Fundamentals of Person-Centred Healthcare Practice

I hope this letter better informs you of how I have viewed person‐centred practice and how it has shaped the way I will practise in future. I would like to welcome you to our planet and hope that you too can become part of the movement towards person‐centred practice.

Yours sincerely,

C Thomson

This letter was written by a student (Caitlin Thomson) who at the time of writing was undertaking education as a specialist community health nurse (also known as a health visitor) at Queen Margaret University, Edinburgh. Caitlin was engaging in an exercise of writing to a fictitious ‘alien visitor’ known as an Osclean explaining person‐centred practice to them.

Imagine you are ‘the Osclean’ Caitlin has written to. What would your response be to her regarding your expectation of your care? Does what she says sound interesting? Would you want to be a part of it – why/why not? Are there things missing from Caitlin's description that you would want to be included? Feel free to present your response in any creative way you are drawn to.

As Caitlin recognises in her reflection, consideration of the person and our understanding of personhood in the context of how we relate to each other have a long tradition in philosophy and you have been introduced to some of these perspectives in Chapter 1. In more contemporary theory, the term ‘person‐centred’ is often considered to originate from the work of Carl Rogers and his humanistic psychological and person‐centred therapy (Rogers 1961). Rogers' focus was on maximising our potential to fulfil our personal life goals, including our need to be autonomous, social, connected with and respected by others, i.e. to be known as a person.

Drawing on all of these traditions, we can summarise being person‐centred as implying the recognition of the broad biological, social, psychological, cultural and spiritual dimensions of each person (i.e. the whole person) in our ways of being and doing as persons.

The core principles of person‐centredness can be seen in an array of models and frameworks applied to different health conditions (for example, Parkinson's disease [Buetow et al. 2016]), different client groups – where the most concentrated work has happened with persons living with dementia (see for example Fazio et al. 2018), and different healthcare settings, for example in critical care units (see for example van Mol et al. 2016). In the context of psychiatric medicine, for example, Mezzich et al. (2009) suggest that person‐centredness can be seen to be operationalised within four dimensions of practice: (i) care of the person (of the totality of the person's health, including its negative and positive aspects), (ii) care for the person (promoting the fulfilment of the person's life project), (iii) care by the person (with clinicians extending themselves as full human beings with high ethical aspirations) and (iv) care with the person (working respectfully, in collaboration and in an empowering manner).

However, we would suggest that these perspectives of person‐centredness are myopic and exclusive – what do we mean by that? Earlier we described the core values that underpin person‐centredness and we highlighted the importance of these values applying to all persons, not just persons using health services. It therefore follows that these values also apply to persons who are directly providing, managing, co‐ordinating, funding and planning services. So when we think about person‐centred practice, we have to think about it in the context of all persons. It is not enough to just think about person‐centred practice in the context of ‘doing practice’ but we also need to think about it in the context of our ‘being’ as a person working in healthcare and how we relate to all other persons, and how they relate to us. In addition, we showed in Chapter 1, through an analysis of the work of Leibing (2008) and Smith (2003), that person‐centred practice cannot depend solely on the values of individual practitioners and their commitment to working in this way. Smith shows clearly that the prevailing moral values in particular cultures have a significant influence on our ability to work in this way, and so presenting person‐centredness from the lens of ‘quality of care experienced by service users’ is a necessary but insufficient approach to person‐centredness. What we need to think about is the continuous development of cultures that can create, nurture, support and reflexively evaluate person‐centredness in the everyday experiences of all persons.

Imagine a situation where you are not respected at work, because your relationships with other team members feel ‘unsafe’, the management style is hierarchical and controlling, autonomy is limited and you don't feel you have a ‘voice’ in decision making. How easy would it be for you to provide person‐centred care to service users in that context? We would argue that whilst you might be able to do so intermittently, sustaining your values of person‐centredness would be challenging to your personhood and in the end the care you provide would suffer. Evidence of the relationship between the person‐centredness of teams in healthcare and quality of care provided to service users is increasing (for example, Albers et al. 2018; ACSQHC 2018; Sinah 2017) and initiatives such as ‘Joy in Work’ ( www.ihi.org/Topics/Joy‐In‐Work/Pages/default.aspx) have been designed to make explicit the importance of team culture for effective patient care. However, initiatives such as this are not enough to continuously develop healthcare contexts that can sustain excellent person‐centred practice.

In Chapter 3we will introduce the macro healthcare context and this will be further developed in Chapter 17. This is important as we need to consider the qualities of the staff, the specific characteristics of the healthcare setting and the engagement processes we use to develop a person‐centred culture – the kind of culture where leaders facilitate meaningful engagement between team members so that they experience the conditions that enable them to provide person‐centred care to service users (Cardiff et al. 2018; Lynch et al. 2018). Evidence of the relationship between work environments that lack respect for individual personhood (characterised by staff burnout and staff turnover) and poor outcomes for service users is now well established in the literature (Lyndon 2016; Dyrbye et al. 2017), thus highlighting the need for organisations to commit to the continuous development of person‐centred cultures.

In this chapter we have introduced you to some key principles and concepts associated with person‐centredness. We have built on Chapter 1, which explored some of the key philosophical principles and especially the idea of personhood. In Chapter 2 we have illustrated why person‐centredness in healthcare practice needs to take account of individual personhood in the context of ‘all persons’. Person‐centred care is just one part of person‐centred practice and having a practice context that supports and actively enables these ways of practising is critical to success. Very few healthcare settings are either completely person‐centred or not person‐centred as it is a much more dynamic process than that. Person‐centred practice is continuously being developed and so it is rarely helpful to label individuals, teams or specific workplace settings as being person‐centred or not. This dynamic nature of person‐centred practice is also influenced by the workplace culture and how the qualities of the workplace help or hinder the continuous being and doing of person‐centredness – more about this in Chapter 3and in many chapters in this book.