Learning about person-centred care: role modelling in clinical practice Helen Ross
Learning Outcomes for the presentation Discuss the impact of role modelling on the facilitation of person-centred care Consider the implications for clinical practice and education Examine how role modelling can be encouraged at all levels in the nursing team
Questions about role modelling came from the findings of a qualitative research study: Understanding and achieving person-centred care in an acute medical ward setting: building on good practice to support nurse education and development.
Background to the study The impetus for the study came from practice: As the university link lecturer I became involved in discussions with student nurses and registered nurses about the significance of rehabilitation nursing and in particular person-centred care. One memorable discussion focused upon the care of a man who had been admitted to the ward following a stroke and was resisting the help offered to him by the nurses.
Questions arising from the discussions Would understanding more about the man s life and interests aid nurses (including student nurses) to care for him in a more beneficial manner? Would meeting his needs more effectively in turn have a positive impact on nurses sense of fulfilment in their work and enhance their understanding of the value of person-centred care?
Methodology Action Research Planning Reflecting Acting Observing/ Evaluating The Action Research Spiral
The study formed the first cycle of an Action Research Study, informed by values of appreciative inquiry, the study had three stages: Stage one: Individual and paired interviews with 14 nurses (registered, student nurses & support workers) Stage two: Individual and paired interviews with physiotherapist, physiotherapy assistant & occupational therapist Stage three: Paired interviews with two nursing lecturers and two professional development co-ordinators.
Data Analysis Framework Analysis resulted in an explanatory thematic framework being developed iteratively from the data and a priori knowledge of the researcher. The framework has a dual purpose: It indicates what needs to be in place for person-centred care to be achieved It provides a structure to inform planning future education and development needs concerning person-centred care.
The explanatory thematic framework Philosophy of the care environment (This may influence or be influenced by all elements shown) Characteristics of relationships that facilitate person-centred care R1- Build and maintain positive relationships within the team and with patients and family R2- Work together, acknowledging roles in the team and shared goals R3- Inclusive, effective communication, which promotes positive and open attitudes R4- Shared learning, developing the capacity to reflect upon and challenge decisions in practice Personal qualities of carers that facilitate person-centred care P1- Hold personal values of compassion, empathy, respect and collaboration P2- Exhibit personal values within all interactions P3- Act as a confident carer and positive role model P4- Apply knowledge and skills to deliver flexible, person-centred care Respecting the principles of person-centred care C1- Responsive assessment, planning and delivery of care according to individual need C2- Involving the person and significant others in decision making C3- Consistently delivering high quality care, attending to respect and dignity regardless of the acuity of need C4- Recognising the little things that make a difference for the person
Whilst person-centred care was the focus of the study it became clear it was not only about the care of the patient. Person-centred care included caring about everyone involved in the care situation. For this to take place, it was crucial for the ward manager to be aware of the need to treat people as individuals and to encourage others to do the same. This formed the basis of role modelling in the team: when you get new staff then you should be encouraging them and setting a good example. (RN3).
In common with each other, the three ward sisters interviewed as part of the study spoke about offering encouragement and support to inspire role modelling at all levels within the nursing team. They believed this motivated the nurses to develop confidence to work flexibly in order to support person-centred care, consecutively becoming a role model to others. From their perspective role modelling was not dependent on seniority, but happened within the team as a whole.
Personal and professional maturity was perceived as being central to role modelling: I think it s maturity as well often you get mature heads on young shoulders... (RN2). Acting as a role model required the nurse to be able to ascertain what elements of the organisational rules and routines could be safely flexed in order to meet person-centred needs. This often came with experience and confidence, whatever the role of the nurse: generally speaking, people are able to identify what s important, what rules you can bend and what you can t and it probably is down to experience. (RN6).
Registered Nurses as Role Models Registered nurses conveyed their feelings about facilitating person-centred care and clearly recognised the impact of their own (and others) role modelling upon student learning: I think as a student you do look a lot to your mentor and follow what they do. I remember a lot of things my mentors did, good and bad. Hopefully you just pick up good things and use the bad things as an example of what not to do. (RN4). If student nurses observe their mentor caring for patients in a personcentred manner it was perceived by participants to have a constructive influence upon the quality of care received by the patient and their family.
Registered Nurses as Role Models Person-centred care can occur in any situation, however brief the interaction. Here a participant talks about how the application of 'person-centred moments' (McCormack and McCance 2010) in A&E can affect the person being cared for and at the same time be used to support practice learning: that moment is a reaction, because you see that that patient needs something there and then, and you do it and that s the moment and it s gone, but the impact that that moment can have can be profound I think it really works, I mean it s not just patients is it, those moments could be with relatives, just that moment of breaking some bad news and the way it s done with a new member of staff. (PDC2). Demonstrating respect and compassion within everyday interactions can undoubtedly enhance person-centred care and help others learn how emergency care can be implemented more sensitively.
Support Workers as Role Models Support workers also had a role in helping student nurses or inexperienced nurses learn in clinical practice and described how they would do this: I d start off by saying talk to the patient as a human being, not just as one person of 28, every person on this ward is different, talk to them as an individual. (SW1). When you think about looking after a person, think to yourself if it was my mum I would like her to be dressed properly, I would like her to be comfortable and everything is neat, her hair combed properly, her teeth brushed and just general appearance. (SW2).
Registered nurses and support workers commonly explained how they would offer advice to a novice carer by asking them to think about their own expectation of care if a loved one was being cared for in similar circumstances to the patient. This was perceived by participants as a bench mark for the provision of high quality person-centred care. For example if a student nurse seemed prepared to accept a patient s reluctance to get washed or have a shave without question, the registered nurse tried to help the student nurse understand the importance of personal hygiene for patient wellbeing: it s alright helping a patient get washed and dressed, but if you haven t cleaned their teeth or brushed their hair or you ve not shaved them I say would you like to come and see your Dad looking like that?. (RN5).
In order for student nurses to fully understand individual care needs, participants explained that it was essential to involve them in every stage of a patient s care, including discussion about the rationale for care decisions. As a result of reflecting on their experiences of working alongside student nurses, some registered nurse participants expressed worries about the current pre-registration education in comparison with their own education and training. One concern expressed was that in today s NHS, student nurses had little time to sit and talk to patients as they were too busy learning about all the documentation of care rather than care delivery. This meant they appeared to be lacking in hands on experience when they arrived on the ward.
I was trained a long time ago [25years] and my training was hands on care. Today, newly qualified staff nurses are coming onto the ward, I don t want to be disrespectful to them, but they lack skills in hands on care They don t have the opportunity to go and sit with the patient and talk to the patient. (RN7). This was frustrating for the registered nurses as they felt that this interfered with the overall ability of nurses to give the level of person-centred care they aspired to. One solution suggested by participants was to afford student nurses more time to get to know their patients and get involved with personal care.
In addition to junior staff or student nurses working alongside experienced support workers and registered nurses, it was also identified as being important to supplement the experience with other methods of teaching and learning. For example having the opportunity to test out differing approaches to care delivery under the supervision of a registered nurse or other qualified healthcare professional. Participants also realised the benefit of student nurses reflecting upon their practice experiences in discussion with more experienced nurses. This helped student nurses understand how professional judgements were used to aid care decisions and retain the emphasis on person-centred care.
Student Nurses as Role Models Despite the criticisms of present day pre-registration nurse education there was no evidence to support the concerns in the student nurse interviews. Student nurse participants repeatedly demonstrated professional insight and awareness of person-centred care. Their explanations of care priorities corresponded closely with the feelings articulated by experienced nurses; that person-centred care was not only a way of determining high quality patient care, but was an expression of the person-centred values held by the participants.
Student Nurses as Role Models Prioritising care based on individual need rather than care being influenced by the perceptions of others in the team was articulated well by student nurses. This was discussed in relation to a registered nurse on a previous placement displaying discriminatory views about a patient during handover: It s hard as a student nurse to try and speak up and say that s wrong or you shouldn t be doing it like that, you should be doing it like this because you do kind of get pressured into how you should act and you daren t speak up it s going to affect your learning, they re [registered nurses / mentors] not going to want to get you involved in things and it s just not nice to be penalised for just speaking up for something that might be wrong or right. (StN1)
Student Nurses as Role Models One way around such challenges was for student nurses to role model caring for patients in a person-centred manner in the hope that others would follow their example: I just went and helped him with whatever he needed, but I don t think I would have the confidence to say: Excuse me, that s not right. I think I d rather just go ahead and do it myself rather than go and tell that person [another nurse] I believe it [my practice] should have an impact on people and they should think just because she [the other nurse] thinks that doesn t mean I have to think that and I can go and do what I want, I ve got my own mind. Hopefully other nurses and support workers will think for themselves, not just go on what other people have told them. (StN1).
Student Nurses as Role Models In a supportive environment, student nurses felt more able to challenge perceptions of care needs and even share knowledge they had gained from their studies with others in the care team. Sharing their learning was an opportunity for students to demonstrate knowledge and understanding about nursing and feel accepted as part of the team. This was especially important to the student nurses when it enabled them to contribute to discussions about care: Students obviously don t know more than the [registered] nurses but sometimes they might have done assignments on different things. I ve just done an assignment on dignity and privacy, so sometimes we can bring little bits of things [information] onto the ward just reminding some staff and other students as well. (StN3).
Working within a culture of learning Nursing Lecturers also reflected upon the importance of positive and open attitudes within the team to aid learning and in turn influence personcentred care: there are some areas where students are supported more than others, and those are the areas where other staff are supported, it s that learning culture taking it from an opposite point of view we want all nurses going out of the university to have and foster a positive culture of care. So I think we need to embed these [concepts] in university learning so students are able to work towards that, because some of the students will be the team leader (and some of them quite quickly); the team leaders that can influence care on those units or work in teams. (NL2).
Lecturers as Role Models Promoting collaborative decision making in order to facilitate person-centred care was emphasised as an central feature of nurse education, therefore it was important that student nurses also perceived lecturers as role models: if we re going to talk about care being patient centred [in university], then it s got to revolve around the patient and their wishes rather than the professional wishes, which sometimes are very different. (NL1). For example student nurses were encouraged to consider the challenges of supporting patients and their family when their decisions may conflict with the professionals perspective.
Everyone is a Role Model so it s every single member of the staff, from how they were treated in the car park, to how they ve been greeted at the front door when they ve come through to find their way to wherever it is I ve seen some porters do fantastic jobs, they re taking patients for tests and things and they re chatting to them and trying to take away those worries. (PDC2).
Questions to leave you with So 1. How can we encourage role modelling at all levels? Is this about the culture of the learning /care environment? 2. Is it enough to learn through observation (sitting by Nellie)? How do we enable Nellie to facilitate learning more effectively? 3. How can the transfer of knowledge in clinical practice be made more explicit? What tools can we use to enhance the transfer of knowledge?
Questions to leave you with So 1. How can we encourage role modelling at all levels? Is this about the culture of the learning /care environment? 2. Is it enough to learn through observation (sitting by Nellie)? How do we enable Nellie to facilitate learning more effectively? 3. How can the transfer of knowledge in clinical practice be made more explicit? What tools can we use to enhance the transfer of knowledge?