The ideologies and subsequent divergent idioms presented a dilemma about the focus of this review, and whether to explore philosophies of care, or concentrate on the reason for the tension and explore literature that pertained to this. The initial literature review initiated the beginning of what Strauss & Corbin (1990) refer to as ‘literature sensitivity’ which enhanced the analytic process by drawing on concepts from which literature is later used to develop theory. Hence, whilst the focus of the initial review was not to explicate personhood in any depth, it became apparent that this formed a significant part of the processes involved in person-centred care. In particular, caring is thought to resonate with the concept of personhood and is discussed in part 3.
47 2.8. Part 3: Restoring the Self and Person
For people with chronic pain, the need to be cared for is no different from anyone else, however, it is acknowledged that the permanence of chronic pain is a situated experience that many struggle to come to terms with (Clarke 2005). However, it is recognised that people with uncontrolled chronic pain endure a daily assault on their self and their individuality (Charmaz 1999), which is often compromised through the constant challenges of the illness trajectory. The subsequent loss of independence and self-worth resulting from the relentless attack of chronic pain was a common observation cited in the literature (Sveilich et al 2005, Clarke et al 2003, Clarke & Iphrofen, 2005) and presented a bleak picture of life living with chronic pain. The ‘self’ is therefore significant and according to Epstein’s (1973) ‘self-theory’, the ‘self’ represents a bodily self [physicality]; an inferred inner self, [esteem, ego and emotions], and the moral self which seeks approval and senses good and bad. It is acknowledged that persistent pain can destabilise both the moral and inner self and force dependence on others (Blomqvist et al 2002) and suggests why the individual with chronic pain defines their self negatively. Hence, the damage to the ‘self’ as a result of chronic pain and illness can ultimately impact on personhood.
Kitwood’s (1967) earlier definition of personhood suggests a symbiotic link between a person’s standing and the relationship with others, hence, it is understood that the self is central to personhood. It is therefore acknowledged that person centred caring is consistent with the key principles of personhood because it embraces actions of listening, understanding, respect, serious attention and regard for another’s ‘self’ (McCance 1997). Similarly, caring is a moral imperative which requires good interpersonal relationships to support therapeutic interventions (McCance 1997) and is predicated on the individual’s epistemological values and underpinned by a moral imperative (Morse 1990). The association between person-centred care and personhood and the self is therefore significant and has been reported by McCormack (2003), McCance (1997), Nolan et al (1997) and Charmaz (2006), but Kitwood’s (1997) work in particular, highlighted the significance between person-centred care and the principles
48 of personhood. Other authors such as McCormack (2003) and Nolan et al (1997) have since used Kitwood’s (1997) work because it linked the concept of personhood with values, the beliefs held by individuals about their rights as persons to be respected (McCormack 2003). Person-centred caring suggests that one’s assumptions are re- evaluated and that the person is treated with the respect and trust that every human being has a right to expect. A central tenet of which requires a paradigm shift from transactional levels of communication between people to an approach that recognizes the other person. In the context of health care, it is thought that this paradigm shift can provide meaning to an experience, which then enables professionals to ‘go beyond the patient to see the person’ (Barker 2001).
Seeing beyond the patient to the person through understanding their biography is thought to be one way to restore the self through an empowering approach that can help the rehabilitation processes (McCormack 2003, Barker 2001). The empowerment of people with chronic back pain is important and could help restore self-esteem and achieving this means developing partnerships that that enables the individual to participate in decision-making (Glenton 2003). Indeed, a recurring theme in the literature emphasised the value of partnerships that enable professionals to use the person’s biography to understand the individual’s needs and embrace their voice in decision-making. It is acknowledged therefore that partnerships that utilise the person’s biography may help restore the self and re-establish independence. Partnering with patients through person-centred care is reported to be influenced by therapeutic relationships that engage with the individual to maximise independence. The importance of the therapeutic partnership was reported in the nursing literature by McCormack (2003) and has been recognised as a fundamental process that influences confidence in the professionals’ clarity and values, and shared outcomes. A similar perspective emerged from occupational therapy literature, for example, Blanks (2004) used Carl Roger’s (1959) principles of client-centred care that embraced respect, empathy and trust to evaluate the therapeutic partnership between clients and occupational therapists. Blanks (2004) qualitative approach illustrated how the relationship between the occupational therapist and the ‘client’ contributed to the
49 development of a partnership. Key findings from Blanks (2004) study highlighted the significance of the therapeutic approach that ultimately worked with the person as opposed to the client or patient. Equally, Lauver et al’s (2002) summary of patient- centred nursing interventions discuss similar concepts and refer to Paulen & Rapp’s (1981) paper which examined the values and philosophy of person-centred care in nursing and outlined the need for respect, humanity, and control. Further, Lauver et al
argued that these attributes were central to person-centred care and were consistent with Radwin’s (1995) Grounded Theory study of nurses’ clinical decision-making. Radwin’s findings reported the need to know the person and that understanding their experiences was crucial to the core processes associated with individualised interventions.
Historically, therapeutic partnerships were viewed as a medium for empowering equal alliances between the professional and the individual (Freshwater 2002) the key concepts of which have since been reflected in nursing and therapy literature and have influenced a number of person-centred models. Barker’s (2001) seminal work within the field of mental health, the ‘Tidal Model’ (2001) is one example which presented an alternative paradigm to ‘caring with’ and highlighted the person as opposed to the patient. His work emphasised that partnership’s should be centred on developing a ‘power relationship’ between health care professionals and advocated that nursing be re-focussed by emphasising the ‘fluid changing nature of human beings’ (Barker 2001 p235). Similar to Blanks (2004) qualitative illustration of the therapeutic relationship, practitioners using Barkers (2001) approach engaged with the individual rather than the disorder or illness by discovering the person through dialogue and partnership working that engaged with the person, illness and health (Barker 2001). Similar approaches have been adopted by other nursing models of person-centred care and frequently refer to the same principles (see Nolan et al 2004). McCormack (2003, 2004, and 2006) in particular has been a frequent commentator on person-centred care in nursing and like Nolan et al (2004), has observed the practice of person-centred care within a geronotological context. McCormack’s work is extensive and has consistently explored the paradigms associated with person-centred care.
50 In 2003, McCormack published a conceptual framework for person-centred care with older people, predicated on hermeneutic philosophy. In his paper, McCormack used conversation analysis and reflective account to highlight the nurses ability to ‘particularise the person who the patient is’ and explored the relationship between the patient and the nurse and the expectations that evolved. McCormack (2003) concluded that person-centeredness was predicated on an authentic consciousness, which was operationalised through five ‘imperfect duties’. Table 4 illustrates these imperfect duties.
1. Informed flexibility: the facilitation of decision-making through information sharing and the