Patient‐centeredness in long‐term care of older patients – a structured interview

Aim. The aim of this study was to describe assessments of older people about patient‐centeredness in the long‐term care of Estonian hospitals, and to determine correlations between patients’ assessments and their socio‐demographic characters. Background. Patient‐centeredness increases patients’ satisfaction and enhances their recovery. Still, patients’ opinions are not always taken into account. Method. A cross‐sectional study included 111 older people in long‐term care of 14 Estonian hospitals. Data were collected in 2008 by means of structured interviews. Results. What patients agreed most was that they were given enough opportunity to carry out activities they were capable of performing themselves. Two thirds of participants had not been sufficiently consulted on who would be providing their care. Half of the participants were not given sufficient opportunity to decide what kind of care was needed and how they would receive it. The more assistance patients needed in daily living activities, the less they considered the care as patient‐centred. Conclusions. From the perspective of older people, the patient‐centeredness in Estonian long‐term care is above average. Providing patient‐centred long‐term care in Estonian hospitals deserves more attention. Relevance to clinical practice. Older people should be more involved in decision‐making, especially those who need more assistance in daily living activities.     

Reconciling evidence‐based medicine and patient‐centred care: defining evidence‐based inputs to patient‐centred decisions

Evidence‐based and patient‐centred health care movements have each enhanced the discussion of how health care might best be delivered, yet the two have evolved separately and, in some views, remain at odds with each other. No clear model has emerged to enable practitioners to capitalize on the advantages of each so actual practice often becomes, to varying degrees, an undefined mishmash of each. When faced with clinical uncertainty, it becomes easy for practitioners to rely on formulas for care developed explicitly by expert panels, or on the tacit ones developed from experience or habit. Either way, these tendencies towards ‘cookbook’ medicine undermine the view of patients as unique particulars, and diminish what might be considered patient‐centred care. The sequence in which evidence is applied in the care process, however, is critical for developing a model of care that is both evidence based and patient centred. This notion derives from a paradigm for knowledge delivery and patient care developed over decades by Dr. Lawrence Weed. Weed's vision enables us to view evidence‐based and person‐centred medicine as wholly complementary, using computer tools to more fully and reliably exploit the vast body of collective knowledge available to define patients’ uniqueness and identify the options to guide patients. The transparency of the approach to knowledge delivery facilitates meaningful practitioner–patient dialogue in determining the appropriate course of action. Such a model for knowledge delivery and care is essential for integrating evidence‐based and patient‐centred approaches.     

Nurse middle managers contributions to patient‐centred care: A ‘managerial work’ analysis

Nurse middle managers are in an ideal position to facilitate patient‐centred care. However, their contribution is underexposed in literature due to difficulties to articulate this in practice. This paper explores how nurse middle managers contribute to patient‐centred care in hospitals. A combination of time‐use analysis and ethnographic work was used to disclose their contribution to patient‐centred care at a micro level. Sixteen nurse managers were shadowed for over 560 hours in four hospitals. Some nurse middle managers seldom contribute to patient‐centred care. Others are involved in direct patient care, but this does not result in patient‐centred practices. At one hospital, the nurse middle managers did contribute to patient‐centred care. Here balancing between “organizing work” and “caring work” is seen as a precondition for their patient‐centeredness. Other important themes are feedback mechanisms; place matters; with whom to talk and how to frame the issues at stake; and behavioral style. Both “hands‐on” and “heads‐on” caring work of nurse middle managers enhances their patient‐centeredness. This study is the first of its kind to obtain insight in the often difficult to articulate “doings” of nurse middle managers with regard to patient‐centred care through combining time‐use analysis with ethnographic work.     

Translating person-centred care: a case study of preceptor nurses and their teaching practices in acute care areas

Aims and objectives. The research aims to explore how preceptors interpret, operationalize, document and teach person‐centred care as they guide students within an acute surgical environment. Background. Person‐centred care is a term that is widely used in the nursing literature; however, its interpretation in nursing practice remains virtually unexplored. This is of great significance to nurses in general but to Irish nurses in particular on whom this study is focused. As preceptor nurses have been identified as key people in the education of clinical students, it was considered important to explore how clinical preceptors promote person‐centred care to current undergraduate nursing students. Design and method. Using a case study design and a qualitative approach, six preceptors were chosen to participate in this study. Data were collected by means of participant observation, review of nursing care records and semi‐structured interviews. Data were analysed in two stages. The first stage involved the identification of themes. In the second stage data were analysed using a number of propositions to examine and explain what was gleaned from the data in the context of what was originally identified in the literature. Results. Findings highlighted that preceptors had a limited conception of person‐centred care. Measures of care reflected the medical model of nursing. Beyond that, preceptors expressed care in terms of good manners or respectful etiquette. Preceptors also had limited appreciation of what learning entails and were sceptical about classroom theory other than what they considered essential for safe practice. Conclusions. This study highlights that preceptors need both internal and external support to implement the changes advocated by the Commission in Nursing in 1998 , the Nursing Education Forum in 2000 , the Department of Health and Children in 2001 and An Bord Altranais in 2003 . Relevance to clinical practice. Person‐centred care is a relatively new concept in nursing and recommended for practice. Preceptors need facilitation with its implementation. In an effort to promote changes in the delivery of health care, it is suggested that university‐based lecturers empower students to practice evidence‐based nursing as students and subsequently as qualified nurses.     

‘I know what I need to recover’: Patients’ experiences and perceptions of forensic psychiatric inpatient care

Patients find forensic psychiatric care inadequate in that they are not treated as individuals and not involved in their own care. The purpose of this study was to describe patients’ experiences and perceptions of forensic psychiatric inpatient care. Semi‐structured interviews were conducted with 11 inpatients. A qualitative content analysis resulted in a recurring theme, ‘I know what I need to recover’, and three main categories: ‘A need for meaning in a meagre existence’, ‘A need to be a person in an impersonal context’, and ‘A need for empowerment in a restricted life’. Participants experienced and perceived forensic care as predominantly monotonous, predetermined, and not adapted to them as individuals, forcing them to fight and adapt to get through it and not lose themselves. Perceived needs were largely ignored or opposed by staff due to the content and structure of care. Findings suggest a need for reflective practices and patient involvement in order to develop and maintain a person‐centred and recovery‐oriented nursing practice. The study adds to previous research showing the importance of patients in forensic psychiatric inpatient care being listened to and involved in their care. The study is reported in accordance with the COREQ guidelines.     

Perspectives regarding what constitutes a “good death” among Thai nurses: A cross‐sectional study

Palliative care is a crucial component in improving peoples' end‐of‐life period. It is important to understand the wishes of people at the end of life and the perceptions of their healthcare providers regarding these wishes. As nurses play a key role in patient care, in this study we set out to determine nurses' perceptions regarding what constitutes a “good death”, comparing what they thought their older patients would prefer to their own preferences for their own end‐of‐life care. Questionnaires asking about various options of end‐of‐life care were distributed to nurses, and they were asked how they thought older people would respond to each of the questions and what their own preferences would be if they were terminally ill. In total, 656 participants were enrolled and they rated relief from suffering as the most important component, both for themselves and for those in their care. More than 80% of nurses agreed with all of the statements on the questionnaire. However, some of the nurses' preferences for their own end of life differed from those they expected their patients to value.     

Next‐of‐kin caregivers in palliative home care – from control to loss of control

Title. Next‐of‐kin caregivers in palliative home care ‐ from control to loss of control. Aim. This paper is a report of a study to describe situations influencing next‐of‐kin caregivers’ ability to manage palliative care in the home. Background. Palliative home care often involves major resources from next‐of‐kin, municipal and county personnel. Next‐of‐kin caregivers’ situation is depicted as so demanding and exhausting that it can affect their mental health and limit their ability to continue as a caregiver. Methods. A qualitative study using the Critical Incident Technique was conducted. Nine next‐of‐kin caregivers from palliative home care were strategically chosen and data were collected using audiotaped interviews in 2005. Findings. The analysis resulted in two main areas: ‘Maintaining control’ and ‘Losing control’. Next‐of‐kin caregivers wanted to maintain control over their lives by being continuously available 24 hours a day and by supporting and taking complete responsibility for all of the patient’s needs. They lost this control when professional assistance was lacking and they described feelings of inadequacy when their physical energy or time was insufficient. They felt incapable as the patient’s physical or mental persona metamorphosed or as serious symptoms developed that they could not control. Conclusion. Next‐of‐kin caregivers and the patients must feel free to choose where palliative home care will be provided and that their choice at any time can be re‐evaluated, due to insecurity or workload changes. When planning for palliative care, they should be informed that having only one caregiver reduces the chances of completing palliative care in the home.     

Family members’ perceptions of the nursing bedside handover

Aims and objectives. To explore families’ perceptions of shift‐to‐shift bedside handover. Background. The potential role families can play in bedside handover is unknown. Understanding family members’ perceptions can provide a foundation for nurses to tailor their bedside handover to family members’ perceptions, encouraging their involvement and potentially improving patient care. Design. Qualitative study, using case study methodology. Methods. The study was conducted with eight family members in one rehabilitation ward in Queensland, Australia, in 2009. Data included observations of bedside handover, field notes and in‐depth interviews. Thematic analysis of data was conducted to identify unique and common themes indicative of family perceptions. Results. Three major themes emerged. The first, understanding the situation, consisted of three subthemes: feeling informed, understanding the patient’s condition and understanding patient’s treatment. The second theme was interacting with nursing staff, with five subthemes, including sharing information, clarifying information, assisting in care, asking questions and interpreting for the patient. The final subtheme was finding value, which contained five subthemes: feeling at ease, feeling included, valuing individualisation, preparing for the future and maintaining patient privacy. Conclusions. Bedside handover provides an opportunity to involve family members in patient care and promote family‐centred care core concepts. Family members value the chance to participate and can ultimately improve the accuracy of handover communication. Relevance to clinical practice. Bedside handover is beneficial for nurses, patients and family members and embodies patient and family‐centred care. Managers should consider its implementation in hospitals, developing strategies such as standard operating protocols for a more family inclusive approach to communication. Nurses may require further training to best undertake bedside handover and involve family members in care. The study suggests expansion of research into this important area of family‐centred care.     

Experiences of self-care in patients with colorectal cancer: a longitudinal study

Title. Experiences of self‐care in patients with colorectal cancer: a longitudinal study. Aim. This paper is a report of a study to explore patients’ experiences of self‐care during a 6‐month course of chemotherapy treatment for colorectal cancer. Background. A greater degree of patient involvement in self‐care is increasingly being encouraged, however, little is known about patients’ experiences of being actively involved in their self‐care. Methods. Semi‐structured interviews were carried out with 11 patients at the beginning and end of their treatment for colorectal cancer in a Scottish cancer centre between March 2005 and June 2006. The ways in which participants were actively involved in managing the impact of undergoing chemotherapy treatment and their understandings of the meaning of self‐care were explored. Findings. Patients carried out self‐care in order to preserve their self‐identity and maintain a sense of normality. Self‐care activities intended to manage both the physical and emotional impact of undergoing treatment included the use of medications and nutritional supplements and reducing food intake, information‐seeking and ‐sharing experiences with fellow patients and rationalizing the purpose and effects of their chemotherapy treatment. Conclusion. Nurses have an important role to play in ensuring that patients’ perspectives and priorities for self‐care, in particular what they do, why they do it and what it means to them, and that they are listened to, in order to help them achieve their desired level of involvement in self‐care. Interventions to promote self‐care should focus on helping people to preserve their self‐identity, as well as managing the emotional toll and physical side effects associated with cancer treatment.     

Negotiation of parental roles within family-centred care: a review of the research

Aims and objectives. To review research published in the past 15 years about how children's nurses’ negotiate with parents in relation to family‐centred care. Background. Family‐centred care is a basic tenet of children's nursing and requires a process of negotiation between health professionals and the family, which results in shared decision‐making about what the child's care will be and who will provide this. The literature highlights inconsistencies in the degree to which nurses are willing to negotiate with parents and allow them to participate in decisions regarding care of their child. There is need to explore further the extent to which nurses communicate and negotiate shared care with children and their parents. Conclusions. Three themes emerged from this review of the literature relating to whether role negotiation occurred in practice, parental expectations of participation in their child's care and issues relating to power and control. Parents wanted to be involved in their child's care but found that nurses’ lack of communication and limited negotiation meant that this did not always occur. Nurses appeared to have clear ideas about what nursing care parents could be involved with and did not routinely negotiate with parents in this context. Relevance to clinical practice. For family‐centred care to be a reality nurses need to negotiate and communicate with children and their families effectively. Parents need to be able to negotiate with health staff what this participation will involve and to negotiate new roles for themselves in sharing care of their sick child. Parents should be involved in the decision‐making process. However, research suggests that a lack of effective communication, professional expectations and issues of power and control often inhibit open and mutual negotiation between families and nurses.     

Observations of nursing staff compliance to a checklist for person‐centred handovers – a quality improvement project

Nursing shift‐to‐shift handovers are important as they impact the care quality indicators such as safety, patient satisfaction and continuity. However, nurses’ handovers have also been criticised and described as unstructured and ineffective. To improve the handovers and involve patients and their loved ones in the process, a person‐centred handover (PCH) model performed at bedside has been developed and tested at Karolinska University Hospital, Sweden. This study reports on the nursing staffs’ compliance to a checklist used for the newly introduced PCH model. A total of 43 PCH sessions were observed at two acute care wards, using a structured observation protocol. None of the observed handover sessions included all the 13 PCH checklist subcomponents. The checklist was used in 18 (44%) of the observed handover sessions. A statistically significant higher number of subcomponents were observed when the nurses used the PCH checklist (6.4 vs. 4.5 subcomponents, p < 0.05). The mean time spent on each PCH was 6 minutes. In 56% of the sessions, the patients were observed to actively participate in the handover. Overall, the nursing staffs’ compliance to the PCH checklist needs to be improved. The observations suggest that training on communication‐oriented tasks would be beneficial to establish a person‐centred handover process.     

Patients' substantialization of disease,the hybrid symptom and metaphysical care

In the context of current scholarship concerned with facilitating integration between the biomedical and the patient‐centred models of care, the article suggests that disease brings about an ontological disruption in patients, which is not directly addressed in either model, and may interfere with treatment and therapy outcomes if not met with a type of care termed here as ‘metaphysical’. The receipt of diagnosis and medical care can give patients the sense that they are ontologically diminished, or less of a human, and along with physicians' approaches to and discourses about disease, may prompt them to seek ontological restoration or security in the same way as psychologically traumatized patients sometimes do: by treating the disease and/or the experience of harm associated with it as a thing that exists per se. I call this ‘substantialization’ of disease (or harm) and draw on Augustine's theory of non‐substantial deficiencies (physiological and moral) and on Plato's and Plotinus's different takes on such defects in order to discuss what substantialization can do for patients. Based on literature that examines patients' ways of talking about and living with their disease, I speculate that substantialization can generate a ‘hybrid symptom’, consisting in patterns of exercising agency which may predispose to non‐adherence. Ways in which physicians could provide metaphysical care are proposed, along with an understanding of chronic patients as hybrid ontological and agentic units, which draws on theories of enactive cognition. I opine that metaphysical care may facilitate integration between the depersonalized and personalized models of care.     

Using holistic interpretive synthesis to create practice‐relevant guidance for person‐centred fundamental care delivered by nurses

Nursing policy and healthcare reform are focusing on two, interconnected areas: person‐centred care and fundamental care. Each initiative emphasises a positive nurse–patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse–patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice‐relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse–patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse–patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person‐centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.     

Iranian nurses’ preparation for loss: finding a balance in end‐of‐life care

Aim. To explore the nurse–patient interaction in terminally ill situations in acute care, focusing on the nurses’ preparation for loss. Background. Caring for dying patients can be a distressing and sometimes even threatening experience for nurses. Despite the vast body of literature on nurse/patient interaction and the quality of end‐of‐life care, few studies focus specifically on nurses’ experience. Design. A grounded theory approach was used to explore nurses’ interaction with dying patients and their families and examine how nurses deal with situations in which the patient’s death is inevitable. Method. Eighteen nurses were interviewed up to three times each at three teaching hospitals in Isfahan, Iran, during autumn 2006. A shortlist of possible participants was obtained by means of theoretical sampling and those who had experienced the death of patients and were able to express their feelings verbally were selected. Results. The results clarified a core consideration: striking a balance between restorative and palliative care, information and hope, expectations and abilities and intimacy and distance. Conclusion. Attaining a balance in caring for dying patients is a major challenge to nurses: it concerns not only their interactions with patients and their families, but also their perceptions of themselves and their actions in end‐of‐life care. Relevance to clinical practice. In end‐of‐life care, it is important for nurses to be able to change the focus of their care when the patient’s condition is diagnosed as irreversible. They also need to be well equipped to maintain a balance, thereby preparing themselves for the patient’s forthcoming death.