Notes on person-centred care: What it is and what it is not

Florence Nightingale first published her Notes on Nursing in 1859. ¹ This is a book of immense inspiration and timeless relevance across the nursing community and beyond, a book which provided a seminal outline of what nursing is and what it is not. I will use Nightingale’s title in this editorial to ask the questions what person-centred care is and what it is not. I endeavour to place the concept in a Nordic context and raise some critical queries in relation to the ongoing theory and practice development of person-centred care.

I have come to understand person-centred care as being more than a set of techniques, skills or procedures. In my understanding, it means a personal way of approaching, connecting and partnering with patients and families that build on social and interpersonal ethics and skills inasmuch as professional skills. It requires a true interest in others’ personal conceptualizations, decisions and priorities relating to health, as well as on professional expertise and skills in systematic attention to and analyses of others’ health and subjective experiences thereof, with an ultimate aim to understand and integrate these into ethical and successful professional practice. Successful practice is here defined as positive patient outcomes, experiential as well as biomedical. Person-centred care then means attending to the relational aspects of life inasmuch as the biological aspects and using narratives to complement ‘what’ with ‘who’ in nursing practice, fostering Buberian I-Thou relations instead of I-it relations and by that working towards integrating the relational ‘being with’ together with the task-based ‘doing for’ in nursing. Person-centred care simply means bringing back the person into care, and by that reinforcing the ever-present ethical demand to uphold dignity, providing autonomy, choice and control, respecting decision making and doing good. It is simple. It is also very complicated.

The conceptual applicability appears to have contributed to the strong academic momentum and practice emergence of person-centred care during the last 15 or so years, and this applicability may well be the factor that most significantly will predict the continuing success and/or failure of the concept. As an Anglo-Saxon concept, person-centred care is commonly described as emerging out of Rogerian psychotherapy and the perceived shortcomings of reductionist medical management of dementia and related disorders as described by Tom Kitwood. ² In addition, the North American and Australian consumer participation movement and the lived experience perspective on health and care as surfacing in North American and Scandinavian life-world research has also contributed. In nursing, the literature on person-centred care as a concept and as an approach to care has evolved from early philosophical and conceptual work out of Great Britain, and has moved towards measurement development, interventions and associated outcomes across Europe, North America and Australasia. A current trend in the literature is exploring how person-centred care can be implemented and sustained in everyday health care practice in various parts of the world, for example in relation to practice guidelines, routines and care standards.

Implementing person-centred care and exploring associated effects are currently in focus for several research groups across the Nordic countries and beyond. The creation of a government funded centre for person-centred care research in Gothenburg³ can be seen as a testament to and/or consequence of the strong Nordic tradition in nursing to recognize and incorporate subjective experiences of illness and collaborative approaches to self-management and care. It seems plausible that the foundational nursing research performed early across the Nordic countries laid the foundation for the concept person-centred care, as well as illuminating the meanings and relevance attached to this concept even long before the concept was established. In that sense, the emergence of person-centred care stands on the shoulders of giants from building on the foundational work of our Nordic nursing research pioneers.

However, the applicability of person-centred care may also be a threat to the aggregation of knowledge and conceptual consistency if not carefully attended to. What seems to be a readiness to define a very broad spectrum of interventions as being person-centred simply by virtue of incorporating even minor aspects of subjectivity or individuality, introduces a threat to the aggregation of knowledge in this field as the extent to which such interventions are comparable is often difficult to decide. There is also a rapid increase of publications based on a variety of concepts such as person-centred, patient-centred, client-centred, consumer-oriented, person-oriented et cetera, and understanding the extent to which these concepts remains comparable is also challenging. In addition, a variety of disparate endpoints together with a remaining black box of interventions (understanding what it is that makes different interventions person-centred) also increases a need for solid analytical matrices for interpreting such studies, so that the conceptual applicability does not mutate into an escalating conceptual inconsistency where pragmatics replace precision.

Some questions also remain in terms of what systems, processes or other forms of support can promote the bedside realization of person-centred care in various care contexts. Collecting and using people’s life stories as a fundament for care is a commonly-used approach, especially in the care of older people and people with dementia. However, there is a variety of concepts being used to describe such approaches, and the conceptual overlap and implications remain somewhat to be disentangled. Other remaining questions involve who should be telling the story (ownership and perspective), what is it that could and should be told (ethics and significance), for whom is it told (co-creation of meaning, dissemination and access), why is it told (presentation of self), how is it implemented (clinical use), as well as where and for how long is it relevant (context and durability).

These questions and the expected variation in answers can be perceived as academic challenges, but also as being at the very core of clinical person-centred care. It is reasonable to expect a clinical between-context variation regarding the content, characteristics and use of life stories for example in residential aged care and acute care, and it is also reasonable to expect a clinical within-context variation between different wards, different staff, and different people. The clinical operationalization and realization of person-centred care needs flexibility between context, persons, and situations, inasmuch as the academic study of person-centred care needs stringency and consistency to further clarify its content, meanings and effects. This delicate balance between flexibility and consistency can be seen as reflecting the duality of nursing as a profession and a discipline, as art and science, as practice and theory.

To conclude, is it possible to answer questions of what person-centred care is, and what it is not? Person-centred care is holistic, flexible, creative, personal and unique. Person-centred care is not reductionist, standardized, detached and task-based.

Not unless the person wants it to be.