Learning Objectives
By the end of this section, you will be able to:
- Describe physical considerations involved in providing person-centered care
- Identify emotional considerations involved in providing person-centered care
- Recognize spiritual considerations involved in providing person-centered care
In the 1940s, psychologist Carl Rogers developed the theory of person-centered therapy, which suggests a person can understand themselves and focus on their self-worth. Rogers believed that the person and the therapist could work together toward personal growth, achieving self-management. The humanistic approach to psychotherapy was founded on Rogers’s theory and included shared decision-making between the person and the therapist. The development of person-centered therapy provided the foundation for person-centered care within health care.
Person-centered, patient-centered, and holistic care are terms that are intertwined; however, they have separate definitions and should not be interchanged. The person-centered care focuses on disease management with the personal, social, and religious beliefs of the person incorporated into the care. Person-centered care includes integrated healthcare services that allow goals, values, and preferences of an individual to be included in the development of a care plan with the healthcare provider. An example of an integrated healthcare service is the Veterans Health Administration (VHA), a federal agency that provides veterans with hospital and long-term health care. An integrated healthcare plan includes informed decision-making about treatment options, well-being considerations for the patient, and an understanding of their comprehensive needs (Figure 6.4).
Shared decision-making and self-management support are part of the six tenets for current practices of person-centered care. When the patient and healthcare provider work together to develop a healthcare plan that meets the goals set by the patient, this is known as shared decision-making (SDM). Support for self-management gives patients with chronic conditions the ability to manage their health and take an active role in their health care. Through the implementation of person-centered care, healthcare providers deliver tools and resources assisting the person to reach their own individual health goals.
When caring for patients, nurses use a framework to help prioritize care. While most patients have multiple needs, the nurse can only address one need at a time. The most recognized framework for prioritizing patient’s needs is Maslow’s hierarchy of needs, which includes physiological needs as the basis of the hierarchy, meaning those needs must be met at least minimally to sustain life and before moving onto the needs above those (Figure 6.5). Examples of physiological needs include oxygen, nutrition, hydration, elimination, thermoregulation, sexuality, activity, and rest. The nurse cannot address other needs for the patient if these basic needs are not being met first. Security, social, esteem, and self-actualization complete Maslow’s hierarchy. A patient cannot have needs met in the social category if the needs below it (physiological and security) are not being met. Maslow’s hierarchy provides the nurse with a framework for prioritizing a patient’s needs while providing person-centered care, which focuses on three considerations: physical, emotional, and spiritual.
Physical Considerations
The nurse should address a patient’s physical considerations when providing person-centered care. For most patients, the physical considerations that are reported as important are pain management, assistance with activities of daily living, and short-term care facility environments. Patients may want assistance with dressing and personal hygiene and express a desire for a clean facility in which to heal. Meeting a patient’s physical needs ensures the nurse is providing person-centered care. For instance, if a patient does not receive timely pain management after surgery, the negative impact on the patient’s overall experience can be significant. For example, if physical pain is not managed well, safety, security, and emotional well-being are affected. The patient may not want to return to the healthcare facility if they received poor pain management after surgery.
Physiological Needs
A person’s physical needs and physiological needs can be intertwined. Physiological needs refer to the functions of the body while physical needs refer to the care of the physical body. A patient is having stomach pains (physical need) and they could also be stating that they have not had a bowel movement in a week (physiological need). The nurse can provide person-centered care by caring for both the patient’s physical and physiological needs. Often, resolving one issue will inadvertently resolve the other. Table 6.2 examines examples of physical and physiological need links.
| Physical Needs | Physiological Needs |
|---|---|
| Stomach pain | Bowel movement |
| Chest pain | Disruption in cardiac circulation |
| Headache | Decreased blood flow to the brain |
| Shortness of breath | Decreased oxygenation of blood from lungs |
Safety and Security Needs
The safety and security needs of a person can include a range of topics, such as personal security, employment, resources, health, and property. For example, being unemployed, underemployed, or not having health insurance should never affect a patient’s ability to obtain care when needed. A person should have their safety and security needs addressed early in the assessment process to avoid missing opportunities for care later as their needs increase. For example, taking a thorough health and social history can allow the nurse to identify specific actions to improve a patient’s security. Another example of addressing a patient’s safety needs might be making sure they have resources to contact if their environment is not secure or safe.
Age and developmental considerations also fall under safety and security. A patient might not be able to care for themselves, placing their safety at risk. For instance, safety and security needs for an infant include providing a secure environment and safe sleep position. An infant feels secure when they are swaddled and held. Safety and security needs for a toddler include preventing drowning and injuries and using car seat safety. Toddlers should be allowed to explore but need to be provided with structure and reassurance. The nurse must fully assess each individual patient’s situation when considering safety and security and connect the patient to appropriate interdisciplinary professionals, who each have their own set of resources to provide assistance.
Life-Stage Context
Financial Status of Older Adults
More than fifteen million Americans are economically insecure and living at or below the federal poverty level. People 65 years old and older often struggle with healthcare costs, and one major adverse life event such as a stroke can change their ability to pay for health care (National Council on Aging, 2022). Nurses should ask questions regarding current financial status and refer patients and their family to additional services, such as Medicaid and facility financial assistance programs.
Emotional Considerations
Emotional considerations for patients include addressing emotions such as fear, happiness, loneliness, sadness, and self-acceptance. The nurse should address emotional needs early in the care process. For instance, if a patient is fearful of having an MRI scan, the nurse needs to address those fears before the patient is scheduled for the test. An MRI scan requires the patient to lie completely still for an extended period, and a patient who is claustrophobic will have difficulty lying still and possibly not be able to complete the exam. If the patient discusses their fears with the nurse, a solution to address these fears can be achieved. Another example might be a patient who is depressed because of the loss of a loved one. If not fully assessed, the patient can easily sink further into an unhealthy state of mind. The nurse needs to be aware of each individual patient’s emotional needs to provide comprehensive person-centered care.
Love and Belonging Needs
One aspect of emotional considerations is a patient’s love and belonging needs. These needs can include friendship, intimacy, family, and sense of connection. Having a relationship with friends, family, or a significant other can provide the support needed for a patient to heal and recover. For instance, consider a patient who has inguinal hernia repair with a mesh support. The post-op instructions state that they are unable to drive or lift more than five pounds for six weeks. This patient has a partner that can be responsible for the day-to-day activities of the household. The patient relies on the mutual benefit aspect of a partnership to help achieve good outcomes after surgery. If the patient did not have a partner or someone they could rely on, a different outcome may be the result because the patient would still have the need for belonging. A patient who didn’t have a partner might try to lift more than five pounds, causing complications with the mesh support and a reoccurrence of the hernia. Love and belonging needs can also be met by providing feelings of self-worth. If someone feels loved, needed, and wanted, they often feel more positive about their own role in life and have more positive self-esteem.
Self-Esteem Needs
The term self-esteem can be defined as confidence in one’s own worth or abilities. Self-esteem is based on the patient’s own opinions and beliefs about themselves, which is sometimes hard to change once negativity is associated. Sometimes self-esteem can be developed based on what others have said, which the person can internalize as fact. For example, a person who has been told as a child that they are ugly, fat, or dumb may internalize those words, linking their self-esteem with those negative words. As this child moves through adolescence and enters the stage when other’s opinions are important, their negative feelings may take over and cause unhealthy coping. However, the opposite is also true; if a child has been told they are worthy and important based on their actions and not appearance, the child is less likely to give in to negative feelings about themselves as they mature. A positive self-image is the foundation for healthy mental health, which aids in managing life’s stressors. A nurse who considers a person’s self-esteem needs is better prepared for helping the patient achieve optimal health outcomes.
Link to Learning
Watch this video by Psych Hub about eating disorders to find out more about the complex relationship these disorders have with self-esteem.
Self-Actualization Needs
The realization of one’s potential is called self-actualization. A person who is self-actualized can be described as someone who accepts and appreciates themselves and their accomplishments in life. Self-actualization can be achieved through reflecting on one’s own values and beliefs. A patient who has accomplished self-actualization will be more accepting of their current state of health and may be more willing to participate in the care plan. For example, a patient diagnosed with inoperable cancer may recognize they have led a fulfilling life. The patient focuses on the life journey, not the diagnosis of inoperable cancer. The patient would be considered to have met their self-actualization needs and would be better prepared mentally to handle the notion of death because the patient feels they have met all their life goals.
Spiritual Considerations
Another aspect of providing PCC is taking into consideration the patient’s spiritual needs and caring for the patient’s spirituality. Spiritual care in healthcare facilities includes recognizing and providing care that takes religious customs into account. Spiritual care is mandated by both The Joint Commission and the National Consensus Project for Quality Palliative Care. Nurses are responsible for identifying and understanding a patient’s spiritual needs, assisting the patient in developing the care plan, involving the appropriate healthcare/spiritual professionals, and evaluating the patient’s spiritual care. The nurse should work closely with the patient and healthcare providers to make sure the patient’s spiritual needs are being met. Resources available in the healthcare organization, such as a chaplain, clergy, or nondenominational advisor, are helpful in assisting the nurse to meet the spiritual needs of a patient. Nurses must not be judgmental or biased; they should be open minded to better meet the spiritual needs of the patient. The nurse providing spiritual care for patients should also understand their own spiritual views.
Link to Learning
Nurses can visit the HealthCare Chaplaincy Network (HCCN) to find additional information about meeting a patient’s spiritual needs. HCCN is a nonprofit organization that offers spiritual care-related information and resources.
Concepts Related to Spiritual Health
Spiritual health can be related to achieving self-actualization. Spiritual health care can be described as helping a patient meet their psychological needs and develop a meaningful life. Spiritual health concepts include faith, religion, hope, and love. Faith, religion, and spirituality can be intertwined ideas; however, each has its own meaning. Sometimes nurses equate spiritual health with religious affiliation. However, in today’s world, spiritual health means embracing and understanding whatever the patient considers spiritual. Some people find spiritual peace in tasks such as meditation or yoga (Figure 6.6).
Faith
An absolute trust or belief in something or someone is called faith. A patient can have faith that the nurse will treat them fairly and equitably. They can also have faith in a higher power or entity. Faith does not imply religious affiliation; some patients have a strong faith but do not follow an organized religion.
Religion
The term religion refers to the actual practice of worship within an organized culture or group of like-minded individuals. There are many forms of religion in the world. Some examples include Buddhism, Christianity, and Judaism. Nurses should refrain from making assumptions about the values and beliefs of any religious affiliation. Asking the patient questions about their religious practices will develop a therapeutic nurse–patient relationship, which is needed to provide person-centered care. For instance, if the patient, because of religious beliefs, shuns away from a certain medical practice, such as the administration of blood or blood products, or has specific dietary practices, such as eating only kosher foods, the nurse needs to know this. The nurse should respectfully honor the patient’s wishes and provide resources on alternative treatments or notify nutritional services. Understanding the patient’s religious beliefs ensures PCC is being given.
Patient Conversations
Completing a Spiritual Assessment
Scenario: Indy, an RN for six years, has been assigned to admit Mr. Denzel Bernstein, a new patient to the hospice unit. The patient has end-stage glioblastoma and his significant other and adult children are present at admission. Hospice is focused on comfort, care, and quality of life for someone approaching the end of their life.
Nurse: Hello, my name is Indy, and I am going to be your nurse today. Do you mind verifying your name and date of birth for me?
Patient: My name is Denzel Bernstein and my birthday is July 26, 1965.
Nurse: Hello, Mr. Bernstein, I am here to admit you and would like to ask you some questions about your religious preferences? Is that okay?
Patient: It is okay, but I am tired. Would you please ask my wife, Chava?
Nurse: Sure. Mrs. Bernstein, is it okay if I ask you these questions about your religious preferences?
Patient’s wife: Yes, it is okay.
Nurse: What are your and Denzel’s religious or spiritual preferences?
Patient’s wife: We are lapsed Methodists; we have not attended church in a few years.
Nurse: Do you have any dietary preferences related to your religious or spiritual beliefs?
Patient’s wife: No, we do not.
Nurse: How have your beliefs influenced your behavior during your illness?
Patient’s wife: Denzel was diagnosed two years ago with glioblastoma, and at the time it did not change anything about our beliefs. However, as he is being admitted to hospice and facing his impending death, we have started talking about religion and spirituality again. We have always had a belief in God, and we hope Denzel goes to heaven to see his parents.
Nurse: Would you like me to call the Methodist clergy to come visit with you?
Patient’s wife: Not right now, but maybe tomorrow once Denzel has rested.
Nurse: I would be happy to arrange for a chaplain to visit you and your family. I understand what a hard time this is. I am willing to help you in any way I can during your time here. If there is anything I have not addressed at this time or anything else that comes up later, please do not hesitate to reach out to me.
Hope
The term hope can be defined as how the person views their future. It can be an attitude, an inspiration, or an overall sense that a person feels. As the nurse develops a therapeutic relationship with the patient, hope can be explored. For example, if the patient was diagnosed with an infection that requires long-term antibiotics, the nurse can explore the patient’s hope for recovery. Nurses can also foster hope in families with transparent communication. Incorporating the patient’s wishes ensures the spiritual considerations of a person-centered approach are being met.
Love
Love is discussed as part of Maslow’s hierarchy of needs and allows for a sense of belonging. Love can also be spiritual in nature. Spiritual love can help patients find meaning and purpose in their lives and create kindness and acceptance of themselves and others. When a patient describes spiritual love, it can feel like an intense connection with someone or something. This intense connection can help the patient see and understand things in the world around them differently. A patient who has a deep spiritual love with their significant other may not be bothered when separated from the significant other, knowing the love will sustain the relationship during the separation, such as during a hospitalization.
Aspects Influencing Spiritual Health
Spiritual health includes critical attributes such as transcendence, purposefulness, mindfulness, faithfulness, harmonious interconnectedness, integrative power, multidimensionality, and holistic being (Table 6.3). These terms describe a sense of completeness between one’s mind, body, and spirit. When spiritual health has been disturbed, physical and emotional health can also be affected. Connection with others remains key to the influence of spiritual health.
| Term | Definition | Example |
|---|---|---|
| Transcendence | The state of existing or extending beyond the physical being | Meditating |
| Purposefulness | The state of having a useful purpose | Giving to a charity |
| Mindfulness | The state of being present in the moment | Living in the moment |
| Faithfulness | The act of being faithful | Being loyal to relationships |
| Harmonious interconnectedness | The connection between mind, body, and spirit | Feeling that everyone and everything means something |
| Integrative power | The capacity to obtain what one needs and wants while maintaining human connection | Feeling love |
| Multidimensionality | The state of having connection with people from different parts of one’s life | Having a neighbor who works with your family member and is also your friend |
| Holistic being | The act of being authentic to one’s self in all aspects of life | Looking at everything as whole and connected |
Developmental Considerations
To provide person-centered care, the nurse must assess the patient’s developmental and spiritual needs. The nurse should assess a patient’s knowledge level, communication ability, cognition status, and ability, all of which may affect their spiritual needs. For example, a 4-year-old child will have different spiritual needs than a 74-year-old patient with dementia. The nurse should involve the patient’s family in the healthcare decision-making when it is determined that the patient cannot make spiritual decisions for themselves.
Family Influences
Many patients value their families’ thoughts and beliefs when considering healthcare options. Often, patients will not make any healthcare decisions until they have consulted their family. The nurse should include the family in all aspects of the patient’s care. The nurse should provide the family with opportunities to weigh in on decisions and plans. Scheduling patient meetings with all interdisciplinary team members when the family can attend is one way to ensure PCC is provided.
It is important to remember not every patient will have the same value placed on family opinion. Occasionally a patient will not have a good trusting relationship with their family and not want to consider what they think. In this case, the nurse needs to respect that decision and not push for family opinions. It is vital the nurse respects the patient’s decision regarding privacy and does not discuss private information with other family members without the patient’s permission. It is a patient’s right not to discuss their medical condition or prognosis with loved ones.
Other times the perception of family can mean different things to different people, and genetics may not have anything to do with a person’s perception of family. Some people consider friends their family, rather than actual blood relatives. Regardless of the situation, best practice standards are for the nurse to always respect a patient’s decision regarding who receives their private health information.
Previous Beliefs
Previous beliefs affect how a patient perceives their current state of health. A nurse should ask the patient about their beliefs and past experiences. This is especially true if the patient and/or family had a previous negative experience. For instance, if a patient had a family member experience a negative outcome from a particular medical procedure, the patient’s perception of that medical procedure could forever be altered. The nurse should understand and incorporate the patient’s previous beliefs into the current care plan. The nurse can use therapeutic communication techniques and education about the procedure to alleviate fears and clarify any misinformation. The healthcare provider should explain the risks associated with the procedure and openly and honestly answer any questions the patient has before the patient has the procedure. The nurse is responsible for reinforcing what the healthcare provider has taught the patient and addressing the patient’s anxiety. The nurse also has a responsibility to ensure that the patient understands what they are being told/taught. Nurses often are also the patient’s voice—advocating for patients.
Life Events
Some patients experience life events that require additional consideration when developing a care plan as those life events may impact the patient’s ability to heal. For example, a female patient who was previously sexually assaulted by a male authoritative figure and is seeking treatment for an unrelated medical issue may request a nurse of the same gender due to the trauma associated with her previous life event. The previous trauma may affect how the patient responds to treatment and can disrupt the ability to meet health goals. Loss of a loved one is another life event that impacts a person’s ability to heal and recover. When a nurse cares for a patient who has lost a loved one, that patient should be provided additional resources for grief support, as the previously experienced grief may bring up emotions that affect their ability to cope and heal.
Parish Nursing
Sometimes called faith community nursing, parish nursing is a specialty that focuses on the care of people in a faith community, church, or parish. Parish nurses help their communities by mobilizing volunteers in the faith community to support members in need. Parish nurses could be responsible for organizing volunteers to visit the sick and older people of the faith community. Parish nurses could coordinate blood drives or blood pressure screenings for the members of the faith community. Parish nursing is recognized nationally and internationally. Nurses who wish to practice parish nursing must follow their state’s Nurse Practice Act and the American Nurses Association (ANA) Faith Community Nursing: Scope and Standards of Practice.
Unfolding Case Study
Unfolding Case Study #1: Part 7
Refer back to Chapter 2 Communication and Chapter 5 Cultural Competence for Unfolding Case Study Parts 1–6 to review the patient data. The medical-surgical nurse is providing care to a 28-year-old patient who arrived to the hospital one hour ago from a walk-in medical clinic. The patient speaks Spanish and is accompanied by her bilingual 10-year-old son. She has been admitted to the medical-surgical unit for observation.
| Nursing Notes | 2310: Assessment History and assessment is difficult to obtain because patient does not speak English. Son reports patient was seen at the clinic for a cough, was diagnosed with pneumonia, and was started on a medication to treat it. Patient remains on 2 L oxygen via nasal cannula, breathing pattern appears normal without distress. |
| Flow Chart | 2310: Assessment Blood pressure: 135/75 mmHg Heart rate: 97 beats/minute Respiratory rate: 22 breaths/minute Temperature: 100.1°F (37.8°C) Oxygen saturation: 97 percent on 2 L nasal cannula Pain: 9/10 (ear) |
| Nursing Notes | 0100: Patient given one dose of acetaminophen and reports ear pain is now 4/10. Interpreter has arrived and plans to stay on the unit until morning rounds so they can translate when the provider comes in. Patient resting comfortably, son sleeping on couch at the bedside. |
| Nursing Notes | 0700: Assessment Patient is awake and alert and reports feeling “much better.” Patient reports anxiety about finances and is worried about being able to feed her family. She states that she makes enough each month to get by, but her mother is getting older and beginning to require more care and medications. |
| Flow Chart | 0700: Assessment Blood pressure: 128/72 mmHg Heart rate: 87 beats/minute Respiratory rate: 18 breaths/minute Temperature: 99.1°F (37.3°C) Oxygen saturation: 97 percent on room air |
| Provider’s Orders | 0745: New Orders Discharge after meeting with social worker. |