Enriching lives: A relationship-centred approach to quality care for all by Mike Nolan Professor of Gerontological Nurs

1. Enriching lives: A relationship-centred approach to quality care for allbyMike NolanProfessor of Gerontological NursingSwansea, 13 May 2009

3. The challenge ahead Rise in long-term conditions the greatest challenge to health and social care systems (Kane 2005) Health care systems still mainly focussed on acute care Social policy is underpinned by an individualistic view of society Need for a change in values and a new model of service delivery Relationship-centred care/Senses Framework

4. Modernising adult social care: What�s working? Review of the MASC programme of research Progress, but much remains to be done �Disappointingly the research suggests that user and carer engagement remains underdeveloped at critical points within the social care system�

5. What�s working (cont�d) Need for a combination of a) Transactional processes, eg standard setting based on compliant behaviours b) Transformational processes based on a more value imbued and affective set of relationships generating commitment More complex the policy, more important are transformational processes Super-ordinate set of values Independence, well-being and choice

6. Are these the right values? Independence, well-being and choice �Cultural glue� Consistent with other recent concepts in academic and policy literatures Successful ageing Person-centred care Autonomy and independence Rosy concepts

7. What do we value? �The fantasy of modern life is celebrated in advertising and the media as the healthy, fit young adult, or the well preserved, vital senior citizen� each shaping a fast paced life of unlimited horizons and unimpeded self-direction� (Callahan 2001) �Fundamentally the envisioned change is one of the heart, and the investment required not so much financial as attitudinal� Baker (2007)

8. Successful ageing: what�s not to like? (Scheidt et al 1999) How is success defined? Three requirements for successful ageing - Avoidance of disease and disability - High levels of physical and cognitive functioning - Active engagement with life (Holstein and Minkler 2003) Use of term successful itself is problematic as, by definition, it casts those who do not �measure up� into the alternative �unsuccessful� category Constitutes the �new ageism� (Holstein and Minkler 2003) based on a vision of the �super-aged� (Feldman 1999)

9. The roots of �person-centred� care Pioneering work of Tom Kitwood, Bradford Dementia Group � Dawn Brooker Person-centred care See the person not the disease Creating a positive environment of care Original vision not consistent with current usage Little more than a political slogan (Burstow 2006)

10. Person-centred care � mantra ofthe moment Care that is based around an individual and their needs (DoH 2001) Key values underpinning the �single assessment process� are person-centred care and independence (Norman 2005) Assessment is a person-centred activity with an emphasis on establishing areas of need to maintain or increase independence and quality of life (McCormack and Ford 2000)

12. What of autonomy and independence? Beware the �new gerontology� with its focus on �individually successful ageing� that results in an impoverished view of what a good old age can be� (Holstein and Minkler 2003) Autonomy and individuality are �incapable of underpinning any shared societal responsibility for the health of all its members, including the least advantaged� (Evans 1999) Need a relational view of autonomy that recognises that people are never fully independent (MacDonald 2002)

13. �What do we devalue?� �If geriatrics is the Cinderella of services, Long-term care is the ugly sister� Last refuge (Townend 1963) Sans everything (Robb 1967) �Plagued by powerful negative influences� (Miller et al 2008)

14. The Senses Framework andRelationship-Centred Care Developed over a 25 year period Early clinical concerns about status of LTC and the relationships between family (informal) and professional carers Series of studies exploring the dynamics of these relationships and staff interactions with older people in care settings in late 1980�s, early 1990�s Theoretical influences - Rust out (Pennington and Pierce 1985) - Therapeutic reciprocity (Marck 1990) - Therapeutic quadrangle (Rolland 1988, 1994)

15. The Therapeutic Quadrangle (Rolland 1988) CARER FAMILY PROFESSIONAL CARED-FOR PERSON ILLNESS/DISABILITY

16. Combating �Rust Out� Intellectual itch - What provides a sense of therapeutic direction for staff in LTC environments? Cure Rehabilitation �Good geriatric care� (Reed and Bond 1991) or �Endless residual care� (Evers 1981) �What is geriatric care? Beds, backs and bowels, beds, backs and bowels. No real change and no real challenge! Own work in a day hospital

17. Long Term Care: �W(h)ither Now? The �Senses� (Nolan 1997) - Security - Belonging - Continuity - Purpose - Fulfilment - Significance Not just older people but also staff Mulrooney (1997) Person and relationship-centred caregiving - Respect for personhood - Investing in caring as a choice - Valuing interdependence

18. Making �sense� of �enriched� environments of care The Senses Framework (Nolan 1997, Davies et al 1999, Nolan et al 2001, 2003, 2006, Brown 2006) Security - to feel safe physically, psychologically, existentially Belonging - to feel part of a valued group, to maintain or form important relationships Continuity - to be able to make links between the past, present and future Purpose - to enjoy meaningful activity, to have valued goals Achievement - to reach valued goals to satisfaction of self and/or others Significance - to feel that you �matter� and are accorded value and status

19. �As synthesisers of care we are in the business of creating the right environment for others to grow�

20. Creating the right environment for others to grow? Not just �others� but everyone �If employees are abandoned and abused, probably clients will be too. If employees are supported and encouraged they will take their sense of well-being into their day-to-day work.� (Kitwood 1997) Creating an �enriched environment�

21. Filling in the gaps

22. Towards relationship-centred care Tresolini and the Pew-Fetzer Task Force 1994 Major review of the bases for health care systems and the way that practitioners operate and are trained Relationship-centred care �The phrase �relationship-centred care� captures the importance of the interactions among people as the foundation of any therapeutic or teaching activity. Further relationships are critical to the care provided by nearly all practitioners and a sense of satisfaction and positive outcomes for patients and practitioners. Although relationships are a prerequisite to effective care and teaching, there has been little formal acknowledgement of their importance, and few formal efforts to help students and practitioners learn to develop effective relationships in health care� (Tresolini and the Pew-Fetzer Task Force 1994)

23. Working with family carers as co-experts Questioning; Procedural; Exchange (Smale 1993) Getting the balance right between difficulties, satisfactions and coping strategies ( COPE and CADI, CASI, CAMI) Timing is crucial Carers are realistic, the process itself is helpful

24. Some recent work My Home Life � Help the Aged The CDSS � the �Senses� are relevant in dementia care settings (Ryan et al 2002) Care Commission Scotland Leading into the future programme Agencies in Australia � Helping Hands The CARE Profiles COAT in Sweden and Canada