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RELATIONSHIP CENTERED CARE.
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Discusses the relevance and importance of this type of care.... More...
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Paper Abstract:
Discusses the relevance and importance of this type of care. How nurse practitioners can use this health-care delivery behavior. How relationship-centered care can improve both patient adherence and compliance. Defines the term and its evolvement in recent years. Discusses various theories of interaction within a health care situation.
Paper Introduction:
This research examines the relevance and importance of relationship-centered care to the work of nurse practitioners. The research will set forth a working definition of the term, in the context of emerging health-care-delivery praxis, and then discuss ways in which relationship-centered care can be used as the primary blueprint and guide for fostering improved patient adherence/compliance.
The term relationship-centered care has evolved in recent years to describe a modality of health-care-delivery protocols that focus on the psychological and social as well as medical needs, wants, concerns, and priorities of patients and their families rather than structuring health-care delivery around the priorities of the physician in charge of a case. Also called patient-centered care, in recent years the term of preference for the s
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88). Compliance may also be primarily behavioral in orientation, and thatfact carries with it a range of psychoemotional baggage that clinicianswould ignore at their peril, if it is the case that relationship-centeredtreatments engage patients' psychology as well as the physiology. Buildingcommunity: Developing skills for interprofessional health professionseducation and relationship-centered care. (1998, September 23). Behavior change and compliance: Keys to improving cardiovascular health.(1993). Pitfalls to relationship-centered health care may be inferred fromrelatively uncommon articles in the literature that caution psychiatricnurses against the possibility that psychiatric patients may mistakeprofessionally administered care and a helping attitude for personalemotional attachment. Increasingly, physicians who have recognized the potential fornegative patient outcomes have begun to realize the role of the doctor-patient relationship in fostering compliance. It iscommonplace of treatment of both hypertension and type 2 diabetes that anymedications are to be supplemented by nutrition- and activity-basedinterventions. The work ofpsychology theorist Carl D. The fact that the curricula of relationship-centered medical practiceincludes instruction in "the power and effectiveness of non-interventionallistening" (Remen, 1996) reveals much about the development of relationship-centered theory and the fact that adherents to the practice recognize thetools that can transform theory into effective intervention on behalf ofthe patients. Patient adherence, also patient compliance, as the locution implies,is the name given to the action-oriented willingness of patients to abideby doctors' instructions, including but not limited to medication regimensand other activities and features of recovery and health maintenance. May, D.S., Kiefe, C.I., Funkhouser, E., & Fouad, M.N. But when it is noted that "patients with poorcompliance have a tendency to be depressed and feel unsupported," thepsychological content of a medical situation can readily be appreciated.Furthermore, what the details of the examples presented share is thatbreakdown in patient adherence is located in the efficacy of communication,which ipso facto is a primary feature in the building of any relationship,whether professional or personal. Health professions education and relationship-centered care.Kalamazoo, Mich.: Fetzer Institute. For example,an injured athlete would have to understand that if he wants to playfootball again he will have to show up for physical therapy. In a study of machine-based home health careprotocols for chronic respiratory conditions such as emphysema and chronicobstructive pulmonary disease handled by family caregivers, it was foundthat the high variability in patient compliance and patients' levels ofsatisfaction and with the treatments could be traced in significant part tosome degree of failure to adequately instruct patients in the proper use ofthe nebulizers (Corden & Others, 1997). In other words, as theaccidentals of medicine have become more impersonal, medical theory andprofessionals have sought means to assert a more personal connection to thepatient involved. It's purely professional. (2 , March 15). To the degreephysicians' priorities are set by preference, custom, practice, and thetradition that physicians are in charge of health-care-delivery teams, itmay fall to nurse practitioners to implement the objectives of relationship-centered treatment. This research examines the relevance and importance of relationship-centered care to the work of nurse practitioners. In other words, suchtraining is best addressed with reference to original systems models,wherein linkages between the individual and the entire health care"organism" can be anticipated and addressed appropriately. (1999, December 2 ). Accordingly, the more fully developed thenurse-patient relationship on a psychological level, the more likelypatients are to comply with clinical treatment recommendations. Gulland, A. (1998, February 25). Glover, D., & Furlong, S. In1994, what was to prove a seminal study of the relationship-centered-carediscipline called for increased "competencies" in a whole range of"complexities and uncertainties involved in caring for people's health inrelationships with patients, communities, and other practitioners" (Pew-Fetzer, 1994). HIV-positive and AIDSpatients, for example, are especially at risk if they do not complystrictly to multidrug dosages, time of delivery, and the like (Charnow,1999). Relationship-centered care,often in conjunction with the collaborative-care concept in institutionalclinical settings, can be interpreted as a response to the potential andactual threat to patient well-being that doctor-centered treatmentprotocols may have caused. Remen, R.N. Pew-Fetzer Task Force on Advancing Psychosocial Health Education.(1994). Research on relationship-centered care and healthcare outcomesfrom the Rochester biopsychosocial program: A Self-determination theoryintegration. (1996). Retrieved from the World Wide Web 18November 2 1, at http://www.commonweal.org/corecurric.html. That is because of his theoretical focus on what he callsthe whole person, i.e., the complex of emotions, experiences, relationshipswith significant others, and behaviors that projects outward from theorganism. Bolinas, California: Commonweal Institutefor the Study of Health and Illness. On the face of it, follow-up, simple dosage instructions, andinstruction in the use of therapeutic equipment may seem to have only atangential connection. American Medical News,42, 27. . The more general point is that the legalvulnerability of some nurses and the demands of relationship-centered careneed to be addressed in the training of practitioners, if the benefits ofthis care modality are not to fall before the vicissitudes of a litigioussociety and a controlling administrative environment. Families, Systems & Health, 18, 79-9 . Adherence to AIDS regimens, indeed, has been found to be of utmostimportance, with no opportunity for so-called "drug holidays" an option.This would tend to suggest that bedside manner of doctors or nurses is ofless importance than in the case of behavior-related hypertension ordiabetes treatments. Physicianassessments of patient compliance with medical treatment. (2 ,Spring). The concepts and structures of relationship-centered care have beenconnected to a "biopsychosocial model" that defines systems theory in termsof the nexus of organizational behavior and the network of dynamicinteractions (patient-doctor; doctor-family; patient-nurse, etc.) thatemerge in a given health-care situation (Williams & Others, 2 , p. The relevance of such issues to nurse practitioners is that thenursing profession tends to be on the front line of patient-clinicinteraction and communication. On becoming a person. Melnikow, J. (1998, December). Rees, P.J., & Cochrane, G.M. Melnikow (2 )tracked follow-up family-planning clinical visits of women with problematicpap smears and found that among both insured and uninsured women, those whowere provided with multiple reminders were likely to receive follow-uptests. Among patient populations thathave been historically "underserved" from the standpoint of socioeconomicwelfare, respectful attention to the social experience of thesepopulations, together with a collaborative, team-based approach, appears tohave had beneficial effects on the willingness of patients and families toseek out interventional and prophylactic medical attention when needed andthereby fostering "increased efficiency and reduced costs . (1999, March). Gulland (1998) cites the possibility of professionalconduct hearings looms large and cautions that mental-health nurses mayneed to draw the line between the need for rapport with patients and thepossibility of being misread. First of all, use of the word patient in the term can havethe effect of failing to include the idea that families as well as theindividual under treatment may have a stake in patient outcomes. Physicians often complain of patient noncompliance in thisarea (Behavior, 1993). Long-term cardiovascular safety ofsalmeterol powder pharmacotherapy in adolescent and adult patients withchronic persistent asthma. Some therapies are a "tough sell," he says, such as those with only modest benefits and bad side effects. But to the extent that issues such as depression andphysical comfort are plainly related in the AIDS context, and to the degreethey may impinge on the necessarily strict compliance to suppresspathological symptoms, the need for clinical support, help, andtranspersonal interaction would seem to be important. (1999, April).Compliance with mammography guidelines: Physician recommendation andpatient adherence. . 79).In the nursing profession, correlation has also been identified betweenrelationship-centered care and the emergence in recent decades of theconcept of team-based medical treatment, with health-care professionalssuch as physicians, nurses, social workers, and other specialists engagingin an interdisciplinary effort of patient care (NLN, 1998). Chest, 112,1278-82. HIV suppression requires near-totaladherence. Rogers, C. When physicians fail to warn patients about potential problems, patients often use those complications as a reason to quit taking the medicine, he says (Weibe, 1999; emphasis added). Consent, equity andethics in new nursing. American Druggist, 216, 28-9. It follows that communication isfoundational to relationship-centered care. Do follow-up recommendations for abnormalPapanicolaou smears influence patient adherence? Social Science &Medicine, 47, 1873-6. HMO Practice, 5, 41, 114-12 . (196 ). To the degree patients are able to achieve autonomy in the matter ofhusbanding their well-being in concert with a qualified medical team, theyincur a certain degree of responsibility for that well-being. Circulation, 88, 1376-14 7. M., Morse, D. National League for Nursing, Inc. The term relationship-centered care has evolved in recent years todescribe a modality of health-care-delivery protocols that focus on thepsychological and social as well as medical needs, wants, concerns, andpriorities of patients and their families rather than structuring health-care delivery around the priorities of the physician in charge of a case.Also called patient-centered care, in recent years the term of preferencefor the structure of health care being described appears to have changedfor two reasons. If doctors and patients can have such varying perceptions of the samephenomena, there is little indication of the presence of a relationship-centered clinical structure. The absence of reminders was associated with failure to adhere totest recommendations. One study ofa group of asthmatics found dramatic differences in physician and patientreports of the dynamics of compliance. Frankel, R. Core curriculum in relationship-centered care: AFive-Module Continuing Medical Education Program for Graduate Physiciansand clinical supervision module. Communication is another major factor. The impulse toward relationship-centered health care has evolved sideby side with the ever-increasing rush of technology- and miracle-drug-driven medicine--yet in a kind of opposition to the dynamic of cost-conscious managed care (Frankel & Others, 1991). Retrieved from the World Wide Web 12November 2 1, at http://www.fetzer.org/Resources/pew_fetzer_intro.htm. Corden, Z.M., Bosley, C.M.. Of particular concern to nursing-discipline commentators on thissubject has been the relevance of cultural concerns--not strictly medicalin nature--to medical-treatment protocols. Chest, 115, 642-48. In practiceswhere nurse practitioners function as the primary point of contact for somepatient appointments, the need for patients to communicate with the careprovider remains, and the ability of nurse practitioners to function asboth expert and detective/listener is no less crucial than the same abilityis in a doctor. Theseinstructions may involve the performance of specific actions by patientsand caregivers, who may be professional nurse practitioners or familycaregivers (Williams & Others, 2 ). While Bayliss, et al.,found that simplified instructions for administering dosages tended toimprove as improving patterns of adherence to medication regimens, follow-up from the clinic has also been positively related to patient adherence(Bayliss & Others, 2 1). But a number of studies have found thatfinancial concerns are less positively associated with failures ofcompliance than psychological and communication concerns. Chervinsky, P., Goldberg, P., Galant, S., Wang, Y., Welch, M.B.,Arledge, T., & Stahl, E. In some cases, the need to develop relationship-centered care, repletewith strong clinic-patient communications and a tendency toward honoringthe perceived well-being of patients and their significant others, may benothing short of a matter of life and death. M., Suchman, A. Preventive Medicine, 28, 386-394. Many patients simply do not understand their prescribed course of treatment. . In that regard, Williams & Others (2 1) notewidespread reports of physician frustration at the fact that patientswithhold material information that may have clinical utility until the lastminute of an appointment, together with studies showing that this can betraced to the tradition of doctor-centered care. Secondly,there appears to have been some concern in the physician community that the"patient-centered" idea could be misconstrued as a medical-treatmentprotocol that relinquishes primary responsibility or control for coremedical decisions to patients or families when control of a case actuallyis meant to remain firmly lodged with doctors (Williams & Others, 2 ). Williams, G.C.,. This general idea is present in the notion of relationship-centered care, which does not stop with health-care delivery at the somaticorganism but which takes account of the multiple psychological andexperiential inputs to well-being where medical needs are concerned. Following orders. New York: Simon & Schuster. (1998, March-April). Because professional demands on physicians, including pressures fromhospital administrations and corporate entities to keep costs down, haveincreased in the managed-care structure of health-care delivery, effectivespecialist performance in team collaborations and the need to addresspatient concerns effectively have been identified as a core feature ofrelationship-centered care (Pew-Fetzer, 1994). (2 1,April). Whereas doctors tended to filtertheir perceptions of compliance with clinical advice through their own viewof on the seriousness of a condition and the (sometimes theoretical, almostalways somatic, rarely psychosocial) effectiveness of treatments, patientstended to focus on perceived practical value or benefit of such treatment(Goldberg & Others, 1998). (1999, March). Nursing and Health CarePerspectives, 19, 86-9 . Home nebulized therapy for patients with COPD: Patientcompliance with treatment and its relation to quality of life. Considerthe case of type 2 diabetes, which has been growing at an alarming rate inthe US in recent years and which is positively associated with obesity,cardiovascular disease, heart attack, stroke, and a host of opportunisticdiseases. We are back to the importance of communication: [S]tudies have found high noncompliance among patients with good [insurance] coverage, indicating that cost is not the only issue. But there is evidence that patient compliance or adherence to amedical regimen, whether related to ancillary treatments, exercise, dietmanagement, follow-up appointments, substance abuse, or medicationschedules, can be problematic for a variety of ailments and personalities.To be sure, if patients are overwhelmingly concerned with being able to payfor multiple clinical visits or prescription drugs, they may resistcompliance with doctor orders. ; decreases in hospitalization [and use ofemergency rooms for primary care], cost of care, and use of physicians"(NLN, 1998, p. But the practical elaboration of that relationship may take placeelsewhere in the clinic than in the presence of the doctor, such as in theoffice of the clinic's nurse practitioner and/or dietitian. The linkage between the patient's experience of listening onthe part of the care provider and the experience of receiving care seemsalmost too obvious to be worthy of note. Rogers (196 ) does not appear to beacknowledged as a source of the term relationship-centered care; however,in developing the principles of what he termed client-centered therapy(later person-centered), Rogers could be considered as an indirect sourcefor the modality. References Bayliss, E.A., Park, M.K., Westfall, J.M., & Zamorski, M.A. If the weight of evidence is on the side ofthe view that favorable patient outcomes are negatively related tophysician-centered treatments and positively related to relationship-centered, team-based treatments, then nothing short of a clinicalrevolution of values and priorities seems in order. . Goldberg, A.I., Cohen, G., & Rubin, A.E. In this regard, Glover andFurlong (1998) caution nurses that the integrity of the patient-nurserelationship depends in significant part on effective communication, notleast in the matter of full disclosure to patients that nurses (e.g., on acare-delivery team) are nurses and not doctors. That is, to the degree adoctor controls the dynamic of a clinical visit, transmitting knowledge andinstruction as it were from the top down rather than listening from thebottom up (or for that matter playing detective to probe patient concerns),the patient's sense of autonomy may suffer. NursingTimes, 94, 12-13. The research will setforth a working definition of the term, in the context of emerging health-care-delivery praxis, and then discuss ways in which relationship-centeredcare can be used as the primary blueprint and guide for fostering improvedpatient adherence/compliance. It is also associated, not with mandated daily injections ofinsulin (that is type 1 diabetes), but with insulin malfunction in thebody, often brought about by poor habits of diet and exercise. Frankel, R.M., Campbell, T.L., & Deci, E.L. But the more general needfor strong communication skills, or the ability to engage with patients, tolisten attentively (much in the manner suggested by Carl Rogers) to theexpressed and unexpressed needs of patients appears to be the major driverof this method of care. reductionin broken appointments . One important reason for this appears to be that theavailability of state-of-the-art medicine, irrespective of access limitedby geography or money, does not guarantee that patients will take advantageof it. (1991).Can I really improve my listening skills with only fifteen minutes to seemy patients? JAMA, The Journal of theAmerican Medical Association, 283, 1399. How can I improve patient adherence to prescribed medication?Journal of Family Practice, 5 , 3 3. "We need to do a better job of communicating to patients why they're on this medicine and why they need to be taking it," Dr. Avorn says. Nursing Times, 94, 52-3. But at a time when managed-care mandates limiting"face time" between patient and doctor, the attention devoted to thesometimes complex needs of patients who need help, encouragement, andsupport in the matter of complying with medical directives can readily beseen. Failure to communicate withone's doctor, indeed, can make a material difference in the quality ofcare. Charnow, J.A. Patient compliance with doctors' instructions is a persistent theme ofthe literature, a phenomenon noted, tracked, and scored even when notanalyzed in depth (e.g., Chervinsky & Other, 1999). S., & Beckman, H, B. To the degree the quality ofpatient experience of interaction with care providers can be linked tostronger adherence to care protocols that involve patient awareness andresponsibility, the work of communications counseling and relationshipbuilding can be said to have succeeded. Theimportance of this determination is difficult to overstate, given researchthat suggests physicians as a group do not appear to be particularly adeptat managing the relationship component of their patient load. Wiebe, C. (1997,November).
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