Patients at the Center of Care: A Nurse's Guide

Written by: 
Daymar College

Patient-centered care is the foundation of modern nursing practice. It’s an approach that puts medical decision-making in the hands of the person receiving care and as a concept, its implementation is long overdue. Today’s nurses are part of the first generation to fully embrace the belief that a patient’s needs as they define them, not as the medical community sees them, should be at the center of care.

The Institute of Medicine (IOM) — a non-profit think tank that supports evidence-based healthcare research and defines patient-centered care as that which is “respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”

How does that represent a fundamental shift in the approach to healthcare in the United States? To answer that requires a closer look at how and why the idea evolved.

The Evolution of Patient-Centered Care

Throughout much of history, the authority in the relationship between patients and healthcare providers was tipped in favor of medical professionals. Doctors and nurses gave orders while patients' values were ignored or relegated to the back seat.

This paradigm partially reflected a gap in knowledge and education between patients and providers, and a portion of it was the product of generational respect, but some of it was also a misplaced notion on the part of the medical community that they were the best judges of what patients needed. Some members even resisted increasing patient involvement believing it could adversely affect their ability to make objective clinical decisions.

The concept of patient-centered care is mentioned in medical texts as far back as the 1950s, but it wasn’t until the late 1980’s that it started to gain traction. Patients were becoming frustrated with the care they were receiving, and the healthcare system, on the whole, was failing to meet both its outcome and fiscal goals. Why?
Researchers looking at post-hospitalization satisfaction surveys discovered a common and surprising theme, that patients and their families felt left out of medical decision-making at a time when they were the most vulnerable. Poor communication and a failure on the part of doctors and nurses to consider their values and beliefs when making recommendations were cited as top concerns.

The social and economic characteristics of patients as a group were changing, and so were their expectations. As healthcare expanded, it became more present in people’s lives, and wealthier, better-educated clients, especially the Baby Boomers, wanted to collaborate with medical professionals on their wellness issues as full partners.

Through the next decade, doctors would learn more about the importance of therapeutic communication, and the results were so good that the concept of care centered around the patient as the primary decision-maker grew. Taking a cue from big business, healthcare leaders saw an opportunity to expand on the idea by including complementary customer service principles and extending patient-focused expectations to all healthcare staff.

Ultimately, the final push for patient-centered care came when analysts proved that when providers approach medicine collaboratively, outcomes improve for both patients and providers, and that’s a win for both the community and the healthcare system.

Today, keeping care centered around patients and their families is the new rule, not the exception, and because nurses spend more one-on-one time with clients than any other provider, its benefits are dependent on them as patient advocates and tireless care planners. As a natural extension, cultural and generational competency is now a part of the nursing curriculum, and nurses are proving to be the leaders needed to expand the concept of patient-centered care at every level.

Principles of Patient-Centered Care

Patient-centered care is a team-based approach in which input from clients, families and healthcare providers come together into a comprehensive, but individualized plan of care. A universally accepted definition of patient-centered care and well-defined models for its delivery are pending, but the concept is spreading based on these general principles:

Principle #1: Respect for Patient’s Values, Beliefs and Preferences

Patients are autonomous individuals with the right to make healthcare decisions that are free of undue influence. Each person has unique customs, beliefs and values that providers should treat with sensitivity and respect.

When clients see a doctor, they are looking for a professional opinion, but not everyone’s values align with every recommendation. Some patients have atypical views about healthcare that are driven by unique personal experiences and religious or cultural beliefs. Doctors and nurses need to inform and educate clients about the best possible clinical recommendations, but they should always collaborate with the individual to choose a path forward that meets their needs as a whole person.

Principle #2: Education and Informed Consent

Information is necessary to make sound medical decisions. Patients have the right to know the truth about their condition and prognosis in a timely way as well as the risks and benefits of recommended care. Elective treatments should never be given without the consent of the patient or their representative.
In most settings, patient education is a nursing responsibility. After the doctor has discussed diagnosis, prognosis and treatment options with clients, it’s not usual for questions to come up, and nurses are a go-to source of information. Once taught to gloss over the truth of a difficult diagnosis in the name of compassion, patient-centered care demands gentle and positive honesty on the part of providers. For a client with a terminal illness, their last days belong to them, and no one has the right to change how they might spend them by giving them inaccurate information.

Concerning procedures, as long as a patient’s questions are unanswered, it’s not possible for them to give valid informed consent. Regardless of scheduling or financial considerations, a nurse must advocate for patients by ensuring that care proceeds only when consent is clear.

Principle #3: Comfort

Pain management, assistance with activities of daily living like dressing and bathing and the design of the healthcare environment are the cornerstones of comfort, and it's essential to manage them effectively for all patients.

With the risk of extensive opioid use, healthcare providers now have a harder job to do managing discomfort. Pain is a subjective experience, and it can be debilitating, but the potential for addiction to certain medications is high, and their use should be monitored closely, and their dangers fully disclosed. Prescribing opioids a patient wants but doesn’t need or that will not be effective for their conditions is not patient-centered care.

Assistance with activities of daily living is also a significant part of providing comprehensive care. In busy hospitals, tasks that were not central to clinical needs were once considered less important, but helping patients feel their best makes them more comfortable and willing to engage in their treatment plan. What patient wants to walk in the hallway in front of others in a skimpy hospital gown without bathing or combing their hair?

Similarly, universal design is now an essential part of hospital and medical office construction. Every client should feel welcomed and comfortable in healthcare facilities regardless of their shape, size or mobility restrictions. Universal design is a planning method that considers comfort and accessibility for special needs users.

Examples of design improvements include:

  • Tubs and showers designed for handicapped accessibility
  • Building entrances without stairs or with ramps
  • Flat panel light switches that require little manual dexterity to use
  • Seating that is large enough for bariatric patients and their guests
  • Wheelchairs that are the right fit for every body size
  • Doors that are wide enough for patients using walkers or wheelchairs to navigate
  • Hands-free door opening devices
  • Beds and medical equipment with higher weight limits for heavier patients

Universal design is a good investment for any building type, and it encourages inclusivity, but in healthcare environments where guests are physically frail, its use is exceptionally meaningful.

Principle #4: Emotional Support

People who are ill are vulnerable. Emotional needs arise from both sickness and the provision of care, and it’s the responsibility of healthcare providers to ease those burdens whenever possible. Why?

When a plumber hands a homeowner a hefty bill for clearing a clogged drain, it’s not his or her responsibility to provide financial counsel or even to offer a consoling word or two, but because emotions are an integral part of a person’s well-being, failing to address them adversely impacts both satisfaction levels and clinical outcomes in healthcare. A sympathetic plumber makes a customer happy and creates trust in their relationship, but it doesn’t make the drain any clearer.

Fear, grief and anxiety are powerful emotions that directly affect pain perception and the motivation to participate fully in treatment plans. Studies show they also impact the immune system, and in hospitals where patients report less pre-surgical stress and anxiety, the rate of serious post-operative infections tend to be lower.

Principle #5: Family Involvement

A patient’s family and friends are their most significant source of support. They should be welcomed in the healthcare environment and encouraged to participate in the decision-making process when the patient so chooses.

Of course, not all familial relationships are supportive, and medical providers need to be aware of this issue where it exists, but in general, where other persons were once thought to be stressors for sick patients, now they are considered to be benefits. Open visiting hours and efforts to make family and friends more comfortable in the healthcare environment have been welcomed changes. A good example is the rooming-in option many maternity wards offer for the spouse and children of mothers with newborns.

Improving family involvement has also enhanced care for those in nursing facilities. Long-term care patients are more likely to suffer from cognitive loss, and its effects can leave them unable to make decisions for themselves. When the family members who know them best are invited to participate in their care, they help staff better understand their loved one’s preferences and make it possible for them to provide patient-focused care.

Principle #6: Access to Care

Access to care including making appointments with providers, accessing specialists and locating emergency care should be free of logistical hardship whenever it's possible.

People with full-time day jobs, those who live in rural areas and patients without private transportation are all at a significant disadvantage when seeking healthcare. That’s not only bad for patients, it’s financially problematic when care is received at an emergency room because there is no less costly alternative.

Healthcare organizations are improving their bottom line and patient care by considering the needs of those they serve first by:

  • Opening urgent care centers for off-hours non-emergency needs
  • Adding evening hours at doctor’s offices
  • Recruiting more primary care providers to offer timely appointments
  • Establishing satellite offices and clinics in rural areas
  • Bringing care directly to clients with medical vans and telemedicine services
  • Offering valet parking for patients who can’t walk the distance from remote parking areas
  • Assisting patients with finding affordable medical transportation services
  • Equipping medical offices with necessary diagnostic equipment to prevent hospital trips
  • Increasing access to home-based care services
  • Educating patients about the most timely and cost-effective way to get medical attention
  • Providing clear and easy-to-read contact information

The price of healthcare is also an accessibility issue. Experts believe up to 40-percent of Americans have foregone medical attention because of the cost, and they cite it as a significant source of stress among patients according to AARP. More than half a million personal bankruptcies are attributable to healthcare bills, and it’s crucial for providers to understand the financial balance clients need to achieve in their lives.

Professional recommendations should always be optimal, but when clients decline care based on their inability to pay, looking at more affordable options or helping them find alternative financing is a must. The bottom line is that improving the quality of care counts, but only if patients have access to it.

Principle #7: Coordination and Continuity of Care

With the patient’s consent, the information necessary for different providers to successfully collaborate and optimize care should be shared without professional reservation and regardless of setting.

In 1996, Congress passed the Health Insurance Portability and Accountability Act, also known as HIPAA. This legislation established new rules related to who has the right to see an individual’s medical information and in fact, it may only be exchanged between healthcare providers when necessary and with the patient's consent.
While this puts the onus on doctors and nurses to ensure they obtain consent, it should never be a barrier to the coordination of care. This is one area of patient-centered care in which the medical community is struggling to address.

For example, if a primary care physician doesn’t let a specialist know which medications he or she has prescribed for a patient, it could result in a dangerous duplication. Similarly, diagnostic tests could be repeated unnecessarily, causing care to become cumbersome and inefficient. The transition to electronic health records is making the flow of information easier in general, but HIPAA and the sheer complexity of the healthcare system have created roadblocks.

Signing the necessary consents eliminates some of the issues, but continuity of care between providers, especially related to mental health issues, substance abuse disorders and HIV status, remains difficult.

Healthcare organizations have been vocal about the high cost of obtaining regular consents and safeguarding medical information, but HIPAA represents an important advancement in patient’s rights. Respecting clients' privacy while making it easier to share data is paramount to the continuity of care and is a top challenge for the next generation of nurses, doctors and administrators to meet.

Benefits of Patient-Centered Care

Care centered on the patient benefits everyone with improved patient satisfaction, greater trust in providers, less provider stress, reduction in resources used, and financial sustainability.

Improved Patient Satisfaction

Patients and families who feel they were respected and cared for as individuals consistently report greater satisfaction with the care they received, even if the medical outcome wasn’t favorable. In cases where errors occurred, patients were less likely to blame the provider, and their therapeutic relationship usually continued.

Greater Trust in Providers

Providers who include patients in decision-making and meet their information and education needs are afforded more trust. Clients are more likely to discuss sensitive issues and take recommendations seriously, knowing the doctors and nurses involved in their care have their well-being as a whole person in mind.

Less Provider Stress

When the patient is fully engaged in their care, doctors and nurses no longer bear the full responsibility for every clinical decision. They don’t have to guess what a patient wants; they know because they asked.

With better communication, efficiency also improves, and a more efficient system decreases employee burnout and improves staff retention. Healthcare providers feel that they are better meeting their mission to care for those in need, leading to higher levels of job satisfaction. By implementing patient-centered care practices, Bronson Methodist Hospital in Michigan reduced its nursing turnover rate from 21 to just seven percent.

Reduction in Resource Use

Patients who can access convenient care get help faster when there’s a problem and the resulting interventions cost less. They’re more satisfied and confident with their providers and are less likely to use emergency resources and seek ongoing opinions because of a lack of clear information about their condition. When care is centered on the client, not the diagnosis, people feel their needs as whole persons have been met, and they utilize fewer resources overall.

Financial Sustainability

Outcomes drive healthcare reimbursement. In 2012, Medicare, the largest single healthcare payer in the United States, implemented a value-based program in which hospitals are paid based on the quality of care they provide. Administrators quickly discovered that patient-centered care practices were the top drivers of both satisfaction scores and clinical outcomes and were among the best ways to boost their revenue.

Higher employee satisfaction also helps organizations remain financially sustainable. The same Michigan hospital that reduced nursing turnover rates from 21 to seven percent realized a cost savings of about $3 million over five years.

What Does Patient-Centered Care Look Like in Practice?

Patient-centered care is a broad topic, and as the healthcare professionals most likely to make it a reality in their client’s lives, nurses should find it easy to recognize. These examples show how keeping the focus centered on the clients' needs is making a difference and where improvements are needed.
In Nursing Facilities

Today, the patient-centered care model is helping nursing facilities make their environments more home-like. Limited visiting hours and schedule restrictions are no longer the norms. Instead, open-house atmosphere where residents decide who can visit and when are more common. Patients choose family members or friends to be part of the multidisciplinary healthcare team that meets quarterly. Their input and advocacy keep the client’s values and preferences front and center.

Family is privy not only to updates in their loved one’s medical condition, but they're also informed of changes in mood, how they participate in activities and their general level of satisfaction with their health and living circumstances. Residents are free to choose their doctors, and when everyone is involved, care is well-coordinated. Social workers assist with financial and discharge issues, and if changes in the plan of care are required, collaboration is encouraged.

Newer long-term care facilities are also improving resident access to amenities and activities with universal design. Individual spaces are roomier to allow for the use of adaptive equipment, and bathroom fixtures are optimally placed to improve safety and encourage independent use. Main doors are wide enough to allow access to more than one wheelchair at a time, and ramps permit residents to attend outdoor activities. When a family is visiting, modular furniture makes rooms more comfortable for overnight stays and hospitality services are happy to include guests in the resident's dining plans. Bariatric beds are increasingly available as are handicapped-accessible vans for transportation to out-of-facility activities and doctor's appointments.

In the Hospital

Patient-centered care in the hospital has a slightly different look because, for most people, it’s a short-term stay. Because their conditions are typically more acute, comfort is especially important. When it comes to universal design and guest hospitality, hospitals are leading the charge.
Among complaints in post-hospitalization surveys, were issues with continuity of care and discharge planning. Patients reported the communication between multiple providers was slow and led to confusion among staff while many felt they were discharged prematurely without adequate home support or information about their stay.

What hospitals learned by reviewing this data is that while most of these discharges were likely medically appropriate, they didn’t feel that way to worried, physically weakened patients who felt they lacked critical information and couldn’t take care of themselves safely at home. Some were unable to pick up food or their prescribed medications, while others were unsure of when they should be seen next by their doctor or how to contact a provider in an emergency. Most were surprised to learn that medical centers rarely informed an out-of-network primary physician when their patients were hospitalized.

This was a classic case of patient care centered on the diagnosis, not the individual’s needs. In response, hospitals are stepping up with teams of discharge planners whose only role is to ensure continuity of care after patients go home. Social workers or nurses work with families, primary care physicians and outside agencies to obtain home support and ancillary services like medication and meal delivery to give patients a sense of security and the highest chance for success.

In Primary Care

Primary care providers are the foundation of today’s healthcare system, so patient-centered care naturally emphasizes the importance of that relationship. Trust built on empathy and open dialogue is vital to a doctor's ability to see patients as individuals, not as collections of physical complaints. Training in communication and personal sensitivity are now a part of a physician's education.

This new view of patients as whole persons has led to a team-based approach toward care in primary practice. Doctors feel empowered to seek a range of professional services on a client’s behalf from social services to mental health programs and home health care while nurses are increasingly the compassionate, go-to resources for patients who have questions.

More practices are incorporating technology-based tools to improve patient access to information, and telemedicine is being increasingly accepted by insurers as a way to deliver top-quality care to those for whom transportation is a barrier.

The Future of Patient-Centered Care

If there is one message that the medical community should embrace about the future of healthcare, it’s that consumers and people, patients and their loved ones should always be at the center of care.

The issues surrounding the American health care system’s credibility and financial viability are no accident. They are the result of a misplaced focus on the diagnosis-based, task-driven aspects of care that treat diseases, not people. It’s a long-term, systemic mess.

Changes have already begun, and both patients and providers have a lot to look forward to, but issues that evolved over decades won’t disappear overnight. The fundamental shift in attitude and perspective that come with the new emphasis on patient-centered care are just two decades old, and the system needs to adjust. It’s a process that takes time.

As patients and their families are increasingly taking charge of their health and demanding equality in the process, healthcare leadership is thankfully responding and embracing it with few reservations. Policymakers are recognizing that it’s just the medicine today’s complex medical machine needs, and providers are grateful for a new paradigm that gives them less authority, but ultimately makes them more able to fulfill their mission of healing.

If you're interested in pursuing a nursing degree, we have the degree program for you. Daymar College’s Associate of Science degree in Nursing is designed to provide the foundation for beginning the practice of professional nursing.

The curriculum of nursing education courses, as well as general education classes, can train you to provide patients with care that's safe, effective, patient-centered, timely and efficient. You'll have the opportunity to learn the skill sets that correspond with the level of practice, types of patients served and practice settings at Daymar College. You'll be introduced to the American Nurses Association Code of Ethics. Nurses who adhere to this code of ethics demonstrate competence, continuing self-improvement and personal self-care (wellness). For more information, contact us today!

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