THE PROVISION OF PERSON-CENTRED CARE IN MENTAL HEALTH CARE SETTINGS THROUGH RECREATION THERAPY PROFESSIONALS DEVAN MARK JOSEPH MCNEILL, MA, CTRS Master of Arts, University of Waterloo, 2014 A manuscript-based thesis submitted in partial fulfilment of the requirements for the degree of DOCTOR OF PHILOSOPHY in POPULATION STUDIES IN HEALTH Faculty of Health Sciences University of Lethbridge LETHBRIDGE, ALBERTA, CANADA ©Devan Mark Joseph McNeill, 2025 THE PROVISION OF PERSON-CENTRED CARE IN MENTAL HEALTH CARE SETTINGS THROUGH RECREATION THERAPY PROFESSIONALS DEVAN MARK JOSEPH MCNEILL Date of Defence: November 18, 2025 Dr. Sienna Caspar Associate Professor Ph.D. Thesis Supervisor Dr. James Sanders Associate Professor Ph.D. Thesis Examination Committee Member Dr. Lisa Howard Assistant Professor Ph.D. Thesis Examination Committee Member Dr. Robert Kossuth Associate Professor Ph.D. Internal External Examiner Department of Kinesiology & Physical Education Faculty of Arts and Science Dr. Bryan McCormick Professor Ph.D. External External Examiner Department of Health and Rehabilitation Sciences College of Public Health Temple University Dr. Julia Brassolotto Associate Professor Ph.D. Chair, Thesis Examination Committee iii DEDICATION This dissertation is dedicated to my family. As the first to reach this milestone, I owe this achievement to your patience, love, and unwavering belief in me, even in the moments when I doubted myself. Your support has been my foundation. To my loving partner, Bradley, thank you for the countless conversations, the many adjustments in our lives, and your steadfast encouragement as I worked to complete this degree. I extend my sincere gratitude to my supervisor, Dr. Sienna Caspar, whose guidance, wisdom, and support have shaped not only this work but also my growth as a researcher. I am deeply appreciative of my committee members, Drs. Lisa Howard and James Sanders, for their thoughtful engagement, encouragement, and contributions that strengthened this project in meaningful ways. I also wish to thank my external examiners, Drs. Bryan McCormick and Robert Kossuth, for their insights, questions, and willingness to take part in this process. To my colleagues and friends, thank you for the conversations, the laughter, the shared struggles, and the moments of encouragement that sustained me throughout this journey. Your presence made this work both possible and deeply enriching. iv ABSTRACT This manuscript-based thesis explores the complex dynamics that shape the practice of recreation therapy (RT) within mental health care settings in Western Canada, focusing on person-centred care (PCC), patient privileges, and the staffing practices of RT professionals. It aims to clarify how these factors interact to shape the quality of care and the experiences of both RT professionals and patients. In the first manuscript, a concept analysis was conducted to define and analyze the concept of PCC. This analysis identified five key attributes of PCC: care tailored to the person, active engagement, clear communication and active listening, a holistic perspective, and empathy and compassion. These findings emphasized the importance of fostering an environment that prioritizes personhood, highlighting the need for increased time with patients and the promotion of active listening. The second manuscript utilized institutional ethnography (IE) as a method of inquiry to examine how institutional practices surrounding patient privileges impact RT professionals’ work. By analyzing data from institutional texts and 18 in-depth interviews, this research revealed that institutional practices around patient privileges influence RT professionals’ ability to engage with patients and maintain therapeutic effectiveness. The study identified that variations in practices impacted patient and professional autonomy, privilege assignment, and patient attendance in RT programs. In the final manuscript, IE was used as a method of inquiry to investigate managerial structures and staffing practices that influence the work of RT professionals. Findings from this study suggest that managerial support, well-defined roles, and consistent staffing are essential to improving both the work environment for RT professionals and the quality of care provided to patients. Together, findings from these studies highlight the need for integrated approaches to mental health care that prioritize PCC, ensure clear and consistent institutional practices around patient privileges, and v address staffing challenges. This thesis contributes to a deeper understanding of how organizational and relational dynamics in mental health care can be optimized to improve both patient outcomes and professional well-being. vi CONTRIBUTIONS OF AUTHORS The manuscript presented in Chapter 2, Person-Centred Care in Canadian Mental Health Settings: A Concept Analysis, is the result of a collaborative effort. I acknowledge the significant contributions of Drs. Caspar, Sanders, and Howard. In particular, Dr. Caspar contributed to the conception of the study, data analysis, manuscript drafting, and provided overall supervision. Drs. Sanders and Howard contributed to the study’s conception and manuscript drafting. This manuscript has been submitted to a Canadian mental health journal for publication, with me as the primary author and Drs. Caspar, Sanders, and Howard as co-authors. The manuscripts presented in Chapter 3, The Impact of Patient Privilege Policies on Recreation Therapy Practice in Mental Health Care, and Chapter 4, Exploring Management Structures and Staffing Practices in Recreation Therapy: Challenges and Insights from Mental Health Settings, have not yet been submitted for publication. These chapters also reflect collaborative work with Drs. Caspar, Sanders, and Howard. The co-authors contributed to study conception, data analysis, and manuscript drafting. As with Chapter 2, I will be the primary author of these manuscripts, with Drs. Caspar, Sanders, and Howard listed as co-authors. vii ETHICS STATEMENT The work described in this thesis received research ethics approval from the University of Alberta Research Ethics Board, Project Name “THE PROVISION OF PERSON-CENTRED CARE IN MENTAL HEALTH CARE SETTINGS THROUGH RECREATION THERAPY PROFESSIONALS”, No. Pro00127334, March 31st, 2023. viii USE OF GENERATIVE AI The use of Grammarly and ChatGPT, both generative artificial intelligence tools, played a significant role in supporting the presentation of this thesis. Its primary function was to assist with grammar checks and offer synonym recommendations. It is important to note that ChatGPT was not employed to generate new content or ideas; rather, it was used to refine and diversify the author’s existing writing, enhancing clarity and variation in expression. ix TABLE OF CONTENTS Dedication ...................................................................................................................................... iii Abstract .......................................................................................................................................... iv Contributions of Authors ............................................................................................................... vi Ethics Statement............................................................................................................................ vii Use of Generative AI ................................................................................................................... viii List of Tables ................................................................................................................................ xii List of Figures .............................................................................................................................. xiii List of Abbreviations ................................................................................................................... xiv Chapter 1: Introduction ....................................................................................................................1 Discovering a Problematic ...........................................................................................................4 From Compliance to Critique: My Journey in Mental Health RT Practice .............................4 Recreation Therapy ......................................................................................................................7 My Standpoint ..............................................................................................................................9 Institutional Ethnography .............................................................................................................9 IE: Central Concepts ..................................................................................................................11 Ruling Relations .....................................................................................................................11 Social Relations ......................................................................................................................11 Texts .......................................................................................................................................12 Purpose and Significance of the Study ...................................................................................13 Study Aim and Research Questions .......................................................................................13 Organization of Chapters ........................................................................................................13 References ......................................................................................................................................15 Chapter 2: Person-Centred Care in Canadian Mental Health Settings: A Concept Analysis ........17 Abstract ..........................................................................................................................................17 Introduction ....................................................................................................................................18 Methods..........................................................................................................................................21 Step 1: Select a Concept .............................................................................................................22 Step 2: Determine the Aims .......................................................................................................22 Step 3: Uses of the Concept .......................................................................................................23 Findings..........................................................................................................................................24 Step 4: Defining Attributes ........................................................................................................25 Care Tailored to the Person ....................................................................................................26 x Actively Engaged ...................................................................................................................27 Clear Communication and Active Listening ..........................................................................27 Holistic Perspective ................................................................................................................28 Empathy and Compassion ......................................................................................................29 Step 5: Model Case ....................................................................................................................29 Step 6: Borderline Case ..............................................................................................................30 Step 7.1: Antecedents .................................................................................................................31 Step 7.2: Consequences ..............................................................................................................32 Step 8: Empirical Referents ........................................................................................................32 Discussion ......................................................................................................................................34 Limitations .................................................................................................................................36 Conclusion .....................................................................................................................................36 References ......................................................................................................................................38 Chapter 3: The Impact of Patient Privilege Policies on Recreation Therapy Practice in Mental Health Care ....................................................................................................................................42 Abstract ..........................................................................................................................................42 Introduction ....................................................................................................................................43 Methods..........................................................................................................................................46 Setting .........................................................................................................................................48 Sample ........................................................................................................................................48 In-Depth Interviews ....................................................................................................................49 Texts ...........................................................................................................................................50 Data Analysis .............................................................................................................................51 Findings..........................................................................................................................................52 Assigning Privileges: Implications on Safety and Patient Autonomy .......................................54 Privileges Impacting the Assessment Process in RT .................................................................58 Regulating RT Attendance .........................................................................................................61 Discussion ......................................................................................................................................67 Limitations .................................................................................................................................71 Conclusion .....................................................................................................................................71 References ......................................................................................................................................72 Chapter 4: Exploring Management Structures and Staffing Practices in Recreation Therapy: Challenges and Insights from Mental Health Settings ...................................................................74 Abstract ..........................................................................................................................................74 Background ....................................................................................................................................75 xi Methods..........................................................................................................................................77 Setting .........................................................................................................................................77 Sample ........................................................................................................................................78 Data Collection and Analysis .....................................................................................................79 Findings..........................................................................................................................................81 The Importance of Managerial Awareness and Support ............................................................81 The Impact of Managerial Support on Staffing Coverage Practices in RT Services .................84 The Impact of Staffing Practices on Short-Staffing and Understaffing in RT Services ............88 Discussion ......................................................................................................................................91 Limitations .................................................................................................................................94 Conclusion .....................................................................................................................................94 References ......................................................................................................................................96 Chapter 5: Summary and Synthesis ...............................................................................................99 Summaries and Synthesis of Findings .......................................................................................99 Implications for Mental Health Services .....................................................................................103 Original Contributions of the Study .............................................................................................104 Directions for Policy and Practice ...............................................................................................105 References ....................................................................................................................................108 Appendix 1: Primary Studies Table .............................................................................................109 Appendix 2: Other Peer-Reviewed Literature Table ...................................................................112 Appendix 3: Introduction Letter ..................................................................................................113 Appendix 4: Recruitment Letter ..................................................................................................115 Appendix 5: Participation Consent Form ....................................................................................116 Appendix 6: Interview Guide .......................................................................................................119 xii LIST OF TABLES Table 1: Search Results ..................................................................................................................24 Table 2: Site Characteristics and Institutional Structures ..............................................................53 xiii LIST OF FIGURES Figure 1: PRISMA data search and selection process ...................................................................25 xiv LIST OF ABBREVIATIONS IE Institutional Ethnography PCC Person-Centred Care RT Recreation Therapy 1 CHAPTER 1: INTRODUCTION Mental disorders affect one in every eight people worldwide (WHO, 2022) and one in seven Canadians (Public Health Agency of Canada, 2020). The World Health Organization (WHO, 2022) defines mental disorders as a condition that has clinically significant disturbances in thinking, emotional regulation, or behaviour. For example, individuals with schizophrenia may experience disturbances with hallucinations or delusions. These disturbances can cause significant distress and impair functioning in various areas, including social, occupational, and other activities, for individuals (Public Health Agency of Canada, 2020). Despite advancements in prevention and treatment, persons with mental disorders experience stigma, discrimination, and human rights violations (WHO, 2022). Globally, health systems are failing to respond to the increased needs of people with mental disorders, prompting the World Health Organization (2022) to call for the expansion and improvement of mental health services. The recovery model has gained prominence in Canadian mental health services, shifting the focus from simply treating the patient to caring for the whole person (Alberta Health, 2017). It is important to distinguish this model from the recently introduced Alberta Recovery Model under the Compassionate Intervention Act (Government of Alberta, 2025), which centres on mandatory treatment for persons with substance use and addiction issues. Critics argue that this approach may risk (re)traumatization (Duggan, 2025). In contrast, this thesis adopts the recovery model as outlined by Alberta Health (2017), which prioritizes individual autonomy and supports self-directed decision-making in the recovery process. Alberta Health Services defines recovery-oriented care as an approach that emphasizes working in collaboration with individuals to honour their choices, autonomy, dignity, and self- determination—moving beyond just symptom management (Alberta Health Services, 2020). In 2 its report, Valuing Mental Health: Next Steps (Alberta Health, 2017), Alberta Health promotes the use of person-centred care (PCC) as part of the shift towards the recovery model. PCC places the person receiving care at the centre of all health interventions and decisions and has been labelled as a more holistic approach to care than others, such as the medical model approach to care (Hebblethwaite, 2013). Person-centredness recognizes a person’s individuality and reduces the authoritative relationship that may result from seeing the person as a patient (Slater, 2006). The Mental Health Commission of Canada (2016) prioritizes the use of PCC to improve the availability of quality mental health services. The concept of PCC is growing in both practice settings and research literature (McKay et al., 2021). The concept of person-centredness dates back to the 1940s, when American humanistic psychologist Carl Rogers introduced it as a moral ideal of respecting a person’s autonomy (Thórarinsdóttir & Kristjánsson, 2014). Carl Rogers was one of the first to conceptualize PCC in psychological practice, challenging traditional psychiatric approaches and asserting that individuals have the capacity to guide their own lives (Anderson, 2001). Placing the person at the centre of their care implies that they are actively involved in making decisions about their lives. In the updated Comprehensive Mental Health Action Plan report, the WHO recommends that person-centred recovery-oriented approaches be taught to general and specialized health workers (WHO, 2021a). The WHO (2021b) suggests that PCC is a comprehensive, multidisciplinary, and inclusive mental health care system approach. However, a consensus on the precise definition and implementation strategy for PCC remains elusive among provincial, national, and international organizations, allowing for significant variation in its interpretation. 3 Previous research has highlighted a gap between organizations’ public endorsement of PCC and the actual structural and cultural changes needed for its successful implementation (Hebblethwaite, 2013). McKay et al. (2021) suggest that PCC can be effectively implemented in mental health settings through clear communication, respect for individuals, and the identification of available choices, even when those choices are limited. Despite these insights, McKay et al. (2021) argue that there is insufficient evidence on how to best implement PCC across mental health systems or integrate it into policies universally. Morgan and Yoder (2012) and Slater (2006) discussed personalizing approaches to PCC that encourage decision-making and autonomy of persons in care. However, they fail to fully address the level of engagement required from individuals in the care process. Active engagement involves persons being proactive in decision-making rather than passive recipients of care (Stuart, 2017). In coercive mental health care environments—such as involuntary settings where some force is used, such as locked doors—engaging individuals in decision-making can be particularly challenging. McKay and colleagues’ (2021) scoping review of PCC in coercive settings identified ethical tensions, such as managing safety concerns and restricting choices and decisions. They propose a four-themed framework for PCC in a coercive mental health environment: (1) communication, (2) choice and control, (3) physical spaces, and (4) relationships. McKay and colleagues (2021) conducted a global literature review with limited Canadian content; therefore, this thesis offers a Canadian perspective. While guidelines for implementing PCC exist in the mental health literature, they often lack conceptual clarity and a universally accepted definition (McKay et al., 2021). In the field of recreation therapy (RT), there is also a lack of consensus on the definition of PCC (Hebblethwaite, 2013). Nevertheless, many RT professionals are eager to adopt the PCC 4 approach in their practice despite structural, systems, and policy barriers (Hebblethwaite, 2013). One consideration in providing PCC in mental health environments—particularly involuntary— includes navigating legal frameworks such as Alberta’s Mental Health Act, which restricts a person’s choice and control to manage potentially dangerous behaviours (McKay et al., 2021). These restrictions complicate the implementation of PCC, in part due to the diverse perspectives among healthcare team members. Examining the social relations within organizations may provide insights into challenges faced in shifting to PCC practices. The purpose of this thesis is to explore how the work of RT professionals is socially organized in mental health care services and how this impacts their provision of PCC. Discovering the Problematic Discovering the problematic is the starting point of inquiry and an important step in institutional ethnography (IE) studies (Rankin, 2017b). The problematic focuses on people’s experiences that require further investigation (Rankin, 2017a). The researcher must familiarize themselves with the experienced actualities to identify a problematic (Campbell & Gregor, 2008). The experienced actualities start with my years as an RT professional working in Canadian mental health services. For this inquiry, I draw on Caspar’s (2014) framework for discovering a problematic by discussing my experiences and observations as a former RT professional working in mental health services, including inpatient and community settings. These experiences have shaped my thoughts on PCC and highlighted several institutional barriers that hinder its implementation in practice. From Compliance to Critique: My Journey in Mental Health RT Practice 5 In the early stages of my career as a novice RT professional, I strictly adhered to the policies and procedures set by the mental health agency for providing care. In retrospect, I now recognize that these protocols were designed to control and prescribe treatment rather than promote individualized care. I found it alarming how easily I fell into the routine of following orders and institutional rules without question. Over time, I became increasingly uncomfortable with the highly medicalized focus of the care I was providing. I began to notice that my actions were inadvertently reinforcing a health system centred around the medical model, which was often at odds with alternative approaches such as PCC. My daily work varied greatly depending on the individuals I was supporting in the community. Some days, I would work late into the evening, accompanying individuals to local events such as baseball games. On other days, I would facilitate a leisure education program for a small group of four individuals. I advocated to my manager for flexibility in my schedule to align better with the routines of the individuals in care. As a result, I sometimes missed the daily reports—a team meeting where each person’s progress was discussed (typically held every weekday morning for an hour). By adjusting my schedule to prioritize the needs of the individuals I worked with, I challenged the team’s traditional staffing and scheduling practices. However, in my next position, I faced far less control over my work schedule. Divided between an inpatient mental health unit and a day program, I was assigned fixed hours with little opportunity to advocate for hours that suited the needs of the clients. Unlike my previous role, where I had the flexibility to adjust my hours, the rigid staffing and scheduling practices at this new agency was dictated by the team, with no flexibility for PCC. The absence of RT programs on weekends was particularly detrimental, leaving patients feeling bored, anxious, and lonely. Feedback from patients indicated that the discharge of peers on Fridays often led to feelings of 6 anger and distress that lasted through the weekend. The restrictive nature of this position left me frustrated, as I was unable to provide the holistic care that I had been able to offer in my previous role. In another experience within a mental health hospital’s day program, I was explicitly told by my manager that my role was limited to providing recreation activities—an approach that overlooked the more comprehensive aspects of RT practice. This restriction prevented me from conducting the necessary assessments to understand the individuals’ strengths, interests, needs, and capabilities. Instead of offering personalized care, I was relegated to delivering non- personalized activities designed merely to pass the time. Despite my attempts to advocate for a more person-centred approach, my efforts were stymied by my manager’s clear directive that assessments were not part of my job description, even though they were technically included. Reflecting on my experiences as an RT professional within various mental health institutions, I have come to recognize a persistent tension between institutional expectations and the principles of PCC. The problematic lies in how these institutions often prioritize rigid structures and medicalized models over individualized and holistic care. In practice, I observed how institutional constraints often limited RT’s potential to foster meaningful engagement and well-being. These constraints include inflexible scheduling, restricted scope of practice, and an undervaluation of RT services. These institutional barriers are not only obstacles to practice but also central to my research, which explores how care is structured and delivered within mental health systems. My lived experience within these systems now informs a more critical lens through which I examine institutional practices. It makes me question what is deemed “standard” or “appropriate” care, and to explore how RT can challenge these norms to better serve persons 7 in mental health settings. Ultimately, my research seeks to challenge the way things are usually done to create a system that works better for the people in care. Recreation Therapy The Canadian Therapeutic Recreation Association defines the profession as a “health care profession that utilizes a therapeutic process, involving leisure, recreation and play as a primary tool for each individual to achieve their highest level of independence and quality of life” (Canadian Therapeutic Recreation Association, 2021). They further clarify that an RT professional “uses forms of recreation, leisure, and play as treatments modalities to support purposeful and meaningful interventions that are based on individual strengths and values, and are guided by assessments” (Canadian Therapeutic Recreation Association, 2021). Genoe et al. (2021) argue that this definition of RT aligns closely with the principles of PCC, as it focuses on the individual’s strengths and holistic well-being. Therefore, RT professionals are able to use PCC as an approach that aligns with the Canadian Therapeutic Recreation Association definition. Austin (2018) suggests that the roots of RT’s are closely aligned with applied positive psychology, which shares humanistic values with PCC. According to Heyne and Anderson (2012), “Recreation and leisure are also considered strengths because of their potential to produce innumerable benefits” (p. 110). Unlike the focus on illness and outcomes (e.g., the medical model), strengths-based practice focuses on the benefits and values that recreation can provide for one’s overall well-being (Heyne & Anderson, 2012). A strengths-based approach centres on a person identifying their own goals and interventions of interest. Heyne and Anderson (2012) emphasize the importance of establishing a trusting relationship between the person and the RT professional, which facilitates collaboration and empowers the individual. 8 This trusting relationship shifts focus from an outcome-based approach to a process-based approach, which places the person seeking care at the centre of their health decisions. Literature on RT also recognizes the potential of the “person-centred model” in practice. In the Study Guide for the Therapeutic Recreation Specialist Certification Examination, Stumbo and Folkerth (2018) highlight the importance of focusing on a person’s dreams and goals, aligning with the PCC philosophy. Austin (2018) also advocates for the adoption of “person- centred therapy” in RT, linking it to positive psychology, yet he too fails to provide detailed examples of how PCC can be operationalized in RT practice. Pedlar and colleagues (2001) were among the first to suggest that the connection between RT and person-centredness had virtually no real examples. In interviewing patients about their perspectives on the role of RT professionals on the unit, Pedlar and colleagues (2001) found that “the demands of running particular programs took precedence over patient’s preferences” (p. 22). A seminal contribution to the discourse on PCC in RT is Shannon Hebblethwaite’s (2013) article in the Therapeutic Recreation Journal. Like Austin (2018), Hebblethwaite states that RT is well-positioned to adopt a person-centred approach due to its humanistic roots. However, Hebblethwaite (2013) also identifies significant structural, systemic, and policy barriers that hinder the successful implementation of PCC in practice, despite its inclusion in organizational mission statements. RT professionals in the study discussed structural barriers (e.g., scheduling bathing and eating) that conflicted with offering RT services using a PCC approach (Hebblethwaite, 2013). The practitioners also discussed administrative pressures to provide quantity rather than quality care in practice, making them feel like “statistics run the show” (p. 25). This article provides a foundation for understanding how both the institution and 9 RT professionals value person-centred care but are not empowered or enabled to fully implement it in practice. My Standpoint In IE, the standpoint refers to the point of inquiry—how things work for the individuals or groups in a particular position or site (Smith, 2006). For example, Smith (2006) discusses a study where she took the standpoint of single parenthood from the mother’s perspective. Smith highlights how IE can uncover the structures and processes that shape people’s lives and return knowledge to them about how things are organized (Carroll, 2010). Winton (2019) further emphasizes that IE researchers focus on the individuals who are engaging with them, whether through speaking, reading, or other forms of interaction. The goal of IE is to examine the tensions and contradictions that arise within institutions from the standpoint of a particular group (Rankin, 2017a). The knowledge generated from this standpoint builds an understanding of how activities are coordinated and organized (Rankin, 2017a). For this study, my standpoint was RT professionals working in mental health settings in Alberta, Canada. Institutional Ethnography I employed IE as a method of inquiry to explore the delivery of PCC in Canadian mental health services. IE is distinct from traditional methodologies and is often described as a ‘sociology for people’ (Carroll, 2010), a ‘method of inquiry’ (Carroll, 2010; Rankin, 2017b), and an ‘alternative sociology’ (Winton, 2019). Dorothy E. Smith, the founder of IE, has dedicated her career to refining this methodology, which emphasizes the lived experiences of individuals within institutional settings. Smith’s academic journey, which included completing her PhD at Berkeley and teaching at the University of British Columbia and the Ontario Institute for Studies 10 in Education (OISE) at the University of Toronto, was deeply rooted in her commitment to social change. Through her collaborations with unions, women's groups, and professional associations, Smith sought to understand and address the ways oppression functions in society (Carroll, 2010). Smith’s reflections on her sociological training led her to reconsider traditional methodologies, noting, “I remember thinking that all this sociology I’ve been learning doesn’t really seem to have anything to do with living” (Carroll, 2010, p. 15). This realization inspired the development of IE, which begins by examining the experiences of individuals directly involved in an institutional setting. Rather than focusing solely on individuals, IE investigates the social processes that shape their daily activities within institutions (Smith, 2005). In the fall of 2018, I had the privilege of attending a session co-led by Dorothy E. Smith and Susan Turner in Toronto. Smith’s enthusiasm for IE, even in her early nineties, and her dedication to teaching novice researchers left a lasting impression on me. IE is grounded in its own epistemological and ontological principles for gathering empirical evidence (Rankin, 2017a). In a conversation at the University of Victoria (October 23rd, 2017), Smith provided the rationale for IE’s unique approach. She emphasized the importance of examining participants within their ‘social structure,’ focusing on the coordination of their actions within institutions, workplaces, and organizations. This perspective led Smith to simplify IE’s ontology: it examines what people do—how their actions coordinate with those of others, including their thoughts, language, and emotions. PCC has been a central focus in prior IE research in healthcare settings. Caspar’s (2014) study, for example, used IE to explore PCC in long-term care facilities, focusing on the perspectives of resident care attendants (RCAs). Caspar (2014) found that RCAs often relied on their own skills and assessments rather than consulting residents’ care plans. Additionally, the 11 lack of access to team members for sharing resident information emerged as a significant barrier. Through IE, Caspar uncovered how the social organization of long-term care facilities shaped the delivery of care. IE: Central Concepts Institutional Ethnography relies on several core concepts to guide research projects. In my study, I focused on three central concepts: ruling relations, social relations, and texts. Ruling Relations Ruling relations are social relations established by those in power, often operating at a distance from the local site (Rankin, 2017a). These relations shape how work is carried out at the standpoint level and how it is represented. Ruling relations often remain hidden, even to the workers involved. For instance, in my experience, my manager set the work schedule for RT professionals to align with the schedules of other allied health staff. This ruling—imposed without consideration of the specific needs of the individuals in care—illustrates how such relations govern and constrain the work of RT professionals. By using an IE approach, these hidden ruling relations can be made visible (Rankin, 2017b). Rankin (2017a) provides an example from a post-secondary institution where IE was used to uncover ruling relations within a university’s grade appeal process, which favoured faculty over students. In this case, faculty members worked to gather evidence to justify failing students, reflecting the institution’s priorities. This example illustrates how ruling relations can influence work practices, often to the disadvantage of vulnerable individuals, such as students. Social Relations 12 Smith (2005) defines social relations as more complex than typical human relationships. In IE, social relations refer to the coordination of people’s activities within organizational contexts, often without their conscious awareness (Campbell & Gregor, 2008). These activities are socially organized, and examining them reveals how individuals’ actions are purposefully coordinated within an institution. For example, in my work in mental health care, daily reports served as a formal process for team members to communicate about each client’s status. This was one of many informal instances of social relations that coordinated team members’ actions. By studying these relations, we can understand the connections that go beyond what is immediately observable. Texts In IE, texts refer to the material forms of work—such as paper, images, electronic forms, and communications—that mediate social relations (Smith, 2006). Texts are crucial in IE as they enable researchers to uncover translocal social relations that influence local practices. For example, standardized RT assessments dictate what questions are asked, how assessments are described, and their duration. Texts shape and coordinate people’s activities in ways that may not always be visible or fully understood by the workers themselves. Boss texts are a specific category of texts that facilitate large-scale ruling relations within institutions (MacKinnon et al., 2020). For example, legislation and political processes in mental health services function as boss texts that control the actions of RT professionals without their input or awareness. MacKinnon and colleagues (2020) illustrate how boss texts influence healthcare practices, such as the collection and testing of laboratory samples, and how these texts similarly shape the work of RT professionals in mental health services. 13 Purpose and Significance of the Study This study investigates PCC practices among RT professionals in mental health services. By exploring the socially organized work of RT professionals, this research seeks to provide a fresh perspective on PCC and improve mental health services for individuals accessing care. Recognizing the personhood of those receiving care expands our understanding of how care is provided and perceived (Slater, 2006). This research aligns with the Mental Health Commission of Canada’s (2016) strategy to enhance mental health services, marking a pioneering investigation of PCC within the context of Canadian mental health services. Study Aim and Research Questions The aim of this study is to examine how institutional structures empower or hinder RT professionals in delivering PCC. Two research questions guide this IE study: (1) How is the work of RT professionals socially organized in mental health services? (2) How does the social organization of RT work support, enable, or impede PCC? Organization of Chapters This dissertation follows a manuscript-based format to facilitate the rapid dissemination of findings through scholarly publications. In Chapter One, I introduce the research project, outlining its purpose, significance, and guiding questions. In this chapter, I also describe the methodological approach used in Chapters Four and Five and include a personal reflection on my experiences as a former RT professional in the mental health field. In Chapter Two, I present a concept analysis of PCC in mental health settings from a Canadian perspective. Through this analysis, I identify five defining attributes of PCC, which 14 then enables me to enhance conceptual clarity of the term and offer practical implications for mental health care delivery in Canada. In Chapter Three, I employ IE to explore the influence of patient privilege policies on RT practice. Drawing on interviews with RT professionals from three sites in Alberta, Canada, this chapter highlights how variations in policy implementations impact patient and professional autonomy, privilege assignment, and patient attendance in RT programs. In Chapter Four, I use IE to explore the institutional factors influencing managerial support and staffing practices among RT professionals. The analysis illustrates how these institutional factors affect both professional experiences and the quality of care provided to clients. In Chapter Five, I conclude the dissertation by summarizing and synthesizing the key contributions of this study. In this Chapter, I reflect on the implications of this study for mental health services, highlighting the contributions of my research to the field, and propose directions for policy and practice. 15 REFERENCES Alberta Health. (2017). Valuing mental health: Next steps. Edmonton, AB: Government of Alberta. Alberta Health Services. (2020, August). Recovery-oriented care. Enhancing concurrent capability toolkit: Comprehensive interventions. Quick reference sheet. https://www.albertahealthservices.ca/assets/info/amh/if-amh-ecc-recovery-oriented- care.pdf Anderson, H. (2001). Postmodern collaborative and person‐centred therapies: What would Carl Rogers say? Journal of Family Therapy, 23(4), 339-360. Austin, D. (2018). Therapeutic recreation processes and techniques: Evidence-based recreational therapy (8th ed.). Sagamore-Venture. Campbell, M., & Gregor, F. (2008). Mapping social relations: A primer in doing institutional ethnography. University of Toronto Press Incorporated. Canadian Therapeutic Recreation Association. (2021, July). About Recreation Therapy. https://canadian-tr.org/about-recreation-therapy/ Carroll, W. K. (2010). “You are here’: Interview with Dorothy E. Smith. Socialist Studies/Etudes Socialistes, 6(2), 9-37. Caspar, S. (2014). The influence of information exchange processes on the provision of person- centred care in residential care facilities (Doctoral dissertation, University of British Columbia). Duggan, S. (2025, May 7). Compassionate Intervention Act – Our reaction. Alberta Medical Association. https://www.albertadoctors.org/news/publications/presidents- letter/compassionate-intervention-act-our-reaction/ Genoe, M. R., Cripps, D., Park, K., Nelson, S., Ostryzniuk, L., & Boser, D. (2021). Meanings of therapeutic recreation: Professionals’ perspectives. Leisure/Loisir, 45(1), 35-51. Government of Alberta (2025, May 15). Bill 53: Compassionate Intervention Act. SA 2025 cC- 21.5 Hebblethwaite, S. (2013). I think that it could work but…”: Tensions between the theory and practice of person-centred and relationship-centred care. Therapeutic Recreation Journal, 47(1), 13-34. Heyne, L. A., & Anderson, L. S. (2012). Theories that support strengths-based practice in therapeutic recreation. Therapeutic Recreation Journal, 46(2), 106-128. MacKinnon, K. R., Gomez-Ramirez, O., Worthington, C., Gilbert, M., Grace, D. (2020). An institutional ethnography of political and legislative factors shaping online sexual health service implementation in Ontario, Canada. Critical Public Health, 1-11. https://www.albertahealthservices.ca/assets/info/amh/if-amh-ecc-recovery-oriented-care.pdf https://www.albertahealthservices.ca/assets/info/amh/if-amh-ecc-recovery-oriented-care.pdf https://canadian-tr.org/about-recreation-therapy/ https://www.albertadoctors.org/news/publications/presidents-letter/compassionate-intervention-act-our-reaction/ https://www.albertadoctors.org/news/publications/presidents-letter/compassionate-intervention-act-our-reaction/ 16 McKay, K., Ariss, J., & Rudnick, A. (2021). RAISe‐ing awareness: Person‐centred care in coercive mental health care environments—A scoping review and framework development. Journal of Psychiatric and Mental Health Nursing, 28(2), 251-260. Mental Health Commission of Canada. (2016). Advancing the mental health strategy for Canada: A framework for action (2017-2022). Ottawa, ON: Mental Health Commission of Canada. Morgan, S., & Yoder, L. H. (2012). A concept analysis of person-centred care. Journal of Holistic Nursing, 30(1), 6-15. Pedlar, A., Hornibrook, T., & Haasen, B. (2001). Patient focused care: Theory and practice. Therapeutic Recreation Journal, 35(1), 15-30. Public Health Agency of Canada. (2020, October 8). Mental illness in Canada. https://health- infobase.canada.ca/datalab/mental-illness-blog.html Rankin, J. (2017a). Conducting analysis in institutional ethnography: Analytical work prior to commencing data collection. International Journal of Qualitative Methods, 16, 1-9. Rankin, J. (2017b). Conducting analysis in institutional ethnography. Guidance and cautions. International Journal of Qualitative Methods, 16, 1-11. Slater, L. (2006). Person-centredness: A concept analysis. Contemporary Nurse, 23(1), 135-144. Smith, D. E. (2005). Institutional ethnography: A sociology for people. Rowman & Littlefield Publishers, Inc. Smith, D. E. (2006). Institutional ethnography as practice. Rowman & Littlefield Publishers, Inc. Stuart, H. (2017). What we need is person-centred care. Perspectives on Medical Education, 6(3), 146-147. Stumbo, N. J., & Folkerth, J. E. (2018). Study guide for the therapeutic recreation specialist certification examination (5th ed.). Sagamore-Venture. Thórarinsdóttir, K., & Kristjánsson, K. (2014). Patients’ perspectives on person-centred participation in healthcare: A framework analysis. Nursing Ethics, 21(2), 129-147. World Health Organization. [WHO] (2021a). Comprehensive mental health action plan 2013– 2030. Geneva: World Health Organization. World Health Organization. [WHO] (2021b, August 31). Mental health and forced displacement. https://www.who.int/news-room/fact-sheets/detail/mental-health-and-forced-displacement World Health Organization. [WHO] (2022, July 12). Mental disorders. https://www.who.int/news-room/fact-sheets/detail/mental-disorders Winton, S. (2019). Coordinating policy layers of school fundraising in Toronto, Ontario, Canada: An institutional ethnography. Educational Policy, 33(1), 44-66. https://health-infobase.canada.ca/datalab/mental-illness-blog.html https://health-infobase.canada.ca/datalab/mental-illness-blog.html https://www.who.int/news-room/fact-sheets/detail/mental-health-and-forced-displacement https://www.who.int/news-room/fact-sheets/detail/mental-disorders 17 CHAPTER 2: PERSON-CENTRED CARE IN CANADIAN MENTAL HEALTH SETTINGS: A CONCEPT ANALYSIS ABSTRACT Background: Despite its widespread use in health literature, there is limited understanding of person-centred care (PCC), especially in Canadian mental health settings. Aim: This paper aimed to clarify the concept of PCC for a more comprehensive understanding in the context of Canadian mental health settings. Methods: An eight-step concept analysis was completed to clarify the understanding of PCC. Findings: This analysis identified five defining attributes: care tailored to the person, active engagement, clear communication and active listening, a holistic perspective, and empathy and compassion. Implications for practice include changes to the mental health system by prioritizing time with persons in care, providing more choices, and demonstrating active listening. By recognizing personhood in care practices, practitioners can improve their ability to understand how care is perceived and provided. Keywords: Canada, Defining Attributes, Mental Health Disorders, Person-Centred Care 18 INTRODUCTION Person-centred care is a frequently used term in healthcare literature, particularly older adult literature (Slater, 2006). Although the term person-centred care (PCC) is widely used, the concept is elusive and lacks a consensus understanding (Allerby et al., 2022; Edvardsson et al., 2008; Håkansson et al., 2019). This is particularly true in mental health settings, where there is a recognized lack of conceptual understanding of what characterizes PCC (McKay et al., 2021). A lack of consensus understanding of PCC can make it difficult to measure care outcomes and implement the approach in practice (Burgers et al., 2021). The concept of PCC can be traced back to American humanistic psychologist Carl Rogers’ work from the 1940s (Thórarinsdóttir & Kristjánsson, 2014). Rogers developed the nondirective approach to psychotherapy, which places the person at the centre of their care (Kirschenbaum & Jourdan, 2005). PCC focuses on the person’s individual needs and goals by recognising and respecting the whole person—beyond just their illness or condition (Cloninger & Cloninger, 2011). PCC has since become a concept used internationally. Healthcare systems across the globe are transitioning towards a more PCC approach (Santana et al., 2018). Mental health literature from Australia, Sweden, the United Kingdom, and the United States all use the concept of PCC (Gabrielsson et al., 2015). Even though there is a global use of the concept, mental health literature on person-centred care is sparse in the Canadian context. Many mental health services may purport to implement PCC, yet often lack a comprehensive understanding of the concept. Delivering PCC in these settings involves significant tensions, such as balancing client safety with respecting autonomy in treatment decisions (Gask & Coventry, 2012; McKay et al., 2021). These tensions are particularly evident in the use of involuntary or coercive procedures, which pose substantial challenges to fully 19 realising PCC in practice (McKay et al., 2021). Despite this, Allerby et al. (2022) found that such procedures were not always perceived as barriers to PCC, even though historically, coercive approaches have contributed to the disempowerment and devaluation of persons receiving care (Barker, 2001). Implementing PCC in mental health settings, especially those involving coercion, is therefore essential to improving care quality, though it requires a fundamental transformation of mental health services (Gabrielsson et al., 2015). One objective of the Advancing the Mental Health Strategy for Canada: A Framework for Action (2017-2022) by the Mental Health Commission of Canada (2016) prioritizes access to PCC to improve the availability of quality mental health services. However, the objective fails to offer an explanation of what PCC is and how to implement it. There is an assumption that healthcare practitioners are knowledgeable about PCC and understand how to implement it, particularly in disciplines where PCC is embedded in standards of practice, such as Nursing (Registered Nurses’ Association of Ontario, 2015), Pharmacy (Alberta College of Pharmacy, 2025), and Recreation Therapy (Canadian Therapeutic Recreation Association, 2023). However, Allerby and colleagues’ (2022) study found that practitioners had difficulty defining PCC, even after years of attempting to implement it. With a lack of understanding, Schwind and colleagues (2014) found that mental health healthcare practitioners do not have time or space to determine if their practice is person-centred. Canada has a unique structure and organization of health services, including mental health services (Jenkins et al., 2022). Health care delivery is primarily the responsibility of provincial and territorial governments, resulting in some variation across regions (Jenkins et al., 2022). This uniqueness offers strengths and challenges to persons seeking care. One challenge is that Canadian mental health care has been labelled as a “patchwork” of services and programs 20 with a lack of interconnection and integration (Jenkins et al., 2022). In a comparison between Australia and Canada, the mental health settings significantly differ concerning a person’s autonomy in refusing treatment (Gray et al., 2010). For example, in some Canadian provinces, involuntary patients have the right to refuse treatment (Gray et al., 2010), suggesting that although there are similarities between developed countries, differences in mental health services exist. Differences also extend to the purpose of the involuntary admission process between the two countries (Gray et al., 2010). The right to refuse treatment for involuntary patients may be seen as a strength of the Canadian mental health system. However, the Alberta Government recently introduced legislation under the Compassionate Intervention Act that could undermine the right to refuse involuntary treatment—a practice considered high-risk and lacking high- quality evidence to support or refute its effectiveness (Ritchie, 2025, June 3). Thus, these differences and the uniqueness of the Canadian mental health system offer a need to focus on the further exploration of only Canadian literature. There is value in exploring the actual and possible uses of concepts that create meaning for healthcare practitioners and consumers of mental health services. Breaking down a concept into its elements can assist in determining the internal structures of the concept (Walker & Avant, 2011). We form these concepts by learning the uses of words and by seeing what we understand of words (Wilson, 1963). The use and understanding of words act both as guides to forming concepts and as tests of concepts when formed. To analyze a concept is to present different uses of the word in different real-life contexts (Wilson, 1963). A concept analysis is an intellectual deep dive into how literature connects language to meaning or doing (Schiller, 2018). It is a systematic and rigorous process that allows researchers to explore the basic elements of a concept, including its function and structure (Schiller, 2018). 21 “Concepts provide the ability to categorize, organize, label, discuss, and, consequently, to study phenomena of interest in the discipline” (Rodgers et al., 2018, p. 456). Each concept is categorized into key attributes for enhanced understanding, distinguishing it from similar or related concepts. A concept analysis aims to clarify a poorly understood concept and establish it as a worthwhile phenomenon to be addressed effectively through practice (Schiller, 2018). This concept analysis focuses on person-centred care to recognize a person’s individuality—a meaningful life beyond just functioning, and see the person as active in their care. This analysis of PCC is contextualized in Canadian mental health settings. Adding context when examining a concept can deepen the understanding of the everyday routines, language, interrelationships, and discourses of healthcare practitioners who use the concept (Jakimowicz & Perry, 2015). The purpose of this paper is to clarify the concept of PCC for a more comprehensive understanding in the context of Canadian mental health settings. Without a shared understanding of PCC, efforts to implement it may be inconsistent, especially in coercive and involuntary settings. A clearer conceptualization can help healthcare practitioners align with standards of practice, prioritize PCC approaches and policies, and better recognize the personhood of those in care. Therefore, this concept analysis has direct implications for clinical practice, education, and policy. METHODS This paper used the modified Wilson Method concept analysis by Walker and Avant (2011), an eight-step, iterative process. The first four steps are: select a concept, determine the aims, identify all uses of the concept, and determine the defining attributes. The fifth step 22 includes identifying a model case, which often outlines a clinical situation demonstrating each defining attribute. The sixth step is to identify a borderline case to help clarify the prerequisite defined attributes. The seventh step is to identify antecedents (something that comes before) and consequences of the concept. The final step is to define empirical referents—ways to recognize or measure the attributes. Step 1: Select a Concept Researchers are encouraged to select a topic of interest that is relevant to their professional practice or field (Schiller, 2018). I have selected to focus on person-centred care in this paper because, despite being referenced in various Canadian healthcare standards (Registered Nurses’ Association of Ontario, 2015; Alberta College of Pharmacy, 2025), particularly within the field of recreation therapy (Canadian Therapeutic Recreation Association, 2023), it remains ambiguously defined in the context of Canadian mental health literature. Step 2: Determine the Aims A comprehensive review of peer-reviewed mental health articles can provide an optimal understanding of PCC. For the second step of the concept analysis, Schiller (2018) suggests a deeper reflection on the overall purpose of the analysis. Burgers and colleagues (2021) discussed the difficulty of assessing PCC due to the heterogeneity of definitions, interventions, and outcomes. This analysis aims to clarify the concept of PCC, delineate its attributes, and identify ways it is measured. By doing so, this analysis seeks to contribute to mental health theory by providing a more unified conceptual framework for PCC, and to clinical practice by identifying measurable components that can guide implementation, evaluation, and improvement of person- centred approaches in mental health care. 23 Step 3: Uses of the Concept Researchers are encouraged to consider all uses of the concept (Walker & Avant, 2011). During the initial search process, the term patient-centred care surfaced as a variation and, at times, was considered a synonym for PCC. However, after further exploration of the two terms, it became apparent the difference between patient and person was significant. PCC broadens the perspective of patient-centred care by aiming to live a meaningful life beyond focusing solely on functional well-being (Burgers et al., 2021; Håkansson et al., 2019). PCC recognizes the person and their active role beyond the “patient” status (Coulombe et al., 2016). Person-centredness requires a shift in how healthcare practitioners see the people they work with. Person-centredness recognizes a person’s individuality and reduces the authoritative relationship that may result from seeing the person as a patient (Slater, 2006). Thus, only the concept of PCC was explored for this analysis. An extensive search was conducted to identify PCC in Canadian mental health settings from the following databases: APA PsycINFO (OvidSP), Psychiatry Online (APA), PubMed (U.S. National Library of Medicine), Academic Search Complete (EBSCO), CINAHL Plus (EBSCO), and ProQuest Nursing & Allied Health Premium (ProQuest). The literature search was limited to studies published between 2000 and 2024. A further search for sources was conducted using Google Scholar and reference lists of relevant papers. Inclusion criteria for the search included peer-reviewed sources written in English. PCC in settings other than mental health services and articles outside Canada were excluded. Truncation was used to search for multiple derivatives of root words (see Table 1). 24 Table 1 Search results. #1 Canad* #2 Mental health OR mental illness OR mental disorder OR psychiatric illness #3 #1 and #2 #4 Person-Cent* #5 #3 and #4 FINDINGS The extensive search and selection process for relevant articles resulted in 17 peer- reviewed articles in the concept analysis (Figure 1). Of the 17 articles, 11 were empirical research with quantitative, qualitative, and mixed-methods designs (see Appendix 1). Six empirical research articles targeted the experiences of persons with mental disorders (e.g., depression), while the remaining five explored the experiences of practitioners. The most common practitioner profession in the empirical research articles was nursing. The non-empirical articles accounted for six of the 17 relevant articles on PCC (see Appendix 2). These articles included discussion, commentary, scoping review, open forum, and descriptive. Full-text articles were excluded if they did not originate from Canada, did not address person-centred care, or were not conducted within mental health settings. 25 Figure 1 PRISMA data search and selection process. Step 4: Defining Attributes Discovering a concept’s defining attributes is what Walker and Avant (2011) describe as the heart of concept analysis. This process involves scanning the literature to identify the most frequently used characteristics (i.e., words or phrases) on PCC. All keywords or phrases are gathered and combined based on the exact same or functionally equivalent uses (Schiller, 2018). I identified the initial 12 characteristics found in the 17 articles, which were numbered and organized using Microsoft Excel. Following the guidelines of Walker and Avant (2005), these characteristics were then reduced to the smallest number that still adequately differentiate the Records indentified through database searching (n=366) Duplicate records removed before screening (n=89) Records screened (n=277) Full-text articles assessed for eligibility (n=32) Studies included in concept analysis (n=17) Full-text articles excluded, with reasons (n=15) Records excluded (n=245) 26 concept from another similar or related one. This reduction process involved transforming the combined characteristics into defining attributes, by naming the occurrence of a specific phenomenon (Walker & Avant, 2005). As a result, I initially identified six defining attributes. Through collaborative review and discussion among my supervisor and committee members, this number was reduced to five. In accordance with guidelines recommending the smallest possible set of attributes, we determined that two of the original attributes were functionally equivalent and therefore combined them. The final five defining attributes reflect the most commonly associated characteristics of PCC in the analyzed literature. These attributes form the foundation for a clearer understanding of the concept and serve as a basis for future theoretical or empirical work. Based on this analysis, the following attributes of PCC in Canadian mental health settings include (a) Care tailored to the person, (b) Active engagement, (c) Clear communication and active listening, (d) Holistic perspective, and (e) Empathy and compassion. The following section explores each of these attributes in detail. Care Tailored to the Person Care tailored to the person begins with taking time to know who the person is as an individual (Schwind et al., 2014; Stuart, 2017; Suen, 2016) and assessing their strengths, preferences, and needs (Kopalo, 2017; Martin et al., 2009; Oades et al., 2009). Knowing who the person is and what care works best for them is the focus of this attribute. Each person has different goals, strengths, and capacities (Schwind et al., 2014), which can conflict with the practitioner’s suggested care treatment (Stergiopoulos et al., 2024). A key characteristic of care tailored to the person includes respecting the wishes and preferences of persons in care (Lindsay & Schwind, 2015; McKay et al., 2021), even if they conflict with the practitioner’s suggestions 27 or preferences. Finally, after assessing and respecting the person’s wishes, care plans need to remain flexible based on the strengths, goals, and stage of recovery that the person is in (Thomson et al., 2019). Active Engagement The person in care must be an active part of the care process. Stuart (2017) suggests that the person is not a “passive recipient of care” but actively engaged in the care process. Thus, the person in care sets the direction of the care and therapy (Josefowitz & Myran, 2005). Having an active role in care involves shared decision-making related to care (Stergiopoulos et al., 2024) and collaborative involvement in care planning and rehabilitation (Thomson et al., 2019). A partnership exists between the mental health practitioners and the person in care working towards a common goal (Coulombe et al., 2016; Schwind et al., 2014). This partnership is based on a collaborative (Kolapo, 2017; Oades et al., 2009) and therapeutic relationship (Josefowitz & Myran, 2005) built on trust and safety in mental health settings (Suen, 2016). One of the partnership’s focuses is preventing further deconditioning of people in care (Lindsay & Schwind, 2015). Having a voice and choice in the care plan is particularly important for the person in care in restrictive environments such as mental health settings (Thomson et al., 2019). The person in care has an active role in steering the direction towards their own recovery. Clear Communication and Active Listening Another characteristic of PCC involves using accessible language when mental health practitioners are communicating with people in care (O’Neill et al., 2024). Communication needs to be clear about the situation or circumstances involved in the care process; for example, helping the person in care comprehend difficult to understand aspects of the medical chart 28 (McKay et al., 2021). Listening was listed in several articles (Corbiere et al., 2012; Guilcher et al., 2016; O’Neill et al., 2024; Stergiopoulos et al., 2024; Suen, 2016; Thomson et al., 2019) as an important characteristic of providing PCC. Listening is an active and ongoing process between the mental health practitioner and the person in care (Corbiere et al., 2012; O’Neill et al., 2024; Thomson et al., 2019). Active listening was described as an opportunity for people to talk, which had a high degree of value for those seeking care (Guilcher et al., 2016). Feeling heard is part of the therapeutic process (O’Neill et al., 2024) and leads to efficient and effective coordination of care (Suen, 2016). The creation of this partnership is dependent upon the development of interpersonal competencies of the mental health practitioner (Stuart, 2017), such as being present and being genuine with what is real to the person in care (Josefowitz & Myran, 2005). When using a person-centred approach, listening is encouraged in one-to-one interactions in a private setting (Thomson et al., 2019), free of distractions and interruptions (Lindsay & Schwind, 2015). Communication between the practitioner and the person in care is based on respect rather than being presumptive, suspicious, or judgmental (Guilcher et al., 2016). Holistic Perspective Care focuses on the whole person rather than on individual mental health symptoms (Coulombe et al., 2016). While mental health symptoms are a significant part of mental health care, there is also a need to consider the totality of a person (Lindsay & Schwind, 2015; Martin et al., 2009; Stuart, 2017; Thomson et al., 2019). This holistic perspective of care provides a more comprehensive review of a person’s needs, including mental, emotional, spiritual, and social needs (Stuart, 2017). It considers a person’s education, employment, and housing needs (Guilcher et al., 2016). A practitioner’s consideration of a person’s strengths rather than deficits aligns with a person-centred approach (Lewis & Hasking, 2021). This holistic perspective 29 enables mental health practitioners to look beyond providing care that is only focused on the mental disorder symptoms to the totality of needs of people seeking care. Empathy and Compassion Mental health practitioners’ ability to empathize with people seeking care is central to the provision of PCC. Empathy involves understanding the central issues of the person (Josefowitz & Myran, 2005). Having empathy for someone means attempting to understand them and their world (Thomson et al., 2019). Along with empathy, PCC involves compassion for those seeking care (Guilcher et al., 2016; Lindsay & Schwind, 2015). Seeking support for a mental disorder can be a vulnerable experience for many persons; therefore, compassionate and empathetic interactions with practitioners are critical for person-centred engagement (Guilcher et al., 2016). Step 5: Model Case The model case, which is fictionally constructed by the authors, is created after determining the defining attributes of a concept and serves as a paradigmatic example (Walker & Avant, 2005). The following fictional model case features Noah, an individual seeking mental health support, and exemplifies the five attributes of PCC in a clinical situation. Noah voluntarily admitted himself to a psychiatry unit because of his inability to attend to his personal care needs. After a discussion with the psychiatry unit team, he also wanted to improve his ability to make friends in the community. Noah’s team listened to his new and ongoing needs and began putting together a plan of action. After determining the additional goal, the team gathered resources to support him. While talking and listening to Noah, the team noted that he felt the stigma of living with schizophrenia challenged his ability to have close friends. To ensure the team understood what happened, they spoke with Noah about how devalued he felt 30 in his previous relationships with friends. To address this concern, Noah’s team discussed opportunities to empower him to develop close friendships by encouraging him to join community leisure events. They then learned that Noah loves to run, watch sports, and spend time with animals. Thus, Noah and the team developed a plan for Noah to start volunteering at the humane society and join a local running group. The plan includes growing Noah’s support network so that when he struggles to attend to his personal care, he can reach out to them for support and resources. Noah and his team feel comfortable with the plan to address his current needs. This case study demonstrates how Noah’s care was tailored to his needs, how he was actively engaged in the process, listened to, how the team was empathetic to him, and how the care was holistic. Step 6: Borderline Case Schiller (2018) recommends that a borderline case be considered along with the model case. A borderline case contains between one and the second highest number of attributes (Schiller, 2018); thus, this paper will contain between one and four attributes. By not having all five attributes, a clinical case example can highlight the differences in care from a comprehensive PCC understanding. In the following fictionally constructed borderline case, we explore how Jamie’s care differs from Noah’s care (the model case). Jamie is a patient in a mental health unit because her neighbour called the police to conduct a wellness check due to her erratic behaviours at home. The emergency physician at the local hospital admitted Jamie involuntarily to the mental health unit. Jamie is in her mid-forties, lives alone, is passionate about hiking, and volunteers at a local art museum. The mental health team sat down with Jamie to discuss her concerns. Jamie discussed two main concerns—she feels lonely and wants more friends, and her neighbour is spying on her. Jamie discussed how 31 she spends every night alone, which she finds to be difficult for her. The team listens to Jamie and her concerns; however, they decide to focus on Jamie’s mental functioning by increasing her anti-psychotic medication. After a week of observation, the team discharged Jamie from the unit to her home. Jamie became stressed and anxious at home regarding her concerns with her neighbours, and she feels lonely every night. Jamie feels only some of her needs were met and that the team did not consider other needs she discussed with them. This case study demonstrated how Jaime was provided care and listened to, but that only some of her needs were met by the team, and a failure to see her care from a holistic perspective. Step 7.1: Antecedents Antecedents are events that must occur or be in place before PCC can exist (Schiller, 2018; Walker & Avant, 2011). A defining attribute cannot be an antecedent, but identifying any antecedents can help refine the defining attributes (Walker & Avant, 2011). Of the 17 articles analyzed in this study, nine addressed antecedents. Practitioners who are interested in PCC are encouraged to undergo adequate education and training (Thomson et al., 2019), especially concerning culturally sensitive topics such as stigma (Guilcher et al., 2016). Practitioners’ ability to be self-aware (Lindsay & Schwind, 2015; Schwind et al., 2014), having time to develop a rapport with the person in care (Schwind et al., 2014; Suen, 2016), and having the space and environment that promotes interconnectedness (Corbiere et al., 2012) are all antecedents to PCC. Lastly, having a nonjudgmental care space was listed in many articles (Josefowitz & Myran, 2005; Lewis & Hasking, 2021; Stergiopoulos et al., 2024) as a prerequisite for PCC in mental health settings. The antecedents from this analysis include areas that are the mental health agency’s responsibility, and others include the practitioner’s responsibility for continued professional development. 32 Step 7.2: Consequences Consequences are the possible outcomes of PCC or events that may transpire due to the concept’s existence (Schiller, 2018). The consequences of PCC for the person in care include general outcomes (e.g., quality of care) and specific outcomes (e.g., validation). Consequences emerged as a topic in seven of the 17 articles reviewed. First and most significantly, improving the quality of care was listed in several articles (Barbic et al., 2018; Guilcher et al., 2016; Martin et al., 2009; McKay et al., 2021) as a consequence of implementing PCC. Outcomes of PCC related to the person in care include sustained symptom reduction, a return to functioning (Barbic et al., 2018), and the prevention of any further deconditioning (Lindsay & Schwind, 2015). Other consequences of PCC include the person in care’s experiences being better validated (Lewis & Hasking, 2021) and the enhancement of coping strategies for the person in care (Thomson et al., 2019). Finally, a consequence of PCC for mental health care practitioners includes increased confidence and job satisfaction (Lewis & Hasking, 2021). In summary, the literature overwhelmingly highlights the positive and desirable outcomes associated with PCC. Notably, none of the reviewed studies reported any negative aspects or criticisms of PCC, emphasizing a strong consensus regarding its benefits. Step 8: Empirical Referents The final step of this concept analysis is determining the existing empirical referents, which are indicators of the defining attributes that can be recognized or measured (Schiller, 2018). Unfortunately, only four of the 17 analyzed articles had existing empirical referents. All four articles had indicators of the defining attributes from the healthcare practitioner perspective; 33 two from nursing (Lindsay & Schwind, 2015; Schwind et al., 2014), one from peer workers (O’Neill et al., 2024), and one from mental health staff (Thomson et al., 2019). None of the analyzed articles had existing empirical referents from the perspective of the person in care. The concept analysis highlights a significant gap in the PCC literature, which largely centres on practitioner actions and offers limited insight into the role or perspective of the person in care. However, all the defining attributes can be recognized or measured through the perspective of the person in care and perhaps their family members. The person’s satisfaction with their care would be a strong indicator for the defining attributes in this study. For example, the person in care would be able to recognize and articulate their satisfaction with their engagement in the care process. Josefowitz and Myran (2005) discuss having frequent check-ins with the person in care regarding their understanding of the care process. The care process needs to be collaborative, where the person in care is a full partner in decision-making and planning (Thomson et al., 2019). The person’s satisfaction with their care is a good indicator of the identified defining attributes of PCC. Indicators for clear communication were discussed in the analyzed articles. O’Neill and colleagues (2024) mention that practitioners who maintain neutrality when listening and use accessible language are viewed as more approachable and friendly. The practitioner’s ability to avoid medical jargon when communicating with the person in care would be another indicator of clear communication. Lindsay and Schwind (2015) provide a communication example for mental health practitioners to implement, “Person-centred care is staying really quiet, letting them [persons in care] breathe, walk, feel; don’t interpret for them but offer options” (p. 8). This example indicates the ability to recognize how a practitioner engages in active listening as part of person-centred care. 34 Aside from the person’s satisfaction with their care, practitioners are encouraged to engage in reflective practice (Lindsay & Schwind, 2015) to increase their self-awareness of their involvement in the defining attributes. For example, a practitioner reflecting on their level of understanding of the person in care’s world (i.e., empathy) would be part of their self-awareness practice. DISCUSSION This paper analyzed the concept of PCC in the context of Canadian mental health settings, contributing to the understanding of the complex challenges in using an approach to care in environments that can often be or become coercive. Using a concept analysis, this paper focused on a term’s actual and possible uses (Walker & Avant, 2011). Many familiar attributes were found between this analysis and others, such as respecting the person (Jakimowicz & Perry, 2015; Morgan & Yoder, 2012), empowering individuals (Morgan & Yoder, 2012; Slater, 2006), and holistic care (Morgan & Yoder, 2012). Although familiar attributes were revealed, this paper highlights the significance of separating and distinguishing certain attributes for greater importance, such as distinguishing clear communication and active listening as a separate, stand- alone attribute. A practitioner’s ability to prioritize talking with persons in care over other tasks and work suggests a shift in the care process (Allerby et al., 2022). Listening was also highlighted in the differences between the team’s approach to care in the model and borderline cases presented in this paper. Noah’s team made time to talk to him about his concerns, even if they changed during his stay in the hospital. In contrast, some of Jamie’s needs were overlooked, which left her feeling stressed and anxious after being discharged. Slater (2006) suggests using a consistent definition of PCC, especially in interdisciplinary healthcare settings such as mental health. The defining attributes identified in 35 this analysis could contribute to creating a definition of PCC for Canadian mental health settings. A consistent definition could enhance the communication of mental health services across Canada and, by doing so, contribute to PCC, as identified in the findings. Creating a definition from the findings could also guide the construction of person-centred research instruments or interview guides. The instruments and guides incorporating all defining attributes from this study have yet to be developed. This comprehensive review of PCC literature in Canadian mental health settings can have implications for practice. Enacting PCC can improve care, but requires transforming current inpatient psychiatry practices (Gabrielsson et al., 2015). Gask and Coventry (2012) discuss the lack of time to implement PCC in practice. The attributes of being actively engaged and listening suggest a shift in care focus to prioritize time in mental health settings. To implement PCC, time is required from the practitioner’s practice to engage meaningfully with the person in care. Prioritizing time could be part of the transformation of mental health care practices discussed by Gabrielsson and colleagues (2015). Allerby and colleagues (2022) discuss enhancing PCC in involuntary settings by providing patients with choices—for example, who is present during forced injections or which room to use. Providing choice should be part of the mental health agency’s PCC procedures. However, new person-centred procedures were at times disregarded by psychiatrists (Allerby et al., 2022), which can lead to inconsistencies in care and tensions between staff members. This analysis revealed a lack of antecedents from the mental health agency’s perspective. Research is needed to review how organizational policies, initiatives, guidelines, and legislation impact the implementation of PCC in Canadian mental health settings. 36 Given the lack of empirical referents in the literature from this concept analysis, further exploration of how the defining attributes are assessed and measured would improve our understanding of PCC. Implementing formal and informal satisfaction measures for persons in care would highlight several defining attributes of PCC, as identified in this analysis. To ensure a focus on PCC, persons in care should be involved in these satisfaction measures’ design, language, and layout. Limitations This concept analysis explicitly focused on the uniqueness of Canadian scholarly literature to explore the countries’ approach to PCC in mental health settings. This required a purposeful exclusion of PCC literature from other nations (e.g., Sweden and America). This study focused exclusively on PCC within mental health settings, which may limit the generalizability of the findings to other healthcare contexts. PCC may be shaped by different structural and interpersonal dynamics in settings such as acute or primary care, and future research is needed to examine how these findings translate across these environments. I acknowledge that by only looking at person-centred care, I excluded comparable concepts such as patient-centred care and client-centred care. The focus of this study was on the holistic term of PCC. Finally, this analysis required peer-reviewed scholarly articles for review. Thus, white and grey literature was not included. CONCLUSION Through this concept analysis, key attributes of PCC in Canadian mental health settings were identified: (a) Care tailored to the person, (b) Active engagement, (c) Clear communication and active listening, (d) Holistic perspective, and (e) Empathy and compassion. These attributes 37 help clarify the concept of PCC and provide a framework for recognizing and supporting its application in mental health practice. Having mental health practitioners recognize the personhood of the people they work with expands their understanding of how care is perceived and provided to that person (Slater, 2006). Using consistent language, attributes, and a definition of PCC will help guide mental health practitioners in exploring what matters to each person they work with. However, this analysis also revealed gaps in the literature related to the structural and systemic factors that influence the implementation of PCC, such as organizational policies and regulatory body standards. These factors can significantly shape the extent to which PCC is supported or hindered in practice and should be the focus of future research. 38 REFERENCES Alberta College of Pharmacy. (2025). Person-centred. https://abpharmacy.ca/regulated- members/practice-framework/understanding-professionalism/person-centred/ Allerby, K., Goulding, A., Ali, A., & Waern, M. (2022). Increasing person-centredness in psychosis inpatient care: Staff experiences from the Person-Centred Psychosis Care (PCPC) project. BMC Health Services Research, 22, 596. Barbic, S. P., Kidd, S. A., Durisko, Z. T., Yachouh, R., Rathitharan, G., & McKenzie, K. (2018). What are the personal recovery needs of community-dwelling individuals with mental illness? Preliminary findings from the Canadian Personal Recovery Outcome Measurement (C-PROM) study. Canadian Journal of Community Mental Health, 37(1), 29-47. Barker, P. (2001). The tidal model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8, 233-240. Burgers, J. S., van der Weijden, T., & Bischoff, E. W. M. A. (2021). Challenges of research on person-centered care in general practice: A scoping review. Frontiers in Medicine, 8, 1-9. Canadian Therapeutic Recreation Association. (2023). Standards of Practice for Recreation Therapists and Recreation Therapy Assistants. https://canadian-tr.org/wp- content/uploads/2023/08/CTRA-2023-SoP-FOR-VOTE-August-28th.pdf Cloninger, C. R., & Cloninger, K. M. (2011). Person-centered therapeutics. International Journal of Person Centered Medicine, 1(1), 43-52. Corbiere, M., Samson, E., Villotti, P., & Pelletier, J. F. (2012). Strategies to fight stigma toward people with mental disorders: Perspectives from different stakeholders. The Scientific World Journal, 1-10. Coulombe, S., Radziszewski, S., Meunier, S., Provencher, H., Hudon, C., Roberge, P., Provencher, M. D., & Houle, J. (2016). Profiles of recovery from mood and anxiety disorders: A person-centered exploration of people’s engagement in self- management. Frontiers in Psychology, 7(584), 1-21. Edvardsson, D., Sandman, P., & Rasmussen, B. (2008). Swedish language person-centred climate questionnaire–patient version: Construction and psychometric evaluation. Journal of Advanced Research, 63(3), 302-309. Gabrielsson, S., S𝑎̈venstedt, S., & Zingmark, K. (2015). Person-centred care: Clarifying the concept in the context of inpatient psychiatry. Scandinavian Journal in Caring Sciences, 29(3), 555-562. Gask, L., & Coventry, P. (2012). Person-centred mental health care: The challenge of implementation. Epidemiology and Psychiatric Sciences, 21, 139-144. Gray, J. E., McSherry, B. M., O'Reilly, R. L., & Weller, P. J. (2010). Australian and Canadian mental health acts compared. Australian & New Zealand Journal of Psychiatry, 44(12), 1126-1131. https://abpharmacy.ca/regulated-members/practice-framework/understanding-professionalism/person-centred/ https://abpharmacy.ca/regulated-members/practice-framework/understanding-professionalism/person-centred/ https://canadian-tr.org/wp-content/uploads/2023/08/CTRA-2023-SoP-FOR-VOTE-August-28th.pdf https://canadian-tr.org/wp-content/uploads/2023/08/CTRA-2023-SoP-FOR-VOTE-August-28th.pdf 39 Guilcher, S. J. T., Hamilton-Wright, S., Skinner, W., Woodhall-Melnik, J., Ferentzy, P., Wendaferew, A., Hwang, S. W., & Matheson, F. I. (2016). “Talk with me”: Perspectives on services for men with problem gambling and housing instability. BMC Health Services Research, 16, 340. Håkansson, J. E., Holmström, I. K., Kumlin, T., Kaminsky, E., Skoglund, K., Höglander, J., Sundler, A. J., Condén, E., & Meranius, M. S. (2019). “Same same or different?” A review of reviews of person-centered and patient-centered care. Patient Education and Counseling, 102, 3-11. Jakimowicz, S., & Perry, L. (2015). A concept analysis of patient‐centred nursing in the intensive care unit. Journal of Advanced Nursing, 71(7), 1499-1517. Jenkins, E., Slemon, A., Bilsker, D., & Goldner, E. M. (2022). A concise introduction to mental health in Canada (3rd ed.). Canadian Scholars. Josefowitz, N., & Myran, D. (2005). Towards a person-centred cognitive behaviour therapy. Counselling Psychology Quarterly, 18(4), 329-336. Kirschenbaum, H., & Jourdan, A. (2005). The current status of Carl Rogers and the person- centered approach. Psychotherapy: Theory, Research, Practice, Training, 42(1), 37-51. Kolapo, T. F. (2017). Culturally competent commissioning; Meeting the needs of Canada’s diverse communities: The road map to a culturally competent mental health system for all. Canadian Journal of Community Mental Health, 36(4), 83-96. Lewis, S. P., & Hasking, P. A. (2021). Understanding self-injury: A person-centered approach. Psychiatric Services, 72(6), 721-723. Lindsay, G. M., & Schwind, J. K. (2015). Arts-informed narrative inquiry as a practice development methodology in mental health. International Practice Development Journal, 5(1), 1-12. Martin, L., Hirdes, J. P., Morris, J. N., Montague, P., Rabinowitz, T., & Fries, B. E. (2009). Validating the Mental Health Assessment Protocols (MHAPs) in the Resident Assessment Instrument Mental Health (RAI‐MH). Journal of Psychiatric and Mental Health Nursing, 16(7), 646-653. McKay, K., Ariss, J., & Rudnick, A. (2021). RAISe‐ing awareness: Person‐centred care in coercive mental health care environments—A scoping review and framework development. Journal of Psychiatric and Mental Health Nursing, 28(2), 251-260. Mental Health Commission of Canada. (2016). Advancing the mental health strategy for Canada: A framework for action (2017-2022). Ottawa, ON: Mental Health Commission of Canada. Morgan, S., & Yoder, L. H. (2012). A concept analysis of person-centred care. Journal of Holistic Nursing, 30(1), 6-15. Oades, L. G., Crowe, T. P., & Nguyen, M. (2009). Leadership coaching transforming mental health systems from the inside out: The collaborative recovery model as person-centred 40 strengths based coaching psychology. International Coaching Psychology Review, 4(1), 25-36. O’Neill, M., Michalski, C., Hayman, K., Hulme, J., Steer, L., Dube, S., Diemert, L. M., Kornas, K., Schoffel, A., Rosella, L. C., & Boozary, A. (2024). “Whatever journey you want to take, I’ll support you through”: A mixed methods evaluation of a peer worker program in the hospital emergency department. BMC Health Services Research, 24(1), 147. Ritchie, S. (2025, June 3). Health minister says forced addictions treatment lacks evidence, feds won’t intervene. British Columbia Centre on Substance Use. https://www.bccsu.ca/blog/news/health-minister-says-forced-addictions-treatment-lacks- evidence-feds-wont-intervene/ Registered Nurses’ Association of Ontario. (2015). Best Practice Guideline: People-Centred Care (3rd ed.). https://rnao.ca/bpg/guidelines/people-centred-care Rodgers, B. L., Jacelon, C. S., & Knafl, K. A. (2018). Concept analysis and the advance of nursing knowledge: State of the science. Journal of Nursing Scholarship, 50(4), 451-459. Santana, M. J., Manalili, K., Jolley, R. J., Zelinsky, S., Quan, H., & Lu, M. (2018). How to practice person‐centred care: A conceptual framework. Health Expectations, 21(2), 429- 440. Schiller, C. J. (2018). Teaching concept analysis to graduate nursing students. Nursing Forum, 53(2), 248-254. Schwind, J. K., Lindsay, G. M., Coffey, S., Morrison, D., & Mildon, B. (2014). Opening the black-box of person-centred care: An arts-informed narrative inquiry into mental health education and practice. Nurse Education Today, 34(8), 1167-1171. Slater, L. (2006). Person-centredness: A concept analysis. Contemporary Nurse, 23(1), 135-144. Stergiopoulos, V., Bastidas-Bilbao, H., Gupta, M., Buchman, D. Z., Stewart, D. E., Rajji, T., Simpson, A. I. F., van Kestern, M. R., Cappe, V., Castle, D., Shields, R., & Hawke, L. D. (2024). Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: A qualitative study of patient and family perspectives. BMC Psychiatry, 24(1), 120. Stuart, H. (2017). What we need is person-centred care. Perspectives on Medical Education, 6(3), 146-147. Suen, E. (2016). Quilting stories and embracing culture: An arts-informed narrative inquiry exploring the experiences of an older Chinese Canadian immigrant with depression. University of Ontario Institute of Technology. Thomson, A. E., Racher, F., & Clements, K. (2019). Person-centered psychiatric nursing interventions in acute care settings. Issues in Mental Health Nursing, 40(8), 682-6