Chapter 15
Meeting the challenges of person-centredness in acute care
Christine Boomer1, 2 & Tanya McCance2
1South Eastern Health and Social Care Trust, Northern Ireland, UK
2Ulster University, Northern Ireland, UK
Introduction
The aspiration to deliver a standard of care that reflects person-centredness has been evident in health strategy and policy planning globally for well over a decade (Department of Human Services 2003; Department of Health 2005; National Ageing Research Institute 2006; World Health Organization 2007). The challenges in delivering person-centred care in practice, however, continue to be well recognised, with hospital care often being a focus for the ongoing debate. This debate has been fuelled by high-profile inquiries and reviews suggesting that the experience of hospital care is variable and often fails to meet the expected standard (Francis 2013). These challenges are a result of the increasing complexity surrounding the provision of health care, particularly within acute care environments, and are reflected in the context, including influential components such as health and social care policy, strategic leadership and workforce developments. In response to these challenges different approaches have been promoted to improve the experience of care for both patients and staff. This chapter will provide insight into the challenges in providing a positive care experience and, using case studies, demonstrate different approaches to the development of person-centred practice within acute care.
Person-centredness within acute care
The promotion of person-centredness in acute care is well rehearsed, with a widespread acceptance of the principles that underpin such an approach. The literature, however, provides examples of experiences in acute care environments that do not always reflect these principles. Studies focusing on this area confirm acute hospitals as inherently complex environments and emphasise the challenges in delivering person-centred care in this context. Bolster and Manias (2010) provide a good example of this in their qualitative study focusing on person-centred interactions between nurses and patients during medication activities. The key findings highlighted care that was centred on routines rather than individualised assessment and management, with little opportunity for patient participation. The two main contextual barriers identified were: (1) communication challenges with the multi-professional team such as the pharmacist and the medical team; and (2) time constraints perceived by the nurses as restricting their ability to engage with patients and to facilitate meaningful discussions about medication. The quality of engagement with patients is similarly reflected in other studies. Clisset et al. (2013) explored ways in which current approaches to care in acute settings had the potential to enhance personhood in older people with dementia, and concluded that health-care professionals were not grasping opportunities to make their care person-centred, suggesting that ‘good practice appears to be in “pockets” as a result of individual practitioners rather than comprehensive and consistent across services’ (p. 1502). In a more general study focusing on patients’ experiences of in-hospital care, Laird et al. (2015) also highlighted the fragility of person-centred care, identifying one overriding theme of vulnerability at the junctures of systems, care processes and nurses’ responses. This type of evidence provides an important foundation for engagement in a dialogue about interventions that enable practitioners working in acute care environments to engage in the effective person-centred practice.
Case study 5.1: Implementing a practice development programme within an acute care setting
Aim
A practice development programme was implemented over a period of 2 years within an acute hospital setting, aimed at enabling nursing teams to explore the concept of person-centredness within their own clinical setting, in order to improve care delivery.
Context
The person-centred care programme was delivered in a large health and social care organisation, with approximately 20,000 staff, of which almost 6800 are nurses and midwives. The organisation serves a local population of 340,000 people but also provides regional services. The programme was undertaken at a time of unprecedented change, when services for health and social care in this region were being reorganised. The organisation in which the programme was delivered was the result of a merger with several other organisations, and at the time of commencement of the programme was less than one year established. The programme was delivered across nine acute inpatient areas covering a range of specialties including: cancer inpatient unit; mental health inpatient unit; brain injury unit; specialist and general medical inpatient wards such as chest medicine, cardiology and neurology; and eyes and ear, nose and throat theatre department.
The programme
The programme was underpinned by the Person-centred Nursing Framework, which acted as a lens to offer greater insights and understanding of person-centredness at practice level. The programme structure comprised facilitated activities in line with a practice development approach including a series of facilitated workshops (n = 5), with ongoing monthly support provided through a project team. Each workshop focused on key themes including: promoting an understanding of person-centredness; developing a shared vision; determining the quality of the user experience; systematically developing practice; and celebrating success. Each workshop profiled relevant activities to enable teams to engage with the processes more widely back in their own clinical areas.
Outcomes
Participation in this practice development programme produced some positive outcomes for staff.
- Staff experienced a level of engagement in person-centred practice that was characterised by positive ways of working and building relationships. There were times when there was a high level of commitment and energy, and this was reflected in the level of engagement across the participating sites. However, there were times when maintaining momentum was a challenge due to the organisational context.
- While the values that underpin person-centred care were not new to participants, the significance was in how they embraced person-centred values in practice, even in the challenging context described above. Participants acknowledged the difficulty of recognising how person-centred values are reflected in practice, both in support of best practice and in recognising aspects of practice that needed to change. There was also a fundamental shift during the programme when some participants began to recognise the meaning of ‘person’ in person-centred care, a central tenet of this way of working.
- Person-centredness in practice was impeded by conflicting priorities characterised by a sense of feeling pressurised, limited staffing and resources, and the challenges of an evolving context, particularly within the provision of services in acute hospitals. There was a constant tussle between conflicting priorities and the desire to live out person-centred values in everyday practice.
Source: McCance et al. (2013). Reproduced with permission of the Foundation of Nursing Studies.
Case study 15.2: The Productive Ward (PW): ‘Releasing time to care’
Aim
The Productive Ward programme aims to improve four dimensions of care: patient safety and reliability of care, patient experience, staff well-being and efficiency of care.
Context
The programme was initially implemented as part of a regional pilot, following a drive for the use of LEAN approaches in health and social care. Within one organisation serving a population of 345,000 over a wide geographical area with a workforce of 10,000 staff (approx. 3300 nurses and midwives), two sites were chosen to implement and test the programme: a maternity ward and a specialist surgical ward. These sites were chosen due to their contrasting cultures and contexts, thereby gaining insights for implementation across the wider organisation. Person-centredness was a core theme in the organisation’s corporate and Nursing and Midwifery strategies, therefore the evaluation focused on determining the potential for the productive ward programme to influence this agenda.
The programme
Led by the ward manager, ward implementation teams undertook the three foundation modules within the Productive Ward programme. Knowing How we are Doing aims to assist the ward team to determine their starting position, a baseline. Activities undertaken included developing a ward vision and observations. The Well Organised Ward aims to enable teams to simplify their workplace, reduce waste by having everything in the right place, at the right time; and by concentrating on how areas should be improved. Activities undertaken included ‘activity follow’ and ‘waste walk’. Patient Status at a Glance builds on work undertaken in the first two modules with further analysis of data from the tools used, e.g. activity follow analysis, information boards, handovers, discharge management, and availability/accessibility of information. Each module followed a six-step process: prepare, assess, diagnose, plan, treat and evaluate. Ward teams had access to a facilitator and attended training on the use of the various tools within the programme.
Outcomes
The programme captured staff motivation for improvement achieved through a number of quick wins. It had an impact on person-centredness, in particular on the Care Environment, especially relating to the physical environment. The often simple changes, e.g. stock availability and having equipment to hand, freed up staff time. Staff in both sites expressed feeling valued alongside a stronger sense of team, having demonstrated creativity to achieve multi-professional engagement.
Additional positive outcomes for staff included the acquisition of new skills and improved communication. Staff also felt they had more control, articulated as having taken back ownership of the ward. Managers too noted positive changes in the environment and atmosphere in the sites, expressed as a feeling of calmness reflected by, e.g., reduced noise levels. Staff did express anecdotal outcomes for their patients, and the staff teams were clearly excited from their participation in the programme, articulating a greater satisfaction in terms of their experience of care.
As a result of the pilot the programme was seen as a way in, to begin to engage staff in examining areas of practice more critically. However, an approach underpinned by practice development methodology was adopted for the ongoing implementation of the programme, with a clear intent of focusing on person-centredness, an area not explicit within the original programme.
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