AACN Essentials

The Essentials

Domain 2: Person-Centered Care

Descriptor: Person-centered care focuses on the individual within multiple complicated contexts, including family and/or important others. Person-centered care is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate. Person-centered care builds on a scientific body of knowledge that guides nursing practice regardless of specialty or functional area.

Contextual Statement: Person-centered care is the core purpose of nursing as a discipline. This purpose intertwines with any functional area of nursing practice, from the point of care where the hands of those that give and receive care meet, to the point of systems-level nursing leadership. Foundational to person-centered care is respect for diversity, differences, preferences, values, needs, resources, and the determinants of health unique to the individual. The person is a full partner and the source of control in team-based care. Person-centered care requires the intentional presence of the nurse seeking to know the totality of the individual’s lived experiences and connections to others (family, important others, community). As a scientific and practice discipline, nurses employ a relational lens that fosters mutuality, active participation, and individual empowerment. This focus is foundational to educational preparation from entry to advanced levels irrespective of practice areas.

With an emphasis on diversity, equity, and inclusion, person-centered care is based on best evidence and clinical judgment in the planning and delivery of care across time, spheres of care, and developmental levels. Contributing to or making diagnoses is one essential aspect of nursing practice and critical to an informed plan of care and improving outcomes of care (Olson et al., 2019). Diagnoses at the system-level are equally as relevant, affecting operations that impact care for individuals. Person-centered care results in shared meaning with the healthcare team, recipient of care, and the healthcare system, thus creating humanization of wellness and healing from birth to death.

Entry-Level Domain 2 Competencies

2.1 Engage with the Individual in establishing a caring relationship.

  • 2.1a Demonstrate qualities of empathy.

  • 2.1b Demonstrate compassionate care.

  • 2.1c Establish mutual respect with the individual and family.

2.2 Communicate effectively with individuals.

  • 2.2a Demonstrate relationship-centered care.

  • 2.2b Consider individual beliefs, values, and personalized information in communications.

  • 2.2c Use a variety of communication modes appropriate for the context.

  • 2.2d Demonstrate the ability to conduct sensitive or difficult conversations.

  • 2.2e Use evidence-based patient teaching materials, considering health literacy, vision, hearing, and cultural sensitivity.

  • 2.2f Demonstrate emotional intelligence in communications.

2.3 Integrate assessment skills in practice.

  • 2.3a Create an environment during assessment that promotes a dynamic interactive experience.

  • 2.3b Obtain a complete and accurate history in a systematic manner.

  • 2.3c Perform a clinically relevant, holistic health assessment.

  • 2.3d Perform point of care screening/diagnostic testing (e.g. blood glucose, PO2, EKG).

  • 2.3e Distinguish between normal and abnormal health findings.

  • 2.3f Apply nursing knowledge to gain a holistic perspective of the person, family, community, and population.

  • 2.3g Communicate findings of a comprehensive assessment.

2.4 Diagnose actual or potential health problems and needs.

  • 2.4a Synthesize assessment data in the context of the individual’s current preferences, situation, and experience.

  • 2.4b Create a list of problems/health concerns.

  • 2.4c Prioritize problems/health concerns.

  • 2.4d Understand and apply the results of social screening, psychological testing, laboratory data, imaging studies, and other diagnostic tests in actions and plans of care.

  • 2.4e Contribute as a team member to the formation and improvement of diagnoses.

2.5 Develop a plan of care.

  • 2.5a Engage the individual and the team in plan development.

  • 2.5b Organize care based on mutual health goals.

  • 2.5c Prioritize care based on best evidence.

  • 2.5d Incorporate evidence-based intervention to improve outcomes and safety.

  • 2.5e Anticipate outcomes of care (expected, unexpected, and potentially adverse).

  • 2.5f Demonstrate rationale for plan.

  • 2.5g Address individuals’ experiences and perspectives in designing plans of care.

2.6 Demonstrate accountability for care delivery.

  • 2.6a Implement individualized plan of care using established protocols.

  • 2.6b Communicate care delivery through multiple modalities.

  • 2.6c Delegate appropriately to team members.

  • 2.6d Monitor the implementation of the plan of care.

2.7 Evaluate outcomes of care.

  • 2.7a Reassess the individual to evaluate health outcomes/goals.

  • 2.7b Modify plan of care as needed.

  • 2.7c Recognize the need for modifications to standard practice.

2.8 Promote self-care management.

  • 2.8a Assist the individual to engage in self-care management.

  • 2.8b Employ individualized educational strategies based on learning theories, methodologies, and health literacy.

  • 2.8c Educate individuals and families regarding self-care for health promotion, illness prevention, and illness management.

  • 2.8d Respect individuals and families’ self-determination in their healthcare decisions.

  • 2.8e Identify personal, system, and community resources available to support self-care management.

2.9 Provide care coordination.

  • 2.9a Facilitate continuity of care based on assessment of assets and needs. 

  • 2.9b Communicate with relevant stakeholders across health systems.

  • 2.9c Promote collaboration by clarifying responsibilities among individual, family, and team members.

  • 2.9d Recognize when additional expertise and knowledge is needed to manage the patient.

  • 2.9e Provide coordination of care of individuals and families in collaboration with care team.

Advanced-Level Domain 2 Competencies

2.1 Engage with the Individual in establishing a caring relationship.

  • 2.1d Promote caring relationships to effect positive outcomes.

  • 2.1e Foster caring relationships.

2.2 Communicate effectively with individuals.

  • 2.2g Demonstrate advanced communication skills and techniques using a variety of modalities with diverse audiences.

  • 2.2h Design evidence-based, person-centered engagement materials.

  • 2.2i Apply individualized information, such as genetic/genomic, pharmacogenetic, and environmental exposure information in the delivery of personalized health care.

  • 2.2j Facilitate difficult conversations and disclosure of sensitive information.

2.3 Integrate assessment skills in practice.

  • 2.3h Demonstrate that one’s practice is informed by a comprehensive assessment appropriate to the functional area of advanced nursing practice.

2.4 Diagnose actual or potential health problems and needs.

  • 2.4f Employ context driven, advanced reasoning to the diagnostic and decision-making process.

  • 2.4g Integrate advanced scientific knowledge to guide decision making.

2.5 Develop a plan of care.

  • 2.5h Lead and collaborate with an interprofessional team to develop a comprehensive plan of care.

  • 2.5i Prioritize risk mitigation strategies to prevent or reduce adverse outcomes.

  • 2.5j Develop evidence-based interventions to improve outcomes and safety.

  • 2.5k Incorporate innovations into practice when evidence is not available.

2.6 Demonstrate accountability for care delivery.

  • 2.6e Model best care practices to the team.

  • 2.6f Monitor aggregate metrics to assure accountability for care outcomes.

  • 2.6g Promote delivery of care that supports practice at the full scope of education.

  • 2.6h Contribute to the development of policies and processes that promote transparency and accountability.

  • 2.6i Apply current and emerging evidence to the development of care guidelines/tools.

  • 2.6j Ensure accountability throughout transitions of care across the health continuum.

2.7 Evaluate outcomes of care.

  • 2.7d Analyze data to identify gaps and inequities in care and monitor trends in outcomes.

  • 2.7e Monitor epidemiological and system-level aggregate data to determine healthcare outcomes and trends.

  • 2.7f Synthesize outcome data to inform evidence-based practice, guidelines, and policies.

2.8 Promote self-care management.

  • 2.8f Develop strategies that promote self-care management.

  • 2.8g Incorporate the use of current and emerging technologies to support self-care management.

  • 2.8h Employ counseling techniques, including motivational interviewing, to advance wellness and self-care management.

  • 2.8i Evaluate adequacy of resources available to support self-care management.

  • 2.8j Foster partnerships with community organizations to support self-care management.

2.9 Provide care coordination.

  • 2.9f Evaluate communication pathways among providers and others across settings, systems, and communities.

  • 2.9g Develop strategies to optimize care coordination and transitions of care.

  • 2.9h Guide the coordination of care across health systems.

  • 2.9i Analyze system-level and public policy influence on care coordination.

  • 2.9j Participate in system-level change to improve care coordination across settings.