Personcentred practice with older people models, methods and outcomes

1
Person-centred practice with older people -
models, methods and outcomes

• Professor Brendan McCormack, Director of Nursing
  Research PD, University of Ulster Royal
  Hospitals Trust, Belfast
• Adjunct Professor, Monash University, Australia
• Visiting Professor, University of Northumbria

2
ICN Statement

• The goal of nursing care is to assist older
  persons in achieving optimal health, wellbeing,
  and quality of life, as determined by those
  receiving care or consistent with the values and
  known wishes of the individual
• (ICN on Healthy Ageing Fact Sheet)

3
How Person-centred are we?

• Most nurses do not know the patients and the
  values they hold.
• Emphasis on information giving rather than
  information exchange.
• Nurses control conversations and order of care,
  following a predetermined agenda, e.g. ADLs.
• Patients records largely reflect nursing control.
• Little attention paid to patients coping
  abilities.
• Little opportunity for patients to exercise their
  autonomy due to a lack of power.
• Organisational constraints limit patients ability
  to exercise autonomy.

(McCormack, 2001 McCormack et al, in progress)
4
Person-centred Practice

• Rights and social justice.
• Sharing of the power relationship between
  practitioner and patient.
• Autonomy of the individual to determine their own
  destiny.
• Centrality of values and the sharing of values
  between practitioner and patient.

5
Principles of person-centred nursing

• respect for persons
• the rights of individuals as persons
• the values and beliefs of individuals
• mutual respect and understanding
• the development of therapeutic relationships

Being person-centred requires the formation of
therapeutic relationships between professionals,
patients and others significant to them in their
lives.
6
Autonomy as Authentic Consciousness (McCormack
2001)

• By authentic is meant a way of reaching
  decisions which are truly ones own- decisions
  that express all that one believes important
  about oneself and the world, the entire
  complexity of ones values
• (Gadow, 1980)

7
The Russian Doll Model of Autonomy

• On the outside there is the obvious person and
  my overt behaviours, actions and interactions.
  But this outer self is in many ways a superficial
  picture and it is often constrained by hidden
  emotions and beliefs that may not be overtly
  presented.

8
Person-centred Practice as Humanistic Caring

• Deep respect for the autonomy of the patient as
  person.
• Acceptance of the persons life ways.
• Transformation of experience through therapeutic
  relationships .
• Healing of the body and a restoration of
  individual self-worth.
• Consistency of care is essential (and more
  important than continuity of care).
• Acknowledgment of individual biography and
  working with narrative identity.
• (McCormack 2001, 2004)

9
Knowing the Person

• Each person has his own and unique life, his own
  memories, hopes, expectations, habits, and
  biases. Each has had a responsibility in the
  management of his own life ... Each has found
  support, reinforcement, guidance, and correction
  from loving and perceptive others and each has
  suffered at the hands of others.

10
Need for Education

• re-educate those with old and established
  ideas that all the patient needs is toilet
  attention and feeding, and secondly, to educate
  the rising generation of nurses to the scope and
  interests of the work

(Norton, 1954)
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Educational Preparation for Person-Centred
Gerontological Nursing

• Gerontological nursing education continues to be
  problematic
• Lack of consistency
• dependency focused
• technical care orientated
• Lack of Recognition of the expertise of
  gerontological nurses
• Focus on observable tasks
• Tasks seen as simple
• Not sexy for new graduates!
• Skill mix ratios based on observable simple
  tasks

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An example of a simple task

• KNOWLEDGE/SKILL NEEDED
• Assess mood state
• Judge attention span
• Assess concentration
• Know the persons learning ability
• Assess memory orientation
• Be aware of perceptual awareness
• Problem solve in-action
• Psychomotor ability to do the task
• Assess reaction time judge pace
• Be aware of the persons social intactness

• TASK
• Helping an older person with dementia to eat and
  drink

13
A Narrative Experience

• Di Disley
• An experienced registered nurse
• Well established person-centred values
• Has focused a lot on Susans care in supervision
• Problem of paternalistic approach
• Susan
• Is in early-stages of dementia
• A determined woman
• Difficult relationship with her partner
• shoots from the hip
• Drifts in and out of rational conversation

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Help given to Di with recognising her expertise
and developing her person-centredness

• Individual Learning Development Programme
• Narratives of practice (stories)
• Analysis of narratives through clinical
  supervision
• Reflection on practice
• Formal education modules
• Coaching in practice
• Skills development
• Portfolio of evidence

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• I am now able to recognise and acknowledge my
  own skills that I have. I feel confident and
  comfortable with these when working with older
  people. I feel more able to recognise others
  need for help on the same journey and that that
  can vary. I can feel the warmth of another
  person, see their anxiety and can balance this
  against my own expectations of them in the short
  term, to enable growth to occur. In recognising
  how far you can take them, it is important not to
  loose sight of the beginning of that journey and
  their starting point.

16

• Walk with me on my journey
• I need to know youre there
• To listen, guide and comfort me
• My wounded self-repair
• Walk with me on my journey
• Be it to health or death
• Work with me at my chosen pace
• Show me that caring is love and grace
• Walk with me on my journey
• A difference you can make
• A smile, your presence, a gentle touch
• Can mean so very much
• Walk with me on my journey
• A companion for me be
• Be a therapeutic carer
• Make this bearable for me
• Walk with me

(Disley McCormack, 2002)
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Person-centred Practice

• Being in Relation persons exist in relationships
  with other persons
• Being in a social world persons are social
  beings
• Being in Place persons have a context through
  which their personhood is articulated
• Being with Self being recognised, respected
  treated as a person impacts on a persons sense
  of self
• (McCormack, 2004)

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A Framework for Person-centred Nursing/Practice(
McCormack McCance, in press)

• Professor Brendan McCormack, Director of Nursing
  Research PD, University of Ulster Royal
  Hospitals Trust, Belfast
• Tanya McCance, Reader, University of
  Ulster/Ulster Community Hospitals Trust

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Framework Origins

• A conceptual framework for person-centred
  practice with older people
• (McCormack 2001, 2003
• Caring in nursing practice the development of a
  conceptual framework
• (McCance 2001, 2003)

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Person-centred nursing and caring

• Concept of person underpins many theories of
  humanistic caring.
• Synergistic relationship between values and
  caring activities.
• The nurse-patient relationship is central and
  nursing understood as a human science enables
  caring processes to have a significant impact on
  patient outcome.
• (McCance, 2001)
• Synergistic relationship between caring and
  person-centredness and the use of humanistic
  caring frameworks enables person-centredness to
  be realised
• (Dewing, 2004)

21
Developing the Person-Centred Nursing Theoretical
Framework

• Reading and re-reading of original underpinning
  research
• Mapping of concepts
• Reconstruction of (mid-range) theoretical
  framework and refinement of concepts
• Construction of pictorial representation of
  framework
• Testing the face validity of the theoretical
  framework
• Continuous refinement of the theoretical framework

22
The Person- Centred Nursing Theoretical Framework
23
Attributes of the nurse
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Pre-requisites

• Professionally competent
• Developed interpersonal skills
• Commitment to the job
• Clarity of beliefs and values
• Knowing self

25

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

Context in which care is delivered
26
The Care Environment

• Appropriate skill mix
• Systems that facilitate shared decision making
• Effective staff relationships
• Organisational systems that are supportive
• The sharing of power
• Potential for innovation and risk taking

27

• Appropriate skill mix
• Shared decision
• making systems
• Effective staff
• relationships
• Supportive
• organisational
• systems
• Power sharing
• Potential for
• innovation and risk
• taking

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

Delivery of care through a range of activities
28
Care Processes

• Working with patients beliefs and values
• Engagement
• Having sympathetic presence
• Sharing decision making
• Providing for physical needs

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• Appropriate skill mix
• Shared decision
• making systems
• Effective staff
• relationships
• Supportive
• organisational
• systems
• Power sharing
• Potential for
• innovation and risk
• taking

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

• Working with patients
• beliefs and values
• Engagement
• Having sympathetic
• presence
• Sharing decision making
• Providing for physical
• needs

Results of effective person-centred nursing
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Person-centred Outcomes

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

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• Appropriate skill mix
• Shared decision
• making systems
• Effective staff
• relationships
• Supportive
• organisational
• systems
• Power sharing
• Potential for
• innovation and risk
• taking

• Professionally competent
• Developed interpersonal
• skills
• Commitment to the job
• Clarity of beliefs and
• values
• Knowing self

• Working with patients
• beliefs and values
• Engagement
• Having sympathetic
• presence
• Sharing decision making
• Providing for physical
• needs

• Satisfaction with
• Care
• Involvement with
• Care
• Feeling of Well-
• Being
• Creating a therapeutic
• Culture

32
The Person- Centred Nursing Theoretical Framework
33
The Royal Hospitals Trust Person-centred Nursing
Project

• PROJECT TEAM
• Professor Brendan McCormack , (PI)
• Dr Tanya McCance , (Co-PI)
• Paul Slater, Research Associate, UU/RGH
• Charlotte McArdle, Deputy DoN, RGH
• Joanna McCormick, Nurse Consultant Critical
  Care, RGH
• Robert Garbett, Research Fellow, UU/RGH
• Carolyn Kerr, Lead Nurse, Theatres
  Anaesthetics, RGH
• Paula Forrest, NDF RBHSC
• Jan Dewing, Independent Consultant/Senior
  Fellow

34
Project Aim
To evaluate the effectiveness of person-centred
nursing (PCN) when introduced into a range of
clinical areas within an acute hospital setting.
35
Research Questions

• Does PCN make a difference to
• a) patients perception of caring
• b) nurses perceptions of caring
• Does PCN make a difference to
• a) patient outcomes of
• (i) satisfaction with care
• (ii) involvement in care?
• b) nurses outcomes of
• (i) job satisfaction
• (ii) morale
• (iii) sickness and absenteeism
• (iv) stress
• (v) retention?
• What are the experiences of the journey towards
  PCN?

36
Methodology

• Pragmatic quasi- experimental design
• Informed by theoretical framework for
  person-centred nursing

37
Design

• Quantitative measures Pre-test/post-test and
  Interval
• Nursing Context Index (NCI) 21 Constructs
• Perceptions of Nursing Index (PNI)
• Satisfaction and Experience of being nursed
• Caring Dimensions Index
• Qualitative sources -Mapping the journey
  throughout
• Taping of naturally occurring conversations
• Field notes
• Problem solving sessions
• Project team meetings
• Ward/dept. planning meetings
• Facilitator notes
• Follow up interviews with participants at each
  data collection stage
• Intervention phase based on PD framework

38
Development of the Instruments

• A systematic analysis of current literature using
  recognized search engines
• Focus on outcomes of previous person-centred
  research
• Identified job satisfaction, stress, and
  organizational factors as indicators
• Battery of potential instruments no single
  comprehensive instrument

39
Standardised Instruments

• Nursing Stress Scale
• Work Stress Scale
• Nursing Satisfaction Scale
• Quality of Work Life Scale
• Nursing work index Revised NWI-R

40
Nursing Context Index

• Focus groups validation using nominal group
  technique (n 13)
• Identified factors that cause stress, influence
  job satisfaction, and specific to the hospital
• Validated by Expert panel
• Pilot study (n 23)

41
Finalised Instrument Person-centred Nursing
Index

• Nursing Context Index
• 21 Constructs covering job stress (9),
  satisfaction (4) and organisational culture (8)
  associated with person-centred nursing
• Seven point Likert-scale
• Caring Dimensions Index (35 items)
• Demographic details, such as age, grade

42
Statistical Testing

• Test retest
• Administered to all clinical settings
  twice,1-month apart
• Excellent stability in scoring over the 1-month
  period
• Correlation coefficients
• Pearsons product (0.98)
• Spearmans rank (0.98)

43
The study design
Post-test
44
Participating Clinical Areas

• Regional intensive care unit
• Sexual health clinic
• Older people rehabilitation
• Paediatric infectious diseases
• Medical admissions unit
• General surgery
• Cardiology
• Operating room

45
Response Rates
46
Intervention Framework

• Values Beliefs

• Learning in from Practice

Person-centred Nursing

• Culture Context of Care

(Garbett McCormack, 2003)
47

• Values Beliefs

• Learning in from Practice

Person-centred Nursing

• Culture Context of Care

48
Use of the PCN Theoretical Framework

• Facilitation teams used the framework to
• analyse barriers to change
• focus particular developments
• evaluate developments

49
Practice Exemplar 1

• Joanna McCormick, Nurse Consultant, Critical
  Care, Royal Hospitals Trust

50
The Intensive Care Journey
51
Self Allocation
Supervision
E Grade Dev Programme
DE Grade
Education
T3 Away Day
04
(2 W Shops)
Zone Workshops
(April/May 04)
Reflective Practice
Effective Communication T3
Zone leaders
F G W.Shop March 04
Improving Continuity Care
F Grade Workshop 17/10/03
Evaluation of Zones
off duty 18/4/04
Alison Binnie Workshop Aug 03
Values clarification exercise/education July/Aug
03
PCN FEB-MAY 03
Majellas Tree
52
The Person-centred Nursing Project in the
Rehabilitation of Older People
53
Context

• Rehabilitation Unit in the Royal Hospitals
• 100 beds x 3 wards
• Day hospital
• 6040 mix of registered/unregistered nurses
• Development Research Fellow (FT)/Facilitator (Rob
  Garbett)
• Activities
• Assessment developments
• Pre-discharge suite
• Interdisciplinary decision-making
• Reflective practice
• Continuity of care developments

54
Practice development critique

• Working with values and beliefs
• Its about working with people not on them

• How do you keep people
• on board with all this?

55
Practice development critique

• Understanding culture and context
• Knowing where we are at
• Its the simple things ..
• What do you do if
• Theres no staff
• Your area is involved in other projects?!

56
Practice development critique

• Supporting learning in and from practice
• Making the time making things happen
• When you create the links it starts to make
  sense
• Youve got to grow a set!

57
Growing a set

• An unqualified member of a project group came to
  one of our regular meetings with an issue. She
  (a qualified nurse) wont work in the way we
  agreed. We talked around how the way we were
  trying to work (working with, not on) meant
  that we needed to help him develop strategies for
  selling the new way of working. This meant
  taking responsibility rather than using the ward
  hierarchy, or as he said, you have to grow a
  set!

58
Practice development critique

• Being systematic and rigorous
• It opened our eyes!
• You dont want to do it if you cant see what
  its for
• Working in a heavily researched organisation

59
Tape recorded data Interaction between nurses
and patients (1)
Showing sympathetic presence
Chatting
For example, talk that appears warm and friendly
but without obvious therapeutic intent
For example, picking up on a persons comments
to find more out about them and their home
circumstances
60
Tape recorded data Interaction between nurses
and patients (2)
Getting work done
Sharing decision making
Opportunities for interaction occurred while
getting tasks done for example drug
rounds. Interaction could be mainly task focused
There was evidence that tasks could be used to
work with patients, for example making choices
about whether to take analgesia
61
Impact staff and patients
62
Nursing Stress
63
Nursing Satisfaction
64
Organisational Commitment
Staff turnover decreased from 17.6 in 2003 to
6.8 in March 2005
65
October 04 to February 05 15 increase in scores
They listen They ask what you want to do and
how Balancing patients wishes with theatre flows
PERCEPTIONS OF NURSING INDEX
staff stay with me
Impact on patient care
IMPACT ON EXPERIENCE
IMPACT ON ENVIRONMENT
Erosion of traditional boundaries
STORY TELLING Narrative project providing
evaluative data
INCREASED FEEDBACK
USERS FORUMS Providing a voice for patients and
carers
FEEDBACK AS A WAY OF WORKING Building patients
evaluation into routine record keeping
66
Caring Dimensions Index Perceptions of Nursing
67
Summary Results (1)

• Comparison group scored overall satisfaction
  levels below the intervention group satisfaction
  scores.
• Comparison group reported greater dissatisfaction
  with nursing.
• Intervention group show overall increase in
  satisfaction with nursing.
• Stress decreased on four of the five constructs
  two were significantly different (workload and
  uncertainty regarding treatment). Conflict
  with other nurses increased (positive result).
• Largest change in satisfaction was in personal
  and professional satisfaction.

68
Summary Results (2)

• Significant changes were reported for
  organisational factors of autonomy and
  organisational support.
• The intervention group showed a correlation
  between a decrease in intention to leave the
  organisation in the next year and a mirrored
  increase in organisational commitment.
• The comparison group changed from intending to
  leave to an intention to stay but their final
  score equaled the starting score of the
  intervention group.
• There was a positive change in patients
  experience of being nursed across all the
  clinical settings (problem of ceiling effect).

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Achievements Learning
70
Achievements

• The project has provoked increased clarity around
  person-centredness
• Strategically embedded in nursing and midwifery
  strategy within the RGH
• Theoretical framework international impact
• Data collection (evidence) to show impact of
  practice development
• Reached end point through very difficult
  circumstances
• Rich learning to develop a recipe for project
  facilitation learning from negative as well as
  positive experience to guide future project
  development/facilitation
• Theoretical framework useful PD decision-making
  tool
• evidence in practice of people considering person
  centredness and its evaluation
• Person centred nursing index
• an evaluative tool
• strong validity and reliability
• international interest in further testing

71

• When people who are not used to speaking are
  heard by people who are not used to listening,
  then real change occurs

72

• Acceptance of the Prevailing Moral Culture is in
  itself immoral
• Oscar Wilde