CARL ROGERS PERSON-CENTRED APPROACH

Introduction

Carl Rogers (1902-1987) a psychologist developed the person-centred approach theory mainly in relation to the therapist and the client and initially named it the client-centred approach. Rogers later referred to this theory as person-centred rather than patient-centred in order not to reduce the individual’s autonomy and consequently lend the client to difficulties. The approach therefore is to turn individuals (clients) into subjects of their own therapy. In his theory it was noted that individuals are endowed with the power of self actualization and through their own perception of resources inherent in them, they can provide remedy for change in their difficult situations, provided a facilitating environment exists This view as expressed by Rogers implied that every person has a tendency to grow and attain a certain level of actualization. He observed that in order to allow the client (person) asses his/her own wisdom and self defeating behaviours and also engage in therapeutic movement with the therapist, there must be a conducive climate. Three conditions were identified for this relationship to thrive favourably: Genuineness (Congruence), Empathy and Unconditional Positive Regard.

GENUINENESS (Congruence)

In this relationship the therapist is expected to show a real sense of genuine attitude towards the client’s feelings and thoughts, be willing and ever present to assist them in whatever situation they may be. He should be transparent and discourage the attitude of being the superior in the situation. This attitude would in turn retain a high sense of confidence in the client towards realization of him/herself in therapy. Any deviation from this attitude renders the process unworkable.

UNCONDITIONAL POSITIVE REGARD (Total Acceptance)

According to Rogers, the therapist in this situation must show non-judgemental and total acceptance to the client’s feelings and his perceptive world as a whole to enhance his process of recovery. This total acceptance of the client’s attitude and perception should

be devoid of whatsoever differences that might exist between them either culturally or socially. However in doing so the therapist should ensure the safety and security of the client.

EMPATHETIC UNDERSTANDING

In his theory, showing empathy refers to the ability of the therapist to show positive sensitivity to the client’s world, his perception towards recovery and also communicate his feelings to the client. This will convey a special meaning to the client of his relationship with the therapist and consequently solidify their mutual relationship towards the expected therapeutic movement. Rogers continue to state that any deviation from these attitudes on the part of the therapist makes it difficult for the process to continue. This empathetic attitude is more exhibited by therapists who are more confident about their own identity and can cope with other person’s world without any fear.

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PERSON-CENTREDNESS AS A CONCEPT

Person-centeredness a concept in health care delivery has poor and conflicting definitions over the years and is considered one of the best ways of health care delivery in which patients are valued as individuals (Winfield et al. 1996). It has further been observed by

(Slater 2006; Leplege et al 2007), that the concept of person-centredness has been described using different terms like patient-centred, client-centred, person-centred interchangeably which makes it most often unclear which consistent term to use in the description of the concept. Notwithstanding all these difficulties, Kitwood (1997) defined person-centredness as “a standing or status that is bestowed upon one human being by others in the context of relationship and social being. It implies recognition, respect and trust”. (p.8) Kitwood (1997) further used person-centredness to formulate ideas and ways of working which puts much emphasis on communication and building relationships in care.

Brooker (2004), elaborating on person-centred approach found out that the definition of the term has such characteristics as:

· Respecting and valuing the individual as a full member of society

· Providing individualised places of care that are in line with people’s changing needs

· Understanding the perspective of the person and providing a supportive social psychology in order to help people live a life of relative well-being.

Dwelling on these definitions of Kitwood and Brooker, it is evident that they are built on the works of Carl Roger’s (1950), which developed person-centred approach as a way of facilitating psychological growth (Natiello 2001).In addition a critical look at Kitwoods definitions definitions showed that personhood has been considered very essential. (Dewing 2008) observed that Person-centredness is often associated with gerontological nursing and more particularly issues relating to dementia care and have personhood as a basis of promoting its practice. It is therefore relevant to explore the philosophical and theoretical underpinnings of personhood in as much as it recognised in person-centredness (Baker 2001; Ford & McCormack 2000; Fares 1997).

Baker (2001) declared that personhood is consistent with individuality and has three dimensions; the person’s world which relates to understanding the person’s needs, self relating to emotional and physical security and others which signify social and material world that considers the need for interventions and a sense of belonging and place.

Similarly (Ford & McCormack 2000) recognises personhood as the person’s ability to rational make decision by virtue of his reflection on available needs, choices wants and desires. On the contrary this ability to make rational decisions might be difficult particularly in persons with dementia (Kitwood 1997), however choices can be offered to the person.

Harre (1998, p.6) drawing on the work of Apter (1989),concludes that ; a sense of personal distinctiveness, a sense of personal continuity and a sense of personal autonomy important phenomenon that best described personhood. Elsewhere in literature, transcendence – (a state beyond material or usual existence) has been referred to as an essential characteristic for description of personhood (Heron 1992 & Kitwood 1990a, 1997).This goes to establish the assertion that “personhood” can be accessed from three type of literature- theology and spiritual, ethics and social psychology and each of these literature gives different meanings to attributes relating to personhood (Kitwood 1997, p.8).

McCormack (2004) compared the definition of person-centredness by Kitwood and his own findings in an extensively reviewed literature and concludes that four concepts

should be considered in describing person-centred nursing. These are: Being in Relation, Being in Social Context, Being In Place, Being With Self.

Being In Relation

Being in relationship emphasizes the point that, for any effective person-centred care to commence, continue and achieve success ,the nurse and the patient should be in a good interpersonal relationship and this relationship requires valuing of self, moral integrity, reflective ability, knowing self and others as derived from reflection on values and their place in the relationship. Being in relationship is also reflected in one of the seven attributes of person-centredness identified by Slater’s (2006) concept analysis-evidence of a therapeutic relationship between person and health care provider. He further states that this relationship between the person and care provider must be one of mutuality, mutual trust and non-judgemental which does not take into consideration the balance of power.

Being In Social Context

This is the interconnectedness of persons with the social world in which individuals create meaning to themselves through being in the world. Being able to understand the social world of the person enables one to clearly identify things that are considered paramount in their lives Slater (2006).

Being In Place

Andrew (2003) declares that concept of ‘place’ and its impact on health care delivery is poorly understood in nursing. Andrew further argued that ‘places’ are not just physical but involve situated human intentions within them.(Andrew, 2003; Luckhurst & Ray, 1997; Hussain & Raczka, 1997) contends that attention must be paid to ‘place’ in care relationships for its important role. In order for nurses to be facilitators of person-centredness, care values must be balanced with other organisational values no matter how

difficult it might be, to enable the process of the concept to continue smoothly (Woods 2001). A similar idea was expressed by Johns (1995) that nurses cannot freely fulfil their moral obligation to patients without taking cognisance of organisational and professional implications. To buttress this McCormack et al (2002) asserts that whilst it is important for nurses to facilitate person-centredness, other contextual issues such as staff relationships, organisational systems, power differentials and the extent to which the organisation tolerates innovative practices and risk taking should be worth noting.

Being with Self

Knowing self is very central in person-centred nursing approach. This is important in that, health care providers need to identify their personal values first in order to respect the values of other patients under their care, to avoid trampling over their autonomy and cultural needs paramount to person-centredness (Downs, 1997; Ford & McCormack, 2001; McCormack, 2001b; Nolan, 2000).Further, knowing self enables the nurse to make comparisons of current lifestyles and behaviours of the patient with his preferences and values of life in general as a clue to enhance care process (Meyers,1999).

PERSON-CENTRED PRACTICE BASED ON AUTHENTIC CONSCIOUSNESS

Based on the four concepts- Being In place, Being In relationship, Being with self, Being In social context, McCormack (2003) outlined five conceptual models in consistent with current nursing principles. These are: Authentic consciousness (McCormack 2001a, 2001b, 2003 and 2004), Positive person work (Packer 2003), the senses Framework

(Nolan et al 2001), Skilled companionship (Titchen 2000, 2001 p.80) and The Burford Nursing Development unit model (Johns 1994). McCormack developed a conceptual

framework for person-centredness practice based on Authentic consciousness. He identified five imperfect duties on which the framework will operationalize.further, McCormack (2003) declared that for person-centredness to operate effectively in practice, factors such as the patient’s value, the nurse’s values and the context of care environment.

For the purpose of this study, imperfect duties and factors (Patient’s values, the nurse’s values, context of care environment) on which person-centred practice operationalize will be explored to highlight their effect on the concept.

According to Immanuel Kant’s morale theory cited in (Sullivan, RJ 1990), imperfect duties are described as wide, broad and limited such that it gives room for discretion but within the rules of the organization within which one works. There is no means of offering an exhaustive and a priori account of how the duties are to be fulfilled. The five imperfect duties discussed earlier are as from (the conceptual framework of McCormack 2003):

· Informed flexibility: this is the facilitation of fdecision making based on information dissemination and the integration of new information into established perspectives and care practices.

· Mutuality: the recognition of the others’ values as being equally paramount in decision making.

· Transparency: making clear the intentions and motivations for action and the boundaries within which care decisions are set.

· Negotiation: patient participation through a culture of care that values the views of the patient as a legitimate basis for decision making while recognizing that being the final judge of decisions is of secondary importance.

· Sympathetic presence: this is an engagement takes into consideration the uniqueness and value of the individual by appropriately responding to cues that maximize coping resources through the recognition of important agendas in daily life.

PATIENT’S VALUES

In person-centred practice respect for patient’s values are identified as being central in order to achieve an effective process of the concept (Dewing, J. 2002; William,B. & Grant. 1998; McCormack 2001).It is important to develop a clear picture of what patient’s values about their life and how they make sense of what is happening around them. Helping the individual to have realization in care makes them to tolerate the incongruency of their illness and also helps them to plan for future, to do this, there is the need to build a baseline value history of the patient through biographical accounts and narrative story.(Meyers, D.T. 1989).The complex nature of most health care decisions couple with anxiety, fear of illness, dependency and other aggressive tendencies results in the patient’s decision making ability being diminished.( Buchanan & Brock, 1989) Argued that if patients are left to be in total control of their health care decisions, most often than not their choice of treatment decision might not work effectively towards their well being as expected. They further argued that, as much as patients are expected to participate in decision making regarding their health, they should also be protected sometimes from harmful consequences of their own choices.

According to Seedhouse, D. (1986) health has different meanings to different people and is also given various degrees of relevance by individuals. It therefore implies that there is no single care intervention that can be considered best for everyone. Whiles are a particular approach is applicable in one situation it may not be same in the other. In view of these, health care decisions need to adopt a negotiated approach between the patient and the practitioner (McCormack, 2001).

NURSE’S VALUES

In spite of partnership being a common phenomenon in person-centred practice where nurses are encouraged to be lenient in their presentation to patients, it is unusual for nurses to present their own views as a part of information that patients are given to help their decisions.Gadow (1980) argued that in as much as patient’s values should be dominant in the decision, nurses values also contribute to enhance the efficiency of the process but in a less explicit manner. Nurses expressing their values in care decisions should not really be a problem if there is partnership, since these will help the patient to have more insight into the nurses’ position regarding their care.

CONTEXT OF PRACTICE ENVIRONMENT

Despite more attention on nurses and patient values the care environment also play a significant role in the person-centred process in which there is the tendency to either promote or hinder its smooth running (McCormack et al 2002; Rycroft-Malone et al 2002).In facilitating person-centredness nurses are faced with difficulties of having to cope with the morale obligations to patients as well as organisational and professional implications (Johns, 1999).this situation has been confirmed by recent analysis f context undertaken by McCormack et al (2002). Yarling (1990) expressed a similar view to earlier researchers above that, in modern health care delivery, while nurses are expected to engage in autonomous decision making they are limited in exercising their authority.

THE CONCEPT OF PERSON-CENTREDNESS IN REHABILITATION

Clare et al. (2006) define rehabilitation as “an individualized approach to helping people with cognitive impairments in which those affected, and their families work together with health care professionals to identify personal-relevant goals and strategies for addressing these”. This definition clearly shows a connection between rehabilitation and the concept of person-centredness. Leplege et al (2007) argued that the notion of person-centredness have been used interchangeably as patient- centred ,client-centred, individual- centred, person-directed. Reasoning along this argument, implies that the term has a multidimensional use. In order to establish further the description of this terminology, Leplege and his colleagues undertook a conceptual analysis of person-centred concept in the field of rehabilitation and identified few supportive concepts that clearly elaborate on the use of the term.

THE PERSON’S SPECIFIC HOLISTIC PROPERTIES AND DIFFICULTIES IN EVERYDAY LIFE

Person-centredness as a means of addressing the person’s specific and holistic properties suggests that in dealing with individuals, their biological and psychosocial needs must be considered as paramount as opposed to classical analytic medical attention on the functionality of specific organs and related medications prescribed for relief of ailment. In their view regarding person-centredness in rehabilitation, the term seeks to address difficulties in everyday life of disabled persons in such a manner as to reflect their needs and social adjustment. Rehabilitation alone without person-centredness seems more technical and ignores other aspects of the patient’s life.

PARTICIPATION AND EMPOWERMENT

It is further argued that disabled persons be given more decisional autonomy in order to be aware of what is happening to them, the way they perceive treatment and care offered them and other variations about care available to them. Patients of disability should not

be passive about interventions available to them; they should be allowed as key participants. It is however stressed that the concerns of disabled persons are not different from able persons and therefore equal attention is supposed to be given to both.

RESPECTING THE PERSON ‘BEHIND’ THE IMPAIRMENT

Respecting the person in spite of his/her impairment or the disease reflects the notion that disabled persons be accorded the dignity and respect they deserve, because disability can be considered as part of ‘normal’ life and therefore should not be treated with pity and stigmatization. Leplege et al therefore declared person-centredness as anti-reductionism which seeks to hold in high esteem views and rights of disabled persons in decision making regarding their health care.

PERCEPTION OF PERSON-CENTRED NURSING ACROSS NATIONAL AND INTERNATIONAL DIVIDE

The concept of person-centred care has long been associated with the nursing profession, and understood in principle as; establishing mutual trust and understanding with individuals, respecting their values and rights as a person, and developing therapeutic relationships with them and others associated with their care.

The good aspect of delivering care in the philosophical context of person-centredness cannot be over emphasised, but it has been observed that translating the main concept into daily practice is always met with challenges (McCormack & McCance 2006).The reasons for these inefficiencies manifest in different forms and are seldom indicative of

the context in which care is delivered, coupled with constant changes that occur particularly within health and other social care sectors.

Person-centredness has been in existence with health care delivery for some time now and is consistent with policy direction and reflected in many approaches to delivery of care. The concept manifests itself in policy directions across both national and international health care sectors.

In the United Kingdom the concept of person-centredness is embedded in most health care policies such as The Dignity in Care Campaign (DoH, 2006) and The National Service Framework for older people (DoH 2001). Further, recent publications by the Royal College of Nursing (RCN) emphasised challenges for nurses and midwives in provision of dignified and sensitive care, in its report on health care.

In Northern Ireland, the focus is on promoting “person-centred standards”- (respect, attitude, privacy and dignity, communication, behaviour) across health and social care sectors. It has been observed that within the health service, the drive to promote effectiveness and efficiency in performance management has not been high. As a result, patients, clients and their families receive less attention in care delivery as indicated in a range of quality and clinical indicators (DHSSPS 2007a; Nolan, 2007).

Whilst the term “person-centred” care is rampant in the UK health and social care literature and policy documents, the underlying principles of person-centred care are similar to that of international movements that is focused on humanizing the health and social care experience. This is evident in the “Skaevinge Project” carried out in Denmark (Wagner L. 1994). In his action research, focus was on preventative work and also to ensure the rights of residents in care homes as citizens in society. This model again helps in putting to shape the future of residential care and the design of care homes internationally. Wagner infused into his work such principles underpinning person-centred care as autonomy, citizenship, dignity and respect, to enhance efficiency of his

model. Health care policies around the world adopt these principles and use them in several policy frameworks related to social and health care sectors.

In Australia for instance, person-centred care has been a solid foundation of facility accreditation in “The Aged Care Standards and Accreditation Agency” and the New South Wales department of nursing has its focus on enhancing practices and models of care to support person-centredness across all specialities.

Developing models that enhance care and promote person-centred principles has become a vital issue in health and social care. A notable instance is the Institute for Health care Improvement (IHI) in the United States of America. Most governments in the West have initiated transformations and innovated frameworks in health and social services through most of the practices of the IHI. Majority of the plans initiated by these governments focused on person-centred care mainly through transformation systems and redesign of clinical services.