Table 4. Assessment Skills that Demonstrate PCC and CSC.

Theme	Subthemes	Representative Quotes
Content	Conduct a patient-centered (individualized) assessment	You have to know your patient; you have to know what's going on with the patient. I think the assessment, and patient-centered care are all wrapped up together, because you can't understand your patients without a thorough assessment. P2 You can't do the same assessment for every single person. You should have a baseline, but whatever comes up, you need to focus on that. P10 I identify what's important to the person because if you listen, they'll usually tell you what would be most helpful to them. And so that's usually where I start. It's whatever is most on their mind, most problematic, what they're most scared about or concerned about. P12
	Conduct a culture-sensitive assessment	I want to make sure I am not judgmental, instead I am just curious. I am attentive to their milieu, and then I start to ask questions. I want to know what their belief system is, their cultural interpretation of things, and how they feel about what's going on. I also ask, “What has your experience been with healthcare providers? What's been good, what's been bad?” So that we can make sure that we're starting where they are at when we give them information, so they can understand and can make it their own and buy into it. P14
	Conduct a holistic assessment	You have to look at the whole person, not just the disease. We have to pay attention to the whole human being. P9 Your assessment is obviously going to include the physical assessment piece, but it also includes an assessment of how they really are doing. How are they functioning at home? How does their environment impact them? What kind of needs do they have beyond the obvious healthcare needs? Paying attention to just really a lot of things. P16
	Assess psychosocial factors	You need to assess environment and social issues, which are frequently more important than their physical assessment. P3 The family dynamics, environment, finances, everything plays a part in trying to get them managed at home and you have to deal with all of those things. P7 I try to put the whole picture together by using the OASIS as a starting point. So as I'm going through the OASIS, I'm doing that whole comprehensive psychosocial assessment. P13
	Assess learning needs	I find out where they are at in their trajectory of owning their health and wellness and management of their disease, rather than their disease managing them. I ask, “How confident are you that you can manage whatever their primary issue is. I ask them and the family that.” I ask, “Does this disease control you, or do you control the disease?” Opening the door to the conversation. P13 Assess what they know and then work from there. Don't ever assume that the patient knows. Ask what has the doctor told you? What did you learn in the hospital? So that we can kind of take it from there. Not reinvent the wheel and not confuse them with giving different information. P14
Processes	Converse, don't interrogate	So a lot of times when we're doing an OASIS, we're able to really dig into their health history and really help them understand things. I use the OASIS as a springboard for deeper questions... So we just kind of get into more of a conversation. P18
	Follow-up on patient cues	To do a good assessment, you have to combine your critical thinking with empathy. You have to pick up on the patient's cues. P11 I usually take cues from the patients. So whatever issue they identify, I just kind of listen and further develop that until it's kind of done. Because I sometimes think if you don't listen to them, they can't hear you at all. P12