Assesment of nursing theory

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directions thoroughly. Follow submission requirements. Make sure all elements on the grading rubric are included. Rules of grammar, spelling, word usage, and punctuation are followed and consistent with formal, scientific writing. 5. Title page, running head, body of paper, and reference page must follow APA guidelines as found in the 6th edition of the manual. This includes the use of headings for each section of the paper except for the introduction where no heading is used. 6. Ideas and information that come from scholarly literature must be cited and referenced correctly. 7. A minimum of four (4) scholarly literature references must be used. Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Chapter 7 Person-Centred Nursing Outcomes and their Evaluation Introduction Outcomes are the results expected from effective PCN. The literature on PCN is weak in terms of methods for evaluating outcomes, with little clarity about outcome focus, methodologies or methods. We have identified three themes for outcome measurement. Outcomes in these themes can be demonstrated from the perspectives of both staff and patients/families. In this chapter, we will explore these three themes from the perspectives of challenges, approaches and tools (Figure 7.1). The chapter will begin with an overview of outcome evaluation in nursing with a particular focus on how caring outcomes are reflected in the literature. The challenges associated with determining outcomes from PCN will then be discussed. A framework for evaluating outcomes from PCN will be proposed that takes account of the evaluation of processes and outcomes arising. Finally, the chapter will propose a variety of methods that can be used to evaluate PCN outcomes. Outcome Evaluation in Nursing Measuring the effectiveness of nursing is problematic. There is a large and diverse literature that attempts to determine both the key indicators for outcome measurement and methodological approaches. The nursing literature also highlights the challenges associated with evaluating the effectiveness of nursing due to the Figure 7.1 Person-centred outcomes themes. • feeling involved in care, • having a feeling of wellbeing, • the existence of a therapeutic environment, described as one in which: • decision-making is shared, • staff relationships are collaborative, • leadership is transformational, • innovative practices are supported. Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 112 Person-Centred Nursing diversity of perspectives and frameworks that underpin the practice of nursing. The challenges associated with what has been referred to as ‘the invisibility’ of nursing is also a significant issue in the evaluation of nursing outcomes. The invisibility argument refers to the nature of nursing practice itself. Unlike other health care professionals, many nursing practices cannot be delineated as specific interventions where there is a clear input matched to an outcome – for example, a physiotherapist can evaluate their input to a patient’s improvement following a fractured neck of femur repair in terms of the number and types of specific treatments (interventions) offered and the rate of improvement determined by the objective measurement of movement. Much of the work of other health care professionals (e.g. physiotherapists) is treatment or intervention specific and thus the outcome from these interventions has greater potential for outcome evaluation. Nursing on the other hand, whilst engaging in specific treatment interventions, often does so as a part of an ongoing and continuous engagement with patients/service users and so aspects of practice associated with providing a specific intervention (such as administration of intravenous therapies, treatment of a pressure sore or assisting with nutrition) are ‘hidden’ and not visible or open to objective measurement. In a discussion paper, McQueen (2000) highlights the incongruity that exists between models of care that emphasise the importance of therapeutic relationships between patients, families and care staff, whilst at the same time little emphasis is placed on these activities in the measurement of nursing outcomes. McQueen (2000) argues that if nurses are required in this way, then the interpersonal and emotional nature of the work needs to be recognised in clinical practice, education and research and be included in the way that nursing effectiveness is measured and evaluated. Staff nurse Orla Dempsey works in an acute medical ward where she is a primary nurse to six patients, each of whom have varied care needs. Orla is on duty with a care assistant (nurses aide). At the beginning of the shift, Orla undertakes an assessment of the care needs of the patients she is working with in order to determine how best to plan her work and that of the care assistant (nurses aide) for the shift. Some patients have very specific ‘technical’ care inputs that Orla is able to clearly identify and to which she can allocate a specific period of time. The rest of their care needs can largely be met by the care assistant (nurses aide) with Orla’s supervision. The remainder of the patients have more complex care needs that include technical interventions. Orla prioritises these patients as those she will dedicate most time to and in planning their care includes the technical interventions. She builds these into the overall plan of care. During the shift, the care assistant approaches Orla and lets her know that Shaun, one of the patients whom she has been allocated, Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation needs his intravenous nutrition replaced as the previous one is complete. Orla views this as a ‘straightforward’ and ‘uncomplicated’ task to do. However, whilst chatting with Shaun during the procedure she discovers that Shaun is deeply concerned about how he will resume his sexual relationship with his partner. Orla spends an hour talking this through with Shaun, discussing options with him and identifying sources of support, as well as attending to other aspects of his physical care needs. Later in the day, whilst completing the workload allocation record for a ‘nursing workload audit’, Orla documents her work with Shaun under two headings – ‘specific treatment’ and ‘patient support’. However, she feels deeply dissatisfied with this as she knows that during that time she also provided comfort, engagement, empathy and personal care but it is not possible to show these in the audit record. Some authors are critical of the ‘invisibility’ and ‘hidden’ arguments in health care practice and suggest that these arguments are more reflective of the need to understand ‘complexity’ in many health care practices (Plsek & Greenhalgh, 2001; Cutliffe & Wieck, 2008). The complexity of nursing is a key consideration and helps to make sense of why nursing effectiveness cannot be judged on ‘output’ alone, but that there need to be frameworks developed that evaluate outputs/outcomes in relation to inputs (Spilsbury & Meyer, 2000; Meyer & Sturdy, 2004). Internationally, much work has been undertaken on determining outcome indicators for nursing by organisations such as The International Council of Nursing (ICN) (development of nursingsensitive outcome indicators http://www.icn.ch/matters_indicators .htm) and the National Database of Nursing Quality Indicators in the United States (Montalvo, 2007). In addition, research into the ‘expertise of nursing’ has begun to identify the complexity of nursing work and the importance of evaluating the effectiveness of this work beyond simple input/output models (Hardy et al., 2009). A recent review of aspects of nursing linked to patient outcome from the UK ‘National Nursing Research Unit’ (Policy ⫹ 2008) highlighted the complexity of measuring outcomes in patient care. The authors highlighted ‘failure to rescue’ and health care-associated infection as nurse-sensitive outcomes, but falls and pressure sores were less sensitive. They also highlight that positive contributions of nursing to outcomes such as well-being or recovery are less well addressed in nursing outcome frameworks. However, Maben and Griffiths (2008) highlight those aspects of care that patients most value, including: • • • • A holistic approach to physical, mental and emotional needs, patient-centred and continuous care. Efficiency and effectiveness combined with humanity and compassion. Professional, high-quality evidence-based practice. Safe, effective and prompt nursing interventions. 113 114 Person-Centred Nursing Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. • • Patient empowerment, support and advocacy. Seamless care through effective teamwork with other professions. These aspects of patient care feature less strongly in nursing outcomes frameworks but yet are consistent with the principles and values underpinning PCN. Outcome Evaluation in Person-Centred Nursing The evaluation of nursing specific outcomes arising from the adoption of a person-centred approach to practice is underdeveloped and there are few reports of published person-centred outcome evaluation in the literature. Whilst the principles and values of personcentred care/nursing are enshrined in much contemporary nursing and health care policy and strategy, the empirical evidence available to support it as an operational framework for nursing and health care delivery is as yet unconvincing. Descriptive accounts of PCN leave little doubt that it does impact on patient’s experience of care services and nurses experiences of caring. However, there is a need to develop creative strategies for evaluating the complex processes that underpin person-centredness in practice. Research in areas of vulnerable people such as older people and people with intellectual disabilities has shown it to be effective in promoting patient choice, improving the experience of being cared for and patient involvement in care (Parley, 2001; Dewing, 2002; Clarke et al., 2003). Despite this, the evidence to support its impact on nursing is sparse. Attempts have been made to evaluate the impact of PCN in specific aspects of care, for example, the impact of person-centred showering (bathing) on bathing-associated aggression, agitation and discomfort in nursing home residents with dementia (Sloane et al., 2004; Hoeffer et al., 2006), the impact of multisensory environments on older people with dementia (Hope & Waterman, 2004), the evaluation of the development of ‘relationship skills’ between nurses aides and patients (Medvene et al., 2006) and exploration of how preceptors interpret, operationalise, document and teach personcentred care with students in a surgical setting (McCarthy, 2006). Other studies have evaluated person-centred planning with people with intellectual disabilities (Robertson et al., 2007), the experience of woman-centred care (Pope et al., 2001) and a number of studies that have evaluated the impact of person-centred care on people with dementia from a variety of perspectives (Dewing, 2008c). Person-centred nursing, as a model, reports the advancement of traits such as adequate staffing levels, decentralised structures, professional practice models of delivery and professional development issues (Binnie & Titchen, 1999) as a result of systems changes adopted to facilitate its implementation. The work of Binnie and Titchen (1999) remains one of the few studies that systematically analysed development of a person-centred culture in an acute care setting1. Evidence from Binnie and Titchen’s Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation research suggested that adopting this approach to nursing provides more holistic care. In addition, it may increase patient satisfaction with the level of care, reduce anxiety levels among nurses in the long term and promote team working among staff. Binnie and Titchen, however, did not test these assertions and were therefore unable to provide evidence of the suggested relationships. Existing evidence is consistent with the view that being personcentred requires the formation of therapeutic relationships between professionals, patients and others significant to them in their lives and that these relationships are built on mutual trust, understanding and a sharing of collective knowledge (Binnie & Titchen, 1999; Dewing, 2004; McCormack, 2004; Nolan et al., 2004). Binnie and Titchen (1999) tried to make explicit what is a nurse–patient therapeutic relationship. They highlighted the importance of the nurse avoiding the making of assumptions about patients, being ready to listen and to watch with an open mind. The emphasis on skills is essential, both in terms of practical skill and trained presence. This approach requires intelligence, creativity and attention to detail, and transforms the focus of bedside care: in skilled hands, the opportunities presented by everyday bedside caring become the medium through which a patient’s experience of illness can be transformed. (Binnie & Titchen, 1999: 18) We have already suggested that life plans of the individual and enabling and disabling aspects of the context of the care environment are important considerations in PCN. The context of care was seen as having the greatest potential to help or hinder the facilitation of PCN. In modern health care, the fundamental moral situation of nurses is that whilst they are expected to engage in autonomous decisionmaking, they are often deprived of the freedom to exercise moral authority. To exercise their freedom requires nurses to ask questions of their traditional methods of nursing, and having the belief that they can and should change the context of care. The context of care extends beyond autonomy to practice, and can be found, with equal significance, in other organisational factors such as systems of decision-making, staff relationships, organisational systems, power differentials and the potential of the organisation to tolerate innovate practices and risk-taking (McCormack et al., 2002). Hale (1986), using a simple version of PCN, found increased levels of job satisfaction and morale among the staff; nursing stress levels also decreased. Johns (1994) and Ellis (1999) reported similar results. Ellis added that PCN ‘enhanced oneself, ones practice, professional education and the organisation as a whole’ (p. 300), thus highlighting the importance of the evaluation of PCN extending beyond direct patient outcomes, and including staff and organisational outcomes. Complementary evidence from research such as magnet hospitals and models of nursing practice shows that changing an organisations’ culture has an impact on the issues concerning nurses working life 115 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 116 Person-Centred Nursing (Hayes et al., 2006; Manojlovich & Laschinger, 2007; Gunnarsdóttir et al., 2009). The bulk of this evidence draws a causal link between organisational culture change and working environment factors such as retention of staff, job satisfaction and job stress. Yet, Newman et al. (2001) found that, in the United Kingdom, there has been no unified or cohesive approach to workplace planning. The researchers state that there is a governmental acknowledgement of and commitment to the importance of the organisational culture in promoting nurse retention, job satisfaction and reduced stress, yet this commitment has not manifested itself into a single method of implementation (Newman et al., 2001). The Institute of Medicine in the United States reiterated the importance of organisational culture as an aspect of improving nurses’ working environment and proposed guidelines for hospitals based on research conducted into ‘magnet hospitals’ where it identified a number of traits such as professional autonomy and practice control as key in keeping nurses working. The report authors concluded that: Quality problems (nurse retention and patient satisfaction levels) occur typically not because of a failure of goodwill, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the way care is organised. (2001: 25). Person-centred nursing involves the reorganisation of the context of care to promote continuity of care, amongst other things (McCormack, 2003, 2004). The context of care offers the greatest source of facilitation (or hindrance) to the development of a person-centred ethos in the nurse’s workplace (Manley, 2001; McCormack, 2004). Whilst overall, there is a lack of outcome evaluation in PCN, the potential benefits of PCN to patients is more often documented (Parley, 2001; Dewing, 2002; Clarke et al., 2003), with the benefits to nurses not so clearly articulated. The research that exists reports the advancement of traits such as adequate staffing levels, decentralised structures, professional practice models of delivery and professional development issues (Binnie & Titchen, 1999) and with these changes reduced stress levels, increased job satisfaction and nurse retention. Research into organisational culture supports the link between decentralised structures, autonomy and nurse satisfaction and retention (Hayes et al., 2006; O’Brien-Pallas, 2008). In summary, whilst the values and principles of PCN are increasingly espoused in policy and strategy, its evaluation and particularly outcome evaluation is poorly developed. Whilst debates persist about the meaning of underpinning concepts, the appropriateness of models and their implementation, approaches to outcome evaluation receive less attention. Some of this lack of attention is due to the limitations of existing methodologies to capture the complexity of PCN in its entirety and thus it is easier to evaluate sub-elements. In addition, few instruments measure constructs such as ‘patient involvement in care’ and there are few conceptual frameworks of patient satisfaction that explicitly include patient involvement. Previous research and development work focusing on caring in nursing highlights that Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation perceptions differed between patients and nurses, which is discussed in Chapters 3 and 4. Such challenges highlight the need for evaluation frameworks that capture the complexity of the interrelationships of the elements of PCN if it is to be embedded in practice. It is this challenge that we will next address. A Framework for Outcome Evaluation In the PCN Framework presented in this book, we have identified four outcomes that would be achieved from the development of a PCN culture: 1. 2. 3. 4. satisfaction with care involvement with care feeling of well-being creating a therapeutic culture Satisfaction with care is a well-established outcome measure in nursing and health care. However, it is also one of the most challenging outcomes to evaluate. The challenges in evaluating satisfaction with care are many – an inability to determine a universally accepted definition of ‘satisfaction’, the multiple meanings attached to the term that are often highly individualised and idiosyncratic and the lack of comprehensive measurement tools to capture the multidimensionality of the term (Staniszewska & Ahmed, 1999; Edwards & Staniszewska, 2000; Edwards et al., 2004; Entwistle et al., 2004; Entwistle & Watt, 2006). The evaluation of patient satisfaction is often reduced to the level of organisational audit where annual patient satisfaction surveys are a key approach to determining the effectiveness of an organisation. However, such surveys lack depth, fail to capture individual perspectives of satisfaction and lack conceptual rigour (Edwards et al., 2004). From the perspective of PCN, evaluating satisfaction cannot rely on organisational-wide surveys, instead the effectiveness of the care processes and the care context (environment of care) to support these should be central. Feeling involved in care is a key part of contemporary health care strategy and policy and there is an explicit expectation that patients will be active participants in their own care. Examples such as ‘the expert patient initiative’ are predicated on the assumption that people will be active participants in their care and work in partnership with health care professionals. Thus evaluating the extent to which people feel involved in their care would seem to be a key focus of person-centred outcome evaluation. In addition from a staff perspective, being involved in the decision-making process is a key focus of many models of care that aim to ensure that care decisions are made by nurses working directly with patients and is a key indicator in developments such as the magnet hospitals. Having a feeling of well-being underpins the aims of many caring theories, rehabilitation models and care practices. McCance (2003) 117 Person-Centred Nursing clearly articulated how positive care experiences engendered feelings of well-being among patients and is indicative of the patient being valued. Similarly, nurses need to feel valued for their work and thus is also considered a key aspect of outcome evaluation in PCN. Creating a therapeutic culture has been demonstrated to a key factor in the delivery of PCN and the extent to which the environment supports and maintains person-centred principles has been shown to be critical to PCN. In a study aimed at ‘shifting the culture of practice’ in an acute care setting through the introduction of an integrated work-based learning/research/practice development framework (known as the REACH Framework), Boomer et al. (2006) created a conceptual framework for evaluating relationships between structure, process and outcome elements of the REACH programme of work (Figure 7.2). The ultimate aim of the REACH programme is that of creating a person-centred culture. Evidence from research and development underpinning the REACH Framework indicates four types nisational responsibility Reflection t Prac tice Evidence Facilitation Expertise Perso na l accountability Conceptual framework Figure 7.2 The REACH conceptual framework. ig Person-centred culture: • Accountable practitoner • Empowered practitioner • Autonomous practitioner • Patient-centred care Self-awareness in arn Leadership dev elo p m en Orga Le Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 118 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation of outcomes – accountable practitioners, empowered practitioners, autonomous practitioners and the delivery of patient-centred care. In order to achieve these outcomes, three layers of activity are needed: 1. learning mechanisms 2. practice domains 3. individual and organisational responsibility The learning mechanisms (reflection, facilitation and evidence) are key to enabling learning to happen. Drawing on a variety of evidence sources and reflecting on the processes and outcomes of these different types of evidence through facilitated processes has been shown to contribute to the creation of cultures of effectiveness (Manley, 2000b). In the REACH Framework, assessment of nursing expertise and progress with developing expertise is undertaken using an attributes framework. The attributes framework has 28 attributes of nursing expertise. These are divided into three practice domains or groupings: learning, expertise and practice development. The attributes are not skills-based competencies but instead are seen as the qualities and traits of nursing expertise. They are generic across all nursing roles, levels or bands and are therefore transferable across an organisation. The practice domains form the foci for the development of practice. Finally, individual and organisational responsibility is needed if learning is to occur and practice is to change. Consistent with other international evidence, such as that of the magnet hospitals movement, the research of Boomer et al. (2006) identified organisational responsibility, leadership, personal accountability and self-awareness as being key to developing and sustaining a person-centred culture. The commitment from the organisation is demonstrated in the form of resources, support, valuing of staff, receptiveness to change and a commitment to transformational leadership. This leadership is required at multiple levels and is usually epitomised in the vision statement of the organisation. Effective leadership requires a high level of self-awareness and personal accountability and it is argued that within this framework this can be achieved by the development activities (practice domains) and the culture of challenge with support (Wilson et al., 2006) created by operationalising the learning mechanisms (reflection, evidence and facilitation). Through combining the research of McCormack and McCance (2006) and Boomer et al. (2006) (Figure 7.3), an outcomes framework can be developed that captures the key dimensions of PCN, set within a person-centred culture. A realistic approach to evaluating outcomes Figure 7.3 sets out the five constructs that can be evaluated in the context of PCN: 1. satisfaction with care 2. involvement with care 3. nursing well-being 119 120 Person-Centred Nursing Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 4. the existence of a therapeutic culture 5. enablers of person-centred cultures A realistic evaluation approach provides a useful way of framing these constructs into a holistic evaluation framework. Pawson and Tilley (1997) contend that realistic evaluation offers researchers the opportunity to look at evaluation from a real-world perspective. Realistic evaluation was developed with the aim of trying to overcome some of the difficulties encountered with measurement and the effects of causation within complex social systems. Pawson and Tilley (1997) argue that evaluations of social programmes take place in environments that are rapidly changing and in which the setting is just as important as the intervention being evaluated. Therefore, it is important to go beyond the study of the usual cause and effect relationships that are emphasised in more traditional approaches to evaluation. Therefore rather than asking if the intervention works, or comparing one intervention to another, realistic evaluation sets out to answer ‘what is it about a programme that works (the mechanisms of change), why it works, for whom it works, and in what circumstances it works’. Pawson and Tilley (1997) developed the following formula to represent this: Context (C) ⫹ Mechanism (M) ⫽ Outcome (O). Satisfaction with care Systems that facilitate shared decision-making Effective staff relationships Professionally competent Involvement with care Developed interpersonal skills. Commitment to the job Appropriate skill mix The sharing of power Organisational systems that are supportive Nursing wellbeing Potential for innovation and risk taking Clarity of beliefs and values Knowing ‘self’ (selfawareness from REACH Framework) Therapeutic culture Empowered practitioner Autonomous practitioner Accountable practitioner Reflective practitioner Evidence use Patient-centred care Working with patient’s beliefs and values Providing for physical needs Sharing decisionmaking Having sympathetic presence Engagement Enabled by: Facilitation Organisational responsibility Leadership Figure 7.3 Mapping of outcomes related foci from the PCN Framework (McCormack & McCance, 2006) and the REACH Framework (Boomer et al., 2006). Person-Centred Nursing Outcomes and their Evaluation Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Mechanisms Context Facilitation Organisational responsibility Individual practice contexts and therapeutic cultures Leadership Outcomes Satisfaction with care Involvement with care Feeling of well-being Figure 7.4 Mechanisms, context, outcomes evaluation framework. This means a programme (such as the development of PCN) includes all the players (e.g. teams, patients, families), the venue (the setting in which person-centredness is being developed) with its past and its history. Mechanisms for change are formed by identifying the capacities (e.g. potential for change), resources (e.g. people), constraints and choices (e.g. identified need for change) facing key stakeholders. The relationship between the mechanism and the outcome is dependent upon the context or location and social norms, that is where it takes place and how the rules of that place influence the mechanism and outcome. Therefore, the evaluator is looking to see what implications the existing context has on the success or failure of the intervention, what the context–mechanism–outcome configuration is and how this can influence the future development of interventions. Realistic evaluation takes into account both the process and context of change. This results in exploration not only of outcomes but also of conditions that were present to enable those outcomes to occur – something that has been argued for earlier in the context of determining outcomes from nursing interventions. Tolson (1999) and Redfern et al. (2003) suggest that realistic evaluation placed within research and practice presents nurses with a tactical resolution to evaluating innovative nursing practice and offers an explanatory dimension to evaluation. Therefore, considering the five constructs that can be used to evaluate PCN, the adoption of a realistic evaluation approach lends itself to developing evaluation frameworks that take account of the processes used to develop person-centredness (mechanisms), the settings within which the developments take place (context) and the resulting outcomes (Figure 7.4). Methods for operationalising the outcome evaluation framework Mechanisms In our framework, the mechanisms for enabling PCN (facilitation, organisational responsibility and leadership) operate at an organisational level, that these are mechanisms that need to be in place/ enabled to be in place in order for an organisation to demonstrate corporate responsibility for person-centredness. However, mechanisms 121 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 122 Person-Centred Nursing may also operate at different levels of an organisation and this will be illustrated further when we discuss ‘context’ issues, as the analysis of the practice context will trigger mechanisms for development at this level also. Facilitation The term ‘facilitation’ is used to describe a variety of activities, ranging from teaching activities through to humanistic approaches to enabling others. At its simplest, facilitation means ‘a technique by which one person makes things easier for others’ (Kitson et al., 1998). More recently, Shaw et al. (2008) have defined facilitation as being about: a helping relationship, essentially one of enabling others and consequently self, through transitions to achieve growth/development and ultimately self-actualisation. (Shaw et al., 2008) Harvey et al. (2002) state that the concept of facilitation appears to have emerged from the fields of counselling and student-centred learning, influenced in particular by the work of Carl Rogers (1969). In Roger’s work and subsequent developments (e.g. by Heron, 1989), facilitation refers to a process of enabling individuals and groups to understand the processes they have to go through to change aspects of their behaviour or attitudes to themselves, their work or other individuals. Shaw et al. (2008) have drawn on a broad range of ideas both from co-learners and from the literature in facilitation and humanistic caring (Carl Rogers, 1969; Mayeroff, 1971; Swanson, 1991, 1993; Dewey, 2004), all of which is underpinned by a particular view of persons and personhood. Enabling as caring recognises and accommodates the four different modes of being in the world according to certain philosophies, in that it focuses on helping relationships, the importance of the person and transitions (which requires addressing issues of context) and growth/development. Much of the work that a facilitator will do is with groups as well as with individuals on a 1:1 basis. The work of John Heron can be very useful here. Heron (1989) describes a facilitator as a person who has the role of helping participants to learn in an experiential group. He believes that an effective facilitator who wants to provide conditions for the development of autonomous learning moves between three political modes: making decisions for learners (hierarchy), making decisions with learners (co-operation) and delegating decisions to learners (autonomy). Heron emphasises the facilitator’s role in addressing issues of feelings within the group, confronting resistance and giving meaning to group discussions; however, he also acknowledges their role in planning and structuring the tasks (from Harvey et al., 2002). This introductory overview of the different ways in which the term Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation ‘facilitation’ is conceptualised raises issues about how our knowledge influences the types of facilitation we can offer and also how facilitation approaches need to be targeted appropriately in order to help individuals and groups access different knowledge sources. The quality of the facilitation relationship can be evaluated through a range of methods, including: • • • • • • Structured individual and group feedback on the process used by the facilitator to enable effective individual and group engagement. Focus group discussions with participants on the effectiveness of (for example) group processes, how the individual addressed individual needs and concerns and the experience of achieving particular tasks. Reflective reviews by individual participants and the facilitator. Mapping of ‘key learning’ achieved by individual participants as the work progresses. 360-degree feedback (Garbett et al., 2007) of facilitator effectiveness. 360-degree feedback has been defined as ‘The systematic collection and feedback of performance data on an individual or group derived from a number of stakeholders in their performance’ (Ward, 1997: 4). Mapping of ‘action points’ agreed and implemented by participants and evaluation of their perceptions of the outcomes arising from the implementation of the action points. Organisational responsibility The primary responsibility of organisations is that of providing the conditions for clinical teams to continuously evaluate their effectiveness in developing person-centred cultures. Attributes of organisations that act as mechanisms for supporting the development of PCN include: • • • • Shared governance approach to nursing management: In this culture, everybody is seen as a leader of something and accountability and autonomy is actively promoted among staff at every level to lead. Continuous quality improvement: The organisation needs to foster a culture that views quality as being everybody’s business. The existence of an explicit person-centred philosophy: This philosophy is reflected in the way practice is organised, how staff are employed and the support mechanisms in place for staff, patients, families and communities. Availability of resources for evidence-informed practice: The organisation fosters a culture of shared evidence-informed decisionmaking between practitioner, patient and others significant to them, through its governance structures and processes. Evidenceinformed practice is the process of shared decision-making based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how and other available robust sources of information (Rycroft Malone et al., 2003). The blending of 123 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 124 Person-Centred Nursing • • • these different types of evidence in the decision-making process may be influenced by factors in the practice context such as available resources, practice cultures and norms, leadership styles and data management. The outcome of the decision-making process should be person-centred, evidence-informed care. A reflective approach to feedback from patients is welcomed and valued at a clinical practice level and patients are encouraged and enabled to reflect on their health and social care experience. Such feedback from patients is welcomed and actively used to continuously develop practice. In working with such feedback and quality improvement, practitioners are active participants in evidence generation and utilisation. Nursing leaders create a culture where evidence utilisation and generation is an explicit part of practice. Clinical leadership and clinical expertise is valued in management frameworks: The central remit of the nurse leader is that of practice developer. He/she does this by role-modelling expertise in practice, creating a culture where person-centredness can flourish, enabling critical inquiry to happen through a variety of approaches (including supervision, supported reflection, staff meetings), actively seeking feedback from service users, working in partnership with staff members and utilising internal and external policy developments as opportunities for further development and improvement. Systematic and continuous evaluation: There is a systematic approach to the evaluation of practice achievements through clinical audit, patient stories and organisational review. Activity reports are made accessible to the public and achievements, no matter how small, are celebrated. In such a culture, learning is an explicit component of practice. To facilitate the process of learning from experience, there needs to be organisational support for the principles and values underpinning practitioner research (McCormack, 2009), combined with an infrastructure that systematically assists nurses to reflect on practice experience, critically review the elements of that practice, actively engage in developing/experimenting with practice and synthesising the learning gained from the process. For this culture to be created, criticism needs not to be suppressed (as a threat or an act of blaming) but is instead welcomed as a part of a continuous learning process. Evaluation of practice in this culture does not rely solely on managerial-driven agendas of efficiency and effectiveness in order to demonstrate corporate accountability. Instead, evaluation is seen as ‘self-evaluation’ utilising a variety of approaches including feedback from colleagues, feedback from service users and feedback from service leaders in a continuous cycle of improvement. For such evaluations to be genuinely of value, they must lead to action – actions that are instigated and owned by practitioners and supported by service leaders at every level. Responsibility for such actions lies with practice leaders, as they are set within the Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation boundaries of broad corporate goals of the organisation. Thus the organisation demonstrates trust among practitioners to exercise their autonomy. Leadership is central to this culture and everybody is seen as a leader of something (transformational leadership). Knowledge generated externally (e.g. from academic communities, professional bodies and statutory organisations) is welcomed in that it helps to place local developments in a strategic context. Creating such a culture does not (in the first instance) require the establishment of ‘new’ structures. However, it does require: • • • • • A commitment to clarifying and making explicit values underpinning practice. Embracing transformational leadership. Being systematic and rigorous in operationalising personcentredness. Commitment to making person-centredness happen. Role clarity among leaders and ‘enablers’ of a person-centred culture. Leadership The importance of nursing leadership is well documented. Since the evolution of nursing through organisational models and frameworks that promote individual autonomy, decentralised decision-making and devolution of control over practice to the ‘point of care delivery’, the need for nurses to engage in leadership styles that are facilitative rather than hierarchical and controlling has increased (PorterO’Grady, 2003). The most widely recognised model of leadership in nursing and the one most often cited in contemporary nursing is that of transformational leadership (Kouzes & Posner, 2007). According to Kouzes and Posner (2007) people follow leaders who inspire them, show passion and vision and who inject enthusiasm and passion for their work. Transformational leadership is characterised by having shared values and vision, adopting a facilitative and enabling approach, role-modelling of expertise, promotion of autonomy, empowerment, reflective feedback and celebration of achievements. Transformational leaders focus on building strong and effective teams and in nursing has been shown to be effective in developing evidence-informed and person-centred practice cultures (Cunningham & Kitson, 2000a,b; Large et al., 2005; Shaw, 2005). Through the study of leaders, Kouzes and Posner have identified the most favoured characteristics of leaders (in order of preference): • • • • • • • honest forward-looking competent inspiring intelligent fair-minded broad-minded 125 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 126 Person-Centred Nursing • • • • • • • • • • • • • supportive straightforward dependable cooperative determined imaginative ambitious courageous caring mature loyal self-controlled independent A leader who has a well-developed ‘vision’ is essential to transformational leadership. The vision must be developed by the leader and then processes put in place to constantly sell the vision to others (followers). Whilst the importance of a vision for practice or a service is essential, we would argue that the idea of the leader developing the vision and then ‘selling’ it is limited. Evidence suggests that the need for teams to own the vision is essential to transformation and thus approaches to developing a ‘shared vision’ between leaders and teams should be adopted (Cunningham & Kitson, 2000a,b; refs). We would suggest that leaders should work with teams to develop a shared vision for person-centredness. Developing change strategies, planning actions and engaging in collaborative relationships towards implementation of changes is more likely to be shared among teams if there is initial ownership of the vision. To demonstrate transformational leadership in action, Kouzes and Posner outline five core practices of transformational leaders and these are presented here as they are consistent with the values underpinning PCN and thus offer a framework for reflecting on and evaluating the effectiveness of leadership practices for PCN: • • • Inspire a shared vision: If leaders are to be followed, then people need to understand where it is they are going! A leader needs to have a vision for PCN and how it would ideally ‘look’ and ‘be lived’ in practice. The vision needs to be articulated to others and in the inspiration of others, the leader generates a culture of dialogue where the vision becomes ‘infectious’ and owned by all. Model the way: What leaders do is far more important than what they say. They set the example for expected behaviours through their daily actions that demonstrate their commitment to stated values and beliefs. In order to do this effectively of course, an organisation needs to have explicit shared values about personcentred practice and how it is intended to be realised in the organisation. Challenge the process: A transformational leader doesn’t accept the ‘status quo’. Leaders continuously search for opportunities to Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation • • innovate, grow and develop, that is generate a culture of continuous quality improvement. Because of their commitment to a shared vision, leaders continuously strive for ‘better practice’ whilst always acknowledging and celebrating achievements along the way. Not all new ideas come from the leader, instead individuals in teams also generate new ideas and the role of the leader is to support the new idea and be willing to challenge the system in order to get the new ideas adopted and converted into everyday practice. Enable others to act: The leader is a facilitator of change, development and innovation. A systematic approach is adopted to the planning of developments and in the support of participants along the way. Leaders are enablers and as such they facilitate critical dialogue, contestation and debate as it is through these processes that active problem-solving and creative solutions are realised. Encourage the heart: A leader needs to set clear standards so that people know what is expected of them. Through generating a culture that values individual contributions to continuous improvement and showing that they ‘expect the best’, leaders generate a ‘self-fulfilling prophecy’. Leaders need to be attentive to individual journeys as the change progresses and recognises the contribution of individuals and teams. Successes need to be celebrated as a team and the story of the development journey is told in recognition of success. The ‘Leadership Practices Inventory’ was developed by Kouzes and Posner and it evaluates these five dimensions of leadership. The instrument has well-established validity and reliability and has been widely used in a number of studies (Kouzes & Posner, 2002, 2003; McNeeseSmith, 1993, 1995; Cunningham & Kitson, 2000a,b; Large et al., 2005) and continues to be the instrument of choice in many studies of leadership in nursing. The use of such an instrument can also be complemented with qualitative evaluation such as focus groups, individual interviews, reflective conversations and values clarification. Points to Ponder Consider your own organisational context and the ‘enablers’ of personcentredness identified here. Consider the following questions: 1. How do these enablers reflect your own organisation? 2. Does your organisation have an explicit focus on developing personcentred cultures? 3. What could you do to initiate discussion or build support for developing ‘organisational responsibility’ for person-centredness? Context Evaluating the context of practice and the existence of personcentred values and behaviours is an essential step in developing PCN. Knowing what aspects of the practice context are consistent with 127 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 128 Person-Centred Nursing the values underpinning PCN, what behaviours are inconsistent with those values and thus identifying what aspects of practice need to change are critical to the identification of the most appropriate development ‘mechanisms’. Two approaches to evaluating practice context are offered – The ‘Context Assessment Index’ (CAI) (McCormack et al., 2009) and the ‘Workplace Culture Critical Analysis Tool’ (WCCAT) (McCormack et al., 2009a). The CAI (McCormack et al., 2009b) was developed as an instrument for identifying the aspects of practice context that enable person-centred practices and those that need to be further developed. The aim of the CAI is to enable health care professionals to assess the context within which care is provided in clinical areas. It can be completed by one person such as a specialist or ward leader, or the tool can be completed by each member of the team. It is recommended that one person coordinates the process. Context is defined as the setting or environment where people receive health care services. Three elements have been identified that form the context to ensure there is person-centred practice (McCormack et al., 2002). These elements are: culture, leadership and evaluation. The CAI assesses these three elements. Each element has characteristics assessed along a continuum from ‘weak’ to ‘strong’. For an effective culture that is receptive to change and has person-centred ways of working, the three elements all need to be ‘strong’. By completing the CAI, a team will be able to assess whether the context in their clinical setting is conductive to person-centred practice and the level of receptiveness of the context to change and development. The tool provides evidence of any changes that need to be made in order to create a strong context. The WCCAT (McCormack et al., 2009a) has been informed by a number of theoretical frameworks and development processes (Table 7.1). The use of these theoretical perspectives are illustrated in the conceptual model in Table 7.2. This model demonstrates the linkages between the different levels of culture as described by Schein (2004) (superficial, middle and deep) and how the phases of observation, reflection and feedback that underpin the WCCAT enable a deep understanding of workplace culture to be achieved and developed in a practice development action plan. The WCCAT adopts a five phase process to undertaking an observation study, analysing the data, feeding back to clinical teams and developing action plans. The five phases are: 1. Phase 1 – Pre-observation: This phase involves the preparation of the setting for observation and preparing the observer for the role. 2. Phase 2 – Observation: Observation of the workplace culture should be undertaken at the negotiated time by two trained observers using the WCCAT observation proforma. Who the observers are may be different in each project in which the Person-Centred Nursing Outcomes and their Evaluation 129 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Table 7.1 Theoretical perspectives underpinning the WCCAT Framework Contribution to the WCCAT The PCN Framework (McCormack & McCance, 2006) The PCN theoretical framework has identified five care processes for patient-centred care and seven attributes of the care environment. These care processes and attributes have informed the observation foci. Critical companionship (Titchen, 2001) Critical companionship is a framework for developing helping relationships. It describes strategies for enabling enlightenment, empowerment and emancipation. In particular the strategies of observing, listening and questioning have informed the facilitation strategies in the WCCAT. Culture (Schein, 2004) Schein describes a conceptualisation of culture that moves from superficial to deeper levels of understanding. The three stages of analysis outlined in the WCCAT are based on this analysis of culture. Workplace Culture (Manley, 2000a,b) Manley developed a set of staff, patient and workplace indicators that she suggests need to be in place for an effective person-centred and learning culture. These have been integrated into the observation foci. Essence of Care (Department of Health [England], 2001c) Patient-focused benchmarks for clinical governance. Nine fundamental aspects of care derived from what patients consider important. Elements of these benchmarks have been integrated into the observation foci. WCCAT is being used and may include different combinations of internal and external observers. Observers should maintain field notes about the experience as a process for reviewing the effectiveness of the observation undertaken. 3. Phase 3 – Consciousness raising and problematisation: When the observation is finished, the observers clarify with individual team members anything they are unsure of. They should also discuss with staff-specific aspects of the observation data that they want to further clarify or gain a deeper understanding of. 4. Phase 4 – Reflection and critique: Both observers compare their observations and agree a common set of issues to feedback to the ward team. During the feedback session, a critical dialogue is facilitated by the observers with staff. This is done by the observers presenting their ‘common issues’ as impressions only and putting them up to challenge by staff. Each observation area is discussed in this way and the discussion includes the comparing of the issues raised with the espoused philosophy/values and beliefs/empirical evidence. 5. Phase 5 – Participatory analysis and action planning: The data analysis phase should be undertaken as a participatory analysis with the ward staff. As many of the ward staff as possible, or a representative sample of staff should participate in the analysis of the data. When a finalised list of themes is achieved and agreed, an action planning workshop with the nurse leader and the staff of the clinical setting to develop an action plan is held. The processes (mechanisms) to be used to facilitate the development of PCN should also be agreed which includes an integrated evaluation framework. Culture levels (after Schein, 2004) Superficial level – What is seen Symbol/artefacts Routines Actions Interactions Middle level – What is lived Consciousness raising and Problematisation Deeper level – What does it mean Clarifying assumptions through reflection and critique Facilitation strategies (after Titchen, 2001) • Observing and listening • Questioning • Articulation of craft knowledge • Feedback • Challenge and support • Critical dialogue Observation areas For example, • Physical environment • Communication • Privacy and dignity • Patient involvement • Team effectiveness • Risk and safety • Organisation of care • Learning culture NB: These observation areas may change according to the context within which the WCCAT is used. The observers adopt the attributes, reflexivity and skills of a qualitative researcher, in observing and listening to clinicians at work in their everyday working environment. Using the WCCAT guidelines and the observation proforma, the observer systematically records aspects of practice relevant to the focus of the observation. The purpose here is to check out if what has been observed matches clinicians’ experience, and in so doing facilitate consciousness raising and problematisation. Consciousness raising is a way of enabling practitioners become more alert with respect to daily practice and to their knowledge embedded in it. The observer poses questions about what has been observed, thus getting clinicians to articulate their craft knowledge. This helps the clinician to surface the tacit understandings that have grown up around repetitive and habitualised practice. Problematisation is making problematic that which had previously been assumed to be satisfactory. It may also refer to the observer pointing out or questioning things not being attended to. Feedback about what has been observed is offered to clinical teams using strategies of high challenge and high support as a catalyst for learning. Observers then engage clinical teams in critical dialogue with respect to this feedback. Critical dialogue promotes collaborative interpretations, critique and evaluation of data and validates clinician’s judgment (where appropriate). This fosters clinician’s self-awareness, reflective and critical thinking. Challenging taken-for-granted assumptions, beliefs, values, expectations, perceptions, judgement and actions in a constructive, interested, supportive way helps clinicians gain new understandings of situations. McCormack et al. (2009). EBSCO : eBook Collection (EBSCOhost) – printed on 9/26/2018 7:43 PM via CHAMBERLAIN UNIVERSITY AN: 330491 ; McCormack, Brendan, McCance, Tanya.; Person-centred Nursing : Theory and Practice Account: s6179623.main.eds Person-Centred Nursing Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 130 Table 7.2 WCCAT conceptual model Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation The conceptual framework underpinning the WCCAT enables a systematic approach to the observation of practice contexts. The observation areas are flexible and can be adapted to suit particular practice contexts. The tool relies on expert facilitators working with clinical teams to develop a programme of observation, data analysis, action planning and implementation that is collaborative, inclusive and participative. Points to Ponder Consider your own workplace and how you perceive PCN currently. Consider the following questions: 1. Do you have explicit shared values about PCN? 2. Do you have an explicit focus in your workplace on the continuous development of PCN? 3. What resources do you have available to you to enable you to assess your practice context using tools such as the CAI and WCCAT? 4. What support would you need to make effective use of these frameworks? Outcomes We have identified three outcomes that can be evaluated. However, these outcomes need to be considered alongside the enablers and contextual issues in order to demonstrate the M, C, O relationship – that is, the relationship between the mechanisms (processes, inputs) used to develop PCN, the context (the contextual issues that enable or hinder PCN to be realised) and the processes achieved. A key premise of our PCN Framework is that nurses as care givers need to be enabled to engage with person-centred principles and operationalise these in their practice. A key consideration here is the extent to which nurses feel satisfied and involved with their work. Equally, it has been recognised that whilst there is a lot of emphasis on providing care that is person-centred, translating the core concepts into professional practice is challenging, with few research studies reported that evaluate the caring outcomes that may arise from PCN (McCormack & McCance, 2006). Therefore, we propose the use of the ‘Person-Centred Nursing Index’ (PCNI) (Slater, 2006) and ‘patient stories’ (Hsu & McCormack, 2006) as effectives methods for evaluating the three outcomes from PCN (satisfaction with care, involvement with care, feeling of well-being). The Person-Centred Nursing Index The PCNI was generated from an amalgamation of key findings from an extensive systematic literature review, focus groups and a pilot study (McCormack et al., 2008). Its psychometric properties were tested and strong evidence of its validity and reliability was established (Slater, 2006). The PCNI comprises three sub-scales – ‘The Nursing Context Index’ (NCI) and ‘The Caring Dimensions Inventory’ (CDI) and ‘The Nursing Dimensions Inventory’ (NDI). 131 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 132 Person-Centred Nursing The NCI – A Measure of Nursing Perceptions of a Therapeutic Culture: Given the complexity of PCN, it is important that any evaluation of it takes account of each of the different attributes of PCN outcomes indicated in the outcomes framework (Figure 7.3). The NCI focuses on these attributes and how these attributes effect organisational factors such as job satisfaction, job stress and outcome variables like nurses’ job commitment and intention to leave the job due to the absence of the factors that enable PCN to happen. Organisational culture research supports the link between the attributes and outcomes (Manojlovich & Laschinger, 2007; Gunnarsdóttir et al., 2009). Research into the validity and reliability of the NCI (McCance et al., 2008) demonstrated that adequate staffing levels and nurse management were strongly related to job stress and job satisfaction. None of the organisational traits were directly related to nurses’ intention to leave. However, the stress scales and job satisfaction scales were significantly related to intention to leave. Adequate staffing levels, good inter-professional relationships and effective nurse management at a unit level, (requisites of PCN) have causal links with higher job satisfaction (Manojlovich & Laschinger, 2007) and nurse burnout (Gunnarsdóttir et al., 2009). The NCI has been shown to be a well-founded and valid measure of PCN and that it can be used to provide a picture of relationships between factors in a nurse practice environment (Slater et al., 2009). The CDI and NDI: The CDI was developed by Watson and colleagues (1999, 2001). It comprises 35 operationalised statements of nursing actions designed to elicit the degree to which participants perceive these actions as representative of caring using a five-point likert scale. The items included in the instrument have been categorised as ‘psychosocial’, ‘technical’, ‘professional’, ‘inappropriate’ and unnecessary activities: • • • • • Technical nursing: Items that indicate technical and professional aspects of nursing (14 items). Intimacy: Getting to know a patient and becoming involved with them (10 items). Supporting: Items that indicate helping the patients with spiritual matters (2 items). Unnecessary nursing: Aspects of nursing that are not inappropriate or unprofessional but would not normally be expected of nurses (4 items). Inappropriate aspects of nursing: Nursing actions, which, in addition to being unnecessary, are certainly not, recommended aspects of nursing (5 items). The CDI provides data on nurses’ experience of caring. The patients’ experience of caring is measured using the NDI. The NDI (Watson et al., 1999) was developed to assess non-nursing views on what constitutes caring. It was based on Watson’s initial work with the CDI and differed in the perspective from which caring was viewed. Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation It has been used to effectively assess non-nursing populations’ perceptions of caring (Watson et al., 1999). The CDI has been used to ascertain perceptions of caring from the perspective of a range of groups, including registered nurses, nursing students and non-nursing students (Watson et al., 1999, 2003a), between different clinical areas and specialities (Lea & Watson, 1995, 1999; Walsh & Dolan, 1999) and from an international perspective (Watson et al., 2003b). An evaluation of the use of the CDI and NDI by McCance et al. (2008) identified consistent scoring of 12 core statements over the 5 time points, suggesting it provides a strong indicator of nurses’ perception of caring. The findings also mapped onto the PCN Framework of McCormack and McCance (2006). Mapping the core statements onto the PCN Framework reaffirms the strong correlation between caring and PCN as perceived by nurses. In relation to person-centred processes, the statements that remained consistent over time spanned across the five components presented in the PCN Framework, with none emerging stronger than any others. This reinforces the validity of the range of person-centred processes presented within the PCN Framework. The findings also highlighted the need for good communication skills and their centrality in developing therapeutic relationships. In stark contrast with the nurses, McCance et al. (2008) found that the perception of patients on their experience of caring was variable, with very few statements remaining consistent over time. This would suggest that the promotion of a culture of person-centredness does not translate into a difference in patients’ perceptions of caring. The item that was most significant was the importance of ‘involving a patient in care’. This reinforces the importance of involving patients and clients in decisions made regarding their care and treatment, and thus its importance as an outcome indicator of PCN. Patient stories In life generally, we are recognised by our narrative identities (Gadamer, 1993), that is ‘who’ we are as individuals and in communities, who speaks; who acts; who recounts oneself and who is the moral subject (McCormack, 2002). So, for example, in a care situation, our narrative identity will be recognised by the various roles played out – the person being cared for, the professional carer, the family member, the cleaner, etc. Narrative is grounded in ‘story’. Stories represent a holistic view of persons and are shaped and reshaped by our engagement with others. Because of the richness of stories and their holistic nature, patient story telling has become an important and accepted method of evaluating the quality of the experience of care and service delivery by patients and families (Down, 2004). In a study that focused on developing person-centred practices in a rehabilitation unit for older people, Hsu and McCormack (2006) developed a framework for collecting and analysing patient 133 134 Person-Centred Nursing Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Situation (S) Evaluation (E) Problem (P) Solution or Response (R) S: background of the narrator (patient). P: how the past shapes perceptions of the present? P: how the present shapes perceptions of the past? R: how both shape perceptions of now to the future? E: why some elements are evaluated differently from others? Figure 7.5 The SPPRE Framework for organising narratives. stories and translating them into service improvement plans. A three step approach to the analysis of patient stories and their translation into action plans was developed and tested in practice: Step 1 – Organisation of narratives: This step involves organising the identified narratives into time sequences. The ordering of the narrative follows the SPPRE Framework set out in Figure 7.5. Step 2 – Problem–solution pattern framing: Using Hoey’s problem– solution pattern framework (http://www.developingteachers.com/tips/ pasttips58.htm accessed May 2010) is the next step. During this step, the organised narrative is discussed to identify the problems identified by the patient/family (based on past and current perceptions), the potential range of solutions that are either directly proposed by the patient/family or that can be surmised from the story itself and the solution patterns that are revealed through the patients narrative, that is the pattern of solutions that the patient has drawn upon in the past and their future ambitions. Steps 3 – Discussion and action: Group discussions are facilitated with teams drawing upon key questions derived from the individual patient stories and relating discussions to the PCN Framework (McCormack & McCance, 2006). Actions are identified for the development of person-centredness and mechanisms for addressing these actions identified. Points to Ponder Consider your own workplace and how you evaluate PCN currently. Consider the following questions: 1. Could the use of these methods enable you to demonstrate the effectiveness of your practice? 2. What support do you have available to you to enable the analysis of the data you collect? 3. What facilitation support do you have available to you? 4. What resources do you have available to you to enable you to evaluate the outcomes from your PCN developments? 5. What support would you need to make effective use of these methods? Summary of Key Points The literature on PCN is weak in terms of methods for evaluating outcomes, with little clarity about outcome focus, methodologies or Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing Outcomes and their Evaluation methods. We have identified three themes for outcome measurement and suggest that PCN should be able to demonstrate outcomes in these three themes – satisfaction with care, involvement with care, feeling of well-being. Outcomes in these themes can be demonstrated from the perspectives of both staff and patients/families. We have proposed that the adoption of methodological principles derived from realistic evaluation can overcome many of the challenges associated with critiques of outcome evaluation in nursing. The adoption of these principles enables the identification of context-specific mechanisms to be identified for the development of person-centredness and the application of methods to evaluate the three outcomes arising. This approach enables a systematic articulation of process–outcome patterns and the transferability of methods to other settings through shared learning. However, what is clear is that in order for these outcomes to be achieved, a continuous participatory and inclusive developmental approach needs to be adopted in the development and evaluation of PCN. Endnote 1. Binnie and Titchen do not refer to ‘person-centredness’ in their work. Instead, they use the term ‘patient-centredness’. However, the principles and values underpinning the research and development work and the culture developed bear all the hallmarks of a person-centred culture and PCN. 135 Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. This page intentionally left blank Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 32 Person-Centred Nursing right to self determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development. (McCormack et al., 2008b: 1) Moving these conceptual ideas into frameworks that can be applied and evaluated in practice, however, remains the challenge. Whilst there is increased understanding of person-centredness and other related concepts that underpin nursing, how they are operationalised in practice needs to be understood if improvements in care are to be realised. Several frameworks have been developed within nursing with an explicit focus on developing person-centred practice. Examples include: the Burford NDU Model, developed with a focus on acute hospital care (Johns, 1994); the Senses Framework developed originally in the context of older people in a care home setting (Nolan et al., 2004); and the Tidal Model developed for use within mental health (Barker, 2001, 2002). The Framework described in this book, however, recognises and builds on the interconnectedness between caring and person-centredness. We would argue that the attributes of caring are implicit within a philosophy of PCN and by drawing on the existing evidence base in relation to these and other related concepts, provides a firm foundation on which to develop practice. The Person-Centred Nursing Framework1 The PCN Framework was developed for use in the intervention stage of a large quasi-experimental project that focused on measuring the effectiveness of the implementation of PCN in a tertiary hospital setting (McCormack & McCance, 2006; McCormack et al., 2007). The Framework was derived from McCormack’s conceptual framework (2001b, 2003) focusing on person-centred practice with older people, and McCance et al.’s framework (2001) focusing on patients and nurses experience of caring in nursing. These two conceptual frameworks were selected for the following reasons: • • • • they were each derived from a humanistic perspective of caring initial review of the frameworks indicated a high degree of consistency across individual concepts and thus a high degree of face validity they were both derived from inductive and systematic collaborative research processes collectively, they represented a synthesis of the then available literature on caring and person-centredness. McCance et al. (2001) conducted a phenomenological study using narrative methods to explore patients’ and nurses’ experience of caring in nursing. The conceptual framework that emerged comprised three major constructs adapted from Donabedian’s (1982) Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. A Theoretical Framework for Person-Centred Nursing structure, process and outcome model, not unlike the approach used by Mitchell et al. (1998) to develop the ‘Quality Health Outcomes Model’. Structures were categorised as: nurse attributes (professional competence, interpersonal skills, commitment to the job and personal characteristics); organisational issues (time, skill mix and the nurse’s role) and patient attributes. The processes of care covered a wide range of nursing activities that constituted caring as perceived by patients and included: providing for patients’ physical needs; providing for patients’ psychological needs (providing information, providing reassurance, showing concern, communicating); being attentive, getting to know the patient, taking time, being firm, showing respect and the extra touch. The outcomes emanated from the process of caring and included a feeling of well-being (affective and physical), patient satisfaction and effect on the environment. McCormack (2001b) conducted a hermeneutic study combining methods of conversation analysis in order to explore the meaning of autonomy for older people in acute care settings. Through the analysis of 14 case studies of nurse–patient relationships a conceptual framework for person-centred practice was developed based on an understanding of autonomy as ‘authentic consciousness’ (McCormack, 2003). The emerging conceptual framework for person-centred practice has three constructs. The first construct identified five nursing roles, referred to in the Framework as ‘imperfect duties’ (negotiation, informed flexibility, mutuality, transparency and sympathetic presence). The second construct articulated differing levels of engagement between patients and nurses in order to sustain a therapeutic caring relationship (engagement, partial disengagement, complete disengagement). The third construct described those factors that impact on the quality of the engagement between nurses and patients, including the context of the care environment, the nurse’s values history, the patient’s values history and the nurse’s knowledge and experience. Reflecting on the relationship between humanistic nursing and the concept of caring and person-centredness as discussed earlier, it is not surprising that there were commonalities between the work of McCance (2003) and McCormack (2003). Work was undertaken to develop a combined framework, with the ultimate aim of providing a mid-range theory for PCN. The origins of the Framework, with its foundations in nursing practice, provide a unique perspective for nursing that conceptually links caring and person-centredness. Developing the Framework The process of developing the PCN Framework, presented in Figure 3.1, involved a series of systematic steps. Identifying the similarities and matched elements of each conceptual framework was an important first step and confirmed the strong relationship between caring and person-centred practice. For example, McCormack 33 i u pp PROCESSES CARE fe Sh ss ar i i St ffe on Ma k ing S y s t e De cis i ms Engagement t ion a nd R is k Ta king • Th e Shared Decision-Making ill Sk o n s ill Sk m m it m ent • Co to • Ap p th e ro pr i J o l e at al t• • en C nm T ro EN E E NV I R ONM r E C AR e TH t nv i er p lE i ar x Mi Having Sympathetic Presence s ic a ty •S ed ha r • Satisfaction with Care • Involvement with Care • Feeling of Well-Being • Creating a Therapeudic Culture Ph y of nova r In •E l fo PERSON-CENTRED OUTCOMES n t • De v e lo p ete ed mp In t ia Providing Holistic Care Co en ct i ve Working with the Patient’s Beliefs and Values y K ow er ot • s• P •P s t em af f •S ll no io ips a Re t la h ns ng ie f s a nd Va l ue Bel e ‘S n w n g E QU I S IT I E RE R S •P • P ’ ro e Or g a nis a t iona l S y lf o r t iv s o b Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Person-Centred Nursing s 34 Figure 3.1 The PCN Framework. (2003) identified contextual factors that reflected many comparable elements captured by McCance (2003) under ‘structures’. Similarly, the ‘imperfect duties’ described by McCormack (2003) incorporated elements of the process of caring described by McCance (2003). The second step involved the exploration of areas of difference using a critical dialogue with co-researchers (n ⫽ 6) and with lead practitioners from a range of clinical settings (n ⫽ 16) as a means of reaching agreement in relation to where these elements might fit within the new framework. The concepts underpinning both conceptual frameworks were then discussed. These conversations took the form of focused discussions using critical questioning techniques to unravel each concept. The original sources of literature and data were consulted in order to ensure shared clarity of meaning of key terms in each framework. These conversations were tape-recorded and listened to after each discussion in order to identify key elements of each framework that needed to be retained or amended in the combined framework. Key concepts from both conceptual frameworks were listed and a first draft of the PCN Framework was constructed. A period of testing the Framework was undertaken. Two focus groups were held – one with co-researchers (n ⫽ 6) and one with lead practitioners from a range of clinical settings (n ⫽ 16). The Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. A Theoretical Framework for Person-Centred Nursing draft framework was presented and their views on clarity, coherence and comprehensibility sought. Prior to the focus groups, the individual frameworks (McCance, 2003; McCormack, 2003) were provided as background to enable discussion. Significantly, the ease with which lead practitioners engaged with the Framework and were able to contextualise elements within their clinical environments was the most important indicator. Furthermore, co-researchers were able to identify ways in which the Framework could be used in their research to focus decision-making. For example, the Framework was used to facilitate teams to analyse barriers to change (arising, for example, from differences in beliefs and values), focus particular developments in practice (e.g. the sharing of ‘power’ with patients) or evaluate developments as they progressed through the intervention (e.g. changes made to the care environment). The Framework has been refined with co-researchers and project participants throughout the intervention period of the larger quasi-experimental project referred to earlier. Before describing the Framework in more detail, however, it is important to place it on the continuum of theory development, as this often influences its use in practice. In order to do this we will refer to the seminal work of Fawcett (1995), who describes a hierarchy of nursing knowledge that has five components. At the highest level of abstraction is the meta-paradigm that represents a broad consensus for nursing, which provides general parameters for the field, and next to this are philosophies, which provide a statement of beliefs and values. Conceptual models are at the next level and provide a particular frame of reference that says something about ‘how to observe and interpret the phenomena of interest to the discipline’ (Fawcett, 1995: 3). Theories are the third component in the hierarchy, which are less abstract than conceptual models. They can be further described as grand theories or middle-range theories with the latter being narrower in scope and ‘made up of concepts and propositions that are empirically measurable’ (p. 25). Fawcett (1995) distinguishes between conceptual models and mid-range theories, in that mid-range theories articulate one or more relatively concrete and specific concepts that are derived from a conceptual model. Furthermore, the propositions that describe these concepts propose specific relationships between them. The final component in the hierarchy of nursing knowledge is empirical indicators, which provide the means of measuring concepts within a middle-range theory. The PCN Framework has been described as a middle-range theory in that it has been derived from two abstract conceptual frameworks, comprises concepts that are relatively specific, and outlines relationships between the constructs (McCormack & McCance, 2006). The following sections will describe the concepts within the Framework and how they relate, thus demonstrating its value as a middle-range theory. 35 36 Person-Centred Nursing Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Overview of the Framework Within this section we will provide an overview of the PCN Framework and the relevance of the Framework to practice. The Framework essentially comprises four constructs: • • • • prerequisites which focus on the attributes of the nurse the care environment which focuses on the context in which care is delivered person-centred processes which focus on delivering care through a range of activities expected outcomes which are the results of effective PCN. The relationship between the constructs of the Framework is indicated by the pictorial representation, that is, to reach the centre of the Framework, the prerequisites must first be considered, then the care environment, which are necessary in providing effective care through the care processes. This ordering, ultimately leads to the achievement of the outcomes – the central component of the Framework. It is also acknowledged that there are relationships within, and across constructs, some of which are currently being tested through further research. The prerequisites focus on the attributes of the nurse and include: being professionally competent; having developed interpersonal skills; being committed to the job; being able to demonstrate clarity of beliefs and values; and knowing self. Professional competence focuses on the knowledge and skills of the nurse to make decisions and prioritise care, and includes competence in relation to physical or technical aspects of care. Having highly developed interpersonal skills reflects the ability of the nurse to communicate at a variety of levels. Commitment to the job is indicative of dedication and a sense that the nurse wants to provide care that is best for the patient. Clarity of beliefs and values highlights the importance of the nurse knowing his/her own views and being aware of how these can impact on decisions made by the patient. This is closely linked to knowing self and the assumption that before we can help others we need to have insight into how we function as a person. The care environment focuses on the context in which care is delivered and includes: appropriate skill mix; systems that facilitate shared decision-making; the sharing of power; effective staff relationships; organisational systems that are supportive; the potential for innovation and risk-taking; and the physical environment. Appropriate skill mix highlights the potential impact of staffing levels on the delivery of effective person-centred care, and emphasises the importance of the composition of the team in achieving positive outcomes for patients. Shared decision-making is dependent on systems and processes being in place that facilitate a dialogue between those involved in the caring interaction. This can include patient, family member and/or carer or indeed nurse, doctor or another health professional. This is also closely linked to the development Copyright @ 2010. Wiley-Blackwell. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. A Theoretical Framework for Person-Centred Nursing of effective staff relationships and to the sharing of power. It is, however, important to note that the sharing of power also relates to the power base between the patient and the nurse, which reflects one of the basic tenants of person-centredness described earlier. The identification of supportive organisational systems acknowledges the incredible influence organisational culture can have on the quality of care delivered and the freedom afforded to practitioners to work autonomously, reflecting the potential for innovation and risk-taking. Finally, the physical environment recognises the impact of the physical surroundings on nursing practice. These characteristics of the care environment are consistent with the conceptual development of the concept of context undertaken by McCormack et al. (2002) and Rycroft-Malone et al. (2002). Key characteristics of context arising from these studies include the culture of the workplace, the quality of nursing leadership and the commitment of the organisation to the use of multiple sources of evidence to evaluate the quality of care delivery. As previously highlighted, the care environment and the components described here have a significant impact on the operationalisation of PCN and have the greatest potential to limit or enhance the facilitation of person-centred processes (McCormack, 2004). Person-centred processes focus on delivering care through a range of activities that operationalise PCN and include: working with patient’s beliefs and values; engagement; having sympathetic presence; sharing decision-making and providing holistic care. This is the component of the Framework that specifically focuses on the patient, describing PCN in the context of care delivery. Working with patients’ beliefs and values reinforces one of the fundamental principles of PCN, which places importance on developing a clear picture of what the patient values about his/her life and how he/she makes sense of what is happening. This is closely linked to shared decisionmaking. This focuses on nurses facilitating patient participation through providing information and integrating newly formed perspectives into established practices, but is dependent on systems that facilitate shared decision-making (the care environment). This must involve a process of negotiation that takes account of individual values to form a legitimate basis for decision-making, the success of which rests on successful processes of communication. McCormack (2004) illustrates the links between these processes stating that ‘knowing what is important forms a foundation for decision-making that adopts a “negotiated” approach between practitioner and patient’ (p. 35). Having sympathetic presence highlights an engagement that recognises the uniqueness and value of the individual and reflects the quality of the nurse–patient relationship. Finally, providing holistic care focuses on meeting the needs of patients, which maybe physically, psychological, social or spiritual in nature. Outcomes are the results expected from effective PCN and include: satisfaction with care; involvement in care; feeling of wellbeing and creating a therapeutic environment. Patient satisfaction 37
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