“Individualised care” from patients’, nurses’ and relatives’ perspective—a review of the literature

Abstract

This paper provides an overview of the empirical research literature on individualised care. It offers a description of the methods that have been used in studies of individualised care over the years, and then discusses the meaning and realisation of individualised care from patients’, nurses’ and relatives’ points of view in order to highlight needs for further research. The review focuses on empirical articles retrieved from the MEDLINE database published between 1973 and June 1999. It draws attention to the complexity of individualised care, which at first sight may look like a relatively straightforward nursing activity. It is shown that a wide range of methods have been used to study individualised care in the current literature. There is a lack of research where patients’ experiences of the individuality of care in hospital settings are concerned.

Introduction

The treatment of each individual as a unique person is a cherished value in nursing care (ICN, 1973; Curtin and Flaherty, 1982; Rumbold, 1989; Wilson-Barnett, 1989). Therefore, individualised care is a crucially important concept for health care. In the theoretical literature individualised care is described as an essential component of nursing (Meleis, 1991; Jones and Kamath, 1998; Waters and Easton, 1999) and as a central tenet in clinical practice (Peplau, 1952; King, 1981; Burgener et al., 1993). Nurses’ moral knowing is expressed in their respect for the individuality of each patient (Jenny and Logan, 1992). As Levine (1967) has pointed out, this essential concept in patient-centred nursing care rests on the individualisation of the patient and his care. Individualised care has also been identified as a philosophical phenomenon, an important principle (Levine, 1967; Jones and Kamath, 1998; Segesten et al., 1998), and therefore is essential to nursing.

Individualised care can offer many important advantages. Nurses who can develop individualised care strategies are most likely to promote wellness and health functioning in populations (Boyle, 1989), quality of care (Perälä and Hentinen, 1989; Åstedt-Kurki and Häggman-Laitila, 1992; Gilloran et al., 1993; Twaddle et al., 1993; Oleson et al., 1994; Wimo et al., 1993; Hansebo et al (1998), Hansebo et al. (1999); Rantz et al., 1998; Waters and Easton, 1999), and maintain functional abilities and autonomy (Colling et al., 1992). According to Twaddle et al. (1993) the continuity of care was improved by individualising care according to the needs of women. If care is individualised, there is more time to meet everyone's wishes (Rader et al., 1996). It also improves quality of life (Rader et al., 1996) and gives greater patient satisfaction (Twaddle et al., 1993; Wigens, 1997).

Individualised care focuses on the individual and his or her specific health problem. It is tailored to one person and is therefore patient-centred. According to Cox and Roghmann (1984), the individualisation of care involves taking into account the client's individuality and allowing that individuality to determine interpersonal approaches and health–illness management actions. It could be argued that care pathways and standardised care represent the opposite of individualised care (Jones and Kamath, 1998). Individualised nursing care allows for many different responses to similar situations with different patients (Wigens, 1997; Jones and Kamath, 1998), while medically bounded care pathways and standardised guidelines direct nursing care on biomedical, disease-oriented model (Wigens, 1997).

Care pathways identify a group of patients with a common health problem, are intended for use in specific illnesses or treatments and are based on general recommendations (Walsh, 1997; Wigens, 1997; Jones and Kamath, 1998). Disease-focused care pathways, standardised care and care plans have been criticised for being task-oriented and routinised, focusing as they do on nursing actions rather than individual patient needs (Smith, 1991; RCN, 1992; Wigens, 1997). In contrast, the individualised care discourse focuses on the quality of care, calling for a reduction in the routinisation of care (Wigens, 1997). Task-centred routines and effects on unforeseen events have been identified as factor limiting individualised care (Redfern, 1996). Also van Servellen (1988) has highlighted the right of patients to have their uniqueness protected and the individuality of patients’ responses to standardised treatment and focuses care on individual patient's needs. Health care is in essence a balancing act between individual needs and collectively directed care. There is need for research to identify the nursing activities that promote individualised care.

Individualised care has been discussed in many different contexts. Its meaning has been influenced over the years by the sometimes interchangeable use of the term with other concepts, which of course adds to the confusion. The concept appears frequently in the primary nursing literature (Mackay and Ault, 1977; van Servellen, 1988; Perälä and Hentinen, 1989; Smith, 1991; Athlin et al., 1993; Thomas, 1994). Individualised care may deal with the question of how care is organised, but an important notion is the missing imaginative element from communication between practitioner and patient (Scott, 1995; Redfern, 1996). It is this imagination which is often lacking in those whose role enactment and moral strategy are of a poor quality.

Some authors have applied the principles of individually planned care in an attempt to make care more individual (Fields et al., 1991; Hallberg and Norberg, 1993; Twaddle et al., 1993; Wimo et al., 1993; Berg et al., 1994; Gants, 1997; Hansebo et al (1998), Hansebo et al. (1999)). Individualised care favours attempts to improve aspects of care and the well-being of the patient. Changes in ward organisation (Mackay and Ault, 1977; Smith, 1991; Hallberg and Norberg, 1993; Berg et al., 1994), caring techniques and strategies (Boyle, 1989; Wimo et al., 1993; Rowles and High, 1996; Alexy et al., 1997; Buchanan et al., 1997), and caring philosophy (Colling et al., 1992; Redfern, 1996; Jones and Kamath, 1998; Rantz et al., 1998; Segesten et al., 1998) have also contributed to more individualised care. Individualised nursing care allows for many different responses to similar situations with different patients (Wigens, 1997; Waters and Easton, 1999). Individuality of care can also be used as an assessment tool of care (Sheil et al., 1995; Buchanan et al., 1997).

The data reveal a rather limited and disjointed perception of the concept. Many studies have either not defined what they purport to measure or limited their definitions to what the authors have seen as large components of the whole concept. Firstly, there is the type of definition that is broad and sweeping and that therefore tells us little about the possible components of individualised care or how the concept could be operationalised. For example, Berg et al. (1994) defined individualised care as finding the best possible strategy to provide care for each patient. Secondly, there are definitions that break down the concept into a series of dimensions. The definition by Cox and Roghmann (1984) and borrowed by Brown (1992), Brown (1994) highlight the interaction between the client and the caregiver.

The third set of definitions focuses exclusively on one or some parts of the whole concept. For example, Wimo et al. (1993) suggest that individual care planning is based on the patient's disease, physical and psychological needs, family history, life events, habits, friends, hobbies etc. Special emphasis should be put on the patient's own needs and preferences. The focus in individuality includes past environmental and cultural influences that affect the person's response pattern (Burgener et al., 1993), while Jones and Kamath (1998) includes delegation of responsibilities and decision-making in individualised care.

Definitions of individualised care were not sufficiently detailed to allow for systematic analysis of the content of the concept because the concept is defined in no more than a minority of the studies (n=10). As is clear from the definitions, the individual person is the starting point of individualised care. The verb tailoring is used synonymously with individualising care (Brown (1992), Brown (1994); Twaddle et al., 1993; Thomas, 1994), and is operationally defined as attending to the client's singularity, discussing client singularity and clinical assessment–management content in association rather than separately; and producing interventions that are explicitly personalised to the individual. The definition by Mackay and Ault (1977) also comprises the family and the community. “Individualised care involves meeting the specific and comprehensive physical, psychological and social needs for each patient. A knowledge and understanding of the patient as an individual, as a member of a family and a resident of a community, is the basis of care.” Most of the definitions are research-specific, but there is also one example of a non-research-specific definition, i.e. Cox and Roghmann's (1984) definition from the Interaction Model of Client Health Behaviour. The concept may compete to explain the same phenomenon as long as the concepts remain immature (Morse et al., 1996) and therefore there is need for research to clarify the concept of individualised care.

Although the concept of individualised care is relevant and important in nursing, research into individualised care has highlighted a number of problems in this area. Firstly, there is little evidence of individualised nursing care in practice (Mackay and Ault, 1977), and there are also difficulties in delivering individualised care (Wigens, 1997; Waters and Easton, 1999). Needs for individualised care also vary, and more work needs to be done to individualise care for specific populations, age groups and cultures (Buchanan et al., 1997). Furthermore, there is still lack of information about how individualised care is realised in nursing practice, especially from the patients’ point of view. Although the search in MEDLINE did produce two instruments designed for the measurement of individualised care (Mackay and Ault, 1977; van Servellen, 1988), there exists no suitable instrument for measuring individualised care from patients’ points of view.

The purpose of this article is twofold. First, it describes the methodologies used in studying individualised care. Second, the results of empirical research will be overviewed. We begin by describing briefly different uses of the concept of individualised care, research fields/environments, study populations, methods used, and the reliability and validity of articles reviewed (see Kirkevold, 1997). Then we move on to describe the realisation of individualised care from patients’, caregivers’ and relatives’ points of view. This work was carried out as a starting point to link prior work, and this knowledge will be used for further research to develop an instrument for the measurement of individualised care. The knowledge derived from the analysis can be used to help develop the quality of care and methods of evaluating quality in nursing practice.