How well is patient-centred care applied in practice?

Patient-centred care (PCC), as defined by the Institute of Medicine, provides care that is responsive to, and respectful of each patient’s needs, values and preferences, to ensure the individual’s values guide all clinical decisions.¹ This is a crucial health-care concept as it separates disease (characterised by pathophysiological aspects, such as symptoms, diagnosis and treatment) and illness (describing the overall patient experience, including the effect on individual wellbeing, feelings, ideas and lifestyle).² Understanding these differences enables the health-care professional to understand the disease and work alongside patients as they experience illness, to increase patient-centred decision-making.²

To highlight the importance of this health-care model, this article explores cultural safety, family/patient support networks, active patient involvement and participation in care, and the nurse-patient relationship. It incorporates personal experiences from our clinical placements to demonstrate how these concepts are utilised in health care from the perspective of a student nurse. We also include practices we feel can be improved to ensure the best patient outcomes.

Cultural safety

Cultural safety has been defined as: “An outcome of nursing education that enables a safe, appropriate and acceptable service that has been defined by those who receive it.”³ This encompasses, but is not limited to, differences in ethnicity, religious beliefs, sexual orientation, gender, age, socioeconomic status and disability.⁴ It is enacted by the nurse, but allows the recipient of care to determine whether their care was safe.⁵ Safety is a subjective term that is deliberately used to give the person receiving health care the power.⁵ Cultural safety is also included in the Nursing Council’s Code of Conduct (the code). Principle two is: “Respect for the cultural needs and values of health consumers”.⁴ Failure to fulfil this principle would breach the standards registered nurses (RN) are expected to uphold.

Cultural safety is a vital component of the undergraduate nursing curriculum and is in the forefront of many student nurses’ minds during clinical placements. However, this concept was only developed in the early 1990s and therefore differences exist in its implementation.⁵

An experience recalled by a second-year student nurse demonstrates the contrast between the concept of cultural safety and its lack of implementation by some RNs. The student nurse and their assigned preceptor were undertaking the care of an elderly Indian woman who did not speak English and was reliant on her family to translate. None of the health-care staff had provided this woman or her whānau with communication resources, such as the translating service.

The student nurse was asked to assist the woman with hygiene care. The student questioned their preceptor about how they were supposed to ask permission, as the family was not present to translate. The RN dismissed the query, replying that the patient didn’t care. No attempt was made to communicate with, or gain consent from the patient. When there is no attempt made to communicate, nurses can’t deliver culturally competent care. Standard 2.2 of the Nursing Council’s code states the nurse must: “Assist the health consumer to gain appropriate support and representation from those who understand the health consumer’s first language culture, needs, and preferences.”⁴

The preceding scenario breached this right. The care was not culturally safe and therefore not patient-centred. The link between these two concepts is mutually inclusive because it would be impossible to achieve PCC without considering what was most important to a patient.

The foundations for cultural safety are cultural awareness and cultural sensitivity. Cultural awareness is the first step in sensitising people to differences. Cultural sensitivity involves alertness to the legitimacy of difference, self-exploration, and the impact this may have on our treatment of others.⁵ In our clinical experience, RNs attended frequent workshops related to clinical nursing skills. However, none we knew of were patient-centred education sessions.

Family and patient support networks

Family and support networks are an essential aspect of PCC.⁶ Families have been defined as close blood relatives, such as children, siblings or relations through marriage.⁷ Close friends are also considered family to some, as support networks are individualised, depending on personal values.⁷

Nurses must respect that patients have the right to have one or more support people during their care, if they choose, except where the safety of the patient or support person may be compromised.⁸

Support networks are essential for patients, as they provide extensive informal care and are an integral part of patients’ psychosocial context and family members create an environment that enhances patient safety within the hospital.⁶ There is a correlation between family support in a hospital environment and good health outcomes,⁹ so it is crucial nurses promote these relationships. However, some patients may have no such support.

One student nurse experienced the use of family and support networks in the clinical setting. The student explained that, during the care of a patient, the patient’s wife and daughter would always be there, attend to cares and assist in translation, as the patient spoke Tongan and could not fluently speak or understand English. The family members were active participants in this patient’s care. They also supported him by attending his procedures, such as colonoscopy, as was agreed to by the staff involved. Staff greatly appreciated this family support, as it improved the patient’s care and ensured his family advocated for him. This example shows how family and support networks can benefit patients in health-care settings.

A recent systematic review summarises research papers related to interventions that showed an improvement in health or wellbeing for the family as a whole.¹⁰ It includes home-visiting services, the Whānau Ora programme, and brain injury intervention.¹⁰ These nursing interventions were successful in improving the health of patients. The literature review stated that: “The identified papers include some models and some tools which may be useful for consideration by services aiming to effect change at the level of the family in Counties Manukau”.¹⁰ This research could be used in other district health boards to emphasise the importance of the family’s involvement in PCC.

Patient participation

Patient participation is a fundamental concept of PCC¹¹ and is reflected through patient engagement and involvement with their care and wellbeing.¹² Terms considered synonymous with participation include engagement, involvement, collaboration and cooperation.¹¹

Patient participation encompasses patient involvement in informed decision-making, enabling patients to express opinions regarding various treatment alternatives and consent to health team instructions.¹² Patient participation is essential in health-care decision-making and widely regarded as significant in health-care quality, patient safety and clinical effectiveness.¹³

By respecting patient autonomy and empowering patients in their treatment, adherence to the treatment plan is promoted.¹² This enhances patient wellbeing and ensures better provision of health maintenance services. Other benefits include the promotion of patient knowledge, satisfaction, perceived quality of care and, ultimately, an improvement in their condition.¹²

However, in clinical practice, patient participation can occasionally be poor, as experienced by a second-year student nurse. Nurses planned the care for the patients at the nurses’ station, based on entries and recommendations written by the medical team from the previous shift. They did this without meeting the patient or asking for patient input. There are various challenges in involving patients in their care, including patient enthusiasm, the nurse’s approach and ambiguous expectations and roles.¹¹ The severity of the patient’s condition may impede some forms of participation. The patient’s inclination to be active, collaborative or passive in their patient role, in conjunction with different understandings of patient and nurse collaboration, can further hinder patient involvement. Nurses can create barriers to patient involvement, eg being task-focused, appearing busy, or making assumptions about what patients want.¹¹

However, principle three of the code promotes advocacy and protection of patient wellbeing by working in partnership with the patient.⁴ It highlights the significance of upholding patients’ independence, perceptions and preferences.

Nurses can, therefore, facilitate patient involvement through bedside handovers. Patients prefer bedside handovers to traditional private office handovers, due to the social aspects.¹⁴ Patients get to meet and familiarise themselves with the nurses taking care of them and are included in discussions related to their wellbeing. Assumptions and misconceptions are mitigated, as patients are present for clarification and can contribute to decision-making.

By inviting and encouraging patient input, nurses foster a genuine relationship with their patients, which further enhances patients’ engagement in their care and perception of self-worth.¹⁴ Nurses also benefit from these interactions by being able to assess the patient and assess patient participation.¹¹ The differing expectations of nurse-patient partnerships are thus addressed.¹⁴

A second-year student nurse’s positive experience illustrates the use of patient participation to attain PCC. A patient was about to be discharged and told the student nurse of his apprehension about the health-care team’s wish that he self-inject medication subcutaneously. The student nurse acknowledged the patient’s fear and discussed alternatives and potential actions by the nurse and student nurse to support him in managing his care, including education and supervision with his self-injections. The patient then decided to practise self-injecting medication subcutaneously under the guidance of the nurse and student nurse. Initially, he was cautious and hesitant. However, by the time the patient was ready to be discharged, his confidence had increased greatly. He was capable and competent in self-administering medication. This exemplifies how patient empowerment and wellbeing is achieved when patients collaborate and engage in their care, leading to the overall promotion of PCC.

Nurse-patient relationship

A beneficial nurse-patient relationship plays an integral role in PCC. It is paramount that nurses and other health professionals foster trusting relationships with their patients. The code states that such relationships are built on respect, partnership and integrity.⁴ From a clinical perspective, when patients trust their health-care professionals more, they are more likely to demonstrate healthy behaviours, experience fewer symptoms, and indicate a higher quality of life and satisfaction with their care.¹⁵

Although establishing a therapeutic relationship is considered mutually beneficial, several barriers may prevent a nurse from building such connections. Effective communication is needed to establish a trusting relationship, but language differences often prevent nurses from understanding a patient’s concerns.¹⁶ While the use of professional interpreters can improve care and communication between patient and care providers, research indicates the quality of communication between a provider and patient, even with interpreters, remains suboptimal.¹⁷ Family members can help to an extent. However, they lack the training and understanding of medical terminology that professional interpreters have.¹⁸

Caring for patients for whom English is not their language can also prove a challenge, as interpreters can only be booked for a short period. Without interpreters, instructions can be misunderstood and the establishment of a trusting relationship can be hampered.

The time constraints nurses are routinely under are also a barrier to establishing patient-centred communication.¹³ One study found that these time constraints led to a focus on diagnosis and treatment, potentially preventing a nurse from asking the patient to voice any concerns.¹³ The same study also found that patients expected nurses to be busy. This was another barrier to communication, as patients felt reluctant to ask questions, out of respect for the nurse’s time.¹³

In our clinical experience, we found nurses often tried to engage with patients regularly. The patients themselves also held a great deal of respect for the nurses and generally followed instructions. However, work overload was an obstacle to patient-centred communication in some cases. In a conversation with a student nurse, one dissatisfied patient complained of nurse negligence and a lack of involvement in her care. The student nurse who cared for her admitted the day was hectic, and work overload was a significant factor in preventing effective communication.

Practice recommendations for the nurse-patient relationship

Solving the burden of work overload on a nurse’s shift is a complicated issue, but attempts to improve work distribution may allow nurses more time to initiate conversations between patients and improve patient-centred communication. Encouraging student nurses to take more responsibility for their patients will also help them improve their time management skills. A difference in spoken language is another difficult issue to resolve. One way to address this issue is to focus on recruiting an ethnically and linguistically diverse workforce.¹⁷ By doing this, nurses may be able to better empathise and communicate with patients who are more comfortable speaking in their home tongue, thus promoting patient-centred communication.¹⁷

While PCC is taught thoroughly, there are barriers to fully implementing it in the clinical environment. It is up to all nurses – students and RNs – to work towards meeting the ideal of PCC in all clinical settings.

Georgia Bond, Joshua Christiaan, Michael Kessell, Maryanne Ma’asi, Sarah McCulloch and Stephanie Tea were second-year nursing students at the University of Auckland when they wrote this article, with the guidance of their lecturer Kylie Hodgson.

References

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