Introduction: Reflective essay on person centred care
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Modern day Healthcare has increasingly embraced concepts of client-centred practice and empowerment. However, Taylor (2003) posits that existing literature on the subject does not give clear and unambiguous descriptions of the ways by which nurses can empower clients. Nonetheless, nursing practice is inclusive of people from very different backgrounds. In my ward for example, a high proportion of the nurses did not get their initial qualifications and experience in the UK, and my mentor too did not start of as a nurse from the UK. As a result of this, in the absence of well defined guidance for patient empowerment as a practice concept (by regulatory authorities), nurses and other healthcare practitioners will always encounter difficulties in the performance of their duties – in recognition of patient empowerment as a concept.
The way patient care is manifest in hospitals has evolved over time and now centres around collaborative working with different teams coming together to ensure that client care and outcomes are improved (Hansson et al 2008), (Hewison and Stanton 2003). Working in this way requires that the patient is an inclusive and active partner in his care planning and care delivery. This new way of working has also been emphasised by the government introducing the agenda for patient-centred care and patient empowerment. The Department of Health stipulates that the NHS needs to empower patients more and give them control over their healthcare (DoH 2008) and the World Health Organisation (WHO) also requires that patients are always consulted before any procedure is carried out on them (WHO website). The whole concept of empowering patients may not be new to healthcare practitioners because some healthcare practitioners are known to have spoken about making efforts to carry the clients along in the process of their care delivery (Stewart et al. 2002), but Paterson (2001) claims that some healthcare professionals have also been known to use subtle and covert ways to avoid fully implementing the patient empowerment requirement even at the risk of going against regulation to empower patients. Empowerment has been (in essence) practitioner defined to suit the practitioners. As an example, at the MDT meetings I attended, the patients’ views were not adequately promoted, and considering the requirements of the patient empowerment agenda, the patient is supposed be in charge of his healthcare.
I raised this with my mentor and the ward manager, and recommended that the patient be consulted before, and updated after every meeting that has to do with his care delivery. Acknowledging client empowerment as a way forward and in emphasising the need for this modern way of working, the Prime Minister in a key message in January 2008 said that patients are to be treated as active partners in their care. Brown et al (2006) consider that for care to be client-centred, care delivery must be focused on the client and empower and engage the client to his/her full potential as a partner in his/her care delivery. Whereas the client-centred concept requires that what is best for the patient is done, patient empowerment requires providing clients with adequate information and the knowledge required to make informed decisions and take control of their lives (Kielhofner 2002). The issue of patient empowerment raises an issue about empowering intellectually disabled persons who cannot make such decisions on their own. If an adult with intellectual disability does not have complete ability to communicate, their choices can be diminished which in turn can make it particularly difficult to ensure that their opinions are heard (Cameron and Murphy 2002); and even in instances where a nurse is designated the health facilitator for the client, there is no guidance as to how much decision making can be undertaken on his behalf (Martin and Carey 2009). These further complicate issues in nursing management for a qualified nurse and will call on good managerial skills. Modern healthcare practice environment is a highly regulated one with stringent requirements of the healthcare practitioners. The continued drive for improvement in both healthcare delivery service and the patient’s experience and quality of life (DoH 2005) have led to the promotion of improved integration between healthcare disciplines and agencies, and regulatory requirements to promote the concept of patient empowerment (DoH 2008), (Corsello and Tinkelman 2008), (Glasby and Parker 2008). Empowerment is a natural phenomenon and is essential to humans.
Patient empowerment may be resisted by nurses because of existing nurse-patient relationships (Nyatanga and Dann 2002) and so a deliberate cultural shift needs to be pursued to inculcate nurses with the shift in paradigm. To achieve, the nurse will need additional training, and the clients ought to be carried along in drawing up treatment plans. The more the client is involved in the treatment planning, the more the client appreciates his/her part in the patient empowerment agenda, and the more the satisfaction with the care delivery service. I have used simple courtesies like saying ‘thank you’ to the client, and realised it brightens their day very much and also makes them much happier and willing to discuss their feelings and opinions with me. The convergence of management and nursing has evolved over the past few decades and management is often cited as the reason for failings, and also as the likely solution (Pollitt 1993) to many of the problems in the NHS. Management was first formally defined by Henry Fayol (1949) as the composite function of planning, organizing, coordinating, commanding and controlling activities or events. More recent definitions in management theory look at management from the perspective of empowerment, total quality management, organizational culture etc. (Hewison and Stanton 2003). Leadership and management skills in nursing overlap to a very large extent but whereas leadership skills are needed in the more personal aspects like mentoring and motivation, management skills are needed to meet organizational targets and the management of available resources.
With the problems associated with recruitment and retention of nurses in the health sector, and the attendant high turnover of nurses came an additional expectation of nurse-managers to help reverse the trend (even though several of the pioneering nurse-managers had not had formal managerial training) (Contino 2004). Contino (2004) described the managerial skills required of a good nurse manager to include change management, communicating plans, managing the flow of information, managing nursing ROTAs and managing finances (income and expenses). Courtney et al (2002) rate financial management knowledge as one of the top requirements for a nurse manager in order to understand financial forecasts, financial plans, financial ratios and financial performance ratios. A nurse manager needs to be very conversant with current practices and concepts. A good understanding of service improvement and knowledge (and use) of the available developmental resources for nurse improvement like the Leadership at Point of Care programme (Janes and Mullan 2007) are essential for successful nurse-management.
Carney (2009) reported that clients were more likely to be dissatisfied whenever they felt the nurse leader was incompetent. The Nursing and Midwifery Council (NMC) requires that the nurse is conversant with and aware of current developments in practice by way of continued professional development after qualifying as a trained nurse. To manage a team well, a nurse will need very good communication skills in addition to the authority to take decisions within the boundaries of his/her responsibility (Cross and Prusak 2002), (Carroll 2005) as and when necessary. A nurse manager should be a good team-player and able to multi-task (Jaynelle and Stichler 2006) and possess very good communication skills that go beyond language and/or grammar, to listening, being assertive and ensuring that the nurse’s decisions are enforced especially when the nurse speaks on behalf of a client (or helps to amplify the clients voice) (Harris 2003).
The nurse manager should ensure that adequate communication links are established between the client and the MDT so that client views are always considered. The nurse manager should patiently try to clearly understand the patient (Lynden 2006) so as to be able to ensure client’s views are accommodated in client’s care delivery. In situations of acute ailments, clients can present with intellectual disability or a moderated ability to communicate verbally which can make it difficult to understand their opinions or wishes (Cameron and Murphy 2002) for their care process. To be a leader, today’s nurse will need to be able to command the respect of other team members. To achieve acceptability nurse managers need to be people with high integrity and people management/motivation skills and be able to work in a collaborative setting (Carroll 2005). Integrity in this perspective is synonymous with honesty (Kouzes and Posner 2002) and several studies have highlighted the importance of honesty for nurse management or leadership because people (clients and nurses alike) will want to assure themselves that their leader is worthy of their trust (Kouzes and Posner 2003). During my placements in an adult care unit of a major hospital, from observation and interaction with patients and healthcare staff, my attention was drawn to a plight of some of the patients in my care: I realised that some of the patients were not being allowed to determine the course of their treatment as required by the patient empowerment agenda (DoH 2008) and this was more especial in patients with acute ailments.
There was a lack of full management implementation of the Patient empowerment agenda, with particular emphasis on the relevance given to the patient’s choice (or voice) in the patient’s care delivery. The quality of care delivery is assessed by its ability to improve patient care through the collaborative team work of healthcare professionals and how patient-focused the care delivery is. For the purposes of this work, I shall refer to a renal patient in my care during my placement as Mr. B (not real name). All references to him or a hospital do not identify either. When Mr. B was … and was refusing to be compliant, I approached him and had a talk with him. I discovered that his lack of compliance was in protest of the fact that he was not aware he was being put on … reinforcing the position of Corsello and Tinkelman (2008) that clients will respond better to care that encourages their participation and is considerate of their specific needs. To ensure that this did not happen again, I brought the patient’s complaint to the attention of my mentor and ensured that the multi-disciplinary team was made aware by adequately documenting my findings and observations. I regularly sought advice and guidance from my mentor because mentoring and role-modeling are active ways of knowledge transfer in large organizations (Carney 2009) and improves the care delivery service. Service improvement remains a core requirement for the Knowledge and Skills Framework for a registered nurse (DoH 2004) and requires an all-party embracing culture of seeking continuous improvement (Janes and Mullan 2007) where honest and periodic performance appraisals are evident.
Service improvement in the NHS has been an issue of high importance and has necessitated the establishment of groups that are charged with charting out improvements within the NHS – like the ‘NHS Improvement’ (NHS Improvement Programme 2008). Practicing nurses are encouraged to keep abreast with developments from such groups. A new service improvement concept of ‘patient-safety’ is gaining popularity in healthcare although regulatory definition is not yet specific (Feng et al 2008). Flin and Yule (2003) claim patients can be injured through the actions of healthcare staff, and Feng et al (2008) insist that a blame and shame culture inhibits learning from mistakes and can exacerbate incidences of mistakes. To this end (in the UK) an Expert group was established that recommended that the culture around error reporting shifted towards finding the cause of the error rather than the culprit (DoH 2000). Nurses are often under pressure from shortage of nursing staff, and a change in the nursing environment can improve patient safety and outcomes (Lin and Liang 2007). During my placements, I observed that Mr. B was often in bed for prolonged periods between nursing visits. I appraised the risk of the situation and ranked his needs by priority. He looked like he was beginning to get sore from immobility, so I delegated his need for exercise to the physiotherapist in the MDT, and having assessed the competency level of the HCA on the ward, I delegated the tasks of keeping Mr. B’s environment clean and regularly turning him to air his back to the HCA. The HCA had been previously supervised for this task and had been assessed as competent to perform it satisfactorily.
To achieve the required improvements which accompany patient empowerment that the NHS strives for, there must be a change from the current culture where the nurse sees the client as a patient (Nyatanga and Dann 2002) towards seeing clients as part and parcel of the decision making in their care delivery. Quality will be improved when patient empowerment/voice in patient care is active, client engagement is on a regular basis, and nurses are more patient in hearing patients out and in attending to patient calls. Patient safety issues including the security of the patient, proper risk assessment, maintaining cleanliness of his environment and regular visits should be the norm