Background
Psychiatric inpatient care is intended to promote recovery from the most acute phase of mental illness. Among examples of good practices reports however depict a care environment far from ideal [
1]. Patients treated for psychoses and other severe mental illnesses describe not being respected as human beings or being reduced to a disease [
2‐
4]. They try to cope with a restrictive care environment that is at times unsafe and incomprehensible [
2,
3,
5]. They find themselves in a passive patient role, subordinate to ward staff and psychiatrists [
2,
3,
6]. Staff, on their part, depict an everyday situation where they try to provide good care in a suboptimal environment, where the patriarchal structure limits their possibilities to work proactively [
6‐
8]. Instead, they must react to acute situations. All of this hinders positive staff-patient encounters. Although it is clear from patients’ accounts that positive interactions with staff improve the inpatient experiences [
2,
5,
9], low degrees of patient/staff interaction have been reported over the last decades [
10,
11]. Numerous research reports conclude that psychiatric inpatient settings need to develop more collaborative, interactive, flexible and supportive care to improve conditions and outcome for both patients and staff [
7,
11‐
15].
Person-centered care (PCC) has been suggested as an approach to better meet the demands of a more efficient, qualitative and ethical care for complex and chronic diseases [
16,
17]. The value-based concept lacks a clear definition and different ways of interpreting PCC have been described in terms of being holistic and addressing the person as unique; addressing difficulties in everyday life; considering the person as an expert of his/her life; or acknowledging the person behind the illness [
18]. Within psychiatry, PCC has been conceptualized as being culture-dependent (reliant on attitudes and procedures reflected by staff and the organization), inter-personal, and empowering [
19]. A recent review describes a core of PCC in terms of reoccurring principles; empathy, respect and engagement, relationship, communication and shared decision-making, holistic and individualized focus along with coordinated care [
20]. These principles address the complexity, uniqueness, capacity and reciprocity of each patient, basing PCC in the philosophy of personhood [
17]. While PCC shares several of these principles with other concepts, such as patient-centered care, the latter is suggested to focus on a functional life where PCC aims at a meaningful life [
20]. This aim puts PCC in very close relation to the psychiatric concept recovery-oriented practice, which further promotes connectedness, hope and optimism, identity and empowerment [
21] and incorporates a societal dimension in the ambition of restoring patients’ lost access to society as worthy citizens [
22]. As PCC is a model of care in which patients and staff work towards recovery, and a recovery-oriented organization is needed to fully work in a person-centered way, the two are considered to be intertwined [
23].
Staff are gatekeepers in the transformation of care towards a more person-centered practice. Development of new ways of thinking and working is essential to this end. Being at the center of this process, staff perceptions provide valuable information on the process of improving care. Within oncological inpatient care, staff report experiencing opportunities for increased patient participation and improved teamwork following the implementation of structured PCC procedures [
24]. However, they also report limitations in the practice of PCC as some actions or routines remain patriarchal or task oriented. Staff have described supportive leadership, staff qualities and person-centered attitudes along with inter-professional cooperation as facilitators for person-centered care [
25‐
28]. Barriers include a culture that remains biomedically- or task-oriented [
26,
27,
29], diverse understandings of PCC [
27,
30], and practical aspects like time constraints or patient characteristics such as impaired ability to communicate [
26,
27,
29‐
31].
Relatively few PCC implementation studies are set in psychiatric services why experiences from staff are scarce. One US study showed that outpatient staff embraced PCC, but tensions arose when trying to practice it within traditional organizations [
32]. A person-centered care model, the Tidal Model [
33], was implemented in a psychiatric forensic unit from which staff reported a shift of focus from patient to person, a more equal distribution of power, relationships marked by empathy and respect, improved collaboration and improvements in both quality of and satisfaction with their own work [
34]. The complexity of implementing PCC in psychiatric care was highlighted by psychiatric emergency unit staff who described making use of practical parts of the model but losing the underpinning philosophy due to knowledge gaps or the task-oriented and biomedical agenda dominating ward [
35]. Shared decision-making (SDM) is an important ingredient in PCC [
36]. A recent integrative review [
37] captured staff perceptions of how SDM enhanced relationships between patient and staff, and how, in turn, a good relationship facilitated SDM. Although SDM is highly accepted by staff, poor insight into patients’ circumstances and needs is seen as a limitation for staff participation, as are time restraints [
37].
The objective of this study is to explore psychosis inpatient staff’s understanding of PCC, and their experiences of working to increase person-centeredness, following an educational intervention and the implementation phase that ensued. The intervention, Person-centered psychosis care (PCPC), aimed at increasing the overall level of person-centeredness at four psychosis wards in a Swedish major city [
38,
39]. The educational intervention was based on the Gothenburg model of PCC which was developed in non-psychiatric care [
17,
40], and used a participatory design. Staff evolved their person-centred thinking through six educational course days which were spread out over 6 months, interspersed with practical testing of person-centred features such as attaining a patient’s narrative, working in partnership with the patient to form care plans and documenting the agreements. Through the creation and testing of practical projects, participants then worked to transform their ward practices. One third of all staff attended the educational days, and remaining staff were involved through knowledge translational activities and involvement in the practical projects.
The educational intervention and implementation are described in more detail in the study protocol [
38] which presents the planned evaluation of PCPC in its entirety.
Discussion
Participants understood person-centered care as being about patient involvement in care and care being tailored to fit the individual. This understanding was translated into practice, described by participants as deliberate work to activate the patients, providing information and preparing patients for shared decision-making during care planning. The view of the patient as a capable person was seen as the underlying assumption in support of patient participation. This was also expressed more directly by staff in terms of identifying an individual patient’s skills and resources and encouraging their involvement both during and after the ward stay. PCC was perceived as an approach, rather than a method. This contrasts with findings of a previous study [
35], in which staff adopted certain methods but not the philosophy of PCC. Staff experiences in our study might in part be explained by the character of the intervention which emphasized patient-as-person as the foundation, and encouraged individualized ways to acknowledge this in practice [
38], rather than providing a preset structure that staff were expected to follow [
44].
Several participants addressed individualized care as a core feature which is related to the view of the patient as a unique person. A willingness to understand this person is illustrated by statements highlighting the power of the narrative. Statements suggested a patient’s choices might become understandable, if she is allowed to tell her story; she is not rejected as crazy or uncooperative. On one hand this represents person-centeredness as the patient is given credibility and acknowledged as a part with a say; on the other hand, it reflects an ongoing interpretative precedence as staff overlay their interpretation of the patient’s story. We believe this is an important area of discussion, as it involves a potential conflict in trusting a patient’s capacity while s/he is affected by psychotic symptoms. Previous researchers have concluded that inpatients with schizophrenia are able to participate in shared decision-making processes [
45]. On an individual level they must however face epistemic injustice, the discrimination, based on prejudice, of their capacity as a knower, implicated by both the patient role [
46] and the psychosis itself [
47]. For the patient’s narrative to become the opening door to a truly person-centered care, staff need to reflect on how they assess and interpret the narrative.
Staff reported several changes related to the PCC intervention, one being improved relations. Improved empathy, respect and contact have been reported from several settings after the implementation of PCC approaches [
48], including inpatient forensic psychiatry [
34]. Improved relations could be considered a key to other types of change. In our study several aspects of the improved care environment, such as job flow and satisfaction, related directly to patient relations. Improvements in job quality and satisfaction have been reported by staff in PCC studies set in other care settings [
34,
49]. Enhancing patient relations might be a means of improving staff work experience. On the other hand, our findings suggest tensions between improved job satisfaction and the emotional toll of engagement, previously described in non-psychiatric care settings [
48]. This has also been expressed in terms of stress as staff have to try to fit in features of PCC into traditional care delivery models or balancing conflicting priorities [
26,
44]. Our findings, taken together with those reports suggest that not only staff but also the care organization itself must align with PCC.
Participants described change in patient behavior; patients were more active and, in some cases, demanded more of staff. This was suggested to be a direct effect of patient inclusion in the work with care plans, as well as the improved sharing of information. Similar experiences were reported from medical wards after the implementation of PCC; patients who were well-informed were aware of their capability and influence, which seems to have increased their satisfaction and engagement in self-care [
50]. Our study also suggest a greater calm in patients, related to improved structure and communication which aligns with previous findings of patients being more calm and independent with PCC in place, while losing self-esteem and becoming passive in non-PCC practice [
48]. Results suggest that if patients are given the opportunity and knowledge, their role in the care process can evolve, which reflects the very basis of PCC; the philosophy of the person as someone capable.
Several barriers for the implementation and practice of PCC emerged in our study. The complexity of the concept of PCC was put forward and participants depicted divergent understandings of the abstract concept, which became apparent when staff endeavored to translate theory into practice. This issue has been reported by staff and researchers from a wide range of health care settings, including psychiatric inpatient care [
27,
48]. When implementing PCC as a practical routine, there is a risk that the essence of the approach -to acknowledge the personhood of the patient- can be lost. Participants also described differences in the degree of staff engagement, relating this to variation in both understanding and interest, an issue previously reported in several PCC implementation studies [
48,
51]. Participants directly addressed a gap between doctors and the rest of staff. This has been addressed by PCC-researchers who attributed the power relations built around doctors as a barrier for change [
26]. Although the traditional hierarchy of the care organization runs deep, PCC might influence power relations on the ward. In our study nursing assistants describe an evolving role with more responsibility and credibility in the care team, and nurses described improved teamwork, suggesting the dynamics of the person-centered approach improved collaboration within the care team.
Lack of time and everyday tasks taking precedence over PCC innovations were also put forward as barriers for change in our study. Similar findings are reported from other PCC implementations [
27,
51]. Parallel to this finding, reports suggest that once PCC is implemented it actually saves time, as patients goals are more efficiently supported and patients themselves take more responsibility [
26]. There are also reports of staff slipping back to task-oriented care when the workload becomes high [
49], suggesting that successful implementation of PCC needs to overcome both the initial struggle while working to establish change, as well as the more long term situation since burdensome ward situations might trigger old behaviors. Managers in this and other studies [
25] addressed the disruptive nature of staff turn-over, acknowledging the importance of continuous work within the care model. The current situation with high staff turnover and recruitment difficulties is a major challenge. PCC might however be a way to retain, and attract, staff. Improved ward climate is suggested in this study, and studies within outpatient psychiatry have suggested that the culture and climate of the organization impact on staff attitudes, which in turn predict turnover [
52]. Further, one participant in our study described actively seeking employment at our clinic because of our ongoing work with PCC, others talked of improved work situation in terms of more fun, engaging and smooth job. Quantitative evaluations of work attitudes such as job satisfaction are however needed in the inpatient setting as positive associations between PCC and job satisfaction reported from geriatric care settings [
53‐
56] cannot be directly extrapolated.
As acute psychosis severely affects cognitive processes and social interactions, we had anticipated that participants would highlight illness-related issues as barriers for PCC implementation. Such reports were uncommon, and the same was the case for involuntary care procedures. Coercive procedures were not seen as barriers, but rather situations in which the PCC approach was considered particularly relevant. Earlier studies are in line with this thinking, finding PCC possible to practice even within involuntary situations [
57]. An issue that surfaced regarding patient interaction was instead related to language difficulties. The use of interpreters hampered the patient-staff connection, as noted in other care settings [
26,
31]. This was anticipated as conversation is the natural starting point for a person-centered relation.
Participants in our study identified both informal and formal facilitators of PCC. The former included a solution-oriented mindset as well as the heterogeneity of the team which stimulated new approaches to care. Formal facilitators were medical students (summer only) and a resource person (year-round) who aided and stimulated their co-workers in increasing person-centeredness in everyday care tasks. The fact that the resource person was much appreciated by staff, as well as participants’ explicit wish for continuous and structured supervision demonstrates the need for long-term support for the development of person-centered care approaches over time. Such a need has been suggested in the dementia care setting [
28], and seems highly relevant also in the care of persons with serious mental illness.
The results of this study provide a deeper understanding of PCC in a hospital setting for persons with acute psychotic illness. The qualitative approach and the non-randomized sample of participants however makes the transferability of results to other settings limited and caution is warranted when making conclusions for the study population. The small sample size might limit the range of staff experiences and thus the result. However, all ward based professions and roles were represented (including psychiatrists). The professions and roles not represented (psychologist, physiotherapist, occupational therapist) were those that are called in as consultants when needed. Recruiting was purposive, to ensure a wide range of experiences in the data. Participants were recruited partially by open invitation, which might lead to an overrepresentation of staff who were positive to the intervention. Our results reflect staff members’ subjective experiences, and outcomes measured in an objective manner might differ. Previous research has shown that the presence of a person-centered thinking doesn’t necessarily result in person-centered actions [
58], and care staff tend to overrate their performance [
59]. While our study provides snapshots depicting actual delivery of PCC, we do not know the extent to which patients actually received person-centered care. A study limitation is the lack of an objective measure of person-centeredness at the ward level, which could allow for triangulation of our findings.
We chose to collect data through focus group interviews which comes with some considerations related to the interaction of participants. Participants might be affected by each other, conforming to the group’s overall thoughts or withholding statements that might be unwelcomed. Interviewers tried to access the divergent perspectives of all participants, and both “positive” and “negative” statements were encouraged. Still, interviews with individual staff members might have yielded other results.
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