Understanding the added value of nurse-led, person-centred care in atrial fibrillation: looking beyond between-group differences

This invited commentary refers to ‘The effects of a nurse-led, person-centred outpatient clinic on patient-reported outcomes in patients with atrial fibrillation—a randomised controlled trial’ by L. Holmlund et al. https://doi.org/10.1093/eurjcn/zvag028 Atrial fibrillation (AF) is a highly prevalent long-term condition associated with symptom burden, impaired quality of life, and increasing healthcare utilization.1 The 2024 European Society of Cardiology (ESC) guidelines emphasize that AF management should extend beyond rhythm and rate control to include education, shared decision-making, and ongoing support for self-management within comprehensive and multidisciplinary models of care.2 Within this context, nurse-led and person-centred approaches are increasingly viewed as central to delivering sustainable, high-quality AF services. Holmlund et al.3 report a randomized controlled trial evaluating a nurse-led, person-centred outpatient clinic compared with usual physician-led care for people with AF. Participants in both groups received structured follow-up over 6 months. Patient-reported outcomes were assessed using a combination of generic, condition-specific, and illness perception measures, including the EuroQol five-dimension three-level questionnaire (EQ-5D-3L),4 Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA),5 Brief Illness Perception Questionnaire (B-IPQ),6 and Hospital Anxiety and Depression Scale (HADS).7 This approach enabled assessment of broader health-related quality of life alongside more proximal cognitive and emotional responses to living with AF. The nurse-led intervention was explicitly underpinned by person-centred principles, while the comparator arm reflected contemporary, structured usual care. The nurse-led clinic drew on established person-centred care processes that have been widely discussed within cardiovascular nursing. These include eliciting the patient narrative, co-creating goals and a personal health plan, and documenting this plan to safeguard the partnership between patients and professionals.8 Such approaches aim to move care beyond information provision alone, towards supporting individuals to make sense of their condition and engage actively in their care. The trial did not demonstrate statistically significant between-group differences in patient-reported outcomes at 6 months. However, both groups showed improvements in generic health-related quality of life and mental aspects of arrhythmia-related symptoms. Notably, within-group analyses suggested improvements in illness perceptions among participants attending a nurse-led clinic, including increased perceived personal control and reduced concerns and emotional responses related to AF. These findings merit careful interpretation. The absence of between-group differences should not be assumed to indicate that the nurse-led, person-centred intervention lacked value. Usual care in this study was clearly active and time-rich, incorporating education, lifestyle advice, and risk factor discussion that align with ESC recommendations for person-centred AF management.2 When usual care already reflects many person-centred principles, detecting additional benefits attributable to role or model of delivery becomes inherently challenging. Participant characteristics also provide important context. Many participants were recently diagnosed with AF and reported relatively preserved baseline quality of life. By 6 months, scores approached population norms, suggesting potential ceiling effects. In addition, the timeframe may have been too short for person-centred goal-setting and behavioural change to translate into detectable differences in generic quality of life outcomes, particularly in individuals with early or less symptomatic disease. The within-group changes observed in illness perceptions in the nurse-led arm are therefore of particular interest. Illness perceptions shape how individuals interpret symptoms, cope with uncertainty, and engage in self-management over time.9 From a person-centred perspective, these changes may represent early and meaningful shifts that precede improvements in broader outcomes. This reflects broader concerns within person-centred nursing scholarship that generic outcome measures may fail to capture the relational and process-based elements through which person-centred care is enacted and experienced by service users, including professional ways of being and supportive practice environments.10–13 Recent cardiovascular nursing editorials have highlighted the risk of equating person-centred care with shared decision-making or education alone, arguing instead for greater attention to culture, context, and the attributes of practitioners and teams.14 O’Donnell and Cook11 similarly emphasize that person-centred nursing practice is enacted through everyday interactions, values-based behaviours, and therapeutic relationships, which may not be fully captured by generic patient-reported outcome measures within traditional trial designs. For cardiovascular nursing practice, this trial offers several important insights. First, it demonstrates the possibility of nurse-led outpatient follow-up grounded in person-centred principles for people with AF. Second, it reinforces that high-quality, relational care can positively influence patient experiences and perceptions, regardless of professional role. This suggests that service redesign should focus not only on who delivers care but also on how care is delivered and supported within clinical systems. Furthermore, the study raises important considerations regarding outcome selection in trials of person-centred interventions. While health-related quality of life remains an important endpoint, it may be insufficiently sensitive to capture early or mechanism-level effects of person-centred care. Outcomes such as patient activation, self-efficacy, experience of care, and illness understanding may offer complementary insights and align more closely with the theoretical foundations of person-centred nursing practice. Future research would benefit from longer follow-up periods, inclusion of more diverse and comorbid AF populations, and the integration of process evaluations to explore how person-centred care is enacted in practice. Hybrid effectiveness-implementation designs may be particularly valuable for capturing both outcomes and contextual influences. Economic evaluation is also warranted, given the growing interest in nurse-led models as a response to increasing service demand and workforce pressures. The trial by Holmlund et al.3 provides a valuable contribution to the evolving evidence base on nurse-led, person-centred AF care. Although superiority over an active usual-care comparator was not demonstrated, the findings highlight the potential benefits in illness perceptions and reinforce the importance of high-quality, supportive care. Rather than viewing these results as negative, they should be considered informative for future intervention development, outcome selection, and service design within cardiovascular nursing. Ultimately, the study reinforces that advancing person-centred cardiovascular care requires not only new models of service delivery but also measurement approaches capable of capturing the relational, contextual, and experiential outcomes that matter most to patients. Asriel Juvenal Chamos (Conceptualization [lead], Writing—original draft [lead], Writing—review & editing [lead]) and Micheal Lynch (Writing—review & editing [equal]) None declared. No new data were generated or analysed in support of this research.