PRACTICE DEVELOPMENT – PERSON-CENTRED PRACTICE

Beyond ‘person-centred’ care: a new vision for gerontological nursing
Mike R. Nolan
PhD, MA, MSc, RN

Professor of Gerontological Nursing, Department of Community, Ageing, Rehabilitation, Education and Research (CARER), School of Nursing and Midwifery, The University of Sheffield, Northern General Hospital, Sheffield, UK

Sue Davies

PhD, MSc, BSc, RGN, RUV

Senior Lecturer in Gerontological Nursing, School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK

Jayne Brown

M. MedSci, DipEd, RGN

Lecturer, School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK

John Keady

PhD, RMN

Senior Lecturer in Nursing Research, Faculty of Health, University of Wales, Gwyneed, UK

Janet Nolan

MEd, BA, RGN, RUV

Lecturer, School of Nursing and Midwifery, The University of Sheffield, Rotherham, UK

Submitted for publication: 28 October 2003 Accepted for publication: 19 December 2003

Correspondence: Professor M.R. Nolan The University of Sheffield Department of Community, Ageing, Rehabilitation, Education and Research (CARER) School of Nursing and Midwifery Samuel Fox House Northern General Hospital Herries Road, Sheffield S5 7AU UK Telephone: 0144 226 6849 E-mail: m.r.nolan@sheffield.ac.uk

NOLAN M.R., DAVIES S., BROWN J., KEADY J. & NOLAN J. (2004)

International Journal of Older People Nursing in association with Journal of Clinical Nursing 13, 3a, 45–53 Beyond ‘person-centred’ care: a new vision for gerontological nursing Currently considerable emphasis is placed on the promotion of person-centred care, which has become a watchword for good practice. This paper takes a constructively critical look at some of the assumptions underpinning person-centredness, and suggests that a relationship-centred approach to care might be more appropriate. A framework describing the potential dimensions of relationship-centred care is provided, and implications for further development are considered. Key words: person-centred care, relationship-centred care, senses framework

The greatest challenge facing our health and social care system is to get services right for older people. Philp (2003, p. 24) Nurses working with older people have always experienced difficulties in articulating the knowledge, skills and expertise underpinning their practice and their impact on patient care. McCormack (2001, p. 290)

Introduction
The launch of a new plan for the National Health Service (NHS) in the UK (Department of Health, 2000) marked the most radical series of reforms to the NHS since its formation in 1948. The far-reaching changes that were envisaged
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recognized that services needed to be more responsive to future health challenges, particularly those posed by the growing numbers of older people. Fuelled by increasing concerns that older people are not receiving the quality of care that they required (HAS, 1998), a key aim of the plan is to eliminate ageism and to create a culture in which any form of discrimination based on the age of an individual becomes ‘unacceptable’. A year later the National Service Framework (NSF) for Older People (Department of Health, 2001) was announced, which for the first time set national standards of care for older people in the UK. Two principles lie at the heart of the NSF: the promotion of ‘person-centred care’; and

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1988. 1997. It is probably in the latter area. 1997. 1995) that person-centred care has been fully articulated. rehabilitation (Nolan et al. and dementia care (Kitwood. and the promotion of a 46 philosophy that treats people as individuals that has resulted in the emergence of the ‘contemporary speak’ of personcentred care. we will suggest that it may well perpetuate.R. from an ethical standpoint.. ‘Patient’. Nolan et al. 1994) will be presented. 1999). which it is suggested can be used as the foundation for enhancing the care older people receive from both health and social services. 45–53 . particularly in nursing (see McCormack. 1998). and the promotion of national care standards for older people. where it is defined as care that ‘respects others as individuals and is organized around their needs’ (Department of Health. Williams and Grant (1998) contend that person-centred care mandates that practitioners know what it is like to live ‘a certain kind of life’. Evans (1999. 1997. 2001). (2003) point out. including the least advantaged’. Kitwood & Bredin. following a consideration of global trends in ‘gerontic’ nursing. and to question whether it is simply an evangelical ideal (Packer.. Notions of independence and autonomy also infuse related concepts such as ‘successful ageing’ (Scheidt et al.M. As McCormack (2001) concludes. 8) defines personhood as the ‘standing Ó 2004 Blackwell Publishing Ltd. Scheidt et al. 2004). (2000) concluded that notions of ‘client-centredness’ would become the watchword for quality care in the twenty-first century.. 1990. 1999). However.. 2001. p. Kitwood (1997. neither the ‘deficit’ nor the ‘heroic’ model adequately capture the experiences of most older people. particularly within the nursing literature (McCormack. some have begun to doubt if person-centred care can actually be achieved. practice and academic literatures. International Journal of Older People Nursing in association with Journal of Clinical Nursing. Indeed. 1997). 3a. as defined in the NSF. 1993.. (ii) value interdependence and (iii) invest in caregiving as a choice. This is consistent with the vision of person-centred care promoted in the NSF. 2000). that have at their heart a definition of person-centred care that focuses on meeting individual need.. may well be misguided. This focus on individuality reflects wider trends within health and social care which emphasize the importance of promoting the independence and autonomy of older people. particularly one which emphasizes individual autonomy (Kitwood. Nolan et al. with these two aims being inextricably linked. 1999). which privileges individual need is inadequate. which underpin the ‘heroic’ model of the ageing process which depicts ageing as a primarily positive experience. Kivnick & Murray. p. 1989. the rooting out of age discrimination in the NHS. particularly in a hospital setting (McCormack. 2002). 1997. have become major policy drivers (Hanford et al. 2001). including long-term care (Henderson & Vesperi. as Reed et al.. 2003). Much depends here on how we view what it means to be a person. 1997 for an accessible introduction. However. While autonomy might well be a central notion in health care ethics (MacDonald. However. together with a framework. Indeed. following the pioneering work of Tom Kitwood and colleagues at the Bradford Dementia Centre (Kitwood. and McCormack. There are several complex metaphysical and existential arguments underlying the notion of personhood that we do not have the space to rehearse here (but see Kitwood. 1992a. even within dementia care. we would agree that respect for personhood is nevertheless essential. An alternative vision based on relationshipcentred care (Tresolini et al. it is the application of consumerism to health care. a concept of autonomy based on individualism and independence becomes ‘untenable’ in the context of health care for older people. Person-centred care Person-centred care is an oft quoted but ill-defined concept that has nevertheless exerted a considerable influence on the policy. and there can be little doubt that Kitwood’s ideas have provided a new sense of direction and purpose for practitioners. 1999. poor standards of care for older people. is not the panacea that it is held up to be. 2004). ‘The Senses Framework’ (Nolan. Mulrooney (1997) suggests that there are three prerequisites that largely determine the quality of care older people receive. This heroic model provides a counter balance to the deficit model in which ageing is viewed mainly in terms of decline (Reed et al. then it would appear that a strategy for fundamental reform. 2001). 13. If this is the case. rather than eliminate. These are that caregivers: (i) respect personhood. Others too have been sharply critical of an heroic approach to ageing. Davies et al. and that this requires that they have knowledge of people as individuals. Nay et al.b. 13) contends that autonomy is ‘incapable of underpinning any shared societal responsibility for the health of all its members. learning disability (Williams & Grant. ‘client’ or ‘person-centred’ care reflect the emergence of new approaches to work with older people in a range of care environments. Indeed. 2002). after considering these positions carefully. 1997). In presenting an alternative vision we will use Mulrooney’s (1997) analysis of person and relationship-centred care to suggest that there are more appropriate foundations for enhancing the care of older people than autonomy and individualism. 1995). Kitwood & Benson. which together with notions of greater user involvement. This paper argues that person-centred care.. Respecting personhood While we have argued that a vision of person-centred care.

Valuing interdependence Several authors contend that the relative failure of modern day health care to address the needs of people with chronic illness has arisen. 2000). complementary and symmetrical relationships result. 2003).. International Journal of Older People Nursing in association with Journal of Clinical Nursing. nurses need to pay greater attention to their ‘external’ relationships. multicultural society in which the major demands arise as a result of chronic illnesses (Tresolini et al. 1997. Rather there is a need to create a ‘milieu’ in which all participants are meaningfully involved. Jones et al. and the way that nurses relate to the other professions involved in the delivery of care also requires careful consideration. It was recognition of the deficiencies in current systems of health care delivery that prompted the emergence of ‘relationship-centred care’ (Tresolini et al. 2000).. She suggests that if a more meaningful dialogue is to occur then certain conditions have to be met. However. but asserts that we need to subscribe to a relational view of the concept which sees human beings as belonging to a network of social relationships within which they are ‘deeply interconnected and interdependent’. 2002). The emergence of relationship-centred care During the early 1990s there was ‘intense national debate’ in the US about the future of health care. Personcentred care. that focuses on the nurse–patient relationship (McCormack. 2004). The importance of creating a positive nurse–patient relationship has recently been more fully acknowledged (Bright. In order to advance this debate a Task Force was established to consider a differing approach to health care 47 Ó 2004 Blackwell Publishing Ltd. As McCormack (2001) contends. 2002). 1997) and interdependence and communitarian values neglected (Clark. Clark. it is important to recognize that the best relationships are reciprocal (MacDonald. especially with other disciplines. Rønning. or person-centred nursing.Person-centred care and gerontological nursing or status bestowed upon one human being by others in the context of a relationship (our emphasis)’. 1995. This was prompted by growing disenchantment with existing arrangements amongst both practitioners and patients who recognized the relative failure of the American health care system to address the needs of a diverse. 2002). if personhood is best understood in the context of relationships (see above). to develop. 45–53 . This is rarely the case in modern day health care. On this basis a reciprocal relationship develops in which ‘both parties grow as a result’. with its focus on responding to acute conditions (Nolan et al. 1994). it is important that the values that both patients and nurses bring to an encounter are made explicit.. 13. 1994). 2001. For this to happen it is essential that practitioners account for and value the ‘multiple voices’ within caregiving relationships (Pryor. and which reflects the existence of multiple environments of care (Pryor. Whall (1999) argued that nursing has been too self-absorbed for the last 20 years and that. which focuses on ‘individuals’ and their needs.. dependence and interdependence (Rønning. Evans. in no small measure. we firmly believe that it is not just relationships with patients and their families that are essential (Nolan et al. Just as with the arguments advanced above with respect to the nurse– patient relationship. In ¨ reflecting on the way forward for gerontological nursing in the twenty-first century. From an ethical standpoint MacDonald (2002) recognizes the importance of autonomy. from the promotion of an individualistic view of the world in which independence has become ‘lionized’ (Kivnick & Murray. and are used to underpin a process of negotiation that results in mutual recognition of each other’s beliefs.. interactions between differing disciplines are only likely to thrive when partnerships based on ‘mutual respect and self-determination’ are created so that reciprocal. It has been suggested that the majority of problematic situations that arise when caring for older people do so because of differences of opinion between colleagues who feel that their opinions and values are not listened to or acknowledged (Forsgarde et al. 1997. Fagermoen. Such relationships are created and sustained in situations where all parties appreciate the need to achieve an appropriate balance between independence. 3a. an appreciation of which is essential to ‘any attempt to understand the experience of growing older. believing that there is a need to replace an individualistic view of autonomy with one based on ‘interconnectedness and partnership’ that recognizes the uniqueness of each individual. 2001. 2002). 2004) is unlikely to promote such relationships. 2004).. 1999. In promoting a new approach to the nursing care of older people McCormack (2001) advocates a remarkably similar stance. Mintz & Marosy. McCormack. However. 2000. foremost amongst which is the need to make explicit ‘the underlying assumptions or premises that each participant holds and the beliefs and meanings that they bring to the situation’. 2002. but also the interdependence that shapes our lives. Such considerations apply equally to nurse–patient relationships. 1997). 1997. or to provide meaningful care or services to older adults’. Such arguments serve to reinforce Mulrooney’s (1997) second prerequisite for good quality care – valuing interdependence. Advancing similar arguments Clark (2002) contends that we can only fully understand an individual case by ‘situating’ it within a rich matrix of relationships and socio-cultural beliefs. and therefore valuing interdependence becomes a central concern (Clark. 2002). which constitute the ‘essence’ of new nursing (McCormack.

Both are changed in the process… (and) from an inseparable unit of interdependent subjects’. International Journal of Older People Nursing in association with Journal of Clinical Nursing. with it increasingly being seen as boring. with only 1% of those in training identifying gerontological nursing as their preferred career option (Happell. The aim was to promote the closer integration of such concepts into the educational preparation of all those working within the health care system. Interestingly there is evidence to suggest that efforts should not be directed at students’ attitudes towards older people per se. This is something to which we will turn our attention shortly. However. 1994. Following a review of the literature Lee et al.M. p. These authors suggest that there is a need to highlight the potential sources of job satisfaction in gerontological nursing if it is to attract and retain staff. 45–53 . 2001). Furthermore. such as a lack of resources and a poor physical environment. Work with older people is often perceived to be of low status and to be less attractive. Their own study with clinical psychologists demonstrated that trainees feel that they have little of value to offer older people and that such beliefs betray both ageist attitudes and trainees’ own fears of ageing and death. Rather she suggests that the conditions of work. 22). 2002). Likewise. 2001). their families. as they are the medium for exchanging the information. where student nurses view work with older people as being unchallenging. which reflected the ‘importance of interactions amongst people as the foundation of any therapeutic or healing activity’ (Tresolini et al. every participant in a health care encounter ‘interprets and constructs a subjective world. rather than fully formed. However. Herdman (2002) asserts that the reasons for this are complex and are not necessarily the result of negative attitudes towards older people per se. whether family members or paid carers. The Task Force went on to suggest the basis for an educational system that would promote relationship-centred care but recognized that the concept was emerging. We would suggest that such a vision of health care is likely to prove far more useful than one based on notions of person-centred care. Investing in caregiving as a choice Mulrooney’s (1997) third prerequisite is based upon the premise that individuals providing care to older people. recruitment and retention of staff are currently priority areas. staff from all disciplines. the Task Force proposed a new model for health care delivery that they termed ‘relationship-centred care’. As the Task Force noted. the most telling reason that nurses do not choose to work with older people is because they believe that such work will not enhance their clinical skills and career prospects. Certainly our own recent study. in Hong Kong. and that further work was needed to ‘explicate the dimensions of a relationship-centred approach to care’. Similar conclusions have been reached in other countries such as Australia. which are seen to provide the experiences necessary for a solid career platform. Herdman’s (2002) study indicated that the percentage of students who would actively choose to work with older people decreased as they neared qualification. Nolan et al. based upon the interdependence of psychological. However. Others have reached similar conclusions. the largest ever conducted in the UK. social and biological factors. are unlikely to ensure care of the highest quality unless they have a positive predisposition towards such care. The interactions between these groups constitute the ‘defining force’ in health care. As a result of these deliberations. 2001). and noted that the persistence of negative attitudes towards work with older people as being of ‘great concern’ (Standing Nursing Midwifery Advisory Committee. 3a. prior to that there is a need to consider Mulrooney’s (1997) third prerequisite for good care for older people – investing in caregiving as a choice. but rather to counter the view that gerontological nursing provides little challenge and represents a poor career option. A recent major review of gerontological nursing in the UK concluded that ‘the goal of ensuring high quality nursing care for all older people in the NHS remains elusive’. On the basis of recent studies it would seem that there is a need for considerable remedial action if gerontological nursing is to become a more attractive career prospect. unstimulating and frustrating (Happell & Brooker. exert a negative influence.. This is a major concern for gerontological nursing where issues of motivation. the belief that working with older people provides little stimulation and challenge is not confined to nursing. However. feelings and concerns needed for a better understanding of the meaning of illness. when compared with areas such as accident and emergency or surgery.R. and the wider community. noting that even when student nurses have positive intentions to work with older people they soon learn that gerontological nursing is seen as ‘uninteresting’ by peers (McKinlay & Cowan. untechnical and unrewarding. 2003). Such relationships exist at several levels including those between patients. concerning students’ views and experiences Ó 2004 Blackwell Publishing Ltd. exciting and important than nursing in acute or rehabilitative contexts (Standing Nursing Midwifery 48 Advisory Committee. and these worlds are modified by the dialogue between them. 13. (2003) argue that such a perception exists in virtually all professions within the health and social care fields. it seems that negative dispositions towards gerontological nursing are heightened throughout nurse training. These authors argue that there has to be a concerted effort to promote work with older people if newly qualified staff are to be attracted to the area.

129) reached a similar conclusion when she argued that ‘the central problem in geriatric nursing is the central problem in all nursing… nurses working with older people do not know why they do what they do’. As with Clark (2002). 2000) needed to promote genuinely empowering and reciprocal caring relationships. Whall promotes a wider multidisciplinary approach to care. 1997. with Clark arguing for a move away from the ‘disembodied slipperiness’ of highly abstract concepts and theories towards a framework that helps to ‘situate’ the care of older people within the set of relationships that provide the context for the help that they need.. However. 2003). We discovered that students hold initially positive views of work with older people but that these are significantly influenced by their prior experience with older people. The ‘Framework’ is underpinned by the belief that all parties involved in caring (the older person. and that there is a need to identify the ‘fundamental similarities’ that characterize such inter-relationships. • continuity – to experience links and consistency. 3a. This means turning attention to the types of ‘supportive social conditions’ (MacDonald. 1991). Wadensten and Carlsson (2003) assert that there is a pressing need to identify a framework suggesting how ‘gerontological nursing care should be provided’. • purpose – to have a personally valuable goal or goals. 248). as McCormack (2001) asserts. or a recourse to notions such as ‘good geriatric care’ (Reed & Bond. However.. and paid or voluntary carers) should experience relationships that promote a sense of: • security – to feel safe within relationships.. their experiences whilst undergoing training. This is hardly surprising when it is considered that the most commonly adopted ‘models’ of nursing provide little or no guidance about how to work positively with older people (Wadensten & Carlsson. and believed that they could ‘make a difference’. We would suggest therefore that. Davies et al. p. 2002). Whall (1999) believes that the search for such a perspective will be more successful if nursing is motivated less by its own narrow professional concerns and instead focuses on ‘what is good for clients rather than good for the discipline’. when there was an appreciation of more subtle and less overt forms of ‘improvement’ or benefit then students were far more likely to see the therapeutic potential and reward of working with older people. just as with psychiatric nursing. family carers. 2001. 1999. as he suggests. the essence of nursing ‘lies in the nature of the nurse–patient relationship’. Nolan et al. 2001. When this was defined largely in terms of cure or physical improvement then gerontological nursing was viewed less positively. skills and expertise underpinning their practice and their impact on patient care’ (McCormack. 13. 2001. The result can be ‘aimless residual care’ (Evers. In many ways the problem is a perennial one and is indicative both of the dominant biomedical view of ageing (Reed et al. 1991) with its emphasis on ‘getting the work done’. 1999). Against such a background nurses have ‘always experienced difficulties in articulating the knowledge. enjoyed their placements as a student. Nolan et al. Davies et al. and the attitudes of qualified staff. 1997). 1994) what we mean by relationship-centred care so that we can identify the conditions in which positive caring relationships can be created and sustained. • belonging – to feel ‘part’ of things. The belief that nurses could ‘make a difference’ and have a positive impact on the lives of older people was a primary motivation. • significance – to feel that ‘you’ matter. would support such a position. particularly in non-acute settings. 45–53 . Over two decades ago. International Journal of Older People Nursing in association with Journal of Clinical Nursing. 49 Ó 2004 Blackwell Publishing Ltd. 1997. Wells (1980.Person-centred care and gerontological nursing of gerontological nursing (Nolan et al. Indeed. all too often students were exposed to environments of care where they struggled to see what ‘difference’ nursing made and where work with older people was portrayed as having little to offer. nurses are often left with the work that no one else wants or values.. The ‘Senses Framework’ The ‘Senses Framework’ (Nolan. Others have also called for a guiding perspective to provide a better sense of direction for gerontological nursing (Whall.. then. 2002) captures the subjective and perceptual dimensions of caring relationships and reflects both the interpersonal processes involved and the intrapersonal experiences of giving and receiving care. We would agree with Brechin (1998) that good care is best understood in terms of the inter-relationships between those giving and receiving care. p. gerontological nursing continues to struggle to define its ‘proper focus’ (Barker et al. following a review of 17 ‘models’ of nursing. 2003). If students had positive prior experience of work with older people. then they were far more likely to want to go and work in gerontological nursing when they qualified. Conversely. 1999.. much turned on how ‘making a difference’ was construed. • achievement – to make progress towards a desired goal or goals.. We would suggest that ‘relationship-centred care’ potentially provides such a perspective but would agree that there is a need to ‘further explicate’ (Tresolini et al. If. 2002) or to the ‘milieu of care’ (Pryor. In the interim others too have pointed out that. It is here that we believe that the ‘Senses Framework’ (Nolan.. we have to understand the ‘rules’ guiding such relationships. and the pervasive influence of notions such as autonomy and independence. 2002) has much to offer.

to ensure that personal standards of care are maintained by others. to meet challenges successfully. purpose. a community of gerontological practitioners • For family carers: To be able to maintain/improve valued relationships. To have secure conditions of employment. harm. Subsequently the ‘Senses Framework’ has been subjected to detailed empirical study involving interactive focus groups Table 1. Seamless. Following empirical work (Davies et al. International Journal of Older People Nursing in association with Journal of Clinical Nursing. the Framework has since been the subject of extensive empirical testing.. 1997). Therefore. 1998) without detriment to personal well-being. (2001) summarized the ‘senses’ as in Table 1. To receive competent and sensitive care • For staff: To feel free from physical threat. Nolan et al. to use skills and ability to the full • For family carers: To feel that you have provided the best possible care. Expectations and standards of care communicated clearly and consistently • For family carers: To maintain shared pleasures/pursuits with the care recipient.M.. to make progress towards therapeutic goals as appropriate • For staff: To be able to provide good care. to feel satisfied with ones efforts. exposure to good role models and environments of care. To be able to relinquish care when appropriate A sense of continuity • For older people: Recognition and value of personal biography. 45–53 . to pursue (re)constructive/reciprocal care (Nolan et al. that your work and efforts ‘matter’ • For family carers: To feel that one’s caring efforts are valued and appreciated. to be able to confide in trusted individuals to feel that you are not ‘in this alone’ A sense of purpose • For older people: Opportunities to engage in purposeful activity facilitating the constructive passage of time. consistent care delivered within an established relationship by known people • For staff: Positive experience of work with older people from an early stage of career. which has highlighted its value in understanding good quality caring relationships in acute hospital settings for older people (see Davies et al. Nolan et al. pain and discomfort. and an extensive consideration of the relevant literatures in relation to older people. To have the emotional demands of work recognized and to work within a supportive but challenging culture • For family carers: To feel confident in knowledge and ability to provide good care (to do caring well – Schumacher et al. to feel satisfied with ones efforts. which involved an initial overview of some 22 000 references and a more detailed reading of approximately 2000. rebuke or censure. 2004). 1999). to maintain involvement in care across care environments as desired/appropriate A sense of belonging • For older people: Opportunities to maintain and/or form meaningful and reciprocal relationships. whether delivered by self or others. Although initially developed as a means of providing a rationale for care within longer term institutional settings (Nolan. a clear set of goals to which to aspire • For family carers: To maintain the dignity and integrity. to contribute towards therapeutic goals as appropriate. to exercise discretionary choice • For staff: To have a sense of therapeutic direction. The essence of the Senses Framework is that all participants need to experience these senses if good care is to result. to develop new skills and abilities A sense of significance • For older people: To feel recognized and valued as a person of worth. to make a recognized and valued contribution. it is not just the nurse and patient who are ‘in relation’ (McCormack. p. To be able to provide competent standards of care. 50 Ó 2004 Blackwell Publishing Ltd. to know you have ‘done your best’. skilful use of knowledge of the past to help contextualize present and future. 175). To have adequate support networks and timely help when required. 1999). such ‘senses’ are nevertheless prerequisites for relationships that are satisfying for all parties involved. It is now apparent that although what creates a sense of security. belonging. 1996) A sense of achievement • For older people: Opportunities to meet meaningful and valued goals. to experience an enhanced sense of self From Nolan et al. to feel safe and free from threat. to be able to identify and pursue goals and challenges.. achievement and significance will vary across differing groups and caring contexts.. to belong to a peer group. that one’s actions and existence are of importance.R. (2001. 3a. that you ‘matter’ • For staff: To feel that gerontological practice is valued and important. to feel part of a community or group as desired • For staff: To feel part of a team with a recognized and valued contribution. The Six Senses in the Context of Caring Relationships A sense of security • For older people: Attention to essential physiological and psychological needs. continuity. well-being and ‘personhood’ of the care recipient. 13.

as was their potential to promote a better shared understanding. both within rostered placements and during extra curricular work as care assistants. 2001). • I can identify with this (Senses Framework) as it relates closely to my practice. One of the main conclusions of the Advancing Gerontological Education in Nursing (AGEIN) Project (Nolan et al. staff experienced the senses for themselves. Moreover. Several ways in which such a culture could be achieved were suggested during the workshops. aspects of care that participants felt were often lost in debates about evidence-based care. they frequently picked up similar messages in respect of older people.. it was apparent that they helped to provide a sense of direction as reflected in comments such as: • the senses could help us to celebrate success. While it was recognized that a change of culture among staff was required. Environments can be impoverished in two main ways. • they make the seemingly insignificant significant.. They were not made to feel that they ‘belonged’. In total. 2002). participants were asked to consider whether the ‘senses’ resonated with their own experiences and ‘spoke’ to them in a language that they understood and related to. Overall. then experiences were altogether more positive. much of the discussion focussed around the value of the senses for staff themselves. 3a. having applied the senses to their own situation participants. students themselves were not valued and supported. In such environments nobody. there was little continuity of care. Significantly. several participants felt that if staff were valued and supported themselves they would be better able to value and support older people. and which recognized mistakes as learning opportunities rather than seeking to apportion blame. staff attitudes and care practices to which students are exposed. which celebrated success rather than concentrating on failure. especially staff. Conversely. the relevance of the senses for several stakeholder groups was endorsed. • they can help us to define best care. one relating primarily to the physical environment. 45–53 . Students certainly did not feel ‘significant’ in such environments and believed that there was little that they could do to change this. if students were exposed to ‘enriched’ environments of care where staff actively worked to create the ‘senses’ for both older people and for students. or not. and lack of time for anything other than physical care often served to reinforce students’ perceptions that gerontological nursing had little to offer as a future career. • I feel a connectedness to these. was the nature and quality of their clinical experience. family carers. in those workshops involving professionals. outdated equipment. 2002 for a detailed account). 13. that they belong. Furthermore. to experience continuity.Person-centred care and gerontological nursing and workshops with practitioners. However. Crucially.. and frequently during the latter. It was apparent from the workshops that the senses provided a means of highlighting important. The senses were seen as highly relevant to the care of older people by all groups. 2002) and in-depth case studies we were able to identify the characteristics of what we term ‘impoverished’ and ‘enriched’ environments of care for older people (Brown. and that the staff did not believe that what they did was accorded value and status. However. Practitioners believed that the senses were implicit within their existing philosophy of care but that the Framework helped to make them more explicit. and to perceive a 51 Ó 2004 Blackwell Publishing Ltd. in such environments. and a pervasive feeling of a general lack of purpose and direction. in such environments. There was much talk of the need for strong and visionary leadership and of a supportive culture. as the actions of more permanent staff often demonstrated that older people themselves were not seen as significant. Occasionally during the former. the key was seen to be vision and leadership. which provided a greater sense of therapeutic potential and more subtle and appropriate indicators of ‘success’. for staff in particular. 2002) was that a major determinant of students’ future decisions to work with older people. but often taken-for-granted. a diverse multidisciplinary set of professionals. However. For example. • they highlight what gets lost in evidence-based care. and it is in capturing the need for all parties to feel secure. On the basis of both large-scale surveys (Nolan et al. with participants believing that they could provide a means of overcoming the prevalent ‘NHS blame culture’ by helping staff to ‘feel good about what we do’. felt better able to relate the senses to older people and their carers. students were exposed to ‘impoverished’ environments in which staff shortages. the other to the more subtle and difficult to address. and the ‘senses’ were acknow- ledged as providing a way of realizing a ‘vision’ of care in which ‘fundamental’ elements were valued and accorded status (Standing Nursing Midwifery Advisory Committee. least of all older people themselves. carers and older people to determine if the senses capture those elements of relationships that participants considered important. Importantly. 196 people took part in these various activities comprising older people. In particular. and paid but unqualified care assistants in both institutional and community settings (see Nolan et al. experienced the ‘senses’. it was with the student nurses that the most detailed data were collected. participants at all the workshops saw the need for a new vision and direction for work with older people. International Journal of Older People Nursing in association with Journal of Clinical Nursing.

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