Introduction
This chapter explores the relationship between patient-centred care and holism and how these can be explored within a humanising care philosophy. The complex way of being of the expert nurse is then explored through the lens of the professional gaze (the professional practice of engaging in scanning, selective perception, recognition, diagnosis of and response to clinical deterioration) and factors that affect clinical decision making in practice.
Humanising health care and the role of the expert critical care nurse in identifying and managing any shortcomings are a key feature of each chapter.
What is Patient-Centred Care?
Patient-centred care (PCC) has a long tradition in nursing practice and is recognised as a core concept in health care and in quality improvement. It derived from the humanistic psychologist Karl Rogers in the 1940s (Rogers 1951) when he wrote about client centred therapy. Here he spoke of the bio-psychological perspective and that a person is shaped by their biological, psychological and social perspectives and as such clinicians needed to think beyond biology. Since Rogersâs work scholars have offered many definitions and concepts for PCC which will now be explored and will show that it is the delivery of care that respects patient needs, preferences, and values and that this is not specific to situation or location.
Slatore et al. (2012: 411) identified that âPCC has 5 domains, these being the bio-psychosocial perspective, with a focus on information exchange; the patient as a person; sharing power and responsibility; the therapeutic alliance; and the clinician as a personâ. They highlight that information exchange, and effective accurate risk communication are at the centre of the bio-psychosocial perspective; that addressing patient concerns and listening to the patient about their concerns is treating the patient as a person. To treat a patient as a person involves shared decision making and ensuring the patient is involved in the planning of care and the sharing of power and responsibility.
Patient-centred care became more prominent as changes in nurse education occurred, as new advanced nursing roles and as new technologies were more evident. The evolution of PCC resulted in several dimensions and frameworks being produced for use in specialist areas, such as Kitwoodâs (1997) exploration of Dementia; Mead and Bowers (2000) on the medical model development of a medical framework; and Nolan et al.âs (2001) perspective on gerontology. Many studies have identified core elements of PCC in nursing and medicine. For example Hobbs (2009) offered a dimensional analysis of PCC and Rauta et al. (2012) explored PCC in the preoperative setting. Manleyâs (1989) research offered proposals for introducing Primary Nursing in ICU, as a method of work organisation in ICU, where the same nurse cared for clients from admission to discharge and by doing this a therapeutic relationship developed which led to greater PCC and job satisfaction for nurses. Whilst PCC continues to strive in practice today Primary Nursing, despite being valued, tends not to have a strong presence. Indeed today PCC, and not Primary Nursing, is central to UK and international political policy (see Box 1.1 below).
Box 1.1 UK Policy That Supports Patient-Centred Care
- Department of Health (2000) National Service Framework for Coronary Heart Disease; Modern Standards and Service Models.
- Department of Health (2001) National Service Framework for older people.
- Department of Health (2006) Dignity in Care Campaign.
- Department of Health (2012) NHS England: Compassion in Practice. Nursing, Midwifery and Care Staff, Our Vision and Strategy.
- Health Improvement Scotland (2017) People at the Centre of Health Care. Person-Centred Health and Care.
- NHS Wales (2015) Health and Care Standards.
- World Health Organisation (2015) Preparing a Health Care Workforce for the 21st Century: The Challenge of Chronic Conditions.
Furthermore, patient involvement in delivery and design of services is at the forefront of modern health care and healthcare reform (Forbat et al., 2009; Angood et al., 2010; Mockford et al., 2011). Here literature discusses how PCC requires that people are treated as individuals, that care is centred on the person and not the disease, that autonomy is fostered and there is respect of the rights of the person. It explores how that person has a choice in the planning of their care which is derived from their explicit requirements rather than the requirement of the health professional; and enabling these components requires the building of mutual trust and understanding in order to find a common agreement about care which is contextually and culturally defined. This concordance requires the development of therapeutic relationships and McCormack and McCance (2010) believe this is achieved through expert communication and continuity of care. Key to this is quality care, which according to the Institute of Medicine (2001) is the provision of safe, timely, effective, equitable care, and in our evolving world needs to be culturally competent, appropriate and âuniquely tailored to care to patients with diverse values, beliefs and behavioursâ (Johnson, 2015: 87).
