Abstract
After reading David Edvardsson’s 1 ‘Notes on person-centred care: what it is and what it is not’, published in the June issue of this journal, I have decided to reflect on this excellent editorial. Firstly, I can’t refrain from commenting on the impressive and growing interest in adopting a person-centred approach in research as well as in medical and nursing care. When out of curiosity, I ‘googled’ ‘person centred nursing theory and practice’, my search results indicated there had been 830,000 hits on the subject, and without filtering the results, I am certain there is something about the concept of person-centred care that is attracting this attention. For example, it seems that substantial grants have enabled the development of person-centred care centres with the intention to individualize and improve continuity of care. Also connected to the evidence-based demand, research that has a person-centred care perspective is seemingly encouraged. It appears that research grant applications that do not have a convincing statement about how their research connects to person-centred care, may find themselves without funding. Furthermore, in the last year I have noticed how several submissions to this journal have at least one or two sentences about person-centred care, indicating there is an increased awareness about the topic and global interest in penetrating the meaning of person-centred care. By the time this issue of Nordic Journal of Nursing Research reaches you, an international conference on philosophy in nursing with a focus on person-centredness will have been held in August in Stockholm, Sweden, as well as a conference in Spain, held by the European Society for Person Centred Health Care.
What and why?
What has contributed to a seemingly changing view of the ‘patient’ as a human being suffering from an illness? Seeing the person as an individual and not the illness, respecting patients’ need of involvement in their care and treatment, is often cited in nursing literature as essential in providing good care.
As David points out, the concept of person centred care is not new, but can be traced back to many schools of thinking in the ‘helping’ professions. Rogerian 2 client-centred psychotherapeutic approach is a classic example. Harry Stack Sullivan, 3 in his attempts to modernize psychiatry more than 65 years ago, believed that in order to understand the individual, it is important to be aware of his or her social context, which suggested that the interpersonal relationships in the helping professions involves more than two people.
As my research over the years originated with an interest in ethical aspects of psychiatric nursing, I am reminded that the idea of person centred care can be found in some literature in nursing and ethics that I first became acquainted with. A nurse theorist who has inspired many nurse scholars is Hildegard Peplau, who in ‘Interpersonal Relations in nursing’ first published 1952, emphasized the importance of nurses understanding their own behavior. 4 Similar to many nurse-theorists, Peplau’s conceptual model on interpersonal relations is constructed from theories outside the academic domain of nursing. Peplau, influenced by Harry Stack Sullivan, 3 referred to the psychodynamic relationship between the nurse and the patient. The objective of the conceptual model she constructed was to provide a framework to be used in psychiatric practice. In short, it can be described as a goal-oriented, interpersonal process, consisting of interactions that involve two or more individuals who are mindful of the patient’s interests. Although Peplau did not discuss the nurse’s role in ethical terms, she did this indirectly by raising the question of the patient’s expectations of the nurse and the importance of the nurse’s awareness of who the patient is as an individual. Because the nurse and patient were strangers when they first met, it was the nurse’s responsibility based on her interpersonal skills to establish a trusting relationship.
Peplau held the view that when a person is ill and in need of treatment and care, the relationship between the nurse and patient is asymmetric and power-related. I think we can all identify with the sense that when we are ill, we in many ways feel insignificant, vulnerable and dependent on the nurse or the physician. In general, we trust they will help us by leveraging their professional knowledge and skills. However, we may at the same time feel a need to maintain our integrity and reserve details of our lives only to people we know and trust.
Keeping in mind that there are different views on what it means to be a person, its basic humanistic meaning is often described as the relational core of nursing ethics. The current discourse on relational ethics based on relational knowledge begins with understanding the whole person and not just the illness. The works of renowned clinical bioethicists, such as Edmund Pellegrino and David Thomasma 5 who were experts in the field of medicine more than 30 years ago, contributed to a view of medical ethics, and inspired the development of nursing ethics, which not only is faithful to professional codes of ethics, but also emphasizes the importance of an empathic understanding. A physician’s responsibility to his or her patient goes beyond being a doctor. Not possessing medical knowledge means that patients are essentially placed in a vulnerable situation with regards to their need for medical treatment. Within all aspects of the health profession, empathy is endorsed by being aware of one’s moral responsibility to individuals who entrust their lives and well-being to others. Similarly, phenomenological philosophy has in many ways deepened the meaning of person-centeredness in nursing as well as in other health care disciplines. More recently, the perspective of relational ethics that builds on the ontology of phenomenological ethics, such as Logstrup, 6 emphasizes a personal moral responsibility for the wellbeing of the other.
As David Edvardsson also reminds us, ‘the ever-present ethical demand to uphold dignity, providing autonomy, choice and control, respecting decision making and doing good’ (p. 65) may be accepted as a guiding nursing philosophy. In other words, a person centred care approach seems to reflect the fundamental values of good nursing care and is consistent with the current ICN codes of nursing ethics. Consequently, there is a strong moral component that combines what and why of person-centred care. However, what are some factors that may prevent the message from potentially losing its way to the practical field of nursing? Is there a conceptual problem with the idea of person-centred care that may intervene the sending or response to this message? Now we come to the how can person-centred care be translated into practice?
First of all, we need to keep in mind that conceptualizing person-centred care and, as a consequence, patient participation has its limitations. Theories and concepts are human inventions that can be renamed either based on empirical research or a paradigm shift in a particular scientific discipline. We do not discount previous theories or perspectives of care, but can see these in retrospect. Moreover, cultural contexts, health-care policies and, most of all, medical technological advancements, can cause significant changes in modes of thinking and research priorities. To respect a person’s need and right to be either actively or passively involved in decisions concerning his or her health and well-being requires embodied interpersonal skills and, above all, moral competence.
In a recent publication, Edmund Pellegrino
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highlights: Those we treat are patients, not consumers, clients, customers, insured lives, items on a balance sheet, or centers of profit or loss. Patients are human beings who suffer, who bear the burden of illness (p. 22).
In conclusion, it would be remiss to forget that there are many regions of the world in which a person-centred approach would seem out of reach. While some nurses and nurse researchers in some parts of the world have the privilege to discuss person-centred care, other nurses are morally challenged by lack of medicine, clean water, food – in other words, keeping their patients alive and their own lives safe from disease.