This is the fifth article in a nine-part series describing the Principles of Nursing Practice developed by the Royal College of Nursing (RCN) in collaboration with patient and service organisations, the Department of Health, the Nursing and Midwifery Council, nurses and other healthcare professionals. This article discusses Principle D, the provision of person-centred care. Authors Kim Manley, at the time of writing, lead, Quality, Standards and Innovation Unit, Learning & Development Institute, RCN, London; Val Hills, learning and development adviser, RCN, Yorkshire and the Humber; and Sheila Marriot, regional director, RCN, East Midlands.
Canterbury. ac. uk Keywords Nurse-patient relations, person-centred care, Principles of Nursing Practice These keywords are based on subject headings from the British Nursing Index. For author and research article guidelines visit the Nursing Standard home page at www. nursing-standard. co. uk. For related articles visit our online archive and search using the keywords.
The fourth Principle of Nursing Practice, Principle D, reads: ‘Nurses and nursing staff provide and promote care that puts people at the centre, involves patients, service users, their families and their carers in decisions, and helps them make informed choices about their treatment and care. ’ The provision of care that is experienced as right by the person receiving it is at the core of nursing practice. Principle D sets out to endorse and expand on this point, which is often summarised as providing person-centred care – a philosophy that centres care on the person and not only their healthcare needs.
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The King’s Fund uses the term "nursing standard" - "the person in the patient" to convey the same point (Goodrich and Cornwall 2008). There is a consensus that person-centred care equates with quality care (Innes et al 2006, Royal College of Nursing (RCN) 2009), although the service users involved in developing the Principles indicated that they wanted to receive person-centred, and safe and effective care. Such inter-related care is based on best evidence, which is blended with the needs of the individual within specific contexts.
Healthcare teams, healthcare provider organisations and governments often articulate an intention to deliver person-centred care. However, achieving it is often challenging and difficult to sustain. Achieving person-centred care consistently requires specific knowledge, skills and ways of working, a shared philosophy that is practised by the nursing team, an effective workplace culture and organisational support. While all members of the nursing team endeavour to provide person-centred care, some nurses have more transient contacts with patients and those important to them.
Examples include staff working in operating departments, general practice or outpatients. The challenges in these situations include skill in developing rapid rapport and ensuring that communication systems respect the essence of the person and protect his or her safety in a way that maintains person-centred values and continuity of care. Person-centred care can be recognised by an active observer or the person experiencing care. The following might be experienced or observed:
- A focus on getting to know the patient as a person, his or her values, beliefs and aspirations, health and social care needs and preferences. Enabling the patient to make decisions based on informed choices about what options and april 6 :: vol 25 no 31 :: 2011 35 art & science principles series;
- assistance are available, therefore promoting his or her independence and autonomy;
- Shared decision making between patients and healthcare teams, rather than control being exerted over the patient. Enabling choice of specific care and services to meet the patient’s health and social care needs and preferences;
- Providing information that is tailored to each person to assist him or her in making decisions based on the best evidence available.
Assisting patients to interpret technical information, evidence and complex concepts and helping them to understand their options and consequences of this, while accessing support from other health and social care experts:
- Supporting the person to assert his or her choices. If the individual is unable to do this for him or herself, then the nursing team or an appointed formal advocate would present and pursue the person’s stated wishes.
- Ongoing evaluation to ascertain that care and services continue to be appropriate for each person.
This involves encouraging, listening to and acting on feedback from patients and service users. Other attributes of the nursing team include being professionally competent and committed to work, and demonstrating clear values and beliefs (McCormack and McCance 2010). In addition, nurses should be able to use different processes in the development of person-centred care: working with patients’ values and beliefs, engaging patients and mental health service users, having a sympathetic presence, sharing decision making and accommodating patients’ physical needs (McCormack and McCance 2010). People from minority ethnic groups often experience barriers to person-centred care.
There is a need to understand the way in which different minority groups within local populations access information and how different cultural understandings, languages and communication styles influence perceptions of personalised care (Innes et al 2006). A shared philosophy For person-centred care to achieve its full potential, the approach needs to be practised by the entire nursing team. This requires a shared philosophy and ways of working that prioritise person-centred behaviour, not only with patients and those that are important to them, but also within the team.
The wellbeing of staff and the way in which they are supported also needs to be person-centred as staff wellbeing positively affects the care environment for staff and patients. For a shared philosophy to be realised in practice, person-centred systems and an effective workplace culture need to be in place (Manley et al 2007, McCormack et al 2008). Such systems focus not only on structures and processes, but also on the behaviours necessary to provide person-centred care. An effective workplace culture has a common vision through which values are implemented in practice and experienced by patients, service users and staff.
This culture demonstrates adaptability and responsiveness in service provision, is driven by the needs of users and has systems that sustain person-centred values. Clinical leadership is pivotal in promoting effective cultures. This is achieved through modelling person-centred values, developing and implementing systems that sustain these values, encouraging behavioural patterns that support giving and receiving feedback, implementing learning from systematic evaluations of person-centred care and involving patients in decision making (Manley et al 2007).
To determine whether person-centred care is being delivered or how it can be improved, workplaces need to use measures or methods that enable systematic evaluation to take place. These should be embedded within patients electronic "nursing standard". Knowledge, skills and ways of working Each member of the nursing team is expected to provide person-centred care, although the required knowledge, skills and competences may come from the wider nursing and healthcare team. Principle A, through its focus on dignity, respect, compassion and human rights, is the essential basis for providing person-centred care (Jackson and Irwin 2011).
However, other qualities, such as the ability to develop good relationships are required: "The relationship between the service user and front line worker is pivotal to the experience of good quality/person-centred care/ support" (Innes et al 2006). Developing good relationships with patients and colleagues requires team members to be self-aware and have well-developed communication and interpersonal skills. These skills enable the nursing team to get to know the person as an individual and enable other interdisciplinary team members to recognise these insights through effective documentation and working relationships.
Getting to know the patient is a requirement for nursing expertise, but is also dependent on the way that care is organised (Hardy et al 2009). 36 april 6 :: vol 25 no 31 :: 2011 records to reduce the burden of data collection and analysis. The Person-centred Nursing Framework (McCormack and McCance 2010) identifies a number of outcomes that may inform these measures, including satisfaction with care, involvement in care, feeling of wellbeing and creating a therapeutic environment. The RCN (2011) recognises that different measures may already be in place to support evaluation of person-centred care.
It is encouraging teams and organisations to submit their measures to the RCN for endorsement. The measures should meet certain criteria, for example they should be evidence-based, take into account stakeholder and other perspectives, and be practicable. Endorsed measures can be shared with others through the RCN website. Organisational support Innes et al (2006) made the point that organisations have an important role to play in enabling person-centred care through the promotion of user-led services. This can be achieved through overcoming bureaucratic structures such as increased management and budget-led services.
It is important that management provides support to the front line nursing team in its day-to-day work and recognises the importance of nurse-patient relationships to this endeavour. This support may be, for example, through initiatives that release time to care through lean methodology (a quality improvement approach that focuses on making processes more efficient and reducing waste) (Wilson 2010), and practice development methodologies associated with person-centred cultures (McCormack et al 2008). access clinic; service-users are seen weekly for a brief intervention (10-15 minutes).
Service-users appreciate this alternative to the usual one-hour appointment every two weeks and find the approach less threatening. The clinic is run by a nurse prescriber who is able to titrate medication against need or therapeutic benefit while delivering high quality psychosocial interventions in a brief intervention format. The clinic is supported by a service user representative. This representative gives confidence to service-users who may be lacking belief in their ability to achieve lifelong abstinence and provides service users with an introduction to other community based self-help support networks.
After service users have engaged with the service through the quick access clinic, they progress to an appropriate level of key working intervention to meet their more complex needs. This initiative illustrates a number of elements of Principle D, including the use of a formal advocate service, drawing on a service representative, who supports the patient in his or her choices as well as helping him or her to assert his or her wishes. The approach provides a flexible service whereby clinical interventions are provided by a nurse practitioner, and complex needs are assessed quickly.
The service user and the nursing team work in partnership to decide when the patient is ready to embark on the next level of interventions required to meet the patient’s complex needs. Conclusion Principle D emphasises the centrality of the patient to his or her care. It requires skill from each member of the nursing team. The potential contribution of each member to person-centred care will be enhanced if everyone in the team is using the same approach. Such an approach requires a workplace culture where person-centred values are realised, reviewed and reflected on in relation to the experiences of both patients and staff NS.
- The nursing team treats drug users for an initial 12 weeks in a quick References Goodrich J, Cornwall J (2008)
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