Should a Patient Choose their Management Plan in Person Centred Physiotherapy Care?

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8th Feb 2020 Health Reference this

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The construct of person-centered care is ever changing, consequently impacting on the interaction between a physiotherapist and the patient. Providing patient centered care involves arranging and conveying healthcare, depending on patients’ needs, inclinations and encounters (Dukhu et al. 2018). In the Australian health care setting, this principle has been practiced for over a decade and is reflected in the Australian Charter of Health Care Rights (ACSQHC, 2007), as well as the Australian Safety and Quality Framework for Health Service Standards (ACSQHC, 2011). The contention of this essay is to discuss individual-focused models of physiotherapy care and whether a patient should have the capacity to pick their own management plan. One argument may suggest patients have complete control in deciding treatment goals. On the other hand, health professionals possess the appropriate knowledge and expertise, therefore have the right to dictating treatment plans. However, ultimately equal partnership between the patient and healthcare professional is essential in order to a develop a successful treatment plan that all parties are satisfied with.

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Barry (2012) contended, ‘for some decisions, there is one clearly superior path, and patient preferences play little or no role’. Arguments in favour of patients independently making health care decisions are dismantled by cognitive, affective or behavioural deficiencies that deem a patient unfit to gain informed consent and participate in decision-making.Be that as it may, basic to submitting to morals, the physiotherapist must increase educated assent from the patient before recommending treatment or moving forward with the overall care plan. Furthermore, as stated by the General Medical Council in 1998, the prerequisites for informed consent require a level of patient commitment to the decision at hand. Autonomous self actualization, decision making and the sanctioning of interpersonal drive to develop trust all stem for appropriate informed consent. This leads to greater compliance during therapeutic intervention. With regards to the decision making process, the family of the patient should also be involved in the circumstance when the patient is unable to consciously make an accurate choice that reflects their opinion due to their mental state. Hence, stressing the importance of a holistic approach when adapting treatment for the patient.

The therapeutic relationship within the health care system has traditionally been characterized as paternalistic (Komrad, 1983). Through employment of such an approach, the clinician acts as the sole decision maker, based on what they determine to be in the patient’s best interest. However, through excluding patients from their own treatment plans and when making key decisions persistent disappointment may be observed in interactions between the clinician and patient. Patients may also experience reduced self confidence when asking questions, an inability to address concerns about their care plans and overall hesitation when communicating with the clinician in regards to their personal beliefs, for fear of being viewed as impolite or inappropriate. Furthermore, the relationship between the therapist and the patient is diminished due to paternalistic tendencies exhibited by the physiotherapist. Moreso, if the individual receiving treatment considers their contribution to be dulled as a result of decreased understanding and awareness, they are more inclined to become passive recipient of treatment (Epstein et al., 2007).  A 1995 study performed by Donovan et al. found that between one-third and one-half of all patients had poor or a complete lack of compliance pertaining medical advice and prescriptions. Interestingly, patients were absent from decision-making processes was absent from these records. Ultimately, adoption of a paternalistic approach in the healthcare setting should be avoided in order to foster positive clinician-patient relationships, effective communication and decision making.

On the contrary, the primary principles of patient-centred care focus on the ethical paradigms of autonomy and the right to self-determination (Jo Delaney, 2018). The definition of autonomy is independence or self-rule. The philosophy behind this principle is that every patient is an independent being with a unique background based on genetics, upbringing, culture, religion and personal experiences. Because of these differences, it is simply not possible for a healthcare professional to determine what is the best treatment or management for every patient presenting for care. Therefore, by providing an autonomous individual a comprehensive understanding of their problem, that individual, will be best able to decide what the most appropriate treatment would be (Lo, 2009).

The combination of clinician knowledge and patient understanding are crucial in avoiding an unfavorable result. The merger of inputs from both, can be achieved when the therapist adopts the role as an educator in order to guide the patient to a logical decision (Coulter, 1999). If the patient assumes the role of making decisions as their sole focus, this leads to a preferred and enhances health outcomes, as seen within an expanding body of evidence. Thus, improving patient adherence encourages patient autonomy. The advantage of patient involvement in their own treatment plans has been explored in many different studies. The advantages include but are not limited to; increased confidence and satisfaction, improved quality of life, decrease in apprehensiveness, refined comprehension of their situation, increase in their positivity with regards to communication, patient empowerment, increased monitoring and evaluation of services, decisions based on multiple perspectives, greater transparency, improved ability in dealing with inequalities in health and access, career progression due to positive feedback and reduced likelihood of patient dissatisfaction (Vahdat, Hamzehgardeshi, Hessam & Hamzehgardeshi, 2014). A mixed method study found that practitioners who achieved top patient outcomes were seen to include a person-centred care in their clinical reasoning. This is in stark contrast to the practitioners who scored average results; who exhibited little to no person-centred care in their clinical reasoning. Whilst the physiotherapist is usually well-informed about diagnostic techniques, epidemiology, treatment and prognosis of the patient conditions, it is the patient alone who has to deal with the experiences of their condition/illness, and is fully aware of their personal and social state of affairs, attitudes, potential risks, values/beliefs and preferences. Therefore, in order to manage conditions successfully, both types of knowledge are integral, and both parties should exchange information and make decisions in a joint manner (Coulter, 2011).

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The attributes and concerns of the physiotherapist are portrayed as impacting on the engagement and relationships – described by different authors as a ‘therapeutic alliance’ (Mead & Bower, 2000), ‘therapeutic engagement’ and ‘engagement’ (McCormack et al., 2011; McCormack and McCance, 2017). The elaboration of these terms emphasize the importance of respect, accurate division of power and responsibility, a shared perspective on goals, personalizing and customizing health interventions. Aside from improving health outcomes, patient participation gives rise to more a willing and conducive individual. Moreover, clinicians develop a more constructive attitude toward patient participation and in most cases consider it to be a special privilege. A major role within the discipline of physiotherapy is to adhere to the ethic of patient autonomy to ensure the disclosure of information, understanding for the patient, relieving feelings of duress (if present) and to develop adequate decision making skills (Walton, 2002).

Historically, paternalism has been a traditional characteristic of therapeutic relationships. However, the notion that health professionals maintain the right to make clinical decisions based on what they discern to be in the best interest of the patient, even for patients capable of making decisions for themselves, is outdated and archaic. Within a modern healthcare setting, physiotherapists should adapt to person-centred models of care, which underpins the values of mutual respect, understanding of the individual’s needs and values, fully involving their perspectives, as well as their right to autonomy and self-determination. Whilst patients should have the right to choose their own management plan, the physiotherapist provides the role of an educator in order to guide and empower the patient to reasonable decision-making (Coulter, 1999). Therefore, emphasis should be placed on equal partnership; the combination of clinician knowledge and patient insight when planning and developing treatment plans in order to manage conditions and enhance health outcomes successfully.

References:

The construct of person-centered care is ever changing, consequently impacting on the interaction between a physiotherapist and the patient. Providing patient centered care involves arranging and conveying healthcare, depending on patients’ needs, inclinations and encounters (Dukhu et al. 2018). In the Australian health care setting, this principle has been practiced for over a decade and is reflected in the Australian Charter of Health Care Rights (ACSQHC, 2007), as well as the Australian Safety and Quality Framework for Health Service Standards (ACSQHC, 2011). The contention of this essay is to discuss individual-focused models of physiotherapy care and whether a patient should have the capacity to pick their own management plan. One argument may suggest patients have complete control in deciding treatment goals. On the other hand, health professionals possess the appropriate knowledge and expertise, therefore have the right to dictating treatment plans. However, ultimately equal partnership between the patient and healthcare professional is essential in order to a develop a successful treatment plan that all parties are satisfied with.

Barry (2012) contended, ‘for some decisions, there is one clearly superior path, and patient preferences play little or no role’. Arguments in favour of patients independently making health care decisions are dismantled by cognitive, affective or behavioural deficiencies that deem a patient unfit to gain informed consent and participate in decision-making.Be that as it may, basic to submitting to morals, the physiotherapist must increase educated assent from the patient before recommending treatment or moving forward with the overall care plan. Furthermore, as stated by the General Medical Council in 1998, the prerequisites for informed consent require a level of patient commitment to the decision at hand. Autonomous self actualization, decision making and the sanctioning of interpersonal drive to develop trust all stem for appropriate informed consent. This leads to greater compliance during therapeutic intervention. With regards to the decision making process, the family of the patient should also be involved in the circumstance when the patient is unable to consciously make an accurate choice that reflects their opinion due to their mental state. Hence, stressing the importance of a holistic approach when adapting treatment for the patient.

The therapeutic relationship within the health care system has traditionally been characterized as paternalistic (Komrad, 1983). Through employment of such an approach, the clinician acts as the sole decision maker, based on what they determine to be in the patient’s best interest. However, through excluding patients from their own treatment plans and when making key decisions persistent disappointment may be observed in interactions between the clinician and patient. Patients may also experience reduced self confidence when asking questions, an inability to address concerns about their care plans and overall hesitation when communicating with the clinician in regards to their personal beliefs, for fear of being viewed as impolite or inappropriate. Furthermore, the relationship between the therapist and the patient is diminished due to paternalistic tendencies exhibited by the physiotherapist. Moreso, if the individual receiving treatment considers their contribution to be dulled as a result of decreased understanding and awareness, they are more inclined to become passive recipient of treatment (Epstein et al., 2007).  A 1995 study performed by Donovan et al. found that between one-third and one-half of all patients had poor or a complete lack of compliance pertaining medical advice and prescriptions. Interestingly, patients were absent from decision-making processes was absent from these records. Ultimately, adoption of a paternalistic approach in the healthcare setting should be avoided in order to foster positive clinician-patient relationships, effective communication and decision making.

On the contrary, the primary principles of patient-centred care focus on the ethical paradigms of autonomy and the right to self-determination (Jo Delaney, 2018). The definition of autonomy is independence or self-rule. The philosophy behind this principle is that every patient is an independent being with a unique background based on genetics, upbringing, culture, religion and personal experiences. Because of these differences, it is simply not possible for a healthcare professional to determine what is the best treatment or management for every patient presenting for care. Therefore, by providing an autonomous individual a comprehensive understanding of their problem, that individual, will be best able to decide what the most appropriate treatment would be (Lo, 2009).

The combination of clinician knowledge and patient understanding are crucial in avoiding an unfavorable result. The merger of inputs from both, can be achieved when the therapist adopts the role as an educator in order to guide the patient to a logical decision (Coulter, 1999). If the patient assumes the role of making decisions as their sole focus, this leads to a preferred and enhances health outcomes, as seen within an expanding body of evidence. Thus, improving patient adherence encourages patient autonomy. The advantage of patient involvement in their own treatment plans has been explored in many different studies. The advantages include but are not limited to; increased confidence and satisfaction, improved quality of life, decrease in apprehensiveness, refined comprehension of their situation, increase in their positivity with regards to communication, patient empowerment, increased monitoring and evaluation of services, decisions based on multiple perspectives, greater transparency, improved ability in dealing with inequalities in health and access, career progression due to positive feedback and reduced likelihood of patient dissatisfaction (Vahdat, Hamzehgardeshi, Hessam & Hamzehgardeshi, 2014). A mixed method study found that practitioners who achieved top patient outcomes were seen to include a person-centred care in their clinical reasoning. This is in stark contrast to the practitioners who scored average results; who exhibited little to no person-centred care in their clinical reasoning. Whilst the physiotherapist is usually well-informed about diagnostic techniques, epidemiology, treatment and prognosis of the patient conditions, it is the patient alone who has to deal with the experiences of their condition/illness, and is fully aware of their personal and social state of affairs, attitudes, potential risks, values/beliefs and preferences. Therefore, in order to manage conditions successfully, both types of knowledge are integral, and both parties should exchange information and make decisions in a joint manner (Coulter, 2011).

The attributes and concerns of the physiotherapist are portrayed as impacting on the engagement and relationships – described by different authors as a ‘therapeutic alliance’ (Mead & Bower, 2000), ‘therapeutic engagement’ and ‘engagement’ (McCormack et al., 2011; McCormack and McCance, 2017). The elaboration of these terms emphasize the importance of respect, accurate division of power and responsibility, a shared perspective on goals, personalizing and customizing health interventions. Aside from improving health outcomes, patient participation gives rise to more a willing and conducive individual. Moreover, clinicians develop a more constructive attitude toward patient participation and in most cases consider it to be a special privilege. A major role within the discipline of physiotherapy is to adhere to the ethic of patient autonomy to ensure the disclosure of information, understanding for the patient, relieving feelings of duress (if present) and to develop adequate decision making skills (Walton, 2002).

Historically, paternalism has been a traditional characteristic of therapeutic relationships. However, the notion that health professionals maintain the right to make clinical decisions based on what they discern to be in the best interest of the patient, even for patients capable of making decisions for themselves, is outdated and archaic. Within a modern healthcare setting, physiotherapists should adapt to person-centred models of care, which underpins the values of mutual respect, understanding of the individual’s needs and values, fully involving their perspectives, as well as their right to autonomy and self-determination. Whilst patients should have the right to choose their own management plan, the physiotherapist provides the role of an educator in order to guide and empower the patient to reasonable decision-making (Coulter, 1999). Therefore, emphasis should be placed on equal partnership; the combination of clinician knowledge and patient insight when planning and developing treatment plans in order to manage conditions and enhance health outcomes successfully.

References:

  • Australian Commission on Safety and Quality in Health Care. (2007). The Australian charter of healthcare rights in victoria. Retrieved from: https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Charter-PDf.pdf
  • Australian Commission on Safety and Quality in Health Care. (2011). The Australian safety and quality framework for health service stands. Retrieved from: https://www.safetyandquality.gov.au/national-priorities/australian-safety-and-quality-framework-for-health-care/
  • Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine366(9), 780-781.
  • Coulter, A. (1999). Paternalism or partnership?: patients have grown up—and there’s no going back. BMJ: British Medical Journal319(7212), 719.
  • Coulter, A. (2011). Engaging patients in healthcare. McGraw-Hill Education (UK).
  • Donovan, J. L. (1995). Patient decision making: the missing ingredient in compliance research. International journal of technology assessment in health care11(3), 443-455.
  • Dukhu, S. Purcell, C. Bulley C. (2018) Person-centred care in the physiotherapeutic management of long-term conditions: a critical review of components, barriers and facilitators. International Practice Development Journal, 8(2), 1-27, retrieved from: https://www.fons.org/Resources/Documents/Journal/Vol8No2/IPDJ_0802_2.pdf
  • Jo Delaney, L. (2018). Patient-centred care as an approach to improving health care in Australia. Collegian, 25(1), 119-123. doi: 10.1016/j.colegn.2017.02.005
  • Komrad, M. S. (1983). A defence of medical paternalism: maximising patients’ autonomy. Journal of medical ethics9(1), 38-44.
  • Lo, B. Resolving ethical dilemmas.
  • McCormack, B., Dewing, J., McCance, T. (2011). Developing person-centred care: addressing contextual challenges through practice development. The Online Journal of Issues in Nursing. 16(2), 1-3. doi: 10.3912/OJIN.Vol16No02Man03
  • McCormack, B., McCance T. (2017) Person-centred practice in nursing and healthcare: theory and practice. (2nd Ed.). London, England: Wiley-Blackwell.
  • Mead, Nicola, and Bower, Peter. “Patient-centrednes: A Conceptual Framework and Review of the Empirical Literature.(Statistical Data Included).” Social Science & Medicine 51.7 (2000): 1087. Web.
  • Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient Involvement in Health Care Decision Making: A Review. Iranian Red Crescent Medical Journal, 16(1). doi: 10.5812/ircmj.12454
  • Walton, M. (2002). Patients’ autonomy: does doctor know best?.

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