Person-centeredness a concept in health care delivery has poor and conflicting definitions over the years. Person-centred care can be considered one of the best ways of health care delivery in which patients are valued as individuals (Winfield et al. 1996). Slater emphasized that a wide spectrum of health care providers use person-centredness out of context (2006).
It has been identified in the literature (Binnie & Titchen 1999) that person-centred nursing provides a holistic health care which tends to minimize anxiety among nurses and uphold patient involvement in the care process; however culture and other contextual difficulties exist that influence its effective implementation. It is therefore necessary for health care providers to tread cautiously on autonomy and cultural issues in order not to impede the process (Downs 1997, Ford & McCormack 2000, McCormack 2003b, Nolan 2000).
Leplege et al (2007) in his conceptual analysis identified four key elements on which person-centredness was built - specific and holistic properties of the person, difficulties in everyday life, the person's participation and empowerment and respecting the person behind the impairment. In this regard, person-centredness is considered diverse and multidimensional. It continues to explain that the history of person-centredness has been made to exist on two solid basis- subjective experience of the patient and involvement of the patient in medical decisions and other activities. In recent extensively reviewed literature of (McCance et al 2008), person-centred nursing was identified as a practice in which there is formation of therapeutic relationship between patients/families and nurses on the basis of mutual trust.
Brilowski and Wendler (2005), declared that therapeutic relationship which enhances the concept of person-centred nursing has some elements of care such as working with attitudes and feelings, accepting the other, dealing with variability and purposeful action which when put into practice enhances efficient care delivery.
Anderson (1998) viewed a holistic approach to person-centred care as one in which a person's values, beliefs and life story are considered paramount. Notwithstanding all attributes mentioned, a patient's past and present lifestyles are necessary in deductions made about their care (Baker 2001; Clarke et al 2003; Downs 1997; Erricson et al 2001; Ford & McCormark 2000; McCormack 2003a; Nolan 2000.)
Slater (2006) declares that person-centredness consists of components of a person rather than nurse-patient power-laden relationship. It further stresses on dealing with ethical issues/values of the patient in care delivery.
Researchers (Gerstein et al. 1993, Stewart et al 1995, Winfield et al 1996) declared that person-centred care is considered as one of the best ways health care is delivered to patients and can be seen as a way of valuing individuals. However, the Patient's view and other organisational issues should be considered ideal in person-centred practice as a basis of promoting holistic care,Price (2006). Von Dietze and Orb (2000) buttressed on the earlier view that, while nurses are involved in therapeutic relationship considered as part of person-centred process, they need to be compassionate in view of emotional clashes that are bound to occur. The nurse as a professional in the field needs to be tolerant. Person-centredness has been identified in most health care and nursing literatures as a concept which has a link with previous works on therapeutic care, (McCormack & McCance 2006).
Person-centred care as a basic principle of nursing does not only emphasise standard roles of a nurse but also recommends issues for practice (Chinn and Krammer 1999). According to Kirpal (2004), person-centred care at times puts the nurse at risk of alienation and other frustrations when attention is focused on one-on-one nursing. In a related development, while the nurse-patient/families relationship is well encouraged, cordial relationship between the nurse and other professionals to promote effective health care delivery must also be considered important (Nolan et al. 2003).
Jones (2006) observed that most attributes of person-centred nursing are essential for its practicability but difficult to measure. Person-centred care regarded as a powerful and patient-sensitive tool in health care has been identified most often as lacking practicability (McCormack & McCance 2006). In a related manner it has been emphasised that important aspects of person-centred care are not practiced professionally.
The Person-centred Nursing (PCN) framework has been developed through a systematic procedure of interrelating existing conceptual frameworks to person-centred nursing and other health care literatures. This framework has four (4) indirectly related areas (constructs); prerequisites, care environment, person-centred processes and expected outcomes resulting from person-centred nursing (McCormack & McCance 2006). The relationship between elements of the construct suggested that in order to continue with an ideal person-centred process, patients' views must be critically considered and involved in decision making.
The PCNI has consequently been developed used with the aid of path analysis to produce advanced statistical model to measure the relationship between factors in the framework (Slater 2006). However, the statistical evidence obtained is limited to acute hospital settings. There is the need to carry out a further research into the reliability and validity of the PCNI to substantiate its applicability across clinical settings.
A review into the background of the study showed that the PCNI has been developed in tandem and the theory (conceptual framework) has under gone modifications over time since its development. It is therefore true that the PCNI has outlived its usefulness in measuring person-centred practice in the theory, coupled with this it has a lengthy questionnaire which needs to be reduced. As a result, the PCNI does not map onto the theoretical framework. It is therefore necessary to develop and test an instrument explicitly based on the theoretical framework.
The main aim of this research is to:
Systematically develop an instrument (PCNI) to measure person- centredness based on an extensive literature review and dialogue with experts in the field of person-centredness;
Test the psychometric properties of the PCNI;
Examine the PCNI usability across 5 clinical settings in each of the 5 Trusts in Northern Ireland;
Explore practice environment factors important to nurses from different clinical settings;
Modify the PCNI to accommodate the views of all nurses while maintaining its brevity and appropriateness;
Use the PCNI to gauge change in a clinical setting as it implements a program of person-centred practice.
The study will consider development and testing of an instrument to measure change in health environment as it moves towards person-centredness.Mixed methods approach will be used to explore and test factors relevant to practice environment. Mixed methods by definition, uses qualitative and quantitative modes of data collection. This method would be used in order to answer sufficiently different aspects of research questions posed in the study. Delphi technique and Focus group (Nominal Group Technique) designs will be considered as qualitative methods in the study. The Delphi technique will be used for ranking and reaching consensus on the suitability of definitions of factors in the constructs of the person-centred nursing framework. The Nominal Group Technique will be employed to generate items on each of the factors defined which will be used to design a questionnaire for the study. The instrument will be pilot tested and examined for psychometric properties and necessary modifications. The pilot testing will enable the researcher to study nurses' perception of person-centred process and the effect of care environment on their work. In the quantitative method, cross sectional design will be employed. This design will collect information from nurses in the different clinical settings by use of questionnaire, at a specified time period. The use of this method will enable trends and causal relationships between elements of the framework to be studied. Methods involved in this study are logically outlined in stages as follows:
Stage 1: Development Of Instrument
In the development of the instrument for this study, the Delphi technique will be used to reach consensus on definition of factors in the conceptual framework alongside focus groups in which Nominal Group Technique will be employed to generate items to be used in a questionnaire for the study.
The Delphi Technique
A Delphi Technique comprising 21 international experts in the field of person-centred nursing will be used to reach consensus on definition of factors in the person-centred nursing conceptual framework. This technique is a method of structuring a group procedure in order to allow interaction among a group of individuals on a particular issue to arrive at consensus opinion (Harold et al 2002). The idea of this technique being used in the study is to clarify and identify definition of factors that operate within the person-centred nursing framework. Participants invited for both groups will be made aware of rules of confidentiality, anonymity and respect for others' views before the start of discussion.
The Delphi technique will be used in three rounds of exploration on predetermined seventeen (17) elements from three (3) constructs-(Prerequisites, Care Environment and Care Process), in the conceptual Person-Centred Nursing framework to ensure face and content validity of the definitions. The expert panel will examine and rank definitions of factors provided until a consensus is reached on all.
A focus group comprising United Kingdom based International experts will then be employed using Nominal Group technique (NGT) to generate items for each of the definitions on which consensus was reached. The use of focus groups in this research is important since it provides quick but quality information based on deeper insights, brainstorming and interactive discussions (Parahoo 1997).The nominal group technique used in this study is to help in a quicker generation of items in which domination of discussions by a single person is discouraged and full participation of passive group members are highly encouraged (Delbecq & Van de Ven 1971). Items generated will be collated and given out to the expert panel of the Delphi group to examine its consistency with the definitions. Those found to be less focused on the definitions, will be discarded. Fifty-one (51) refined items-three for each factor will be collated into a pre-designed questionnaire consisting of three broad constructs; Care process- 15, Prerequisites-15, and Care environment- 21 items for pilot testing.
Stage 2: Pilot Testing Of Questionnaire
The instrument will be refined based on guidelines for questionnaire development and testing. The questionnaire will be given out to a sample of nurses in one clinical setting drawn from one Trust for pilot testing as a step towards the main survey. The clinical setting use in the piloting will not be part of the main survey. Questionnaires piloted will be collated, refined and critically examined item by item for clarity, ambiguity and clear understanding of certain terminologies used in the wording of the items. The pilot testing will help the researcher fine tune the main questionnaire, put it into proper layout and ensure its viability for analysis in the main study.
Stage 3: Main Survey
Five stratified clinical settings shall be drawn from each of the five Trust Hospitals in Northern Ireland. The clinical settings will be stratified to ensure homogeneity within each stratum in respect of professional specialization and heterogeneity between strata in terms of different areas of specialization. All nurses in each clinical setting shall be selected from the five strata based on the criteria of being (i)Registered Nurse (ii) work full time (iii) Be in the clinical setting for at least 6months (iv) Willing to participate.
This sample is selected so as to obtain a good representation of views on person-centred nursing practice for all nurses across Northern Ireland. The inclusion criteria have been used in order to obtain quality responses from nurses who are actually qualified to practice.
Questionnaires shall be distributed to nurses within and across Trusts with the consent of the ward sisters or managers who will provide the number of nurses working at the settings. A deadline of two weeks shall be given for the return of questionnaires and a week of follow-up visit to retrieve questionnaires not returned. Questionnaires collected shall be collated and categorised by construct and clinical setting for data analysis.
Stage 4: Usability Study
The PCNI will be used in one selected clinical setting considered to have engaged in a programme of practice development to become more person-centred. The instrument will be administered to nurses in this clinical setting at two different phases; Pre-intervention and Post-intervention Phases. At the Pre-intervention phase data collected be analysed and based on findings in the result, the post intervention phase will be carried out to monitor the progress of person-centred nursing practice in the clinical setting. Changes that occur over time will be examined and addressed.
Data retrieved from the questionnaire will be collated into a complete sample for further analysis. Exploratory factor analysis and path analysis will be used in the data analysis. The exploratory factor analysis will analyse the factor structure of the (PCNI). Principles relating to questionnaire development and factor analysis (Hair et al) will be used to establish the factor structure of the instrument. Reviewing a literature of Slater (2009), Principal component analysis will be employed initially to identify the number of factors that will be drawn based on latent root criterion in which eigenvalues less than one is considered insignificant and therefore discarded. Kaiser-Meyer-Olkin tests will be carried out to test sampling adequacy for small partial correlations among items.Barletts sphericity test will also test if the correlation matrix formed is an identity matrix indicating that the factor model is inappropriate .Three criterion for item inclusion in the factor will be
observed; three or more items per factor, items will have no cross factor loadings, Hair et al.(2006) observed that with a sample of 400 to 500 respondents maximum factor loading should be 0.35 to be included in a factor. Structural equation models will then be constructed by the use of LISREL software in the determination of relationships among the elements empirically. These equation models are equations that contain more than one variable (elements) and representing series of interrelated dependent relationships simultaneously. Path analysis diagram will be constructed and used to:
(i) Examine a Model for complete sample.
(ii) Examine the relationship between factors and person-centredness.
(iii) Examine the differences in (i) between clinical settings and Trusts.
The use of NHS staff-nurses for the study required full ethical approval to carry out the research. It is therefore mandatory to abide by procedures spelt out in the RSCR Research Ethics Framework.
Consultations have been made with the Director of Nursing in the Acute and Community hospitals for approval of the proposed research to be carried out with staff of the NHS in the various Trusts. Application for ethical approval will be sought from the University Research Ethics Committee and Northern Ireland Research Ethics Committee in line with national protocol for commencement of the research.
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