Principles Of Person-centred Care Research Articles

Teaching Person-Centered Care and Interprofessional Collaboration through a Virtual Mental Health World Café: A Mixed Methods IPE Pilot Project

The purpose of this convergent mixed methods interprofessional education (IPE) pilot project was to help health profession students gain valuable insight about the experiences of people living with mental illness, to help them have a better understanding of person-centered care and have greater knowledge about the importance of interprofessional collaboration. A developmental workgroup which consisted of mental health consumers, four interdisciplinary students, and our team developed and implemented a virtual Mental Health World Café IPE event. Twelve other students attended the World Café event. A paired sample t-test was used to examine group differences between pre- and post-test scores for the Interprofessional Socialization and Valuing Scale and the Texas AHEC Survey measures among the four student leaders and the 12 student participants of the virtual Mental Health World Cafe. We conducted individual interviews with the four student leaders and collected reflective journals from the 12 students who attended the World Café event. We examined to what extent the statistically significant quantitative results supported the qualitative results separately for the student leaders and for the student participants of the virtual World Café. We also examined how both the quantitative and qualitative findings aligned with the key components of the Patient-Centered Care in Interprofessional Collaborative Practice Model. While the project allowed the students to reflect upon how they may apply the principles of person-centered care and interprofessional collaboration, the impact of the consumers on the student’s experiences was profound and resulted in widespread engagement of the students who attended the event.

Montessori Method applied to dementia, a person-centered global approach Part 1: Origins and principles

While dementia care is going through a major crisis, a strong call for the development of person-centered care for persons with a diagnosis of dementia has recently emerged. Person-centered care (PCC) is a philosophical and theorical intervention framework acknowledging that the individual is still a person who can live positive life experiences and relationships, despite a progressive disease, even at severe stages. It has arisen as a response to a medical model, focused on pathology and deficits. The benefits of PCC have been well documented. However, questions remain about how to concretely provide it. In this context, the Montessori method applied to dementia represents one way to apply person-centered care to person with dementia. Based on the philosophy and principles of the scientific pedagogy developed by Maria Montessori, it integrates PCC principles, associated with rehabilitation techniques, to promote constructive engagement in meaningful activities, to give back sense of control to the person with dementia, and to allow the person to have a role in the community. In this article, we will first present the person-centered care philosophy, its main principles, and effects. Secondly, we will describe a brief historical perspective of the Montessori method for person with dementia. Then, we will present Montessori principles in a detailed and structured way.

Key Considerations When Providing Physical Rehabilitation for People with Advanced Dementia

Dementia is a growing global challenge with numbers set to increase rapidly in the coming years. Evidence suggests that exercise can be effective in improving cognitive functioning, but the evidence does not yet support improvements in other key domains such as quality of life or physical ability. The aim of this study was to explore the key components that needed to be considered when providing physical rehabilitation to people with advanced dementia. The study used a qualitative approach involving semi-structured focus groups with health care professionals who are experts in delivering interventions to people with advanced dementia. As a pragmatic study seeking to inform the development of interventions, a thematic coding approach was used to make sense of the data. We collected data from 20 healthcare professionals who reported that key considerations needed to be considered from both an assessment and an intervention perspective. The assessment needed to be person centred and, with the right people engaged and using outcome measures that were meaningful to the patient. The actual intervention also needed to follow the principles of person-centred care, with emphasis placed on the importance of taking time to build a rapport with the person, but also reducing any of the barriers that would prevent effective engagement, such as unsuitable environments. Our study suggests that while there are barriers and challenges to providing interventions and rehabilitation to people with advanced dementia, appropriate person-centred, tailored interventions can be effective and therefore should be offered.

Information needs in patients with bladder cancer undergoing radical cystectomy - A qualitative review with thematic synthesis.

Worldwide, bladder cancer is the eleventh most common cancer. Self-care is significant after surgery and optimal information needs to be individualized. This will help the patient to understand and become involved in their own care. This study investigated experiences of information needs in patients with bladder cancer undergoing radical cystectomy. A qualitative review study with a thematic synthesis according to the PRISMA Statement Guidelines was performed. Thirteen peer-reviewed original articles were included. This review highlighted that patient experienced unmet information needs about postoperative care and self-care. Patients also experienced receiving too much information in a limited time. This led to difficulties in understanding and processing the information. Patients also experienced limited information about sexual and psychological support and requested more information about physical activity. Information is essential but needs to be adapted and based on person-centred care principles related to the patients' needs and wishes. Unmet needs impact patients' lives and are associated with misunderstandings and insecurity, which need to be considered in cancer nursing. The review was not registered.

P074“Care about me as a human”: Building affirming relationships with transgender and gender-expansive patients

<h3>Objectives</h3> Prior research has mostly focused on discrete clinical components of transgender care and contraceptive counseling, often centering clinician viewpoints. This qualitative study explores transgender and gender-expansive (TGE) perspectives on a range of healthcare experiences, with a focus on affective and interpersonal factors that impact quality of care, access to care, and provider relationships. <h3>Methods</h3> We conducted in-depth interviews with 16 TGE individuals. Participants were asked questions about their values, needs, and reflections around primary, gender-specific, and reproductive healthcare experiences. Beyond clinic-based practicalities, interviews centered deeper inquiries into more substantial influences on person-centered care, including barriers to care and quality of provider relationships. <h3>Results</h3> Interviews were conducted with 16 TGE individuals. Similar themes emerged across different types of care, including an emphasis on person-centered care and high-quality provider relationships. Participants identified quality relationships with a healthcare provider to be at least as important as provider literacy on transgender-specific issues. Additionally, participants expressed the desire to be treated by their healthcare provider as an individual, with unique health goals, barriers, and priorities that may not match those of other TGE individuals. <h3>Conclusions</h3> In defining inclusive and affirming care, participants placed emphasis on genuine provider relationships, individualized care, and normalization of transgender identities. Implementing affirming healthcare should rely less on a checklist of trans-specific competencies and more on the principles of person-centered care. This research should be considered when implementing healthcare services, in order to provide care that is affirming and inclusive for TGE individuals.

The principles of person-centredness in quality patient care-Evaluation of the Community Pharmacy Services Quality Guidelines in Estonia.

Person-centredness is considered a key component of quality healthcare and the core competence of all healthcare professionals. However, person-centred care (PCC) is not often considered a priority for improving the quality of healthcare. This study aimed to evaluate to what extent the PCC principles are included in the Community Pharmacy Services Quality Guidelines (CPSQG) in Estonia. The deductive content analysis was performed using the PCC framework developed by Santana etal. Approximately 2/3 (n=78) of the CPSQG indicators (n=126) in the practical guide used in Estonian community pharmacies support PCC principles. These results demonstrate that quality service itself includes some PCC components, as it forms an integral part of quality care and is directly related to its development. More than half (61.6%) of the CPSQG indicators were divided into process (covering the interaction of pharmacists and patients), one fourth into structure (mainly represented as environment and operation topics), and one tenth into outcome category (access to care). This result is in line with the situation of pharmacies in Estonia, where the current focus is on developing and implementing quality services (e.g., quality guidelines, e-tools supporting dispensing, restructuring of counselling area for private consultations) and finding the necessary resources for described activities. To support a more effective application of PCC principles in the community pharmacy practice, the CPSQG should be supplemented with indicators identifying patients' individual preferences, values, and needs. Additionally, interactions with other healthcare professionals should be encouraged, and they should be engaged in developing the CPSQG.

Benefits and harms of interventions to improve anxiety, depression, and other mental health outcomes for autistic people: A systematic review and network meta-analysis of randomised controlled trials.

Nearly three out of four autistic people experience mental health problems such as stress, anxiety or depression. The research already done does not guide us on how best to prevent or treat mental health problems for autistic people. Our aim was to look at the benefits and harms of different interventions on mental health outcomes in autistic people. We searched all the published randomised controlled trials (RCTs) about interventions for mental health conditions in autistic people until 17 October 2020. We also searched for RCTs that were not published in peer-reviewed journals. These were obtained from registers of clinical trials online. We then combined the information from all these trials using advanced statistical methods to analyse how good the interventions are. Seventy-one studies (3630 participants) provided information for this research. The studies reported how participants were responding to the intervention for only a short period of time. The trials did not report which interventions worked for people with intellectual disability. In people without intellectual disability, some forms of cognitive behavioural therapy and mindfulness therapy may be helpful. However, further research is necessary. Many trials used medications to target core features of autism rather than targeting mental health conditions, but these medications did not help autistic people. Until we have more evidence, treatment of mental health conditions in autistic people should follow the evidence available for non-autistic people. We plan to widely disseminate the findings to healthcare professionals through medical journals and conferences and contact other groups representing autistic people.

‘I am the educator and the learner at the same time’: a qualitative survey of the knowledge and use of adult learning theory in UK musculoskeletal physiotherapists' patient education

Background/Aims Patient education is a core component of musculoskeletal care, yet broad definitions exist and effective delivery methods are unclear. Musculoskeletal physiotherapists' use of patient education has been described as individualised and collaborative, reflecting a person-centred model of care. However, discrepancies between perceived and actual practice, and therapist-centred approaches to education, have been observed. Little is known about the theoretical basis of musculoskeletal physiotherapists' patient education practice, yet the adult learning theory frames how adults interact with education and echoes the principles of person-centred care. The aim of this study was to analyse the use of adult learning theory to inform patient education practice among UK musculoskeletal physiotherapists. Methods This study used a novel, online questionnaire to collect quantitative and qualitative data from a self-selecting sample of UK musculoskeletal physiotherapists, using a multimodal recruitment strategy. Complete responses were provided by 66 participants. Categorical and narrative data were collected and descriptive and thematic analyses undertaken. Results Participants generally self-rated their educational competencies highly, with the exception of evaluating patient education. Participants were more familiar with reflective and self-directed learning than with other adult learning theories. Two main themes were described: implicit adult learning theory knowledge and challenges in applying adult learning theory. Conclusions The results suggest that musculoskeletal physiotherapists may have implicit knowledge of adult learning theory, yet challenges exist in applying them. This finding supports the establishment of ongoing training in educational skills for physiotherapists and could be used as a catalyst for musculoskeletal physiotherapists to reflect on their knowledge and use of adult learning theory.

Digital communication in primary care: A qualitative descriptive study of patient interviews considering person-centred care

With the growing demand for primary care, provision needs to be efficient, yet retain person-centred and integrated care. Digital communication is suggested as a way to settle these aspects, although there is insufficient knowledge regarding the end-user's perspective. The aim of this study was to describe patients’ experiences of digital communication in their primary care contact, while considering aspects of person-centred care. A purposeful sample of 16 patients (aged 28–85 years) was interviewed via telephone in a qualitative design, and verbatim transcripts were analysed using inductive thematic analysis and a subsequent deductive approach in relation to a person-centred care framework. The study was reported following the COREQ guidelines. The findings indicate that, from a patient perspective, digital communication enables independent contact where one crafts one's medical history at a time and place convenient for oneself, providing opportunities for the primary care triage to consider one's individual input. These aspects of digital communication serve person-centredness, although they were less suitable for certain health issues, but a human interaction was most appropriate when health concerns were ambiguous or complex. Thus, digital communication may serve patients in primary care, but the development and implementation of such services must move beyond technical and professional perspectives. In order to facilitate integrated care, further emphasis is needed on both patients’ experiences, and the principles of person-centred care.

From dementia mindsets to emotions and behaviors: Predicting person-centered care in care professionals.

Background and ObjectiveHigh-quality care standards for dementia care are increasingly based on person-centered care principles. To better understand facilitating factors of person-centered care this research focuses on individual characteristics of care professionals. Applying mindset theory to dementia care, we examined dementia mindsets (viewing dementia symptoms as either malleable or fixed) in care professionals. We tested whether there is a positive relationship between a malleable dementia mindset and person-centered care as well as a negative relationship between a fixed dementia mindset and person-centered care. Moreover, we examined whether care professionals’ emotional responses in care situations help explain associations between dementia mindsets and person-centered care.Research Design and MethodIn two cross-sectional studies, care professionals of long-term care facilities (total N = 370) completed a measure of dementia mindsets and reported their emotional and behavioral responses to five care scenarios. Regression and mediation analyses were performed.FindingsThe tested hypotheses were partially supported. A fixed dementia mindset predicted reported person-centered care negatively, while a malleable dementia mindset did not. Mediation analyses suggest that reduced negative emotions may underlie the association between a malleable mindset and reported person-centered care, while reduced positive emotions in care situations may underlie the association of a fixed mindset and reported person-centered care. Study 2 partially replicated these findings. A fixed mindset and positive emotional responses were the most robust predictors of reported person-centered care.Discussion and ImplicationsThis study extends knowledge on facilitators (positive emotional responses to care situations) and barriers (fixed dementia mindset) to person-centered care in care professionals working with persons with dementia. We discuss how dementia mindsets and emotional responses to care situations may be a fruitful target for trainings for care professionals.

Effects of a Person-Centered eHealth Intervention for Patients on Sick Leave Due to Common Mental Disorders (PROMISE Study): Open Randomized Controlled Trial

BackgroundSick leave due to common mental disorders (CMDs) is a public health problem in several countries, including Sweden. Given that symptom relief does not necessarily correspond to return to work, health care interventions focusing on factors that have proven important to influence the return to work process, such as self-efficacy, are warranted. Self-efficacy is also a central concept in person-centered care.ObjectiveThe aim of this study is to evaluate the effects of a person-centered eHealth intervention for patients on sick leave due to CMDs.MethodsA randomized controlled trial of 209 patients allocated to either a control group (107/209, 51.2%) or an intervention group (102/209, 48.8%) was conducted. The control group received usual care, whereas the intervention group received usual care with the addition of a person-centered eHealth intervention. The intervention was built on person-centered care principles and consisted of telephone support and a web-based platform. The primary outcome was a composite score of changes in general self-efficacy (GSE) and level of sick leave at the 6-month follow-up. An intention-to-treat analysis included all participants, and a per-protocol analysis consisted of those using both the telephone support and the web-based platform.ResultsAt the 3-month follow-up, in the intention-to-treat analysis, more patients in the intervention group improved on the composite score than those in the control group (20/102, 19.6%, vs 10/107, 9.3%; odds ratio [OR] 2.37, 95% CI 1.05-5.34; P=.04). At the 6-month follow-up, the difference was no longer significant between the groups (31/100, 31%, vs 25/107, 23.4%; OR 1.47, 95% CI 0.80-2.73; P=.22). In the per-protocol analysis, a significant difference was observed between the intervention and control groups at the 3-month follow-up (18/85, 21.2%, vs 10/107, 9.3%; OR 2.6, 95% CI 1.13-6.00; P=.02) but not at 6 months (30/84, 35.7%, vs 25/107, 23.4%; OR 1.8, 95% CI 0.97-3.43; P=.06). Changes in GSE drove the effects in the composite score, but the intervention did not affect the level of sick leave.ConclusionsA person-centered eHealth intervention for patients on sick leave due to CMDs improved GSE but did not affect the level of sick leave.Trial RegistrationClinicalTrials.gov NCT03404583; https://clinicaltrials.gov/ct2/show/NCT03404583

Whole Team, Whole Person High-Involvement Quality Improvement Training for VA Community Living Center Leaders

Long-term care is a challenging environment for quality improvement due to the high resident acuity, wide variation in resident needs, and wide variation in types and backgrounds of the large staff across three daily shifts. We report results from a learning collaborative undertaken to improve care quality and staff quality improvement skills in the VA CLCs through development of high functioning relationally coordinated teams operating in accord with person-centered care principles. The collaborative included 27 CLCs. Over 9 months leadership teams completed action assignments supported by 5 workshops and regular group coaching calls. Evaluation included fidelity monitoring (attendance, mid- and final progress reports), satisfaction questionnaires, and review of the VA quality measures (CLC Compare). Pre-post participant evaluations revealed a significant increase in positive responses to the question “to what extent do you think applying these new skills/knowledge will improve quality in your CLC?” and positive responses trending toward significance in ratings of abilities to apply new skills. Open-ended survey comments were positive and indicated change in understanding and practice: “utilizing the daily huddle to facilitate real time communication afforded the team a proactive approach to providing care and reducing acute exacerbations. We are able to avert, evaluate as a real time team and make it happen in the now not as a look back.”; “definitely unified front-line staff and CLC leadership.” Some changes were achieved in CLC Compare quality scores (e.g., falls with major injury rate had a 9.6 reduction (average rate = 3.39 pre, 3.07 post)).

Providing person-centred care to older people with intellectual disabilities during the COVID-19 pandemic: experiences of direct support workers

Background: Although the current preventive measures relating to COVID-19 can lead to challenges in the daily work of direct support workers (e.g. keeping 1.5 m distance), it remains vital to uphold the principles of person-centred care when working with older people with intellectual disabilities. The current study explores the extent to which direct support workers have been able to apply a specific form of person-centred care (i.e. integrated emotion-oriented care, or IEOC) when working with older people with intellectual disabilities during the COVID-19 pandemic. Method: Six direct support workers from five facilities serving older people with intellectual disabilities in the Netherlands participated in this qualitative study. They participated in a two-hour focus group, which was transcribed verbatim, and the transcript was analysed thematically. Results: Three themes emerged: (i) the negative impact of changes due to the COVID-19 measures on service users; (ii) the adaptation of direct support workers to changes due to the COVID-19 measures; and (iii) putting the needs and wishes of service users first. Conclusion: This study provides first impressions into the experiences of direct support workers providing person-centred care to older people with intellectual disabilities during the COVID‐19 pandemic.

Nurses' perceptions and beliefs related to the care of adults living with multimorbidity: A systematic qualitative review.

To identify and synthesise the available qualitative evidence on nurses' perceptions and beliefs related to the care of adults living with multimorbidity. The rising prevalence of adults living with multimorbidity has increased demand for health care and challenges nursing care. No review has been conducted to date of the studies of nurses' perceptions and beliefs related to the provision of care to guide policy makers, practitioners and further research to identify and deliver quality care for persons living with multimorbidity. Systematic review of qualitative studies conducted in line with the PRISMA checklist. Eight electronic publication databases and sources of grey literature were searched to identify original qualitative studies of the experience of nurses caring for adults with multiple chronic conditions with no restrictions on the date of publication or study context. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Data were extracted using the Joanna Briggs Institute standardised data extraction tool for qualitative research. Data synthesis was undertaken through meta-aggregation. Eleven qualitative studies were included in the review. All studies met eight or more of the 10 assessment criteria of the JBI Critical Appraisal Checklist for Qualitative Research. Four synthesised findings were generated from the aggregated findings: (i) the challenge of providing nursing care; (ii) the need to deliver holistic and person-centred nursing care; (iii) the importance of developing a therapeutic nurse-patient relationship, and (iv) delivering nursing care as part of an interprofessional care team. The complexity of multimorbidity and the predominant single-disease model of chronic care present challenges for the delivery of nursing care to adults living with multimorbidity. The nursing care of persons with multimorbidity needs to incorporate holistic assessment and person-centred care principles as part of a collaborative and interprofessional team approach. CRD42020186773.

The impact of implementing a person-centred pain management intervention on resistance to change and organizational culture

BackgroundResistance to change and organizational culture are essential factors to consider in change management in health care settings. Implementation of structural change remains a challenge. There is a lack of studies providing information on the impact of implementation processes on the organization. The aim of this study was to describe the impact of implementing a systematic change process concerning postoperative person-centred pain management on resistance to change and organizational culture in an orthopaedic spine surgery unit.MethodsThe study was set in an orthopaedic spine surgery unit at a university hospital. Person-centred bundles of care for postoperative pain management of spine surgery patients were developed in co-creation by a multi-professional expert group and implemented throughout the care pathway. The intervention was underpinned by theories on organizational culture and inspired by principles of person-centred care. Quantitative data were collected using the Resistance to Change Scale and the Organizational Culture Assessment Instrument and analysed using descriptive statistics.ResultsThe findings showed a low resistance to change decreasing during the study. The organizational culture shifted from a result-oriented to a formalized and structured culture after the implementation. The culture preferred by the staff was team-oriented and participation-focused throughout the study. The discrepancy between the current and preferred cultures remained extensive over time.ConclusionIt is challenging to describe the influence of the development and implementation of a postoperative pain management program on organizational culture as well as in terms of resistance to change, in a complex health care setting. In the current study the unit was under organizational strain during the implementation. Albeit, the important discrepancy between the current and preferred organizational culture could imply that structural changes aren’t enough when implementing person-centred pain management structures and needs to be combined with relational aspects of change.

Meaning in Life for Patients With Severe Dementia: A Qualitative Study of Healthcare Professionals' Interpretations.

The need for meaning in life is a key aspect of being human, and a central issue in the psychology of religion. Understanding experience of meaning for persons with severe dementia is challenging due to the impairments associated with the illness. Despite these challenges, this article argues that meaning in life is as important for a person with severe dementia as it is for everyone else. This study was conducted in a Norwegian hospital and nursing home context and was part of a research project on meaning in life for persons with severe dementia. The study builds on two other studies which focused on how meaning-making and experience of meaningfulness appeared in patients with severe dementia. By presenting the findings from these two studies for a group of healthcare professionals and introducing them to research on meaning in life, the aim of this study was to explore how healthcare professionals interpret the patients' experience of meaning in life in practise for patients with severe dementia in a hospital and nursing home context, and to highlight its clinical implications. The study was conducted using a qualitative method with exploratory design. The data were collected at a round table conference, a method inspired by a mode of action research called “co-operative inquiry.” Altogether 27 professional healthcarers, from a variety of professions, with high competence in dementia care participated together with six researchers authoring this article. This study revealed that healthcare professionals were constantly dealing with different forms of meaning in their everyday care for people with dementia. The findings also showed clear connexions between understanding of meaning and fundamental aspects of good dementia care. Meaning corresponded well with the principles of person-centred care, and this compatibility allowed the healthcare professionals to associate meaning in life as a perspective into their work without having much prior knowledge or being familiar with the use of this perspective. The study points out that awareness of meaning in life as an integrated perspective in clinical practise will contribute to a broader and enhanced repertoire, and hence to improved dementia care. Facilitating experience of meaning calls for increased resources in personnel and competence in future dementia care.

The importance of person-centred care and how to achieve it

This article discusses the important concept of person-centred care and how this can be achieved. Following an introduction defining what is meant by this term and contrasting it with the term patient-centred care, the relevant and pertinent parts of the Nursing and Midwifery Council code will then be identified and discussed. The four principles of person-centred care will then be presented. The role of the support worker and nursing associate will be made clear in how the wishes and needs of patients can be gained. Self-awareness, emotional intelligence and communication will be discussed in relation to this. Finally, two potential barriers to the successful achievement of person-centred care will be identified.

The Distinct Value of OT: Examination of Person-Centered Care in Practice

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. Health care is shifting from volume to value, and there is a need to define the distinct value of services. OT is founded on the principles of person-centered care, and the intentional use of these strategies must be part of evidence-based outcomes in order to solidify the value of OT services. This study examined the use of person-centered care in clinical practice, and results were used to develop capacity-building strategies for implementation of a person-centered approach. Primary Author and Speaker: Elizabeth Jayne Braun Additional Authors and Speakers: Erin Casey Phillips, Hannah Corner Contributing Authors: Shayla Murphy, Alayna Pullara, and Nathan Kies

Delivering informed measures of patient centred care in medical imaging: What is the international perspective?”

Focus on patient experience and patient centred approaches within healthcare has substantially increased since the Picker Institute (a not for profit organisation) was established in the 1980′s [15]. The Picker Institute's vision for ‘the highest quality person centred care for all, always’ outlines eight principles of person-centred care which health care providers should strive for [15]:

Care Staff’s Sense-making of Intimate and Sexual Expressions of People with Dementia in Dutch Nursing Homes

ABSTRACT Objectives: The Person-centered Care (PCC) philosophy emphasizes close care relationships to enable care professionals to recognize the needs of nursing home residents with dementia. This study explored how care professionals make sense of resident behavior with regard to intimacy and sexuality. Methods: 26 nursing home care professionals (15 Nurses, 9 Health Care Professionals and 2 Managers) completed in-depth interviews that were subjected to an Interpretative Phenomenological Analysis (IPA). Results: Three thematic layers were identified. 1. Care Professionals pursue a “true” understanding of intimate and sexual behavior that underpins a resident’s expression. 2. When care professionals feel the need to protect themselves, they can reframe a specific care relation in order to continue care. 3. The social context around the resident, from family to professionals (i.e. peers), influences interpretation of behavior and, consequently, the provision of care. Conclusions: Intimate and sexual expressions of residents can put care relations under pressure. Care relations that lack professional distance may compromise care professionals’ judgments, impede their natural boundaries and decrease their well-being. Clinical implications: Along with implementing PCC principles, organizations should empower staff to develop, discuss and include self-reflection skills and personal boundaries within their work.