0001); at time 4, 23 items (H = 041; p < 0001); and at time 5, nine items (H = 045; p < 0001). All positively scored and statistically signicant items for each of the ve time points are displayed in Table 3. In contrast to the nurse sample, patients rated 2 of the 35 statements as caring on all ve occasions, which were involving a patient in care and providing privacy for a patient. A further 11 statements were scored as caring on four of the ve occasions (Table 3). Unlike the nurses responses, the variability in ranking and scoring was much more pronounced with patients, which was reected in the distribution of items across each of the data collection points. Comparison between the nurses and patients responses indicated a low degree of congruence, with only six items

common across Tables 2 and 3. These items included: listening to a patient; being with a patient during a clinical procedure; involving a patient in care; reporting a patients condition to a senior nurse; observing the effects of medicine on a patient; and making a nursing record about a patient.

Discussion
The consistent scoring of 12 core statements over the ve time points provides a strong indicator of nurses perception of caring. Figure 2 presents the PCN framework, with these 12 core statements mapped onto the relevant constructs. All the core statements (items from the CDI) fall within either prerequisites or care processes and are bulleted under specic components within each of these two constructs. Mapping the core statements onto the PCN framework reafrms the strong correlation between caring and PCN as perceived by

Table 3 Statements that were considered caring by patients across four or ve time points Ranking/time Statement 1 3 4 5 6 9 10 11 12 16 17 18 21 Listening to a patient Providing privacy for a patient Assisting a patient with an ADL Being with a patient during a clinical procedure Involving a patient in care Getting to know the patient as a person Reporting a patients condition to a senior nurse Sitting with a patient Giving reassurances about a clinical procedure Observing the effects of medication on a patient Making a nursing record about a patient Being cheerful with a patient Being technically competent with a clinical procedure Construct Intimacy Intimacy Technical Intimacy Intimacy Intimacy Technical Intimacy Unnecessary Technical Technical Intimacy Technical 1 4 7 19 16 11 15 12 16 1 10 16 2 14 (441) (440) (396) (413) (433) (414) (423) (407) (449) (436) (398) (442) (418) 2 4 (445) 2 (455) 14 7 13 11 16 1 8 (413) (436) (416) (423) (400) (456) (434) 3 1 13 10 4 2 7 12 3 (461) (393) (411) (435) (444) (432) (407) (442) 4 7 9 19 16 11 15 12 17 3 9 18 4 13 (437) (436) (391) (407) (431) (411) (426) (406) (447) (436) (399) (440) (423) 5

2 (451) 6 (400) 4 (435)

9 (431)

11 (408) 4 (435) 8 (425)

3 5 6 1

(443) (427) (400) (460)

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Having sympathetic presence Being with a patient during a clinical procedure Working with patients beliefs and values Being honest with a patient Engagement Keeping relatives informed about a patient Sharing decision making Involving a patient in care Providing for physical needs Measuring the vital signs of a patients Instructing a patient about aspects of self-care

Professionally competent Measuring the vital signs of a patient Consulting with a doctor Reporting a patients condition to a senior nurse Making an nursing record about a patient Developed interpersonal skills Listening to a patient Explaining a clinical procedure to a patient

OUTCOMES

Figure 2 Mapping of nurse items onto the person-centred nursing framework.

nurses. It is interesting to note that in relation to personcentred processes, the statements that remained consistent over time spanned across the ve components presented in the PCN framework, with none emerging stronger than any others. This would appear to reinforce the validity of the range of person-centred processes presented within the PCN framework. The main focus, however, relating to prerequisites was on professional competence and developed interpersonal skills. This emphasises the need for good communication skills and their centrality in developing therapeutic relationships. This notion is reinforced through a concept analysis undertaken by Chambers (2005) who identied communication as an antecedent to the development of therapeutic relationships. The emergence of the item getting to know the patient from time points 35 has particular relevance. This demonstrates the increasing awareness of nurses within the intervention sites of this fundamental premise for delivering PCN. Furthermore, it could be argued that the consistently topped ranked statement listening to the patient is the skill through which nurses will get to know patients. This is reinforced by McCormack (2004) who, in his exploration of personcentredness, highlights the importance of developing a clear picture of what the patient values about his/her life and how he/she makes sense of what is happening (p. 34). This nding also suggests that the development of PCN does impact on nurses perceptions of caring. In stark contrast, the perception of patients on their experience of caring was variable, with very few statements remaining consistent over time. This would suggest that

promoting a culture of person-centredness does not translate into a difference in patients perceptions of caring. The inconsistency in the items ranked important over time could be due to many factors, not least the variation in how individual patients experienced their care episode. There were two statements, however, that did remain consistent over time, one of which was involving a patient in care. This again reects the underpinning philosophy of personcentredness and the importance of involving patients and clients in the decisions made regarding their care and treatment. There is, however, research evidence that identies the challenges in achieving this goal in practice (Coyle & Williams 2001, Brown et al. 2006) and this brings us back to the rationale behind the design of this quasi-experimental study. The incongruence between patients and nurses perceptions of caring is evident from this data and is a nding that has consistently been reported in the literature. This was demonstrated through an early review of the caring literature by Kyle (1995) who concluded that nurses identied more expressive behaviours (care about dimension) as indicators of caring more frequently than patients, and patients identied the instrumental nursing behaviours (care for dimension) as care indicators more frequently than nurses. There are many possible reasons that could be presented as to why this disparity exists. For example, it may be interpreted as reective of the idiosyncratic nature of patients views of what constitutes caring. One of the fundamental principles for person-centredness is getting to know the person and working from this basis in terms of meeting their needs. The difference between nurses and patients perceptions of caring
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and what each considers important has implications for PCN if the fundamental premise is a shared understanding of what is important in the nursepatient relationship and hence what can maximise the therapeutic effect of that relationship. The goal, however, is not necessarily to align perspectives but to be cognisant that there might be differences in orientation that will impact on this relationship.

be used to inform developments in practice and that provide evidence of positive outcomes for patients. Finally, there is a caution for nursing to avoid making assumptions about what is important in the experience of caring. The evidence would suggest that as nurses we need to recognise what the patient considers as caring and use this to inuence changes in practice, where the prime goal is to promote person-centeredness.

Conclusions
In conclusion, the use of the CDI (and the NDI) are tools that can generate data and provide indicators that are useful in the development of person-centred practice, as veried from the main ndings from this study, which are summarised below: 1 Nurses perceptions of caring were consistent over time, identifying a core set of indicators that were reective of components within the PCN framework; 2 Patients scored the item involving a patient in care consistently over time, an underpinning principle of personcentred practice; 3 The emergence of the item getting to know the patient identied by nurses is a signicant indicator for the development of person-centred practice; 4 The incongruence between nurses and patients perceptions of caring has signicant implications for the development of person-centred practice. Developing and using measures that can provide such insights into practice is important in demonstrating effectiveness and in identifying areas for improvement. Central to this is having access to valid and reliable instruments that can provide indicators relating to aspects of nursing practice that are traditionally hard to measure. Furthermore, obtaining data from the perspective of both patients and nurses in a comparable way, provides potential to bridge the gap between provision of nursing care and the patient experience, thus contributing towards a person-centred culture. It also provides the opportunity to explore in more detail why differences exist between nurses and patients and how nurses interpret a philosophy of person-centredness in practice, focusing on awareness of their own values and beliefs about person-centred care.

Contributions
Study design: TMcC, BMcC; data collection and analysis: PS and manuscript preparation: TMcC, BMcC, PS.

References
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Relevance to clinical practice

The implication for practice arising from the ndings presented in this paper relates to three key areas. The rst is the need for increased awareness and understanding of the synergy between the concepts of caring and person-centredness and how this relates to professional nursing practice. The second focuses on the use of tools that provide data that can
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