INTRODUCTION
Twentieth century (western) societies are increasingly individualised. This is not only reflected in general politics, opinions and lifestyles but also in healthcare. Partly this is a result of an increased knowledge about the human genome, allowing for more individualised treatment plans (âpersonalised or precision medicineâ), and partly because of scarce healthcare resources resulting in increased selfâmanagement and more patient responsibility for their own health. A welcome side effect of this individualisation is an increased attention to the person behind the patient and, related to this, more attention to individual needs and preferences in treatment and care. This personâcentred movement is not new, but has so far been captured through discourses of patientâcentredness (in contrast to doctorâ or diseaseâcentredness) and patientsâ rights, which already represent important paradigm shifts in healthcare. Personâcentredness has, however, continued to develop and also incorporates concepts like positive health, wellâbeing and individualised care planning as well as the inclusion of the person of the healthcare provider. Personâcentredness can thus be summarised as promoting care of the person (of the totality of the personâs health, including its ill and positive aspects), for the person (promoting the fulfilment of the personâs life project), by the person (with clinicians extending themselves as full human beings with high ethical aspirations) and with the person (working respectfully, in collaboration and in an empowering manner) (Mezzich et al., 2009). Personâcentredness implies recognition of the broad biological, social, psychological, cultural and spiritual dimensions of each person, their families and communities. The personâcentred approach is closely linked to Carl Rogersâ humanistic psychology and personâcentred therapy (Rogers, 1961) with a focus on the fulfilment of personal potentials including sociability, the need to be with other human beings and a desire to know and be known by other people (the origins of personâcentredness will be further explored in Chapter 2). It also includes being open to experience, being trusting and trustworthy, being curious about the world, being creative and compassionate. This perspective has been particularly influential in the field of dementia care.
Personâcentredness has permeated all fields in healthcare. For example, personâcentred nursing has been defined as an approach to practice that is established through the formation and fostering of healthful relationships between all care providers, patients/clients/families and significant others (McCormack and McCance, 2017). It is underpinned by values of respect for persons, individual right to selfâdetermination, and mutual respect and understanding. Personâcentred nursing practice is about developing, coordinating and providing healthcare services that respect the uniqueness of individuals by focusing on their beliefs, values, desires and wishes, independent of age, gender, social status, economy, faith, ethnicity and cultural background and in a context that includes collaborative and inclusive practices. In addition, personâcentred nursing practice aims to plan and deliver care that takes account of the personâs context including their social context, community networks, cultural norms and material supports. Personâcentred medicine is anchored in a broad and holistic approach that is critical of the modern development of medicine, which has been dominated by reductionism, attention to disease, superâspecialisation, commoditisation and commercialism (Mezzich et al., 2009). These authors argue that this has resulted in less attention being paid to âwholeâperson needsâ and reduced focus on the ethical imperatives connected to promoting the autonomy, responsibility and dignity of every person involved.
Changes in the delivery of healthcare services have been significant over the past 25 years. The increasing demands on emergency services, reduction in the number of available hospital beds, shorter lengths of stay, increased throughput and the erosion of Health Servicesâ commitment to the provision of continuing healthcare have all impacted on the way healthcare services are provided and the practice of healthcare professionals. In addition, the prevailing culture of consumerism has enabled a shift away from societyâs collective responsibility for the provision of an equitable and just healthcare system to one that is based on individual responsibility, increasingly more complex models of insuranceâbased services and a growth in healthcare as a private forâprofit business.
The combined effects of these strategic changes to healthcare globally, major changes to the organisation of services, a dominant focus on standardisation and risk reduction with associated limits on the potential for creative practice have all had an impact on the ability of healthcare practitioners to develop personâcentred approaches. McCormack (2001) suggested that there was a need for âa cultural shift in philosophical valuesâ in healthcare if authentic personâcentred healthcare is to be realised for all persons. The following quote from one of the participants in McCormackâs research highlighted the need for this shift:
Since then there have been significant developments globally in advancing personâcentred healthcare within a dominant philosophy of people as persons who have responsibility for their own health.
PERSONâCENTREDNESS IN HEALTHCARE
The use of the term âpersonâcentredâ has become increasingly common in health and social care services at a global level. While a cynical view would argue that the term is being used as a âcatchâallâ for anything concerning high quality health and social care, an alternative perspective would suggest that it is representative of something more significant than this, i.e. a movement that has an explicit focus on humanising health services and ensuring that the person using health and social care services is at the centre of care delivery decisionâmaking. This global focus on personâcentredness has, as a consequence, resulted in a growing body of evidence supporting the processes and outcomes associated with personâcentredness in health and social care.
Holding the personâs values central in decisionâmaking is essential to a personâcentred approach to practice. Talking with patients and families about values and using the outcomes from these discussions as a means of evaluating how well their autonomy and selfâdetermination is being respected is a useful vehicle for exploring the processes of careâgiving as opposed to a focus on how well the care outcomes were achieved using, for instance, PROMS (Patient Reported Outcome Measures) and PREMS (Patient Reported Experience Measures). For example, the focus on achieving a short length of stay may not always be consistent with the values of the patient or family. In such situations, without the practitioner, patient and family clarifying their values base and its relationship to the goal of care, there is potential for conflict. The skill involved in balancing a duty of care to the patient whil...