Learning Objectives
By the end of this section, you will be able to:
- Explain patient-centered nursing care
- Recognize how providing patient-centered care increases interaction among stakeholders
- Describe interventions nurses can include in the care plan to promote holistic nursing care
The term patient-centered care (PCC) is a healthcare delivery model that aims to ensure the patient is an equal partner in their health care. Patient-centered care can be described as the framework for providing care to individuals. Relatedly, holistic care is aimed at healing all parts of the body, mind, and spirit. Holistic nursing strives to care for all the needs of the body, mind, and spirit. Holistic care is a philosophy for nursing linked as far back as the beginning of the profession. Florence Nightingale, the founder and first theorist of nursing, developed the Nightingale theory still incorporated in nursing today. See Chapter 1 Introduction to the Nursing Profession: Evolution, Theories, and Practice for details regarding nursing theories. Nightingale believed a person’s health was directly tied to their physical environment, and healing the whole person was the nurse’s goal. She encouraged the addition of clean air, clean environment, and sunlight in order to care for a person. This could be accomplished by opening a window to let in sunlight and fresh air. This simple task not only removed germs from the environment but also increased the patient’s feeling of happiness when they felt the warmth of the sun. She believed in providing a bath to a patient to reduce germs and increase feelings of worthiness and cleanliness.
Patient-Centered Care
Patient-centered care aims to empower patients to become active participants in their care, with the hope of giving them self-management in the process. Healthcare providers are patient advocates who strive to provide safe, efficient, cost-effective care. Patient-centered care requires improved communication among healthcare professionals and patients. For example, when a patient visits a doctor’s office, they are allowed to focus on describing how they are feeling and functioning versus just discussing the progression of a diagnosed disease. Another example of improved communication is when patients are encouraged to use electronic patient portals to review upcoming appointments and suggested treatment plans. Empowering patients to get involved in their care increases the probability of compliance.
Nurses are tasked with providing patient-centered care to focus on the whole person. As part of the nurse–patient relationship, nurses are primed to understand and incorporate more patient-centered care during healthcare delivery than other healthcare providers. For instance, consider a patient who reports overall pain and sleepiness. While the physician may diagnose the patient with depression, the nurse may uncover that the patient’s close friend died recently and the patient is spending more time in bed. The nurse was able to spend more time discovering why the patient had the complaints, and these contributing factors could add to why the patient is complaining of overall pain. The nurse might also question the patient about their daily routine and eating habits to provide more clues for better patient-centered care. The nurse looks at the whole patient, not just the diagnosis or complaint, to get a better understanding of the situation. The nurse can collaborate with the physician and act as a liaison between the physician and patient to improve care and outcomes.
Patient-centered care models emerged as best practice standards in nursing and can be achieved through care coordination and integration of care. For example, nurses demonstrate respect for patients’ values, preferences, and expressed needs. Nurses can provide patients with information and education related to disease development and progression. They provide patients with both physical and emotional support, while attempting to alleviate patients’ fear and anxiety. Patient-centered care also includes the involvement of family and friends.
Benefits of Patient-Centered Care
There are multiple benefits of patient-centered care. Patients who receive patient-centered care report more satisfaction with care received, higher rates of patient engagement, and better healthcare outcomes. The benefits can translate into faster recovery and lower emergency room visits or readmission rates, all of which affect the total cost of patient care. Positively affecting the total cost of patient care allows for healthcare providers to meet benchmarks set by health insurance companies, which lowers population-wide healthcare costs.
Link to Learning
The American Medical Association (AMA) website discussed trends in healthcare spending along with policy research perspectives.
Care Coordination
The term care coordination is the specific coordination among team members to organize healthcare activities. Care coordination is an important factor in providing effective, efficient, and safe patient-centered care. High-quality, high-value care is delivered as the best care possible with efficient resources achieving optimal results for each patient. Consider a patient receiving a timely referral or quick turnaround time getting an appointment with physical therapy. High-value examples include multiple specialties within one practice, such as physical therapy, occupational therapy, and speech therapy available in one practice. Care coordination goals for the nurse should include the delivery of high-quality, high-value health care.
Care coordination also provides a foundation for improving patient care outcomes, which benefits the patient, providers, and the healthcare system. Care coordination can be as simple as establishing accountability and agreeing upon responsibility within the healthcare team. For example, creating a care plan for an individual with diabetes would include podiatry, endocrinology, ophthalmology, diabetes education, and nutrition services. Another example might be coordinating pediatric care for a child with juvenile arthritis.
Care coordination also involves linking the patient with community resources and aligning community resources with population needs. For example, when facilities utilize integrated electronic health records across specialties, it allows healthcare providers real-time access to accurate patient information such as screenings, laboratory tests, and prescriptions. With this integrated access, duplicating laboratory tests does not occur, which controls overall costs.
Link to Learning
The Agency for Healthcare Research and Quality’s Care Coordination Quality Measure for Primary Care (CCQM-PC) is a free downloadable survey in the public domain that assesses adult patient experiences with care coordination in primary care settings.
Transparency in Care
When establishing trust in a patient–healthcare provider relationship, it is important to have transparency. Transparency gives the patient protection and greater control over the care they receive. Many healthcare providers utilize electronic health records so patients can see the results of their own laboratory tests and exams, providing transparency with the test results. When providers review with patients the necessity for why certain diagnostics are ordered, such as a magnetic resonance imaging (MRI) scan versus a computerized tomography (CT) scan, this is another example of transparency.
Transparency can include data and interoperable systems as well. For instance, hospital outcomes data are publicly available so that healthcare consumers can choose where they receive care. Data transparency provides patients with the information to make smart decisions about the quality of the health care and receive the best value for their healthcare dollars. Transparency in health care promotes care coordination and the concept of high-quality, high-value care. As patients are more aware of the costs, able to make better choices for care, and participate in programs that promote care coordination, better health outcomes should occur. Transparency also increases accountability and competition among healthcare organizations.
Link to Learning
From the Agency for Healthcare Research and Quality, the TeamSTEPPS 3.0 Pocket Guide is a quick reference tool for communication among healthcare providers. Download the app and use it during patient care.
Increased Interaction
Increased interaction is an important tenet of PCC. Patient-centered care increases interaction among the patient and the healthcare providers and can include other stakeholders in the patient’s care, such as the patient’s family and the interdisciplinary healthcare providers. As part of the interdisciplinary healthcare team, nurses are responsible for improving communication during rapidly changing medical conditions. One way a nurse can improve communication is by implementing more frequent patient room checks. Increased interaction and improved communication, such as following up with patients after surgical procedures, with test results, or after new medications are started, has positive effects on patient satisfaction, length of stay, and adverse events (Wang et al., 2018).
Patient Involvement in Decision-Making
Patient-centered care promotes the patient to be an active team member in their own care plan. Increased interaction among team members means the patient is involved in all aspects of the decision-making process. Research suggests that patients who participate in decision-making not only have better healthcare outcomes, improved satisfaction with health care, and reduction of healthcare costs, but also can reduce their mortality from chronic disease (Paterick et al., 2017). A patient who is involved in self-managing their chronic conditions has a better prognosis and longer quality of life than patients who are not involved in self-management (Delaney, 2018).
Family Involvement in Decision-Making
When families are involved in the decision-making process, patients are more prone to following through with the care plan because the family can provide additional resources for the patient. Many times, patients rely on a loved one or significant other to provide support and guidance. Making sure all parties understand ensures compliance with the assigned healthcare tasks. If a patient is under 18 years of age or is not capable of making decisions for themselves, then a family member is typically assigned as the medical power of attorney, or the person in charge of making medical decisions for the patient. Patients can deem someone as medical power of attorney in charge of making medical decisions for them if they are unable to. Regardless of the scenario, to achieve care coordination, the patient’s family should be involved in the decision-making process to achieve better outcomes.
Support for Self-Management
Increased patient interaction also means supporting the patient in self-management of their own healthcare needs. One way to achieve this goal is when the nurse empowers the patient through education. Nurses should help patients realize they are in control of their own health; health care is not a passive process in which only the healthcare provider tells them what to do. A patient’s health is self-managed based on the decisions they make throughout the day, week, months, or years. For example, if a patient has diabetes and chooses to eat a high-sugar, high-carbohydrate snack, that action will have a negative effect on their health. The nurse can provide education on snacks with a low glycemic index and empower the patient to make health-conscious decisions.
It is also the nurse’s responsibility to inform the patient that they have options for their care. Patients should be encouraged to explore different treatment options if they feel another plan is more reasonable. Interacting with the patient as a key team member in their care plan enables support of self-management.
Patient Conversations
How Nurses Can Empower Patients with Information
Scenario: Nurse walks into the room in the healthcare provider’s outpatient office to complete an assessment. The nurse starts by taking the patient’s blood pressure.
Nurse: Hi, my name is Alice, and I am going to be your nurse today. Is it okay if I take your blood pressure?
Patient: Yes.
Nurse: Your blood pressure is 144/86.
Patient: Is that normal?
Nurse: Your blood pressure is a little high. We consider a normal blood pressure around 120/80.
Patient: Should I be worried? What do the numbers mean?
Nurse: There are two numbers for blood pressure: a top number and a bottom number. The top number is the amount of pressure your heart must exert against your blood vessels when your heart is at work. It is called the systolic number. The bottom number is the amount of pressure your heart must exert against the blood vessels when your heart is at rest. It is called the diastolic number. High blood pressure increases your risk for stroke, heart attack, kidney disease, and eye disease.
Patient: I thought my blood pressure was high. That is why I came here today. What can I do to lower my blood pressure?
Nurse: There are many things you can do to lower your blood pressure, such as decrease your salt intake, exercise, stop smoking, drink less alcohol, maintain a reasonable weight, and avoid stress. Do you think there are some behaviors that I just listed that you could work on?
Patient: Yes, I can decrease my salt intake and exercise more. Thank you for talking to me about high blood pressure.
Nurse: I will get some educational pamphlets regarding ways to lower your blood pressure for you to take home today just in case you need to look back over them later. I also suggest you get an at-home blood pressure monitor, so you can start recording your blood pressure daily. Bring your recording log into the office next time you come in so we can see how your changes are helping to improve your blood pressure.
(Based on Funnell, 2000.)
Thoughtful Practice
Practicing care in a way that reflects compassion and incorporates empathy for a patient’s unique situation is known as thoughtful practice. The patient remains the nurse’s center of attention, which promotes the patient’s overall well-being. Thoughtful practice allows for reflection upon everyday situations and finding ways to make improvements. Tasks, such as delegation and decision-making, are founded on thoughtful practice. Nurses who incorporate thoughtful practice strive to develop therapeutic nurse–patient relationships to provide a more patient-centered approach to meeting healthcare needs.
Self-Knowledge
Nursing is a life-long learning process. Increasing self-knowledge, the understanding of one’s own motives and character, is an important aspect of being a nurse. Nurses should participate in ongoing education. Nurses have a responsibility to their profession and to their patients to keep up to date on current research. Researching the most current evidence gives the nurse a way to incorporate knowledge into their practice. To provide effective, quality PCC, the nurse needs to be as knowledgeable as possible in the patient’s individual healthcare needs. Nurses join relevant nursing societies or participate in statewide nursing organizations, which provide nurses with current data and research to increase self-knowledge.
Providing Holistic Nursing Care
Holistic nursing care encompasses treating the patient’s mind, body, and spirit as one. The American Holistic Nurses Association (AHNA) is a specialty nursing association that was developed to help nurses practice health more holistically through advocacy, research, and education. Nurses can join the AHNA and be linked with resources for practicing nursing more holistically.
Link to Learning
The American Holistic Nurses Association is where nurses can find resources for practicing health care more holistically. Click on the resource tab at the bottom of the page and complete one of the self-care modalities.
Interdisciplinary Holistic Healthcare Providers
Interdisciplinary holistic healthcare providers include traditional treatments along with complementary and alternative treatments to provide overall health and well-being. Complex health problems that require a team approach or coordination of palliative care are two examples where interdisciplinary holistic healthcare providers would be utilized. For example, a patient on palliative care might require their spiritual, psychological, and physical needs to be met. When a team of interdisciplinary holistic healthcare providers convene to work with the patient to manage an illness, the patient is more likely to meet positive health outcomes. For example, a patient in the intensive care unit (ICU) who was in a motor vehicle accident with fractures of the jaw and leg, a collapsed lung, and head contusions would require many different disciplines to care for them including orthopedic specialists, physical therapy, occupational therapy, neurologists, neurosurgeons, pulmonologists, nutrition specialists, and pharmacists. All the team members work together to provide a quicker recovery process for the patient.
Common Holistic Treatments
There are many holistic treatments for patients. Some holistic treatments are provided by interdisciplinary healthcare providers and require certifications. For instance, acupuncture should only be performed by a certified acupuncturist. However, there are several holistic treatments that can be completed by nurses. Examples include aromatherapy, massage, touch, and hot/cold application. Nurses should attempt to incorporate holistic interventions into their patients’ care plans only after confirming with the rest of the clinical team that the treatments are safe and will not interfere with the medical plan. Some holistic interventions, such as aromatherapy, guided imagery, hydrotherapy, massage, and progressive relaxation, do not require special prescriptions or extensive training, meaning the patient can also complete the tasks independently.
Aromatherapy
The use of essential oils via inhalation or diluted application to the skin is known as aromatherapy. An essential oil is an oil extracted from the flower, bark, leaves, or fruit of plants. Many essential oils are thought to have properties that provide symptom relief. When the essential oil is inhaled, the olfactory nerve is activated, which then stimulates the activation of the amygdala, the emotional center of the brain. This stimulation can boost mood and may help with anxiety, depression, or insomnia. Aromatherapy can be used to treat nausea, decreased appetite, or dry mouth. For example, ginger, peppermint, and licorice have all been shown to alleviate nausea. Nurses should educate patients about the possible benefits of aromatherapy, as well as how to properly use essential oils by advising patients not to consume them and to avoid drug interactions or possible allergies.
Guided Imagery
A holistic treatment used to reduce anxiety is guided imagery. In guided imagery, the nurse directs the patient to close their eyes and picture a scene that makes them comfortable and relaxed or provides a feeling of peacefulness, such as a beach. The nurse would encourage the patient to notice everything about the scene, such as the way the sun feels on the skin, the color of the water, the sounds of the surf, the scents of the breeze, and the taste of the foods eaten. Patients can be educated to do guided imagery on their own when they are feeling stressed, anxious, or depressed. Guided imagery has been used as pain management therapy for patients suffering from chronic pain and for women in labor.
Hydrotherapy
The use of water to reduce pain, swelling, and sore muscles is called hydrotherapy. It can be administered with hydromassage blankets or in swimming pools, whirlpools, hot tubs, and physiotherapy tanks. Hydrotherapy allows the muscles to relax and can ease joint pain. The warmth of the water stimulates dilation of the blood vessels, promoting blood circulation and reducing fluid accumulation in interstitial cells (Figure 6.2). Caution must be taken to avoid too much time in the water as negative effects can occur such as maceration of the skin.
Clinical Judgment Measurement Model
Recognize Cues: Asking Subjective Questions about Patient Cues
Before recognizing cues, nurses must make sure they have enough data about a patient’s situation to interpret the information. For example, consider an adult patient who reports weeping from the lower extremities. The nurse does not have enough information to determine the patient’s needs and may ask a series of questions such as “Have you ever experienced weeping in your legs before? When did you first notice the weeping? Have you done anything at home that made it better or worse?” The patient’s responses provide the nurse detailed information from which to form an educated hypothesis and start determining what actions to take for the patient. The nurse should recognize, based on the provided cues and clinical judgement measurement model, that this patient would not be a good candidate for hydrotherapy as they already have emaciated skin in the lower extremities.
Massage
Massage is widely used as a holistic treatment for pain, muscle soreness, and stress reduction. Massage can be done at the bedside by a nurse, a physical therapist, or a massage therapist who is specifically trained in massage techniques. There are several types of massage, including aromatherapy, chair, deep tissue, hot stone, lymphatic, prenatal, shiatsu, sports, and Swedish massage. Some types of massage are beneficial to a certain part of the body. Lymphatic massage, for example, is used for the lymph system to promote less lymphedema and can be used in patients who have had lymph nodes removed (Figure 6.3). The benefits of all types of massage are lowering heart rate, improving immune function and circulation, and increasing relaxation. Nurses should educate patients not to massage lower extremities if they are diagnosed with or are expected to have deep vein thrombosis (DVT), or blood clots in the lower extremities, as the massage could accidently dislodge the DVT and elicit negative outcomes, such as stroke.
Progressive Relaxation
Another holistic technique that nurses can administer is progressive relaxation. During progressive relaxation, the nurse guides the patient to get comfortable and encourages the patient to start with a muscle group such as the feet or toes. The nurse instructs the patient to contract and then relax that body part and then move up to the next set of muscles. Working in a systemic order, when finished, the patient should have contracted and released all the major muscle groups. This progressive relaxation of all the muscles can bring a sense of calmness. Progressive relaxation can help lower blood pressure, ease muscle tension, and increase a patient’s perception of overall well-being.
Holistic Care across the Life Span
Holistic care across the life span includes maternal/newborn, pediatric, and geriatric populations (Table 6.1). A nurse can meet the holistic needs of the maternal and newborn population by encouraging healthy pregnancies. Healthcare providers educate women about ways to maintain a healthy pregnancy by avoiding stress and unhealthy behaviors such as smoking. Newborn holistic care includes education for the parents such as bath safety and car seat safety. Nurses can provide holistic care for the pediatric population by involving the family throughout the care process. For the geriatric population, the interdisciplinary team should be included along with the patient’s family so that all the patient’s needs can be met.
| Developmental Stage | Physical Needs | Psychological Needs | Spiritual Needs |
|---|---|---|---|
| Maternal/ newborn | Discuss healthy diet | Provide education about postpartum depression | Refer to counseling if fetal demise occurs |
| Pediatric | Provide age-appropriate anticipatory guidance | Discuss with parents how to support a child’s self-esteem needs | Encourage parents to connect with the child daily |
| Geriatric | Discuss vaccines such as pneumonia and shingles | Encourage service in community, such as volunteering | Suggest sharing stories and memories with loved ones |