Person-centred Practice in emergency care: what are

the challenges?Vidar Melby & Donna McConnell

University of Ulster

Personcentredness:a

prehospital emergency care

perspectiveDr Vidar Melby, UU, Joint Research and Writing with

Mats Holmberg, PhD-StudentKarolinska Institute, Stockholm, and Professor BO

Suserud, Prehospital Research Institute, Borås, Sweden

Patient experience stressful, injured or ill, awaiting ambulance clinicians, or strapped to chair or trolley, unfamiliar environment, limited space in ambulance. Care is often urgent.

Limited research focus on core caring concepts in prehospital emergency care.

Melby V. et al. 2012. Patient comfort in pre-hospital emergency care: a challenge to clinicians. Journal of Paramedic Practice, 4, 7, pp 389 - 399

Existing knowledge

Having Sympathetic Presence – Ambulance patients’ perspectives A development from being

lonely to being cared for. A temporary presence. A caring presence. After the presence ends – back

into a lonely struggle despite being under hospital care.

• Holmberg,M., Forslund, K., Wahlberg, A.C. and Fagerberg, I. (2013) To surrender in dependence of another; the relationship with the ambulance clinicians as experienced by patients (Submitted)

• Quotation: “Then something happens and people come to help you and open up themselves. They talked and cared as I was a family member…You get very warm and happy from that. I got that feeling.”

Providing Holistic Care – Ambulance Nurses’ Perspectives Encounter the person as unique

and in a unique situation. The patients feel that the whole

caring encounter is managed by the clinicians.

Assessments are based on physical, psychological and social perspectives.

• Quotation:• “…that the doors are locked and the oven is switched off

if the patient is alone in the apartment. You always have in mind if there are pets, younger people or children in the apartment.”• Holmberg, M. and Fagerberg, I. (2010) The encounter with the unknown: Nurses lived experiences of their responsibility for the care of the patient in the Swedish ambulance service. Int. J. Qualitative Stud Health Well-being 5 (2) DOI: 10.3402/qhw.v5i2.5098

Engagement – Ambulance Nurses’ and Patients’ Perspectives

Ambulance Nurses

To inform and prepare. Understand the patients’

experiences. Encounter without pre-made

assumptions.

Quotation:“In a practical way I try to tell the patients what my thoughts are. What will happen next. So that not a lot of things happens that the patient doesn’t understand.” (Nurse)

Ambulance Patients

• Being involved.• Being respected and acknowledged.• Being important.

Quotation:“They talked directly to me they really did. They asked me where I had pain and if they should get the stretcher. They talked in a daily manner and I felt immediately a relief…” (Patient)

Challenges in the Prehospital Emergency Care Context?

The balance between medical treatment based on set protocols and personcentred care.

• Maintaining Core Caring Concepts while effecting Evidence Based Emergency Interventions.

• Shared Decision Making – are patients happy to relinquish autonomy?

• Effective Communication – collaboration in care.• Innovative Working Culture – freedom to be innovative –

working within strict medically based protocols.

Exploring Person-Centredness in the

Emergency Department

Donna McConnell PhD Student

Prof Tanya McCance

Dr Vidar Melby

Dr Paul Slater (adviser)

‘It’s a war zone, people were crying in pain’, ED patient, Belfast Telegraph, 23.03.12

‘the current ED system in NI is de-humanising and patients are not getting the quality of care they deserve or that nurses want to provide’ (RCN 2012)

Pensioner dies alone on hospital trolley U105fm, 2012

I saw a nurse just standing there in tears’, ED patient, Belfast Telegraph, 23.03.12

We pay lip service

to providing

services that are

patient and client

focused’ RCN

spokesperson 2012

‘We’re at breaking point’, warns Northern Ireland

director of nursing , Belfast Telegraph 2012

Person-centred practice has shown to transform practices for patients...

• increased choice and involvement in decision making

• improved quality of nurse/patient engagements

• staff taking time to get to ‘know’ the person in a more meaningful way

• staff were more person-centred, in their language and team-work

• a reduction in ritual and routine

....and staff

• a shift in values to appreciate caring over the technical aspects of nursing care

• increased effectiveness of teamwork and workload management

• improved staff relationships with more effective collaborative working

• increased personal and professional job satisfaction - less intention to leave posts

• a more effective use of resourcesMcCormack et al (2010)

Themes from the literature

• Outcomes for patient and relatives • what they want vs. what they received• Outcomes for staff• - Aggression and violence • Staffs’ values and beliefs• - a culture of ‘worthiness’ • - medical tasks and technology valued over caring• Staffs’ role in managing the service

What the literature said patients and relatives wanted in ED

• Competence of staff

• Waiting times

• Pain controlled

• Provision of information and explanation tailored to needs

• Small actions which gave physical comfort

• A family presence

• Developed interpersonal skills

• - nurses taking care of the patient and engaging in active listening

• - being present and fully engaged with them in the moment

• To be near their relatives and touch or talk to them and know what was happening to them

Literature - patients experienced…

Non-urgent patients received a series of fragmented courtesy encounters and found it difficult to make themselves seen or heard. They projected their dissatisfaction elsewhere and tried to maintain relationships with staff by being ‘good’ patients (Nyström et al 2003, Nyden et al 2003, Elmqvist et al (2011)

A feeling of not being considered as an individual and a lack of caring as predominant features (Nyström et al 2003)

..abandoned, exposed, vulnerable, ashamed, ignored, insecure, frightened forgotten or unwelcome (Kihlgren et al 2004, Gordon et al 2010, Möller et al 2010, Elmqvist et al 2011).

Literature - staff experienced… – aggression and violence

Pain, anxiety, lengthy waiting times, alcohol and substance misuse, overcrowding, lack of information

One nurse described a feeling as if the whole waiting room hated them and stated ‘it just wrecks my spirit’ (Hislop and Melby 2003)

Negative consequences include powerlessness, frustration, isolation and vulnerability, anger, anxiety, fear, worry, decreased job satisfaction

All experienced ED nurses understood the term ‘eat our young’ … (Baumberger-Henry 2012)

‘it felt like ‘being kicked in the teeth’ (Pich et al 2011)

At times staff may inadvertently contribute to violence by being overtly authoritative, being judgemental and confrontational, rude and condescending (Ferns 2005, Lau et al 2012, Pich et al 2011)

OUTCOMES• Satisfaction with care• Involvement with care• Feeling of well-being• Creating a therapeutic culture

Literature - staff values and beliefs…- a culture of worthiness

Staff experienced frustration with “frequent fliers” and “regulars” (Bergman 2012, Muntlin et al 2010)

Patients who arrived with trivial conditions, prior expectations of treatment and expectations of preferential treatment breached cultural beliefs (Fry 2012).

‘‘You have a positive bag sign, when I see the ambulance pull up and the bag’s on the trolley. I just immediately think, right, you’re in the waiting room’’ (Fry 2012)

Staff held a collective belief system beliefs of what was considered ‘true’, ‘right’ and ‘good’ (Fry 2012)

Sbaih (2002) states this is a reflection of staffs’ desire to keep the department running smoothly rather than a moral judgement of worth.

Literature - staff values and beliefs… - medical tasks and technology valued over caring

Interactions with patients were only initiated when undertaking doctor’s instructions. These nurses defined good trauma care by good technical care (Winman and Wikblad 2004)

Medical treatment is highly valued while nursing care is undervalued…ED nurses are socialised by the social authority and status of medicine (Nyström 2002)

‘our patients do not need nursing care, they are just waiting for a medical examination’ (Nyström et al 2003a)

We are not good at giving nursing care. We are trained in acute care, giving nursing care does not come automatically (Kihlgren at al 2005)

Literature – the care environment…- staffs’ role in managing the service

Processes outside the departments impact on the quality of care. ED staff are at the mercy of other departments to allow transfer of patients (Nugus and Forero 2011, Pickard et al 2004)

Inability to move patients on in the system leads to overcrowding, low staff satisfaction, decreased compliance with clinical guidelines, decision-making errors, an increase in adverse events, and waiting times (Nugus and Forero 2011)

CARE ENVIRONMENT• Appropriate skill mix• Shared decision making systems• Effective staff relationships• Supportive organisational

systems• Power sharing• Potential for innovation & risk taking• The physical environment

Paradoxically nurses have managerial responsibility of the ED but do not have managerial control over medical staff there. When doctors do not come to see the patient’s nurses do not know what to tell them (Elmquist et al 2012).

Literature –care processes…- staffs’ role in managing the service

There was no strategy for patient participation. It was offered when staffs’ conditions were met i.e. time to engage with the patient, staffs’ genuine interest and the patient’s medical priority being the current focus for attention (Frank et al 2008)

Due to commitments of other tasks registered nurses found it difficult to provide individualised care leaving basic nursing care to be carried out by unqualified staff (Hwang et al 2008, Bergman 2012).

CARE PROCESSES• Working with patient’s

beliefs and values• Engagement• Having sympathetic presence• Sharing decision making• Providing holistic care

Efforts to achieve workflow can cause work to become mechanical where interpersonal encounters are reduced to a technical meeting preventing the establishment of a patient relationship on individual level (Andersson et al 2011, Khokher et al 2009)

Aim

The aim of this study is to explore person-centred practice within the ED environment.

• 2 stages

• Stage 1, objective 1

• Staff questionnaire

• Stage 2, objective 2

• Staff interviews

• Patient interviews

Methodology

Pilot study

• Undertaken in August 2013• 4 Minor Injury Units • 23 registered nurses• 19 fully completed questionnaires returned or

completed online

The Prerequisites scale appeared to have good internal consistency, a = .97 Professionally Competent a = .841Developed Interpersonal Skills a = .896Being Committed to the Job a = .945Knowing Self a = .885Clarity of Beliefs and Values a = .903

The Care environment scale appeared to have good internal consistency, a= .96 Skill-Mix a = .706Shared Decision-making Systems a = .828Effective Staff Relationships a = .945Power Sharing a = .928Potential for Innovation and Risk Taking a = .838The Physical Environment a = .843Supportive Organisational Systems a = .90

The Care Processes scale appeared to have good internal consistency, a = .961

Working with Patients Belief and Values a = .887Shared Decision-making a = .932Engagement a = .883Having Sympathetic Presence a = .862Providing holistic care a = .862

The 30 item PREREQUISITES SCALE 5 point likert scale [1 = Strongly Disagree to 5 = Strongly Agree].

Total sum score 130 (Mean 4.3)

Staff agreed that they possessed the necessary prerequisites for person-centred practiceProfessionally Competent (8 items) Strong agreement (mean = 4.5)

Developed Interpersonal Skills (5 items) Strong agreement (mean = 4.6)

Being Committed to the Job ( 7 items) Agreement (mean = 4.4)

Knowing Self (5 items) Agreement (mean = 4)

Clarity of Beliefs and Values (5 items) Agreement (mean = 3.9)

The 36 item CARE ENVIRONMENT scale 5 point likert scale [1 = Strongly Disagree to 5 = Strongly Agree]. Total sum score 137.16 (mean 3.8)

Staff agreed that they worked in a care environment conducive to person-centred practiceSkill-Mix (3 items) Agreement (mean = 4.2)

Shared Decision-making Systems (5 items) Neutral (mean = 3.4)

Effective Staff Relationships (5 items) Agreement (mean = 4.2)

Power Sharing (6 items) Agreement (mean = 3.9)

Potential for Innovation and Risk Taking (6 items)

Agreement (mean = 4)

The Physical Environment (4 items) Agreement (mean = 4.1)

Supportive Organisational Systems (7 items) Neutral (mean = 2.9)

The 30 item CARE PROCESSES scale 5 point likert scale [1 = Strongly Disagree to 5 = Strongly Agree]. Total sum score 124.32 (mean 4.1)

Staff agreed that they engaged in the necessary care processes to deliver person-centred practiceWorking with Patients Belief and Values (7 items)

Agreement (mean = 4)

Shared Decision-making (5 items) Agreement (mean = 4)

Engagement (7 items) Agreement (mean = 4.1)

Having Sympathetic Presence (6 items) Agreement (mean = 4.3)

Providing holistic care (5 items) Agreement (mean = 3.9)

• 2 stages

• Stage 1, objective 1

• Staff questionnaire

• Stage 2, objective 2

• Staff interviews

• Patient interviews

Methodology

Conclusion

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