NSCIG201 Concepts in Nursing

Edith Balint originally depicted person-centered care in 1969 and ever since then the concept has undergone several evolutions to emerge as an essential and indispensable ideology in the delivery of healthcare services in various jurisdictions [1]. The definition and operationalization of this concept might vary based on the jurisdiction in which it is being adopted. However, the general principle underlying the concept is universal – “patients are unique human beings and should be treated likewise.” This essay aims to capture the essence of person-centered care and critically examine the facilitators and inhibitors in the promotion of person-centered care services, aligned with the tenets of collaboration, inclusion, and patient participation. The exclusive focus of the essay will be on the workplace factors that inhibit and promote person-centered care. The essay will further delineate factors that need to change within practice settings that help in the establishment of person-centered care.

Person-centered care

Person-centered care (PCC1) is a valued policy in contemporary health care settings. The opinions of the patient, the patient’s family members and his/her near ones are being increasingly incorporated in the care plan of the patient. Current global healthcare policies are aiming at patient empowerment in the decision-making part of treatment [2]. This has many benefits. First, the person-centered approach has been seen to foster patient empowerment by increasing self-efficacy, optimizing treatment outcomes, and improving patient well-being [3]. Second, this approach has also lead to the increase of patient’s adherence to medication and optimal use of healthcare resources [3]. Third, it has increased patient satisfaction related to healthcare providers.  Fourth, this approach had reportedly diminished the healthcare service costs. Patient’s opinions are seen to complement the health care provider’s perspective and add unique information about the effectiveness of health care services [4]. World Health Organization has highlighted person-centeredness as a core competency of healthcare workers like nurses, doctors, and other professionals in the team.

Difference between patient-centered care and person-centered care within the context of Practice development

Patient-centered care (PCC2), though often used synonymously to patient-centered care, is greatly different from person-centered care. First, PCC2 focuses on episodic orientation, whereas, PCC1 focuses on episodes of health issues as a part of the life-course experience of health. Second, PCC2 is usually focused on the management of diseases, and PCC1 views diseases as an interrelated phenomenon that determines overall health. Third, PCC2 views body systems as distinct (partial view) and PCC1 views the mind and body as interrelated and hence considers the person as a whole (holistic view) [5]. Fourth, PCC2 views comorbidity as a number of chronic diseases, and PCC1 views comorbidity as combinations of different types of illness and thus focuses on multimodal treatment. Fifth, PCC2 traces the evolution of patient’s diseases while PCC1 traces the evolution of health problems that people experienced as well as their diseases [5].

Practice development (PD) refers to the various strategies undertaken by healthcare systems – improving staff knowledge and skills, systemic facilitation, rigorous and consistent processes to achieve evidence-based person-focused care, for the improvement of healthcare practice and enhancement of a person’s holistic well-being.

The principle differences between the two approaches (PCC1 and PCC2) should be taken into consideration before implementing changes through practice development. While the practice developmental approach in PCC2 is majorly aimed at emphasizing on organizational approaches for achieving changes, the PD in PCC1 is more focused on transformation at a healthcare practice level (micro-system level). At the micro-system level, the healthcare professionals, practice team, and practitioners closely communicate with service users through the patient pathways. In a person-centered healthcare system, the PD aims to acquire integrative effectiveness in the services provided, at every system level (micro, macro, and mezzo) to ensure the best standard quality of services to the users.

Workplace factors that inhibit person-centered care

The first step to bringing about an innovative transformation in nursing practice is acquiring an in depth understanding and evaluation of the factors prevalent in the workplace that might inhibit person-centered care. The following section discusses factors (at the micro-level) in nursing practice that have worked as a barrier in the successful implementation of PCC1 approach.

First, staffing constraints have been a pervasive problem in nursing setup, which degrades the quality of services provided to users. It has been recognized that the number of staff and user ratio is much below the expectation. There is a dearth of trained nurses, who can competently handle clients in the absence of experienced and trained nurses. On a given day, the number of nurses working is not enough to handle the client pressure and this situation is amplified by staff absenteeism [6]. Most often than not, nurses are pooled by the administration without specialty experience and appropriate training. A significant lack of context-specific experiential knowledge in the permanent staff also contributes to the detrimental quality of services [6].

Second, the workload on the nurses is immensely high, alongside time constraints. An increase in patient presentation worsens this situation. The workload on each nurse is colossal due to the nurses-clients ratio. Staffs are unable to provide quality care, enough time, and detailed information to improvise the plan according to the needs of the clients [6]. The nurses have to multitask in such a chaotic and demanding environment to keep up with the pressure only to compromise mindful and person-centered care. Patient’s opinions are seldom taken into consideration and a structured administrative protocol is followed for every patient, leaving no provision for personalized care.

Third, unsupportive attitudes of the nurses and other staff are a huge barrier in PCC1. Personal biases of nurses towards clients’ variables (age, gender, ethnic, racial background) often result in disengagement and a lack of interest in quality improvement [7]. Some nurses are cynical towards the PCC1 approach and are indifferent to change. This attitude might be instigated by the circumstantial lack of choice for the clients in a clinical setup. For instance, if someone is pregnant, she will have no other option but get the baby delivered.

Fourth, inconsistent leadership from the higher authority like the supervisor and managers makes it difficult to sustain workplace morale. There is an absolute absence of succor from the higher-ups. Often times, improvisation in care structure made by the nurses, are not supported by their supervisors. Aspiring nurses feel demotivated, incompetent, boxed-up, and misdirected with such inflexibility in the system. Workload also increases stress and burnout in the nurses leading to increased absenteeism [8].

Fifth, increased demand for documentation has created additional work pressure for the nurses. Documentation pressure takes up most of their time, which they could allot to the client care. Person-centered care gets lost among the documents that the nurses have to track to ensure ethical and moral practice.

Sixth, organizational focus on high turnover has led to a shift in the ideology of the nurses [9]. Nurses are so much under pressure to ensure more clients are taken care of in a day to increase the capital that they have to, often unwillingly, compromise their caring principles [9].

Workplace factors that enable person-centered care

There are factors in the workplace that facilitates the incorporation of PCC1 in nursing practice. These factors are essential for the overall development of healthcare services. Organizations should aim for implementing these factors at the micro-level to ensure patient empowerment [10]. The facilitating factors in nursing practice are outlined in the following sections.

First, nursing leaders focusing on the promotion of PCC1 approach to the nurses in practice can increase interest and engagement in PCC1. Leadership styles focused at clearly and concisely communicating the expectations of PCC1 to the nurses can help reduce negative biases towards the approach [11]. A PCC1 culture within the nursing practice will facilitate employee engagement, and improve staff relations. Leaders can achieve this by discussing the PCC1 approach with the nurses in detail and pervasively across situations to ensure they organically acquire a PCC1 stance through their training process. Leaders can also act as role models for demonstrating the professional attitude they need to acquire to ensure PCC1.

Second, staff satisfaction is an important determinant in the success of PCC1 approach in the nursing setup. If the nurses are supported and encouraged for their endeavors, it will not only improve the nurses’ mental well-being but also enhance self-efficacy, engagement and focus in the nurses [12].

Third, positive staff relations improve collaborative efforts and positive outcomes for the clients. Helping each other at the workplace reduces stress, improves interpersonal relationships and social identity, improves decision-making, and reduces absenteeism. Nurses can contribute to each other’s work and create a positive, harmonious, and conducive care environment [13].

Fourth, at the macro level, devising a formal structure can support PCC1. A framework can be created for the interdisciplinary team taking care of the clients to ensure sound communication between the staff and the patient and patient families. Orientation programs can be of great assistance for new recruits and professionals.

Fifth, cultural diversity among the nurses can improve communication and understanding of the diverse client population [14]. However, this factor can also act as a barrier in PCC1.

Sixth, a positive professional attitude represents commitment and interest in one’s work. Besides possessing clinical skillfulness, a competent nurse should acknowledge the client’s narrative, repeatedly confirm it and document it [15]. Nurses who consider their clients as active and capable decision-makers of one’s own health are able to successfully impart components of PCC1 in their practice.

Changes needed in nursing practice to enable a culture of Person-Centered Care

Transformation can occur at the organizational level and interpersonal level in the nursing practice to facilitate PCC1.

At the organizational level, a formal framework can be created for every member of the integrative care team to follow the guidelines of PCC1. The formal PCC1 structure can be incorporated through an update of the organizational guidelines and policy that includes PCC1 as a mandatory approach.  This is essential to building a PCC1 culture, where every care team member walks and talks in the language of PCC1.

Additionally, the organization should pay immediate attention to the recruitment of more qualified, specialist nurses and staff members to handle the daily workflow. This is essential for reducing errors and burnout in nurses. If the nurses-clients ratio is increased, each nurse will have enough time to discuss the holistic wellness plan, which will consider patients’ opinions, grievances, needs, and choices. This will not only result in positive client outcomes and improve the quality of services but also increase client empowerment, well-being and optimism. Essentially, improved services will also increase turnover, if that is the objective of the institution.

Factors like work pressure, lack of resources, fear of a lawsuit in case of errors, demand for multitasking, client grievances, time constraints, etc., result in huge stress, anxiety, and exhaustion in the nurses, stripping them of their work enthusiasm. The organization should include an hour of stress-relieving session for the nurses, once a week, where the nurses can learn stress management techniques, vent their emotions, share their problems and ideas with each other, and discuss coping skills. This will greatly improve nurses’ dedication and concentration, and decrease absenteeism, ensuring smooth flow of work.

At an interpersonal level, leaders should acquire a supportive leadership style, providing robust orientation and empowering guidance to the nurses [16]. In such a culture, nurses will be allowed to use their innovation to personalize care for each patient. Leaders should use positive reinforcement like verbal praise, incentive policies to improve engagement and work satisfaction.  Induction programs, seminars, and training sessions should be frequently held by the organization to orient staff to the nuances of the PCC1 approach. Skill training should be provided to all nurses, irrespective of their experience, qualification, position, and role.

A positive and supportive associate relationship can greatly improve work satisfaction and motivation of nurses. Transparent, informal, and frequent communication between practicing nurses creates an intimate rapport and supportive environment to work in. Many times, a supportive colleague has intervened and stopped an error from occurring through direct communication like, “Are you sure you want to do this? Don’t you think you need to consider the opinion of the patient’s family?”

Therefore, the major areas which require changes in nursing practice are the number of active specialist nurses, and organizational policies at the macro level, leadership style, nurses’ attitudes, team unity, and communication style at the micro-level. If these changes are implemented, a PCC1 culture can be practically established in healthcare settings.

References

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