Eigen regie en waardigheid in de zorg: een kwestie van persoonsgerichte praktijkvoering

Eigen regie en waardigheid in de zorg: een kwestie van persoonsgerichte praktijkvoeringDe gezondheidszorg is aan sterke veranderingen onderhevig. Pregnant is de ontwikkeling naar ondersteuning van eigen regievoering van cliënten. In deze bijdrage plaatsen we twee kanttekeningen bij de invulling van dit begrip. Vanuit een neoliberaal marktdenken ligt de focus op de controleerbaarheid van leven en gezondheid. Dit doet echter geen recht aan de kwetsbaarheid die mensen ook ervaren en hun behoefte aan respect, erkenning en als mens geacht te worden. Vanuit een bureaucratisch organisatie denken staat de beheersbaarheid van organisaties in termen van doelen en kosten centraal. Dit leidt tot fragmentatie van zorg en dreigt professionals tot uitvoerders van regels en procedures te maken. Persoonsgerichte praktijkvoering kan deze knelpunten ondervangen. Het is het voortdurend samen vormgeven van relaties en structuren binnen zorg-, leer- en werkomgevingen zodanig dat eigen regie en waardigheid van alle betrokkenen worden gerealiseerd.  Eigen regie is dus geen individuele aangelegenheid, maar een kwestie van “grensoverschrijdend samenwerken” en verbinden vanuit verschillen in waarden, kennis en betekenisgeving. Persoonsgerichte praktijkvoering biedt daarbij een alternatief model voor het expertmodel, dat is aangeduid als het samenwerkingsmodel. Autonomy and dignity in healthcare: a matter of person-centred practice Healthcare in the Netherlands is subject to major changes. Due to rising living standards and new technologies in healthcare, people are living longer and this is related to an increase in multimorbidity. The demand for and cost of healthcare are rising as a result. In the process of trying to transform healthcare and reduce costs, the government is trying to increase the amount of self-care and self-sufficiency. Significant herein, is the development towards support for clients' self-management. This is not a new concept: patient empowerment and patient autonomy have been on the agenda since the 1970s. In order to explain the difficulties that healthcare is encountering in supporting patient autonomy, we use the theory of the American sociologist Eliot Freidson (2001), who makes a distinction between the logic of the market (consumerism), the logic of the organization (managerialism) and the logic of the profession (professionalism). Based on his theory, we would expect that although consumers do now have a stronger voice in their own healthcare, neither patients nor professionals experience autonomy in current healthcare practices. First of all, from a neo-liberal market perspective, the focus of self-management is on the controllability of life and health. However, this does not take account of the vulnerability that people experience and their need for respect, recognition and treatment as human beings. Consequently, patients often do not feel they are seen as people in their own right and do not feel supported in dealing with difficult life questions and issues. Secondly, from an organizational and bureaucratic perspective, the controllability of organizations in terms of goals and costs is central. This leads to the fragmentation of care, leaving patients to manage not only themselves but also their care. Organizational bureaucracy also conflicts with professional autonomy, turning professionals into the enforcers of rules and procedures. Person-centred practice can provide a solution to help overcome these issues and is the subject of increasing attention worldwide. It is part of a humanization movement in healthcare which sees the personal and interpersonal dimensions as essential to good care (McCormack & McCance, 2010; Hummelvoll, Karlsson & Borg, 2015; Jacobs, 2015). Our vision of person-centred practice is inspired by the ethics of care, relational psychology and relational constructionism. These currents are critical of individualism and the focus is on control and manageability in contemporary healthcare. Person-centred care is defined as the continuous co-creation of relationships and structures within care, learning and work environments in such a way that the patient’s own direction and dignity are realized. Self-management is therefore not an individual matter, but a question of “working together across the boundaries” of differences in values, knowledge and meanings. Person-centred practice provides an alternative model for the expert model, which is referred to as the cooperation model. In this model, collaboration involves not only professionals from various disciplines and sectors, but also clients and their stakeholders in healthcare. The expertise required for this by participants is known as dialogical or relational expertise. The intention of cross-border cooperation is to contribute to sustainable change by developing relationships and structures that promote autonomy and dignity.The current transformation of healthcare to provide more support for self-management will benefit from a critical reflection on market forces, and in particular its implicit assumptions of the controllability of individual lives and organizations. People are vulnerable and have a deep-seated need for respect and recognition, even if they are no longer able to manage and organize their own lives. Professionals and organizations benefit from working on the basis of core values to support their own self-management. Self-management is therefore not an individual matter, but a matter of “working together across boundaries” and connecting amidst differences in values, knowledge and meanings. Person-centred practice provides important insights in how to approach this

Facilitators and barriers to autonomy:A systematic literature review for older adults with physical impairments, living in residential care facilities

Autonomy is important in every stage of life. However, little is known about how autonomy is enhanced for older adults living in residential care facilities (RCFs). This leads to the research question: which facilitators and barriers to autonomy of older adults with physical impairments due to ageing and chronic health conditions living in RCFs are known? The results will be organised according to the framework of person-centred practice, because this is related to autonomy enhancement. To answer the research question, a systematic literature search and review was performed in the electronic databases CINAHL, PsycINFO, PubMed, Social Services Abstracts and Sociological Abstracts. Inclusion and exclusion criteria were derived from the research question. Selected articles were analysed and assessed on quality using the Mixed Methods Appraisal Tool. Facilitators and barriers for autonomy were found and arranged in four themes: characteristics of residents, prerequisites of professional care-givers, care processes between resident and care-giver, and environment of care. The established facilitators and barriers are relational and dynamic. For a better understanding of the facilitators and barriers to autonomy for older adults with physical impairments living in RCFs, a description is based on the 35 included articles. Autonomy is a capacity to influence the environment and make decisions irrespective of having executional autonomy, to live the kind of life someone desires to live in the face of diminishing social, physical and/or cognitive resources and dependency, and it develops in relationships. The results provide an actual overview and lead to a better understanding of barriers and facilitators for the autonomy of older adults with physical impairments in RCFs. For both residents and care-givers, results offer possibilities to sustain and reinforce autonomy. Scientifically, the study creates new knowledge on factors that influence autonomy, which can be used to enhance autonomy

How staff act and what they experience in relation to the autonomy of older adults with physical impairments living in nursing homes

Autonomy is important for people, even when they have physical impairments and are living in nursing homes. The way staff respond to residents is important for the realisation of autonomy. In order to gain knowledge about what nursing home staff, registered and assistant nurses, occupational therapists and nutritional assistants do and experience in relation to the autonomy of residents, a qualitative study design was chosen. Shadowing, a non-participatory observation method, was used. A total of 15 staff members of a care unit from two different nursing homes participated. Short interviews followed these observations to reflect on intentions of observed activities. The COREQ guidelines were used to report on the study. Four activities to enhance autonomy were identified: getting to know each older adult as a person and responding to his/her needs; encouraging an older adult to perform self-care; stimulating an older adult to make choices; and being aware of interactions. The exploration showed that staff considered it important to strengthen autonomy of older adults living in nursing homes and that they used different activities related to autonomy. However, activities could both enhance as well as hinder autonomy

Autonomy in nursing homes:Viewpoints of residents with physical impairments and staff

Introduction: Although the importance of maintaining autonomy for nursing home residents is recognised, little is known about this process in daily practice. Aim: The aim was to explore how residents maintain autonomy and how staff acts in relation to the autonomy of residents. Method: Shadowing, a non-participative observational method, including a short interview at the end, was used. Seventeen residents with physical impairments living in two different nursing homes were shadowed in their own environment during daily activities. Moreover, fifteen staff members, working in the same nursing homes, were shadowed. Field notes of the shadowing were typed out and the recorded interviews were transcribed verbatim resulting in a report per respondent. These were coded and thematically analysed. Results: Residents maintained autonomy by; ‘being able to decide and/or execute decisions’, ‘active involvement’, ‘transferring autonomy to others’, ‘using preferred spaces’, ‘choosing how to spend time in daily life’ and ‘deciding about important subjects’. Four activities of staff were identified; ‚getting to know each older adult as a person and responding to her/his needs‘, ‚encouraging an older adult to self-care‘, ‚stimulating an older adult to make choices‘ and ‚being aware of interactions‘. Discussion and Conclusion: Maintaining autonomy requires effort from both residents and staff. Although most residents with physical impairments experience restrictions in their autonomy because of the care-environment they live in, residents seemed to maintain autonomy in daily life. Moreover, staff consider it important to strengthen the autonomy of residents and use different activities to enhance autonomy. Relevance for research and practice: These insights help to improve autonomy of nursing home residents because the perspectives of both residents and staff are included. Therefore, the next step is to transfer these insights towards nursing home practice in such a way that it enhances staff and older adults to better maintain autonom

Identifying sources of strength: resilience from the perspective of older people receiving long-term community care

This study seeks to explore the sources of strength giving rise to resilience among older people. Twenty-nine in-depth interviews were conducted with older people who receive long-term community care. The interviews were subjected to a thematic content analysis. The findings suggest that the main sources of strength identified among older people were constituted on three domains of analysis; the individual-, interactional and contextual domain. The individual domain refers to the qualities within older people and comprises of three sub-domains, namely beliefs about one’s competence, efforts to exert control and the capacity to analyse and understand ones situation. Within these subdomains a variety of sources of strength were found like pride about ones personality, acceptance and openness about ones vulnerability, the anticipation on future losses, mastery by practising skills, the acceptance of help and support, having a balanced vision on life, not adapting the role of a victim and carpe-diem. The interactional domain is defined as the way older people cooperate and interact with others to achieve their personal goals. Sources of strength on this domain were empowering (in)formal relationships and the power of giving. Lastly, the contextual domain refers to a broader political-societal level and includes sources of strength like the accessibility of care, the availability of material resources and social policy. The three domains were found to be inherently linked to each other. The results can be used for the development of positive, proactive interventions aimed at helping older people build on the positive aspects of their lives

Innoveren versus verouderen?

Tijdens psychologiecolleges krijgen studenten een foto voor hun neus. De vraag is, wat zie je. Wat blijkt: de ene student ziet meteen een jonge vrouw, de andere een heks. Wie heeft gelijk? Pas na lang kijken zien beide studenten zowel een een jonge vrouw als een heks. Een goede manier om studenten er van bewust te maken dat een bepaalde manier van kijken bepaald wat je ziet

Balancing Risk Prevention and Health Promotion: Towards a Harmonizing Approach in Care for Older People in the Community

Many older people in western countries express a desire to live independently and stay in control of their lives for as long as possible in spite of the afflictions that may accompany old age. Consequently, older people require care at home and additional support. In some care situations, tension and ambiguity may arise between professionals and clients whose views on risk prevention or health promotion may differ. Following Antonovsky's salutogenic framework, different perspectives between professionals and clients on the pathways that lead to health promotion might lead to mechanisms that explain the origin of these tensions and how they may ultimately lead to reduced responsiveness of older clients to engage in care. This is illustrated with a case study of an older woman living in the community, Mrs Jansen, and her health and social care professionals. The study shows that despite good intentions, engagement, clear division of tasks and tailored care, the responsiveness to receive care can indeed not always be taken for granted. We conclude that to harmonize differences in perspectives between professionals and older people, attention should be given to the way older people endow meaning to the demanding circumstances they encounter (comprehensibility), their perceived feelings of control (manageability), as well as their motivation to comprehend and manage events (meaningfulness). Therefore, it is important that both clients and professionals have an open mind and attempt to understand each others' perspective, and have a dialogue with each other, taking the life narrative of clients into account.status: publishe

Nurturing cultural change in care for older people: seeing the cherry tree blossom

Research into workplace mentoring is principally focussed on predictors and psychosocial and instrumental outcomes, while there is scarcely any in-depth research into relational characteristics, outcomes and processes. This article aims to illustrate these relational aspects. It reports a co-constructed auto-ethnography of a dyadic mentoring relationship as experienced by mentor and protégé. The co-constructed narrative illustrates that attentiveness towards each other and a caring attitude, alongside learning-focussed values, promote a high-quality mentoring relationship. This relationship is characterised, among other things, by person centredness, care, trust and mutual influence, thereby offering a situation in which mutual learning and growth can occur. Learning develops through and in relation and is enhanced when both planned and unplanned learning takes place. In addition, the narrative makes clear that learning and growth of both those involved are intertwined and interdependent and that mutual learning and growth enrich and strengthen the relationship. It is concluded that the narrative illustrates a number of complex relational processes that are difficult to elucidate in quantitative studies and theoretical constructs. It offers deeper insight into the initiation and improvement of high-quality mentoring relationships and emphasises the importance of further research into relational processes in mentoring relationships

Wanneer voel je je thuis?: op zoek naar het thuisgevoel van mensen met dementie

Het is zo belangrijk: je thuis voelen in je eigen huis. Maar thuisgevoel is ook een lastig te omschrijven begrip, zeker voor mensen met dementie. Om zicht te krijgen op wat het thuisgevoel van mensen met dementie inhoudt, hebben onderzoekers van Fontys Hogescholen een kleinschalig onderzoekproject uitgevoerd waarbij gebruikgemaakt werd van een creatieve werkvorm: het zogeheten ‘moodboard’. Ondanks het toenemend aantal kwetsbare ouderen dat in de toekomst zelfstandig thuis zal blijven wonen, zullen verpleeghuizen naar verwachting belangrijke woonzorgvormen blijven. Dan zal er echter wel wat moeten veranderen, want momenteel is verblijf in een verpleeghuis voor veel mensen nu niet bepaald een ideaal van de oude dag. Nederlandse verpleeghuizen hebben een negatief imago en worden te vaak gezien als kille, steriele gebouwen waar weinig tijd is voor persoonlijke aandacht. Daarom is het belangrijk dat bij de (ver)bouw van verpleeghuizen rekening wordt gehouden met wat mensen het gevoel geeft ergens thuis te zijn. Om hier meer zicht op te krijgen is binnen het nieuwe meerjarige project van Fontys Hogescholen – ‘Verpleeghuis van de Toekomst’ (VETO) geheten – onderzoek gedaan naar wat dit thuisgevoel voor bewoners met dementie inhoudt

Working towards integrated community care for older people: empowering organisational features from a professional perspective

Although multi-disciplinary cooperation between professionals is a prerequisite to provideintegrated care in the community, this seems hard to realise in practice. Yet, little is knownabout the experiences of professionals who implement it nor about the organisational fea-tures professionals identify as empowering during this cooperation process. Therefore,a case study of a multi-disciplinary geriatric team was performed. The data-collectionincluded observations of meetings, in-depth interviews and focus groups with professionals(N = 12). Data were analysed inductively and related to the three organisational levels withinthe model of organisational empowerment of Peterson and Zimmerman. Signs of empow-ering organisational features on the intraorganisational level were mutual trust and clearworking routines. On the interorganisational level important features included improvedlinkages between participating organisations and increased insight into each other’s tasks.Tensions occurred relating to the inter- and the extraorganisational level. Professionals feltthat the commitment of the management of involved organisations should be improvedjust as the capacity of the team to influence (local) policy. It is recommended that poli-cymakers should not determine the nature of professional cooperation in advance, but toleave that to the local context as well as to the judgement of involved professionals