Researching nursing practice: does person-centredness matter?

© Blackwell Publishing Ltd 2003

Nursing Philosophy

,

4

, pp. 179–188

179

Original A

rticle

Blackwell Science, LtdOxford, UKNUPNursing Philosophy1466-769XBlackwell Publishing Ltd 20034Original Article

Researching Nursing Practice: Does Person-Centredness Matter?

Brendan McCormack

Correspondence: Brendan McCormack, Nursing Development

Centre, 3rd Floor, Bostock House, Royal Hospitals Trust,

Grosvenor Road, Belfast, BT12 6BA, UK. Tel.: 028 9034 6394;

fax: 028 9026 3433;

e-mail: [email protected]

1

A version of this paper was first delivered as an invited keynote

address to the Royal College of Nursing Northern Ireland

Research and Quality Group (NIRAQ) Conference, November

2002.

Researching nursing practice: does person-centredness matter?

1

Brendan McCormack

DPhil (Oxon ) BSc (Hons) Nursing PGCEA RGN RMN

Professor of Nursing Research/Director of Nursing Research and Development, University of Ulster/Royal Hospitals, Belfast, Northern Ireland, UK

Abstract

Person-centredness is common speak in nursing and health care litera-ture. Increasingly there is an expectation that practitioners adopt per-son-centred principles in their practice and organizations are expectedto respect the values of the service user. However, in the researchmethodology literature, there is little explicit attention paid to the con-cept of person-centredness in research practice. Instead, there continuesto be a reliance on traditional ‘ethical principles’ to guide effectivenessin research work. This paper argues that the principles of person-centredness that are espoused in nursing practice should also underpinnursing and health care research. A framework for person-centredresearch is proposed and issues concerning its implementation in prac-tice are discussed.

Keywords:

person-centredness, research, person-centred research,

knowledge, praxis.

Introduction

Person-centredness is common speak in contempo-rary nursing and health care discourse. In the field of

practice development, for example, the need fordevelopment work to be driven by a commitment toincreased effectiveness in person-centred practice ismade explicit (Clarke & Proctor, 1999; Garbett &McCormack, 2002). There is little argument againstthe centrality of person-centredness, other thanrecent work suggesting that it is more appropriate totalk about relationship-centred care rather than per-son-centred care (Nolan

et al

., 2001a), but essentiallyboth are driven by the importance of holding ‘person-hood’ central to decision-making in health care prac-tice. Whilst this person-centred discourse is excitingand is leading to significant changes in the way thathealth care is delivered, even a cursory review of the

180

Brendan McCormack


Nursing Philosophy

,

4

, pp. 179–188

literature highlights that the language of person-centredness hasn’t pervaded the research methodol-ogy literature. Indeed, whilst there is much debateabout the meaning of personhood, its operationaliza-tion in practice and the implications of adopting thisway of being, none of this debate appears to havepermeated the research literature. It seems ironic thatresearch into person-centredness continues to adoptformulaic research approaches without any apparentexplicit consideration for the topic under study.

This paper contends that the principles of person-centredness need to be adopted in research designsthat have the explicit intention of understandingnursing practice and/or the quality of patient care. Ifa central drive in health care is that of increasingperson-centredness, then surely research that aims tostudy nursing practice should adopt this also as adriving principle. This assertion, however, raises par-ticular challenges to researchers and these will beexplored in this paper.

To begin with, it is appropriate to say somethingabout the nature of knowledge and knowledge gen-eration in nursing and how this links to our under-standing of different kinds of nursing action. It isthrough distinguishing between differing forms ofaction that we can begin to see the relevance of aperson-centred agenda in research and development.

Research and knowledge generation

No man [sic] is allowed to put his mother into the stove

because he desires to know how long an adult woman will

survive at a temperature of 500

∞

Fahrenheit, no matter how

important or interesting that particular addition to the store

of human knowledge may be . . .

. . . the right to knowledge is not the only right; and its

exercise must be limited by respect for other rights, and for

its own exercise by others. [George Bernard Shaw (1856–

1950) (Shaw, 1934), p. 255]

Shaw contends that knowledge generation for itsown sake is an unsustainable position to adopt. Shawhighlights the fact that whilst the generation ofknowledge is a laudable activity, it cannot be set out-side of other values. Consider an example fromresearch:

The study was a clinical trial exploring the effectiveness of

a particular drug. This was a unique study and the need for

the research was identified by a practising nurse (the nurse

who undertook the study). The data collection involved the

nurse collecting blood samples on three different occasions

from participating patients. The researcher had difficulty

recruiting an adequate sample and the final sample was five

patients. Ethical approval for the study was gained, but with

a much larger predicted sample. Whilst the blood samples

were analysed rigorously, the sample size was too small to

make any statistically significant statement about the effi-

cacy or otherwise of this drug. The nurse concluded that

whilst a larger study was needed, the study was useful as it

allowed the opportunity to develop skills in this kind of

research. But what issues does this example raise for us as

researchers, supervisors, academics and students (the so-

called ‘research community’). Does the nurse have the right

to conduct such a study? Is the knowledge generated useful

in its own right, irrespective of its utility? What is the respon-

sibility of the researcher to the participants (the study had

ethical approval)? Do patients have any responsibility for

the development of nursing knowledge? Where does respect

for persons come into the decision-making process?

Coulter (2002) discusses the distinction between‘those who know and do not act and those who actand do not know’. What is being suggested here isthat there are those groups who strive to know butdo not engage in acting on the basis of that knowingand those who act but do not always have the knowl-edge to underpin their reasoning for acting in a par-ticular way. This argument could be seen to underpinthe traditional divide that exists between researchers(those who strive to know) and practitioners (thosewho act). Further, the reasons why practitioners viewresearchers as being in their ‘ivory tower’ becomeclear as there is a perceived hierarchy between thebearers of the knowledge and those who need theknowledge to support their practice. This subordina-tion of practice to research has always been in evi-dence and is highlighted by the way academicresearch is supported in health care organizationsoften at the expense of practical concerns (e.g. a hos-pital team’s decision to participate in another clinicaltrial without direct consultation with the ward teammembers), career decisions made by nurses (i.e. mov-


181


Nursing Philosophy

,

4

, pp. 179–188

ing into a research career is seen as career progres-sion whereas staying in clinical practice is not) andlittle progress being made in committing researchersto the active dissemination of findings other thanthrough academic publications. The hierarchical rela-tionship that exists between the putative knowledgegenerators and the knowledge users is one that hasgreatly influenced the development of knowledge innursing. Coulter (2002) makes a similar argument inan educational context and I will draw upon his useof Aristotle’s understanding of forms of action toarticulate the point.

Aristotle distinguished between two kinds of action– poiesis and praxis (Welldon, 1987). Poiesis means‘making action’ and praxis means ‘doing action’. Poie-sis involves action that is focused upon achieving apredetermined end, that is, the construction of aproduct or an object (e.g. a completed research study)is its end point. Poiesis is, according to Carr (1987, p.169), ‘… a species of rule-following action’. The worthof knowledge generated in this way is judged on thequality of the end product. The worth of the knowl-edge generated is decided upon by the way it isjudged to conform to recognized and predeterminedstandards and current understanding of what countsas good quality in the particular area under study. Wesee this evidenced in the way that quality of researchis judged, based on the relationship between dataanalysis and research findings and their generalizabil-ity. To return to the previously cited research exam-ple, the nurse followed the right rules, demonstratedskill in mastering the research design and whilst theoutcomes are not generalizable, the methodology is(with a larger sample size), as it conforms to recog-nized understandings for conducting such a study. Butis it person-centred – clearly not.

‘Praxis’ on the other hand is not necessarily con-cerned with the end product, but is instead concernedwith morally worthwhile good that cannot be prede-termined in advance as it is dependent on the contextin which the action is undertaken. The achievementof an end product and the process of getting there arenot separate entities, because the quality of the endproduct is inseparable from the means of gettingthere. Good practice, understood as ‘praxis’, involvesmore than the application of a theory or the exercise

of a skill. Determining the right thing to do at theright time and in the right way [often seen as theessence of clinical effectiveness (see, e.g. Kitson

et al

.,1998)] involves a particular kind of knowledge –‘practical knowledge’ (Eraut, 1985, 2000). Titchen(2000) describes it as ‘professional craft knowledge’or ‘practical know-how’. This knowledge is expressedand embedded in practice, is often tacit and intuitiveand it combines perception, reasoning and virtue. Toreturn to the research example, a concern with praxiswould have caused the researcher to perceive theproblems inherent in the design; think rationally onthe balance of means and ends and on the basis of theprinciple (virtue) of respect for persons decide on thefeasibility of continuing with the research. This con-cern is consistent with a person-centred approach topractice.

Person-centredness and person-centred research

Person-centredness is concerned with our right tohave our values and beliefs as individuals respected,that is, our personhood. It is argued that it is thesevalues that give us our uniqueness and our authentic-ity (McCormack, 2001a). Respect for persons reflectscommitment to having a deep understanding of theother person as a thinking and feeling human beingwith potential to change and develop. Person-centredpractice is thus predicated on the value of person-hood. It requires us to know the values held byanother in order to treat them as persons. It requiresus to work with individual beliefs, values, wants,needs and desires and to adopt approaches to workthat enable flexibility, mutuality, respect, care andbeing with another in an interconnected relationship(McCormack, 2001a). So how does such a philosophyimpact on the way we research nursing practice?

It is important to state that this is not a plea for allresearch to be based on action research, practitionerresearch or the broad school of methodologies thatare labelled ‘qualitative approaches’. Suggesting thatresearch approaches such as action research do notsupport the subordination of practice would be naiveas many authors (e.g. Gaventa & Cornwall, 2001)highlight the way in which action research can indeed

182

Brendan McCormack


Nursing Philosophy

,

4

, pp. 179–188

manipulate and abuse power as much as any othermethodology. The issue here is not one concerningthe making of methodological decisions in researchdesigns, but is instead a decision that requires theresearcher to consider key principles underpinningthe research approach irrespective of the methodol-ogy being adopted. In my view, these principlesshould be no less person-centred than those adoptedby practitioners in the development of practice. Thisis a key challenge, as the closest many researchers getto being person-centred is completing the ethicalapproval form and hoping that it will get through theprocess without too many hold-ups. But what woulda person-centred research framework look like inpractice?

Principles of person-centred research

Pritchard & McCormack (2001) have identified prin-ciples that should underpin person-centred researchwith older people. However, experience with otherclient groups would suggest that these principles aremore generally applicable to research designs that areconcerned with understanding nursing practice.

The previously cited research example does notconstitute a person-centred approach to research.Clearly, the researcher had limited experience in con-ducting this kind of study and thus did not have theexpertise to conduct this research as per the initialdesign. Yes, important learning was achieved, but thepatients were used as a means to anothers’ end ratherthan an end in themselves. A person-centredapproach to the design of a research project wouldtake into consideration the knowledge needed to con-duct the research, the skills needed by the researcherand participants in the research design, the experi-ence appropriate to the research design and the like-lihood of the research outcome being achieved. Thisclearly has implications for students, supervisors andpotential participants. Students should be clear aboutthe knowledge they possess about the researchdesign, the skills needed to conduct the research andprior experience of undertaking such research. How-ever, of even greater importance here is the role ofthe research supervisor. Supervisors need to knowthe knowledge, skills and experience of research stu-

dents in order to advise them appropriately in design-ing the research study. Funding for research needs toconsider this carefully. There needs to be a muchmore ‘up-front’ relationship between researchers andpotential participants with regard to the knowledge,skills and experience of the researcher, that is, thepotential participant shouldn’t assume the experienceof the researcher.

The time investment

Person-centred research requires a sustained commit-ment to participants in order to ensure the value ofthe person is held central. For many researchers,working with predetermined deadlines, this is oftenan impossible goal. However, there is clearly a moralissue of means and ends here as discussed earlier. Forexample, if we are committed to changing the healthcare experiences of service users, then is it ethical toundertake an isolated survey of users’ views of a ser-vice or practice without a long-term commitment toacting on the results of the survey? Evidence fromaudit, quality and research activities would suggestthat this commitment is not always present (Haines& Jones, 1994). The key issue is that researchersshould consider a long-term vision for their researchin advance of undertaking the first step in theresearch journey and in doing so have a clear under-standing of how best to commit to a sustainedinvolvement in each stage of the research – fromdesign through to implementation and beyond.

The preparation of the environment

Research into person-centred practice highlights theimportance of the environment of care in enablingand sustaining a person-centred approach (Mc-Cormack, 2001a; Nolan

et al

., 2001b). Issues such asteam–patient relationships, interprofessional rela-tionships, the organization of practice, systems andapproaches to work and the quality of leadership areall key factors in delivering person-centred practice.However, what is interesting is that there appears tobe little debate about how these issues are addressedin the conduct of research. It is not unusual in mycurrent experience for research to be in progress in


183


Nursing Philosophy

,

4

, pp. 179–188

wards and departments without the full knowledge ofstaff working in those settings. There appears to bean assumption that if consent has been achieved fromthe key participants then we don’t have to worryabout others who may be less directly involved in theresearch. This is in part driven by a positivist agendaof reduction and control and thus the setting of theresearch is reduced and controlled as much as thedata collection processes themselves. Paying atten-tion to the context of practice is important in a per-son-centred approach to research and rather thantrying to control it, I contend that we should try toembrace it, as it may help the overall researchapproach rather than hinder it. Key issues to considerwould include:

•

team structures and processes;

•

team relationships;

•

the organization of work;

•

communication systems;

•

attitudes to research and development among teammembers, and

•

incentives for staff participation and/or support.

The socialization of researchers

The drive to complete research studies in the shortesttimeframe possible is increasing all the time as insti-tutions are often judged on their ‘research study com-pletion rates’ as an indicator of quality. In the UK,the Research Assessment Exercise (RAE) has beena key influence on this agenda with the allocation ofresearch funding to universities in part, being madeon the basis of completion rates. This drive is influ-encing greatly the attitude of funders to part-timePhD study, which is increasingly being frowned upon.Whilst the difficulties associated with part-time studyof any kind are in no way being denied, the approachalso has clear benefits. In a ‘research proposal writinglearning set’ that I facilitate, I find myself in increas-ing levels of conflict with participants as I try toencourage them to study full-time, whilst they arguefor part-time status. Their rationale is usually to dowith their need and desire to stay in practice whilstconducting their research, because not being in prac-tice would compromise their connection with the

practice they wish to study and thence their researchwork. This argument is convincing if we believe thechallenges of bridging the so called ‘theory–practicegap’. The traditional view of researcher socializationstill prevails (Rolfe, 1996) despite the espoused val-ues of the primacy of practice. To have a researchcareer means leaving practice, studying full-time fora PhD, undertaking postdoctoral work and joining anestablished research team and working one’s way upthrough the academic ranks (e.g. assistant, officer,senior officer, reader, professor). I would argue thatthere is an alternative research career route that asyet has been given little serious consideration, that of,the ‘researcher-practitioner’. A research career in thismodel would look something like – undertakingpart-time

PhD

study

with

a

clear

practice

focus,

under-taking postdoctoral work in a practice setting, co-ordinating small-scale practitioner-research projects,developing practice-based research teams, leadingpractice-based research programmes and workingone’s way through a clinical-academic career struc-ture. A clinical-academic career structure wouldinclude research practitioner, senior research practi-tioner, clinical reader and clinical professor. How-ever, such routes and associated positions are few andthere continues to be much scepticism about theirappropriateness among the majority of the academiccommunity.

Negotiation and renegotiation of boundaries with users

Evidence suggests that health service users continueto experience systems of domination that limit theirability to fully participate in care decisions or toinfluence the basis on which decisions are reached(Walker & Dewar, 2001; McCormack, 2001a). Acentral theme of contemporary policy agendas is theactive and systematic involvement of users in servicedevelopment decision-making (Department of Health(England), 2001; DHSSPS, 2001; Scottish ExecutiveHealth Department, 2001). The centrality of patientinvolvement running through these various policydocuments is not new and the challenge therefore isto make systematic involvement a reality. Existingmethods of involvement include user panels, forums,

184

Brendan McCormack


Nursing Philosophy

,

4

, pp. 179–188

outreach initiatives, partners in research and advocacy(Thornton, 2000). However, evidence suggests thatdespite these models, there is a need to significantlydevelop both the process and methods of involvementand increase opportunities for collaborative partner-ship working to make the process meaningful andeffective (Department of Health (England), 2001)].The prevailing culture of health care delivery is slowto change (Kennedy, 2001). This is in part due to thefact that development requires a change in attitudes,that views working with patients in partnership as amutual process of growth and development. Address-ing the contextual and attitudinal issues that inhibitpractitioners from involving patients and developingperson-centred approaches to care requires more thanthe development of service standards. Creativeapproaches to the active involvement of service usersin research, practice development and quality initia-tives need to be found. Approaches such as emanci-patory practice development, appreciative inquiryand narrative inquiry are all enabling the develop-ment of person-centred involvement and participa-tion by service users and service providers. Theseapproaches can sit alongside more traditionalresearch methods and frameworks and serve toenhance rather than hinder them. As researchers, wehave much progress to make in moving beyond thetokenism that currently exists and to fully embrace aperson-centred approach to involvement.

Seeking and gaining consent

Research in western society is preoccupied with arational discourse of informed consent (Johnstone,1989). Indeed, the increasing control being exerted byethics committees and research governance frame-works excludes approaches to consent that are notobjective and rational. Whilst research ethics is drivenby a Kantian deontological moral framework(MacIntyre, 1992), the dominance of a rational-logical approach to decision-making within this phi-losophy prevails. The result of this is that largesections of populations are excluded from giving con-sent other than through ‘proxies’. Existing evidencesuggests that proxy consent is unreliable as it assumesthat an individual’s values are known and understood

by another person (Buchanan & Brock, 1989).Because of this dominance, client groups such as peo-ple with dementia are largely excluded from the con-sent process or, worse, are sidelined as a suitablepopulation to study directly. Much research witholder people with dementia is conducted via ‘reliableinformers’ on the basis that they are able to representthe person – an unreliable position to adopt as previ-ously argued. Elsewhere, I have argued (McCormack,2002) that a narrative-based approach to informedconsent can provide a means of engaging people withdementia in the consent process. Dewing (2002)argues for ‘process consent’ whereby the researcherpays attention to the whole person (e.g. their feelings,behaviours and responses) as a legitimate form ofconsent in person-centred research designs. Whilstthese approaches are new and in early stages of devel-opment, it is clear that consent in person-centredresearch goes beyond the signing of a consent formand if these populations are to be engaged with aspersons, then ethics committees need to support avariety of consent approaches.

Representing views authentically

How are the voices of participants in analysed datarepresented by researchers? For example, in the writ-ing of a research report, the voice of the researcheris presented through an academic discourse thatrarely represents ‘normal talk’ (Drew & Heritage,1992). However, in the same reports, quotes fromparticipants are presented in their natural form, com-plete with stutters, repetition, hesitancy, poor gram-mar and syntax and incomplete sentences. This doesnot represent a position of equality, as the researcher(the writer of the research report) is in the positionof power and can thus present different forms of dis-course for the researcher and those being researched.It could be argued that if we are truly person-centredas researchers then both voices should be equallyrepresented. If we are going to be person-centred inour representation of the view of service users thenwe need to agree with participants how they wishtheir voices to be represented and strive to engageparticipants with verifying the construction ofresearch reports and publications. As a minimum, we


185


Nursing Philosophy

,

4

, pp. 179–188

need to move from the position of peppering researchpapers with

ad hoc

quotes from participants with littleconsideration about how they might feel about seeingtheir ‘talk’ represented in this way.

Disengaging from the setting

It goes without saying that if we are adopting a per-son-centred approach to research, then the process ofdisengaging from the setting needs careful consider-ation. Person-centredness is predicated on the basisof a social relationship bestowed on one human beingby others in the context of a relationship. The termi-nation of any relationship needs careful planning tobe undertaken successfully and satisfactorily for bothparties (Ridley & Jones, 2002). This is no less impor-tant than any other nurse–patient relationship. The‘hit and run’ approach to research participants is notperson-centred but is instead an abuse of anotherperson’s humanity as it reduces them to the level ofobject that serves to meet another’s (the researcher)end. Researchers need to consider the issue of ‘pay-back’ to research participants. Examples of wherepay-back has been provided in studies include clinicalsupervision sessions, seminars, supporting actionfrom preliminary findings, speaking at public meet-ings of voluntary groups and collaborative writingwith participants. The appropriate management ofdisengagement can be a form of celebration of thecompletion of successful work and the growth expe-rienced. The inappropriate management of disen-gagement results is hurt, resentment and reducedcommitment to further participation.

Necessary and sufficient conditions for person-centred research

In considering how best to embrace a person-centredresearch approach, there are a range of factors thatare necessary to consider (such as having informedconsent), but these in themselves are not sufficient tosustain this approach. I would argue that if we asresearchers and developers of practice are to embraceperson-centredness then we need to reconsider theprinciples that underpin our research practices. Theprinciples presented here have been developed in my

research into person-centred practice in working witholder people (McCormack, 2001a,b) and are currentlybeing used in ongoing research and developmentactivities. Each ‘condition’ is described and ‘enablingfactors’ (i.e. factors that need to be considered inorder to operationalize the condition) proposed.

Condition 1: informed flexibility –

the facilitation of decision-making through information sharing and the integration of new information into established perspectives

This condition highlights the need for the researcherto be an active facilitator of decisions in the proposedresearch setting and throughout the research period.New information related to the project needs to beintegrated into prior information and participantsactively engaged in decisions. It requires theresearcher to have a flexible approach to the wayparticipation is negotiated and to be able to use avariety of conversational approaches in doing this.Being person-centred requires the researcher to besensitive to the practice setting and the variety ofunpredictable challenges that might arise.

Enabling factors

• Have a repertoire of conversational approaches innegotiating the research process.• Be flexible in the organization of the research andadopt a nonroutinized approach to data collectionpractices.

Condition 2: sympathetic presence –

an engagement that recognizes the uniqueness and value of the individual, by appropriately responding to cues that maximize the person’s opportunity to participate/not participate

Working with sympathetic presence as a researcherplaces responsibility on the researcher to be sensitiveto cues that research participants may be givingregarding their participation in the research. It is nor-mal protocol for consent forms to include an opt-outclause for research participants. However, given thepower relationships at play, this may not be easy for

186

Brendan McCormack


Nursing Philosophy

,

4

, pp. 179–188

participants to do. A person-centred researcher needsto be sensitive to verbal and nonverbal cues fromparticipants and help them make an appropriate deci-sion regarding participation or nonparticipation.

Enabling factors

• Recognition of the power of language and theeffects of language on the autonomy of the otherperson.• The use of an appropriate questioning style thatfacilitates the setting of a person-centred conversa-tion agenda.

Condition 3: negotiation –

participation through a research framework that values the views of the participant as a legitimate basis for decision-making

This is particularly important in the process of gain-ing consent. The signing of a consent form representsthe objective component of the consent process.However, for many vulnerable groups, the attentionto process consent issues (Dewing, 2002) is key. Pay-ing attention to behaviours, feelings, comments, emo-tions and interactions is important in ensuringeffective participation or nonparticipation byresearch participants.

Enabling factors

• Working within a collaborative framework that val-ues the ‘subjective’ views of the participant equallywith other ‘objective’ measures.• Establishing a negotiation framework that seeks toclarify the person’s values in the situation.• Recognition of the interdependence of people insociety.

Condition 4: mutuality –

the recognition of others’ values as being of equal importance in decision-making

The research literature places heavy emphasis onthe values of the researcher and depending on theresearch design, the explication of values is seen aseither an appropriate or inappropriate activity.

However, this condition makes explicit the need forconsidering the values held by participants inresearch decision-making. Knowing the underpin-ning values held by patients, nurses, clinical teamsand other participants is essential to effective per-son-centred decision-making. Researchers shouldmake time to get to know (as far as possible) thevalues held by potential participants and shared byclinical teams.

Enabling factors

• A willingness to listen to and understand partici-pants’ expression of their values and to hold thesecentral to decision-making.• A willingness to work with the perceptions andunderstandings of others and to consider these per-ceptions in the overall research plan.• A willingness to learn from the relationships estab-lished with participants.

Condition 5: transparency –

the making explicit of intentions and motivations for action and the boundaries within which decisions are set

It is not untypical in the design of research studies forthe significant decisions regarding design to be madeby the researcher in isolation of potential participantsor people with an understanding of the issues thatmight directly impact on potential participants. Thiscondition of ‘transparency’ requires the researcher tomake clear the intentions of the research before deci-sions about data collection are made and also to makeexplicit the boundaries of the research, that is, whatis and is not possible (for example).

Enabling factors

• An understanding of professional boundaries indecision-making.• An understanding of responsibility and account-ability in professional decision-making.• A person-centred approach to risk assessment andrisk-taking.• A willingness to make explicit intent and motiva-tion for actions.


187


Nursing Philosophy

,

4

, pp. 179–188

The adoption of these conditions would enable thedevelopment of a person-centred approach toresearch and development. These conditions are notuniversal principles. What I mean by this is that theyare guiding principles or what Kant refers to as‘imperfect duties’. The term ‘imperfect duties’ isderived from Kant (Sullivan, 1990). In the develop-ment of his universal theory and the categoricalimperative, Kant made a distinction between perfectand imperfect duties. Perfect duties are strict andenforceable. Principles can be morally ‘forced’ tohonour the duty prescribed. Being moral entails com-pliance with valid rights, no matter whether doing soconflicts with other moral goods or other values.

In contrast, imperfect duties are ‘wide, broad andlimited’ – ‘they leave us a play-room for free choicein following the law’ (Sullivan, 1990, p. 52) as thereis no means of offering an exhaustive and

a priori

account of how the duties are to be fulfilled. Suchduties as compassion, concern, benevolence, respectand care would all be imperfect duties. One cannotforce someone to be caring. Instead, imperfectduties rely on the moral character of the individual,or what Kitson (1987) refers to as ‘a moral attitude’

.

Kant views such duties as ‘imperfect’ because inethical decision-making one may have to decidebetween competing duties and account must betaken of the context in which decisions are made.Nurse researchers should not only focus on devel-oping moral-reasoning and decision-making skills,but also on developing moral sensitivity and anindividual sense of moral responsibility. In thissense, the importance of education for moral-rea-soning and for the character traits that are desiredin a relationship such as that between a nurse-researcher and research participant is paramount,that is, their operationalization is dependent on theparticular research design and the particular contextin which it is set.

Conclusions

This paper has argued for the development of person-centred approaches in research and developmentpractices. To a large extent many of the proposedways of working are tentative as we have little evi-

dence thus far upon which to base a person-centredresearch framework. The challenge for academiccommunities is to explore ways of linking in a moreproactive way, the agendas of researchers with theagendas of practitioners. The dominant relationshipthat exists between academic and practice communi-ties (i.e. knowledge provider and knowledge user) isuntenable in the long term. If research governance isto move beyond rhetoric of ‘protection of vulnerablepeople’ then person-centred principles need to beadopted. Thus to answer the original question posed– yes, person-centredness does matter.

References

Buchanan

A.E. & Brock

D.W. (1989)

Deciding for Others: The Ethics of Surrogate Decision Making.

Cambridge University Press, Cambridge.

Carr

W. (1987) What is an educational practice?

Journal of Philosophy of Education

,

21

, 163–186.Clarke

C. & Proctor

S. (1999) Practice development: ambi-guity in research and practice.

Journal of Advanced Nurs-ing

,

30

(4), 975–982.Coulter

D. (2002) What counts as action in educational action research.

Educational Action Research

,

10

(2), 189–206.

Department of Health (England) (2001)

The National Ser-vice Framework for Older People.

Department of Health, London.

Department of Health Social Services and Public Safety (DHSSPS) (2001)

Best practice – best care: a framework for setting standards, delivering services and improving monitoring and regulation in the HPSS.

(A consultation paper.) DHSSPS, Northern Ireland.

Dewing

J. (2002) From ritual to relationship: a person-centred approach to consent in qualitative research with older people who have a dementia.

Dementia

,

1

(2), 157–171.

Drew

P. & Heritage

J. (1992)

Talk at Work: Interaction in Institutional Settings

. Cambridge University Press, Cambridge.

Eraut

M. (1985) Knowledge creation and knowledge use in professional contexts.

Studies in Higher Education

,

10

(2), 117–133.

Eraut

M. (2000) Non-formal learning and tacit knowledge in professional work.

British Journal of Educational Psy-chology

,

70

, 113–136.Garbett

R. & McCormack

B. (2002) A concept analysis of practice development.

NTResearch

,

7

(2), 87–99.Gaventa

J. & Cornwall

A. (2001) Power and knowledge. In:

Handbook of Action Research: Participative Inquiry in

188

Brendan McCormack


Nursing Philosophy

,

4

, pp. 179–188

Practice

(eds P. Reason & H. Bradbury), pp. 70–80. Sage, London.

Haines

A. & Jones

R. (1994) Implementing findings of research.

British Medical Journal

,

308

, 1488–1492.Johnstone

M.J. (1989) Bio Ethics – A Nursing Perspective. WB Saunders, London.

Kennedy I. (2001) Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995 Command Paper: CM 5207. Department of Health, London.

Kitson A.L. (1987) A comparative analysis of lay caring and professional (nursing) care relationships. International Journal of Nursing Studies, 24(2), 155–165.

Kitson A., Harvey G. & McCormack B. (1998) Approaches to implementing research in practice. Quality in Health Care, 7(3), 149–159.

MacIntyre A. (1992) After Virtue – A Study in Moral Theory. Duckworth, London.

McCormack B. (2001a) Negotiating Partnerships with Older People: A Person-Centred Approach. Ashgate Press, Aldershot.

McCormack B. (2001b) Autonomy and the relationship between nurses and older people. Ageing Society, 21, 417–446.

McCormack B. (2002) The person of the voice: narrative identities in informed consent. Nursing Philosophy, 3, 114–119.

McCormack B. (2003) ‘Knowing and acting’ – a strategic practitioner focused approach to nursing research and practice development. NTResearch, 8(2), 86–100.

Nolan M., Davies S. & Grant G. (2001b) Working with Older People and their Families: Key Issues in Policy and Prac-tice. Open University Press, Buckingham.

Nolan M., Keady J. & Aveyard B. (2001a) Relationship-centred care is the next logical step. British Journal of Nursing, 10(12), 757.

Pritchard E. & McCormack B. (2001) Research for Geron-tological Nursing. Distance Learning Module. Royal Col-lege of Nursing Institute, London.

Reeve C.D.C. (1992) Practices of Reason: Aristotle’s Nico-machean Ethics. Clarendon Press, Oxford.

Ridley J. & Jones L. (2002) User and Public Involvement in Health Services: A Literature Review. Scottish Human Services Trust, Edinburgh.

Rolfe G. (1996) Closing the Theory–Practice Gap: A New Paradigm for Nursing. Butterworth-Heinemann, Oxford.

Scottish Executive Health Department (2001) Our National Health: A Plan for Action, a Plan for Change. Scottish Executive Health Department, Edinburgh.

Shaw B. (1934) Prefaces. In: The Doctor’s Dilemma (ed. B. Shaw), pp. 237–281. Constable & Co., London.

Sullivan R.J. (1990) Immanuel Kant’s Moral Theory. Cam-bridge University Press, Cambridge.

Thornton P. (2000) Older People Speaking Out: Developing Opportunities for Influence. Joseph Rowntree Founda-tion, York.

Titchen A. (2000) Professional craft knowledge in patient-centred nursing and the facilitation of its development. University of Oxford DPhil Thesis. Ashdale Press, Kidlington.

Walker E. & Dewar B. (2001) How do we facilitate carers’ involvement in decision making? Journal of Advanced Nursing, 34(3), 329–337.

Welldon J.E.C. (translator) (1987) The Nicomachean Ethics – Aristotle. Prometheus Books, New York.

Documents

Researching nursing practice: does person-centredness matter?