Development of Person Centred Nursing Care

The aim of this essay is to describe the history of person-centred care, explain why person-centred approach is important in healthcare environment and how it is achieved. This essay will also explain the concept of a person-centeredness, the concepts of a person and personhood and the issues arising from this perspectives. Furthermore, it will describe the core concepts and frameworks. Concept of person-centred care (PCC) and patient-centred nursing framework (PCNF) suggest that all healthcare staff should focus onto values and beliefs of an individual while realising the importance of knowing self and competency amongst other factors within the healthcare staff (McCormack & McCance, 2010; Royal College of Nursing (RCN), 2010). Principles of PCC are underpinning many guides, codes and publications. These are here to assist the healthcare staff making sure that the individual at the centre of their care will experience high quality care (Department of Health (DH), 2012; Nursing and Midwifery Council (NMC), 2008; RCN, 2010). Because of the complex nature of PCC this essay will only explain the above mentioned principles in more depth (values and beliefs of an individual, knowing self and competency). Furthermore, this essay will identify the issues involved in delivering PCC, including the media case involving Mid Staffordshire NHS and Francis report (2013).

From historical point of view the term person-centeredness was developed by psychologist and one of the founders of the humanistic approach Carl Rogers, who focused mainly on creating therapeutic relationships with his clients. Rogers identified three core conditions important in delivering person-centred therapy – empathy, therapeutic genuineness and unconditional positive regard for all clients (Josefowitz & Myran, 2005). Empathy is described as the ability to put oneself in the person’s place, imagining how one would feel in their situation (NMC, 2010). Accurate level of empathy and congruence defines the genuineness (Truax et al., 1966) of the therapist. Rogers (1957) describes unconditional positive regard as the acceptance of person’s positive, negative feelings and experiences.

Now that the historical background of the person-centred approach was explained, it is important to understand the concept of a person. This concept represents the humanness and the way one is constructing a way of life. Attributes of a person such as desires, motives, memory and others, shape moral values, spiritual or religious and political beliefs and also emotional involvement in relationships (McCormack & McCance, 2010). Among several perspectives explaining the concept of a person there is the hierarchy of attributes perspective, which suggests that to be classed as a person, one has to collect several physical and psychological attributes (McCormack & McCance, 2010). The issue surrounding this approach is that an individual suffering from dementia (loss of a memory attribute) would automatically lose the person status (McCormack & McCance, 2010). Concept of personhood defined by Kitwood (1997) suggests that in context of relationship and social being, others give a status to human being. This status is based on trust, respect and recognition. Regardless of the differences, these perspectives can be connected through the authenticity. It is a process of self-discovery based on person’s values, ideals and actions. It is a realisation of ones potential and also acting on this potential while accepting the responsibility for the consequences of life choices (Starr, 2008).

Respecting and accepting a person as an individual, their values and beliefs and providing an individual approach to person’s needs and care is fundamental in PCC because it ensures that the person is participating in their healthcare as an equal partner (RCN, 2014). RCN (2014) also states that involvement of a person in their own care is beneficial for the person because they experience greater satisfaction with care and the system becomes more cost-effective. VIPS framework suggests that to ensure PCC it has to be understood that every single human life has an absolute value. Each person’s values and beliefs are unique and therefore each person requires an individual approach. All health care staff should be able to see and understand the world from the person’s perspective and create a supportive social environment (Brooker, 2004). McCormack (2004) defined four core concepts of person centred nursing paying attention to personal values and beliefs in his first core concept – being in a social context. For a nurse the social context of a person means a true understanding of person’s context (their values, beliefs and life experiences) which allows creating a life plan that nurtures an individual personhood (McCormack, 2004). Schofield (1994) states that concerns in care can be clarified when individual’s biographical details and social context are recognised by an experienced nurse. Furthermore, being able to work with ones beliefs and values reduces generalisation based on pre-conceptions and previous experiences (McCormack & McCance, 2010). Clarke et al. (2003) found out that this biographical approach improves PCC as it encourages healthcare staff to see the person and not a patient, which is helpful in building relationships with patients and their family. McCormack’s (2004) remaining core concepts are – being in relation, being in place and being with self. Being in relation emphasises the importance of relationships between healthcare staff and the person. Being in place suggests that the place where care is delivered has an impact on the care experience. Being with self explains that forming of values and beliefs is based on knowing self.

While these four core concepts were focusing on the person in care, there are also frameworks that relate to the nursing staff. PCNF is a tool which enables nurses to explore PCC in their practice (McCance et al., 2011). PCNF comprises of four main components including prerequisites, care environment, person centred processes and expected outcomes. Prerequisites are the attributes of the nurse which include self-awareness, professional competency, development of interpersonal skills and also commitment to the job (McCormack & McCance, 2010). In nursing, knowing self or self-awareness means the way nurses see themselves and the way they construct their own worlds. This has an influence on their practice and engagement with people (McCormack & McCance, 2010). Being self-aware is important, because if the nurse is able to recognise her/his own feelings and the effect these feelings have on the ability to be fully focused on the person in their care, it is less likely that the nurse will create a block in compassionate care. Reflection on self awareness and identification of personal feelings and blocks improves person-centred nursing practice (Devenny & Duffy, 2013). Nurses and student nurses are also required to recognise their limits of competency. Professional competency in nursing requires skills, knowledge and is seen as the ability to prioritise and make judgements and decisions (McCormack & McCance, 2010). Nurses have to attend and participate in trainings to maintain and develop their competency (NMC, 2008). These trainings and standard of education for all nursing staff is set by NMC and all registered professionals are required to continue to learn and develop their skills throughout their careers (McCormack & McCance, 2006).

Competent and self-aware nurses can create optimal person-centred care environment. Care environment represents a context in which care is delivered. Effective staff relationships, shared decision making, skill mix, organisational system and also physical environment are important, because they all contribute to delivering high quality PCC (McCormack & McCance, 2010). Throughout every stage of life people expect that delivered care will be consistent, right and meeting individual’s needs (DH, 2012). Therefore, PCC moves away from the previous medically orientated care to collaborative, holistic and relationship-focused care. Positive relationships between the care staff and the person and also the relationships between the care staff themselves are very important because they create therapeutic environment, especially when the team is effective (McCance, McCormack & Dewing, 2010). Multidisciplinary teams focus on supporting and caring for people while collaborating (DH, 2012). Nurses play a crucial role within multidisciplinary teams delivering person centred processes. This mean that nurses provide holistic care; they actively engage people in informed decision making and that the nursing staff is working with and respecting person’s beliefs and values. Nurses are also able to shape person’s experience by delivering high standard care (DH, 2008). To achieve a high quality care all health care staff should have sympathetic presence while working with people (McCormack & McCance, 2010). Involvement in care, feeling of wellbeing, creating therapeutic environment and overall satisfaction with care are included in expected outcomes of PCC (McCormack & McCance, 2010).

Person centred activities allow a person to be involved in their care as an equal partner (RCN, 2014). Collins (2014) states that these activities include self management support (SMS), shared decision making (SDM), collaborative care and support planning.

In SMS a person is encouraged to develop the knowledge about their conditions so they can become skilled and confident managers of their own health. Building person’s capabilities should be based on incorporation of evidence-based health information (Collins, 2014).

In SDM person is encouraged to make a single informed decision about their own health with confidence. Person’s understanding of evidence-based information about treatment risks and probabilities is crucial (Collins, 2014).

Collaborative care and support planning merges SMS and SDM together enabling the person gain the knowledge about their conditions, become a confident self-manager ensuring they are able to make informed decisions about their care or support they are receiving (Collins, 2014).

Despite all the efforts of many health care professionals, there are times when PCC fails to be delivered. One of the major issues in providing PCC in nursing is the fact that a little attention is paid to care experience of a person. This is due to a great pressure on professionals and teams to be highly effective and efficient (McCormack & McCance, 2010). This is quite obvious in Francis report (2013) which concludes that Mid Staffordshire NHS was focusing more on financial pressure and becoming the foundation trust rather than quality of care provided. Furthermore, the achievement of targets was also highly prioritised. Acceptance of poor standards of care within the health care teams resulted in denial of privacy, dignity, food, water, assistance in toileting and in many cases in death of patients (Francis, 2013). As a result of this, importance of PCC is now embedded in several policies such as Principles of Nursing Practice (RCN, 2010), National service framework for older people (DH, 2001), The Code (NMC, 2008) and Compassion in Practice (DH, 2012).

It can be concluded that the concept of PCC has been around for decades starting with Rogers and his humanistic approach, emphasising the importance of putting the person into the centre of holistic therapy and care (Josefowitz & Myran, 2005). PCC involves the patient in their care. Respecting and working with person’s values and beliefs should be achieved by knowing self and being a competent registered professional with an updated knowledge (McCormack & McCance, 2010). Despite the efforts of many health care professionals, it was obvious after Mid Staffordshire NHS case and the publication of Francis report (2013) that some health care teams were failing in many fundamental aspects of PCC leading to death of many patients. After this media case several publications were published by the governing bodies embedding person-centeredness in order to ensure this will not happen again in the future.

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