Investigating patient centered care in an acute older adult ward - a qualitative study

This project investigates patient centred care on an acute older persons' unit in a NHSTrust in the UK. It uses a method based on grounded theory, integrated with anethnographic approach to examine the knowledge, beliefs and behaviour of staffworking on an acute older persons' unit regarding patient centred care. The data wasgathered over a period of one year using interviews and participant observation.The National Service Framework for Older People produced by the Department ofHealth (DOH) is the first ever, comprehensive strategy to ensure fair, high quality,integrated health and social care services for older people. It is a 10 year programme ofaction linking services to support independence and promote good health, specialisedservices for key conditions, and culture change so that all older people and their carersare always treated with respect, dignity and fairness (DOH 2001). Patient-centred careis central to this strategy, however Nolan & Davies (2002) suggest that patient-centredcare may not be the panacea that it is held up to be and may perpetuate, rather thaneliminate poor standards of care for older people. Nolan et al (2002) stated thatalthough 'patient-centred care' has challenged many negative stereotypes and lies atthe heart of the NSF for older people, it presents a rather limited vision. They insteadpromote 'relationship-centred care' initially proposed by the Tresolini and Pew-FetzerTask Force (1994), this focuses on the relationships that form the context of care.McCormack in his 2004 review observes that patient-centred practice is a recurringtheme in the gerontological nursing literature, there are many descriptive accounts ofattempts at developing patient-centred practice but in reality there are few studies thatidentify the benefits of this way of working. He raises the question that perhaps goodquality care for older people and patient-centred care may indeed be the same thing,suggesting that we shouldn't chase after an ideal of patient-centredness, but insteadstrive for a constant state of 'becoming more patient-centred' in our practice.Dewing (2004) looked at five frameworks that appear to promote patient-centrednessin nursing which for the for the most part, are all conceptual and all advocate the values of patient-centred care. Dewing questions the collective belief thatperson-centred care is now being achieved when the degree to which practitionersknow the older person is actually very limited, claiming that this is exacerbated by thelimited vision of patient-centred care set out in the National Service Framework forOlder People. Dewing recommends further work into translating the complexconceptual frameworks into ones that are meaningful to older people and the nursesworking with them. In her conclusion Dewing suggests that when frameworks areused in a technical way, the older person and/or oneself is made to 'fit' into theframework. The challenge of nursing older people in a patient or relationship-centredway is often aggravated by trying to consciously and intentionally use frameworks. Aspatient-centred care is the central philosophy around which services for older peopleare being developed and how they are likely to develop in the future, it is prudent tolook at whether this way of caring translates from theory into practice and how itaffects the patient experience.Semi-structured interviews were conducted with staff nurses and healthcare assistantson the three wards on the older persons unit. 60 'personal memos' and field notes wererecorded in over 100 hours spent on the wards as a participant observer.The interviews and field notes were analysed. Quotes and pertinent material thatrelated to each other were sorted by hand into eight initial categories. These categorieswere analysed further and sorted into four final themes. The themes identified fromthe data were used to form a descriptive analysis. The results of the study generatedinsights into the nature of patient centred care in the acute care of older people. Thefour major categories which emerged from the findings, are discussed and analysed inthis thesis. These were 'it's about the individual', 'if only we had time', 'it's 98%relationships' and 'too posh to wash'.The conclusions describe the factors affecting patient centred care and how these arerelated to practice and policy. Evidence of patient centred care was observed on theward and also relationship centred care was recorded. While many nursing activities were consistent with patient centred care the study results also highlighted factorsinfluencing these activities and suggests opportunities to perhaps help improvenursing practice. To ensure patient centred care remains at the core of nursing practiceon the OPU nurses should carry out ongoing assessment of patients needs in relation totheir care and try to encourage patients to participate actively in their care. From thesefindings it is apparent that a patient centred approach would have to involvepractitioners having appropriate space and support to enable them to work in thismanner. This may require the provision of clinical supervision and training and spacefor reflection on their work with older people. They themselves would need to feelvalued and recognised both by their colleagues and the organisation that they workfor