Discuss About The Functional Impairment Chronic Conditions.
The 2010 report by the Australian Commission on Safety and Quality in Healthcare defines Patient Cantered Care (PCC) as a new strategy in the planning, providence and evaluation of care which is based upon a therapeutic and mutually beneficial relation between patients, their families and healthcare providers and can be applicable to patients from all age groups and also can be practiced in any healthcare setup (safetyandquality.gov.au, 2018). In PCC, the specific health needs and the intended healthcare outcomes forms the driving energy for all the healthcare related decisions and quality assessments. This system allows the formation of partnerships between the patients and their healthcare providers, and fosters the providence of clinical care as well as emotional, mental, spiritual and financial support for the patients (catalyst.nejm.org, 2018; Edvardsson et al., 2017).
PCC involves several dimensions of care such as: respecting the preference and values of the patient, providing emotional care; improving physical care; providing information, communication and education given to patients and their families; ensuring continuity and proper transition of care; foster coordinated care, support the inclusion of family and friends and improving accessibility to care. The core elements of the PCC framework has been identified as: a) education and sharing of information and knowledge; b) family and friend involvement; c) team management and collaboration; d) focusing on spiritual and non-medical aspects of care; e) respecting the preferences and needs of the patient; f) uninterrupted access and flow of information (afetyandquality.gov.au, 2018). Patient Centred Care is also used interchangeable with many other terms like Consumer Centred Care, Personalized Care, Person Centred Care and Family Oriented Care. All there terms refers to the same concept of care and support being provided to the patient and their family (afetyandquality.gov.au, 2018; Liberati et al., 2015; Constand et al., 2014).
The following study is aimed to understand whether PCC can be helpful to improve health outcomes among hospital inpatients. The study will analyse three key journal articles to identify different factors that might help in the improvement of health outcomes among hospital inpatients, with supporting evidences from various other studies to critically evaluate the selected articles and to prove/disprove its validity.
Can PCC help to improve health outcomes among hospital inpatients?
|
P(opulation) |
Hospital Inpatients |
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I(ntervention) |
Patient Centred Care |
|
C(omparison) |
Non Patient Centred Care |
|
O(utcome) |
Improvement in health outcomes among the target populations |
Search for the key journal articles was conducted on Google Scholar. The first search for a primary research article was done using the keywords “Person Centred Care” AND “discharge process”. The keywords were selected to understand the effect of PCC on the discharge process of inpatients, and from the resultant 91,500, a filter on the date of publishing was used, which reduced the articles to 17,200. For the first key Journal article, the first result was used, which is a study by Ulin et al., (2016). For the second study, the keywords “person cantered care” AND “chronic conditions” was used, and filtered for studies published after 2014, which showed a result of 17,200 studies. The first study by Kogan et al. (2016) was selected for the analysis. This study helped to understand the effect of PCC on the care for chronic conditions. For the third study, the keywords, “patient cantered care” AND “patient’s perceptions” were used, which showed 81,700 results. The third study by Hudon et al. (2011) was selected, since the first two was more than 10 years old.
The primary article selected for the analysis uses a primary research to study the effect of PCC on the discharge process of hospital outpatients, while the two supporting articles secondary analysis of literature review on the effect of PCC on chronic care and perceptions of the patient towards the care. This is based on the key aspects of PCC which focuses on the patient’s perceptions and the providence of continued care for the patient, which is an important requirement in chronic conditions.
Moreover, a primary research is useful for the analysis of fresh and unused data to support or dispute a given hypothesis. Primary research allows the assessment of the raw data collected in the study, in order to support the basic philosophies of the process, and to understand if the results from the data are in alignment with the philosophy. Also, selection of secondary researches (for the two secondary articles) is important to understand the evidences available in scientific literature which can be used to support or contradict the findings from the primary research, and help to understand any gaps in knowledge, which can be further expounded upon (Bryman & Bell, 2015).
PCC is a nursing theory, which was designed by Faye Glenn Abdellah, to address the 21 nursing problems. The author recommends ten steps to understand patient’s problems and eleven skills that are needed to improve the nursing care plan or a treatment typology for the patient. The identification of the patient’s problems can include 10 steps, which are: 1) Learning to understand the patient, 2) finding out relevant and significant information, 3) Making generalisations on information that is available to relate to similar challenges on present nursing scenarios, 4) Identifying therapeutic plan, 5) Generalisations is tested and additional generalisations done with the patient, 6) Validating the conclusions drawn by the patient related to the nursing problems, 7) Continuing the observation of the patient to identify factors affecting their behaviour, 8) understanding the reaction of the patient and their families to the care plan and involving them in the plan, 9) understand how nurses think and feel about the nursing challenged perceived by the patient, 10) developing a comprehensive care plan, based on the identified information and feedbacks (Alligood, 2017).
The 11 Nursing skills that are required according to Faye Glenn Abdellah’s theory include: observing health status, communication, knowledge application, educating patient and their families, work planning and organization, resource material usage, personnel utilization, problem solving abilities, leadership, therapeutic use of self abilities and nursing procedures (nursing-theory.org, 2018).
Faye Abdellah explained patient centeredness’ of care in the form of the motion swinging pendulum, which shifts between three stages: nursing centred, client centred and disease centred, with the client centeredness being at the middle of the other two positions. This implies that shifts from nursing centred care to disease centred care passes through the patient centred approach, termed as the “care pendulum” (Alligood, 2017).
Figure 1: Care Pendulum, source (Alligood, 2017).
According to the Arizona College of nursing, a patient centred care is an important nursing theory, favoured by several aspects such as the ability of nurses to act as healthcare leaders, the significant proportion of healthcare workforce occupied by nursing profession, epoch of ageing baby bloomer, rapid increase in chronic illnesses and mortality cause due to it (60% of all deaths worldwide and an improvement in the advance nurse education system (nursing-theory.org, 2018). This shows that PCC is an important component of the nursing practice.
Ulin et al. (2016) pointed out that discharge planning is an important factor that helps to connect the gap between hospitals and home and for patients suffering from chronic cardiac conditions (most of whom are elderly and fragile, suffering from co morbidities and functional decline cause by the burden of the symptoms of the disease), effective discharge planning can help in an efficient discharge process. The study tried to analyse if Gothenburg person-centred care planning (gPCC) can help to develop and promote a proactive care planning, and lead to an impro0vement in the efficiency of discharge process, compared to the usual care given in hospitals to the patients suffering from deteriorating cardiac conditions. The study included 248 patients, 123 of whom were in regular care group and 125 under gPCC based care plan. The participants were hospitalised Swedish patients diagnosed with chronic heart failure (CHF), admitted between February 2008 to April 2010. IN the usual discharge process, support is given when the patient needs help from the municipality, and the discharge was not done in a systematic or timely manner. The plan was prepared by the individual nurses who provided care for the patient and was not based on predetermined values. In the gPCC intervention, the HealthPlan started with the narratives from the patient, which involved the regular life and symptoms leading up to their hospitalization. The resources of the patient are also identified, which also included the healthcare objectives and motivations of the patient This information is then summarized and a gPCC care plan is developed based on it, which also involves investigation plans, treatment objectives and duration of stay in the hospital. Based on the plan so devised, the first notification to home care service and primary healthcare services are given. Moreover, regular evaluation and revision of the gPCC health plan is done for all domains of care such as: management, symptoms, resources, as well as treatment. The evaluated plan then forms the basis of the second notification, which provided precise and detailed information on the anticipated status of the patient as well as anticipated discharge outcomes. The third notice is given when the patient is ready for discharge and the estimated length of stay in the hospital. The results showed that for the gPCC group, the notifications sent to community home help services and home nursing care services were frequent (33.8%), compared to the non gPCC group (12.1%). Also, the gPCC group has a timely discharge planning conference which was done within the first to fifth day compared to non gPCC groups, in which the discharge planning was done in 28 days (maximum). Moreover, the length of stay in the hospitals also was less in case of gPCC group (11 days) than the non gPCC group (35 days). The authors suggested that in the gPCC model, patients are considered capable and competent to plan their own care, which helps to improve their discharge process, facilitating their involvement in it.
The gPCC thus fosters the involvement of the patient in the care and discharge process, which is important factor that helps to understand the patient and their expectations or views, and developing the care plan based on these expectations. The continual sharing of the discharge plan and notifications with compare and primary care services also helps in the better coordination of care, which are all important aspects of PCC. This proves the efficacy of gPCC based discharge process, which has resulted in a reduced length of stay in hospital for patients treated following the PCC model, compared to non PCC based care setups. Fors et al. (2016) also supported the use of the PCC based approach for care, suggesting that it builds a coordination between patients and healthcare providers through the continuum of care, and also helps to improve the self efficacy without causing any deterioration in the clinical outcomes. Studies by Ekman et al. (2011) also showed that a fully implemented PCC strategy can help to reduce the hospital stay and help in the maintenance of functional performance among patients hospitalized for chronic heart failure, without causing an increase in the risks of readmission or affecting the health related quality of life of the patients.
Kogan et al. (2016) studied the effect of PCC on older adults suffering from chronic conditions and functional impairments utilising a systematic review of literature. The authors were able to identify nearly 3,000 articles between 1999 and 2014 on PCC for older adults, and reviewed 132 sources on the same topic. From these selected 132 non-duplicate studies, the authors outlined 15 descriptions of PCC, which addressed 17 values or principles. The six most significant aspects of the PCC model, identified by the authors from the review of the selected literature were found to be: 1) Holistic Care, 2) respect and value to patient and their views and opinions, 3) respect to patient’s choice and autonomy, 4) respect to patient’s dignity, 5) fostering self-determination among patients and 6) foster a sense of purposeful living among the patients. The evidences so identified by the author’s highlights the growing interest towards PCC based approaches, as well as multiple definitions of PCC which shows several common aspects and overlaps. This study thus helped to develop a consensus definition of PCC, outline the essential components and elements and explain the approaches to implement PCC in care services of older patients. The findings of the research was used as a basis for the statement by the expert panel of the American Geriatrics Society, giving a standardised definition as well as specific elements of PCC applicable for the care of older patients suffering from chronic conditions or functional impairments.
The association between chronic conditions or long term conditions with functional impairments and activity limitations have been proposed by Chiauzzi et al. (2015). While Pellisé et al. (2015) suggested out that chronic conditions (such as adult spine deformity) affected the health related quality of life (HRQL). This has also been supported by many other studies which showed that chronic conditions reduced the overall quality of life of the patients. Jia et al. (2016) estimated the deterioration in the quality of life among patients diagnosed with chronic dysfunctions such as depression, hypertension, diabetes mellitus, stroke, cardiac dysfunctions, arthritis, asthma, emphysema and cancer. The study involved patients of age 65 years or more, and showed a lower QOL among patients suffering from one or more of these diseases, compared to patients without any chronic conditions. This proves that QOL is an important aspect affected during chronic diseases. Edvardsson et al. (2014) proposed that patient centeredness of PCC is an important aspect which helps to improve the quality of life of the patients. This shows the applicability of PCC based care strategies for chronic conditions, especially among older adults.
Li and Porock (2014) pointed out that PCC is a holistic philosophy which addresses the needs of the whole person, instead of only certain aspects, while Constand et al. (2014) proposed that PCC fosters a sense of respect towards the patient by healthcare providers, and incorporated strategies for effective communication, health promotion and partnership and thereby address the core elements of patient centered care provision. Similarly, Pulvirenti et al. (2014) opined that PCC can help to maintain respect to patient’s autonomy in taking his/her own clinical and healthcare decisions, and ensure respect and dignity foe the patient. All these aspects support the findings by Kogan et al. (2016).
Hudon et al. (2011) studied the perceptions of the patients on patient centred care in family medicine, by utilising a systematic review of literature using Embase, Medline and Cochrane databases on studies published between 1980 and 2009. The authors selected the articles based on 3 criterions: 1) studies that used self administered instruments to measure the perceptions of the patients in PCC, 2) studies that used psychometric or quantitative methods of development and validation and 3) studies relevant to ambulatory and family medicine aspects. 3,045 articles were identified by the authors, of which 90 were examined, from which 26 studies were selected that included 13 instruments for measuring the selected outcome. This included 2 instruments for measuring the patient’s perceptions towards PCC and 11 instruments on relevant subscales or items.
Based on the literature review, the authors proposed a conceptual framework for PCC, which involves 4 aspects: bio-psychosocial perspective of patient, patient as a person, , therapeutic alliance and sharing power and responsibility. The framework also includes 4 domains: the whole person, patient doctor relation, common ground and disease/illness experience. This is represented in the diagram below.
Figure 2: Conceptual framework of PCC (source: Hudon et al., 2011)
The study shows the importance of understanding the perceptions of the patient in the planning of the care model. The importance of the perceptions of the patients towards the care given to him/her has been supported by many authors. Mohammed et al. (2016) highlighted that the experiences of the patient is a key aspect of value based purchases, and it can be useful as a measure of service quality, which can be used to improve healthcare services. Similarly, Rathert et al. (2015) also pointed those perceptions of emotional support given in healthcare as a strong relation with the overall care ratings given by the patient. This means, the providence of emotional support can be linked to favorable perceptions towards the care given to patients. Constad et al. (2014) also supported the importance to address the perceptions of the patient, which can be helpful to reduce a sense of frustration felt by the patients. The adverse effect of anger, frustration, depression or disappointment on the health outcomes have also been supported by many studies (Kitayama et al., 2015; Sirois et al., 2015; Rayner et al., 2016; Bock et al., 2016). This shows the importance of PCC to address the perceptions of care by the patients, address any frustrations or grievances and foster a sense of patient centered care that focuses on their wishes, views and expectations.
Conclusion:
Patient Centered Care, as the name suggests is a care model which places patient at the centre of the care. The planning, providence and care evaluation is draws its basis from the development of a therapeutic relation between patient and the healthcare provider, and can be used for any patients in any setups. It fosters a positive partnership between the carers and the patient and it helps to develop a holistic model of care which addresses not only the medical or clinical needs of the patient, but also the mental, emotional, spiritual and even financial needs of the patient. The care model at its core focuses on the preferences, values and expectations of the patients, which becomes a part of the care plan, and also allows the education of the patients and their families. The three selected journal articles shows specific aspects of the PCC, which helps to improve the overall health outcomes of patients. These three articles are used to evaluate whether PCC can be useful to improve health outcomes among hospital inpatients. Analysis of these studies and available literature shows the following aspects: PCC can help to reduce the length of hospital stays and improve the discharge process, PCC helps to improve the health outcomes for patients suffering from chronic diseases and functional impairments and PCC also helps to improve the perceptions of care of the patient. These show that through PCC, it is possible to maintain the importance of patient at the centre of the care plan, focusing on their perceptions towards care, providing effective care for long term conditions and functional impairments and reduce the stay in hospitals (and thus foster a speedier recovery process).
Hence it can be safely concluded, that with the application of PCC based care approaches, it is possible to improve the health outcomes among hospital inpatients, and hence can be strongly suggested to devise the care plan for all hospital inpatients, especially for older patients, suffering from long term or chronic conditions and functional disabilities.
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