This position paper was prepared by Alison Kitson and team on behalf of the members of the International Learning Collaborative (ILC), a voluntary group of international nurse leaders and supporters of nursing, united by a vision to improve the fundamentals of patient care. The purpose of the two-day event was specifically to discuss whether there was a problem in how patients experience the basics of care and, if so, how we could go about improving these. Indeed, North American participants (especially Kagan) noted that American nursing discourse offers little direct translation of the term 'Fundamentals of Care'.
Indeed, part of the problem may be that the fundamentals of care are no longer in the hands of nurses. We target key nursing and other healthcare leaders in order to create a shared vision and shared accountability for reformulating and redefining the fundamentals of care.
The proposed solution
We need concrete descriptions of how we are going to redesign patient care and how these descriptions shape what is in place at the healthcare system level and at the policy level. The disconnect between staff, patients, executives, organizational leadership, regulators, and payers on how care is valued and delivered must be addressed. This led participants to consider whether the root of the problem lay deep within the psyche of the nursing profession itself.
In the drive to modernize and professionalize, have we lost sight of the core values and activities that are central to patient care. Or is this a broader societal pattern where individuals are less inclined to show kindness, compassion and care to others even if it is a necessary job requirement. There is international agreement that nursing is facing a number of challenges in how it operationalizes care.
Around the world, the nursing workforce is becoming more chronically fatigued through various initiatives, not only in the UK, but in Canada, the US, Australia and Sweden to name but a few. However, none of these initiatives seem to be working to the extent we would like. We need to reclaim the fundamentals of care and work out how we ensure its safe, competent, compassionate delivery to our patients.
Defining the Fundamentals of Care
Approach to developing the fundamentals of care framework
A new perspective on an age old challenge
The reflective question for many nurses will be "How can I reduce the potential harm I can do today?" Written so sharply, one is challenged to consider how resources and rationing become part of the daily experience of the nurse, prioritizing one patient's care needs over another's. This is part of the complication of delivering the fundamentals of care, but not the complexity. Similarly, staff relations are a complication rather than a complexity in the equation; staff is a mediator rather than an integral part of the fundamentals of care debate.
However, the preliminary question is what kind of care the system requires, is it task-oriented or humane engagement. The nurse requires expert mentoring to be able to balance the demands of assessing and providing the basics of care with the other responsibilities of the nursing role. Mentoring, support, role modeling, and guidance in providing the basics of care will create a way of caring for patients that redefines their centrality in care and legitimizes their importance in the therapeutic process.
They can draw meaning from each episode of care and facilitate the healing process for the patient. Patients generally equate the type and quality of care they receive with the staff who provide it (Marshall et al 2012; Kitson et al i 2013b). Reviews of the patient-centred care literature (Kitson et al 2013a) also confirm the central importance of patient participation and involvement in their care, where the participating patient is.
All of the above elements will be part of the new Fundamentals of Care Conceptual Framework.
The emerging Fundamentals of Care Conceptual Framework
The Fundamentals of Care Framework: Committing to and establishing the relationship
- Commitment to the caring relationship
- Establishing the assessment process
How does the nurse develop the ability to focus on the patient in real time without being distracted. Both the patient and the nurse should regularly review progress and provide feedback to each other on how things are going. The patient and the nurse also negotiate who else should be involved in this reporting process (e.g. next of kin or carer).
This assessment is not a formal clinical nursing assessment of the patient; it's more about creating trust and commonality. The nurse can assess the patient's level of understanding of their clinical condition. What do I need help with? From the initial stage of relationship building, the patient journey is characterized by the nurse and patient working together to integrate.
The dynamic described in this part of the framework is the patient's journey from potentially being totally dependent on the nurse to helping them with their everything. The nurse's role in this part of the framework would be to make an assessment with the patient of their basic care needs and then develop a joint plan that would help the patient move from addiction to. If the patient remained fully dependent, the nurse's role would be to work with them and their wider care network to ensure continued safe, dignified and respectful care.
The basis of care assessment process includes three dimensions: the physical needs of the patient; their psychosocial needs and finally an assessment of the type of nurse-patient relationship established to meet the patient's needs.
The Fundamentals of Care Framework: Contextual Factors
- Contextual factors: system level enablers
- Contextual factors: policy enablers
These relational activities will take place between nurse and patient, nurse and nurse, nurse and team, and nurse and other health care providers. For the nurse and patient, this part of the journey is about setting realistic goals and objectives for recovery and optimal independence and well-being (recognizing that not all patients will achieve independence). It is also about ensuring integrity between the physical, psychosocial and relational aspects of each care experience.
These very real challenges lead to the final part of the framework: the external circle – the context in which care is implemented. Culture – this includes the system's values and norms and in particular requires clear statements about the organization's goals, how staff are respected and valued; and the organization's clear commitment to innovation and learning (both formal and informal education). Important in this debate is determining the kinds of questions that nurses and patients should ask of managers, leaders, and policymakers at each level of the system.
You will be told about our nurse managers and will be introduced to our senior nurses, doctors and other members of the healthcare team. They are often perceived as being outside the direct influence or control of the individual nurse or patient, but they nevertheless need to be identified and discussed in the ongoing debate about improving the fundamentals of care. We work with all members of the healthcare team to ensure the process is positive and educational.
Seen in this way, conversations between nurses and patients about some of the broader policy issues could shape and influence strategic planning and accountability processes in the health system.
The Fundamentals of Care Action Plan
Link knowledge translation strategies to FOC delivery, know how to prioritize care Contribution of senior. The time and activities around establishing the relationship and integration of the care must be. How FOC is taught in terms of inductive and deductive reasoning Further exploration of mentor/clinical facilitator roles.
How to train nurses and professionals to understand and attend to the first-person experience of illness and to work in partnership. There will be a need to develop a new set of tools suitable for evaluating the implementation of the FOC. Mapping the boundaries of the FOC can be facilitated by exploring concepts such as 'missed care'.
Explore the use of existing frameworks such as the Medical Research Council's complex intervention framework Patients/service users should be involved in the development of instruments to measure patient experience/quality of care. Explore the role of accountability frameworks and funding models in the health system to enable/impede the adoption of FOC principles and practices. Policy makers should adopt a facilitative rather than a dictatorial attitude by disseminating best practice and emphasizing the standards to be achieved and the responsibility for doing so.
In the US, the sticking points are payment reform emphasizing pay for performance and pay for quality, efforts to bundle payment for accountable care organizations and patient-centered medical homes, and the research agenda of the Patient-Centered Outcomes Research Institute (PCORI).
Summary
Referencing
Goodrich, J 2012, 'Supporting hospital staff to deliver compassionate care: are Schwartz Center rounds working in English hospitals?', Journal of the Royal Society of Medicine, vol. A narrative review and synthesis of the health policy, medicine, and nursing literature, Journal Advanced Nursing, vol. Kitson, AL, Dow, C, Calabrese, JD, Locock, L & Athlin, AM 2013b, 'Stroke survivors' experiences of the basics of care: a qualitative analysis', Int J Nurs Stud, vol.
Experiences of care and the impact of staff motivation, affect, and well-being, Final Report, National Institute for Health Services Delivery and Organization Program (currently under peer review),. Marshall, A, Kitson, A & Zeitz, K 2012, 'Patients' perspectives on patient-centred care: a phenomenological case study in one surgical unit', Journal Advanced Nursing, vol. Menzies-Lyth, I 2002, 'A case study of the functioning of social systems as a defense against anxiety', in A Rafferty & M Traynor (eds), Exemplary research for nursing and midwifery, Routledge, London.
Needleman, J & Hassmiller, S 2009a, 'The role of nurses in improving hospital quality and efficiency: real world results', Health Affairs; full. Needleman, J, Parkerton, PH, Pearson, ML, Soban, LM, Upenieks, VV, & Yee, T 2009b, 'Overall Effect of TCAB on Initial Participating Hospitals', The American Journal of Nursing, vol. Participation of Unit Nurses: Frontline Implementation on TCAB Pilot Units', The American Journal of Nursing, vol.
Tadd, W & Calnan, M 2009, 'Caring for older people: Why dignity matters – the European experience', in L Nordenfelt (ed.), Dignity and the Care of the Elderly, Blackwell Publishers, Oxford.
Appendices
Fundamentals of Care Delegate List
Elaine Strachan-Hall Oxford University Hospitals Trust √ Emily Ang National University Cancer Institute √ Gigi Yebra Oxford University Hospitals Trust x Jackie Bridges University of Southampton x. Joanna Goodrich Point of Care-program, King's Fund x Jocelyn Cornwell Point of Care-program x Katherine Murphy The Patients Association x.
Fundamentals of Care Template
