The way to patient-centered care (2010)

Institutions across the country have implemented patient-centered models since the recommendations put forth by organizations such as the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality (AHRQ) to adopt a philosophy of patient-centered care (PCC).1,2 This has had the positive result of focusing attention on quality and patient safety strategies, as well as the inclusion of patient and family perspectives into patient care and organizational decision making.3 But experts note that little attention was given to patient-centered nursing in the IOM and AHRQ reports.4 Although it's nearly universally accepted that PCC is best delivered through multidisciplinary teams, the development of patient-centered nursing practices can serve to strengthen the contribution of the discipline of nursing at the multidisciplinary table. Despite the fact that PCC is widely used in healthcare today, there's no agreement or consensus on its definition.5 This means that it can vary from one practitioner to another and from one institution to another. Recently, nurse researchers have responded to the need for clarification, and their efforts have resulted in movement toward an evidence-based foundation for nursing practices. PCC as alleviating patient vulnerabilities Hobbs explored the published literature on PCC relevant to the discipline of nursing and identified its various meanings.5 The result was a conceptual model that synthesized all of the meanings into a comprehensive whole and then described how all of the elements of PCC, expressed as dimensions, were interrelated. This conceptual model organizes the existing research and clinical knowledge about PCC into a meaningful whole so that when viewed through the lens of this model, a common understanding of PCC is achieved and everyone who subsequently uses the term will be talking about the same thing.6 Because the acute care environment was the context in which PCC was discussed in the literature, the model was limited to this setting. Patient-centeredness occurs when actions and processes are directed toward reducing or eliminating patient vulnerabilities. Patients enter the acute care setting because they're suffering; they have needs that illness has imposed on them and they're unable to meet these needs themselves. During their hospitalization, patients are vulnerable not only because of compromised physiologic states but also because of threats to their personal identity (such as feeling alienated or perceiving a lack of control).5 Therapeutic engagement of the patient is the process through which vulnerabilities are addressed. A complex series of situations and interactions between the nurse and the patient based on the development of trust that's delivered through a caring approach is crucial to engaging the patient. When therapeutic engagement is successful, the patient receives effective care, needs are met, and suffering is lessened. In order for care processes to be directed toward reducing vulnerabilities, the nurse must know the patient and adapt the plan of care to include the patient's particular life circumstances, perspectives, beliefs, and values. The meaning that illness may have to that particular patient should also be considered. Incorporating these unique patient features into care practices and communicating the information to other nurses and team members prevents erosion of individual identity. The skills, knowledge, and competencies of the nurse influence his or her ability to achieve the goal of alleviating vulnerabilities.5 Because the complex interactions between the nurse and patient are central to PCC, Hobbs recommends examining the qualitative and quantitative research on nurse-patient interaction.5 Synthesizing this body of literature and evaluating its strength and quality will provide the best available evidence on PCC on which to base nursing practices. Linking concepts to outcomes The research of Radwin and colleagues is another example of the effort to clarify patient-centered nursing.4,7,8 However, these researchers advanced the knowledge base not only by identifying and measuring patient-centered interventions for cancer patients, but by then linking the interventions to desired outcomes. Radwin first sought to identify, through qualitative research, the perspectives of cancer patients about the care they received.7 This research resulted in a middle-range theory describing the concepts of high-quality cancer nursing. Patient-centered interpersonal interventions and desired outcomes were drawn from these concepts. Next, the researchers developed and tested The Oncology Patients' Perceptions of the Quality of Nursing Care Scale that operationalized the interventions and outcomes from the middle-range theory.8 The patient-centered nursing interventions were responsiveness (the ability to meet needs in a caring and attentive manner), individuation (the ability to personalize care according to the patient's feelings, preferences, and desired level of involvement), coordination (the ability to promote communication among other nurses and the patient), and proficiency (the ability to provide knowledgeable, skillful nursing care). These interventions are consistent with and similar to the processes identified in Hobbs' conceptual model. The desired health outcomes were trust in nurses (the patient's confidence that the care was appropriate, reliable, and as successful as possible), authentic self-representation (the patient's sense that he or she has shared authentic, truthful information about him or herself), optimism (the patient's beliefs that he or she has made appropriate treatment choices and is hopeful about treatment outcomes), and a sense of well-being (the patient's positive emotional state). Finally, in a nonexperimental longitudinal study, the researchers investigated the relationships between the patient-centered nursing interventions and the desired health outcomes.4 The findings indicate that when care is individualized, patients are more likely to share truthful information about themselves and believe that they made appropriate choices, are hopeful about the outcome of treatment, and have a greater sense of well-being. When nurses are perceived as responsive and proficient, patients are more likely to trust them. Setting expectations The work by both Hobbs and Radwin and colleagues are examples of how knowledge becomes more refined and precise so that it can guide research and practice. The ability to articulate and measure processes that have come to be known as the hidden work of nursing establishes an initial evidence base for patient-centered nursing practices.9 A comprehensive analysis of the literature and further research will expand this knowledge to other practice settings and with other patient populations, which will further allow evidence-based guidelines and protocols to guide patient-centered nursing practice. Given the current evidence, it's important that nurse managers set the expectation that nurses engage patients in trusting relationships and deliver attentive and individualized care that builds trust, respects choices, and enhances a sense of well-being so that patients feel less vulnerable. It's equally important to share with other nurses and the multidisciplinary team information unique to each patient such as values, beliefs, life circumstances, and personal meaning of illness.