Learning
Matters
MYLES HARRIS
UNDERSTANDING
PERSON-CENTRED
CARE
for Nursing Associates
9781529708912_C.indd 6 14/07/2020 10:00
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The Role of Nursing Associates in Person-Centred Care: NHS Historical Perspective, Study notes of Nursing
The history of the NHS and its impact on the formation of the nursing associate profession. It discusses the significance of person-centred care and the role of nursing associates in providing it. The document also covers the evolution of the NHS and the various milestones that have shaped its current structure.
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Learning
Matters
MYLES HARRIS
UNDERSTANDING
PERSON-CENTRED
CARE
for Nursing Associates
1
NMC STANDARDS OF PROFICIENCY FOR
NURSING ASSOCIATES
This chapter will address the following platforms and proficiencies: Platform 1: Being an accountable professional At the point of registration, the nursing associate will be able to: 1.1 understand and act in accordance with the Code: Professional standards of practice and behaviour for nurses, midwives and Nursing Associates, and fulfil all registration requirements 1.8 understand and explain the meaning of resilience and emotional intelligence, and their influence on an individual’s ability to provide care 1.9 communicate effectively using a range of skills and strategies with colleagues and people at all stages of life and with a range of mental, physical, cognitive and behavioural health challenges 1.10 demonstrate the skills and abilities required to develop, manage and maintain appropriate relationships with people, their families, carers and colleagues 1.11 provide, promote, and where appropriate advocate for, non-discriminatory, person-centred and sensitive care at all times. Reflect on people’s values and beliefs, diverse backgrounds, cultural characteristics, language requirements, needs and preferences, taking account of any need for adjustments
Chapter
Providing person-centred care
Providing person-centred care it serves is very different. Table 1.1 is a timeline of significant events that have happened in the history of the NHS. Table 1.1 Timeline of the NHS Decade What happened? Why is this important for nursing associates providing person-centred care? 1940s • 1948: Establishment of the NHS by the then Minister of Health, Aneurin Bevan. The original three core principles of the NHS still guide its development today:
- that it meets the needs of everyone;
- that it be free at the point of delivery;
- that it be based on clinical need, not ability to pay. 1950s • 1954: Sir Richard Doll and Sir Austin Bradford Hill published a paper in the British Medical Journal (BMJ) stating that there was a link between smoking and cancer. At this time, 80 per cent of the adult population in the UK were smokers.
- 1955: Polio vaccination introduced.
- 1957: The Percy Report advised the government that, where possible, people with mental healthcare needs should be cared for in the community, not in large institutions.
- 1959: The Mental Health Act 1959 laid out that people with mental healthcare needs should be considered equal to those with physical healthcare needs, and care should be community-based. The 1950s was a pivotal moment in promoting good health with the introduction of vaccinations and the recognition that smoking was linked to cancer. Mental healthcare finally got the recognition it deserved, and patients were cared for more appropriately. 1960s • 1962: Enoch Powell’s hospital plan served as a framework for the development of district general hospitals for populations of approximately 125,000 people. The establishment of district general hospitals marked a point in time when the NHS needed to adapt to care for an increasing population. 1970s • 1972: Computerised tomography (CT) scanners were introduced to provide 3D images of inside the human body, supporting medical diagnosis. Technology began to play an important part in patient care. (Continued)
Chapter 1 Decade What happened? Why is this important for nursing associates providing person-centred care? 1980s • 1980: The Black Report recognised health inequalities.
- 1985: The Whitehall II study investigated the effects of socio-economic factors on health and wellbeing, involving 10,000 civil servants. The Black Report was formal recognition that there were health inequalities in the country. This was consolidated by the Whitehall II study, which found evidence that the socio- economic backgrounds of people affected their health. Whitehall II is still ongoing at University College London and is a well-known study of the ageing process. 1990s • 1990: The NHS Community Care Act 1990 disbanded the centralised NHS into 57 NHS trusts, meaning that health authorities managed their own budgets to serve their local populations. The NHS Community Care Act 1990 was another paradigm shift to serve an even larger population and attempt to manage the accompanying financial demands. 2000s • 2000: The four-hour target for A&E was established, covering arrival to transfer, admission or discharge.
- 2009: The NHS Constitution was published and the Care Quality Commission (CQC) was launched. The use of A&E services was greater than ever before, so the four-hour target was introduced to speed up the flow of patients through emergency departments. The NHS Constitution is the most current document explaining the values of the NHS, whereas the CQC inspects the quality of health and social care services. 2010s • 2012: The Health and Social Care Act 2012 established NHS England and Public Health England (PHE), as well as ending primary care trusts (PCTs) and introducing clinical commissioning groups (CCGs) to manage the finances of local services.
- 2013: The Francis Report exposed the failings of Mid Staffordshire NHS Trust after an in-depth investigation.
- 2013: The Cavendish Review found that health and social care support workers need better education and support. The two reports published in the 2010s were extensive and shook the modern NHS. The system failed patients, and the recommendations made were to prevent such a catastrophe from happening again. Notably, funding for education for healthcare support workers was dramatically increased. The financial system was reorganised again. The executive management was divided into NHS England for patient services and PHE to promote health and well being. Source : BHF (2018) Now that you have read about some significant events that have happened in the history of the NHS, complete Activity 1.1, which will help you to explain and understand how the history of the NHS has shaped the nursing associate profession in the present day. Table 1.1 (Continued)
Chapter 1 As a nursing associate, it is important for you to have an understanding of the micro- organisations that manage the NHS because the decisions they make directly affect your clinical practice. Complete Activity 1.2 to consolidate your understanding. Activity 1.2 (^) Reflection Rearrange the list in Table 1.2 into a thought cloud, starting with the NHS in the middle. Link all the different micro-organisations together to illustrate how the NHS management system is structured. As this activity is based on your own reflection, there is no outline answer provided at the end of the chapter. After completing Activity 1.2, you will have a clearer picture of how the NHS is managed. Your thought cloud may look complex, but this is a true representation of the systems in place that ensure the NHS meets the standards described in the NHS Constitution (DHSC, 2015). At this point, you have learned about the NHS’s past and present, but what about the future? What is next? Across England, there are trials of new systems of health and social care services, called vanguard sites. Vanguard sites aim to encourage organisations to work more closely together, including the collaboration of physical and mental healthcare needs, in sustainability and transformation partnerships (STPs). STPs are groups of organisations that work together to achieve the objective of vanguard sites; there are 44 in England. STPs aim to transition into integrated care systems (ICSs). ICSs work together with a joined budget to coordinate care and improve services for people who live in a particular community. In short, ICSs aim to manage the limited resources of the NHS more efficiently and provide continuity of care across their organisations’ services. This involves working with other bodies, such as local authorities, social care services and public health organisations, in order to drive up standards of service. What does all of this change mean for patients? Some services in the NHS are moving closer to patients to provide the care they need where most people would choose to be – at home. There is a substantial increase in support to improve and maintain good health, thus reducing the intense pressure on hospital services (King’s Fund, 2017). There are, however, some points for consideration. Regional health specialist services will become more common, which means that patients may need to travel further for specialised care. Moreover, the NHS will need to continue to change over the next few decades. Although more change may seem arduous, change is very much needed in the NHS because our patients continue to change. As a nation, we are living longer, with more complex care needs, so NHS services need to be able to meet new patient needs. Make sure you keep up to date with how the NHS is managed and the services that it provides throughout your career, as this will have an impact on your future as a nursing associate. See Chapter 8 for advice on how to keep your practice up to date and current.
Providing person-centred care The multidisciplinary team The NHS is clearly complex, but where do nursing associates fit in this system? A multidisciplinary team (MDT) is a group of health and social care professionals who work together to provide care for patients. You are part of this team and have a unique, important role. Before going into which professionals make up an MDT, we need to discuss what a professional is. Being a professional is more than doing a good job. As a nursing associate, you are a health and social care professional, but what does this actually mean? There are many attributes of a health and social care professional that are important for you to understand. Professionals’ behaviour is of a consistently high standard, even when not at work. Being a professional is also about being in a professional community: we have common values and morals, we always strive to do our very best in everything we do, and we always continue to learn and adapt our practice. All of this is done in the best interests of the patients we care for. Table 1.3 lists important key documents that guide you in being a professional, with a short explanation of how they do this. Table 1.3 Key documents The Code (NMC, 2018b) The standards of clinical practice and behaviour that are expected of all nurses, midwives and nursing associates. Leading Change, Adding Value (NHS England, 2016) A framework of ten commitments that guide the NHS workforce to provide the best quality person-centred care. The NHS Constitution (DHSC, 2015) This document explains the values of the NHS, including what patients and employees can expect from the service. It can sometimes be hard to understand how overarching policy documents such as these relate directly to your practice as a nursing associate. To help you understand this, read through the following box, which breaks down each document and explains how it is relevant to your daily practice. Understanding the theory: key documents
The Code (NMC, 2018b)
This document is fundamental to your practice, and you are encouraged to know it in depth. There are four sections that guide your clinical practice: ‘Prioritise people’, ‘Practise effectively’, ‘Preserve safety’, and ‘Promote professionalism and trust’. Another important document closely linked to The Code is the Standards of Proficiency for Nursing Associates (NMC, 2018a). Take the time to read this too because it outlines your scope of practice.
Leading Change, Adding Value (NHS England, 2016)
The ‘Leading change’ section is grouped into three topics: ‘Health and wellbeing’, ‘Care and quality’, and ‘Funding and efficiency’. As a nursing associate, you can positively contribute to all of these. First, it is part of your scope of practice to promote health and wellbeing for patients in your care. Second, you use evidence-based practice to provide person-centred care (see later in this chapter). Lastly, by using resources effectively and efficiently, you will reduce (Continued)
Providing person-centred care Attending an MDT meeting for the first time can make some people feel anxious because there might be a lot of people in the room. However, it is important to remember that everyone in the MDT is there to support each other, as well as supporting the patient in achieving their goals. Once you have been to a few MDT meetings, you will gain more confidence, and eventually you may contribute to the discussions. Whether you have been to one or many, attending an MDT meeting is a very useful learning opportunity because you gain an insight into the roles of other professions, as well as how they have a positive impact through providing person-centred care. Once you have attended an MDT meeting, complete Activity 1.3 to consolidate what you have learned. Do not limit yourself to completing this activity once, though. Each MDT meeting you attend will be different, so you can learn something new from each meeting you attend. Activity 1.3 (^) Reflection After attending an MDT meeting, think about your answers to the following questions:
- What was the role of each professional who attended the meeting?
- If the patient attended, how did this affect the meeting? If the patient did not attend, how do you think the meeting might have gone differently if the patient was present?
- What were the strengths and achievements of the meeting?
- How could the meeting have been improved? As this activity is based on your own reflection, there is no outline answer provided at the end of the chapter. As previously discussed, the main aim of an MDT is to meet patients’ needs. At this point in the chapter, you will be able to recognise that each patient is different and their needs unique, even if a group of patients have the same diagnosis. In other words, the MDT cannot care for patients using generic principles because this would not meet individual patients’ needs. A person-centred approach to care, however, ensures that each patient is cared for as an individual and their needs are met. What is person-centred care? Every registered practitioner and support worker that has direct or indirect patient contact should critically analyse the positive and negative impacts of their decisions to ensure that all NHS services operate with a person-centred approach. It is also important to emphasise the phrase ‘each patient’. While we can group patients together by many different characteristics, such as age, sex or the condition they are living with, it is important to remember that each person is unique, even identical twins. These differences occur due to our genetics, the environments in which we live and our life experiences. The influencing factors that cause these differences can be explained by the social determinants of health , which are summarised in the following box.
Chapter 1 To explore the ideas outlined in the previous box, it may be of benefit to examine a specific example of a health condition. The following case study is based on a patient living with the common long-term condition asthma. Understanding the theory: social determinants of health Originally published in the seminal article by Dahlgren and Whitehead (1991), PHE (2017) explains that the social determinants of health are:
- genetic and personal factors;
- lifestyle choices;
- interpersonal relationships with family, friends and the community;
- living and employment conditions: � food production; � education; � work environment; � unemployment; � water and sanitation management; � health and social care services; � housing;
- general socio-economic, cultural and environmental conditions. Quite simply, these influencing factors are what determines the health and wellbeing of a patient, as well as what makes them unique. Two patients sitting next to each other will have completely different backgrounds in relation to their social determinants of health, so it is impossible to care for them in exactly the same way, even if they may have the same health concern. It is therefore important to understand the different social determinants of health, as understanding these for each of your patients will enable you to deliver effective person-centred care. Case study: George George is a 27-year-old man who has had asthma since early childhood. When he has an asthma attack, he finds it difficult to breathe and has an audible wheeze. What causes George’s asthma attacks are known as asthmatic triggers, some examples of which are animal fur, cold air, dust, exercise, pollen and sress. Not all of these asthmatic triggers need to be present to cause an asthma attack, and furthermore each person living with asthma has a different response to asthmatic triggers. To control his asthma attacks, George self-administers his salbutamol inhaler, following the instructions written on the prescription. It is impossible to write down an algorithm that determines which asthmatic triggers will cause an asthma attack because everyone is sensitive to asthmatic triggers at different
Chapter 1 the rationale (and evidence) behind an intervention, you could word your question as follows: ‘I’ve not seen this intervention before. I’m interested to know the evidence base behind it. Please could we go through it together?’ You can adapt this wording to suit the situation you are in; however, by asking the question in this way, you are demonstrating that you have professional curiosity, and the person you are speaking with is less likely to misinterpret you and feel you are being accusatory. In short, you are promoting teamwork and a learning culture in the area you are in. This has massive benefits for staff because people then feel they can ask questions and develop their practice. Moreover, patients benefit because the staff are working together to provide evidence-based care. Think back to earlier in this chapter when it was outlined that person-centred care means we critically analyse the positive and negative impacts on each patient we care for. By adopting this approach, you are thinking about the impact on the patients you are caring for, and therefore demonstrating person-centred care. Self-awareness Person-centred care is not solely about knowing your patient and what makes them an individual; you also need to know yourself. More specifically, you need to know and understand how you have an impact on the patient. The impact you make may be very positive; however, you must be cautious of making a negative impact on the patient. As you have been reading, each patient is unique because of their social determinants of health. Social determinants of health help us to understand each patient’s individuality in relation to their health; however, they can also help us to understand patients’ personalities. This also applies to you. Nursing associates can be patients, of course, but the more pressing point here is that your background defines you as a person, and by extension informs the choices you make and the personality you have. Your approach to a task may be completely different to that of one of your colleagues who completed the apprenticeship with you, despite the fact that you both studied at the same institution. Activity 1.4 explores this in a little more detail. Activity 1.4 (^) Reflection Consider how you approach writing an academic essay. Do you leave it all to the last minute, needing the pressure of an impending deadline? Or do you prefer to follow the recommended route of creating a structured study plan, completing the essay comfortably before the deadline, because you find this is a better way to manage your stress levels? Compare your thoughts with friends and colleagues. You may recognise that you are all completing the same task but have very different methods. As this activity is based on your own reflection, there is no outline answer provided at the end of the chapter. How do your reflections in Activity 1.4 relate to person-centred care? Consider the responses you received from your friends and colleagues, and how differently they interpreted the standardised process of writing an academic essay. Imagine the diversity of interpretations in the varied and high-pressured environment of clinical practice. The way that you and your colleagues
Providing person-centred care approach any task will inevitably be different. It is positive to have professional individuality because a diverse workforce is a reflection of the patients we care for; however, it is important to mitigate against possible negative effects on a patient. This should help you to understand why having increased self-awareness of your own strengths, weaknesses and preferences will help you and your colleagues to provide the best quality person-centred care. Diversity in the NHS workforce is clearly beneficial; however, let us refocus on how you can have an even greater positive impact on person-centred care. Working as a nursing associate is a privilege because you are in a position to care for people when they are at their most vulnerable, and they trust you to do so. We must recognise, however, that working as a nursing associate can be stressful and emotive due to the high pressure of caring for people when they are vulnerable. This leads on to another important point: you need to be continually conscious of your attitudes and behaviours because they affect other people. In other words, allowing yourself to choose a negative outlook will cause your colleagues and patients to do the same. Alternatively, actively ensuring that you have a positive attitude and behaviour will encourage others to adopt the same approach. This can be a very powerful force for good, especially if you meet a patient or colleague having a bad day. (It is worth remembering that it is likely your patients will almost always be having a worse day than you.) Read through the following box to help you understand how your attitudes and behaviours affect other people. Understanding the theory: Betari’s box Betari’s box is a tool you can use to illustrate how your own thoughts and actions have an effect on other people (Mind Tools, 2019a). This could be your colleagues, your patients, or even your friends and family after you arrive home from work. First, you need to identify your attitudes, which are determined by your feelings and/or prejudices. Next, you need to identify how your attitudes affect your behaviour. A note of caution: you must be honest with yourself about your behaviour. For example, you may naturally have strong facial expressions, so your thoughts and feelings are obvious to those around you. Ask a genuine friend or colleague if you are not sure. Your attitudes and behaviours then lead on to affect another person’s attitude. Lastly, the way you have affected someone’s attitude affects their behaviour. If you apply the process in Betari’s box to a clinical practice setting, you will be able to recognise if your attitudes and behaviours have a positive or negative effect on other people. In other words, your attitudes and behaviours may alter a patient’s attitudes and behaviours, which could lead to them making the wrong decision or feeling worse. A positive example would be actively listening to a patient who is depressed and demonstrating empathy, which may elevate their mood, thus supporting them in managing their depression. Regularly completing the process outlined in Betari’s box will help you to be mindful of your attitudes and behaviours throughout your career, as well as encouraging you to channel positivity into your clinical practice. Having consistently positive attitudes and behaviours will encourage others to have the same approach, including both your colleagues and patients. Positivity leads to an increase in efficiency and effectiveness, so the quality of patient care will increase. By choosing to practise in this way, you are choosing to promote person-centred care.
Providing person-centred care For more information about MDTs and the meetings they have, read this publication by NHS England. Price, B. (2019) Delivering Person-Centred Care in Nursing. London: SAGE. This book is an excellent introduction to person-centred care that has comprehensive content and a clear structure. Although it is intended for nursing students, much of the material is also relevant to nursing associate practice. Willis, P. (2015) Shape of Caring Review (Raising the Bar). Available at: www.hee.nhs.uk/ our-work/shape-caring-review This is the publication of an extensive review into the education and professional development of nursing and healthcare support workers following the Mid Staffordshire NHS Trust scandal. Useful websites 16Personalities Free Personality Test: www.16personalities.com/free-personality-test For an in-depth insight into your personality and characteristics, this website provides a free test based on the work of Myers and Briggs, which will help you to identify your strengths and areas for improvement.