Exploring person-centredness: a qualitative meta-synthesis of four studies

Person-centredness as a concept is becoming more prominent and increasingly central within some research literature, approaches to practice and as a guiding principle within some health and social care policy. Despite the increasing body of literature into person-centred nursing (PCN), there continues to be a 'siloed' approach to its study, with few studies integrating perspectives from across nursing specialties. The purpose of this paper is to present the results of a study undertaken to explore if the secondary analysis of findings from four different and unrelated research studies (that did not have the main aim of researching person-centredness) could inform our understanding of person-centred nursing. A qualitative meta-synthesis was undertaken of the data derived from the four unrelated research studies undertaken with different client groups with long-term health conditions. A hermeneutic and interpretative approach was used to guide the analysis of data and framed within a particular person-centred nursing framework. Findings suggest 'professional competence' (where competence is understood more broadly than technical competence) and knowing 'self' are important prerequisites for person-centred nursing. Characteristics of the care environment were also found to be critical. Despite the existence of expressed person-centred values, care processes largely remained routinised, ritualistic and affording few opportunities for the formation of meaningful relationships. Person-centred nursing needs to be understood in a broader context than the immediate nurse-patient/family relationship. The person-centred nursing framework has utility in helping to understand the dynamics of the components of person-centredness and overcoming the siloed nature of many current perspectives.     

Sliding doors: Did drama-based inter-professional education improve the tensions round person-centred nursing and social care delivery for people with dementia: A mixed method exploratory study

This educational intervention takes place when the population of older people with dementia is increasing. Health and Social care professionals must work jointly in increasingly complex contexts. Negative attitudes towards older people are cited as a contributor to poor care delivery, including the use of dismissive and/or patronising language, failing to meet fundamental needs and afford choice. ‘Sliding Doors to Personal Futures’ is a joint, drama-based, educational initiative between NHS Education Scotland and the Scottish Social Services Council, delivered using interprofessional education (IPE) towards encouraging person-centred health and social care.This paper considers whether ‘Sliding Doors’ had an impact on social work and nursing students' attitudes to older people, person-centred care and interprofessional collaboration. Two groups of third year students were studied; one from nursing and one from social work. A mixed methods approach was taken and attitudes and attitudinal shifts measured and discussed.Quantitative results demonstrated that social work students made positive attitudinal shifts in some questionnaire items and collectively the social work students were more person-centred than nursing students in their care approaches. The qualitative data however, drawn from focus groups, illuminated these results and highlighted the link between the ability for a professional to be person-centred and the conceptual view of risk within the particular profession. Risk acceptance, the theoretical position of social work, may facilitate person-centred care, whereas the perceived risk-averse nature of the nursing profession may inhibit it. Students' attempts to understand the quantitative results, without understanding the restrictions and parameters of each other's profession, led them to revert to stereotypes and negative views of each other as practitioners.The paper concludes that there is an important difference between nurses' and social workers' frames of reference. It is suggested that IPE in its current form will not impact positively on outcomes for older people, unless both professions can openly acknowledge the reality of their professional contexts and develop an understanding of each other's professional restrictions, opportunities and aspirations.     

Development of a framework for person-centred nursing

This paper presents the development and content of a person-centred nursing framework. BACKGROUND AND RATIONALE: Person-centred is a widely used concept in nursing and health care generally, and a range of literature articulates key components of person-centred nursing. This evidence base highlights the links between this approach and previous work on therapeutic caring. METHODS: The framework was developed through an iterative process and involved a series of systematic steps to combine two existing conceptual frameworks derived from empirical studies. The process included the mapping of original conceptual frameworks against the person-centred nursing and caring literature, critical dialogue to develop a combined framework, and focus groups with practitioners and co-researchers in a larger person-centred nursing development and research project to test its face validity. FINDINGS: The person-centred nursing framework comprises four constructs -prerequisites, which focus on the attributes of the nurse; the care environment, which focuses on the context in which care is delivered; person-centred processes, which focus on delivering care through a range of activities; and expected outcomes, which are the results of effective person-centred nursing. The relationship between the constructs suggests that, to deliver person-centred outcomes, account must be taken of the prerequisites and the care environment that are necessary for providing effective care through the care processes. CONCLUSION: The framework described here has been tested in a development and research project in an acute hospital setting. Whilst there is an increasing empirical base for person-centred nursing, as yet little research has been undertaken to determine its outcomes for patients and nurses. The framework developed can be described as a mid-range theory. Further testing of the framework through empirical research is required to establish its utility for nursing practice and research.     

Screening for wandering among older persons with dementia

Wandering is a necessary human activity for many persons with dementia. Nursing and therapy practice in the UK must adopt a more person-centred and evidence-based approach to practice in this area. Risk is a potential that something might happen and remains present until it happens. Focusing on screening for wandering in those with dementia can enable nurses to use their skills to assess the person's nursing care needs in this area, prescribe care that promotes safe wandering and may begin to enable practitioners to recognise the benefits of safe wandering for the person. Proactive care planning and delivery should reduce the need for excessive crisis interventions when the person with dementia has progressed to a level of risk unacceptable to nurses.     

Using drama to improve person-centred dementia care

kontos p.c., mitchell g.j., mistry b. & ballon b. (2010) Using drama to improve person-centred dementia care. International Journal of Older People Nursing 5 , 159–168 Aims and objectives. We implemented a 12-week drama-based educational intervention to introduce to dementia practitioners person-centred care that emphasizes the notion of embodied selfhood (defined as non-verbal self-expression). Background. Person-centred dementia care guidelines emphasize the assessment of individual needs, and where appropriate, the use of non-pharmacological interventions before resorting to pharmacological management. However, dementia care is not consistent with these guidelines suggesting conceptual limitations and reliance on passive knowledge translation strategies. Design and methods. Focus groups and semi-structured interviews with practitioners (n = 24) in two nursing homes in central Canada were undertaken to assess the effectiveness of the drama-based components of the intervention. Results. Our findings suggest that drama was effective as an educational modality, and helped implement the person-centred approach into practice. Significant practice outcomes included: new awareness that residents’ body movements and dispositions can convey meaning; seeking biographical information from families; increased time efficiency; and supporting residents’ independence. Conclusions. Our findings make an important contribution to person-centred dementia care by broadening the notion of personhood, and by facilitating implementation using drama. Implications for practice. As an enhancement of person-centred care, the support of embodied selfhood may significantly improve residents’ quality of life, quality of care, and practitioners’ care-giving experience.     

Knowledge,facilitators and barriers to the practice of person-centred care in aged care workers: a qualitative study

The current study describes aged care workers' interpretation of the concept of person-centred care; and identifies the barriers that exist to impede its practice, and the facilitators that encourage person-centred care practice. Data were collected from interviews with aged care workers from two residential aged care facilities providing both high and low care for residents with and without physical and psychological issues based in Australia. Data were analysed to identify and explore categories of meaning for barriers and facilitators. Analysis is grounded in Brooker's VIPS framework for person-centred dementia care which is utilised as a comparative tool for analysing participants' understanding of person-centred care. Findings revealed that aged care workers have a reasonable but incomplete understanding of person-centred care. Insufficient time and residents' dementia behaviours acted as barriers to care workers' provision of person-centred care. Teamwork was found to facilitate person-centred care by increasing instrumental and relationship resources     

Nursing assistants' behaviour during morning care: effects of the implementation of snoezelen, integrated in 24-hour dementia care

AIM: This paper reports an investigation of the effects of the implementation of snoezelen, or multisensory stimulation, on the quality of nursing assistants' behaviour during morning care. BACKGROUND: Nursing assistants in long-term dementia care are often unaware of the impact of their behaviour on patient functioning. Snoezelen is a psychosocial intervention that might improve the quality of caregiver behaviour by combining a person-centred approach with the integration of sensory stimuli. METHODS: A quasi-experimental pre- and post-test design was implemented in 12 wards for older mentally infirm patients at six nursing homes. The experimental group intervention was a 4-day in-house 'snoezelen' training, stimulus preference screening and supervision meetings. The control group received usual nursing home care. The effectiveness of the intervention was studied by analysing 250 video recordings, which were assessed by independent observers using a 4-point measurement scale developed for this study and based on Kitwood's Dialectical Framework. RESULTS: The results showed a statistically significant increase in 'Positive Person Work' and decrease in 'Malignant Social Psychology' (total scores) after the implementation of snoezelen. Nursing assistants in the experimental group also improved by statistically significant amounts on all subitems of 'Positive Person Work'. The mean number of sensory stimuli, offered explicitly, increased. CONCLUSION: The implementation of snoezelen succeeded in effecting a change to a more person-centred approach during morning care. The results indicate that nursing assistants' behaviour can be positively changed provided that the new care model has been successfully implemented.     

The use of life story work with people with dementia to enhance person-centred care

mckeown j., clarke a., ingleton c., ryan t. & repper j. (2010) The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing 5 , 148–158 Background. Person-centred care has been linked with quality of care but difficulties remain in person-centred care being implemented in care practice. This study explores the use of life story work to enhance person-centred care with people with dementia. Aims and objectives. The study investigates how life story work is: understood and developed in practice; experienced by all participants and affects the delivery and outcomes of care. Design and methods. The experience of older people with dementia, family carers and care staff in using life story work was explored within an NHS Health and Social Care Trust. A multiple case study design was adopted within a constructivist approach. Semi-structured interviews, observation, conversations were employed. Findings. Life story work has the potential to: enable care staff to see the person behind the patient; allow family carers to uphold their relatives’ personhood; enable the voice of the person with dementia to be heard, verbally and non-verbally; be enjoyable for all concerned and enable the person with dementia to feel proud about themselves and their lives. Conclusion and implications for practice. Life story work has the potential to enhance person-centred care for older people with dementia and their families. Taking a practice development approach ensures that life story work can be implemented sensitively and is sustained in practice.     

Promoting positive approaches to dementia care in nursing

This article provides an overview of factors relevant to dementia care today. The number of people experiencing dementia is increasing and dementia is at the forefront of health policy. The evidence base for person-centred approaches and interventions in dementia is expanding and nurses are central to implementing these across care settings. This is an exciting and challenging time for dementia care and nursing has a major role in leading and developing these changes in practice. The article discusses the importance of wellbeing and the Mental Capacity Act in assessing and caring for people with dementia. Psychosocial and pharmacological approaches to dementia care are described and the need to support carers of people with dementia is emphasised.     

Translating change: The development of a person-centred triage training programme for emergency nurses

Within health care, there has been a change in practice from an illness-orientated service to one that is more health-focused and person-centred. The concept of person-centredness is frequently espoused by practitioners as being not only a desirable, but a necessary element of health care provision. Indeed, nationally and internationally, person-centred care has underpinned many healthcare documents and policies. Person-centred practice focuses on providing care, utilising a variety of processes that operationalise person-centred nursing and include working with patients′ beliefs and values, engagement, presence, sharing decision-making and providing for physical needs.In the field of emergency nursing, the incorporation of person-centred care and its holistic foundation may require a significant shift in practice. There is evidence to suggest that emergency nurses view their role as one, which is predominantly concerned with providing urgent physical care, rather than one, which espouses the theories of holistic healthcare. To this extent, being person-centred in the context of emergency care, requires the nurse to move beyond the traditional notions of his/her role and to embrace the more holistic aspects of patient care. The aim of this article is to critically analyse how a change in nurse-led triage training in one Irish Emergency Department facilitated an improved person-centred approach in practice.     

The applicability of a recovery approach to nursing people with dementia

Objectives

Recent developments in nursing to people with mental health conditions of working age have been underpinned by the recovery approach. This paper critically reviews the idea of recovery in relationship to people with dementia and examines its applicability to dementia care nursing.

Design

The paper critically reviews literature relating to the use recovery approach and the people with dementia, particularly their nursing care. The paper identifies common ideas within two approaches and suggests how the recovery approach may underpin nursing care to people with dementia.

Data sources

A search of CINAHL, Medline and PsycINFO was undertaken from 1987 onwards using keywords ‘recovery’, ‘nursing’ and ‘dementia’.

Results

The paper found that the recovery approach shares many ideas with person-centred approaches to dementia care and illustrates this in relationship to well-being, social inclusion, self-management, and hope.

Conclusion

The paper concludes by suggesting that dementia care nursing should draw on ideas taken from the recovery approach and identifies each approach drawing on ideas that have come together in postpsychiatry.     

Person-centred care for people with dementia: a quality audit approach

This paper addresses the concept of person-centred care for people with dementia by consideration of an audit process using dementia care mapping as the audit tool. It is argued that this tool is best for identifying the lived experiences of the people in receipt of care. As a result it is able to identify the overall culture of care and its level of 'person-centred' approach. The audit was conducted on 12 units, half of which were day units and the others catering for inpatients. Five patients were mapped on each day for a 4-day period. The results give some idea of the quality of care and identify where improvement is necessary. Scores such as well-being values and the Dementia Care Index give clear signposts to the level of person-centred care and highlight where staff development is necessary. Recommendations are given to aid on-going planning.     

Personhood and dementia: revisiting Tom Kitwood's ideas

Person-centred care is often cited as an aim of gerontological nursing and promotion of personhood is said to be the basis for person-centred care. As such, it forms a cornerstone value for many gerontological nurses, particularly those working in dementia care. Tom Kitwood's ideas and definition of personhood are widely referred to in the literature and used in the dementia care field. More recently, there is a move to critique and partially reject Kitwood's ideas on personhood. This paper has three aims: (i) to explore some central ideas around key theories of personhood (ii) to critique Kitwood's work on personhood. (iii) To summarize current critiques of Kitwood's ideas and provide a response that outlines why Kitwoods' ideas are still relevant. It is suggested many critiques ignore Kitwoods' ultimate purpose; that of moral concern for 'others'. However, the main criticism put forward in this paper is that, rather than completely rejecting personhood theories, Kitwood locates his work on what it means to be a person within a traditional Cartesian personhood framework, albeit from a revised or pragmatic viewpoint. Finally, it is suggested that definitions of persons and personhood need to take account of the body and time (corporeality and temporality) and gerontological nursing may want to reassess how much allegiance is given to basing nursing frameworks on the concept of personhood.     

Concepts of health: implications for public health work

This article explores the health concepts of community health care (CHC) nurses in relation to their potential roles as public health workers. On examining Ewen's (1998) study of CHC nurses' role perceptions, it is evident that an individualized, person-centred, holistic approach to care continues to dominate practice. The public health role within CHC nursing remains underdeveloped and is equated with primary prevention with the well population. A 'community-as-foreground' model is proposed as a useful way of redefining CHC nursing practice to incorporate public health. The discussion revolves around the need for a broader view of health to include a political and social dimension, and considers the role of education and practice in achieving this.     

What constitutes good care for people with dementia?

Person-centred care for people with dementia is an aspiration of both family and professional carers, but what constitutes person-centred care and how it can be achieved is less clear. This article describes a Swedish study in which in-depth interviews were completed with both family and professional carers of people with dementia with the purpose of exploring what they considered to be "best care". Important areas of similarity and difference were identified and the results suggest that both groups of carers need to work closely together if person-centred care is to become a reality.     

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.     

Practice development: individualized care

This article describes the development of a person-centred approach to working with older people. The main focus is on developing the ward leader as a key facilitator of practice development work. This process was enabled through external facilitation of the role and project management. The stages of the project work are outlined using an established practice development framework, which ensured a systematic approach to the change process. Registered nurses developed their skills and knowledge in clinical leadership and by the end of the project, nursing care had moved away from meeting the physical needs of the patients only, to a more individualized approach to patient care.     

Aggressive behaviour by people with dementia in residential care settings: a review

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.     

Seeing the person behind the patient: enhancing the care of older people using a biographical approach

Recent policy statements have stressed the need for fundamental changes to the NHS, especially to the hospital care of older people. Person-centred care underpins such changes. If practitioners are to deliver person-centred care, then they need to learn more about the patient as an individual. One way that this might be achieved is through biographical approaches. This paper describes the findings of a developmental study undertaken over a 6-month period to investigate the introduction of a biographical approach to care on a unit in a NHS hospital. It concentrates on the views of the practitioners who used the approach. The study aimed to explore whether a biographical approach - in the form of storytelling - might be used to encourage person-centred practice. Using a practice development approach, the study explored the views of older people, their family carers and practitioners regarding their participation in life story work. Initial data were collected by focus groups with staff from a nursing home who regularly used life stories as a basis for care planning. Further data were collected through focus groups, semistructured interviews and observation - undertaken before and after the introduction of life story work - with older people, family carers and practitioners. Findings revealed that life stories helped practitioners to see patients as people, to understand individuals more fully and to form closer relationships with their families. Support workers also said how much they enjoyed using the approach to inform their care. Further longitudinal research is required to investigate biographical approaches more fully and to work more closely with practitioners to explore how biographical approaches can be undertaken as part of standard practice and be integrated into the culture and management of care.     

Interventions for confusion and dementia. 5: Changing cultures

Previous articles in this series (Vol 7(15): 891-94; Vol 7(17): 1018-20; Vol 7(19): 1145-49; Vol 7(20): 1247-50) have explored the promotion of quality of life for people with dementia and how this can be achieved through existing interventions. This final article moves from discussing specific interventions to cover wider issues around healthcare beliefs and values. A brief historical overview of dementia care is given, outlining the inherited structures and values. Much valuable work has been carried out by the Bradford Dementia Group, who has described changes in dementia care as moving from an 'old' to a 'new' culture. This 'new culture', offering a comprehensive person-centred approach to holistic care, is explored with reference to the work of Kitwood, who has done much to promote quality of life for people suffering from dementia.