How can you ensure the needs of patients are put at the centre of your practice? Gwyn Owen, the CSP’s professional officer for CPD, looks at the key issues
Last November, England’s health secretary Jeremy Hunt unveiled details of the ‘friends and family’ test, which from April will enable patients to give feedback on the quality of their care.
Patients will be able to tell which wards, A&E departments, maternity units and hospitals are providing the best care, he noted.
While the ‘test’ and the politics and process behind it have been criticised, the principle of actively involving service users in decisions about the services they receive is vital to that service’s well-being. Involving people in decisions about their care or service is enshrined in the process of negotiating valid consent that sits at the heart of professional practice.
And the principle of involving service users in the design, planning and implementation of services has been a key strand in government policy since the late 1990s in all four UK countries – whether in the fields of health, social care or education.
Increased service user participation is also evident in the CSP’s activities in its Council, committees and working groups, for example.
It is now widely accepted that involving service users in the design, planning and implementation of services is ‘best practice’.
But despite the evidence and the policy drivers, we still see cases in which service users have had little or no involvement in decisions about their care.
Numerous reports have drawn attention to the absence of a culture and processes that value and respect service users as individuals.
They also highlight organisational and professional issues around communication, power-sharing and collaborative working.
This article explores the issues around person-centred decision making from a physiotherapy perspective and signposts you to some resources and activities that will help you think critically about your own practice.
What is person-centred decision making?
There are many different definitions of person-centred decision making, but they all describe the principle and process of actively involving service users (whether actual or potential) in shaping the design, planning and implementation of a service.
The expectation that CSP members will put the needs of service users at the centre of their decision making is highlighted in section 3.1 of the CSP’s Code of Professional Practice (www.csp.org.uk/code).
The processes associated with person-centred decision making are outlined in Section 4 of the CSP’s Quality Assurance Standards (www.csp.org.uk/standards).
Section 4.2 talks about respecting service users as individuals and placing them at the centre of service planning and physiotherapy management.
Section 4.3 focuses on providing information to enable service users to participate fully in their care.
This statement links to Section 5 of the CSP’s Quality Assurance Standards, which focus on the process of negotiating and recording valid consent.
Shifts in balance of power
Implementation of person-centred decision making draws on values of respecting and empowering the individual.
Adopting these values may require us to think critically about power and relationship dynamics in practice.
Healthcare professions have traditionally adopted a patriarchal model of practice – one that acts in the of the patient’s ‘best interest’.
While this principle is still present and expressed in our duty of care for example, person-centred decision making demands that we are responsive to individual needs, and work to empower someone to participate in the decision making process.
This shift in the balance of power can be seen in the language used within some of the literature on person-centred decision making.
Some authors avoid using ‘patient’ (replacing it with ‘person’) because of the word’s association with the traditional patriarchal model of care – of things being done to, rather than being done with, people.
The process of person-centred decision making can be traced through the physiotherapy literature from the 1990s onwards (see references below).
This body of work argues that person-centred decision making requires a shift in the sorts of knowledge we value.
Traditionally, physiotherapy has adopted a medicalised approach to decision making – collecting information from a variety of sources to arrive at a differential diagnosis and intervention for the individual.
This process focuses our attention towards collecting objective data, and assumes that a person’s issues are predictable, measurable and generalisable.
A truly person-centred approach to decision making recognises that someone’s experience is socially constructed – it depends on who they are, their personal history and context.
The process of collecting and processing information here requires us to actively listen to and value the other person’s subjective experience and their expertise, and to become comfortable with the idea of multiple realities.
I’m sure you can think of situations where you’ve met two people that have been given the same diagnosis. Their objective measurements (such as X-rays, scans, range of movement and strength) are comparable.
And yet, when you meet them your expectations are challenged. Their presentation and personal experience of living with their condition is vastly different – because of their personal circumstances, and how they and others construct their condition.
As well as attending to our values – of people and types of information – person-centred decision making also requires us to think critically about how we offer information in a way that respects the individual’s situation, which may require us to adapt our approach to communication.
And this is where person-centred decision making can become extremely challenging – because of the environments, resources, organisational cultures, policies and protocols in practice.
That’s why the CSP’s code is invaluable. Because it expresses expectations of practice, we can use it to challenge systems that compromise our ability to meet those expectations.
Use the activity and resources to help you think critically about your person-centred decision making. fl
- Use Ernie and the Cookie Monster to explore the impact of information giving and sharing decision making.
- Visit the shared decision-making section of healthtalkonline website (these stories are available in a variety of formats, such as text, video, audio) to explore person-centred decision making from a service user’s perspective.
- Use the CSP Quality Assurance Standards audit tools to show evidence that you have your achievement of sections 4 (patient-centred decision making) and 5 (consent).
- Visit: www.csp.org.uk/standards
- Visit the patient-reported outcome measures section of the CSP’s website to find some standardised tools to help you collect information about people’s experiences of physiotherapy services.
- Use the CSP’s online catalogue at: www.csp.org.uk/professional-union/library to find the articles cited in this article and/or about person-centred decision making in your field.
- Visit the 15 steps toolkit (launched last month) on the NHS Institute for Innovation and Improvement’s website at: www.institute.nhs.uk/productives/15stepschallenge/15stepschallenge.html to find out how NHS trusts in England are being supported to evaluate their services from a service user’s perspective.
- Delaney C et al (2010) Physical Therapy 90(7)1068-1078
- Edwards I, Richardson B (2008) Physiotherapy Theory and Practice 24(3)183-193
- Edwards I et al (2005) Physiotherapy 91(4)229-236
How to use this article for your CPD
This activity can be worked through on an individual basis, or used to promote peer reflection.
As this activity is focused on involving service users in decision making, take care to anonymise the situation without losing the essence of the story.
Think back to a situation in which you had to take responsibility for making a decision with a service user.
Briefly outline the situation, practice context and the decision(s) you were making (if you want to share this experience, take care to anonymise the situation without losing the essence of the story).
Describe the process you used to come to the decision.
Analyse the decision-making process, focusing on the values and skills required:
How involved were both parties in the decision-making process?
Where there specific issues/factors that influenced individual’s ability to be involved in the decision-making process? (Such as time, information, environment, and protocols)
What sorts of information/knowledge were used to arrive at the decision?
Were some pieces of information or knowledge valued more than others? (For example, were objective findings emphasised more than subjective experience?)
Where was the overall balance of power in the decision-making process?
Is this approach to decision-making typical of my practice?
Is my approach maintained and supported by organisational factors? (protocols, policies, resources, environment, for example)
What have I learnt about my decision-making practice?
How will I use this learning to inform my future decision-making practice?
Remember to record this activity and store it safely in your CPD portfolio.
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