Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: Qualitative observation and interview study

Abstract

Background

There is increasing emphasis on person-centred care within the literature and the health care context. It is suggested that a person-centred approach to medication activities has the potential to improve patient experiences and outcomes.

Objectives

This study set out to examine how nurses and patients interact with each other during medication activities in an acute care environment with an underlying philosophy of person-centred care.

Design

A qualitative approach was used comprising naturalistic observation and semi-structured interviews.

Setting

The study setting was an acute care ward with a collaboratively developed philosophy of person-centre care, in an Australian metropolitan hospital.

Participants

Eleven nurses of varying levels of experience were recruited to participate in observations and interviews. Nurses were eligible to participate if they were employed on the study ward in a role that incorporated direct patient care, including medication activities. A stratified sampling technique ensured that nurses with a range of years of clinical experience were represented. Patients who were being cared for by participating nurses during the observation period were recruited to participate unless they met the following exclusion criteria: those less than 18 years of age, non-English speaking patients, and those who were unable to give informed consent. Twenty-five patients were observed and 16 of those agreed to be interviewed.

Results

The results of the study generated insights into the nature of interactions between nurses and patients where person-centred care is the underlying philosophy of care. Three major themes emerged from the findings: provision of individualised care, patient participation and contextual barriers to providing person-centred care. While the participating nurses valued a person-centred approach and perceived that they were conducting medication activities in a person-centred way, some nurse–patient interactions during medication activities were centred on routines rather than individualised patient assessment and management. These interactions were based on nurses’ perceptions of what was important for the patient and did not provide opportunities for patient participation. Two main contextual barriers in relation to a person-centred approach to medication activities were identified as multidisciplinary communication and time constraints.

Conclusions

While some nurse–patient interactions during medication activities were consistent with the principles of person-centred care, the study results highlighted factors that influence the nature of these interactions, and identified opportunities to improve nursing practice. To ensure person-centred care is applied to medication activities, nurses should undertake ongoing assessment of patients’ needs in relation to their medications and encourage opportunities for increased patient participation.

Introduction

The provision of person-centred care is commonly regarded as a crucial component of delivering high quality health care, and features prominently in the literature and philosophy statements of health care organisations (Coyle and Williams, 2001, Mead and Bower, 2000, Sheard, 2004). An emergent focus on a person-centred approach has occurred as a result of the increasing emphasis on improving processes and outcomes of care- and a growing awareness of consumer rights and expectations (Dawood, 2005, McCormack, 2003, Manley, 2004). A person-centred approach to health care delivery is purported to be effective and efficient, and result in improved patient outcomes (Holman and Lorig, 2000).

Despite the emphasis on person-centred care and claims that it leads to improvements in patient experience and outcomes, there are multiple interpretations of person-centred care across nursing and other health care disciplines (Cahill, 1996, Lutz and Bowers, 2000). However, within the varying definitions and conceptual views, key attributes of person-centred care can be identified and are intrinsically linked: the existence of a therapeutic relationship between nurses and patients, the provision of individualised care and evidence of patient participation (Cahill, 1996, McCormack and Titchen, 2001, Redman and Lynn, 2004). The person-centred nursing framework developed by McCormack and McCance (2006) emphasises the importance of these key factors being underpinned by the nurses’ understanding of the patients’ beliefs and values. In addition, the person-centred nursing framework articulates the attributes and skills of nurses and the characteristics of the care environment that are required in order to achieve person-centred processes. The complexity of providing person-centred care is highlighted, thus supporting the view that establishing and maintaining a person-centred approach across an organisation or in a clinical unit is complex and challenging. Some authors assert that very few services can truly claim to deliver person-centred care (Baker et al., 2003, Lutz and Bowers, 2000).

Medication activities provide an opportunity to examine nursing practice for evidence of a person-centred approach, due to the high level of interactions occurring between nurses and patients during these activities. Medication administration and education are aspects of patient care that are performed by nurses and most patients have some form of medication administered to them by a nurse during a hospital admission (Osborne et al., 1999). Previous research has shown that the relationship between health professionals and patients and the ways in which information is provided is critical in enhancing medication concordance and management (Manias et al., 2007, Pound et al., 2005, Williams et al., 2008). Worthington (2003) states that a partnership between the nurse and the patient consistent with person-centred care can have a significant influence on patients’ understandings and attitudes towards their medications and on the degree of compliance with their medication regimens. An individualised person-centred approach to medication activities also has the potential to improve patient experiences and outcomes including: increased opportunities for patient education about medications, administration of medications at a time that is most appropriate for the patient and a decreased risk of medication error (Reid et al., 2002).

Despite the purported benefits of a person-centred approach to medication activities, there is scant literature which seeks to describe or examine the nature of interactions between nurses and patients during medication activities. The studies that have been undertaken in this area demonstrate that the interactions between nurses and patients during medication activities are rarely consistent with the principles of person-centred care. Previous research has demonstrated that nurses’ approaches to medication activities are often not based on an assessment of patients’ individual requirements, and can be determined by task-orientated routines (Martens, 1998, Haglund et al., 2004, Manias et al., 2005). Each of these three studies examining interactions between nurses and patients during medication activities had a different focus; medication discharge education provided by nurses to patients, medication administration in an inpatient psychiatric setting and protocol use by graduate nurses, respectively. It is a potential limitation that these researchers did not utilise person-centred care as a framework to examine their findings, however, the outcomes of each study demonstrated significant similarities related to routinised nursing practice lacking individualised patient assessment. This task-based approach is incongruent with a person-centred philosophy, where the emphasis is on providing individualised care, which values and respects the patient as a person (Radwin, 1996, Suhonen et al., 2002). An individualised approach to medication activities involves a dialogue between nurses and patients, where the needs and preferences of the patient are identified and an ongoing plan is developed collaboratively to meet these needs. Nurses’ assessment of the needs and preferences of individual patients were not evident in these studies (Martens, 1998, Haglund et al., 2004, Manias et al., 2005).

It is readily apparent that an approach to medication activities that is based on routine and tradition is unlikely to meet the needs of individual patients. Reid et al. (2002) evaluated a pilot program on a surgical unit in the United Kingdom, utilising multiple methods of evaluation including observation of practice, documentation audits and staff questionnaires. The aim of the program was to implement a less regimented and more individualised, person-centred approach to medication activities. The findings revealed that despite the new program, patient assessment remained separate from the process of medication activities and the assessment data was not used to inform medication decisions. The incongruence between a person-centred philosophy and task-orientated patient care, suggests that implementing an individualised, person-centred approach to medication activities is more complex than merely changing systems and processes related to medication administration for patients. However, the findings of the study were limited in that patients’ views were not directly sought as part of the evaluation, which would appear to be contradictory in a project designed to evaluate person-centred care.

The complexity of implementing a sustainable person-centred approach is supported by the work of Rycroft-Malone et al. (2001), which is also reported by Latter et al. (2000). This work involved a multiple case study approach to investigate the contribution of nurses to medication education for patients- across an area trust in the United Kingdom. Seven different clinical areas were chosen for their significance in relation to medication education and represented adult, care of the older person, mental health and community nursing contexts. Consistent with the findings of related studies, the results demonstrated that a majority of nurse–patient interactions were dominated and led by nurses, and contained relatively simple information which is incongruent with person-centred care (Cahill, 1996). Overall, the case study approach employed by researchers generated very rich data. However, the study focuses on medication education as a discrete component of medication activities undertaken by nurses and the findings may not be able to be applied to medication management more broadly.

Significantly, the findings of Rycroft-Malone et al. (2001) revealed some atypical interactions between nurses and patients in both the community mental health context and the rehabilitation ward (Rycroft-Malone et al., 2001). The interactions in these settings were less dominated by nursing staff in comparison to other clinical areas such as acute medical wards and surgery-based clinics. There was evidence of nurses providing a broad range of information about medications, such as monitoring medication outcomes and side effects, which was driven by identification of patient needs and preferences. In contrast to other clinical settings, both the community mental health and rehabilitation units had a person-centred philosophy of care. The nurses from these settings emphasised an individualised, holistic approach, with respect and partnership being central to nurse–patient interactions. This engagement of clinical nurses in application of the philosophy of care was notably absent in the implementation of a person-centred medication model evaluated by Reid et al. (2002). However, it could be argued that the rehabilitation and community mental health areas identified in the Rycroft-Malone et al. (2001) study may have different challenges to acute care settings in relation to individual workload and time constraints, which may also have impacted on the nature of nurse–patient interactions.

The aim of this study was to examine the nature of interactions between nurses and patients during medication activities in an acute care setting with an underlying philosophy of person-centred care. The study sought to answer the following research question: How do nurses and patients interact with each other during medication activities in an acute care environment with an underlying philosophy of person-centred care? Two further subsidiary questions were also explored:

• What are nurse and patient perceptions of their experience relating to medication activities?

• What factors influence the nature of these interactions?

In the context of this study, medication activities were defined as the following processes: communication with the patient about medications, patient assessment and evaluation in relation to medications administered, patient education, and communication with multidisciplinary team (Manias et al., 2005).