Developing Person-Centred Care: Addressing Contextual Challenges Through Practice Development

Journal Club Article: McCormack, B., Dewing, J., & McCance, T. (2011). Developing person-centred care: addressing contextual challenges through practice development. OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 3.

This article aims to identify and discuss issues to consider in the development of person-centred care. As healthcare moves into service deliver for the individual then the focus of person-centred care will become increasingly important in training nurses of the future and current ones to deliver care on an individual level.

What is Person-Centred Care?

McCormack et al. (2011) define person-centred care as “an approach to practice that is established through the formation and fostering of therapeutic relationships between all care providers, patients, and others significant to them.”

How to Deliver Person-Centred Care?

“Developing person-centred care is not a one-time event; rather it requires a sustained commitment from organisations to the ongoing facilitation of developments, a commitment both in clinical teams and across organizations.”

  • Practice context,
  • Workplace culture,
  • Learning culture,
  • Physical environment.

The authors suggest in healthcare there are ‘person-centred moments’, at the individual level with ad hoc experiences of person-centredness occurring but not at a sustained and meaningful level.

“…it must further be considered how person-centred moments can be transformed into ‘person-centred cultures’ of practice…”

Culture

“The international drive (particularly over the past 15 years) to ‘modernise’ healthcare systems has led to a significant focus on the impact of culture on the clinical effectiveness of staff and service-user experiences of health and social care. Cultures are also characterised by shared values, team effectiveness, a commitment to continuous learning and improvement, and transformational leadership.”

“The key goal in the development of a positive learning culture is to recognize and overcome individual, group, and organizational barriers in order to move towards an effective culture and to overcome the features of workplaces that nurture hierarchical management and horizontal violence (Brown & McCormack, 2011).”

Person-centred care must underpin culture of teams and organisations. This requires empowerment and emancipatory practice to occur throughout the organisation. The traditional hierarchy and autocratic practice will need to be addressed to create an organisational change.

Contextual Factors and the Development of Person-Centred Care

The authors ask us to consider the shifts when it all worked, it clicked into place and the team worked. Admission, discharges, post ops, deterioration, family updates, all staff were well supported and you finished with a buzz and achievement that you expected nursing to on a regular basis. Positive thoughts here, hopefully you can recollect one shift in recent times (even you UK NHS staff).

Why can’t it be like this all the time?

This is the question we need to ask and reflect on. What was it about this shift that made it all work and how can we replicate this. So for person-centred care the focus is not just on the client but also the healthcare team. If they cannot perform to their best, then the service will not excel.

The authors recognise and “acknowledge that we do not work in a state of utopia, and that everyday practice is challenging, often stressful, sometimes chaotic, and largely unpredictable”. So some days will just be awful, sad and depressing but if we can make them fewer then surely staff satisfaction, teamwork, burnout and other stressors could be reduced.

Education focus: Active Learning 

A learning culture is a culture in which nurses view their work as exciting and revitalising, offering them the prospect for both personal and professional growth.

“Active learning draws on many activities including multiple intelligence’s, critical reflection, learning from self, and also conversations and shared experiences with others, all of which enable facilitation of change in the workplace. Central to active learning is both the translation of learning into practice so that the practitioner’s own practice is experienced differently and the enabling or facilitating of active learning with others. Active learning takes knowledge, in its many forms, and looks at how it can become (emotionally) meaningful for individuals and teams.”

How do I move towards this way of nursing?

“Developing Person-Centred Care Through Emancipatory Practice Development Practice which emphasises the central place of learning through everyday practice, what we have come to describe as ‘active learning.”

The Environment

“the physical environment needs to work in concert with the cultural values in care teams and the ways of working that enable person-centredness to be realised. In this respect, two aspects of the physical environment need to be attended to, namely, the built environment and the aesthetic environment. Most hospitals and healthcare facilities have been designed and built with ‘clinical efficiency,’ and not personcentredness, in mind.”

Summary

In the development of a framework for person-centred nursing, McCormack and McCance (2010) identified a range of attributes of practice contexts that impacted on the operationalisation of person-centred care. Of particular significance were workplace culture, learning culture, and the physical environment. The health organisation needs to provide conditions that are necessary for staff to feel empowered.

Keywords: person-centred; emancipation; culture; active learning; transformational leadership.

Reference

McCormack, B., Dewing, J., & McCance, T. (2011). Developing person-centred care: addressing contextual challenges through practice development. OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 3.

McCormack, B., Manley, K, & Garbett, R. (2008). Practice Development in Nursing. [sample here]

 

 

 

 

 

Educating Nurses for the Future of Healthcare

Now I am using my speciality area of ICU as the focus article, but the themes will cross all areas of the hospital system looking into the future. So the question will be how education approaches the task of training the nurses of the future? Look at the themes of personalised medicine, telemedicine, more communication but less face to face time and we see an outline of healthcare in the year 2050.

Article: Vincent, J. L., Slutsky, A. S., & Gattinoni, L. (2016). Intensive care medicine in 2050: the future of ICU treatments. Intensive Care Med. DOI 10.1007/s00134-016-4556-4.

The hospital is definitely smaller than in the past with lots of ICU beds, but very few other beds. And, it looks more like a five-star hotel than a hospital, with nice shops and restaurants in the lobby—it makes you forget you’re in hospital.

Person-centred healthcare delivery is considered gold standard and what we strive to deliver, so making the environment match the service seems a sensible approach. One question we need to ask now is the generic nature of checklists, okay in an emergency situation to assist human factors but it may be time to stop looking at simplistic check lists as the complex multi system failure patient is here and so we need more complex systems to support these patients and artificial intelligence is ready to help.

A lot of the time the screen is blank, but it displays alarms when anything goes wrong and can show anything you want to see at the push of a button: trends in variables, all kinds of curves, laboratory results, X-rays, consultant’s notes, you name it. There’s also a really cool system that teaches me all about my medical condition and that can connect me with other patients who have similar medical issues. The computers that control this can somehow link me to patients around the world who have similar values, expectations, and concerns to mine.”

if you press the red button, a nurse immediately appears on the screen over any other data display, asking what you need or want!

Face to face and loss of the human touch but time critical responses to meet the needs of the patient, not when we can get there. It will be interesting for both nursing and medical staff how the role of telemedicine will impact on the professions and communication strategies. Remember robots may well be doing the hands on care in the hospital and in the home.

but now I’ve got a percutaneous sensor that measures almost every lab test. Everything seems to be non-invasive.

This is the critical thinking part, what will be needed in the future from the nurse is a response to the alert system, as artificial intelligence will provide risk scores and responses to the changes of each individual patients 24 hours a day. But will the nurse need to understand the changes and trends of the patients observations, or are these skills no longer required and other skills need to be developed? Don’t think about extended nurse roles such as line insertion or minor surgery, this is now completed by robots.

“the bed kept moving to assess how much fluid I needed while my cardiac response was monitored by the probes. There was even a closed-loop system driven by a computer that continued to deliver fluid challenges as long as my cardiac output was responsive, combining it with titration of vasopressors and inotropic agents.”

Closed-loop systems mean interventions will occur when actually needed from clinical data and in a timely response by automated systems. Is there any need for human interaction and training required here?

I’m also receiving extracorporeal lung/renal/metabolic support—this is an impressive system that, by passing my blood through an external system, oxygenates it and cleans it.”

What is ICU domain now, may well just become regular treatments in the future. And as society may expect more health longevity and technology delivers more, then maybe the hospital becomes an extension of the ICU. Every patient will be automatically monitored like a current ICU patient now anyhow.

They do quite a lot of surgical procedures here, but there are hardly any surgeons: all surgery is done remotely with surgeons only present in case of exceptional technical breakdown.

Again robots are leading the way. So what will the nurse and medic do in these circumstances, will it be one professional overseeing numerous procedures at multiple sites? Simulation training will be using robotics and virtual reality for an interactive and realistic training experience (high fidelity rules for the simulation purists).

Worried it all becomes a little impersonal? don’t worry……

You might think this all sounds a bit inhuman, but it’s not at all. Although there are fewer doctors doing procedures and interventions, the ones that are present are much more available to talk to you, to explain, answer questions, and reassure me and my family.

Research: big data rules.

they have this huge database of all the patients’ results and outcomes for the past 25 years, so that they can see if anyone else had the weird syndrome I had, and then figure out the best way to treat it.”

So the question remains on how we approach education to train the nurse of the future, will it be humans or robots? Maybe the nurse educator needs to put coding near the top of the skills list.

Keywords: robotics, virtual reality, artificial intelligence, robots, telemedicine, nurse training; person-centred care.

References

Vincent, J. L., Slutsky, A. S., & Gattinoni, L. (2016). Intensive care medicine in 2050: the future of ICU treatments. Intensive Care Med. DOI 10.1007/s00134-016-4556-4

Mesko, B. (2017) The Medical Futurist (TMF).