Chapter 3
The Person-centred Practice Framework
Tanya McCance1 & Brendan McCormack2
1Ulster University, Northern Ireland, UK
2Queen Margaret University, Edinburgh, UK
Introduction
In this chapter the person-centred nursing theoretical framework developed by us (McCormack & McCance 2006, 2010) will be updated, taking account of a multi-disciplinary and interprofessional context. The framework comprises four key domains: prerequisites for person-centred practice; the care environment; person-centred processes; and person-centred outcomes. In the previous edition of this book (McCormack & McCance 2010) we provided a comprehensive exploration of each construct within the four domains of the Person-centred Nursing Framework, placing it in the context of existing theoretical and research literature. We would encourage our readers to refer to this original source for the detailed description and to gain an understanding of the origins of the framework, which is founded on the concepts of caring and person-centredness. It is our intention in this chapter to relate the continued development of the framework to contemporary perspectives on caring, compassion, dignity and flourishing and to illustrate their relevance to changing models of health and social care.
Development of the framework: the story so far…
The development of the Person-centred Nursing Framework has spanned nearly a decade and during that time it has been used in a variety of different ways, across a range of contexts. The framework is underpinned by empirical research, was developed as part of a large-scale research study, and continues to be tested and refined through an ongoing programme of applied research (http://www.science.ulster.ac.uk/inhr/pcp/index.php). At this stage it is important to reaffirm the key constructs of the framework that have remained stable, but also highlight how the framework has evolved over time.
Development of a framework for person-centred nursing (McCormack & McCance 2006)
The original framework published in 2006, presented in Figure 3.1, was developed for use in the intervention stage of a large quasi-experimental research study, which focused on measuring the effectiveness of the implementation of person-centred nursing in a tertiary hospital setting (McCormack et al. 2008). The framework was derived from McCormack’s conceptual framework (McCormack 2003) focusing on person-centred practice with older people, and McCance’s framework focusing on patients’ and nurses’ experience of caring in nursing (McCance 2003). The process for developing the framework is described in this original paper, but the key message that has stood the test of time is the shared philosophical underpinnings that formed the sound basis for the development of the Person-centred Nursing Framework. The philosophy underpinning the framework is embedded in the concept of being a ‘person’ as discussed in Chapter 2, and is consistent with a philosophy of human science, which focuses on what it means to be human. Human science principles that form the foundation of the Framework include human freedom, choice and responsibility; holism (non-reducible persons interconnected with others and nature); different forms of knowing (empirics, aesthetics, ethics and intuition); and the importance of time and space, and relationships (Watson 1985).
Figure 3.1 A framework for person-centred nursing.
Source: McCormack & McCance (2006). Reproduced with permission of Wiley.
The original framework essentially comprised four domains:
- 1. Prerequisites, which 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.
- 2. Care environment, which focuses on the context in which care is delivered and includes: an appropriate skill mix; systems that facilitate shared decision-making; effective staff relationships; supportive organisational systems, the sharing of power, and the potential for innovation and risk-taking.
- 3. Person-centred processes, which focus on delivering care to the patient through a range of activities and include: working with patients’ beliefs and values, engagement, having a sympathetic presence, sharing decision-making and providing for physical needs.
- 4. Expected outcomes, which are the results of effective person-centred nursing and include: satisfaction with care, involvement in care, feeling of well-being, and creating a therapeutic environment.
The relationship between the constructs of the framework was represented pictorially, in that to reach the centre of the framework, the attributes of staff must first be considered, as a prerequisite to managing the care environment, in order to provide 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 between the constructs.
The period of time following the publication of the original framework was characterised by wide exposure to the framework, mainly within nursing but on an international stage. This main focus was to generate much needed critical dialogue and debate about its applicability to practice. A significant driver at this early stage was the integration of the framework into Practice Development, which is described as an approach to improving practice that has the development of effective person-centred cultures as its core purpose (McCormack et al. 2013). The relationship between the framework and practice development is given full attention in Section 3 of this book. The key message at this time was the utility of the framework as a means of operationalising person-centredness in practice, recognising that at a level of principle the idea of person-centredness is well understood, but the issue is often recognising it in practice. The framework became increasingly recognised as a tool that shone a light on practice and brought a shared understanding and a common language to person-centredness in nursing.
Person-centred nursing: theory and practice (McCormack & McCance 2010)
The publication of the Person-centred Nursing Framework in the first edition of this book in 2010, which is presented in Figure 3.2, consolidated the four domains and many of the constructs within the framework, and the relations between them. At this stage only a few changes were made to the original framework as a result of critical dialogue and feedback:
- the addition of the physical environment as a component within the care environment in recognition of the impact of our physical surroundings on person-centred practice; and
- amendment to the component providing for physical needs to read providing holistic care, in recognition of the range of interventions undertaken by nurses that are not always physical in nature.
Figure 3.2 The Person-centred Nursing Framework (McCormack & McCance 2010)
Following this publication, the framework continued to be used as a tool for practice and to be tested through ongoing research (e.g. Lynch et al. 2011; McCance et al. 2013; Buckley et al. 2014). More interestingly, however, it began to have influence across other areas such as strategy and policy within nursing, and in health care more broadly (e.g. DHSSPSNI 2010, 2013; Royal College of Nursing 2010). Nursing education and leadership development were other areas that began to demonstrate the usefulness of the framework in different contexts. These developments are the focus of Section 4 of this book.
The Person-centred Nursing Framework: a middle range theory
From the outset, the Person-centred Nursing Framework was described as a mid-range theory (McCormack & McCance 2006). Its place on the continuum of theory development was made explicit by McCormack and McCance (2010) drawing on 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 metaparadigm 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, p. 3). Theories are the third component in the hierarchy; these 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’ (Fawcett 1995, p. 25). Fawcett 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 Person-centred Nursing 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 concepts. Recent advancements have been made to develop empirical indicators to measure concepts within the framework, with further work ongoing (Slater et al. 2015).
More recently, the Person-centred Nursing Framework has become a recognised model of nursing (McCormack & McCance 2015). The essence of nursing depicted within the framework reflects the ideals of humanistic caring, where there is a moral component and practice has at its basis a therapeutic intent, which is translated through relationships that are built upon effective interpersonal processes. Hence, the definition of nursing used within the framework is as follows:
Person-centred nursing is an approach to practice established through the formation and fostering of therapeutic relationships between all care providers, service users and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self-determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development.
The framework highlights the complexity of person-centred nursing, and through the articulation of the key constructs, emphasises the contextual, attitudinal and moral dimensions of humanistic caring practices. There is, however, a growing interest and relevance of the Person-centred Nursing Framework to multi-disciplinary and interprofessional team working, which we hope will characterise further development of the framework as we move forwards into the future, and is the context in which we present the next iteration of the Person-centred Nursing Framework within this book.
From person-centred nursing to the Person-centred Practice Framework
When looking to the future, it is our aim to situate the Person-centred Nursing Framework within a broader context to illustrate its applicability to a wide range of health-care workers. This section presents the framework as it currently stands, which is presented in Figure 3.3. As a starting point it is important to emphasise that the four domains and many of the constructs within the Person-centred Nursing Framework have remained stable over time. Furthermore the relationship between the domains has also been validated through use of the framework in practice and research, supporting the assumption that the prerequisites must first be considered, then the care environment, both of which are necessary in providing effective care through the care processes in order to deliver person-centred outcomes. There have, however, been further changes made to constructs within the framework since the 2010 publication, which will be highlighted in the remainder of this chapter.
Figure 3.3 Person-centred Practice Framework.
Prerequisites
The prerequisites focus on the attributes of staff and are considered the key building blocks in the development of health-care professionals who can deliver effective person-centred care. Attributes 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. There is no hierarchy in relation to these attributes, with all considered of equal importance, but it is the combination of attributes that reflects a person-centred practitioner who can manage the challenges of a constantly changing context.
Professionally competent
The knowledge, skills and attitudes of the practitioner to negotiate care options, and effectively provide holistic care.
In the context of person-centredness, competence is more than simply undertaking a task or demonstrating a desired behaviour, but is more reflective of a holistic approach that encompasses knowledge, skills and attitudes. When discussing the concept of competence there are three main approaches adopted in the literature: a task-based or behaviourist approach; a general attributes approach; and the holistic approach (Hager et al. 1994). The holistic approach is consistent with the underpinning values of person-centredness and places emphasis on bringing together individual abilities derived from a combination of attributes and tasks to be performed within particular situations, that also incorporates professional judgement. Sundberg (2001), when discussing a holistic approach to competency development, provides a pragmatic view of competence as:
- knowledge – what you learn in education;
- experience – what you gather in your job, at your workplace and in social life;
- abilities to use your knowledge and experience (p. 104).
He argues that we are not able to develop another person’s competence, considering this to be in the hands of the individual, but what we can do is ‘set the scene, provide the tools and act like catalysts’ (p. 104).
The appropriate and relevant competencies for practitioners are reflected in many competency frameworks reported in the literature, the most important being those produced by the regulatory bodies who govern the professions. The implicit assumption within the Person-centred Nursing Framework is that the minimum standards for registration will be met by a professional. The prominence of person-centredness as a concept within competency frameworks and in the delivery of curricula is growing. The challenge in professional education, however, is not dissimilar to the dilemma in practice – we use the term freely but it tends to reflect an understanding of person-centredness at a level of principle, without the follow-through that enables it to be operationalised in practice. This issue is illustrated in Chapter 7 of this book by O’Donnell et al. In this chapter they describe the findings of a meta-synthesis of person-centredness in nursing curricula that was led by O’Donnell and colleagues at Ulster University. They concluded that despite the merits of person-centred practice being widely espoused in contemporary health-care literature, there was limited evidence of approaches to explicitly facilitate this in the construction and/or delivery of nursing curricula. There are, however, advancements in this area, with person-centredness becoming a core concept within curricula alongside innovative approaches to curriculum development becoming more evident as illustrated by the example provided in Chapter 7.
Developing person-centred practitioners doesn’t stop at the point of registration. Following registration there is a requirement on practitioners to continue to learn and develop, and to acquire skills that enable them to become more expert in practice. The challenge, however, in the development of expertise is the influence of workplace culture. Culture shapes the values shared by teams in the workplace and this also applies to the competencies that are considered most important within a team. An illustration of this can be drawn from emergency care, where value is placed on a medical-technical competence over caring (McConnell et al. 2015). Patient safety is also high on the agenda across the globe, and approaches to demonstrate improvement in clinical indicators that contribute to the endpoints of morbidity and mortality are continuously being promoted in health care. Some of the most saddening and shocking stories within health care, however, are often less about technical competence and minimising physical harm and more about the dehumanising experience of health care. The highly publicised Francis Report (Francis 2013), followed by the Berwick Inquiry (Berwick 2013), provided stark evidence of this within a UK context. Furthermore, the call for more compassionate care is a global message (e.g. WHO 2007; Lown et al. 2011; Dewing et al. 2014a), emphasising the need to develop practitioners who are committed to a holistic approach to practice that takes account of the needs of patients as people.
Developed interpersonal skills
The ability of the practitioner to communicate at a variety of levels with others, using effective verbal and non-verbal interactions that show personal concern for their situation and a commitment to finding mutual solutions.
Person-centredness is built on positive relationships and is dependent on a strong interpersonal skill base. Effective communication requires a combination of good verbal and non-verbal skills. Verbal communication deals with what is said (speech), and what is heard (listening), whilst non-verbal communication is concerned with body language such as posture, proximity, touch, movements, facial expressions, eye contact, gestures and other behaviours, which can add another layer of communication to verbal messages. There are many professional texts available that focus on these fundamental communication skills; however, we would argue that person-centred communication is more than the sum of its parts and that each interaction is dependent on the people involved. In essence we communicate with individuals based on what we know about them as people. This will influence what we say, how we say it, the language used and the use of specific strategies. Getting this right is really important because the impact of poor communication can be profound and often increases the vulnerability experienced by patients and their families.
At one level, a warm friendly practitioner is indicative of good interpersonal skills, and the impact of this on patients and families, and indeed other team members, should not be underestimated. The appropriate use of humour can also build rapport (Tanay et al. 2013; Tremayne 2014). There is, however, a need to move beyond simply building rapport to developing trusting partnerships that will ensure holistic needs are identified, making shared decision-making a real possibility. As professionals we can be warm and friendly, but if we don’t have the courage to step into the world space of another person and engage in the important conversations, then our impact will only ever be superficial. This requires professionals to develop advanced communication skills that enable them to engage in courageous conversations in order to get to the heart of what is important to the person. As previously argued by McCormack & McCance (2010), the development of effective interpersonal ability is linked to the notion of emotional intelligence as described by Goleman (1999). Emotional intelligence uses emotions intelligently and is a combination of knowing ‘self’ and knowing ‘others’ in the context of emotional beings; that is, how I and others that I relate to respond emotionally. It is through an understanding of ‘self’ as an emotional being that we can respond effectively to the emotional behaviours of others, and this aligns closely to the attribute of ‘knowing self’ within the Person-centred Nursing Framework.
Knowing self
The way an individual makes sense of his/her knowing, being and becoming as a person-centred practitioner through reflection, self-awareness, and engagement with others.
As professionals we are also persons with our own life history and experiences, which shape how we develop relationships and how we engage at an emotional level. We grow as persons during our lifetime through engagement with the social world, and it is this that informs our personal meanings, beliefs and values and determines ‘who I am’. In the context of the Person-centred Nursing Framework, this implies that the way an individual sees himself/herself, and the way they construct their world, can influence how they practise as a professional and how they engage with others. The development of self-awareness, however, is not a skill that can be taught, but comes with lifelong learning and personal growth that is based on self-reflection. Facilitated self-reflection is one mechanism for increasing our self-awareness and understanding our behaviours. Schon (1983) suggests that the capacity to reflect on action so as to engage in a process of continuous learning is one of the defining characteristics of professional practice and is aligned to the notion of competence described previously. Being able to reflect in action (while doing something) and on action (after you have done it) has become an important feature of professional training programmes in many disciplines. In becoming a person-centred practitioner we also have to be open to giving and receiving feedback and being able to work with that feedback through critical reflection. Increasing personal self-awareness, however, can be difficult as it can push us to face the things we don’t like about ourselves and also can bring to the fore painful experiences from the past that colour how we act in the present.
Clarity of beliefs and values
Awareness of the impact of beliefs and values on care provided by practitioners/received by service users and the commitment to reconciling beliefs and values in ways that facilitate person-centredness.
The Person-centred Nursing Framework identifies clarity of beliefs and values as one of the prerequisites that enable practitioners to work with the care environment. According to Manley (2004), ‘values determine what people think ought to be done’ (p. 55, italics in original) and these are closely linked with moral and ethical codes. Beliefs on the other hand are ‘what people think is true or not true’ (p. 55). Beliefs and values are interrelated in that ‘it is difficult to separate values from their believed effect’ (p. 55). Finally, basic assumptions involve beliefs, interpretation of beliefs plus values and emotions and are understood as accepted truths that are held unconsciously and are taken for granted (Brown 1998). Very often we live in a world of assumption without even realising it. The ideal situation is for practitioners to develop and agree a set of professional values that are shared by everyone and then lived out in everyday practice. This, however, is the greatest challenge because often the espoused values of the team (i.e. the values we talk about) do not match the behaviours seen in practice. The development of person-centred cultures is built on the premise that everyone is committed to closing the gap between values that are talked about and how those values are demonstrated (or not, as often can be the case) in behaviours observed in practice. The aspiration is an effective workplace culture where specific values are shared in the workplace, for example person-centredness, lifelong learning, high challenge and high support, and are realised in practice through the development of a shared vision and mission, with individual and collective responsibility to maintain this standard (Manley et al. 2011). Practice development is the improvement methodology that offers a suite of tools and approaches that enables teams to work towards these goals (McCormack et al. 2013; Dewing et al. 2014b).
Commitment to the job
Demonstrated commitment of individuals and team members to patients, families and communities through intentional engagement that focuses on providing holistic evidence-informed care.
Being committed to the job at its most fundamental level reflects dedication and a sense that the nurse wants to provide care that is best for patients and their families. Commitment at individual level reflects the nurse who demonstrates a high level of commitment to patients and families by going the extra mile. Commitment to the job, however, is more than going the extra mile. It is also linked to the idea of intentionality defined as ‘the fact of being deliberate or purposive’ (www.oxforddictionaries.com). The concept of intentionality is discussed in the caring literature by several nurse theorists. Watson (1985) defines caring as ‘a value and an attitude that has to become a will, an intention or a commitment that manifests itself in concrete acts’ (p. 32). Furthermore, she believes that ‘our intentionalities inform our choices and actions, helping us to be sensitive and mindful about what is most important in our lives and work’ (p. 17). Commitment to the job in this sense is more than simply acts of kindness but about taking mindful action that is informed by different types of evidence.
Commitment at an individual level, however, can be hard to sustain if it is at odds with the philosophy within the team. When this situation arises the committed practitioner finds they are constantly swimming against the tide and becomes disillusioned and dissatisfied with the standard of care within the team. The contemporary leadership literature emphasises the importance of transformational leadership, described by Kouzes and Posner (2002) as ‘enabling others to act’, by embracing approaches that foster collaboration, building trust and providing visible support. Individuals and teams, however, also work within organisations, highlighting commitment at an organisational level. Furthermore, it is suggested from the literature that organisational commitment is influenced by organisational culture, and understanding organisational culture is important because ‘it influences how we understand organisational life and the meaning we place on activities’ (Manley 2011; Napier et al. 2014). This emphasises the relationship between commitment to the job and clarity of beliefs and values not just at an individual level, but at team and organisational levels.
The care environment
In the previous section the attributes of staff were discussed and described as prerequisites for person-centred practice. We would argue, however, that irrespective of the characteristics of staff, unless the care environment is conducive to person-centred ways of working then the true potential of teams cannot be fully realised. This reflects a complexity within the care environment that focuses on the context in which care is delivered. Increasingly, context is recognised as having a significant impact on clinical and team effectiveness. There is an increasing literature in the field of knowledge translation and knowledge utilisation focusing on: exploring the meaning of context; identifying the key elements of context and their enabling or hindering qualities (for evidence/knowledge use); and developing approaches to measuring the impact of context on clinical and team effectiveness, including impact on patient outcomes (Rycroft-Malone 2004; McCormack et al. 2009; Rycroft-Malone et al. 2013). What is increasingly recognised is that context is a complex phenomenon, and whilst it may be easy to state what it is (in our case context refers to the care environment) it is less easy to delineate its characteristics and qualities. To some extent this difficulty reflects the relationship between context and culture, an area that is explored in greater depth in Section 2 of this book. The position taken in relation to the framework is that context is synonymous with the care environment, and contained within the care environment are multi-faceted characteristics and qualities of the environment (people, processes and structures) that impact on the effectiveness of person-centred practice. To this end, seven characteristics of the care environment are described within the framework including:
- appropriate skill mix;
- systems that facilitate shared decision making;
- the sharing of power;
- effective staff relationships;
- organisational systems that are supportive;
- potential for innovation and risk-taking;
- the physical environment.
Furthermore, we would contend that the constructs that comprise the care environment have a significant impact on the operationalisation of person-centred practice and have the greatest potential to limit or enhance the facilitation of person-centred processes (McCormack et al. 2011).
Appropriate skill mix
Skill mix is most often considered in a nursing context and means the ratio of registered nurses (RNs) and non-registered nurses in a ward/unit nursing team. In a multi-disciplinary context it means the range of staff with the requisite knowledge and skills to provide a quality service.
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