APPROACH TO LITERATURE SEARCH
In writing this literature review standard search engines such as MEDLINE OVID, ISI WEB OF KNOWLEDGE and PSYCHINFO. Search terms such as person-centred (to include person-centered and patient-centred) was combined with nursing in ISI WEB OF KNOWLEDGE and 45 papers identified. A further search was undertaken with search terms person-centredness combined with nursing in which 7 papers were identified. These were cross referenced with the original 45 papers and identified to be included in it. Similar searches were carried out in PSYCHINFO and MEDLINE OVID databases which tends to produce similar results of similar article found earlier. In total 37 papers were selected and their abstracts read. From these, 28 papers were selected that were explorations of the concept of person-centredness and person-centred nursing and were used in this review. A snowballing procedure was also used to identify further publications from the reference sections of retrieved articles. Seven books known to deal with person-centred issues, humanistic psychology and person-centredness were used as well in this review.
CARL ROGERS PERSON-CENTRED APPROACH
Carl Rogers (1902-1987) a psychologist developed the person-centred approach theory mainly in relation to the therapist and the client and initially named it the client-centred approach. Rogers later referred to this theory as person-centred rather than patient-centred in order not to reduce the individual's autonomy and consequently lend the client to difficulties. The approach therefore is to turn individuals (clients) into subjects of their own therapy. In his theory it was noted that individuals are endowed with the power of self actualization and through their own perception of resources inherent in them, they can provide remedy for change in their difficult situations, provided a facilitating environment exists. Rogers explained further that the client has a better knowledge of their ailment than the therapist does and they can set their own goals. This view as expressed by Rogers implied that every person has a tendency to grow and attain a certain level of actualization. He therefore concludes that the therapist is to limit him/herself to assisting the individual realise self actualization whiles providing conducive conditions towards development. Rogers however regard this approach to dealing with the client as being opposed to both behaviourism and psychoanalysis. He observed that in order to allow the client (person) asses his/her own wisdom and self defeating behaviours and also engage in therapeutic movement with the therapist, there must be a conducive climate. Three conditions were identified for this relationship to thrive favourably: Genuineness (Congruence), Empathy and Unconditional Positive Regard.
In this relationship the therapist is expected to show a real sense of genuine attitude towards the client's feelings and thoughts, establish a direct person-to-person relationship and be willing and ever present to assist them in whatever situation they may be.He should be transparent and discourage the attitude of being the superior in the situation. In addition, he/she must be able to unify his emotional feelings, the awareness of this experience and what is being expressed towards the client. This attitude would in turn retain a high sense of confidence in the client towards realization of him/herself in therapy. Any deviation from this attitude renders the process unworkable.
UNCONDITIONAL POSITIVE REGARD (Total Acceptance)
According to Rogers, the therapist in this situation must show non-judgemental and total acceptance to the client's feelings and his perceptive world as a whole to enhance his process of recovery and gaining self-confidence. This total acceptance of the client's attitude and perception should be devoid of whatsoever differences that might exist between them either culturally or socially. However in doing so the therapist should ensure the safety and security of the client.
In his theory, showing empathy refers to the ability of the therapist to show positive sensitivity to the client's world, his perception towards recovery and also communicate his feelings to the client. This will convey a special meaning to the client of his relationship with the therapist and consequently solidify their mutual relationship towards the expected therapeutic movement. Rogers continue to state that any deviation from these attitudes on the part of the therapist makes it difficult for the process to continue. This empathetic attitude he explained, is more exhibited by therapists who are more confident about their own identity and can cope with other person's world without any fear.
In effect Carl Rogers approach is not only individualistic but also individualising since it is promoting the autonomy of the client/individual and making him/her the centre of the process.
PERSON-CENTREDNESS AND PERSONHOOD
Person-centeredness a concept in health care delivery has poor and conflicting definitions over the years and is considered one of the best ways of health care delivery in which patients are valued as individuals (Winfield et al. 1996).Consolidating on the view of Winfield et al, person-centredness covers a whole range of different ideas expressed and interpreted in a variety of ways by different researchers of various backgrounds; hence it is considered as having a heterogeneous origin that makes it difficult to arrive at a particular definition Leplege et al (2007). Meanwhile, Leplege et al continue to express the view that the concept of person-centredness has been developed following two powerful historical trends such as; the subjective experience of patients now being considered as a reference point in medical care and patients involvement and participation in decision making of their care. It has further been observed by (Slater 2006; Leplege et al 2007), that the concept of person-centredness has been described using different terms like patient-centred, client-centred, person-centred interchangeably which makes it most often unclear which consistent term to use in the description of the concept.
Brooker (2004), elaborating on person-centred approach found out that the definition of the term has such characteristics as:
- Respecting and valuing the individual as a full member of society
- Providing individualised places of care that are in line with people's changing needs
- Understanding the perspective of the person and providing a supportive social psychology in order to help people live a life of relative well-being.
Considering this definition of Brooker's, it could be realised that his works in person-centred care is consistent with that of Carl Roger's (1950), which developed person-centred approach as a way of facilitating psychological growth (Natiello 2001).In addition, a critical look at Kitwoods definitions showed that personhood has been considered very essential in his works of person-centred care for persons with dimentia. Dewing (2008) observed that Person-centredness is often associated with gerontological nursing and more particularly issues relating to dementia care and have personhood as a basis of promoting its practice. It is therefore relevant to explore the philosophical and theoretical underpinnings of personhood in as much as it is recognised in person-centredness (Baker 2001; Ford & McCormack 2000; Fares 1997).Kitwood (1997, p.8)) describes personhood as "a standing or status that is bestowed upon one human being by others in the context of relationship and social being. It implies recognition, respect and trust". The word "person" as contained in personhood relates to various attributes that represent our humanness and other challenging factors in our life McCance et al (2009), he further stated that persons should be accorded respect and be treated as ends in themselves but not as means to an end as espoused in the principles that guides ethical, legal and moral frameworks of nursing and health care. Drawing on the works of Frankfurt (1989) and Hare (1981), McCormack concluded that the ability to engage in reflective evaluation of action distinguishes persons from other creatures
and that the reflective person is capable of forming and abandoning relationships or remain alone as he/she may desire. In order to relate person to personhood, Frankfurt (1989) intimated that due to disabling illness for instance, a person may not be able to turn his desires to actions but he is still free to form those desires and decide possible actions as before. McCance et al (2009), concludes that it is this "moral personality" and humanity that draws the difference between persons and other species hence our personhood. Baker (2001) declared that personhood is consistent with individuality and has three dimensions; the person's world which relates to understanding the person's needs, self relating to emotional and physical security and others which signify social and material world that considers the need for interventions and a sense of belonging and place.Similarly (Ford & McCormack 2000) recognises personhood as the person's ability to make rational decision by virtue of his reflection on available needs, choices wants and desires. On the contrary this ability to make rational decisions might be difficult particularly in persons with dementia (Kitwood 1997), however choices can be offered to the person.
Harre (1998, p.6) drawing on the work of Apter (1989),concludes that ; a sense of personal distinctiveness, a sense of personal continuity and a sense of personal autonomy important phenomenon that best described personhood. Elsewhere in literature, transcendence - (a state beyond material or usual existence) has been referred to as an essential characteristic for description of personhood (Heron 1992 & Kitwood 1990a, 1997).This goes to establish the assertion that "personhood" can be accessed from three type of literature- theology and spiritual, ethics and social psychology and each of these literature gives different meanings to attributes relating to personhood (Kitwood 1997, p.8).
McCormack (2004) in an extensively reviewed literature concludes that four concepts are in consistence with person-centred nursing. These are: Being in Relation, Being in Social Context, Being In Place, Being With Self.
Being In Relation
Being in relationship emphasizes the point that, for any effective person-centred care to commence, continue and achieve success ,the nurse and the patient should be in a good interpersonal relationship and this relationship requires valuing of self, moral integrity, reflective ability, knowing self and others as derived from reflection on values and their place in the relationship. Being in relationship is also reflected in one of the seven attributes of person-centredness identified by Slater's (2006) concept analysis-evidence of a therapeutic relationship between person and health care provider. He further states that this relationship between the person and care provider must be one of mutuality, mutual trust and non-judgemental which does not take into consideration the balance of power.
Being In Social Context
This is the interconnectedness of persons with the social world in which individuals create meaning to themselves through being in the world. Being able to understand the social world of the person enables one to clearly identify things that are considered paramount in their lives Slater (2006).In order to understand the person's social context, it was suggested in gerontology that "life plans" can be used as this presents a clear picture of what one really wants to do in life (Meyers 1998: 49).This view has been supported by McCormack (2004) that this plan evolves overtime where new experiences consistent with ones life are integrated towards the attainment of future goals. As espoused in the works of other researchers elsewhere, the use of life plans in biographical approach to assessment serves as a good basis for negotiated decision making (McCormack 2001a, Nolan et al, 2001 & Clarke, 200).
Being In Place
Andrew (2003) declares that concept of 'place' and its impact on health care delivery is poorly understood in nursing. Andrew further argued that 'places' are not just physical but involve situated human intentions within them.(Andrew, 2003; Luckhurst & Ray, 1997; Hussain & Raczka, 1997) contends that attention must be paid to 'place' in care relationships for its important role. In order for nurses to be facilitators of person-centredness, care values must be balanced with other organisational values no matter how difficult it might be, to enable the process of the concept to continue smoothly (Woods 2001). A similar idea was expressed by Johns (1995) that nurses cannot freely fulfil their moral obligation to patients without taking cognisance of organisational and professional implications. To buttress this McCormack et al (2002) asserts that whilst it is important for nurses to facilitate person-centredness, other contextual issues such as staff relationships, organisational systems, power differentials and the extent to which the organisation tolerates innovative practices and risk taking should be worth noting.In literature reviewed so far there is no study that specifically dealt with solutions to as to how organisational structures should be reframed to help nurses provide person-centred care devoid of fear anxiety and intimidation. However, Edvardson et al (2008) in there study proposed further research into how organisational structures and variables (eg. management) promote or obstruct person-centredness.
Being with Self
Knowing self is very central in person-centred nursing approach. This is important in that, health care providers need to identify their personal values first in order to respect the values of other patients under their care, to avoid trampling over their autonomy and cultural needs
paramount to person-centredness (Downs, 1997; Ford & McCormack, 2001; McCormack, 2001b; Nolan, 2000). There is emphasis on the importance of having a clear understanding of what patients and others important to them value about their life and perception of things happening to them as these forms the basis of adopting a "negotiated" approach between the patient and the carer Brown et al (1992). Further, knowing self enables the nurse to make comparisons of current lifestyles and behaviours of the patient with his preferences and values of life in general as a clue to enhance care process (Meyers, 1999).
In spite of the good attributes mentioned about person-centred practice, translating the core values of the concept into professional practice is difficult, however few studies did report on outcome of care in person-centred nursing (McCormack & McCance 2006).Additionally, person-centred practice in health care institutions is hindered by competing demands on constantly depleting resources available to these institutions (McCormack 2001).Couple with the problem of implementation a further review of literature shows that over the years there is lack of valid instruments to measure person-centred practice (Coyle & Williams 2001, Adams et al 1995) until recently when Slater (2006) developed the person-centred nursing index (PCNI).
PERSON-CENTRED NURSING MODELS
Literature reviewed so far revealed five conceptual nursing models which are in consistent with person-centred practice - The authentic consciousness (McCormack 2001a,2001b,2003 and 2004), positive person work (Packer 2003), senses framework (Nolan et al 2001),
skilled companionship ( Titchen 2000,2001 p.80) and the Burford Nursing development Unit model (Johns 1994).To achieve the aims of this study, the five models will be briefly reviewed. Out of these, the authentic consciousness framework (McCormack 2001a,b, 2003)
as articulated through McCormack and McCance's theoretical framework (2006) will be examined as it forms the theoretical framework from which the intervention strategies in this study will be developed, and as such will inform the development of the person-centred nursing index.
THE SENSES FRAMEWORK
The senses framework (Nolan et al., 2001) was developed based on the US relationship centred model of health care. This framework was underpinned by the subjective and perceived dimensions of caring relationships that exists for the older people (Dewing 2004).The framework further stipulates that all parties involve in the caring (the older person, families and nurses) should experience a kind of relationship that promotes:
- Security- feel safe within relationships;
- Belonging- to feel 'part' of things;
- Continuity- to experience links and consistency;
- Purpose- to have personally valuable goal or goals;
- Achievement- to make progress towards a desired goal or goals;
- Significant- to feel that 'you' matter.
Adopted from Nolan et al (2004)
It is therefore evident from this framework that in order to experience good care all participants in the care process must experience these senses, hence it is not only the nurse and the patient who are 'in relation' (McCormack 2004) but all others. Similar to the Burford model, this framework does not explicitly focus on nurse-patient relationship or nurse-carer relationships; as a result there is a situation where nurses consider themselves as one part of a much bigger social group around older people (Dewing 2004).Dewing however explained further that, in person-centred practice it is essential that nurses considers the older person as a social being which also in consistent with the Authentic Consciousness model. This framework however provides a limited directives as to how nurses can attend to each of the senses (Nolan et al.; 2001, p.175).
The skilled companionship framework developed by Titchen (2000, 2001) offers nurses an opportunity of highly skilled relationship-based work with patients. This is because it has bee considered elsewhere in literature that the more skillful or expert a nurse is the more accurate they are in their judgement and predictions about care (Benner and Wrubel, 1989). The framework was imbued with humanistic influenced by works of (Carl Rogers 1983), critical (Habermas 1972& Fay 1987) phenomenological and spiritual (Campbell 1984) perspectives. The conceptual framework uses the metaphor of a companion accompanying another with a variety of ideas which will be useful on their journey (McCormack 2004).According to McCormack, for skilled companions to enter into therapeutic relationship with patients and families, it requires a professional artistry in terms of synchronicity, balance, attunement, interplay and perspective transformation. Three domains are identified with this framework for developing practice expertise; the relationship, rationally-intuitive and the 'self' domains. The relationship domain in particular has been identified as one that emphasizes the use of practical strategies in their active involvement
with care, based on its concepts of 'reciprocity' (the mutual giving and receiving in relationship), 'mutuality' (working with patients and families), 'particularity' (knowing the patient as a person) and 'graceful care' (using all aspects of self), McCormack (2004).
POSITIVE PERSON WORK
The positive person framework has been developed by Packer (2003), drawing on the works of Kitwood and the Bradford Dementia Group (Kitwood 1997a, b).This model has been developed to create equal opportunity for people with dementia and those professional and lay carers attending to their needs (McCormack 2004). According to (Keady et al 2003), the model was developed on 12 core elements (recognition, negotiation, collaboration, play, timalation, relaxation, validation, holding, giving, facilitation, creation, and celebration). Keady et al continue to explain that these elements are neither mutually exclusive nor should all of them be expected to be present all the time to keep the care process running. Among all the person-centred nursing models discussed in this study, the Positive Person Work is the only model that pays much attention to the intrapersonal and intrapsychic aspects of being a person (Dewing 2004).
THE BURFORD NURSING DEVELOPMENT UNIT (BNDU) MODEL OF NURSING
The BNDU holistic model of nursing (Johns 1994) was developed from four key components of the philosophy for practice - external environment of care, internal environment of care, social viability and the nature of care as described by (Johns 1991).The model is underpinned by a philosophy of humanistic caring and focuses explicitly on building therapeutic relationship between nurses and patients through the concept of reflective practitioner which is the central theme of the model (McCormack 2004).This framework is seen as very helpful in two directions; it enables the nurse to take into consideration the live experience of the patient in care and also facilitates the nurse to reflecto
n the interaction of feelings between him/her and the patient as they are in therapeutic relationship (Buthcer & Dewing, 1994). Another key aspect of the model is the assessment process and its core question 'what information do I need to be able to nurse this person'? (Johns 1994).This question according to (McCormack 2004) is answered by nine other questions which seek to create a picture of the person that reflects their biography. Compared to other frameworks discussed in this study the BNDU model has a little focus on clinical elements of health and illness (Dewing 2004).
PERSON-CENTRED PRACTICE BASED ON AUTHENTIC CONSCIOUSNESS
The authentic consciousness framework (McCormack 2001a,b, 2003) has been developed through research that explored autonomy in relation to older people in care (McCormack 2001). The framework is underpinned by the concept of 'authenticity' and its effect on care relationship between the nurse and the older people. The framework further emphasizes 'negotiated relationship' as means through which an effective partnership working can be enhanced between the nurse and the older people. According to Gadow (1980), authenticity refers to "decisions that express all that one believes important about oneself and the world, the entire complexity of one's value". In the view of Gadow, this description of authenticity refers to the act of making decisions which are actually one's own. He continue to explain that to enhance person-centred approach to nursing, nurses need to be aware of freedom of self- determination for patients as a fundamental human right based on interconnected relationship with each other. However the role of a nurse in person-centred nursing is to be available and use his/her practical expertise to offer personal assistance to patients in an environment of personal freedom and self judgement. (McCormack 2003).It has been observed that being in total connectedness with patients sometimes lead to 'ethical blindness' (Benner & Wrubel 1989). In order to avoid this situation, the nurse needs to move in between three levels of engagement (engagement, partial disengagement and complete
disengagement)McCormack (2003). According to McCormack, there is engagement when the patient and a nurse are connected in a care partnership such that there is respect for each other. On the other hand, there is partial disengagement if the care relationship between the nurse and the patient no longer work together due to any form of disagreement and it takes sometime for the two parties to take stock and find solution to the problem when no solution is sought immediately and it extends for some period of time then complete disengagement occurs. However, mechanisms such as clinical supervision (Bishop 1998), supported reflective practice (John 1997) and case reviews (Robbins 1998) exist for resolution of these problems of engagement.McCormack (2003) observed that, to establish a good therapeutic relationship with patients, there is the need to consider contextual factors, the patient's authenticity, and put 'imperfect duties' into practical use. He identified five imperfect duties on which the framework operationalized. For the purpose of this study, imperfect duties (informed flexibility; mutuality; transparency; sympathetic presence; and negotiation) which are consistent with the process of authentic consciousness will be discussed.
According to Immanuel Kant's morale theory cited in (Sullivan, RJ 1990), imperfect duties are described as wide, broad and limited such that it gives room for discretion but within the rules of the organization within which one works. However there is no means of offering an exhaustive and a priori account of how the duties are to be fulfilled.
- Informed flexibility: this is the facilitation of decision making based on information dissemination and the integration of new information into established perspectives and care practices.
- Mutuality: the recognition of the others' values as being equally paramount in decision making.
- Transparency: making clear the intentions and motivations for action and the boundaries within which care decisions are set.
- Negotiation: patient participation through a culture of care that values the views of the patient as a legitimate basis for decision making while recognizing that being the final judge of decisions is of secondary importance.
- Sympathetic presence: this is an engagement takes into consideration the uniqueness and value of the individual by appropriately responding to cues that maximize coping resources through the recognition of important agendas in daily life.
Source: (adopted from McCormack 2003)
McCormack (2003) declared that for person-centredness to operate effectively in practice, factors such as the patient's value, the nurse's values and the context of care environment have to be considered very essential. The study will therefore have a critical discussion on these factors and their effect or influence on person-centred practice.
In person-centred practice respect for patient's values are identified as being central in order to achieve an effective process of the concept (Dewing, J. 2002; William,B. & Grant. 1998; McCormack 2001).It is important to develop a clear picture of what patient's values about their life and how they make sense of what is happening around them. Helping the individual to have realization in care makes them to tolerate the incongruency of their illness and also helps them to plan for future, to do this, there is the need to build a baseline value history of the patient through biographical accounts and narrative story (Meyers, D.T. 1989).The complex nature of most health care decisions couple with anxiety, fear of illness, dependency and other aggressive tendencies results in the patient's decision making ability being diminished.( Buchanan & Brock, 1989) Argued that if patients are left to be in total
control of their health care decisions, most often than not their choice of treatment decision might not work effectively towards their well being as expected. They further argued that, as much as patients are expected to participate in decision making regarding heir health, they should also be protected sometimes from harmful consequences of their own choices.
According to Seedhouse, D. (1986) health has different meanings to different people and is also given various degrees of relevance by individuals. It therefore implies that there is no single care intervention that can be considered best for everyone. Whiles are a particular approach is applicable in one situation it may not be same in the other. In view of these, health care decisions need to adopt a negotiated approach between the patient and the practitioner (McCormack, 2001).
In spite of partnership being a common phenomenon in person-centred practice where nurses are encouraged to be lenient in their presentation to patients, it is unusual for nurses to present their own views as a part of information that patients are given to help their decisions.Gadow (1980) argued that in as much as patient's values should be dominant in the decision, nurses values also contribute to enhance the efficiency of the process but in a less explicit manner. Nurses expressing their values in care decisions should not really be a problem if there is partnership, since these will help the patient to have more insight into the nurses' position regarding their care.
CONTEXT OF PRACTICE ENVIRONMENT
Despite more attention on nurses and patient values the care environment also play a significant role in the person-centred process in which there is the tendency to either promote or hinder its smooth running (McCormack et al 2002; Rycroft-Malone et al 2002).In facilitating person-centredness nurses are faced with difficulties of having to cope
with the morale obligations to patients as well as organisational and professional implications (Johns, 1999).This situation has been confirmed by recent analysis f context undertaken by McCormack et al (2002). Yarling (1990) expressed a similar view to earlier researchers above that, in modern health care delivery, while nurses are expected to engage in autonomous decision making they are limited in exercising their authority.
IMPACT OF PERSON-CENTRED NURSING
Slater et al (2009), reports that there is lack of quantitative evidence to support the benefits derived from using person-centred nursing approach in care delivery, even though few studies did attempt to quantify its impact on patients and nurses it is on a small scale. This situation has made some researchers to conclude that person-centred nursing is not achievable and that it exists as an evangelical ideal (Parker 2001). Most findings identified on person-centred nursing are qualitative in nature and has enough information towards positive practice but are of limited generalizability across settings and small scale (Binnie & Titchen 1998, 1999; Tonuma & Winbolt 2000). Prior to the adoption of person-centred practice in clinical settings, the culture of practice has been characterised by rigid routines,rituals and a care delivery that is beneficial to nursing staff and ward administration (Tonuma & Winbolt 2000).However as developmental strategies begun to take root in the settings guided by principles of person-centred nursing, hierarchical structures were removed giving rise to participative model in which nurses are involved in decision making which helps keep stress levels down and increased good communication between all health professionals (Slater et al 2009).Evidence from the literature of (Binnie & Titchen 1998, 1999) also emphasized that person-centred approach to care delivery enhances patient satisfaction with care, promotes good interpersonal relationship among staff and changed care process to become more holistic. A further evaluation on the person-centred nursing as a model revealed numerous benefits such as adequate staffing levels, professional
development issues, decentralised structures among others that comes as a result of organizational changes to facilitate the implantation of the model (Binnie & Titchen 1998). Inspite of all these, (Ford & McCormack 2000) argued that the impact of person-centred nursing care relative to nurse patient outcomes can rarely be measured or quantified due to complexity and interaction of various factors that operate within the process of person-centred nursing.
THE CONCEPT OF PERSON-CENTREDNESS IN REHABILITATION
Clare et al. (2006) define rehabilitation as "an individualized approach to helping people with cognitive impairments in which those affected, and their families work together with health care professionals to identify personal-relevant goals and strategies for addressing these". This definition clearly shows a connection between rehabilitation and the concept of person-centredness. Leplege et al (2007) argued that the notion of person-centredness have been used interchangeably as patient- centred ,client-centred, individual- centred, person-directed. Reasoning along this argument, implies that the term has a multidimensional use. In order to establish further the description of this terminology, Leplege and his colleagues undertook a conceptual analysis of person-centred concept in the field of rehabilitation and identified few supportive concepts that clearly elaborate on the use of the term.
THE PERSON'S SPECIFIC HOLISTIC PROPERTIES AND DIFFICULTIES IN EVERYDAY LIFE
Person-centredness as a means of addressing the person's specific and holistic properties suggests that in dealing with individuals, their biological and psychosocial needs must be considered as paramount as opposed to classical analytic medical attention on the functionality of specific organs and related medications prescribed for relief of ailment. In
their view regarding person-centredness in rehabilitation, the term seeks to address difficulties in everyday life of disabled persons in such a manner as to reflect their needs and social adjustment. Rehabilitation alone without person-centredness seems more technical and ignores other aspects of the patient's life.
PARTICIPATION AND EMPOWERMENT
It is further argued that disabled persons be given more decisional autonomy in order to be aware of what is happening to them, the way they perceive treatment and care offered them and other variations about care available to them. Patients of disability should not be passive about interventions available to them; they should be allowed as key participants. It is however stressed that the concerns of disabled persons are not different from able persons and therefore equal attention is supposed to be given to both.
RESPECTING THE PERSON 'BEHIND' THE IMPAIRMENT
Respecting the person in spite of his/her impairment or the disease reflects the notion that disabled persons be accorded the dignity and respect they deserve, because disability can be considered as part of 'normal' life and therefore should not be treated with pity and stigmatization. Leplege et al therefore declared person-centredness as anti-reductionism which seeks to hold in high esteem views and rights of disabled persons in decision making regarding their health care.
PERCEPTION OF PERSON-CENTRED NURSING ACROSS NATIONAL AND INTERNATIONAL DIVIDE
The concept of person-centred care has long been associated with the nursing profession and understood in principle as; establishing mutual trust and understanding with individuals, respecting their values and rights as a person, and developing therapeutic relationships with
them and others associated with their care.The good aspect of delivering care in the philosophical context of person-centredness cannot be over emphasised, but it has been observed that translating the main concept into daily practice is always met with challenges (McCormack & McCance 2006).The reasons for these inefficiencies manifest in different forms and are seldom indicative of the context in which care is delivered, coupled with constant changes that occur particularly within health and other social care sectors. Person-centredness has been in existence with health care delivery for some time now and is consistent with policy direction and reflected in many approaches to delivery of care. The concept manifests itself in policy directions across both national and international health care sectors.
In the United Kingdom the concept of person-centredness is embedded in most health care policies such as The Dignity in Care Campaign (DoH, 2006) and The National Service Framework for older people (DoH 2001). Further, recent publications by the Royal College of Nursing (RCN) emphasised challenges for nurses and midwives in provision of dignified and sensitive care, in its report on health care.In Northern Ireland, the focus is on promoting "person-centred standards"- (respect, attitude, privacy and dignity, communication, behaviour) across health and social care sectors. It has been observed that within the health service, the drive to promote effectiveness and efficiency in performance management has not been high. As a result, patients, clients and their families receive less attention in care delivery as indicated in a range of quality and clinical indicators (DHSSPS 2007a; Nolan, 2007).Whilst the term "person-centred" care is rampant in the UK health and social care literature and policy documents, the underlying principles of person-centred care are similar to that of international movements that is focused on humanizing the health and social care experience. This is evident in the "Skaevinge Project" carried out in Denmark (Wagner L. 1994). In his action research, focus was on preventative work and also to ensure the rights of
residents in care homes as citizens in society. This model again helps in putting to shape the future of residential care and the design of care homes internationally. Wagner infused into his work such principles underpinning person-centred care as autonomy, citizenship, dignity and respect, to enhance efficiency of his model. Health care policies around the world adopt these principles and use them in several policy frameworks related to social and health care sectors.In Australia for instance, person-centred care has been a solid foundation of facility accreditation in "The Aged Care Standards and Accreditation Agency" and the New South Wales department of nursing has its focus on enhancing practices and models of care to support person-centredness across all specialities.
Developing models that enhance care and promote person-centred principles has become a vital issue in health and social care. A notable instance is the Institute for Health care Improvement (IHI) in the United States of America. Most governments in the West have initiated transformations and innovated frameworks in health and social services through most of the practices of the IHI. Majority of the plans initiated by these governments focused on person-centred care mainly through transformation systems and redesign of clinical services.