Guest blog authored by Stephen McKenna & Samuel Richardson Velmans, Postgraduate Student Mental Health Nurses at City, University of London
Sam and Stephen are second-year postgraduate student mental health nurses at City, University of London. Their research interests include therapeutic autonomy and alliances, nursing as politics, and the concept of ‘caring’ understood as part of the first-person experience of illness and recovery.Before becoming a student nurse, Sam graduated from Bristol University with a BA in Philosophy, where he studied under Havi Carel, choosing to specialize in methods of understanding the lived-experience of chronic illness.Stephen was previously a support worker, research assistant and patient advocate at the National Hospital for Neurology. He holds a BA and MA also from the University of London and is an alumnus of the NHS Staff College. Stephen can be contacted on Twitter at @sjpmck.
The distinction between ‘person-centred care’ and ‘person-centred caring’ rests on two primary beliefs. First, that knowing the names of values (such as being ‘person-centred care’, or compassionate) is not a sufficient basis for the provision of good care. Second, that the varied attempts by healthcare institutions to guarantee that their nursing staff deliver ‘person-centred care’ actually risk having the opposite effect, that of inhibiting the ability of nurses to carry out caring that is centred on the patient.
When expressing person-centred care in a language abstracted from daily activities and subjectively lived experiences – for example “no decision about me, without me” – we may mistakenly assume that we act it out in reality, and that our intended ‘person-centredness’ is actually experienced by the service-user. When accepted uncritically, as part of a job description or professional standard, the phrase ‘person-centred care’ becomes merely a signal that we think the right things, with no guarantee that we do them effectively.
Moreover, well-intentioned attempts to enact person-centred care may accidentally result in practices that obstruct – or worse are entirely separate from – the activity of caring and experience of being cared for. They may, ironically, create a system that is task-centred rather than patient-centred. To give one example, in our experience the expectation to fulfil person-centred care during the admission process can be satisfied by uploading a completed care-plan to the notes of a patient within their first twenty-four hours on the ward. Not only is it unlikely that the information required to fill-out the care-plan was actually gathered within that short space of time, but the primary need being met is that of the institution, not the individual patient. Spending time in the nursing office completing ‘person-centred care’ tasks that can be achieved without personal interaction cannot be called person-centred caring.
To provide individualised care, we must seek to understand an individual’s own subjective experience of their illness and our role as nurses in caring for that individual. Mental illness isn’t simply in one’s head, it’s effects are embedded in one’s whole experienced world. Put differently, individuals don’t ‘have’ illness, they ‘exist’ it. For example, consider the patient afraid to go into their bedroom, because every time they do, they experience fighting a stranger. Although the experience of being confronted by a stranger is delusional (empirically there never was a man in the room), this patient is not delusional about having that experience. Therefore, their fear is justified.
If the patient’s experienced world is part of their experienced illness, then we nurses, by inhabiting that world in an inpatient setting, are ourselves a constituent part of the experienced illness, and can also the experienced recovery from that illness. This is difficult to dispute when we acknowledge that, on any given ward, nurses are with patients twenty-four hours a day, every day, all year round. In this respect, the nursing team differs from all other healthcare professionals. We are intimately bound to the patient’s experienced world. Therefore, we should consider that everything we do as nurses is potentially therapeutically salient, which is easy to forget among the repetition of routine tasks.
We believe that ward nurses possess the creativity to facilitate person-centred caring. However, we contend that a unique kind of self-awareness is needed to bring this about, one in which, as nurses, we conceive of our words and actions as participating in the experience of another’s illness. As such we do not think a new institutional model of nursing is necessary. We have faith that by giving proper credence to the subjective experience of illness, model-users (i.e. us nurses) can become model-makers not just for our patients, but also ourselves.