Transforming primary healthcare through person-centred practice: a mixed-method study from the perspectives of healthcare providers

Abstract

Objective

Effectively administering person-centred care (PCC) in primary healthcare hinges on healthcare providers and their work environment embodying, endorsing and actively engaging in PCC principles. Therefore, it is crucial to investigate the extent to which person-centred practice is implemented among healthcare providers, the working environment and organisational support.

Design

This mixed-method cross-sectional study was conducted through a translated and validated questionnaire comprising 59 items covering three distinct domains: attributes of healthcare providers (prerequisites), the context in which care is delivered (care environment) and the extent of providing care (care processes). Associations between regions, job categories, clinic type and service year duration with the PCC practice level were analysed and stratified according to the 17 constructs. All comments from the free-text responses were thematically analysed.

Setting

Public primary healthcare clinics within the Malaysian central zone regions of Selangor and Kuala Lumpur-Putrajaya.

Participants

A total of 3800 primary healthcare providers, including family medicine specialists, medical officers, medical assistants, pharmacists, pharmacist assistants, nurses, occupational therapists, physiotherapists and dietitians.

Results

‘Developed interpersonal skills’ (mean: 5.77, SD: 0.819), ‘being committed to the job’ (mean: 5.48, SD: 0.892) and ‘knowing self’ (mean: 5.44, SD: 0.990) were among the constructs with the highest scores. Meanwhile, ‘supportive organisational system’ (mean: 4.62, SD: 1.188) and ‘clarity of beliefs and values’ (mean: 4.84, SD: 0.953) had lower mean scores, suggesting areas for improvement in teamwork and organisational support. The findings also underscored significant disparities in scoring, potentially stemming from differences in work cultures and hierarchical dynamics, particularly regarding shared decision-making and inclusivity among seniority levels.

Conclusion

Recognising the impact of seniority, workload and diverse work cultures among different job categories, leveraging each other’s strengths can catalyse successful PCC implementations. The pursuit of instilling and implementing PCC practices calls for a comprehensive organisational transformation, emphasising the need for sustained efforts to enhance support structures and facilitate shared decision-making within healthcare organisations.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Person-centred care (PCC) is vital in healthcare delivery, focusing on meeting patients’ needs and outcomes. However, the extent of implementation and the specific factors influencing PCC practice among healthcare providers, the working environment and organisational support in primary healthcare settings remained unclear.

WHAT THIS STUDY ADDS

• This study uncovers the connection between healthcare providers’ dedication, expertise and challenges, such as perceived time constraints and heavy workloads. It underscores the crucial role of organisational support and shared decision-making in successfully implementing person-centred care.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study promotes a collaborative approach to effectively implement PCC in primary care, acknowledging the impact of seniority, workload and diverse work cultures across different job roles. These findings inspire innovative pathways for shaping policy formulations to improve patient care quality and organisational effectiveness.

Introduction

Primary healthcare (PHC) embodies a holistic health strategy aiming to attain the highest level of well-being across all stages of life, from inception to the end of life.¹ This approach addresses the needs and preferences of individuals, families and communities. The essence of PHC lies in its commitment to addressing health concerns at its roots, emphasising the importance of individuals, families and communities.² Moreover, the evolving population dynamics and shifting disease burdens necessitate a more comprehensive approach in PHC. This shift involves moving away from the conventional disease-centred model, which often emphasises medical opinions over addressing the genuine concerns of the patients.³ Limitations such as brief consultation times, inadequate continuity of care and insufficient patient engagement have been identified as barriers to effective implementation of a person-centred approach within the PHC system, which is highly significant.⁴

Person-centred care (PCC) is defined as ‘an approach to practice that is established through the formation and fostering of therapeutic relationships between all care providers, service users and others significant to them, underpinned by values of respect for persons, individual right to self-determination, mutual respect and understanding’.⁵ It acknowledges and values ‘personhood’, recognising that everyone deserves to be heard and empowered through mutual and collaborative interactions.⁶ It also emphasises a comprehensive and holistic approach that considers physical, psychosocial, emotional and cultural factors that impact a person’s well-being. The impact of PCC is abundant in improving clinical outcomes, satisfaction and quality of life.7,10

McCormack and McCance asserted that, for PCC to be effectively delivered, both healthcare providers and their work environment, in this case, the PHC, must embody, endorse and actively engage in PCC principles.¹¹ This requires a supportive ecosystem in which active learning, ongoing training and sustained organisational backing are consistently in place to equip providers with the knowledge, skills and motivation needed to practise PCC effectively.¹² In essence, healthcare providers must first experience and internalise PCC within their own professional environment before they can extend the same quality of PCC to their patients.

To foster the adoption of PCC among healthcare providers, a foundational requirement is comprehension and competency, achieved through iterative training.13,15 Achieving this necessitates a supportive working environment committed to PCC development. In PHC, where the concept of a person-centred approach is still developing, a transformative shift in the organisational culture is imperative to embrace PCC principles genuinely.¹⁶ Despite this, the evidence indicates a prevalence of isolated PCC moments rather than a pervasive PCC culture, highlighting a dependence on individual awareness and commitment to implementing PCC rather than a comprehensive organisational approach.¹¹ Therefore, it is essential to investigate the extent to which PCC is implemented among healthcare providers, the working environment and the support from the organisation. Such exploration enables the identification of strengths and opportunities for improvement in care, whether at the individual or organisational levels.

Since the enrolment of the Ninth Malaysian Plan in 2006, healthcare priorities in Malaysia have evolved from solely focused on disease management to a more holistic person-centred approach.¹⁷ This transition involved broadening services to include outreach programmes, engaging communities in care and ensuring continuity of care through the empanelment of patients to the same health teams in primary care settings.¹⁸ Given the broad scope of PCC covering various domains in practice and the differing terms used to describe PCC, the evaluations of PCC have been conducted in multiple studies covering different domains of the practice or target population. Exploring PCC practice from a comprehensive perspective, including various important domains and considering healthcare providers’ viewpoints, is essential. This approach enables the integration of existing evidence with broader perspectives, leading to a more holistic improvement in current practices.

While various tools exist to measure person-centred concepts,¹⁹ many explored proxy measures and outcomes, with very few exploring PCC practice or PCC culture.²⁰ The current study utilised a PCC measurement tool to measure PCC practice and culture among healthcare providers. The tool was developed based on a well-established PCC framework and tested and validated globally.²¹

The study used an explanatory sequential design approach to investigate the PCC practice level among healthcare providers and their organisations within the PHC context. This approach allows for a comprehensive understanding by quantitatively measuring PCC levels and then exploring potential explanations through subsequent qualitative analysis. The findings offer valuable insights into potential factors influencing PCC levels, informing policymakers and relevant stakeholders on strategies to enhance organisational practices at a macro level.

Method

Study design and tool

This mixed-method cross-sectional study using an explanatory sequential design approach explored person-centred practice through the translated and validated Malaysian version of the Person-Centred Practice Inventory-Staff (PCPI-S) questionnaire.²² The questionnaire comprises 59 items, developed from the Person-centred Practice Framework by McCormack and McCance, encompassing 17 distinct constructs that are further grouped into four domains.²¹ The fourth framework domain, the person-centred outcomes, was not part of the 59-item PCPI-S since the focus was on evaluating processes and practice. The Malaysian questionnaire consisted of English and Malay versions, cross-culturally adapted from the original tool.²² The original instrument underwent forward and backward translation into Bahasa Malaysia, followed by cognitive debriefing during pretesting to ensure clarity, cultural appropriateness of terminology and preservation of the original meaning.²² It was part of a more extensive Primary Care Systems for Person-Centred Provider Practices (National Medical Research Register (NMRR)-18-309-40447) study with the detailed method and sample sizing described elsewhere.²³ The translated and validated questionnaire retains the 59 items covering the three distinct domains: attributes of healthcare providers (prerequisites), the context in which care is delivered (care environment) and the extent of providing care (care processes).²⁴ The translated questionnaire demonstrated high internal consistency, with composite reliability mostly exceeding 0.6 across items and domains. Confirmatory factor analysis supported the three-domain structure.²⁵

Study population

The questionnaire was distributed to all healthcare providers, including family medicine specialists (FMS), medical officers, medical assistants, pharmacists, pharmacist assistants, nurses, occupational therapists, physiotherapists and dietitians working in public PHC clinics within the Malaysian central zone regions of Selangor and Kuala Lumpur-Putrajaya. No minimum duration of service was set to be included in the study. Clinic staff on leave or unavailable during the study period were excluded.

Data collection

A universal sampling approach was applied to all eligible clinics and healthcare providers, with a total of 4531 questionnaire packs dispatched. Representatives from each clinic distributed and collected the questionnaires. Before answering, written and signed consent was collected from all respondents. Respondents were given 2 weeks to complete the questionnaire and instructed to place their filled-out questionnaires in the provided envelope, sealing it securely. Respondents could choose to answer the questionnaire in English or Malay.

The questionnaire’s items explored the perceived frequency of PCC practice in respondents’ workplaces through a seven-scale option: never, rarely (~10%), occasionally (~30%), sometimes (~50%), frequently (~70%), usually (~90%) and all the time (100%). Each scale was given a score ranging from one to seven, with never=1 to all the time=7. The average score was calculated based on each item and construct’s mean and SD. Henceforth, the term ‘level’ referred to PCC practice frequency, with higher levels corresponding to the higher frequency of practice. In addition, free-text comment boxes were included for every item throughout the questionnaire, asking participants if there was anything else they would like to add about their experiences related to the items.

Data analysis

Quantitative analysis

Following data cleaning, the data were evaluated for missing values and skewness. The characteristics of respondents and the clinics were described. The mean and SD of continuous data were described, while frequency (n) and percentage (%) described categorical data. The level of PCC practice, represented by the score derived from the questionnaire, was presented next. The average score for the 17 constructs, derived from all items in each construct, was calculated and tabulated.

Next, the study explored associations between regions, job categories, clinic type and service year duration with the PCC practice level, stratified according to the 17 constructs. Regions referred to the two central zone areas (Selangor and Kuala Lumpur-Putrajaya). The nine job categories were further collapsed into six groups (nurse, pharmacist, allied health, medical assistant, FMS and medical officer and others) due to smaller numbers of respondents in certain groups. The clinic types were based on the daily attendance of patients at the clinic. They reclassified as high attendance clinic (type I with attendance of more than 800 patients per day), moderate attendance clinic (type II with attendance of 500–799 patients per day), and low attendance clinic (type III and IV with attendance of 150–499 patients per day).²⁶ The regions, job categories and clinic types were cross-tabulated with the service year duration to understand the effect of seniority in explaining the PCC practice level.

Independent t-tests and one-way analysis of variance (ANOVA) were used to investigate the association, with a two-tailed significance level of 5%. In the case of ANOVA, when significant differences were established, post-hoc pairwise comparisons were carried out with Bonferroni’s correction to control the family-wise type I error rate. Effect sizes were calculated to complement statistical significance, using Cohen’s d for t-tests and partial eta squared for ANOVA. Analysis was performed using SPSS V.25 (IBM SPSS Statistics for Windows).

Qualitative analysis

All free-text responses were imported into NVivo V.20 software (QSR International) and analysed using an inductive thematic approach. Two researchers independently coded all responses, and any discrepancies in the coding were resolved through discussion and consensus, enhancing the credibility of the analysis.²⁷ Subsequently, the responses were thematically organised, allowing for the identification of recurring patterns and themes related to PCC practice in PHC. The barriers and facilitators of implementing PCC were then narratively described based on the identified themes.

To integrate the qualitative and quantitative components, we employed a side-by-side joint display approach, a recognised technique for achieving robust data triangulation in mixed-methods research.²⁸ This involved systematically aligning quantitative results (construct-level PCC scores) with qualitative themes and illustrative quotes. The integration process extended beyond simple mapping: qualitative data were used to explain, complement and contextualise the numerical trends. Specifically, we examined how the qualitative insights elucidated the reasons for the constructs with the highest and lowest PCC scores. Integration of quantitative findings occurred during the interpretation stage. Qualitative themes were deductively mapped to relevant PCC constructs based on conceptual alignment with the quantitative measures. Illustrative quotes were selected to exemplify how qualitative experiences explained or contextualised observed quantitative scores. This integration allowed for data triangulation, enhancing the study’s validity and reliability.²⁹

Patient and public involvement

Patients and/or the public were not involved in this research’s design, conduct, reporting or dissemination plans.

Results

Data from 3800 respondents from 98 primary healthcare clinics were included in the study, with a response rate of 83.9%. The PCC practice levels were normally distributed, with skewness and kurtosis between −1 and 1 across all constructs. The missing values ranged from 3.9% to 8.1% for the items under study. A comparison of analysis between complete and missing data showed no difference in outcomes. Consequently, data from all respondents were retained.

Table 1 describes the respondents and clinic characteristics. Two-thirds of the respondents were from Selangor. Nurses made up the most significant job category (44.2%), followed by FMS and medical doctors (22.3%) and pharmacists (17.6%). More than half of the healthcare providers had been serving the health ministry for >10 years, with about one-fifth having served more than 15 years (18.2%).

Table 1. Respondents and clinics profile.

Characteristics	Count	Percentage
Total	3800	100
Region
Selangor	2526	66.5
Kuala Lumpur-Putrajaya	1274	33.5
Clinic types
High attendance clinic	1680	44.21
Moderate attendance clinic	839	22.08
Low attendance clinic	962	25.32
Job categories
Nurse	1681	44.2
Assistant pharmacist and pharmacist	654	17.2
Allied health	96	2.5
Medical assistant	287	7.6
FMS and medical officer	846	22.3
Others	3	0.1
Unknown	233	6.1
Years of service
≤5 years	663	17.4
5–10 years	1470	38.7
10–15 years	828	21.8
≥15 years	691	18.2
Unknown	148	3.9

FMS, family medicine specialists.

Table 2 shows the crosstabulation between regions, clinic types and job categories with years of service. The majority of respondents who worked in Selangor and Kuala Lumpur-Putrajaya clinics had been serving the health ministry for 5–10 years, 39.56% and 41.64%, respectively. The observed distribution of years in service and clinic types exhibited a congruent pattern with minimal differences.

Table 2. Crosstabulation between variable state, clinic categories, type of clinics and job categories with years of service.

Characteristics	Total	Years of service*
		≤5 years	5–10 years	10–15 years	≥15 years
	N (%)	N (%)	N (%)	N (%)	N (%)
Regions
Selangor	2432	405 (16.65%)	962 (39.56%)	568 (23.36%)	497 (20.44%)
Kuala Lumpur-Putrajaya	1220	258 (21.15%)	508 (41.64%)	260 (21.31%)	194 (15.9%)
Clinic types*
High attendance	1622	329 (20.28%)	636 (39.21%)	377 (23.24%)	280 (17.26%)
Moderate attendance	818	130 (15.89%)	340 (41.56%)	178 (21.76%)	170 (20.78%)
Low attendance	917	170 (18.54%)	384 (41.88%)	196 (21.37%)	167 (18.21%)
Job categories*
Nurse	1667	221 (13.26%)	534 (32.03%)	424 (25.43%)	488 (29.27%)
Assistant pharmacist and pharmacist	649	219 (33.74%)	291 (44.84%)	95 (14.64%)	44 (6.78%)
Allied health	94	17 (18.09%)	50 (53.19%)	24 (25.53%)	3 (3.19%)
Medical assistant	285	120 (42.11%)	90 (31.58%)	48 (16.84%)	27 (9.47%)
FMS and medical officer	832	68 (8.17%)	465 (55.89%)	199 (23.92%)	100 (12.02%)
Others	3	0 (0%)	2 (66.67%)	1 (33.33%)	0 (0%)

^*Unknown categories were excluded from the cross-tabulation table

FMS, family medicine specialists.

Quantitative findings

The mean score of all 17 constructs ranged from 4.62 to 5.77, while the items’ mean scores ranged from 4.00 to 6.16. The construct with the highest score was ‘developed interpersonal skills’ (mean: 5.77, SD: 0.819), followed by the constructs ‘being committed to job’ (mean: 5.48, SD: 0.892) and ‘knowing self’ (mean: 5.44, SD: 0.990). All three constructs belong to the first domain, ‘prerequisites’. The item that received the highest mean score was ‘in my communication, I demonstrate respect for others’ (mean: 6.16, SD: 0.873), followed by ‘I strive to deliver high-quality care to people’ (mean: 5.94, SD: 0.942), both from the same construct ‘developed interpersonal skills’.

In contrast, four constructs with the lowest mean scores, ranging from the lowest being: ‘supportive organisational system’ (mean: 4.62, SD: 1.188), ‘clarity of beliefs and values’ (mean: 4.84, SD: 0.953), ‘shared decision making’ (mean: 4.91, SD: 1.109) and ‘potential for innovation and risk-taking’ (mean: 4.99, SD: 1.081). Three of these constructs belonged to the second domain, ‘care environment’ (‘supportive organisational system’, ‘shared decision making’ and ‘potential for innovation and risk-taking’). The item with the lowest mean score was ‘I challenge colleagues when their practice is inconsistent with our team’s shared values and beliefs’ (mean: 4.00, SD: 1.374), followed by ‘I am recognised for the contribution that I make to people having a good experience of care’ (mean: 4.36, SD: 1.489) and ‘my organisation recognises and rewards success’ (mean: 4.44, SD: 1.518). Table 3 shows the overall PCC level by construct (online supplemental file 1).

Table 3. PCC level by constructs.

Domain	Constructs	PCC level
		Mean	SD
Prerequisites	Professional competence	5.25	0.942
	Developed interpersonal skills	5.77	0.820
	Being committed to job	5.48	0.890
	Knowing self	5.44	0.989
	Clarity of beliefs and values	4.84	0.956
Care environment	Skill mix	5.14	0.905
	Shared decision-making	4.91	1.110
	Effective staff relationships	5.21	1.062
	Power sharing	5.41	0.962
	Potential for innovation and risk taking	4.99	1.081
	The physical environment	5.06	1.041
	Supportive organisational systems	4.62	1.187
Care processes	Working with patients’ beliefs and values	5.11	1.022
	Shared decision-making (Patient)	5.20	1.062
	Engagement	5.38	0.994
	Providing holistic care	5.32	0.990
	Having sympathetic presence	5.43	1.026

^*The detail of constructs and questionnaire items is described in online supplemental file 1.

PCC, person-centred care.

All constructs within the third domain, ‘care processes,’ attained a considerably high mean score of above 5, including a construct with a name resembling one from the second domain, ‘care environment,’ called ‘shared decision-making (Patient)’ (mean: 5.19, SD: 1.060). The shared decision-making in this context pertains specifically to the patient-provider relationship, in contrast to the organisational or interprofessional shared decision-making discussed in the preceding domain.

Tables46 show the associations between several factors and the level of PCC practice, analysed through the t-test and ANOVA, with the detail of post hoc analysis described in online supplemental files 2–4.

Table 4. Association between clinic categories with PCC levels.

Constructs*	High attendance	Moderate attendance	Low attendance		Analysis of variance (ANOVA)
	Mean score (SD)	Mean score (SD)	Mean score (SD)	F value	df	P value
A. Professional competent	5.22 (0.935)	5.18 (0.967)	5.28 (0.936)	2.846	2	0.058
B. Developed interpersonal skills	5.74 (0.823)	5.73 (0.819)	5.81 (0.803)	3.331	2	0.036†
C. Being committed to the job	5.41 (0.902)	5.42 (0.895)	5.53 (0.846)	5.955	2	0.003†
D. Knowing self	5.42 (0.975)	5.36 (0.999)	5.47 (0.992)	2.640	2	0.072
E. Clarity of beliefs and values	4.84 (0.942)	4.71 (0.967)	4.84 (0.953)	6.215	2	0.002†
F. Skill mix	5.15 (0.904)	5.06 (0.929)	5.13 (0.877)	2.838	2	0.059
G. Shared decision-making	4.89 (1.123)	4.78 (1.116)	4.97 (1.080)	6.532	2	0.001†
H. Effective staff relationships	5.15 (1.095)	5.11 (1.038)	5.29 (1.039)	7.833	2	0.000†
I. Power sharing	5.37 (0.977)	5.28 (0.970)	5.51 (0.936)	12.952	2	<0.001†
J. Potential for innovation and risk-taking	4.96 (1.078)	4.89 (1.106)	5.05 (1.065)	4.878	2	0.008†
K. The physical environment	5.03 (1.036)	4.97 (1.061)	5.12 (1.011)	4.637	2	0.010†
L. Supportive organisational systems	4.61 (1.199)	4.48 (1.183)	4.66 (1.179)	5.602	2	0.004†
M. Working with patient’s beliefs and values	5.05 (1.003)	5.01 (1.068)	5.18 (1.001)	6.822	2	0.001†
N. Shared decision-making (P)	5.15 (1.048)	5.13 (1.118)	5.26 (1.048)	4.811	2	0.008†
O. Engagement	5.33 (1.008)	5.34 (1.026)	5.44 (0.932)	4.472	2	0.011†
P. Providing holistic care	5.27 (1.007)	5.25 (0.989)	5.39 (0.951)	5.875	2	0.003†
Q. Having a sympathetic presence	5.36 (1.043)	5.37 (1.044)	5.50 (0.986)	5.693	2	0.003†

Effect sizes for differences in PCC level by clinic categories were estimated using partial eta squared (η²) from the general linear model, ranging from 0.002 to 0.008, indicating very small practical differences.

^*The detail of post hoc analysis is described in online supplemental files 2

^†p<0.005

PCC, person-centred care.

Table 6. Association between years in service with PCC levels.

Constructs*	≤5 years	5–10 years	10–15 years	≥15 years	Analysis of variance (ANOVA)
	Mean score (SD)	Mean score (SD)	Mean score (SD)	Mean score (SD)	F value	df	P value
Professional competence	5.07 (0.892)	5.20 (0.922)	5.35 (0.922)	5.442 (0.993)	22.932	3	<0.001*
Developed interpersonal skills	5.72 (0.802)	5.75 (0.807)	5.77 (0.820)	5.863 (0.852)	3.978	3	0.008†
Being committed to the job	5.29 (0.892)	5.40 (0.878)	5.55 (0.861)	5.746 (0.884)	36.122	3	<0.001†
Knowing self	5.40 (0.996)	5.42 (0.981)	5.43 (0.968)	5.513 (1.012)	1.796	3	0.146
Clarity of beliefs and values	4.68 (0.959)	4.76 (0.951)	4.90 (0.935)	5.080 (0.944)	25.869	3	<0.001†
Skill mix	5.02 (0.891)	5.11 (0.878)	5.15 (0.914)	5.308 (0.933)	12.237	3	<0.001†
Shared decision-making	4.62 (1.156)	4.89 (1.078)	4.95 (1.080)	5.143 (1.121)	25.605	3	<0.001†
Effective staff relationships	5.15 (1.099)	5.17 (1.068)	5.19 (1.034)	5.371 (1.046)	6.724	3	<0.001†
Power sharing	5.32 (0.960)	5.34 (0.961)	5.41 (0.955)	5.627 (0.947)	16.203	3	<0.001†
Potential for innovation and risk-taking	4.86 (1.102)	4.97 (1.062)	4.97 (1.080)	5.150 (1.099)	8.286	3	<0.001†
K. The physical environment	4.85 (1.109)	5.04 (1.004)	5.09 (1.001)	5.257 (1.070)	17.915	3	<0.001†
Supportive organisational systems	4.57 (1.215)	4.53 (1.179)	4.63 (1.178)	4.796 (1.167)	8.009	3	<0.001†
Working with patients’ beliefs and values	4.96 (1.042)	5.07 (0.975)	5.11 (1.033)	5.314 (1.055)	14.896	3	<0.001†
Shared decision-making (P)	5.09 (1.070)	5.21 (1.039)	5.19 (1.021)	5.259 (1.143)	3.096	3	0.026†
Engagement	5.29 (1.020)	5.37 (0.953)	5.41 (0.971)	5.457 (1.060)	3.406	3	0.017†
Providing holistic care	5.24 (1.009)	5.34 (0.949)	5.33 (0.980)	5.339 (1.058)	1.853	3	0.135†
Having a sympathetic presence	5.29 (1.057)	5.41 (0.985)	5.46 (1.023)	5.552 (1.060)	7.536	3	<0.001†

Effect sizes for differences in PCC outcomes by years in service were estimated using partial eta squared (η²) from the general linear model, ranging from 0.005 to 0.066, indicating small practical differences.

^*The detail of post hoc analysis is described in online supplemental file 4

^†p<0.005.

PCC, person-centred care.

All constructs exhibited significant differences when comparing the clinic types (table 4). The perceived PCC level was generally higher in multiple constructs for the clinics with the lowest daily patient attendance. This was especially true for the constructs that explored staff relationships, shared decision-making and commitment to delivering care to patients. For example, in the construct ‘being committed to job’, low attendance clinics had higher mean scores (mean: 5.53, SD: 0.846), as compared with high and moderate attendance clinics (mean: 5.41, SD: 0.902 and mean: 5.42, SD: 0.895, respectively), with a significant difference across clinic types (F (2, 3447): 5.96, p: 0.003). The post-hoc analysis showed significant differences between high attendance with low attendance and moderate attendance with low attendance, where low attendance clinics consistently scored higher PCC levels in most constructs (online supplemental file 2).

Differences between job categories were apparent. All constructs differed significantly, with the allied health category consistently scoring higher levels in most constructs, except the ‘supportive organisational system’ (table 5). Nurses had the second-highest score in most constructs. FMS and medical officers scored among the highest in many constructs but lowest in the ‘supportive organisational system’ (mean: 4.34, SD: 1.189).

Table 5. Association between job categories with PCC levels.

Constructs*	Nurse	Pharmacist	Allied health	Medical assistant	FMS and medical officers	Analysis of variance (ANOVA)
	Mean score (SD)	Mean score (SD)	Mean score (SD)	Mean score (SD)	Mean score (SD)	F value	df	P value
A. Professional competent	5.34 (0.938)	4.97 (1.002)	5.56 (0.876)	5.02 (0.972)	5.36 (0.824)	28.894	4	<0.001†
B. Developed interpersonal skills	5.81 (0.836)	5.77 (0.798)	6.07 (0.703)	5.58 (0.855)	5.74 (0.792)	8.470	4	<0.001†
C. Being committed to the job	5.69 (0.848)	5.12 (0.927)	5.66 (0.785)	5.23 (0.919)	5.40 (0.824)	61.956	4	<0.001†
D. Knowing self	5.52 (0.980)	5.31 (1.051)	5.54 (0.941)	5.35 (0.949)	5.37 (0.964)	7.715	4	<0.001†
E. Clarity of beliefs and values	5.03 (0.915)	4.68 (0.971)	4.84 (0.962)	4.79 (0.944)	4.60 (0.957)	34.851	4	<0.001†
F. Skill mix	5.18 (0.916)	5.05 (0.937)	5.29 (0.862)	5.05 (0.937)	5.16 (0.845)	3.811	4	0.004†
G. Shared decision-making	5.04 (1.071)	4.62 (1.201)	5.39 (1.018)	4.82 (1.152)	4.81 (1.078)	23.981	4	<0.001†
H. Effective staff relationships	5.33 (1.026)	5.05 (1.193)	5.48 (1.040)	5.14 (1.063)	5.08 (1.025)	14.024	4	<0.001†
I. Power sharing	5.54 (0.934)	5.26 (1.000)	5.66 (0.907)	5.44 (0.912)	5.20 (0.979)	23.725	4	<0.001†
J. Potential for innovation and risk-taking	5.15 (1.066)	4.69 (1.171)	5.26 (0.936)	4.94 (1.067)	4.85 (1.015)	27.047	4	<0.001†
K. The physical environment	5.17 (1.039)	4.78 (1.110)	5.55 (0.861)	5.08 (0.996)	4.96 (0.993)	24.328	4	<0.001†
L. Supportive organisational systems	4.80 (1.114)	4.49 (1.303)	4.62 (1.182)	4.46 (1.169)	4.34 (1.189)	24.140	4	<0.001†
M. Working with patient’s beliefs and values	5.28 (0.970)	4.74 (1.156)	5.66 (0.851)	4.87 (1.018)	5.04 (0.936)	46.474	4	<0.001†
N. Shared decision-making (P)	5.25 (1.039)	4.94 (1.184)	5.87 (0.851)	4.88 (1.133)	5.30 (0.936)	29.707	4	<0.001†
O. Engagement	5.45 (0.992)	5.22 (1.040)	5.86 (0.844)	5.16 (1.044)	5.40 (0.920)	15.559	4	<0.001†
P. Providing holistic care	5.36 (0.967)	5.16 (1.126)	5.78 (0.840)	5.07 (1.032)	5.40 (0.882)	16.331	4	<0.001†
Q. Having a sympathetic presence	5.54 (0.992)	5.16 (1.118)	5.91 (0.925)	5.14 (1.133)	5.46 (0.928)	27.102	4	<0.001†

Effect sizes for differences in PCC outcomes by job categories were estimated using partial eta squared (η²) from the general linear model, ranging from 0.002 to 0.040, indicating small practical differences.

^*The detail of post hoc analysis is described in online supplemental file 3

^†p<0.005.

FMS, family medicine specialists; PCC, person-centred care.

Pharmacists scored most constructs the lowest. For example, in the construct ‘being committed to job’, pharmacists scored the lowest (mean: 5.12, SD: 0.927), with a significant difference observed between the various job categories (F (4, 3559): 61.96, p<0.001). The post-hoc analysis revealed the most significant differences in most constructs were between the professions with the lowest score in most constructs, pharmacists and the three professions scoring high levels in most constructs, allied health, nurses and FMS and medical officers (online supplemental file 3).

All constructs differed significantly when comparing the number of years a healthcare provider has been in service (table 6). The pattern showed a tendency for the perceived PCC level to increase with the longer years in service. For example, in the construct ‘shared decision making’, those who have served more than 15 years were the only category with a mean score above 5 (mean: 5.14, SD: 1.121), with a significant difference across years of service (F (3, 3648): 25.61, p<0.001). The most significant differences were between the junior most (had served for 5 years or less) and the senior most (had served for at least 15 years), with significant differences in almost all constructs between these two groups in the post-hoc analysis (online supplemental file 4).

There was a similar pattern in the PCC level between Selangor and Kuala Lumpur-Putrajaya across all constructs except for organisational shared decision-making, where Selangor scored a significantly higher level (t (3759): 2.31, p: 0.021) (online supplemental file 5). Otherwise, the constructs scored highest and lowest were similar in the two regions.

Qualitative findings

A total of 1609 open-text responses were collected from 59 questionnaire items. The key themes and subthemes related to PCC were summarised (online supplemental file 6), and table 7 explains the reasons behind high and low constructs’ scores, providing deeper insight into factors that facilitate or hinder PCC implementation. The main themes are described below. During this process, it was noted that many illustrative quotes originated from questionnaire items corresponding to the same PCC construct. This clustering reflects conceptual convergence between participants’ qualitative accounts and the quantitative items’ focus, rather than a priori coding or forced alignment. For example, the theme ‘lack of organisational support’ emerged inductively across responses and was subsequently aligned with the quantitative construct ‘supportive organisational system’, for which low mean scores were observed, with illustrative quotes primarily from items addressing organisational recognition and feedback.

Table 7. Joint display of integrated quantitative and qualitative findings.

Constructs	PCC level (Mean, SD)	Related qualitative themes	Illustrative quotes	Integrated interpretation
Constructs with the highest mean scores
Developed interpersonal skills	5.77 (0.82)	Effective communication; whole-person care; better quality of care	“I usually make eye contact with my patients when talking to them and show interest in whatever the patient is telling me, and ensure privacy so the patient is comfortable talking to me.” Medical officer, 12 years in service “If the language barrier is present, I will ask another staff member who may assist me.” Pharmacist assistant, 12 years in service “Use of diagrams/chart or communicate by writing with physically challenged patients.” Medical officer, 13 years in service	The high score corresponds with strong communication and interpersonal competencies, as supported by qualitative findings. Respondents demonstrated the capacity to effectively address patients’ needs and limitations within the clinical setting, a skill likely shaped by accumulated training and professional experience. The use of various tools and aids further enhanced their ability to foster positive interpersonal relationships with patients.
Being committed to the job	5.48 (0.89)	Skills and competence; adherence to SOP, guidelines, CPG; knowledgeable in care; continuous learning	“I always give my best effort to improve the quality of patients’ well-being.” Staff nurse, 11 years in service “[I] consider patients’ education background and social support when communicating [to understand their problems].” Medical officer, 5 years in service “I try my best to observe how patients react to how I convey things. I list all options for patients that I can think of. I want to give my best effort as much as I know.” Medical officer, 10 years in service “I train the nurses according to the latest SOP. I also become the facilitator.” Matron, 22 years in service	Quantitative findings indicate a strong sense of commitment among healthcare providers, supported by qualitative accounts of their dedication to delivering high-quality care. Respondents described making every effort to improve patients’ well-being, adapting communication to patients’ backgrounds and social contexts and offering all possible care options. This commitment also extends to mentoring colleagues, with efforts to train staff according to current guidelines and support continuous learning to enhance service delivery.
Constructs with the lowest mean scores
Clarity of beliefs and values	4.84 (0.96)	Seniority; feedback culture	“Not everyone will accept my comments. Sometimes comments bring misunderstandings between colleagues.” Medical assistant, 6 years in service "Not everyone is open to criticism/discussion. In our setting, I realise seniority also plays a role. Whereby doctors much senior to us might not be accepting a junior doctor’s criticism.” Medical officer, 6 years in service “Unless it’s critically affecting our team’s SOP, usually we will just do soft reminding.” Pharmacist, 5 years in service	The low quantitative score is supported by qualitative findings showing that hierarchical barriers and reluctance to challenge colleagues hinder open feedback. Respondents described how criticism is often met with misunderstanding or resistance, particularly when directed toward senior staff. As a result, feedback is frequently softened or avoided, which undermines the development of shared values within the team.
Shared decision-making (organisational)	4.91 (1.11)	Leadership; teamwork; seniority	“The voices [are often] complementary with ranks.” Pharmacist assistant, 1 year in service. "Staff’s opinion [has] mostly not been considered. Opportunities have less been given. Staff’s voice will end up with nothing, basically not supported by superiors.” Staff nurse, 13 years in service “Usually [only] my higher-ups will participate in this kind of [decision-making] meeting.” Occupational therapist, 3 years in service “No chance [opportunity] at all.” Pharmacist, 1 year in service	The low quantitative scores are consistent with qualitative accounts describing limited opportunities for staff, particularly juniors, to participate in organisational decision-making. Respondents reported that input was often disregarded or reserved for senior personnel, reinforcing perceptions of exclusion and highlighting systemic shortcomings in leadership engagement.
Supportive organisational systems	4.62 (1.19)	Lack of appreciation; seniority; leadership	“I was never appreciated by the superiors.” Staff nurse, 15 years in service “I rarely had the opportunity to discuss my career progression with my seniors.” Staff nurse, 10 years in service “The Award [APC] is often given based on seniority. Furthermore, there is only a small quota for the yearly award.” Medical assistant, 5 years in service “[We are] recognised but no rewards.” Medical officer, 10 years in service	The lowest quantitative score is supported by qualitative accounts revealing a lack of recognition and a workplace culture that prioritises seniority. Respondents described feeling undervalued, with limited opportunities to discuss career progression and awards perceived as unfairly distributed. These experiences underscore a need for organisational change to foster a more supportive and appreciative environment.

PCC, person-centred care; SOP, standard operating procedure.

Training and development support

Respondents frequently highlighted the importance of continuous learning through continuing medical education (CME) sessions, workshops and postgraduate opportunities. They attributed their confidence and ability to deliver comprehensive services to these ongoing development initiatives, which corresponded with high scores in ‘being committed to the job’. However, access to professional development was not uniform. Some respondents faced barriers such as lack of managerial approval to further study, time constraints and bureaucratic hurdles, which limited their ability to enhance their skills and knowledge.

Communication skills

Effective communication was consistently recognised as a cornerstone of good practice. Respondents felt confident in their ability to explain treatment options clearly, build rapport and foster informed decision-making. Visual aids were seen as valuable tools to improve understanding, though their use was sometimes constrained by time pressures and limited resources. Overall, communication skills were strongly linked to high scores in the ‘developed interpersonal skills’ construct.

Holistic PCC

Respondents expressed a commitment to delivering holistic care that incorporated empathy, patient needs and family involvement. They valued opportunities to work collaboratively within teams, emphasising that interdisciplinary meetings and discussions enhanced their ability to deliver person-centred services. This theme was closely associated with high scores in ‘being committed to the job’, underpinned by motivation to strive for the best patient outcomes.

Time and workload pressures

Heavy workloads and limited consultation time emerged as major barriers to delivering PCC. Respondents noted that high patient volumes often forced them to prioritise urgent issues, limiting their ability to explore patients’ broader needs or social contexts. Although commitment to patients remained strong, these constraints significantly affected the depth and quality of care provided.

Organisational support deficits

A lack of supportive organisational culture was widely reported. Respondents described feeling undervalued, particularly junior staff who perceived that recognition and appreciation were reserved for senior colleagues. Opportunities to participate in organisational decision-making were limited, and successes were often celebrated only within small peer groups rather than formally recognised. These issues were reflected in the low scores for ‘supportive organisational systems’.

Participation in decision-making

While peer consultation was generally accessible, formal opportunities to contribute to broader organisational decisions were rare. Many respondents, particularly non-senior staff, felt that their opinions were overlooked or disregarded, contributing to low scores in ‘shared decision-making’. This lack of involvement diminished feelings of ownership and engagement within their roles.

Privacy challenges in consultations

Although overall attention to the physical environment scored highly, concerns were raised about compromised privacy during patient consultations. Shared consultation spaces were seen as inadequate for discussing sensitive health issues, often inhibiting open communication and limiting the depth of patient-centred interactions. Financial and infrastructural constraints were cited as barriers to improving consultation environments.

Challenges in addressing colleague practices

Respondents reported reluctance to directly challenge colleagues when practices deviated from shared values, primarily due to fear of conflict and damaging workplace relationships. Instead, they preferred offering gentle advice or reminders. While seeking feedback from peers was common and well-supported, this hesitancy to engage in critical conversations contributed to lower scores in ‘clarity of beliefs and values’.

Discussion

Examining person-centred practices among PHC providers through a comprehensive framework revealed the perceived values and principles driving their motivation to deliver care services. A clear trend appeared where the ‘prerequisite’ domain held the highest valued constructs such as ‘interpersonal skills’ and ‘being committed to job’. Conversely, the ‘care environment’ domain encompassed three constructs rated at the lowest levels: ‘supportive organisational system,’ ‘shared decision-making’ and ‘potential for innovation and risk-taking.’ These findings mirrored results from studies in Germany, Portugal, Finland and Norway that used the PCPI-S tool among healthcare providers.30,34

While variations in scores across constructs and items were evident, it is noteworthy that even the lowest construct score remained relatively high (4.6 on a scale of 1–7). Similar patterns have been reported in other studies,30,34 despite stringent measures to ensure respondent confidentiality and anonymity. Previous validation work on the PCPI-S tool suggested that this tendency may be attributable to social desirability bias, where respondents assign higher ratings to items they perceive as reflecting their professional duties and responsibilities.³⁵ However, this pattern contrasts, to some extent, with the qualitative findings, which revealed more candid reflections on barriers and challenges, as highlighted through the integration of quantitative and qualitative results.

Historically, disease-based medical practice has primarily focused on delivering ‘patient-centred’ or ‘patient-driven’ care, evaluating outcomes based on their impact on clinical well-being.³⁶ The highest-scoring item in this study reflected a recognised commitment to respectful communication, closely followed by dedication to delivering high-quality care, emphases cultivated over decades of healthcare systems championing superior patient care.³⁷ Additionally, the prominence of training opportunities and continuous learning support emerged as a cornerstone. This robust foundation of training avenues and supportive frameworks for skill development equips healthcare providers with enhanced knowledge and abilities, better positioning them to provide comprehensive services to patients and carers.³⁸ Interestingly, the evolution of the term ‘person-centred care’ from ‘patient-centred care’ has led to confusion, as some believe that PCC solely focuses on healthcare providers and patients’ relationships.³⁹ This potentially explains why the third domain, ‘care processes,’ consistently received mid-range scores in this study and others worldwide concerning the procedural aspects of delivering patient care, as it is often regarded as the most critical aspect of care delivery.30,34

The findings also revealed significant disparities in scoring, reflecting potential variances in work cultures, nuanced role definitions, specific job requirements and corresponding expectations within each job category. Allied health and nursing staff consistently scored highest across multiple constructs, with the majority having over ten years of experience, suggesting a correlation between extensive tenure and heightened reported competency levels. In contrast, pharmacists exhibited the lowest scores, particularly in professional competency, potentially linked to the majority having fewer than ten years of experience, interpreted as an early-career developmental phase. Therefore, prioritising ongoing education for less-experienced professionals across categories and fostering interdisciplinary collaboration can effectively leverage strengths and mitigate weaknesses.^{15 40}

Areas requiring improvement are related to teamwork and mutual support within the team. Notably, two items within the ‘supportive organisational system’ construct, focusing on recognising work contributions, scored among the lowest across all items. Despite varying years of service, respondents consistently reported inadequate organisational support, indicating a persistent issue regardless of tenure. Studies suggest insufficient organisational support is linked to reduced job satisfaction, morale, commitment, performance issues and internal conflicts.^{41 42} An indispensable element for cultivating an exceptional work culture is fostering a culture of appreciation.^{12 42} In the qualitative comments, respondents noted that while appreciation need not always manifest through awards or celebrations, they still viewed such gestures as significant.¹²

Seniority and leadership were regarded as significantly influencing shared decision-making, where a perceived lack of inclusivity in crucial decision-making and preferential treatment for seniors hindered many from offering practical solutions to work-related issues. This culture should evolve to respond to changing demographics and increasingly complex health needs. One practical approach is inclusive leadership, in which leaders encourage team participation in an open, psychologically safe environment.⁴³ Interprofessional shared decision-making will ensure consultations occur to overcome each other’s limitations towards delivering the best care.⁴⁴ Task-based or goal-based discussions in smaller groups where everyone ultimately feels included are recommended.⁴⁴

The PCC framework outlines a tiered system, emphasising the importance of reinforcing both ‘prerequisite’ and ‘care environment’ for implementing PCC-oriented ‘care processes’.^{5 25} Apart from the specific constructs, associations between several factors and the level of PCC practice were observed. Allied health and nurses tended to score most constructs higher than the other categories, while pharmacists scored the lowest. The argument suggests that within a shared workplace, distinct work cultures may emerge among different job categories, shaped by the unique aspects of their roles, the inherent nature of their work and the leadership styles they encounter.⁴⁵ The integration of findings suggests that organisational culture and professional roles strongly influence PCC perceptions and practices. Low scores for ‘supportive organisational systems’ and ‘shared decision-making’ were explained by qualitative accounts of hierarchical structures, limited recognition and exclusion of junior staff from decision-making. In contrast, high scores for ‘interpersonal skills’ and ‘commitment to the job’ reflected strong individual dedication despite these organisational constraints. These findings indicate that while providers are personally committed to PCC, systemic cultural barriers, such as seniority-driven practices and lack of inclusive leadership, may limit its full implementation.

An analysis of the crosstabulation between years of service and job categories unveiled noteworthy patterns. The data indicate that most nurses have longer tenures, with more than half having dedicated at least 10 years to their roles, potentially leading to a deeper understanding of patient needs and more developed PCC practices. Conversely, as most pharmacists in this study had served for >10 years, it is possible that being in the earlier stages of their careers may present challenges in establishing solid patient-provider relationships, which could in turn influence their PCC practices. Furthermore, the disparities in work culture among allied health professionals suggested that organisational factors may also significantly influence PCC practices. This emphasises the importance of considering individual characteristics and broader organisational dynamics in understanding and enhancing PCC delivery. Moreover, the absence of significant differences in PCC practices between regions in Kuala Lumpur-Putrajaya and Selangor, except for one construct, implies that geographical location may not be a primary determinant of PCC implementation in Malaysia. This underscores the need for targeted interventions to improve PCC practices across various organisational contexts, considering individual and systemic factors.

Resource constraints, notably the perceived high workload and insufficient time for comprehensive, PCC-based consultations, emerged as a pervasive challenge for PHC providers.⁴⁶ This recurring issue, highlighted across multiple constructs, underscored the global prevalence of overwhelming workloads within the PHC sector.⁴⁷ ANOVA results indicated that clinics with lower patient attendance often achieved significantly higher scores across various constructs. This supports the assertion that workload and burden considerations impact the implementation of PCC practices, exacerbated by an imbalance ratio of allied healthcare providers relative to the population.^{48 49} For the Malaysian context, re-evaluating resource distribution and patient load across different clinic types may be warranted to optimise PCC implementation. Despite the variations in workload and time constraints, all clinic types consistently exhibited a shared challenge: the lowest scores in the ‘supportive organisational system’ and ‘shared decision-making.’ This indicates a universal need for improvement in these constructs, irrespective of perceived workload or clinic type.

Strengths and limitations

The study’s robustness stems from using a comprehensive tool to assess PCC practices grounded in a well-established framework.^{21 22} This tool’s validation across numerous countries and diverse healthcare provider categories underscores its practicality across different settings within the purview of healthcare systems. To the authors’ knowledge, the study was also the first to use the tool through a mixed-method approach, exploring the potential explanation behind the level of PCC practice.

It is crucial to note that the current study relies solely on the perspectives of healthcare providers, introducing a potential bias. The proportion of missing data in this study was relatively low. Although formal tests of missingness mechanisms were not conducted, exploratory cross-tabulations did not suggest substantial differential missingness across key demographic and occupational variables. Considering this potential bias, future research should include additional exploration and triangulation with patients’ perspectives to provide a more holistic understanding of PCC practices in Malaysia. This could also be done by incorporating patients as co-researchers, ensuring a more thoughtful study design.

Conclusion

Healthcare delivery depends greatly on the dedicated healthcare providers, supported by adequate knowledge and skills. However, persistent challenges such as time constraints and heavy workloads require long-term solutions, including reassessing resource distribution. Organisational support and shared decision-making can be strengthened by fostering a work culture that values and recognises staff contributions, and integrating this into organisational practices. Understanding differences in seniority, workload and work culture across job categories and leveraging each other’s strengths may help advance PCC implementation. Overall, implementing PCC requires a comprehensive, continuous and systematic organisational transformation to ensure sustained effectiveness.

Data availability statement

Data are available upon reasonable request.