Relationship-centered Care Research Articles

What We Know, Cures; Who We Are, Heals

Introduction Health care is about curing and healing, art and science, mind and heart, skills and knowledge, technology and compassion, living and dying. Funding in health care is based on a business model of efficiency, while experiences of illness, the delivery and outcomes of care are all about relationship—relationships of individuals with themselves and others. The relational quality of the healthcare workplace affects virtually every dimension of organizational performance: decreased mortality, patient/provider satisfaction, staff retention and budget.[1][2] Relationship centered care (RCC) has been shown to promote cohesion, empathic support and collegiality by balancing science-based practice with the centrality of relationships and the importance of the personhood of practitioners, patients and their families.[3] RCC provides a theoretical model for re-conceptualizing what is vital and significant in health care by developing a paradigm focused on caring, healing and community.[4] From the perspective of RCC, patients are both central and embedded in a web of relationships.[5] This presentation will describe how the theoretical framework of RCC can be translated into a core competency training module in a national curriculum for critical care residents. Method The model we have developed in partnership with Canadian Blood Services’ Deceased Donation team includes strategies to assist clinicians in developing knowledge and skills and clarifying values to form caring, healing relationships with patients and their families, with colleagues and with themselves.[4] It will initially be implemented, as a pilot project, with health care providers who are part of the donation community. This work is particularly important to the donation community as it aligns with continued focus on optimizing end of life conversations to collaboratively and compassionately support patients and patients’ loved ones. The model will include strategies relevant to clinicians' relationships with themselves, patients and patients’ families, and other clinicians. Conclusion This presentation will describe how the theoretical framework of RCC can initially be translated into a core competency training module in a national curriculum for critical care residents and subsequently expanded for other health care providers. It will include a description of measures to determine effectiveness of the various components of the model including ongoing learner and program evaluation. This work is essential to integrating relationship centered care into daily practice thereby transforming the culture within the donation community and the broader health care system. How we work together affects the integrity, functional capacity and resilience of patients, their families, our colleagues and ourselves.[5]

We know what to do, but how do we do it? A metanarrative review of implementation frameworks to guide the iCOACH project

Introduction : An abundance of studies have investigated the many influences on the implementation of healthcare aimed at bridging the gap between recommended practice, what healthcare consumers want and need, and what they actually receive. Yet it is still not well known which implementation approaches work best in the use of knowledge, and the adoption and perpetuation of new ways of providing care in community-based settings.The metanarrative review will purposively inform implementation in the third phase of a programme of research, implementing integrated care for older adults with complex health needs (iCOACH) in New Zealand and Canada. Methods : This work reviewed what is known about implementation that may be suitable to guide the scaling up and evaluation phase of iCOACH. Metanarrative review methods were applied to systematic and narrative reviews of literature on implementation frameworks, theories and strategies. We synthesised heterogenous findings in a way that informs the practice of implementation. Results : Thirty-five systematic and narrative reviews met our inclusion criteria and were appraised, summarised, and qualitatively analysed. The various assumptions, worldviews and findings represented in the literature were subjected to high level analysis and interpretation that identified five metanarratives concerning the constructs, influencing factors, frameworks, and the effectiveness of interventions and strategies employed in implementation. Discussion : A wide range of people have a stake in how to implement what works best and matters most for older adults with chronic health care problems in various community-based settings, not least consumers themselves. We call for collaborative adaptation with stakeholders, most importantly the person receiving care and their family in the implementation of a new model. Conclusions and lessons learned : There is still no ‘silver bullet’ in implementation science in spite of abundant primary and secondary studies. People- and relationship-centred care is fundamental to integrated, community-based care at all levels in the broader health care delivery system. Yet many implementation theories and frameworks neglect these important considerations. All phases of implementation of a new model of care call for collaborative adaptation with stakeholders, the most important being the person receiving care in terms of what matters most to them. Limitations : While our search strategies were extensive we cannot guarantee that we located every systematic or narrative review on this topic. Suggestions for future research : Participatory research methods and realist evaluation approaches informed by this metanarrative review is required of the implementation of a new model of integrated, community-based care for older adults with chronic health problems to establish what has worked best, for whom and how.

QUALITY OF LIFE IN NURSING HOMES: ELEVATING THE STATUS OF RECORDING TO A RELATIONAL PRACTICE

Internationally, nursing home care provision demands radical change. Lack of honesty about the complexity of so-called ‘basic care’ together with performance cultures have created a more transactional and confused environment, detracting from authentic care work grounded in human relationships. A personal outcomes approach, comprising three inter-related components of engaging, recording and using information, can result in more effective, inclusive, enabling and relational ways of working, but raises particular challenges in collective living settings for older people with complex and often fluctuating needs and priorities. This session presents results from an action research study conducted in collaboration with multi-disciplinary staff from six nursing homes in Scotland to facilitate a focus on personal outcomes. Grounded in the philosophy of relationship-centred care, the study recognised the importance of everyday acts of noticing alongside scheduled care planning processes, including being attentive to, and properly valuing, the life stories and more embodied stories of people with communication or cognitive impairments. Building upon the ways staff already come to understand and negotiate what matters to a person and to family members, and thinking about how such insights might be used by others, the study facilitated a shift from recording as a bureaucratic task with a primarily retrospective orientation demonstrating compliance, to a practice foregrounding information useful for maintaining the identity of the older person, building relationships and shaping future care. It also highlighted the practical and ethical dilemmas encountered daily, and the necessity of successful negotiation amongst everyone involved in individual and collective decision making processes.

Relationship-Centered Dementia Care: Insights from a Community-Based Culture Change Coalition.

This article reports on the work of a community-based culture change coalition affiliated with the Partnerships in Dementia Care Alliance, a research network committed to strengthening dementia care through supporting relationship-centered care approaches. Research to date emphasizes negative aspects of dementia care relationships. Drawing on data the culture change coalition collected as part of their culture change work using participatory action research guided by appreciative inquiry, this article examines what relationship qualities contributed to positive dementia care experiences and how positive relationships were created. Five types of care partners participated in the study through questionnaires, focus groups, and a mini appreciative inquiry summit. Data were analyzed collaboratively with culture change coalition members. Early in the analysis process, the aspiration statement "Relationships are at the heart of dementia care in [name of] County," was developed and informed further thematic analysis. Findings revealed several relationship characteristics including friendship, commonality of experience, developing trust and feeling appreciated, reciprocity, and taking time/making time for relationships. As this article illuminates, relationship-centered programs and policies have the potential to foster positive dementia care experiences among diverse care partners in community settings.

Implementation of a Complex Intervention to Support Leadership Development in Nursing Homes: A Multimethod Participatory Study.

Leadership is key to quality improvement in nursing homes. This article reports on the initial analysis of the transformational My Home Life Leadership Support program for nursing home managers being implemented in Scotland. It analyses learning from a multimethod participatory descriptive study. Contribution analysis theory informed the evaluation. Evidence-Based Practice, Relationship-Centered Care, Appreciative Inquiry, and Caring Conversations informed the intervention to develop transformational leadership. Data generation methods included baseline and postintervention questionnaires to describe culture change within the study population, together with more in-depth qualitative data generated from group discussions throughout the leadership support program. Qualitative data analysis was an iterative collaborative process with participants to generate themes about the impact of the program on themselves and their practice. Data showed positive changes in managers' perceptions of their self-awareness, leadership communication and relationship skills, and development of positive cultures. This model offers lessons for those interested in ways to approach the emotional, educational, and cultural dynamics of change in other human service contexts.

Scoping the role and education needs of practice nurses in London.

The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses. A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles. Findings A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients. This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.

Reconciling conceptualizations of relationships and person-centred care for older people with cognitive impairment in acute care settings.

Relationships are central to enacting person-centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person-centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long-term care. The acute care setting is characterized by archetypal constraints which differentiate it from long-term care, in terms of acuity and haste, task-orientated work patterns and influence from "the rule of medicine," all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re-interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re-presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person-centred care versus relationship-centred care by arguing that these are complementary rather than mutually exclusive and can be brought together in one theoretical framework acknowledging personhood as relational in essence.

Effectiveness of person-centered care on people with dementia: a systematic review and meta-analysis.

BackgroundPerson-centered care is a holistic and integrative approach designed to maintain well-being and quality of life for people with dementia, and it includes the elements of care, the individual, the carers, and the family.AimA systematic literature review and meta-analysis were undertaken to investigate the effectiveness of person-centered care for people with dementia.MethodsLiterature searches were undertaken using six databases including Medline, EMBASE, CINAHL, PsycINFO, Cochrane Database, and KoreaMed using the following keywords: cognition disorder, dementia, person-centered care, patient-centered care, client-centered care, relationship-centered care, and dementia care. The searches were limited to interventional studies written in English and Korean and included randomized controlled studies and noncontrolled studies for people with dementia living in any setting.ResultsNineteen interventional studies, including 3,985 participants, were identified. Of these, 17 studies were from long-term care facilities and two studies were from homecare settings. The pooled data from randomized controlled studies favored person-centered care in reducing agitation, neuropsychiatric symptoms, and depression and improving the quality of life. Subgroup analysis identified greater effectiveness of person-centered care when implemented for people with less severe dementia. For agitation, short-term interventions had a greater effect (standardized mean difference [SMD]: −0.434; 95% conference interval [CI]: −0.701 to −0.166) than long-term interventions (SMD: −0.098; 95% CI: −0.190 to 0.007). Individualized activities resulted in a significantly greater beneficial effect than standard care (SMD: 0.513; 95% CI: −0.994 to −0.032). However, long-term, staff education, and cultural change interventions had a greater effect on improving the quality of life for people with dementia (SMD: 0.191; 95% CI: 0.079 to 0.302).ConclusionThis systematic review and meta-analysis provided evidence for person-centered care in clinical practice for people with dementia. Person-centered care interventions were shown to reduce agitation, neuropsychiatric symptoms, and depression and to improve the quality of life. Person-centered care interventions can effectively reduce agitation for a short term using intensive and activity-based intervention. However, an educational strategy that promotes learning and skill development of internal care staff is needed to enhance patient’s quality of life and to ensure the sustainability of the effects of behavioral problems. The feasibility and effectiveness of the intervention, the severity of patient disease, and intervention type and duration should be considered as part of an intervention design.

Caring for self-harming patients in general practice.

INTRODUCTION Intentional self-harm is an international public health issue with high personal, social and financial costs to society. Poor relationship dynamics are known to have a negative influence on the psyche of people who self-harm, and this can increase anxiety and decrease self-esteem, both shown to be significant contributors to self-harm behaviours. Positive and functional social supports have been proposed as a cost-effective and constructive approach in diminishing self-harming behaviours. AIM This qualitative study investigated the aspects of professional, social, familial and romantic relationships that people who have self-harmed identified as having a positive and constructive effect on their self-harm behaviour. METHODS Twelve participants with a history of self-harming behaviours were recruited through free press advertising in primary care and interviewed. The participants ranged in age from 19 to 70 years, and represented New Zealand (NZ) European and Māori from across the Southern region of NZ. RESULTS This study shows that constructive relationships that inhibit self-harm behaviours are characterised by participants' perceptions of authenticity in their relationships, and knowing that other people genuinely care. Feeling cared for within an authentic therapeutic relationship enabled participants to overcome their perception of being damaged selves and gave them the skills and confidence to develop functional relationships within their communities. A relationship-centred care approach may be useful for general practitioners seeking to develop more effective therapeutic relationships with patients who deliberately self-harm.

Teaching Resident Self-Assessment Through Triangulation of Faculty and Patient Feedback

ABSTRACTProblem: To accurately determine one's ability in any clinical competency, an individual must be able to self-assess performance and identify personal limitations. Existing research demonstrates that physicians of all levels are unreliable self-assessors. This poses a concern in medical practice, which requires continuous updates to clinical competencies and awareness of personal limitations. Few published studies examine graduate medical education curricula designed to develop self-assessment skills. Intervention: Conceptual models, such as self-determination theory, suggest that self-assessment is most effectively learned through reflective processes. The Family Medicine Residency Program at Lehigh Valley Health Network developed a learner-centered competency assessment process that integrates advising and performance review. The multisource, observable behavior-based process encourages conversation between resident and advisor. Utilizing feedback from clinical preceptors and patient surveys, advisors guide residents in determining individual learning needs in core competency areas, including relationship-centered care. Development of medical learners' capacity to form relationships is one means to improving the patient experience. Context: This retrospective case study evaluates the accuracy of senior residents' self-assessment in relationship-centered care compared with that of junior residents. The study population includes the 34 residents enrolled from AY 2009–2012. Data sets represent specific 6-month periods and have 3 component scores—Self, Faculty, and Patient—which were triangulated to determine concordance rates by postgraduate year level. Outcome: The concordance rate among first-years was 26.7%, whereas third-years saw 60.0% concordance. A discordance analysis found the Patient score most often deviated from the other 2 scores, whereas the Faculty score was never the sole dissenter. When all 3 scores differed, the Self score frequently fell between the other 2 scores. Lessons Learned: The principles of self-determination theory provide a valuable framework for understanding the development of residents' intrinsic motivation to become lifelong learners. The trend in improved concordance rates among senior residents suggests that prompting learners to triangulate feedback from multiple sources can lead to a shift in perspective about competency. Further study is needed to determine whether our results are generalizable to other competencies and educational settings.

Embedding compassionate care in local NHS practice: developing a conceptual model through realistic evaluation

The aim of this study was to critically analyse the impact of the ‘Leadership in Compassionate Care Programme’ and offer a conceptual model of factors that can embed compassionate care in contemporary health care environments. This three-year initiative (2008–2011) was designed to embed compassionate care in both practice and pre-registration education. Using a realistic evaluation approach this longitudinal qualitative study involved data collection in eight participating wards. The ‘level of adoption’ of the Programme varied across the wards, which pointed to key context and mechanisms that were influential in embedding compassionate care. Contextual factors that promoted adoption of the Programme were stability, support and leadership. The most important mechanisms were appreciative inquiry coupled with skilled facilitation. Powerful practice development techniques focused on articulating and demonstrating values; giving patients, relatives and staff a voice to express their experiences and emotions; and instituting effective feedback mechanisms. In the high adopting wards the main outcomes included personalisation of patient care, an increased sense of involvement for relatives and ‘caring conversations’ becoming an accepted part of working practice. Embedding and sustaining compassionate care demands strategic vision and investment in a local infrastructure that supports relationship-centred care, practice development and effective leadership at all levels.

Developing the Senses Framework to support relationship-centred care for people with advanced dementia until the end of life in care homes.

People with advanced dementia living in care homes can experience social death before their physical death. Social death occurs when a person is no longer recognised as being an active agent within their relationships. A shift is required in how we perceive people with advanced dementia so that the ways they continue to be active in their relationships are noticed. Paying attention to embodied and interembodied selfhood broadens the scope and opportunities for relationships with people with advanced dementia, acting as a counter to social death. This has the potential to improve the quality of care, including end of life care, of people with advanced dementia in care homes. This study examined the role of embodied and interembodied selfhood within care-giving/care-receiving relationships in a specialist dementia care home. Empirical findings and their implications for the development of relationship-centred care and the Senses Framework in care homes are discussed.

Developing a culture of relationship-centred care.

There is a new way of working across a care home group in south east Wales, based on relationship-centred care and an ethos of empowerment for older people in their homes.

Developing a culture of relationship-centred care in a care home group

Developing a culture of relationship-centred care in a care home group

Unexpected happenings: a relationship-centred and active Swedish care home for people with dementia

Unexpected happenings: a relationship-centred and active Swedish care home for people with dementia

Developing a culture of relationship-centred care in a care home group.

This article outlines the development of a new way of working across a group of care homes in south east Wales, based on a philosophy of relationship-centred care and an ethos of empowerment for older people in the homes. The underpinning aim was to enable residents to have a good quality of life, reflecting recommendations made by the Older People's Commissioner for Wales in a 2014 review into the quality of life and care of older people living in care homes in the country. After the introduction of the new way of working, the care home group were approached by a university to take part in a collaborative project offering nursing students clinical placements in the care homes, mentored by registered nurses employed there. The collaboration between the university and the care homes meant that nursing students became enveloped in the person-centred culture, receiving positive exposure to nursing older people early in their careers. It is hoped that the clinical placements may encourage them to consider careers in the specialty.

“If she wants to eat…and eat and eat…fine! It's gonna feed the baby”: Pregnant women and partners' perceptions and experiences of pregnancy with a BMI >40 kg/m2

Introductionwomen with a raised BMI are more likely to gain excessive weight in pregnancy compared to women with a BMI in the normal range. Recent behaviour change interventions have had moderate to no influence on GWG, and no effect on other perinatal outcomes. Evidence is required regarding the social and cultural contexts of weight and pregnancy. No studies to date have included the views of partners. Aimsto explore the experiences, attitudes and health-related behaviours of pregnant women with a BMI >40kg/m2; and to identify the factors and considerations which shape their beliefs, experiences and behaviours, and how these may change during and after pregnancy. 2. To determine the impact, if any, of the beliefs and attitudes of significant members of the women's families and social networks upon the women's experiences, attitudes and health-related behaviours in relation to weight and pregnancy Methodsthis was a prospective serial interview study. Semi-structured interviews were conducted with 11 pregnant women with a BMI >40kg/m2, during pregnancy and after birth, and once with 7 partners (all male) of women. Interview questions were designed to be appropriately but flexibly framed, in order to explore and gather data on participants' everyday life, lifestyles, views, experiences, relationships and behaviours, focussing more specifically on beliefs about health, pregnancy, weight and diet. Thematic content analysis was used to formally analyse and unearth patterns in the data. Findingsthe findings can be grouped into six interrelated themes: the complexities of weight histories and relationships with food; resisting risk together; resisting stigma together; pregnancy as a 'pause';receiving dietary advice; postnatal intentions. These themes are interrelated due to the 'spoiled identity' (Goffman, 1963) that the large body represents in western culture and related stigma. Conclusion and implicationsthis study provides evidence that there exist deeply ingrained social and cultural beliefs among women and in particular their partners, regarding pregnancy diet and weight gain. Further, this study provides evidence that male partners may resist stigmatised risk on behalf of a pregnant partner. All women (and several men) expressed an intention to adopt healthy behaviours and lose weight once their baby was born. Further evidence is required regarding the means by which women who experience stigmatised risk during pregnancy, and their partners, might be engaged and receptive to health advice. Models which draw on ideals of relationship-centred care, and selfefficacy via open discussion with women and families, engaging women and partners by providing them with an opportunity to talk about their beliefs and concerns, could be explored to inform future research and practice.

Care assistant experiences of dementia care in long-term nursing and residential care environments

Care assistants have a unique insight into the lives of service users and those factors which may impede or enhance the delivery of high quality dementia oriented care. To address the paucity of research in this area, the present study examined care assistant experiences of dementia care in British long-term residential and nursing environments. Semi-structured interviews were conducted with eight care assistants and transcripts were analysed using interpretive phenomenological analysis. Super-ordinate themes emerging from the data were psychological wellbeing of the care assistant, barriers to effective dementia care, the dementia reality and organisational issues within the care environment. The study revealed important deficiencies in understanding and varying levels of dementia training. Whilst person centred strategies were being implemented, task orientated care remained dominant. Furthermore, care assistants reported taking the perspectives of those with dementia into account, and actively using these to develop relationship centred care.

A Countercultural Heritage: Rediscovering the Relationship-Centered and Social Justice Roots of Family Medicine-A Perspective from the Keystone IV Conference.

The 2015 G. Gayle Stephens Keystone conference convened a cohort of primary care professionals to discuss what promises personal physicians will make to their patients going forward. New physicians were prompted to rediscover the foundational values of and historic context for family medicine. At the heart of this rediscovery was learning of the writings and teachings of Dr. G. Gayle Stephens, a founder of family medicine who emphasized the essentiality of relationship-centered care and social justice to the new specialty. Dr. Stephens viewed family medicine as being in a countercultural relationship to mainstream medicine, as family medicine fought for justice and equity in an inequitable and fragmented health care system. Here we argue that by reaffirming and renewing this countercultural heritage the new generation of family physicians will have better clarity in approaching the many challenges in health care today. Particularly for trainees and new physicians, the historic lens offered by Dr. Stephens's writing and other foundational documents allows us to better see ourselves in a trajectory of ongoing health care reform.

Transforming Preprofessional Health Education Through Relationship-Centered Care and Narrative Medicine

ABSTRACTIssue: The Institute of Medicine identified health care education reform as a key to improving the error prone, costly, and unsatisfying U.S. health care system. It called for health care education that no longer focuses exclusively on the mastery of technical skills but teaches students the human dimensions of care and develops their ability to collaborate with patients and colleagues to alleviate suffering and improve health. When should this educational reform begin, by what frameworks should it be guided, and which methods should it employ are important questions to explore. Evidence: There is increasing evidence that practitioners' relational skills, such as empathy and reflection, improve patients' health outcomes. Efforts to shift education toward patient-centered care in interprofessional teams have been made at the professional level, most notably in medical schools. However, reform must begin at the preprofessional level, to start cultivation of the habits that support humane care as early as possible and protect against empathic decline and the development of counterproductive attitudes to collaboration. The conceptual basis for reform is offered by relationship-centered care (RCC), a framework that goes beyond patient-centered care and interprofessional teamwork to focus on the reciprocal human interactions at the micro, mezzo, and macro levels of care. RCC identifies practitioners' relationships with patients, colleagues, community, and self as the critical interpersonal dimensions of healthcare and describes a foundation of values, knowledge, and skills required for teaching each dimension. The teaching of these foundations can be facilitated with techniques from narrative medicine, a compatible care model that conceptualizes health care as a context in which humans exchange stories and thus require narrative competence. Implications: We suggest beginning the educational reform at the preprofessional level with the implementation of a formal curriculum based on the 4 RCC dimensions with students expected to gain beginner levels of competency on these dimensions in addition to evidence-based principles of health sciences. This requires interprofessional collaboration among health professions, social science, and liberal arts faculty and training of health professions faculty in narrative medicine. Next, we suggest engaging in incremental change in the organizational culture with professional development and team-building activities. Although we need systematic research on the efficacy of the components of the transformation, their impact on students' learning, and their costs, it is important to engage in efforts to prepare professionals who are able to respond to the complex health needs of individuals and society in the 21st century.