home
HOME  |   CONTACT  |   LOGIN
 
 
GR issues 2007 to present
You are here: Home> Generations Review> GR issues 2007 to present> October 2010> The implementation ...
Back
Policy and Practice
The implementation of a model of person-centred praactice in older person settings in Ireland

Introduction

Bark cracks wide open
Revealing new inner core 
Dancing trees and flows

The Haiku above reflects many of the challenges associated with making person-centred practice a reality in health and social care services.  The promotion of ‘person-centredness’ is consistent with the policy direction of health and social care internationally and is reflected in approaches to the delivery of healthcare.  Person-centred practice is well understood at the level of ‘principle’, as that which is concerned with: treating people as individuals; respecting their rights as a person; building mutual trust and understanding, and developing therapeutic relationships. More recently, the principles of person-centred practice have been developed in a multidisciplinary context.  As healthcare practitioners we have an expectation that people should receive a standard of care that reflects these principles. The inherent good of providing care within a philosophy of person-centredness is irrefutable, but it has been recognised that translating the core concepts into every day practice is challenging (McCormack & McCance 2006; 2010). The reasons for this come in many forms and are often indicative of the context in which care is being delivered, and the fact that we are living in times of constant change, particularly within health and social care.

However, whilst the principles of person-centred practice are promoted, in reality few organisations really understand what person-centredness really means and if it is explicit in organisational values it is done so from a narrow ‘patient quality’ perspective.  Therefore much work is needed to expose the principles (cracking open the bark), achieve a deeper level of understanding (reveal new inner core) and enable service users, families and staff to flourish (dancing trees and flows). In this paper, the processes and outcomes of a two year practice development programme to develop person-centred practice in residential services for older people will be presented.

Background

This national two year practice development programme in the Republic of Ireland (2007-2009) has significantly built on the learning and recommendations of a pilot practice development programme that was undertaken in the Midlands Region (2005-2007).  The programme was managed and delivered by The University of Ulster. The funding for the programme came from the National Council for the Professional Development of Nursing & Midwifery in Ireland and the six participating Nursing and Midwifery Planning and Development Units (NMPDUs). These are centres in each health region of Ireland with responsibility for the continuing professional development of nurses and care workers.  

Programme Aims
The overall aims of the programme were to: implement a framework for person-centred practice for older people across multiple settings in Ireland, through a collaborative facilitation model and to carry out an evaluation of the processes and outcomes. 

For the purposes of this programme, the team defined person-centredness as:

“an approach to practice established through the formation and fostering of therapeutic relationships between all care providers, older people and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development”

Programme Structure and Processes

Eighteen residential units for older people were involved in the Older Persons Services National Practice Development Programme for the development of person-centred practice. The programme commenced in September 2007. Practice development programme groups were established. The groups represented staff from different areas within the units and different grades i.e. Clinical Nurse Mangers, Staff Nurses, Health Care Assistants, Housekeeping, Catering and Administration staff.

The participants from the sites met with the internal facilitator from within their unit and the external facilitator from the NMPDU for a formal programme and skills development day every 6 weeks. As the first year progressed a range of interim meetings and discussions groups were established within the workplace in between these days. In year two these session evolved into project working and action plan implementation groups. The programme had a number of visible activities that took place on a regular basis. Overarching these ‘events’ the programme activities principally involved: (i) developing an understanding of what the work/practice development involves and the competence and confidence to role model the processes to be used (ii) becoming familiar with the Person Centred Framework (McCormack and McCance 2006) and Practice Development Model (Manley et al 2008) as the frameworks used for the programme (iii) developing an understanding of workplace culture and ‘change’ processes (iv) awareness raising activities for different staff groups, older people and families in the programme sites (v) developing a shared vision using Values Clarification Exercises involving the Residents/Patients Families/Carers and all staff within their work place (vi) Active Learning in the workplace (vii) structured reflection (vii) facilitation skills development (viii) developing greater appreciation of and skills in effective group and team working and (iv) working with evaluation methodology and methods.

Programme Evaluation

The processes and outcomes from the practice development programme were evaluated within a framework of cooperative inquiry (Heron & Reason 2001)).  In addition, a number of ‘evaluation instruments’ were used.  These instruments have been developed as components of previous research and development in person-centred practice and have established validity and reliability.  The project leaders, lead facilitators and project participants all acted as co-researchers in the collection and analysis of the data.  Thus this programme had the added benefit of developing evidence gathering and research skills among participants. Data were collected at three time points during the programme: approximately between, December 2007-March 2008 and again at two more time points (January -February 2009 and August-September 2009).

Key  Findings

  1. The personal and professional growth for individuals across different roles and within the health care teams was evident in the analysis of the programme day notes, thus active learning activities were found to be acceptable to the participants and utilised throughout the programme day and in practice. 
  2. Staff and managers became familiar with the Person-centred Practice and practice development frameworks, and learnt a set of core practice development methods and processes.
  3. Significant progress was made in achieving numerous attributes of a person-centred culture. There is no end point to person-centred cultures, thus further development is still needed.
  4. The data demonstrated significant outcomes for nursing and care staff and were statistically proven (see McCormack et al 2010 for details).  These changes relate to the ‘pre-requisites’ of person-centred practice within the person-centred practice framework.  These changes are significant in terms of developing a person-centred culture.  Statistically significant changes included:
    • Preparation for the role
    • Staff support
    • Knowledge of treatment decisions
    • Communication and support
    • Career development
    • Role satisfaction
    • Staffing and resources
    • Commitment to the setting
    • Workload
    • Intention to stay in role
  5. There was significant change in nurses perceptions of caring’.  The data analysis showed that staff had shifted their views from one of seeing technical’ aspects of practice as caring, to a view that the ‘non-technical’ aspects of caring were more important. This was at a statistically significant level (see McCormack et al 2010 for details). 
  6. For residents and families, the data demonstrated significant changes in care practices that resulted in an impact on four key areas of care experiences for older people and their families, with each of them showing qualitatively a change in the practice culture: Hope and HopelessnessChoice; Belonging and ConnectednessMeaningful relationships. 
  7. In the Year 1 observation data there were as many poor practice examples as there were good practice, in the year 2 data set there were significantly lessexamples of poor practice, demonstrating a change in culture.

 

Summary

Developing person-centred cultures is not a one man/woman job and it is clear that it requires commitment from a whole team. Person-centred cultures are not achieved from one-off change events.  A sustained commitment to developing person-centred cultures through ‘bite-sized’ tangible changes to maintain commitment, enthusiasm and morale is needed.  The emerging evidence, such as that reported here, highlights the importance of adopting participatory, collaborative and inclusive developmental processes in order to address the complexity of the change processes needed.  As one of the programme participants suggested:

“Developing person-centred nursing has been like a journey for us.  Some stages of the journey have been rough and some have been smooth.  It has been a bit like a bus trip, collecting as many people as possible on the way and trying to get them to stay for the full experience and not get off too early.  A driver (leader) is needed to keep the bus on the right route but everyone else on board needs to let the driver know where they want to go and support each other in getting there”.

References
Heron J and Reason P (2001) The Practice of Co-operative Inquiry: Research with rather than on people. In Reason P and Bradbury H (eds.) Handbook of Action Research: Participative inquiry and practice: pp179-188. London Sage Publications

Manley K McCormack B and Wilson V (2008) Practice Development in Nursing: International Perspectives.  Blackwell Publishing, Oxford

McCormack B and McCance T (2010) Person-centred Nursing: Theory, models and methods.  Blackwell Publishing, Oxford.

McCormack B, Dewing J, Breslin E, Coyne-Nevin A, Kennedy K, Manning M, Tobin C and Slater P (2010) Developing person-centred practice: nursing outcomes arising from changes to the care environment in residential settings for older people, International Journal of Older People Nursing 5, 93–107

McCormack B and McCance T (2006) Development of a framework for person-centred nursing. Journal of Advanced Nursing 56(5) 1-8.

 

Address for Correspondence:
School of Nursing
University of Ulster 
Shore Road 
Newtownabbey 
Co. Antrim 
Northern Ireland 
email: bg.mccormack@ulster.ac.uk

 

A detailed report that sets out the programme framework, ways of working, detailed findings and recommendations for ongoing work can be downloaded fromhttp://www.science.ulster.ac.uk/inr/publications/index.html

Back Print