Guidelines and person-centred care: the devil in the detail
Increasing the explicit use of evidence-based practice (EBP) is an international aim. A substantial literature has grown around this, particularly in relation to processes by which to introduce evidence-based change into clinical practice. Commonly, these entail introduction of guidelines.
Originally derided as an assault on ‘clinical freedom’, practice guidelines are now available for most major diagnostic groups. In the UK, endorsement and formal adoption within clinical networks has increased pressures for guideline adherence on service providers. Relatively little attention has focused how this is enacted within the therapeutic relationship, an arena in which EBP does not have a conceptual monopoly and may not be dominant.
For nursing, the dominant discourse expressed through multiple models of care is respect and care of the whole person, understood through their life-course, experiences and preferences. Concurrent with the development of EBP, Tom Kitwood’s work with people living with dementia fed ‘person-centred care’ into the nursing mainstream. Simultaneously, governments recognised the need to configure public health services to address the needs, and preferences of the tax-paying public, reflected in policies advocating a ‘patient-centred’ consumer focus. David Sackett’s acknowledgement of the individual patient in his EBP definition has not eliminated tensions between paradigms (Sackett et al. 1997).
The paper by Sanders et al. (2010) in this issue goes to the heart of this dilemma. Interviews with 10 specialist heart failure nurses and non-participant observations in two heart failure clinics explored how these nurses negotiated treatment advice with patients, within the context of an expectation of guideline adherence. Tensions between delivery of advice in line with recommendations linked to best outcomes and potential patient preferences were clear. These nurses accepted the imperative to work towards agreed service outcomes and used their relationships with their patients as media to deliver guideline-supported recommendations. ‘Normalization’ strategies related individuals’ symptoms to the heart failure population experience, and hence validated generic advice for individual application: ‘normal’ symptoms could be managed by ‘normal’ adherence to advice (guideline recommendations).
Is this person-centred or patient-focused care? The authors note the flurry of information delivered, ‘left little space for patients to explain what they wanted’. Given their long-term aims of reducing hospitalization and increasing life expectancy, do the ends justify the means? Is assumed alignment of individual with population benefit any more than assumption?
The authors cite ‘close support and extensive advice’ cite to substantiate claims for ‘patient-centred’ care. Was this acceptable to patients? The authors refer to the transient pleasures of an unhealthy lifestyle, but did not ask.
A distinction is drawn between ‘care valued for its own sake’ and care to produce health outcomes, raising questions – Does this matter? Is there a qualitative difference, and who is the arbiter? Is the aim and purpose to support patient preference or population outcomes?
Nursing historically has struggled to establish its own professional body of knowledge and might be particularly susceptible to external pressure. Is this an indication of nursing still in its novitiate for autonomous decision-making?
The value of this study lies less with its technical merits than the questions it raises – the devil teased out of its detail. These go to the heart of contemporary health care and whilst future directions are suggested, answers are beyond its scope. The ball is firmly in the court of clinicians and academics to devise ways to accommodate conflicting agendas within the clinical consultation.