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International Journal of Nursing Practice
2003;
9
: 202–209
Blackwell Science, LtdOxford, UKIJNInternational Journal of Nursing Practice1322-71142003 Blackwell Science Asia Pty Ltd
93June 2003423
Person-centred practice and older peopleB. McCormack
10.1046/j.1322-7114.2003.00423.xOriginal Article202209BEES SGML
Correspondence: Brendan McCormack, Royal Hospitals Trust,Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland.Email: [email protected]
✠
R E S E A R C H P A P E R
✠
A conceptual framework for person-centred practice
with older people
Brendan McCormack DPHIL(Oxon) BScNsg(Hons) PGCEA RGN RMN
Professor of Nursing Research, Director of Nursing Research and Practice Development, University of Ulster, Jordanstown and Royal
Hospitals Trust, Belfast, Northern Ireland
Accepted for publication November 2002
McCormack B.
International Journal of Nursing Practice
2003;
9
: 202–209
A conceptual framework for person-centred practice with older people
This paper presents a conceptual framework for person-centred practice with older people. The research from which theframework was developed was guided by hermeneutic philosophy and integrated processes of conversation analysis andreflective conversation in data collection and analysis. The research findings suggested that nurses need to be able to par-ticularize the person that the patient is, the relationship that exists between them and the patient, and the understandingsand expectations implicit in the relationship. From these findings a conceptual framework for person-centred practice wasdeveloped. In the framework, person-centredness is premised on the concept of authentic consciousness and is opera-tionalized through five imperfect duties. The factors that enable person-centredness to operate in practice are identified asthe patient’s values, the nurse’s values and the context of the care environment. Considerations for implementing themodel in practice are highlighted.
Keywords:
caring, nurse-patient relationship, older people, person-centred, values.
INTRODUCTION
This paper explores the issue of person-centred practicewith older people. The paper presents a conceptual frame-work for person-centred practice that has been developedfrom a larger research study exploring the meaning ofautonomy for older people in hospital settings. The frame-work emphasizes partnership, which works betweennurses and older people based on a ‘negotiated relation-ship’. The paper presents an overview of the researchfrom which the conceptual framework has been derived, adescription of the components of the framework and anexample of the model in use. The conceptual frameworkpresented in this paper makes a significant contribution to
the growing body of knowledge that challenges the dom-inant emphasis on dependency in gerontology.
1–4
PERSON-CENTREDNESS
In the United Kingdom the idea of person-centred prac-tice is now embedded in the language of multidisciplinarypractice with older people (see, for example, TheNational Service Framework for Older People
5
). Respectfor persons is central to the notion of person-centrednessand is rooted in a Kantian ideal of mutual respect and sym-pathetic benevolence.
6
Therefore, the rights of individualsas persons is the driving force behind person-centredhealth care.
7,4
It represents an attitude of respect for ordi-nary individuals to make rational decisions and determinetheir own ends. The idea of respecting the patient’s rightto self-determination has resulted in a shift in thinkingabout the role of the patient in health care decision mak-ing. Hope and Fulford suggest that this philosophical shift
Person-centred practice and older people 203
requires health professionals to think beyond concepts ofcure based on scientific facts and technical competence, tothe adoption of a more holistic approach that also incor-porates values.
8
Being person-centred requires the forma-tion of a therapeutic narrative between professional andpatient that is built on mutual trust, understanding and asharing of collective knowledge.
AUTONOMY ANDPERSON-CENTREDNESS:
A HERMENEUTIC STUDY
The original research, from which this paper is derived,explored the meaning of autonomy for older people inhospital settings.
9
The overall research approach wasguided by the hermeneutic philosophy of Gadamer.
10
Hermeneutic research does not attempt to interpret thedata from an objective position, but instead creates a dia-logue where the researcher and research participants’perceptions interact. The hermeneutic process is a dialog-ical process between the interpreter’s understanding andthe object being studied. Research participants’ activeinvolvement in this interpretative process is important sothat a ‘meeting of understanding’ can be achieved betweenperspectives of the research participants and the inter-preter in order to create new understandings.
A convenience sample of four hospital nurses recordeddiscussions and conversations between themselves andpatients, and with doctors and other members of thehealth care team, for at least three shifts per week over aone-year period. In addition, interactions between acommunity clinical nurse specialist and her clients, seenin their own home, and the interactions between a recog-nized expert gerontological nurse (identified by usingcriteria derived from the work of Benner,
11
Jasper
12
andGreenwood and King,
13
) and patients in a communityhospital setting were also recorded as a means of ‘testingout’ initial themes generated from the data collected bythe hospital nurses. Fourteen case studies of nurse–patient interactions were achieved. The local researchethics committee (LREC), in the health district where theresearch was being conducted, approved the researchprotocol and management plans. Patients with dementiaor confusion (scoring 5 or less on a Mini-Mental HealthAssessment
14
) were excluded from the study at therequest of the LREC.
The data were transcribed, coded and described usingtechniques of conversational analysis.
15
Conversation anal-ysis was used as a structured approach to describing the
data and deriving interpretive themes, that is, as a tool forthe selection and description of data sets. By using anestablished framework derived from conversation analy-sis, decisions about data choices for analysis would in thefirst instance be informed through the structure of theframework, rather than the researcher’s own subjectivechoices as a ‘data interpreter’. Conversation analysis iden-tifies a limited set of conversational rules within whichdiscourse is constructed and within which participantsperform particular acts within the constraints of this rulesystem. Discourse is action in its own right and not a routeto understanding action. Ordinary conversation is viewedas the predominant medium of action in the social world.Follow up ‘reflective conversations’
16
with the nurses clar-ified and developed the researcher’s initial descriptions ofthe data. Rigour in data analysis was maintained throughan iterative process between researcher and research par-ticipants. Initial themes from the descriptions were devel-oped through focus group discussions with a group ofexpert nurses and a group of patients. Nurses and patientsidentified themes from the descriptions prior to furtherthematic analysis by the researcher. Finally, participatingnurses, the group of expert nurses and the patient groupagreed on the final themes that were developed.
The research findings, which have been reported indetail elsewhere,
17
included the key issues of the effects ofinstitutional discourse, the dynamics of power and con-trol, patients’ access to knowledge, the impact of profes-sional authority, the constraining nature of institutions andthe effect of family and carers on decision making. Allthese factors were seen to act as constraints on the abilityof older people to exercise autonomy. Through the inter-pretive process with participants, 23 ‘principles foraction’ to address these constraints were identified(Appendix 1) and further analysis of these resulted in thedevelopment of the conceptual framework for person-centred practice.
PERSON-CENTREDNESS AS AUTHENTIC CONSCIOUSNESS
The research findings suggest that nurses need to be ableto particularize the person that the patient is, the relation-ship that exists between them and the patient, and theunderstandings and expectations implicit in the relation-ship. It is proposed that this can be achieved through anunderstanding of the person’s authentic values.
Authenticity refers to a way of reaching decisions whichare truly one’s own: decisions that express all that one
204 B McCormack
believes important about oneself and the world, the entirecomplexity of one’s values.
18
Authentic consciousness is a consideration of the per-son’s life as a whole in order to help sustain meaning inlife. Authentic consciousness is not a hierarchical orderingof possible desires, but a clarification of values to maxi-mize potential for growth and development. Existing evi-dence highlights the dominance of routine and ritualizedpractices with older people that do not take account ofindividual beliefs and values.
17,19–21
When working withbeliefs and values, the role of the nurse is to maximizeopportunities for growth through authentic decision mak-ing, that is, decisions that are true to the person’s life as awhole. It is not enough to just take note of another’sbeliefs, values, views and experiences. They must be inte-grated into the biography of that individual.
Being conscious of another’s beliefs and values does nottell the nurse what to do, rather it orientates the nurse toa particular way of being. As Gadow argues, the recogni-tion of beliefs and values allows the patient and the nurseto have the kind of caring relationship that they want tohave, appropriate to the context of care.
18
This helps thenurse place actions in context, or as MacIntyre suggests,‘the act of utterance becomes intelligible by finding itsplace in a narrative’
.
22
In the context of this research, whatthis means is that desires, wishes and needs of an olderperson can best be understood by having a picture of theperson’s life as a whole. Therefore, being person-centredrelies on getting closer to the older person and goesbeyond traditional notions of respecting individuality andindividualized care, such as choices about food and drink,hygiene, waking and sleeping. In this framework, gettingcloser to the patient is achieved through consideration ofthe patient’s authenticity, the adoption of ‘imperfectduties’ and the consideration of contextual factors(Fig. 1).
IMPERFECT DUTIES
The term ‘imperfect duties’ is derived from Kant, whomade a distinction between perfect and imperfect duties.
23
Perfect duties are strict and enforceable. In contrast,imperfect duties are ‘wide, broad and limited’—‘theyleave us a play-room for free choice in following the law’
23
as there is no means of offering an exhaustive and a prioriaccount of how the duties are to be fulfilled. Such duties ascompassion, concern, benevolence, respect and carewould all be imperfect duties as, for example, one cannotforce someone to be caring. Kant views such duties as
imperfect because, in ethical decision making, one mighthave to decide between competing duties and accountmust be taken of the context in which decisions are made.This approach acknowledges the need for guiding princi-ples that are interpreted in the context of the particularrelationship. It highlights the important place of emotionsin decision making by highlighting the importance of emo-tional factors being made explicit and acknowledged asinfluences on the process and outcome of decision making.Issues such as how much the nurse ‘likes’ the patient, theindividual nurse’s personal experiences and the behaviourof the patient are seen as significant.
Returning to the study previously described
9
from thedata analysis, five imperfect duties are considered to beimportant to the operationalization of autonomy asauthentic consciousness:
1.
Informed flexibility: the facilitation of decision makingthrough information sharing and the integration of newinformation into established perspectives and carepractices.
2.
Mutuality: the recognition of the others’ values asbeing of equal importance in decision making.
3.
Transparency: making explicit the intentions andmotivations for action and the boundaries within whichcare decisions are set.
4.
Negotiation: patient participation through a culture ofcare that values the views of the patient as a legitimate
Figure 1.
A conceptual framework of person-centredness asauthentic consciousness.
TransparencyNegotiation
Mutuality Sympathetic Presence
Informed Flexibility
Authentic Consciousness
Person-centred practice and older people 205
basis for decision making while recognizing that being thefinal arbiter of decisions is of secondary importance.
5.
Sympathetic presence: an engagement that recognizesthe uniqueness and value of the individual byappropriately responding to cues that maximize copingresources through the recognition of important agendas indaily life.
THE NURSE AS A FACILITATOR OF AUTHENTIC CONSCIOUSNESS
The imperfect duties act as guiding universal principlesthat are interpreted in the context of the particular caresituation. Adopting a person-centred approach topractice requires nurses to recognize freedom of self-determination for patients as a fundamental and valuablehuman right, based on an interdependent and intercon-nected relationship with each other.
18
Person-centredpractice holds central the knowledge and experience thateach person brings to the care situation and which is nec-essary for decisions that will best serve the patient’s well-being. Examples of this in the United Kingdom includedevelopments in the assessment of care needs of olderpeople,
5
models for involving older people with dementiain decision making
4
and person-centred practices in acutecare nursing.
19
At the heart of this style of nursing is thetherapeutic nurse-patient relationship that requires conti-nuity of care and the acceptance of responsibility for theoutcomes of care. Acknowledging and valuing eachpatient’s biography and their individual perception andexperience of their health care experience is fundamentalto this way of nursing. Its aim is to transform the patient’sexperience of illness and is considered to be a therapy inits own right.
8
The role of the person-centred nurse is tobe there, offering personal support and practical exper-tise, while enabling the patient to follow the path of theirown choosing and in their own way.
However, total connectedness with a patient can lead to‘ethical blindness’,
24
and in order to balance the intensityof an individual relationship with a reflective approach todecision making, the nurse needs to move between three‘stances’ when working with patients.
25
These stances rep-resent different levels of engagement (connectedness)between the nurse and patient.
When engagement is present, the patient and nurse areconnected in the relationship. The nurse and patient areextensions of each other and a care partnership exists.Boykin and Schoenhofer describe this as ‘the dance of car-ing persons’
.
26
Caring exists because the nurse and patient
hold a deep respect for each other. However, a dilemmacould arise in the care relationship which affects the waythe nurse and patient are able to work together, such as adifficult decision, an ethical dilemma or a disagreement.As a result, partial disengagement occurs while the nurseand patient take stock of the situation and formulate theproblem. Such disengagement then requires a period ofcontemplation and, for a period of time, complete disen-gagement occurs. In this stance the nurse and patient con-template the available options from their individualperspectives. They reassess the values that underpin therelationship and decision making. Mechanisms such assupported reflective practice,
27,28
clinical supervision
29
and case reviews
30
all help to achieve this goal. Althoughthe nurse continues to work with the patient in seekingthe most satisfactory resolution, the connectedness in therelationship is broken until such time as a resolution canbe found. A skilled nurse can adopt these different stancesat different times with the patient. Indeed, they were evi-dent in the practice of the expert nurse and the clinicalnurse specialist in the research underpinning this frame-work.
9
In contemplating options and choices there arethree important factors for the creation of an environmentthat facilitates person-centredness. These are the patient’svalues, the nurse’s values and expertise, and the contextof care.
THE PATIENT’S VALUES
Respect for values is central to person-centred prac-tice.
4,7,9
It is important to develop a clear picture of whatpatients value about their life and how they make sense ofwhat is happening. This provides a standard against whichthe nurse can compare current decisions and behavioursof the patient with those values and preferences made inlife in general. Approaches to patient assessment thatinclude a biographical account, using narrative and story,is one method of establishing a baseline value history.Assisting the individual to find meaning in care might helpthem to tolerate the incongruity of their illness and planfor a future.
31
The complexity of many health care decisions coupledwith the stresses and fears of illness, with its related anx-iety, dependency and regressive tendencies, means that apatient’s ordinary decision making abilities are often sig-nificantly diminished. Buchanan and Brock argue that ifpatients hold the ultimate responsibility for their healthcare decisions, then their treatment choices might fail toserve their well-being, as conceived by them.
32
Thus, they
206 B McCormack
argue that the same value of patient well-being thatrequires patients’ participation in their own health caredecisions might sometimes also require persons to be pro-tected from the harmful consequences to them of theirown choices.
When considered in practice, the risk to autonomousdecision making by patients from paternalistic health careworkers is significant. Agich asserts that the means of pre-venting such action is by having a clear picture of what thepatient, and others important to them, really value abouttheir life and how they make sense of the things happen-ing to them.
33
In the exercise of their decision-makingcapacity, patients bring an individual approach to theirconcept of their own well-being. Health means differentthings to different people
34
and is accorded variousdegrees of importance by individuals. Therefore, there isno one single intervention that is best for everyone. Whilecertain procedures might be more appropriate than oth-ers in particular cases, it is the individuality of the partic-ular case that determines the most appropriate approach.For this reason, health care decision making ought toadopt a negotiated approach between practitioner andpatient.
9
THE NURSE’S VALUES AND EXPERTISE
Although the language of partnership is commonplaceand nurses are encouraged to soften their professionalpresentation to the patient, it remains unusual fornurses to present their own views as a component of thearray of information that patients are given to assisttheir decisions. While the patient’s values should be pre-dominant,
18
the nurse’s values also contribute to theprocess. However, these are seldom open and transpar-ent. Indeed, it could be argued that if a mutual relation-ship exists between the nurse and patient, then it isespecially important that the nurse’s values areexpressed, particularly when they conflict with thepatient’s values. If the nurse is truly working in partner-ship with the patient then there is no reason why theexpression of such values should be coercive. Instead,the disclosure of the nurse’s values might help thepatient to understand particular negotiation positionstaken by the nurse and it might offer the patient analternative view when considering their options. How-ever, it has been argued that despite an intention to con-sider patient and nursing values, the context of the careenvironment has a significant impact on the operational-ization of person-centred practices.
35,36
THE CONTEXT OF CARE
The context in which care is provided has the greatestpotential to enhance or limit the facilitation of person-centred practice. When facilitating person-centredness,nurses find they not only balance competing care valuesbut often find it necessary to consider organizational val-ues too. Nurses are not free to fulfil a moral obligation tothe patient without considering organizational and profes-sional implications
37
and, indeed, they might find them-selves having to accept a forced choice on occasion.
38
Incontemporary health care, the fundamental moral predic-ament of nurses is that while they are expected to engagein autonomous decision making, they are often deprivedof the freedom to exercise moral authority.
39
While thefreedom of the nurse is a significant issue in the facilitationof person-centredness, other characteristics of contexthave been found to be of equal significance,
1
such as sys-tems of decision making, staff relationships, organiza-tional systems, power differentials and the potential of theorganization to tolerate innovate practices and risk taking.These findings have been supported in a recent analysis ofthe concept of context.
35
A COMPOSITE EXAMPLE
In order to illustrate the framework in use, the followingexample is offered. The example is derived from dataextracts from the research underpinning this conceptualframework.
9
These extracts have been taken from the dataof one nurse who participated in the study (Pam) and herwork with one patient (Ray).
Pam is a lead nurse in a local community hospital thatspecializes in the rehabilitation of older people followingacute illness. The unit utilises the Burford Nursing Devel-opment Unit (BNDU) model of nursing.
40
Ray, a patienttransferred from the regional general hospital, was admit-ted for rehabilitation following a fractured shaft of his leftfemur. Ray is a gypsy and values his freedom and indepen-dence. Staff in the regional hospital reported that he was‘difficult’, ‘uncooperative’ and ‘refused to do what he wastold!’ When admitted, Pam used the key questions fromthe BNDU model: ‘who is this person?’ and ‘what infor-mation do I need to know to be able to nurse him effec-tively?’ to focus the construction of his biography, assesshis care needs and agree on a care plan. By using thesequestions, Ray shared his core values of personal freedom,intolerance of authority and everyone being equal, whilePam shared her core nursing values of self-determination,honesty and negotiation. Together, they agreed on a plan
Person-centred practice and older people 207
of care that encompassed these values. Pam and Ray drewup a contract of how they would work together and thiswas written into the care plan. The contract included theimportance of them being honest with each other, that alldecisions would be negotiated between them, that all pre-scribed interventions would be fully explained and that hislifestyle would be respected. His care plan includeddetails of when and how he would have physiotherapy,psychosocial activities to assist his transition back to thecommunity and a programme of self-administration ofmedicines. Although disagreements and challenges arosebetween Ray and Pam, renegotiations of his care planoccurred on a regular basis and resolutions were found. Inaddition, Ray attended regular case reviews with the mul-tidisciplinary team and thus felt fully involved in treat-ment decisions.
This example demonstrates the centrality of values tothe relationship between the nurse and patient. Ray feltpart of decisions and Pam ensured that she respected hisvalues in the way she worked with him. Pam worked withhim using skills of negotiation, openness, honesty andconsultation to ensure that their agreed contract was ful-filled. The imperfect duties of informed flexibility, mutu-ality, transparency, negotiation and sympathetic presenceare evident. The community hospital in which this caseexample was situated has invested much time in creating acontext to support person-centredness.
CONCLUSIONS
This paper presents a framework for person-centredpractice that holds as central the concept of autonomyas authentic consciousness. By viewing person-centredness in this way, an understanding of caring rela-tionships is achieved that is not based on one personbeing the final arbiter of decisions but which is, instead,set within a framework of negotiation based on an indi-vidual’s values base. The nurse as a facilitator of an indi-vidual’s authentic consciousness engages in a process ofdynamic caring that maintains autonomy at a time whenfor many older people, their sense of independence isunder greatest threat.
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APPENDIX 1Principles for action
1. Make explicit the care agenda.
2. Recognize that the questioning style adopted affectsthe ability of the older patient to contribute to the settingof the care agenda and their contribution to aconversation.3. Be aware that actions to achieve one outcome mighthave an effect on a previously unrecognized need.4. Have a repertoire of interactional approaches that willenable patient decision making and participation in theplanning of care plans.5. Pose specific and clearly formulated questions thathave a clear aim.6. Respect individuals’ important routines in daily life andnegotiate new components of the care agenda each day.7. Be aware that older patients depend on professionals tominimize or prevent constraints on their autonomy.8. Listen to patients and allow them to tell their story asa legitimate part of assessment processes.9. Wherever possible, encourage patients to identifysolutions for existing problems and care needs, set withinnegotiated parameters of risk taking.10. Get to know patients and establish a negotiated levelof engagement before decisions about degrees of risktaking are made.11. For informed decision making to be facilitated in apatient-centred way, refrain from imbuing decision-making processes with one’s own values.12. Suspend the use of prior knowledge about a patientand their social context until they have been enabled totell their story.13. Recognize that the uniqueness of patients’experiences versus nurses’ familiarity with organizationalroutines limits a patient-centred approach to decisionmaking.14. Accord the patient’s perceptions of their caresituation equal status as those of health care professionals.15. Patients’ subjective views of their lives should berespected in decision making.16. To facilitate patient participation, understand and beconfident with the boundaries of one’s decision-makingpotential.17. Adopt a patient-centred approach to risk assessmentand risk taking.18. Be explicit about the intent and motivation foraction and the parameters within which decisions areset.19. Maximize patients’ independence through thebalancing of patient narrative with established carepolicies and procedures.
Person-centred practice and older people 209
20. Make decisions within a framework of negotiationwith clearly established care goals that are regularlyreinforced and reviewed.21. Make time to help patients to integrate new caredecisions and options into their already established careprogramme.22. Acknowledge and facilitate patients’ emotionalresponses as an important part of facilitating patientparticipation.23. Create opportunities for reciprocity in relationshipswith patients.24. Do not allow age-related perceptions of anindividual’s ability to limit patient participation.
25. Help patients to see beyond their own limitedexpectations of their involvement in care and theirdeference to others.26. Continuously reinforce the value of patients’ decisions.27. Facilitate patients’ emotional coping ability in orderto enhance their independence.28. Recognize that while patients want to be consultedabout care decisions they do not always want to be thefinal arbiter of decisions.29. Recognize that older people should have their beliefsand values considered in the making of decisions butpatients being the final arbiter of decisions is not of primeimportance.
