In mental health nursing, the concept of patient-centred care, also referred to as person-centred care, has gained increasing momentum during the last 20 years. Its value as a fundamental principle underpinning the planning and delivery of mental health care, and as an important component of the help- ing relationship, has been recognized and supported by the nursing profes- sion and literature (NHS Modernisation Agency, 2003; Department of Health [DH], 2004). These initiatives were in response to the concerns raised about the quality of interactions between nurses and services users and their ther- apeutic value (Sainsbury Centre, 1998; Felton and Stickley, 2004). Patient- centred care as a concept is poorly understood in clinical practice. This is
further compounded by the fact that the term patient-centred care is often used in different contexts as though there were an agreed and shared under- standing of the terminology used. It is important therefore to be explicit about what is understood by the term patient-centred care and, more importantly, how it is translated into clinical practice.
Essentially, patient-centred care is a method of helping that is concerned with understanding the client or service user’s needs, and engaging in a model of care based on shared decision making, so that the client can maintain and improve his/her wellbeing (Kitwood and Bredin, 1992). In mental health nursing, this involves putting people at the centre of nursing care (Barker, 2003). One example of a patient-centred theory based approach to nursing is the Tidal Model (Barker and Buchanan-Barker, 2005). As a model of care, it places much emphasis on developing a helping relationship based on respect, trust and collaboration with service users. However, the helping relationship between the nurse and the client does not just happen or should not be taken as a given. Instead, it is built with care over time and based on certain core values, which are essential, particularly if the nurse wants to develop a positive, supportive and therapeutic relationship with the client. While there is extensive literature on the concept of patient-centred care, much of it is theoretical. Few studies have examined how patient-centred care is applied in practice and, more significantly, its usefulness from clients’ perspective.
Nonetheless, studies concerning service user involvement in care, such as the Tidal Model, suggest that models of care based on a more participatory approach are increasing in practice (Cook et al., 2005) albeit slowly and in a piecemeal manner (Felton and Stickley, 2004).
Being person-centred
Person-centred therapy (PCT), originally known as client-centred therapy, was developed by the American psychologist, Carl Rogers, over half a century ago (Rogers 1961). Since then it has been adopted as a model of care in many health professions, including mental health nursing. Being person-centred is at the core of a professional helping relationship. In this case, the focus of mental health nursing is caring for the person who is on the receiving end of this care. Using a person-centred approach is based on the following principles and characteristics of a helping relationship.
A person-centred nurse:
r Appreciates that each person is uniquely influenced by their heredity, the environment in which they are raised, and the values, beliefs and behaviour influenced by the culture in which they were reared.
r Believes that most people strive to reach their optimal potential as much as possible in order to achieve their personal life goals. In this case the mental health nurse considers with the person what are their
life goals, and the part that the therapeutic encounter with the nurse will play in helping the person reach these goals.
r Respects the worth of people. In this instance, the mental health nurse seeks to demonstrate their commitment to the helping process by ac- knowledging that what is troubling the person is real to them. A good example of showing this is listening actively to the person by, for ex- ample, paying attention to what they are saying, making sure that what you are saying is matched by how you are behaving and taking care to clarify with the person what their experiences mean to them.
r Behaves genuinely. One of three main facets of being person-centred is genuineness (Rogers, 1961)–that is, the ability to show that your com- mitment to helping the person is real. You can do this by working col- laboratively with them and not crowding them out of the therapeutic encounter, listening actively and taking time to allow them to present what is troubling them.
r Enables control to remain with the person. In this example, the men- tal health nurse acts a facilitator to help the person identify what is troubling them, possible solutions to overcome these troubles and eval- uation of the impact of the solutions agreed with the person. Using the facilitative categories of Heron’s (2001) six categories of intervention will be useful here. For example, one of Heron’s facilitative categories is catalytic. In this, your role is enabling the person to retain control for change. You can show this through the use of statements such as:
‘List the things that you think might help you overcome this problem.’
See Chapter 5 for further examples of catalytic interventions.
r Recognizes people have basic needs and are motivated to meet these needs. Being mindful of Maslow’s Hierarchy of Human Needs may help in this instance. Based on a seminal paper first published in 1943, Maslow believed that people had five main needs from the basic needs necessary for survival, for example food; safety needs, those that bring comfort, for example health; psychological needs, for example the need for love or to belong, sometimes referred to as love and belonging;
self-esteem, that is respecting others, being respected by others and having self-confidence; self-actualization, the highest order of need, that is the ideal state the person is seeking for themselves (Maslow, 1970).
r Realizes that people’s behaviour is communicating something about their feelings, beliefs, physical and mental state. This is an important part of being person-centred and is especially useful when you are con- fronted with behaviour you find challenging. For example, you can demonstrate this by using an approach called functional analysis. Func- tional analysis is an approach to assessment whereby you try to under- stand what the person’s behaviour represents. You can show this by asking questions such as ‘What do you think your behaviour is telling others about how you’re feeling?’ (Lindberg et al., 1983)
Practice exercise
Consider the seven examples of being a person-centred nurse. Now think of an example from your work with a person for whom you have been caring. Give an example of being person-centred:
r What was the situation exactly?
r What was the person’s presenting problem(s)?
r What aspects of being person-centred did you use?
r What aspects of being person-centred did you not use, and for what reason?
r How did the person react?
r What aspects of being person-centred would you like to develop further and how might you achieve this?
The core conditions of a helping relationship
Rogers (1961) believed that if helpers created relationships with the three core conditions of genuineness, acceptance and empathy, then the people they were attempting to help would begin to understand aspects of themselves that were previously unknown to them. As a result, this would help clients to become more self-confident and autonomous, understand and accept others and be more able to cope adequately with their everyday living. Similarly, in mental health nursing, valuing the views and opinions of service users is considered essential to the therapeutic relationship (Anthony and Crawford, 2000). However, the context of care has the greatest potential to enhance or limit the person-centred care, highlighting that nurses not only have to balance different care approaches and values but often organizational values (Alexander and Bowers, 2004).
The three core conditions are essential regardless of the type of situation in which they are used, for example, whether they are used with a client in an acute admission ward or in the service user’s home in the community. We will now describe the core conditions or skills as described by Carl Rogers of a helping relationship, paying particular attention to the skill of empathy, given its importance as an essential interpersonal skill in mental health nursing.
The core conditions are:
r empathy r congruence
r unconditional positive regard.