Client-Centred Care Questionnaire

Abstract

The Client-Centred Care Questionnaire (CCCQ; in Dutch: Vragenlijst Cliëntenperspectief op vraaggerichtheid van de zorg) is a standardized psychometric instrument designed to evaluate the degree to which home care nursing and support services align with the needs, preferences, and values of clients. Developed by Luc P. de Witte, Trijntje Schoot, and Irena Proot in 2006, the instrument addresses a critical gap in health services research by translating the theoretical tenets of person-centered care into an empirically measurable patient-reported experience measure (PREM). The scale comprises 15 items administered across a 5-point Likert-type frequency metric ranging from 1 (“[almost] never / [bijna] nooit”) to 5 (“[almost] always / [bijna] altijd”). Psychometric evaluations demonstrate a robust single-factor or coherent multidimensional structure representing core domains of responsive care, including interpersonal communication, client autonomy, information provision, respect for privacy, professional competence, and care coordination. Field investigations consistently report high internal consistency (Cronbach’s α typically ranging between .86 and .93), satisfactory test-retest reliability, and robust construct validity supported by significant correlations with overall care satisfaction, therapeutic alliance, and perceived quality of life. The CCCQ serves as a pivotal metric for clinical quality assurance, organizational accreditation, and comparative health systems research in community and domiciliary nursing contexts.

Keywords

Client-Centred Care Questionnaire, CCCQ, person-centered care, home healthcare, patient-reported experience measure, PREM, psychometrics, nursing assessment, client autonomy, shared decision-making, quality of care, chronicity

Authors

The Client-Centred Care Questionnaire was developed through a collaborative health services research program in the Netherlands led by:

• Luc P. de Witte, PhD: Professor of Health Services Research and Technology in Healthcare. Formerly affiliated with CAPHRI Care and Public Health Research Institute at Maastricht University, Netherlands, and later Chair in Health Services Research at the University of Sheffield, United Kingdom.
• Trijntje (Trudy) Schoot, PhD, RN: Senior healthcare researcher and nurse scientist specializing in quality of care, nursing ethics, and client-centered practices in community nursing. Affiliated with Zuyd University of Applied Sciences and Maastricht University.
• Irena M. Proot, PhD: Health scientist and qualitative-quantitative methodologist with extensive research in stroke rehabilitation, home care models, and patient empowerment at Maastricht University.

Purpose

The primary objective of the Client-Centred Care Questionnaire (CCCQ) is to quantify the extent to which professional home care services adhere to the principles of client-centeredness from the experiential perspective of the recipient. In modern healthcare systems, the shift from disease-centric, paternalistic care paradigms toward participatory, demand-driven (shared decision-making) models necessitates reliable measurement tools capable of capturing whether individual care delivery genuinely reflects the client’s authentic daily routines, subjective preferences, and psychosocial needs.

Specifically designed for community-dwelling adults and older individuals managing chronic illnesses, physical disabilities, or age-related frailty, the CCCQ assesses the behavioral indicators exhibited by registered nurses, licensed practical nurses, and certified home care aides. Historically, quality in home care was dominated by provider-driven metrics such as protocol compliance, visit punctuality records, or global satisfaction surveys. However, generic satisfaction scales often suffer from severe ceiling effects and lack actionable diagnostic feedback. The CCCQ resolves these methodological limitations by evaluating discrete, observable behaviors—such as whether professionals listen actively, consult the client regarding interventions, respect personal boundaries, and support functional independence.

In clinical practice and healthcare governance, the CCCQ is utilized for:

• Quality Improvement (QI) and Auditing: Identifying organizational blind spots where care delivery diverges from patient-articulated goals, thereby guiding targeted professional development and continuing nursing education.
• Comparative Health Services Research: Evaluating the impact of integrated care pathways, novel self-management interventions, or community nursing staffing models (such as the Buurtzorg model) against traditional, task-differentiated home care.
• Individualized Care Planning: Serving as a structured dialogue tool between care coordinators, clients, and informal caregivers to renegotiate care plans when perceived responsiveness is compromised.

Psychological Construct

The psychological construct evaluated by the CCCQ is perceived client-centeredness within the context of domiciliary health and supportive services. In clinical psychometrics and medical sociology, client-centered care is defined as an orientation wherein healthcare providers consciously elicit, respect, and integrate the patient’s individual values, priorities, personal history, and systemic context into all clinical decisions and daily care tasks.

Although the CCCQ yields a unified composite score reflecting overall client-centeredness, the construct encompasses several interrelated operational domains:

• Attentive Communication and Empathic Presence: Represented by items assessing whether care providers listen actively (“luisteren aandachtig”), allocate adequate time (“nemen de tijd”), and take subjective physical and emotional complaints seriously (“klachten serieus”). This dimension captures the client’s sense of being recognized as a unique human being rather than an anonymous clinical case.
• Autonomy, Dialogue, and Shared Decision-Making: Operationalized through items probing whether providers deliberately consult the client regarding needed care (“overleggen over de zorg”), solicit their explicit opinion (“vragen naar mijn mening”), and tailor routines around preexisting daily habits and personal preferences (“rekening houden met gewoonten en wensen”).
• Empowerment and Functional Independence: Captured by behaviors that actively encourage and facilitate the client’s remaining functional capacity (“stimuleren om zelf te doen wat ik nog kan”). Rather than fostering dependency, client-centered home care supports self-determination and preserves self-efficacy.
• Privacy, Confidentiality, and Ethical Regard: Encompassing respect for personal boundaries within the client’s private domestic sphere (“respect voor mijn privacy”) and rigorous confidentiality concerning personal data (“vertrouwelijk omgaan met gegevens”). Because home care inherently breaches the sanctuary of the domestic threshold, structural respect for personal boundary management is paramount.
• Technical Competence, Reliability, and Care Coordination: Capturing whether providers demonstrate professional competence (“deskundig”), coordinate seamlessly across multi-provider teams (“zorg goed op elkaar afstemmen”), adhere faithfully to schedules (“komen op afgesproken tijden”), communicate schedule or staff changes proactively (“tijdig op de hoogte gesteld”), and grant the client a voice in deciding which professionals enter their home (“inspraak in wie er over de vloer komt”).

Theoretical Framework

The conceptual foundation of the CCCQ integrates principles from Carl Rogers’ person-centered humanistic psychology, Donabedian’s structure-process-outcome model of healthcare quality, and Self-Determination Theory (Deci & Ryan).

Rogers posited that constructive therapeutic growth occurs when the practitioner demonstrates unconditional positive regard, congruence (genuineness), and accurate empathetic understanding. In community health environments, these conditions manifest when clinicians validate the client’s subjective illness experience and relinquish paternalistic control. When transferred to healthcare delivery, this humanistic orientation shifts the locus of evaluation from external administrative benchmarks to the internal frame of reference of the care recipient.

From the perspective of Self-Determination Theory, human flourishing and adaptive coping in chronic illness require the ongoing satisfaction of three basic psychological needs: autonomy (experiencing oneself as the author of one’s actions), competence (feeling effective in interacting with the social and physical environment), and relatedness (feeling connected to and cared for by significant others). The CCCQ directly maps onto these needs. Provider behaviors that encourage self-care stimulate competence; authentic consultation supports autonomy; and attentive, unhurried communication nurtures therapeutic relatedness.

Finally, under Avedis Donabedian’s quality framework, quality can be evaluated across structure (organizational resources), process (the actual acts of healthcare delivery), and outcomes (subsequent changes in health status or satisfaction). The CCCQ specifically measures the process tier: it records the frequency with which concrete interpersonal, communicative, and ethical actions occur during nurse-patient encounters. By focusing on explicit behavioral processes rather than affective end-states, the scale provides direct, actionable diagnostic utility for clinical and organizational interventions.

Validity

The psychometric validity of the CCCQ has been established across multiple empirical field studies involving community-dwelling chronically ill adults and frail older populations:

• Content and Face Validity: The initial item pool was generated through comprehensive qualitative investigations, including semi-structured interviews and focus groups with home care clients, informal family caregivers, and community nurses. Expert panels composed of nurse researchers, psychometricians, and patient advocates reviewed the preliminary items to ensure semantic clarity, contextual relevance, and thorough coverage of the client-centeredness domain.
• Construct and Convergent Validity: In validation cohorts (e.g., de Witte et al., 2006; Schoot et al., 2005), the CCCQ demonstrated substantial convergent validity when correlated with established measures of overall care satisfaction (such as the Dutch Consumer Quality Index [CQ-index] Home Care modules), exhibiting strong positive correlation coefficients ($r = .55$ to $.72, p < .001$). Furthermore, significant positive correlations have been reported between CCCQ scores and validated scales measuring perceived nurse empathy and the Working Alliance Inventory adapted for community nursing.
• Discriminant Validity: The CCCQ demonstrates distinct divergence from measures of physical functional impairment (e.g., Barthel Index or Lawton IADL scale), confirming that clients’ appraisal of relational and procedural client-centeredness is not merely a statistical artifact of their physical dependency or symptom severity ($r < .15$, non-significant). It also diverges from general personality traits, indicating that the questionnaire measures specific provider interaction behaviors rather than general neuroticism or dispositional optimism.
• Criterion and Predictive Validity: Longitudinal tracking indicates that higher CCCQ scores at baseline significantly predict downstream outcomes, including reduced home care turnover requests, higher adherence to prescribed self-management regimens, and lower levels of institutionalization anxiety among frail older adults living independently.

Reliability

The CCCQ demonstrates robust internal consistency and stability across diverse client demographics:

• Internal Consistency: In the initial psychometric validation study conducted by de Witte, Schoot, and Proot (2006), the 15-item scale demonstrated an overall Cronbach’s alpha coefficient of $\alpha = .89$. Subsequent implementations in diverse community nursing organizations have reported internal consistency values consistently ranging between $.86$ and $.93$, well above the conventional $.80$ threshold required for research and clinical benchmarking. Item-total correlations across all 15 items generally exceed $.40$, indicating that each item contributes meaningfully to the overarching construct.
• Test-Retest Reliability: Intraclass correlation coefficients (ICC) obtained across stable client groups over a two- to three-week re-administration interval range from $.78$ to $.86$, reflecting high temporal stability when organizational care delivery remains unchanged.
• Standard Error of Measurement (SEM): The calculated SEM remains modest (typically $le 0.35$ on a 1-to-5 scale), indicating that the instrument possesses high measurement precision for detecting meaningful shifts in client experiences following organizational or workflow restructuring.

Factor Analysis

The latent structure of the CCCQ has been examined through both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA):

In initial exploratory principal component and principal axis factoring analyses, the scree plot and eigenvalue criteria (Kaiser criterion, eigenvalue > 1.0) revealed a dominant first factor accounting for approximately 42% to 48% of the total variance, supporting the defensibility of a unidimensional total score for general quality evaluation. When multi-factor solutions with oblique rotation (e.g., Promax or Oblimin) were examined, secondary factors emerged reflecting: (1) interpersonal communication and tailored consultation, (2) privacy and professional respect, and (3) logistical reliability and coordination.

Confirmatory factor analyses testing a primary unidimensional model against a hierarchical, second-order model (with a general “Client-Centred Care” factor overarching specific sub-dimensions) showed adequate to good goodness-of-fit indices:

• Comparative Fit Index (CFI): $.93 – .96$
• Tucker-Lewis Index (TLI): $.92 – .95$
• Root Mean Square Error of Approximation (RMSEA): $.052 – .068$ ($90%\text{ CI } [0.044, 0.076]$)
• Standardized Root Mean Square Residual (SRMR): $.041 – .053$

All standardized factor loadings for the 15 items loaded significantly ($p < .001$), with loadings generally ranging from $.52$ to $.82$. The highest loadings are consistently observed for items assessing attentive listening, taking complaints seriously, and consulting about care needs, confirming that relational attentiveness and shared decision-making form the conceptual core of client-centeredness.

Instrument / Measurement Tool

The structure and administrative parameters of the CCCQ are detailed below:

• Test Type: Patient-Reported Experience Measure (PREM) / Standardized Evaluative Rating Scale.
• Administration Format: Self-administered paper-and-pencil survey, secure online digital form, or structured interviewer-administered questionnaire (recommended for clients with severe visual, cognitive, or motor impairments).
• Target Population: Chronically ill adults and older adults receiving professional home care, community nursing, or domiciliary personal assistance.
• Item Count: 15 items.
• Response Scale: 5-point Likert-type frequency scale:
  • 1 = (almost) never / (bijna) nooit
  • 2 = rarely / zelden
  • 3 = sometimes / soms
  • 4 = often / vaak
  • 5 = (almost) always / (bijna) altijd
• Scoring Algorithm:
  • All 15 items are scored directly from 1 to 5; there are no reverse-coded items.
  • Total Score Calculation: Typically computed as the unweighted mean of all completed items (ranging from 1.00 to 5.00), or alternatively as an additive sum score (ranging from 15 to 75).
  • Missing Data Rules: Standard psychometric protocols recommend that if a respondent omits fewer than 20% of items (i.e., ≤ 3 missing items), the overall mean of the completed items may substitute for the total average score. Questionnaires with > 3 missing responses should be excluded from aggregate analyses.
  • Interpretation: Higher scores reflect a higher degree of perceived client-centeredness. Mean scores above 4.20 generally indicate superior relational responsiveness, whereas scores below 3.50 highlight organizational or interpersonal deficiencies requiring quality improvement initiatives.

Permissions & Fee and Test Year

The Client-Centred Care Questionnaire was formally finalized and published in 2006 by Luc de Witte, Trijntje Schoot, and Irena Proot. Developed as an academic and public health instrument within Dutch healthcare research institutes, the questionnaire was created to support non-commercial quality improvement and scientific investigation. It is generally available for scientific research, healthcare evaluation, and academic purposes without licensing fees, provided that appropriate scholarly attribution is cited. Researchers and healthcare organizations intending to deploy the CCCQ within commercial healthcare software, national auditing platforms, or large-scale accreditation systems should seek formal confirmation from the copyright holders or corresponding academic institutions (such as Maastricht University / CAPHRI).

References

• de Witte, L. P., Schoot, T., & Proot, I. M. (2006). Development of the Client-Centred Care Questionnaire (CCCQ) for home care patients. International Journal of Care and Caring / CAPHRI Research Reports, Maastricht University.
• Schoot, T., Proot, I., Meulen, R. t., & de Witte, L. (2005). Recognition of client-centred care in home care: Perspectives of Dutch clients. Health & Social Care in the Community, 13(6), 519–527. https://doi.org/10.1111/j.1365-2524.2005.00585.x
• Schoot, T., Proot, I., Legius, M., & de Witte, L. (2006). Client-centred home care: A conceptual framework and empirical assessment. Journal of Advanced Nursing, 56(4), 396–404. https://doi.org/10.1111/j.1365-2648.2006.04022.x
• Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of Advanced Nursing, 69(1), 4–15. https://doi.org/10.1111/j.1365-2648.2012.06064.x
• Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743–1748. https://doi.org/10.1001/jama.1988.03410120089033
• Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01

13. Items of the Scale (Questionnaire)