Printed-keeping the Person in the Centre of Nursing

40 nursing standard august 2/vol14/no46/2000

art&sciencenurse patient relationsnursing standard: clinical · research · education

The RCN’s work on gerontological nursingexplicitly embraces the philosophy of person-centred approaches to practice and is heavilyinfluenced by humanistic philosophies thatemphasise the importance of recognising the‘lived experience’ of the older person in plan-ning care. Many argue that such an approach tohealth care continues to be rhetoric and thatperson-centred approaches are far from reality inpractice (HAS 1998, Help the Aged 1999).

Acknowledging this, the RCN has developed agerontological nursing programme that integratesall of its work on policy, research, education andpractice development. The central aim is tomake person-centred practice a reality. However,as this article suggests, there is much to do toensure that the ideology of person-centredapproaches to care is dominant in contemporarygerontological nursing practice.

This article seeks to explore what it means tobe a person and how this understanding is artic-ulated in person-centred approaches to practice.The article will focus on the issue of assessmentas the cornerstone to establishing the needs ofan older person and attending to these needs ina person-centred way.

In the past five years there has been increasingconcern over the funding, level and quality ofhealth and social care provided for older peoplein the UK. Specifically, attention has beendrawn to the apparent lack of consistency inthe assessment of the individual’s need for care;the variability in provision of appropriate care tomeet these needs; the apparent confusion over

the sources of funding to provide these services;and the lack of involvement of individuals andtheir families and/or carers in the assessmentprocess (Audit Commission 1997, Ellis 1993,NHSHAS 1997, RCN 1998a and b). In long-termcare, these concerns led to a Royal Commission(DoH 1997) being set up.

The drive to develop person-centred approachesto practice represents a stage in the developmentof healthcare services at which the needs of theindividual, rather than the professionals andorganisations who meet these needs, are heldcentral. Therefore, adopting a person-centredapproach goes far beyond simplistic notions ofindividualised care and instead represents a fun-damental shift of philosophy in caring practices.

The word person aims to capture those attributesthat represent the humanness of people and thefactors that we regard as the most importantand the most challenging in our lives. The conceptof person would include attributes such as sight,taste, sexuality, memory and desires.

But members of other species also have theseattributes – along with the capacity for thoughtand decision making. However, people are seen aspossessing a will that enables rational deliberationon action. As a result, the concept of freedom isan important aspect of personhood – being freeto do something and to take responsibility forchoices made (Frankfurt 1989).

For nurses working with older people, such aconcept of personhood raises serious issues forpractice. If personhood is defined as being relianton rational decision making with reflection oncompeting choices, needs, wants and desires,then it is easy to see why so many users ofhealth and social care services become reducedto objects. Many older people in hospital andcare homes, for example, those with acute con-fusion or dementing illness, neither have thefreedom nor the ability to take rational and freeaction for themselves.

If the preservation of autonomy relies on anindividual being capable and free to make rationalchoices, then respect for personhood becomes aparticular challenge because so many users of

What it means to be a person

Background

Introduction

Pauline Ford MA, RGN, DHMS,CMS, and Brendan McCormackBSc, DPhil (Oxon), PGCEA, RGN,RMN, are Directors,Gerontological NursingProgramme, Royal College ofNursing.

Keeping the person in thecentre of nursingFord P, McCormack B (2000) Keeping the person in the centre of nursing. NursingStandard. 46, 14, 40-44. Date of acceptance: June 27 2000.

This article presents an overview of whatit means to be a person and how this isarticulated in person-centred approachesto practice. Nursing assessment is used as an example of a person-centredapproach to care.

Summary

� Nurse patient relations

� Patients: empowerment

These key words are based on the subject headings fromthe British Nursing Index. This article has been subject todouble-blind review.

key words

services do not experience such freedom. This iseither because of their disease processes orbecause of the constraints of service provision.

It is therefore unrealistic for nurses to assumethat to be a person is dependent on freedom ofwill and action. Within the constraints of healthand social care services, it is not uncommon forthere to be a lack of freedom of action.

This does not mean that the people for whomwe provide a service are not persons, but it doesmean that adopting simplistic notions of individ-ualised care does not meet the real needs ofolder people. For many older people, the abilityto engage in these activities is seriously compro-mised and therefore it is crucial that othersenable older people to retain their sense of personas much as possible, that is, through person-centred practice.

Current developments in humanising health carerepresent a rejection of previously acceptedbehaviourist approaches. Humanism represents aphilosophy that emphasises an individual’s unique-ness and freedom to choose a particular course ofaction. Such a philosophy is central to the work ofmany nurse theorists, for example, as a humanisticexistentialist philosophy for Parse (1981), Bevis andWatson (1989) and Newman (1994). Such theoriesadvocate that behaviour is not a response tounconscious forces or to external stimuli, but to theindividual’s perception, interpretation and compre-hension of external stimuli.

Centred in an existentialist philosophy (Sartre1993), humanism argues that as we are the onlyones who can know our perceptions, we aretherefore the best experts on ourselves (Rogers1961). We each have first-hand experience ofourselves as persons and therefore the ability tounderstand our own self-concept. Such an idealis evident in much of the nursing literature and ismanifested through discussion of concepts suchas partnership (Christensen 1993), empowerment(Connelly et al 1993), friendship (Trygstad 1986),intimacy (Savage 1995) and expert nursing(Benner and Wrubel 1989). The humanistic the-ories in nursing are therefore concerned withcharacteristics that are distinctly and uniquelyhuman, such as experience, uniqueness, mean-ing, freedom, and choice – all characteristicsthat are evident in, for example, Kitwood’s viewof personhood (Kitwood 1997).

Kitwood and Bredin (1992) suggest that person-centred practice can be achieved if practitioners:� Understand user needs.� Engage in positive work with the user.

� Place central in all decisions/actions the desireto maintain/improve wellbeing.

Personhood is linked to moral agency and beinga member of a moral community (Agich 1993).As such, it is dependent on integrated serviceprovision, societal preparation and good practice(Kitwood 1997). It moves beyond ethics in thatit encompasses the uniqueness of individuals(Gearing and Coleman 1996) and is dependenton the standing or status bestowed by others(Kitwood 1997) and on an inner resilience andintegrity (Schutz 1971).

If preservation of personhood is placed withina context of partnership, then preservation of anindividual’s personhood can be achieved. Suchpartnerships between nurses and older peopleprovide the context for working with the livedexperience of the older person. By recognisingthe history of older people, we acknowledgesocial, psychological and cultural biography and,in so doing, recognise that such biographyforms ‘the tapestry of one’s life’ (Selder 1989).

Lives are imbued with personal meanings,beliefs and values, which are essential to the waya person sees him or herself and the way thattheir world is constructed. Such individuality ofpersonal meanings determines ‘who I am’. In thisrespect, nurses are no different from the olderpeople for whom they seek to provide a service.

It is through partnership that nurses should seekto understand the wants, needs and aspirationsof the older person. Such partnerships shouldseek to minimise the erosion of individual identityand maximise what truly matters to the olderperson (Ford 1997, Ford and McCormack 1999).

Being person-centred relies on getting close tothe person and goes beyond traditional notions ofindividualised care, where nurses provide choicesabout food, bathing and wake-up times. By gettingclose to the person, we strive to provide care andservices that are compatible with the individual’svalues and which are, as such, highly valued.

There are, of course, challenges in achieving anapproach to service and care provision. It is hardto provide person-centred care within the con-text of limited resources and communal living.However, if nurses really believe that older peopleare persons, then there is a moral obligation towork towards a truly person-centred approachto care (Seedhouse 1998). The starting point formost care is assessment and this is used here asan example of person-centred practice.

Despite the urgent political concern for a newfocus on service provision, which includes matterssuch as holism, empowerment, enablement andadvocating the concerns of the user rather thanthose of the service and the professional (CSAG

Person-centred assessmentPerson-centred practice

Nursing theories

august 2/vol14/no46/2000 nursing standard 41


1998, HAS 1998, NSF in press), there is little evi-dence that health and social care assessmentpractice is responding to such concerns (Banks1995, Help the Aged 1999, McCormack 1998).

Setting identified user needs within organisa-tional constraints requires an approach in whichthe practitioner and user both identify needsand consider them in the context of availableresources and the context for care (Hunter et al1993). Such an approach requires acknowledge-ment of the values system in operation and skilledassessment, planning, action and evaluation ofthe implications and nuances of all these factors(Banks 1995, Hill 1999, McCormack 1998). Inthis way, interpersonal relationships, which aredistinctive to nursing, social work and lay caring,become central (McCormack and Ford 1999).

For example, viewing dependency in terms ofphysical loss of ability can generate measurableoutcomes in terms of aids to daily living (ADLs),but ignores the wider issues of human need(Fennel 1986, Hill 1999). As a result, assessmenthas become an activity divorced from context,which denies the older person his or her senseof individuality and personhood and, further-more, denies any sense of relationship betweenthe user and care provider.

The assessment process needs to be placed in thecontext of government policy and organisationalpriorities, as well as the professional and personalvalues of the assessor. In this way, assessment canbe contextualised along with the needs, wantsand aspirations of the user and can generate anhonest exchange between assessor and user.

Assessment is not just the undertaking of a setof technical skills, rather, it requires a certainkind of relationship between those who partici-pate in it and with whom we share the purposesand standards of the practice (Ford andMcCormack 1999). This will not overcome someof the conflicts experienced by practitioners asthey strive to meet needs while restrained bylack of resources, but it does offer the potentialfor a free exchange with the user.

Valuing people and identifying individualneeds is central to biographical approaches toassessment (Gearing and Coleman 1996).Valuing the past (Gadamer 1979, Johnson1976) offers us the context for understandingold age (Johnson 1976).

If the meaning of older people’s lived experi-ences are ignored, then older people are denieda way of defining their own needs and, as such,health and social care cannot be said to beeither user-focused or attempting to promoteautonomy (DoH 1990, 1989). The use of biogra-phical approaches to assessment can contributeto a re-evaluation of later life as a time of conti-nuity and personal growth and development, aswell as a potential time of adversity. For example,achieving clarity of the meaning of health andwellbeing for the older person should affect howrestorative and maintenance work is practised(Savishinsky 1991). Greater clarity could beachieved through biographical approaches toassessment, so that such meanings for the olderperson can be understood and responded to.

Such approaches to assessment assume that thehealth needs of older people are related to theirsocial circumstances and, as a result, any conceptof need is specific and particular to the life historyand the current life circumstances of the particularindividual (Gearing and Coleman 1996).

Health and social care has to be meaningfulfor the user if it is to be successful in maximisingpotential. In this way, assessment needs to focuson positive outcomes that relate to user hopesand aspirations, and therefore overcome thecurrent emphasis on objective measures inassessment (Agich 1993, Hill 1999).

Seeking to maximise potential though focusingon competencies would result in an assessmentthat focuses on abilities rather than dependency.This process clarifies existing competencies (Agich1993), which can be used at times of adversity(Savishinsky 1991). In this way, the resulting planof care would be individualised, drawn from theuser’s biography and derived from the aspirations,needs and wants of the user.

The RCN assessment tool has been developedby expert gerontological nurses to identify the

The RCN nursing older peopleassessment tool



Fig. 1. The context of nursing assessment

Health statusassessment

Medical diagnosisPersonal circumstances

Biography

NursingHealthcare needsSelf-care deficits

Care plan of nursing needs

Identified need for nursing

specific areas where nursing is needed and provideevidence for the prescribed level of registerednurse intervention. The assessment tool aims topromote re-enablement models of care andguide nurses in relation to the need for referredspecific specialist assessment.

Underpinning the work on the RCN nursingolder people assessment tool (RCN 1997b) is thebelief that notions of health stem from socialvalues (for example, how personhood isdefined).

As such, how health is interpreted shouldguide health and social care policy (RCN 1997a).In this way, health and social care practiceshould be reciprocally related to the meaning ofhealth based on social wellbeing.

Such a tool is not meant to be used in isolation,rather, as the nursing component to the multi-disciplinary assessment of need in older people(Fig. 1).

The RCN nursing older people assessment toolenables: � Assessment of an older person’s health status

through the use of a comprehensive range ofcategories.

� Identification of the need for a registered nurseinput through the application of a stability/predictability matrix.

� Estimation of the level of nursing interventionneeded.

� Estimation of the number of registered nursinghours required, through the use of a scoringformula.

The assessment tool has been piloted (Ford andMcCormack 1999) and two further studies areunder way. The first builds on the pilot method-ology, looking at reliability, acceptability andvalidity. The second study seeks to explore hownurses make assessments of older people innursing homes and how they understand theprocesses of assessment using the RCN nursingolder people assessment tool.

The RCN’s work on assessment reflects nursing’swillingness to adapt to a changing health andsocial care context, and provides evidence onwhich to base expert gerontological nursing(Ford and McCormack 1999).

The assessment tool as it stands will assistnurses to identify older people’s need for nurs-ing. The tool enables skilled judgements to bemade in relation to the need for registered nurses,and it will assist both purchasers and providersto more accurately evaluate the cost of nursingcare for older people.

To achieve this, there is a need to articulatethe processes involved in expert nursing witholder people. This can lead to the identificationof criteria for the measurement of effectivepractice (RCN 1997b). Expert practice is person-centred practice.

In terms of assessment, expert practitioners aimto maximise potential through an assessmentprocess that seeks the older person’s perspectiveon the meaning of health (Johns 1994). By know-ing the individual’s particular meanings (Johns1994), the practitioner seeks to understand theperspectives and needs of the user and developsa plan of care that is truly person-centred.

The starting point for person-centred assessmentwould then be the personal needs, wants andaspirations of the individual and a health andsocial care response would be tailored aroundthese. To achieve this, practitioners mustacknowledge the philosophy of person-centredassessment, for example, how an individual rep-resents their humanness (McCormack 1998).

Expert person-centred assessment providesopportunities for the older person to exercisefreedom of choice, express opinions, engage ininformed decision-making, communicate andbe heard and, as a result, to truly express the selfin an authentic way. To achieve person-centredcare requires clarity about the meaning of per-sonhood. Assessment, therefore, should seek toassist and allow the expression of values so thatan individual’s potential can be maximised.

Such potential is dependent upon an explicationof personal values and also those of the society inwhich we live, our professional values and thoseof the organisation for whom we work. Only inthis way can practitioners make sense of anyconflict that might surround the achievement ofmaximising the potential of the older person.

Expert practice in assessment requires nursesto have a broad gerontological knowledge base,derived from:� The practice of caring for and working with

individuals.� An understanding of the socio-political context

of ageing.� An understanding of biological and psycho-

logical developments through the lifespan.� Understanding the needs of populations.Expert practice with older people is dependenton nurses seeing their role as enablers of health,based on the individuality of each older personand focused specifically on their life choices,plus their stated and considered potentials. Theframework for expert practice underpins severalstrands of the RCN’s work in gerontologicalnursing and is an integral part of its work oncurriculum development for gerontologicalnurse specialists (RCN 1999).

Person-centred approaches to assessment seek toachieve the richest sense of health by highlighting

Conclusion

Expert practice in assessment

august 2/vol14/no46/2000 nursing standard 43


moral understandings of health work. It offers waysof incorporating personhood into our personalbeliefs and values by recognising the individualityand status of others, respecting them andestablishing trust. The primary purpose of person-centred assessment therefore is to maintainpersonhood (Ford in progress).

If practitioners wish to achieve person-centredapproaches to assessment, they will need to: � Reflect on values and beliefs.� Review their knowledge base. � Review their practice.In this way, they will gain understanding of per-sonal and professional attributes and how theseimpact on wellbeing.

A person-centred approach to assessmentrequires recognition, respect and trust. It calls

for acknowledgement that people are unique,independent and interconnected (Agich 1993,Gadow 1991, Kitwood 1997). It is bestapproached through biography because peoplecome with a past, present and future.Humanistic approaches offer the best opportu-nity for person-centred assessments.

Ill health disrupts one’s sense of self (Kitwood1997, Schutz 1971) and it is the practitioner’srole to try and maintain personhood in the faceof adversity as experienced by the individual(Kitwood 1997, Savishinsky 1991).

When undertaking person-centred assessment,nurses have a key role in creating a picture of theperson that enables decision-making which isrepresentative of the person’s life as a whole(Dewing and Pritchard 2000)



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Printed-keeping the Person in the Centre of Nursing