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Providing patient-centred care in an intensive care unit Kelleher S (2006) Providing patient-centred care in an intensive care unit. Nursing Standard. 21, 13, 35-40. Date of acceptance: July 27 2006.
Summary This article examines the provision of patient-centred care in an intensive care unit where patients’ autonomy may be compromised. It discusses the Synergy Model as a framework for encouraging nurses to transform a technical and potentially dehumanising environment into a humane and healing place.
Author Sean Kelleher is lecturer, Catherine McAuley School of Nursing and Midwifery, University College Cork, Ireland. Email:
[email protected]
Keywords Intensive care nursing; Patient-centred care These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords. PERSON-CENTRED CARE is a concept frequently referred to in health care. It was derived from Karl Rogers’ (1951) client-centred theory which encourages professionals to adopt a biopsychosocial model – understanding that a person is shaped by his or her biological, psychological and social environment and, consequently, treating him or her as an individual. Today the term patient-centred care covers a range of activities from patient involvement in individual care to public involvement in health policy decisions, and encompasses a wide range of academic and practical disciplines. It has been reported to have beneficial effects on patient outcomes and engages patients more actively in their treatment (Stewart 1995). Patient-centred care has been identified as a priority in health care in Ireland and the UK (Williams and Grant 1998, Department of Health and Children 2003, McCormack 2003), and is considered a necessary NURSING STANDARD
element of care and services, particularly for older people (Dewing 2004). This article discusses the origins of patientcentred care and its development in contemporary nursing. Although the term patient-centred care is frequently used, it is not always well understood. Consequently, it is difficult to apply in practice, particularly in areas such as intensive care units (ICUs), where the emphasis is on the use of technology and complex life-saving treatments. While different nursing models have been developed to advance patient-centred care, the Synergy Model is recommended as the most suitable framework to aid its application to practice in the critical care setting.
Origins The origins of patient-centred care lie in caritas, which is a Latin term used in Christian theology and means loving kindness towards another (Wikipedia 2006). This was the motivating force for care of the sick and the charitable work of religious revivals through the centuries (Fulford et al 1996). The initial movement towards professionalisation in the late nineteenth century led to nursing becoming dominated by scientism, and increasingly more removed from personal encounters with patients (Fulford et al 1996). The influences of existential philosophy and psychology offered nurses a new basis on which to practise patient-centred care whereby they began to focus on the subjective experiences of the nurse-patient relationship (Fulford et al 1996). Peplau (1952) defined nursing as a ‘significant, therapeutic, interpersonal process’ and as a ‘human relationship between an individual who is sick or in need of health services, and a nurse especially educated to recognise and respond to the need for their help’. Contemporary theorists december 6 :: vol 21 no 13 :: 2006 35
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art & science critical care nursing have developed this thinking further, suggesting that everyone has an intrinsic, inalienable, unconditional and objective worth or dignity as a person (McCormack 2004). Put simply, personcentred care might broadly be defined as ‘valuing people as individuals’ and, as such, it is regarded as the optimum way of delivering health care (Coyle and Williams 2001).
Patient satisfaction Individualisation has been a key concept in determining standards of nursing care. Schmidt (2003) studied patients’ perceptions of the nursing care they received in hospital and found that patients want to be treated as unique individuals, rather than viewed as a diagnosis or room number. Suhonen et al (2000) found that patients considered individualised care as one of the main determinants of quality and that the technical aspects of care were less important. Individualised care involved the nurse spending time with a patient, explaining his or her care and involving him or her in care decisions. Neglecting to care for patients as ‘unique individuals’ can have profound negative outcomes (Russell 1999). In a study to explore patients’ perceptions, memories and experiences of an ICU, Russell (1999) established that some of the psychological problems experienced by ICU patients may have been prevented by improved communication between staff and patients. While patients found the presence of good communication in ICU therapeutic and reassuring, poor communication caused anxiety and contributed to less than optimal recoveries after discharge. Hupcey (2000) investigated the psychological needs of ICU patients and found that the overwhelming need was to feel safe. Family members and ICU staff were identified as the primary contributors to the patient’s perception of ‘feeling safe’. Patients recognise and value nurses who creatively use all available resources and knowledge to promote patient wellbeing (Watson 2001).
Family involvement Because patients in ICUs are critically ill and are often unconscious, semi-conscious or sedated the traditional nurse-patient relationship is often replaced by a nurse-family member relationship. The importance of close family and friends to the recovery of ICU patients is well documented (Granberg et al 1998, Hupcey 2000, SteinParbury and McKinley 2000). Morse (1997) 36 december 6 :: vol 21 no 13 :: 2006
refers to this as ‘anchoring to significant others’, which helps the patient to maintain a sense of selfidentity and reality. Family members experience high levels of stress when relatives are admitted to ICU (Wong et al 2001, Lee and Lau 2003). Stress in such situations usually makes family members feel disorganised and helpless. As a result they often have difficulty in coping with the situation. This can compromise their ability to interact with and support the patient (Titler et al 1991). Soderstrom et al (2003) conducted a study to describe nurses’ experiences of interactions with family members in ICUs. Results showed that it was natural for some nurses to involve individual family members in the caring process, whereby nurses themselves created contact. Other nurses had little time for family members and reported being afraid of getting too close to them emotionally and having problems creating relationships. Soderstrom et al (2003) describes participants who, when confronted with emotional situations such as the deterioration of a patient, tried to protect themselves by withdrawing and avoiding personal involvement. Other participants suggested that family members sometimes showed mistrust in their professional competence, or disliked them as people. As a consequence the nurse adopted a defensive position and did not become involved any more than necessary with patients and/or family members.
Applying patient-centred care in practice The difficulty that many nurses seem to experience in applying patient-centred care in practice was reinforced for the author in a recent encounter with a number of critical care nurses. While working in the ICU of a major teaching hospital the author had the opportunity to question nurses on what they understood by the term ‘patient-centred care’. Many believed that they were carrying out patientcentred care on a daily basis because the unit was staffed to enable ‘one-to-one nursing’, but they were unable to accurately describe what it was. When confronted with terms such as ‘mutuality’, ‘loving’, ‘reciprocity’ and how they envisaged such concepts could be applied to the nurse-patient relationship, many nurses could not relate them to the critical care environment where they felt the focus of care was on the physical wellbeing of the patient. It has been suggested that such perceptions of care may be influenced by nurses continuing to base their practice on the biomedical model of nursing, where the goals of nursing are perceived as cure-orientated (Pearson et al 2005). The life-threatening physical condition of acutely ill patients in ICUs severely modifies and at times eliminates the possibility of the nurse establishing a mutual and meaningful relationship with the NURSING STANDARD
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patient. This may result in nurses having difficulty in comprehending the experiences of critical care patients and, therefore, they may not adequately address their needs (Dyer 1995, Stein-Parbury and McKinley 2000). This view is supported by Mann (1992) who argues that preserving humanity in the present technological age can be a challenge for all healthcare workers, but particularly for staff working in ICUs. Wilkinson (1992) suggests that the technology particular to ICU environments may deflect the attention of nurses away from patients with the risk that the person being cared for is dehumanised. Providing patient-centred care in ICU There is evidence that patient-centred care, or the concepts inherent in it, have positive outcomes for critically ill patients and their families. However, there is no standard definition of patient-centred care (Williams and Grant 1998, Nolan et al 2004) and, as such, it is poorly understood (Stewart 2001). Any attempt to apply it to practice may, therefore, prove difficult. How can nurses adopt a patient-centred approach to caring for critically ill patients and their families? Having reviewed different frameworks, the majority of which developed from care of the elderly, it would seem that attempts to apply them to the ICU patient may prove difficult. The primary obstacle may be the inability of the critically ill patient to communicate effectively with the nurse because of severity of illness, sedation, intubation, confusion or a combination of these factors.
In 1993, the American Association of Critical Care Nurses (AACN) developed a conceptual framework for practice which was based on the needs of patients and would allow nurses to make optimal contributions to patient outcomes (Hardin and Kaplow 2005). The underlying premise of the resultant Synergy Model is that the characteristics and competencies of patients and families influence the characteristics and competencies of nurses (Table 1). The model describes patient and family characteristics that span the continuum of health and illness. These characteristics help the nurse to recognise each patient’s or each family member’s capacity for health and vulnerabilities to illness. Understanding these characteristics and how they can fluctuate with a patient’s condition, or situation, helps the nurse to recognise the essential nurse competencies that interact to result in the best outcomes for patients (Markey 2001) (Table 2). Stannard (1999) suggests that matching the needs and characteristics of a particular patient and his or her family with those of the nurse creates synergy. Synergy is defined as a phenomenon that occurs when individuals work together in mutually enhancing ways towards a common goal (Curley 1998). Although the Synergy Model has been validated as a theoretical model (Edwards 1999), Dewing (2004) suggests that there are obstacles to translating such conceptual frameworks into sustainable reality for patients, families and nurses. In an attempt to test the Synergy Model
TABLE 1 The Synergy Model: patient characteristics Characteristic
Level 1
Level 3
Level 5
Stability The ability to maintain a steady state of equilibrium.
Minimally stable
Moderately stable
Highly stable
Complexity The intricate entanglement of two or more systems, for example, body, family and therapies.
Highly complex
Moderately complex
Minimally complex
Vulnerability Susceptibility to actual or potential stressors that may adversely affect patient outcomes.
Highly vulnerable
Moderately vulnerable
Minimally vulnerable
Resiliency The capacity to return to a restorative level of functioning using compensatory coping mechanisms and the ability to bounce back quickly after an insult.
Minimally resilient
Moderately resilient
Highly resilient
Predictability A summative characteristic that allows one to expect a certain trajectory of illness.
Not predictable
Moderately predictable
Highly predictable
Resource availability Extent of resources, for example, technical, fiscal, personal, psychological, social, that the patient, family and community brings to the situation.
Few resources
Moderate resources
Many resources
Participation in care Extent to which the patient and family engages in aspects of care.
No participation
Moderate level of participation
Full participation
Participation in decision-making Extent to which the patient and family engages in decision-making.
No participation
Moderate level of participation
Full participation
(Adapted from Edwards 1999)
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art & science critical care nursing in practice the author reflected on a clinical situation that occurred in which he felt that he had acted in a patient/family-centred manner. The author wanted to establish whether the model could accurately describe the factors involved in the decision-making process and, in doing so, articulate his practice.
A personal account A patient was admitted to ICU with acute pancreatitis and end-stage renal failure. On admission Tom (not his real name) was heavily sedated and ventilated and did not recover consciousness before he eventually died four months later. Tom’s care was complex. Because of multiple organ failure he required inotropic
support and haemodiafiltration. Tom’s wife Mary (not her real name) visited him daily and spent many hours at his bedside. I cared for Tom on a regular basis which enabled me to develop a good relationship with Mary. Despite a poor prognosis she remained optimistic that Tom would recover. We spent time talking to each other in his room and she recounted episodes of Tom’s life and their aspirations for the future. I endeavoured to allow time to explain the many interventions, investigations and alarms that are associated with ICU and encouraged her to participate in Tom’s care by assisting with bed baths and a range of motion exercises for his limbs. She was also encouraged to speak to Tom as though he were awake by telling him what she did earlier that day and keeping him up to date on current affairs – a subject he was passionate about – by reading the newspaper aloud to him. I encouraged her to keep a diary of his condition each day – to note any signs of
TABLE 2 The Synergy Model: nurse characteristics Characteristic
Level 1
Level 3
Level 5
Clinical judgement Clinical reasoning, including clinical decision-making, critical thinking and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and experiential knowledge.
Competent
Advanced
Expert
Advocacy and moral agency Working on another’s behalf and representing the concerns of the patient, family and community; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns in the clinical setting.
Competent
Advanced
Expert
Caring practices The constellation of nursing activities that are responsive to the uniqueness of the patient and family, and that create a compassionate and therapeutic environment, with the aim of promoting comfort and preventing suffering. Caring behaviours include, but are not limited to, vigilance, engagement and responsiveness.
Competent
Advanced
Expert
Collaboration Working with others, for example, patients, families and healthcare providers, in a way that promotes and encourages each person’s contributions towards achieving the best and realistic patient goals. Collaboration involves intra and interdisciplinary work with colleagues.
Competent
Advanced
Expert
Systems thinking The body of knowledge and tools that allows the nurse to appreciate the care environment from a perspective that recognises the holistic inter-relationship that exists within and across healthcare systems.
Competent
Advanced
Expert
Response to diversity The sensitivity to recognise, appreciate and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural differences, spiritual beliefs, gender, race, ethnicity, disability, family configuration, lifestyle, socioeconomic status, age values, and beliefs surrounding alternative/complementary medicine involving patients, families and members of the healthcare team.
Competent
Advanced
Expert
Clinical enquiry or innovator/evaluator The ongoing process of questioning and evaluating practice, providing informed practice and innovating through research and experiential learning. The nurse engages in clinical knowledge development to promote the best patient outcomes.
Competent
Advanced
Expert
Patient and family educator The ability to make patient and family learning easier.
Competent
Advanced
Expert
(Adapted from Edwards 1999)
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improvement or deterioration – and asked her to bring in some photographs of Tom, his family and friends. The purpose of the diary was to help her come to terms with Tom’s prognosis and the photographs enabled me to connect with Tom as a man, as opposed to a patient in a hospital bed. Mary was a loving and courageous woman who had been cast into a vulnerable situation that required support, compassion and knowledge. I was therefore surprised to hear two staff members describe her as being ‘interfering’ and at times, ‘demanding’ and ‘disrespectful’ towards them. These nurses were relatively junior and inexperienced in caring for critically ill patients. I spoke with the two staff members to try to clarify the situation and established that they had felt overwhelmed with the responsibility of caring for such a critically ill patient. They often felt unsure about his care, especially when trying to respond to the haemodynamic instability that often accompanies continuous haemodiafiltration. They felt that Mary was continually observing what they were doing and writing things down. On occasion, particularly when Tom required suctioning to remove excessive secretions from his airway making him cough uncontrollably, she requested that somebody more senior came into the room. Both nurses felt that the experience had undermined their confidence. However, the unit was particularly short staffed on the few occasions when they worked with Tom and so they ‘had no choice’. Their lack of confidence in nursing such critically ill patients may have resulted in what Soderstrom et al (2003) describe as ‘unproductive’ nursing, where the nurse adopts a defensive stance and distances him or herself from any meaningful contact. This may have been the catalyst for Mary’s reaction whereby she may have felt that her husband’s safety was being threatened by the nurses’ lack of experience. Some months after Tom’s death I received a letter from Mary in which she expressed her gratitude and respect for the work and quality of care that the nurses and doctors in ICU had given her husband. She requested that I extend an apology to colleagues, whom she named, for occasions when she may have been ‘short-fused’. She said that her most endearing memories of those terrible four months before Tom’s death were the opportunities to sit and talk about him and express her feelings to somebody with a sympathetic ear.
Application of the Synergy Model Clinical judgement My experience in caring for critically ill patients enabled me to feel comfortable in caring for Tom. I was able to NURSING STANDARD
apply critical thinking and clinical decisionmaking skills to ensure Tom received the best possible care. My experience of working with families of critically ill patients enabled me to quickly identify Mary’s vulnerability and her need for support. Advocacy and moral agency In clarifying why Mary was being described as ‘interfering’ and ‘disrespectful’ by colleagues I was working as a moral agent on her behalf. In doing so I highlighted some important clinical concerns for the unit in relation to how junior staff are allocated to patients and the impact on patient safety. Caring practices I believe I created a compassionate and therapeutic environment for both Tom and Mary by actively involving Mary in her husband’s care and by being responsive to her need to express herself. Response to diversity Because I was sensitive to Mary’s vulnerability I was able to anticipate and respond to her needs. It was important for her to see that her husband was being cared for in a caring and professional manner and to understand what was happening to him. She needed to be able to trust the nurse responsible for his care. Only then would she be able to express herself meaningfully. Patient and family educator I allowed time to sit with Mary, actively listening to her and responding to her questions and concerns. Mary and I developed ‘synergy’ through our evolving relationship (Stannard 1999). This synchronised movement between two people has been compared to a dance, whereby skilful dance partners take cues from each other and respond appropriately by altering tone, tempo and movement, resulting in smooth and co-ordinated dance steps (Stannard 1999). Johns (2004) uses a similar metaphor, termed the ‘wavelength theory’, to explain a practitioner’s ability to tune into and connect with the person as his or her experience unfolds. Johns (2004) also describes this movement along the wavelength as a form of dance. Each step is a caring movement sometimes led by the practitioner and sometimes led by the other as appropriate. Newman (1999) describes this as synchronicity and emphasises that relating to the rhythm of another person’s interactive pattern is integral to helping people move through illness and disruptive events. The Synergy Model offers a practical framework which encourages and makes it easier for nurses to articulate and quantify their unique contribution to care. The concept of ‘dancing’ or ‘getting in tune’ with the patient or his or her family satisfies the two main components of patient-centredness: the ability of the healthcare provider to elicit and adopt the patient’s perspective, and the ability to engage the patient and family in the management of his december 6 :: vol 21 no 13 :: 2006 39
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art & science critical care nursing or her illness (Michie et al 2003). The Synergy Model addresses the concept of being available for the patient, which Johns (2004) perceives as being the most important aspect of realistic nursing practice.
Conclusion Patient-centred care frameworks have been developed to make the implicit nature of patient-centred care more explicit and operational. However, unless nurses move from
functional understanding of what nurses do to a philosophical understanding, then patientcentred care will not be realised. The concept of patient-centred care and the positive effect this can have on patients’ and family members’ hospital experiences have been explored. While the term is often used to imply individualised care it is poorly understood and consequently difficult to apply in practice, particularly in the critical care environment where patients’ autonomy is frequently compromised. By incorporating the Synergy Model as an integral part of all patient and family interactions, critical care nurses have the privilege of transforming a technical, potentially impersonal setting into a humane and healing place NS
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