Person‐centred care: clarifying the concept in the context of inpatient psychiatry

This paper reports an analysis of the concept of person‐centred care in the context of inpatient psychiatry. It has been suggested that person‐centred care in inpatient psychiatry might differ from person‐centred care in other contexts, indicating a need to clarify the concept in this specific context. Scholarly papers from health‐related disciplines were identified following a systematic search of the electronic databases CINAHL, PUBMED and PsycINFO, covering records indexed up until March 2014. An evolutionary approach to concept analysis was applied, integrating principles for data extraction and analysis in integrative reviews. The concept of person‐centred care was defined as cultural, relational and recovery‐oriented. It aspires to improve care and calls for a transformation of inpatient psychiatry. The concept is closely related to the concepts of recovery and interpersonal nursing. The result is described in terms of attributes, antecedents, consequences and related concepts. It is concluded that the further development of the concept needs to consider the contexts of the concept at both conceptual and praxis levels. Further research should explore the nature of and relationships between context, culture, care practice and outcomes in inpatient psychiatry from a perspective of person‐centred care. The results of this analysis can provide a framework for such research.     

Beyond ‘person‐centred’ care: a new vision for gerontological nursing

Currently considerable emphasis is placed on the promotion of person‐centred care, which has become a watchword for good practice. This paper takes a constructively critical look at some of the assumptions underpinning person‐centredness, and suggests that a relationship‐centred approach to care might be more appropriate. A framework describing the potential dimensions of relationship‐centred care is provided, and implications for further development are considered.     

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.     

Appreciating the ‘person’ in long‐term care

Background. Internationally, approaches to the long‐term care of older people are changing. New models are being developed that aim to de‐institutionalise care settings, maximise opportunities for older people to participate in decision‐making and move from a predominant medical model of care to one that is community orientated. Aims. The aim of this study is to highlight similarities and differences between the different models that exist and explore the implications of these for the role of the registered nurse in long‐term care. Methods. We chose three models for review as these represent a range of views of person centredness, each having distinct roots and focus. The models chosen were as follows: (i) culture change, (ii) person‐centred practice and (iii) relationship‐centred care. Results. The review highlights two key issues – (i) the distinctiveness of different models and frameworks and (ii) different interpretations of ‘person’. Firstly, we identify a disconnection between espoused differences between models and frameworks and the reality of these differences. The evidence also identifies how some models and frameworks adopt a more inclusive conceptualisation of person and personhood and do not define personhood in relation to role (resident, nurse and family member). Conclusions. There is merit in the development of models and frameworks that try to make explicit the different dimensions of person centredness in long‐term care. However, the focus on the development of these, without sufficient attention being paid to evidence of best practices grounded in the concept of personhood, person‐centred care is in danger of losing its original humanistic emphasis. Further, models and frameworks need to take account of the personhood of all persons. Implications for practice. Registered nurses need to have an understanding of the concept of personhood to make sense of the various person‐centred practice frameworks that exist. Without this understanding, there is a danger that the essence of personhood may be lost in the zeal to implement particular models and frameworks.     

Development and testing of a patient‐centred care competency scale for hospital nurses

This study aimed to develop and test the psychometric soundness of a patient‐centred care competency (PCC) scale for hospital nurses. A cross‐sectional questionnaire survey was conducted among 594 nurses in two teaching hospitals (response rate 99.5%). Reliability and validity analyses were performed. The PCC scale consisted of 17 items divided into four subscales: respecting patients' perspectives (6 items), promoting patient involvement in care processes (5 items), providing for patient comfort (3 items) and advocating for patients (3 items). The Cronbach's alpha coefficient of the entire scale was 0.92, and those for the subscales were 0.85, 0.81, 0.84 and 0.80, respectively. Multitrait scaling analysis indicated that the four subscales had satisfactory convergent and discriminant validity. Significant correlations were found between total PCC scores and overall self‐ratings of patient‐centred care performance (r = 0.60, P < 0.001). The PCC scale was therefore determined to be a highly valid and reliable tool.     

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.     

Patient‐centred care through a broader lens: Supporting patient autonomy alongside moral deliberation

Patient‐centred care (PCC) is an essential component of high‐quality healthcare and shared decision‐making is its cornerstone. Yet, integrating the principles of PCC into healthcare practice is not always straightforward and shared decision‐making can be complicated and ethically demanding. While ethicists and academics routinely debate moral aspects of clinical care, such discussion among clinicians is less overt. In this paper, we use Emmanuel et al.’s deliberative model to provide a practical framework for considering ethical aspects of PCC and shared decision‐making. The model encourages us to appreciate PCC through a broader lens and consider patient autonomy alongside other moral obligations such as justice and the equitable distribution of finite resources. The model can be used by healthcare providers, patients and caregivers to facilitate dialogue and moral deliberation regarding the merit of their preferences and values; in this way, individualised care can be delivered without compromising other important ethical obligations.     

How to make a particular case for person‐centred patient care: A commentary on Alexandra Parvan

In recent years, a person‐centred approach to patient care in cases of mental illness has been promoted as an alternative to a disease orientated approach. Alexandra Parvan's contribution to the person‐centred approach serves to motivate an exploration of the approach's most apt metaphysical assumptions. I argue that a metaphysical thesis or assumption about both persons and their uniqueness is an essential element of being person‐centred. I apply the assumption to issues such as the disorder/disease distinction and to the continuity of mental health and illness.     

The Tri‐focal model of care: Advancing the teaching‐nursing home concept

Providing residential aged care is challenging because of the complexity of residents’ health status, difficulties recruiting and retaining skilled staff, and financial and regulatory constraints. This paper discusses some of these challenges and describes an innovative model of care, termed ‘The Tri‐focal model of care’. This model was developed based on the concepts of ‘partnership‐centred care’, ‘positive work environment’ and the need for evidence‐based practice to underpin all aspects of care. It is envisaged that the implementation of this model will provide a rich learning environment that advances the teaching‐nursing home concept and the quality of residential aged care.     

Caring for people with dementia disease (DD) and working in a private not‐for‐profit residential care facility for people with DD

Caring for people with dementia and working in dementia care is described as having both rewarding and unpleasant aspects and has been studied to a minor extent. This study aims to explore care providers' narrated experiences of caring for people with dementia disease (DD) and working in a private not‐for‐profit residential care facility for people with DD. Nine care providers were interviewed about their experiences, the interviews were recorded, transcribed and analysed using thematic analysis. The analysis revealed that participants were struggling to perform person‐centred care, which meant trying to see the person behind the disease, dealing with troublesome situations in the daily care, a two‐edged interaction with relatives, feelings of shortcomings and troubled conscience, and the need for improvements in dementia care. The analysis also revealed an ambiguous work situation, which meant a challenging value base, the differently judged work environment, feelings of job satisfaction and the need for a functional leadership and management. The results illuminate participants' positive as well as negative experiences and have identified areas requiring improvements. It seems of great importance to strive for a supportive and attendant leadership, a leadership which aims to empower care providers in their difficult work. Using conscience as a driving force together in the work group may benefit care providers' health.     

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.     

Mental health nurses’ experience of physical health care and health promotion initiatives for people with severe mental illness

Health care for people with severe mental illness is often divided into physical health care and mental health care despite the importance of a holistic approach to caring for the whole person. Mental health nurses have an important role not only in preventing ill health, but also in promoting health, to improve the overall health among people with severe mental illness and to develop a more person‐centred, integrated physical and mental health care. Thus, the aim of this study was to describe mental health nurses’ experiences of facilitating aspects that promote physical health and support a healthy lifestyle for people with severe mental illness. Interviews were conducted with mental health nurses (n = 15), and a qualitative content analysis was used to capture the nurse’s experiences. Analysis of the interviews generated three categories: (i) to have a health promotion focus in every encounter, (ii) to support with each person’s unique prerequisites in mind and (iii) to take responsibility for health promotion in every level of the organization. The results show the importance of a health promotion focus that permeates the entire organization of mental health care. Shared responsibility for health and health promotion activities should exist at all levels: in the person‐centred care in the relation with the patient, embedded in a joint vision within the working unit, and in decisions at management level.     

Person-centred integrative care

Rationale, aims and objectives The essential ingredients of effective person‐centred integrative care are described and its benefits are documented in terms of influence on compliance with care, drop‐out rates, enhancement of well‐being and reduction in ill‐being. Method Prior literature on efficacy of person‐centred treatment in medicine and psychology is reviewed and related to definitions of health and well‐being. Results The general characteristics of person‐centred care involve multiple elements. First, the doctor must be aware of the personality of the individual in order to enter into a humanistic dialogue with the person. Second, for a therapeutic alliance, there must be agreement that doctor and patient are working toward common goals. Third, calm reassurance, hope, and respect need to be communicated. Fourth, the doctor and patient need to be empathic and reflective. Fifth, they must identify and implement practical means of promoting health with available resources and a realistic understanding of facts. Conclusion Awareness of who the person is in a therapeutic encounter allows cultivation of a humanistic dialogue, which in turn accounts for most of the variation in clinical outcomes.     

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.     

Multi‐professional communication for older people in transitional care: a review of the literature

Aims and objectives. To synthesise research‐reporting literature about multi‐professional communication between health and social care professionals within transitional care for older people, with particular attention on outcomes, enabling contextual factors and constraints. Background. Older adults experience high rates of morbidity and health care usage, and frequently transit between health services, and community and social care providers. These transition episodes place elders at increased risk of adverse incidents due to poor communication of information. Integrated multi‐professional models of care built on enhanced communication have been widely promoted as a strategy to improve transitional care for older people. However, a range of findings exist in the literature to guide service providers and researchers. Design. Comprehensive literature search and review strategies were employed to identify, describe and synthesise relevant studies. Ten databases were searched in addition to Google Scholar. Conclusions. Specified discharge worker roles, multi‐professional care coordination teams, and information technology systems promote better service satisfaction and subjective quality of life for older people when compared with standard hospital discharge. Improved multi‐professional communication reduces rates of re‐admission and length of stay indicating greater cost effectiveness and efficiency for the health and social care systems. Systems of care emphasizing information exchange, education and negotiation between stakeholders facilitate communication in transitional care contexts for older adults. Conversely, lack of dialogue and lack of understanding of others’ roles are barriers to communication in transitional care. Implications for practice. Enhanced multi‐professional communication, transitional pathways, and role clarity are required to improve the quality, sustainability and responsiveness of aged care into the future. Recommendations for further research include: (i) Investigation of pathways promoting person‐centred care planning including the older person, their family and relevant practitioners; (ii) Development of interventions aimed at improving multi‐professional communication and transitional aged care with marginalised and socially disadvantaged elders on indicators of equity and access; (iii) Investigation of changing roles for practitioners in multi‐professional teams with a focus on community‐based teams including nurses specialising in aged care and general practice.     

A review of safe‐staffing models and their applicability to care homes

Presently, there are a range of evidence‐based staffing tools that have been used to inform nursing, midwifery and health care capacity. These tools are designed to be used with professional judgement and include frameworks such as Rhys Hearn, the National Services Scotland Care Home Staffing Project, a variety of Royal College of Nursing Tool Kits including the Older People in Hospital's tool and the only National Institute of Clinical Excellence approved safe‐staffing tool, Shelford's Safer Nursing Tool. These safe‐staffing tools are used to score a patient's or resident's level of dependency across a number of domains, for example a patient/resident's ability to wash, dress, mobilise or fulfil their own elimination needs. While these tools have been beneficial with regards to informing staff levels there are a number of limitations that are important to highlight. Succinctly, most are not readily applicable to care home settings nor do they focus on more person‐centred aspects of care.     

Shared decision‐making in maternity care: Acknowledging and overcoming epistemic defeaters

Shared decision‐making involves health professionals and patients/clients working together to achieve true person‐centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision‐making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision‐making for caesarean section. The team concluded that shared decision‐making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision‐making (defeaters) are disclosed. Informed consent is not shared decision‐making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision‐making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required.