Essay:Nurses beliefs and values impact on provision of care
The person-centred care approach focuses holistically on the patient as an individual, rather than their diagnosis or symptoms, and ensures that their needs and choices are heard and respected. According to Draper & Tetley (2013: n.p.), person-centred care is defined as “an approach to nursing that focuses on the individual’s personal needs, wants, desires and goals, so that they become central to their care and the nursing process. This can mean putting the person’s needs, as they define them, above those identified as priorities by healthcare professionals.” Theoretically, this is an achievable aim – nursesas a matter of principle should provide care that respects the diversity of the values, needs, choices and preferences of those in their care – but how can any incongruity between the values, beliefs and attitudes of the patient and those of the nurse be reconciled? Is it inevitable that this dissonance will have a negative impact on the quality of person-centred care being provided? This essay will examine the beliefs, values and attitudes of nurses planning and delivering person-centred care, and the impact these issues can have on the provision of that care.
Nurses are expected to practice in a caring, knowledgeable, professional, courteous and non-judgemental manner, and the majority do this as a matter of principle, displaying unconditional positive regard for their patients at all times. However, values, beliefs and attitudes are, of course, subjective to each individual, and in the context of delivering person-centred nursing care, it is important to identify those that are holistic and therapeutic, rather than focussing only on those that are not.
According to Brink & Skott (2013), some diagnoses lead to preconceptions about the individuals receiving them, which subsequently negatively influence their care and treatment. This can be particularly evident in the case of mental illness, which is often mired in stigma, fear, ignorance and discrimination. Research undertaken by Chambers et al (2010: pp. 350) found that “Stigma on the part of mental health professionals affects the quality of care provided for those with mental health problems, as well as their rates of recovery.” Although nurses working within the field of mental health will obviously have more developed skills and knowledge in this subject than those in other specialities of nursing, it is not inconceivable that nurses may harbour some preconceptions about mental illnesses and those diagnosed with them, which may impact on how positively they deliver care to those patients. Those requiring treatment for alcohol abuse or substance misuse may also experience a less empathetic experience in the care of nurses, who may feel that the condition is self-inflicted, or that resources may be better utilised elsewhere. This attitude may be even more prevalent in cases of liver transplant due to alcoholic cirrhosis of the liver, when there may be a misplaced belief that another recipient is more ‘deserving’ of the organ. Other morbidities which can be perceived as having a self-inflicted element (e.g. obesity, smoking-related illnesses, type-II diabetes, addictions) also have the potential to be perceived negatively by nursing staff, who may lack an appropriate level of empathy and compassion, or make assumptions and pre-conceptions about these patients based on their diagnoses.
In a similar manner, patients attempting suicide or deliberately self-harming, may experience stigma, a lack of sympathy and a lack of understanding from nursing staff, especially if the nurse managing their care is also involved in the care of patients suffering from serious illnesses or conditions. Caring for patients attending accident and emergency departments due to para-suicide or deliberate self-harm can evoke extremely negative emotions and attitudes amongst the nursing staff caring for them. Nurses working with such patients report experiencing high levels of ambivalence and frustration. Additionally, deliberately self-harming patients may evoke negative attitudes such as anxiety, anger, and lack of empathy (Ouzouni & Nakakis 2013). A suicidal patient voicing their desire to end their life is expressing a wish. However, in the context of person-centred care, it would be difficult to agree that this wish should be considered as a person-centred need. This could be a source of conflict, difficulty and dissonance as balancing the needs and wishes of the patient in this situation, contradicts entirely the nurse’s duty of care. In such circumstances, it could be argued that the care provided cannot be person-centred, as it is not in line with the patient’s wishes. Obviously it would be neither legal nor ethical for the nurse to allow a suicidal patient to actively attempt to end their life whilst under their care, or to comply with the patient’s wishes not to receive treatment if suicide had been attempted.
Similar ethical considerations may also influence the treatment of patients undergoing procedures to terminate pregnancy, and may negatively influence the extent to which the care received by the patient is truly person-centred. There have been well-documented cases of nurses refusing to assist with these procedures, or to treat patients who have undergone them post-operatively. Predominantly such cases arise due to a conflict with the religious beliefs, moral convictions and ethical stance of the nurses being asked to assist with these procedures. The Nursing & Midwifery Council (2015) states that “Nurses and midwives must at all times keep to the principles contained within The Code: Professional standards of practice and behaviour of nurses and midwives (2015: n.p.).
This code states that nurses and midwives who have a conscientious objection must tell colleagues, their manager and the person receiving care that they have a conscientious objection to a particular procedure. They must arrange for a suitably qualified colleague to take over responsibility for that person’s care. Nurses and midwives may lawfully have conscientious objections in two areas only. Firstly, Article 4(1) of the Abortion Act 1967 (Scotland, England and Wales). This provision allows nurses and midwives to refuse to participate in the process of treatment which results in the termination of a pregnancy because they have a conscientious objection, except where it is necessary to save the life or prevent grave permanent injury to the physical or mental health of a pregnant woman. Secondly, Article 38 of the Human and Fertilisation and Embryology Act (1990). This provision allows nurses and midwives the right to refuse to participate in technological procedures to achieve conception and pregnancy because they have a conscientious objection. This is a highly contentious and emotive issue, and one which attracts much ongoing debate and argument, and is significant as it can be asked at what point does a nurse’s own beliefs and values take precedence over their responsibility and duty to care for their patients’ needs, whatever they might be? Should nurses be permitted to refuse to participate in care procedures that contradict their values or beliefs, or to refuse to provide care to those they deem ‘undeserving’? Does this set a worrying precedent for other contentious procedures to be added to the list (gender reassignment surgery for example)? It could be argued that the nurse’s first responsibility should be their duty of care to their patient, and this surely requires them to take a holistic and person-centred view; a view that should not be clouded by the nurse’s own values system or moral standpoint.
The aspects of person-centred care discussed so far in this essay have been those of a contentious and perhaps, more exceptional nature. However, the more routine, day-to-day aspects of nursing are also susceptible to the influence of nurses’ values, beliefs and attitudes negatively impacting on the quality of person-centred care provision. Giving patients a greater degree of autonomy over their care can lead to some discord as nurses may feel that their professional expertise is being disregarded, and may be concerned that patients’ informed opinions and decisions about their care may be detrimental to recovery or good health. This could lead to nurses adopting a didactic attitude in the belief that they know best, when the patient is equally certain that their decision is the right one for them. Nurses must always ensure that they are viewing the patient as a whole person, and not merely an illness or condition to be treated or managed, as this can lead to ambivalence as nurses attempt to reconcile their desire to deliver effective, evidenced-based care, knowing that patients’ stated wishes or preferences are contrary to this aim. However, if the patient is deemed to have capacity to make informed decisions about their care and treatment, with all the facts at their disposal, nurses must accept this if good, person-centred care is to be delivered (NHS Choices 2014). In the event that the patient does not have the capacity to make informed decisions (e.g. patients suffering from more advanced forms of dementia), then any known pre-morbid preferences and choices should be documented and adhered to where this is practicable. There is always a danger that individuals with dementia receive care that is task-orientated rather than person-centred. Again, nurses may make assumptions regarding what is best for the patient, rather than respecting their choices and preferences.
One of the easiest ways to ensure that care is person-centred is to gather collateral about each patient prior to care or treatment commencing, so a more rounded picture can be formed. This is particularly important when dealing with people from diverse cultural backgrounds, as lack of cultural understanding and tolerance can lead to damaging misconceptions, misunderstandings and unintentional offence, which will not engender good person-centred care. Having some knowledge of patients’ history and background prior to treatment can be a useful tool in terms of developing appropriate care. The flip-side to this however is that unhelpful stereotypes or prejudices may be formed by nursing staff, based on the current or historical background of the patient. Gender (including gender identify), race, age, religious affiliation, employment status, marital status, and educational and socio-economic background can lead to assumptions (both positive and negative) being formed by nursing staff. Whilst the majority of nurses will treat their patients with unconditional positive regard and courtesy, regardless of issues that may be at odds with their own beliefs, values and attitudes, there will always be a minority who will be affected by such issues, and who will allow it to influence the care they provide. The scale of this issue is difficult to quantify, due to a lack of available evidence-based research, but it could be said that one nurse whose attitude negatively impacts on person-centred care is one nurse too many.
We have explored some of the more contentious issues that can and do arise when nurses’ beliefs, values and attitudes do not correspond with those of their patients, and have examined the potential impact this can have on the quality of person-centred care provided. As little research has been carried out into this subject, it is not possible to quantify the scale of the problem, nor to accurately identify where it is most prevalent. However, it is safe to say that the dichotomy between delivering truly person-centred care, whilst reconciling challenges to the nurse’s own core beliefs and values is not one easily solved. Modern nurses are extensively trained and highly skilled professionals, with a wider remit and range of responsibilities than their predecessors. They are however fundamentally human, with the same character flaws and failings as anyone else. It is a completely human trait to be influenced by the information we perceive or receive about others, and everyone has innate beliefs and value systems and, whether we like it or not, innate prejudices. Although it would seem logical that professional nurses have a well-developed sense of understanding and equality, they also deal with a magnitude of very diverse people on a daily basis, generally having very limited time with each. Despite this, the majority of nurses deliver excellent, patient-focussed and person-centred care as a matter of course. Unfortunately there will always be a minority who do not. Nurse education programmes are constantly evolving to meet the shifting demands of health care, so it can only be hoped that recognising, challenging and improving unhelpful attitudes becomes an accepted part of nurse education, and becomes core to person-centred care provision.