A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings Author links open overlay panelZahra Ebrahimi PhD, RN a b 1, Harshida Patel RN, PhD a, Helle Wijk PhD, RN a c, Inger Ekman RN, PhD a b

A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings

https://doi.org/10.1016/j.gerinurse.2020.08.004Get rights and content
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Highlights

  • •

    A comprehensive systematic review on person-centered care.

  • •

    A consensus about the crucial components of person-centered care for older people.

  • •

    A guide to support policymakers and health care professionals in implementing person-centered care.

  • •

    A guide to improve the quality of care for older people, particularly for those with complex health care needs.

  • •

    The crucial components of person-centered care based on Ricœur's philosophy and ethics.

Abstract

The purpose

of this study was to explore the content and essential components of implemented person-centered care in the out-of-hospital context for older people (65+).

Method

A systematic review was conducted, searching for published research in electronic databases: PubMed, CINAHL, Scopus, PsycInfo, Web of Science and Embase between 2017 and 2019. Original studies with both qualitative and quantitative methods were included and assessed according to the quality assessment tools EPHPP and CASP. The review was limited to studies published in English, Swedish, Danish, Norwegian and Spanish.

Results

In total, 63 original articles were included from 1772 hits. The results of the final synthesis revealed the following four interrelated themes, which are crucial for implementing person-centered care: (1) Knowing and confirming the patient as a whole person; (2) Co-creating a tailored personal health plan; (3) Inter-professional teamwork and collaboration with and for the older person and his/her relatives; and (4) Building a person-centered foundation.

Conclusion

Approaching an interpersonal and inter-professional teamwork and consultation with focus on preventive and health promoting actions is a crucial prerequisite to co-create optimal health care practice with and for older people and their relatives in their unique context.

Keywords

Person-centered care
person-centred care
Patient-centered care
Client-centered care
Older person
Older people
Community care
Long term care

Introduction

Ageing population

As a result of the ageing population and its consequences for aged care systems, the provision of cost-effective, high-quality care of older people has been established as one of the major challenges.1 To cope with this demographic change, elderly care continues to be a key priority for government and institutions.2 Person-centered care (PCC) can be an approach to meeting these aims but there is no agreed-upon consensus for delivering such care.3

In the present paper, the concept ‘PCC’ is used as an umbrella term to cover all of the different terms used to convey the same meaning, such as ‘person-centered practice’, ‘client-centered care’, ‘resident-focused care’, etc.

Person-centered care

PCC is a concept that involves meeting the multidimensional needs and preferences of older people dependent on care, by acknowledging the carers as well as the family — taking into account each individual's needs, goals, and abilities.4, 5, 6, 7

PCC focuses on the whole person and involves shared decision-making as well as better communication between health care professionals and patients.8,9 PCC reflects principles of philosophy and ethics, based on mutuality and respect.4 PCC is increasingly emphasized in aged care policies and national guidelines to promote health in old age across Scandinavia, Europe, the US, Australia and beyond.1

Although PCC has a long established tradition in nursing, the awareness of this approach has increased over the past few years, with the aim being to improve patient-related outcomes. Even though there is an overall consensus about the relevance of a person-centered perspective, translation of the PCC framework into practice is needed.5,10, 11, 12, 13, 14 This is particularly true in aged care facilities, where the coexistence of disability, cognitive decline, and chronic conditions, often framed as frailty, challenge older people's everyday life and the provision of care. There seems to be a relationship between person-centeredness, the residents’ ability to perform activities of daily living, and residents’ quality of life.15

Person-centered care – multidimensional and the area for no consensus

Across health systems and settings, PCC still lacks an agreed-upon definition. As a concept, PCC is linked to, e.g., “patient-centered care” in the USA,16 “understanding the patient as a unique human being” in the UK,17,18 and “partnership with the person” in Sweden.4 Published studies use a range of terms, for example, “personally tailored activities” in care of people with dementia;19 “people-centered care on a group level” by WHO;20 “Patient-centered medicine”,18 which is more commonly associated with the acute and hospital setting;21 “patient (and family)–centered care”; “relationship-centered care”; and “personalized care planning”.22 Client-centered care is more prominent in the North American residential and nursing home setting,16,17,23 and there is inconsistent use of PCC.7,24,25 Person-directed care is considered in long-term care policies and guidelines in a number of countries in Europe, North America, and the Pacific Rim.1,26 There is evidence that involving patients in decision-making about their own care leads to improved quality of health care and improved health outcomes.27, 28, 29 In addition, regarding the use of different interventions in different combinations (e.g., patient-clinician communication, shared decision-making, or self-management support), another limitation and hurdle in PCC interventions is the inability to combine the results of varied interventions, surveys and outcome measures across studies.22,30

Many studies and reports discuss the effectiveness of PCC; however, in the absence of consensus on crucial components of PCC, the authors only express the relative success of the different interventions and measures that have been chosen to represent PCC. Although the involvement of patients as partners in PCC has been identified as a common component, the authors in a meta-review noted difficulties in establishing clear results.31

Another comprehensive synthesis of evidence —from 72 review papers with 20 meta-analyses regarding service models that optimize quality of life in older people— identified two overarching classifications of service models, although each had different target outcomes: Integrated Geriatric Care, emphasizing physical function, and Integrated Palliative Care, focusing mainly on symptoms and concerns. Areas of synergy across the overarching classifications included PCC, education, and a multi-professional workforce.32 By contrast, a synthesis of reviews found similarities between the concepts of person- and patient-centeredness.33 The analysis revealed differences in the goals of these two concepts — namely, a meaningful life for PCC and a functional life in the case of patient-centered care.

However, in order to gain a deeper understanding of person-centeredness, we chose to refer to the work of the philosopher Paul Ricœur, who describes a person beyond the one-sidedness of “either or”, and rather as a complex, intertwined and united “ipse” (who) and “idem” (what).34 Ricœur is one of the philosophers who has —through dialogical thinking— tried to build a bridge between the two worlds of science (culture and nature) and thereby redefine science. Therefore, we have selected Ricœur's ethics namely “aiming at the ‘good life’ with and for others, in just institutions” as a theoretical frame of reference in the current review.35

Person-centered care in the hospital setting

PCC has been implemented and explored with regard to the integration of communication and shared decision-making in care for people with cancer;36 in the context of perioperative nursing;37 and self-management support in long-term conditions across settings;38 as well as PCC as a concept of time,39 reconciling conceptualizations of the body,40 and space.41 Researchers affiliated to Centre for Person-Centred Care University of Gothenburg (GPCC) have evaluated PCC in patients with different diagnoses and conditions.42 For example, patients hospitalized with chronic heart failure, who were treated in line with PCC showed a shorter duration of hospital stay,29 a better discharge process43 and a reduction in patients’ uncertainty about their disease and its treatment.44 A reduction in health care costs and maintained functional performance was also found,45 and after an event of acute coronary syndrome,38,46 significantly higher self-efficacy was found in patients with an education below university level when PCC was followed, which indicates that person-centeredness does not only support equal access to care, but also actively contributes to reducing social inequality in health care.38,47

Person-centered care in the out-of-hospital setting

The importance of viewing health from the standpoint of functional, cognitive and social disability dimensions is critical in out-of-hospital settings.48 PCC has been implemented in out-of-hospital settings, such as —for example— maintaining personhood in care for people with dementia,21,49 as a means of overcoming institutionalization, dependency, and depression.15,26,50, 51, 52, 53, 54, 55, 56 The complexity of the interventions and range of outcomes examined in the studies makes it difficult to draw accurate conclusions about the impact of the PCC interventions adopted and implemented in aged-care facilities.

A systematic review57 evaluating the evidence of PCC interventions with aged-care residents and nursing staff found that studies incorporated a range of different outcome measures to evaluate the impact of PCC interventions on these two groups. Only two studies in a Cochrane review described their PCC interventions to be multidisciplinary and goal-directed.58 Structural conditions and the balance between organizational policies and client autonomy has been shown to be challenging in the out-of-hospital setting,59 but staff education has been shown to increase both residents’ well-being and staff satisfaction.60 These studies represent different PCC models to guide person-centered practice in long-term care settings, while McCormack's theory on person-centered practice is one of the most commonly used as a framework in several studies focusing on PCC in elderly care. The cornerstones of this theory are: “(1) being in relation; (2) being in a social world; (3) being in place; and 4) being with self “ (11). Being in relation and in a social world emphasizes the importance of relationships and being interconnected with one's social world. Being in place recognizes the impact of the surroundings and the values one holds about one's life and how it makes sense, which has also been emphasized by Edvardsson and co-workers in their research.61 A systematic literature review based on 132 studies on older adults with chronic conditions identified 15 descriptions of PCC — addressing 17 central principles or values. Although multiple definitions and elements of PCC abound —with many commonalities and some overlap— the field would benefit from a consensus on essential components to clarify how to operationalize PCC in health care and services for older people.6 There is a great need for PCC approaches for older people in the out-of-hospital setting.62 Hence, agreement on the crucial components of PCC is essential for researchers and clinicians to guide PCC development and implementation.

Objectives

This paper aims to explore the content and essential components of person-centered care implemented in the out-of-hospital setting for older people (65+). The following research questions guided the search:

  • 1.

    What is the content/mode of PCC in care for older people implemented in the out-of-hospital setting?

  • 2.

    What components are crucial in person-centered care in the out-of-hospital setting?

Material and method

This systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines.63

Search strategy

A comprehensive literature search was conducted using six electronic databases related to health care: PubMed, CINAHL, Scopus, PsycInfo, Web of Science and Embase. The searches —for research articles published from 1997 to 2019— were carried out between July 2017 and December 2019. The search databases and search terms used to identify relevant articles for this review are shown in Table 1. The same search terms, strategy and limiters used with PubMed were adopted for other databases. The searches were carried out on several occasions, the first of which was in July 2017. Two additional searches were conducted in October and December 2019 to update with newly published articles, including the articles that described person-centered care as person-centered approach or practice. See the search terms for the initial search in Table 1.

Table 1. Databases and search terms used for the initial search.

DatabaseSearch terms
Pubmed (“Patient-Centered Care” or “patient-centered” OR “patient-centred” OR “person-centered” OR “person-centered” OR “resident-centered” OR “resident-centred” OR “client-centred” OR “client-centered” OR “patient-focused” or “individualized” OR “individualised” AND care) [Mesh])
And (“home care” or “home care services” or “home help” or “elderly care center” or “home help services” or “home care nursing” or “home health care” or “community setting care” or “home based care” or “care home residents” or “non- hospitalized care” or “non- hospitalized care” or “residential aged care” or “home and community based service” or “household care” or “household services” or “household help” or “hospital in the home” or “home health and services” or “home care agencies” or “homemaker services” or “housebound care” or “domiciliary care” or “in-home care” or “home social services” or “community care” or “community based services” or “community health nursing” or “homebound patient” or “health services for aged” or “eldercare services” or “municipal elder care” or “continuing care setting” or “aged care facilities” or “aged care residents” or “aged care services” or “housing for the elderly” or “nursing care facilities” or “long-term care facilities” or “old age home” or “nursing home” or “residential care facilities”) [Mesh])
And (“older” or “older adults” or “elderly” or “elder” or “elders” or “older person” or “older people” or “oldest old” or “elderly people” or “geriatric patient” or “older patient” or “elderly care recipient” or “community dwelling patient”) AND Humans [Mesh])
Limiters Intervention, 1997–2017, Article [Publication type], article title and abstract
Cinahl Same search terms and limiters used on Pubmed database
Scopus Same search terms and limiters used on Pubmed database
PsycInfo Same search terms and limiters used on Pubmed database
Web of Science Same search terms and limiters used on Pubmed database
Embase Same search terms and limiters used on Pubmed database

Table 2. An overview of the content and components of person-centered care (PCC) implementation.

Study designContent/Mode of PCC implementationSub-themes/Identified components of implemented PCCThemes/Crucial components of PCC
Quantitative Advance Care Planning including the patient's storytelling approach, and approaches targeting residents with dementia including personal care
Giving voice to the resident through storytelling and personal goal setting
Engaging residents by Client/Community-centered approach. Interactive step-wise action research intervention		 Knowing the person's needs, resources and preferences Advance care plan and goal setting through narratives, shared responsibility and decision-making
Goal setting through storytelling, shared power and responsibility
  Home-based programs addressing specific or multiple needs of residents with chronic health conditions
A theory driven person-centered training intervention		 Communication based on relationship, trust and respect Mutual communication and trusting relationship between staff, the older person and his/her relatives
Qualitative Tailor-made health/care plan
Relation-based practice, role-play scenarios, drama-based education, attentive engagement and trusting relationship		 Conducting a tailored personal health plan through relation-based approaches Conducting a tailored personal health plan through knowing and confirming the patient as a whole person
Knowing the older person as a whole
  Interdisciplinary team meeting and co-creating with the older people and their relatives
Inter-professional teamwork and collaboration		 Confirming the older person as part of the team Inter-professional teamwork and consultation with and for the older person and his/her relatives
Inter-professional consultation and co-creation
  Supporting self-care, assessing decision-making capacity, welcoming, safe, homely and a neat and clean environment, Supporting the older people and their relatives’ engagement in care
An ongoing critical reflective process
Flexible leadership, professional friendship
Being attentive to verbal and non-verbal cues, active listening, recognition, person-centered care plan documentation		 Enhance the older person's capabilities, supporting preventive care and facilitating self-care Building a flexible proactive foundation to strengthen the older person's capabilities and relatives’ engagement in the person-centered co-creation process
Managing of competing values in the team by engagement, professional friendship and keeping distance, a flexible organization and situational leadership
Appropriate person-centered communication skill and documentation

Eligibility/Inclusion and Exclusion Criteria

Papers were included if they were intervention and/or implementation studies of PCC regarding older people (65+) in the out-of-hospital setting. The studies were published in English, Swedish, Danish, Norwegian and Spanish between 1997 and 2019. Only original, peer-reviewed studies were included. Study protocols, instrument evaluation studies and review articles were all excluded. See Fig. 1 for a flow chart outlining the procedure for the selection of studies.

Fig. 1
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Fig. 1. Flow chart outlining the identification, screening, eligibility assessment and inclusion of studies.

Screening and data extraction

All database searches were conducted by the first author (ZE) assisted by an experienced university librarian. The hits were imported to Rayyan (a screening program) during the reviewing process. In Rayyan, an independent, blind screening of the abstracts was performed by the researchers (ZE, HP, POC). During the screening process, any difference of opinion was discussed by the researchers. A senior researcher (HW) screened any remaining articles considered borderline for inclusion. A total of 63 articles were included for quality assessment and analysis. The process of extracting data was conducted by 3 researchers (ZE, HP, POC) working independently. The key information in these studies was extracted and tabulated in Table A1 (see Appendix).

Quality assessment

The Effective Public Health Practice Project Quality Assessment (EPHPP)64 was selected to assess the methodological quality of the quantitative studies. This tool includes components of study design and methods including selection and allocation bias, study design, confounding, blinding, data collection methods, and withdrawals. An overall quality rating was assigned to each article: if no weak ratings were given, the quality of the article was estimated to be “strong,” one weak rating categorized the article as “moderate”. The quality in qualitative studies was assessed using the Critical Appraisal Skills Programme (CASP) Qualitative checklist,65 which consists of 10 questions assessing different aspects of quality in qualitative studies. No article was excluded in this step. All of the included articles were considered to be of good quality —from moderate to high quality, besides two articles, that were assessed as weak.

Analysis

The quantitative data was analyzed by one of the authors (POC) using a deductive thematic analysis (Clark & Brown, 2017). The qualitative data was analyzed by the first author (ZE) through an inductive thematic content analysis,66 according to the following steps. In the first step, all articles were read several times to build an overall understanding of the content. The meaning units were then identified, condensed and coded. Codes with similar content were put together to create a category. The last step was to interpret the common patterns of the categories in order to find the crucial components of person-centered care for older people in an out-of-hospital setting; the resulting crucial components are presented in five interrelated themes. Other authors (HW, HP, IE) independently reviewed the validity of the findings. The last step involved continual discussion between all authors to reach a consensus and synthesize the crucial components of PCC from the findings.

Results

A total of 63 original articles were included in the final analysis — 17 articles with qualitative methods, 2 articles with mixed-methods and the remaining 44 articles were studies using a quantitative method (sample size: 14−1042). The articles included varied widely in terms of the countries and settings. A total of 35 studies were from diverse countries around Europe, 20 studies were from USA and Canada, 4 studies were from New Zealand and Australia, and there were 4 studies from China, Japan, Taiwan and Korea. In total, 32 studies were conducted in nursing homes, and 31 studies took place in the ordinary home with either primary care or home care. For further details on the articles included, see Table A1 in the Appendix. An overview of the content, identified components and crucial components of implemented PCC is described in Table 2.

Key findings from quantitative data

The components of applied PCC for older people in the out-of-hospital context from a quantitative perspective is interpreted and presented in two themes and three sub-themes. Key findings from these studies showed that PCC was implemented through knowing, engaging and empowering the older people, their family, and staff. Furthermore partnership operationalized through mutual communication, trusting relationships and shared responsibility.

Advance care plan and goal setting through narratives, shared responsibility and decision-making

Knowing the person's needs, resources and preferences

Knowing the older person and his/her needs, resources and preferences was emphasized as an essential component of PCC. For instance, the incorporation of pre-specified and discretionary in-person home visits was essential, as this afforded the opportunity to visually identify a wide range of home and personal safety needs (e.g., fall risk, clarifying prescribed medications, risk of wandering), as well as the physical condition of participants and study partners.67, 68, 69 The personal care moment, interactive and step-wise increased the staff self-reported person centeredness and reduced their ‘stress of conscience’ by enabling them to provide the care and activities they wanted to provide.70, 71, 72, 73 Furthermore older people rated a person-centered environment as being in a hospitable, welcoming, safe, homely, neat and clean environment.74 The multicomponent supportive care programs to care for people with dementia at home improved the ability to age in place; the dementia care coordination model with the Maximizing Independence (MIND) at Home reported significant reductions in unmet care needs related to safety.67 These approaches represent an alternative to better prepare and interact with older people with dementia, addressing emotional and relational skills with PCC.72,73,75 The approaches emphasized strategies such as reminiscence, closeness, and connectedness with older people for matching “at the moment capabilities” that helped the older people to respond positively to contact offered and improve wellness.67,76, 77, 78, 79, 80

Goal setting through storytelling, shared power and responsibility

Health care providers and organizations need to promote PCC by engaging people in partnership, i.e., shared decision-making and participation.81,82 This was verified in a Swedish study with non-Swedish older people that focused on determining how they perceived leadership in the nursing home, while also focusing on the particular skills that staff chose as those required to lead PCC effectively and how this approach had or had not contributed to the level of the teamwork in the household.83

Shared power and responsibility were also observed when monitoring the quality of care involving both the older people and their families.81 Engaging older people in an activity-oriented/goal program showed that the residents met their personal goals related to, for example, self-care.84, 85, 86, 87 It was confirmed that the process of personal goal setting was a strategy in and of itself for increasing motivation toward achievement of the goals.84,88,89 The PCC further aimed to create encounters where participants support one another to make decisions in daily life to improve their overall health.83 Engaging older people with these client-centered interventions that were tailored to meet the specific needs of the person aimed to increase basic activities of daily living, improve health-related quality of life, nutrition and mobility; decrease bodily pain; alleviate constipation; and prevent functional decline, depressed mood, and admissions to hospital for acute care.69,84,87,90, 91, 92 A face-to-face motivational approach, along with the provision of information and advice by geriatrician and nurses to older people with chronic diseases who were being treated by polypharmacy, clarified prescribed medications and seemed to improve the level of medication taking.93 The interventions meeting goals for preference fulfillment improved the quality of care and quality of life.94 In addition, the preference for everyday living intervention showed “having regular contact with family” as an important priority. Having privacy, choice about what to eat, when to bathe, and activity options were also important preferences for most of residents.94 However, other interventions such as the “Multi-method program”, did not show the effectiveness of each single intervention.92 This is a good example of “one-size does not fit all”.95, 96, 97 Advance Care Planning —including the patient ‘storytelling’ approach that brings the focus back onto the person— encouraged the older people to communicate their preferences and mitigated their existential distress, in both older people with chronic conditions and, particularly, in those at the end of life.82,94,98,99 The “On the Move” program focused on the timing and coordination of movements critical for preventing functional decline and disability without any increased risk to the older people. In this program, older people and stakeholders were involved in the design and execution of the study, and it was found that it is critical to build lasting relationships and that it was therefore important “to take the time to listen to and socialize with the resident.”82,89

Mutual communication and trusting relationship between staff, the older person and his/her relatives

Communication based on relationship, trust and respect

Mutual communication characterized by trust and respect was found to be a cornerstone in all the interventions, and they were also dependent on the older person's cognitive function and the staff's skills in communicating with those who were cognitively impaired.77,99 Some of the interventions focusing on reaching specific goals or needs of the older people did not appear to engage the staff in iterative communication where the patient could tell the story or improve his/her self-determination. These interventions did not give older people a voice to prioritize their goals.96,100 Home-based programs addressed specific or multiple and varied needs of older people with chronic health conditions and have customized the specific services to the older people, leading to a positive effect on diverse outcomes such as an improvement in daily activities of life, nutritional status, incontinence, physical condition, or mood.82,86,87,92,95, 96, 97,101, 102, 103, 104, 105, 106, 107 The exercise-based programs, i.e., task-specific exercises —focusing on, e.g., muscular strength, coordination and cognitive function— had a greater impact on older people with mild cognitive impairment than on those with moderate to severe cognitive impairment.86,88 Exercise improved function in frail older people,97 resulting in reduced depressive symptoms in older people with depression compared with usual care.108 Trials of activity programs in the community have also yielded increases in activity levels but without improvement or changes in quality of life, self-management outcomes, or depression.86,92,109,110 Person-centered training promoted interdependence, trust and reciprocity as a basis for older people with low cognitive function —and their families— to engage in a partnership with staff.77,89,104,111 The individualized interaction between the older person and the staff helped older people with dementia to cope with their fears, agitation, aggressive behavior and isolation.68,71,72,76,78,79,112 Additionally, individualized interactions involving the family and care assistant significantly improved positive interactive behavior of care-dependent older people with dementia.73,76,78,81

Key findings from qualitative data

The components of applied PCC for older people in the out-of-hospital context from a qualitative perspective is interpreted and presented in three interrelated themes and seven sub-themes. The key findings from these studies showed the importance of conducting a tailored personal health plan, knowing, confirming and empowering the older person in the team — in order to enhance the older person's capabilities, support preventive care and facilitate self-care through an inter-professional teamwork based on friendship and distance with and for older people.

Conducting a tailored personal health plan through knowing and confirming the patient as a whole person

Conducting a tailored personal health plan through relation-based approaches

Creating a tailored personal health plan was an essential component in implementing PCC.111 Trusting relational practice and engagement to know the person as a whole113 through respectful dialogue with the person and his/her relatives were among the other prerequisites for conducting the tailored care plan.114 The dialogue with the older people was practiced by carefully listening to the older people's description and experiences of the illness and life situation, in order to get a better understanding of their needs, problems and wishes.111 A nuanced care plan enabled the older people to have more control over their own life situation,114 supported them in their daily routines and reinforced their capacities to self-manage.111 Among the crucial prerequisites were the older people's narrative of their own experience,115 attention to their bodily and existential needs,116 involvement of the older person and their relatives in the planning of care,117 and the sharing of information and decision-making via interdisciplinary team meetings.111,114

Knowing the older person as a whole

Creating a well-functioning relationship between the older people, their relatives and the staff was among the crucial components in developing PCC.118 The professionals appreciated the relation-based practice, which raised their awareness of diversity in its broadest sense.119 For example, role-play scenarios in drama-based education increased the practitioners’ awareness, insight, patience and optimism with regard to supporting the older people with dementia in their strive towards an independent life.114 The professionals realized that the older people are not a homogenous group and therefore “one size does not fit all”.119 Appreciating this made it possible to know every single person's reality, which was described as a more nuanced effort beyond culture, gender, race, and religion. Research indicates that embedding awareness of diversity in practice can be achieved through active listening and respectful communication.119 Applying relation-based practice increased the professional's confidence and stimulated a behavioral change toward being less prejudicial of older people based on their associated stereotypes.119 There was another point related to knowing the patient as a whole — that is, the intention to avoid reducing the patient to his/her disease/diagnosis. Furthermore, emphasis was placed on the significance of understanding the illness from the patient's perspective, giving spaces for the patient's voice and comprehending how the disease affects the patient's entire life situation.99 The professionals underlined the importance of “all little things” that they expressed or did to confirm the older patient as a person.119 For example, integrating the older person's life history into the conversations was among the efforts made to recognize the patient as an unique person.120 However, knowing the older people with dementia as a person was challenging and depended on the professional's authentic engagement in establishing professional relational practice and discovering the person's life history, priorities and wishes.121 The importance of shifting from a task-oriented approach to person-centered relational practice with the older person was underscored by professionals.113

Inter-professional teamwork and consultation with and for the older person and his/her relatives

Confirming the older person as part of the team

Partnership as a co-creation process was crucial in implementing person-centered teamwork, which was perceived as both a limiting and improving factor for change in individual behavior and organizational procedures and policies.119 User-involvement was an intention that was appreciated by the staff, and is one that requires a flexible approach, including spending sufficient time and having patience during the initial stage of an intervention.122 This long-term process required a modification in the professional's attitudes and practice — a transition from “doing for” to “doing with”122 and from “providing” to “co-creation”.119 A well-functioning interdisciplinary relationship and cooperation between the older people, their relatives and the staff118 were among the crucial prerequisites to create a tailored care plan and to follow up on planned goals.111,119 This minimized overlapping tasks but was perceived as time-consuming.111 Continually adapting co-creation processes could increase users’ awareness of their own potential for improved activities of daily life function through professional user meetings and the inclusion of dialogue with open-ended questions, active listening, and appreciation of users’ views.122

Inter-professional consultation and co-creation

Older people's involvement in decision-making regarding their own care was another essential component in PCC, which required attentive engagement and a trusting relationship.121 Frail older people appreciated their independence, and preferred taking their own decisions and finding solutions by themselves.111 Mechanisms that support older people's involvement in decision-making include actions aimed at (i) increasing the older people's autonomy, control and privacy123; (ii) ensuring that they are taken seriously by health care professionals111; and (iii) providing appropriate information and patient education.114,116 Establishing the basis for decision-making was challenging for health care professionals caring for people with dementia.121 Having an inter-professional teamwork and consultation with the older people, their support networks and key relationship was essential to accurately interpret the person's needs and wishes and thereby involve the person in a meaningful decision-making process.121 Furthermore, relation-based care of people with dementia was practiced through forging a friendship, sharing experience, developing trust and feeling appreciated, as well as taking time and making time.124 Relational care through the shared experience of living with dementia connected and developed bonds with others and helped people to feel a sense of safety and equality, which led to development of trust and appreciation among community health care staff, people living with dementia, and family care partners.124 In addition, factors such as having greater flexibility, staff education and developing skills to engage older people in decision-making were highlighted.125 Studies emphasized the impact of the involvement of older people and their relatives in the creation of an education package to meet needs and take diversity into account,126 building tailored care plans and sharing both information and decision-making by an interdisciplinary team.111,116

Building a flexible proactive foundation to strengthen the older persons’ capabilities and relatives’ engagement in the person-centered co-creation process

Enhancing the older person's capabilities, supporting preventive care and facilitating self-care

Another essential component of PCC was to support the older people in their self-care and enable them to remain independent.111 Frail older people desired to remain independent; they preferred to take their own decisions and to find solutions by themselves in order to have more control over their daily lives.111,127 Accessibility was another important aspect in self-care, which was described in the following terms: older people's access to transparent information about available services; the impact of such services on their health; how to navigate within the health care system; cultural and social factors that affect older people's acceptability; as well as autonomy and capacity to choose appropriate health care services. Furthermore, whether health care services are available and can be reached physically in a timely manner —together with the economic capacity of frail older people to spend their time and resources using health and social care services— were described as factors affecting accessibility.127

From the patient's point of view, a person-centered approach was characterized by: being taken seriously as a ‘worthy’ person by the health care professional with resources and capacities,111,122 being part of the team,119 being involved in decision-making,121 being supported in self-care and maintaining independent lives.111 PCC was described as a shifting focus from reactive care to proactive and preventive care,113 supporting older people's connection to everyday life, which increased their feeling of well-being and enhanced their capabilities to be ‘in charge of’ their self-care.111,116

Managing of competing values in the team by engagement, professional friendship and keeping distance, a flexible organization and situational leadership

Competing priorities in clinical and organizational practice were perceived as a hindrance to the goal of achieving PCC; for instance, the conflict between safety and autonomy117 — or, for example, being effective and working quickly according to old traditional practices competing with the time required to facilitate user's involvement.122 Rules were discussed as an area of focus to avoid rigidity and improve flexibility in care plans. In addition, limited resources —particularly staffing— were commonly mentioned as a reason for lack of follow-through on the older person's goals.117 Perceived conflicts between PCC and medical care were the most frequently reported source of arguments among physicians and nurse practitioners.125 Supporting the resident's and their family's involvement in care planning through regularly scheduled care conferences, and informal engagement between residents or family members and staff in the form of an open door policy were emphasized. Furthermore, the importance of broad commitment across staff roles to the overarching principle of PCC was highlighted.117 In post-acute care situations, the importance of health/medical goals over the older people's preferences needs to be explicitly documented in care planning in order to reduce doubt and perceived conflicts.125

Having a person-centered leadership, a flexible organization and an ongoing critical reflective process to facilitate person-centeredness among staff were among the most important prerequisites for implementing PCC.128 Changing the focus from “doing” to “being” person-centered was stressed, as was building a functioning and integrated team through collaboration, open communication, appreciation and trust.128 A person-centered foundation was characterized by a combination of developing culture and transformational leadership. In addition, the supportive organizational systems put in place to achieve these changes and the practitioners were open to learn from each other and there was a high level of interaction between older people and organizational management to enable practitioners to identify and resolve issues by themselves.115

Appropriate person-centered communication skill and documentation

The importance of appropriate person-centered communication was underscored.120 Person-centered communication was characterized by four indicators: first, to recognize older people as each being a unique person by incorporating their life histories into conversation; second, to negotiate about older people's preferences, desires and needs by consulting them and their relatives; third, to facilitate older people's involvement in the conversation or action; and fourth, validation — which involves expressing and understanding the feelings of the older people with dementia.120 The importance of communication and collaborative skills in motivating and stimulating older people to improve their self-management abilities and independence —such as listening and asking the right questions, understanding implicit messages, and providing feedback— was also emphasized.113 Additionally, allowing sufficient time, speaking clearly and directly, explaining the different options available, pausing to allow the person to process information and repeating information were among the professionals’ communication skills and strategies designed to enable a person with dementia to be meaningfully involved in decision-making.121 Furthermore, “listening to the other person with the heart” by being alert and giving the other person full attention128 and also “being attentive to non-verbal cues” were among other important points regarding person-centered communication.121 Providing PCC was experienced as a learning process that delivered opportunities for personal and professional growth; for instance, attentive listening was undervalued by the staff at the start of the intervention and was described as actually doing nothing, but staff members later realized that attentive listening was indeed “doing something”.113

Building a trusting relationship by taking sufficient time, being attentive, and by keeping their promises113 and confirming the individual as a person by calling him/her by name reinforced the sense of self.120 Furthermore, creating a sociable atmosphere enhanced the sense of connectedness and partnership.113 There were contexts in which missed opportunities for person-centered communication occurred; for instance: when the older person said something but the staff member ignored it and/or moved onto the next topic; when staff began and ended their interactions; when staff members told older people what to do without providing options or without inviting their help in completing the task; when staff did not ask for permission prior to performing an action; when staff members failed to acknowledge the older person's feelings, uncertainty, distress, discomfort, lack of confidence or self-deprecating emotions.120

Many nursing records were incomplete and information regarding psychosocial aspects of care was often lacking, despite the fact that value was placed on documentation of the person's involvement in the health care processes, shared decision-making and care plan.129 The nursing documentation was not completed in partnership with the older people. Nevertheless, documentation focusing on the older person's beliefs and values was perceived as a factor promoting more meaningful relationships between nurses and older people.129 Formulating and documenting a tailored personal care plan through interdisciplinary cooperation minimized the overlapping of tasks. Digitalization may avoid such task overlap, facilitate the exchange of data with other professionals, reduce time-consuming tasks, and increase interdisciplinary cooperation.111

Synthesis

A PCC perspective requires ethics as a basis for analysis and interpretation. Such an ethical view can briefly be formulated as follows: “Aiming at the good life with and for others, in just institutions”.34 In health care, a significant part of the complex biology of human beings can be readily explained. However, in the case of old, ill and dependent people, tracing biological weakness in order to cure the disease —or at least alleviate inconvenience— through relevant treatment and care is not enough. There is also a clear need for knowledge about health and human existential dimensions as well as good and ethical care. Ricœur is one of the philosophers who —through dialogical thinking— has tried to build a bridge between the two worlds of science (culture and nature) and helped to redefine science. Since PCC is based on an epistemology that includes these dimensions of the human being, we have used Ricœur's ethics as a theoretical frame of reference in this paper in an attempt to describe important components published in scientific journals on PCC in the care of older people.35

Accordingly, the components of PCC from both quantitative and qualitative findings have been interpreted and synthesized according to Ricœur's ethics.

Knowing and confirming the patient as a whole person and co-creating a tailored personal health plan

PCC is not a ‘one-size-fits-all’ model, but it is about achieving ‘practical wisdom’ based on an apparent action ethic. Furthermore, PCC is a relation-based approach, which is about being attentive to diversity, knowing and confirming the patient as a whole person, and it thus aims to achieve a nuanced, tailored personal health plan that reinforces the older person's internal and external capabilities in practice.

Inter-professional teamwork and collaboration with and for the older person and significant others

A person-centered inter-professional teamwork is characterized by efforts and processes that aim to include the patient as an equal person in the team and establish the basis for collaboration. Conducting a person-centered health plan involves “aiming at the good life with and for others” through a co-creation process between the professionals, the older person and often his/her relatives/significant others. These collaborative processes involve a professional friendship, mutual communication and ongoing shifting between closeness and distance. Neither the naturalistic objective- nor the humanistic subjective perspective alone can achieve person-centered practice. Hence, ongoing inter-professional team collaboration and co-creation between the inside and outside knowledge “with and for” the older person is essential for implementing PCC.

Building a person-centered foundation

Creating a person-centered foundation in all health care levels and processes is another crucial component, which —in practice— is a challenging ambition. Implementing PCC requires an appropriate “just institutions” foundation, where the opportunities of everyone (all staff, older people and their relatives) to take responsibility are reinforced, with the team members working in mutual respectful partnership, perceiving each other as experts and encouraging and improving each other's abilities. Confirming the older people as members of the team, knowing and supporting them with self-care, and endorsing their resources and capabilities are among the factors that create a proper foundation to implement PCC for older people. Other such factors include reinforcing their access to the health care system in an appropriate manner, time and place, and having a flexible organization based on trusting relationships and authentic engagement.

Discussion

Essential components for implementing PCC, which were confirmed in both the quantitative and the qualitative studies, included knowing the older patient as a person, building a relationship of trust, confirming and utilizing the person's resources, working in an inter-professional team with and for the older person, empowering the person and co-creating a tailored personal health plan with a focus on health promotion and preventive efforts and supporting the older person's opportunities for self-care.

Enhancing the person's capabilities and co-creation of an appropriate health plan with and for the older person were cornerstones for implementing PCC. However, some of the interventions focused on reaching specific goals or needs of the older people and did not involve mutual communication between the older people and the staff.96,100 Furthermore, the majority of these interventions focused on varied needs and impairments of the older people with chronic health conditions and the customization of specific services to older people.82,87,92,95,96,101 PCC should not only focus on the person's needs and impairment, but also on his/her resources and abilities and, furthermore, the health plan should be created in collaboration with the older person — as well as with his/her relatives.98

Even though the target group in the present study were older people in general (65+), most of the included studies concerned people above 80 years. In 15 of the included studies, the participants were diagnosed with dementia in various stages from mild to moderate and severe, and in 32 studies the participants were living in nursing homes. It is well known that high age is a predictor for disability, frailty130,131 and dementia132,133 among the oldest old. However, it is likely that implementing the crucial components of PCC revealed from this review (see Table A1), will be valuable for all persons above 65 years including those with disability and cognitive impairment. For example using the life story approach enabled care staff to see and know the person behind the diagnosis and thereby to enhance PCC to the older persons and their families. It has also been shown to be more effective in preventing and managing behavioral and psychological symptoms of dementia.134,135 Furthermore, implementing PCC in dementia care improved staff awareness and reduced stress. The interventions described increased positive affective (e.g., pleasure and alertness) and positive verbal and nonverbal behavior when involving residents in activities that they were likely to enjoy.67,70,71,76, 77, 78, 79, 80,98

Abilities and capabilities are defined and redefined in different contexts, based on one's physical and non-physical resources, as well as problems and obstacles in relation to the environment.136 Frail older people face a constant challenge in creating harmony and balance in their everyday lives137 despite comorbidity, disability and dependence. In this redefining process, person-centered team collaboration enables consultation between different professionals, supporting the frail older person to redefine themselves and their abilities in relation to the environment's resources and obstacles. A person-centered health plan should be created with and for the older person in the team. PCC based on an established and sustainable philosophy of ethics, originally conceived by Paul Ricœur, is an appropriate solution. Aiming at a good life with and for older people requires collaboration and partnership, where everyone's expertise and knowledge is appreciated and recognized. In the same way, the older person's experience of illness and well-being must be recognized and valued in all health and care processes.

Raising awareness of the value of the engagement and the conflicts that will be present in the creation of a person-centered team is essential for creating a person-centered foundation for care. The person-centered health plan is the ‘practical wisdom’ that is co-created through team collaboration and partnership in a just foundation, where interpretation conflicts between inside and outside perspectives will encourage each other and drive the health care system from fragmented, reactive and task-oriented efforts towards a person-centered, proactive and coherent continuum of health care processes with and for older people.

Strengths and Limitations

The complexity of PCC and a lack of consensus regarding the definition of ‘person-centered’ leading to a wide variation in the implementation of PCC were among the factors that were challenging in choosing relevant search terms for this review. For instance, for person-centered care within some disciplines —for example, occupational therapy— the word ‘care’ is not used; the terms ‘person-centered practice’ or ‘person-centered approach’ are employed. However, the search for relevant studies for this review was performed on three occasions. In the first search, the terms used were as per Table 1; in the second, we used the same search terms but replaced ‘care’ with ‘practice’ and ‘approach’; and the third and final search was conducted to update the latest published studies. This approach may reduce the reproducibility of the searching process. However, the approach was unique in that it included a large range of definitions of person/patient/client-centered care/approaches and practice regarding older people in different communities, cultures and countries, which can also be considered a strength of this review.

Another strength of this review is that it includes studies that describe PCC from the point of view of older people, in addition to that of staff and stakeholders. Furthermore, the included studies have explored PCC from different perspectives — inter-personal and professional relationships, environmental considerations, the health care process and health care organization.

Another strength of this review is the application of a congruent ethic for approaching the review throughout all of the steps including choosing different search terms of PCC from diverse disciplines, including studies with qualitative and quantitative methods, and rigorous analysis of the data. Ricœur's ethic was also chosen to synthesize the results in order to confirm and stress the importance of dialectical movement between different views about science that describe PCC from both natural/objective and cultural/subjective perspectives.35 This review emphasizes that, in order to understand and implement PCC, an intertwined web of sciences and knowledge is clearly required

Conclusion

Approaching interpersonal and inter-professional teamwork and consultation with a focus on preventive and health promoting actions is a crucial prerequisite to co-create optimal health care practice with and for older people and their relatives in their unique context. Awareness of the ethical basis of PCC facilitates the provision of genuine and collaborative care that is flexible and can be adapted by all health care professionals together with the older person and significant others.

Acknowledgement

Funding: This work was supported by The Swedish Research Council (grant number 2017-01230) and the Centre for Person-Centred Care at the University of Gothenburg, Sweden (GPCC) (date for approval 2019-11-01).

Appendix B. Supplementary materials

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References

Nurses’ policy influence: A concept analysis Akram Arabi,1 Forough Rafii,2 Mohammad Ali Cheraghi,3 and Shahrzad Ghiyasvandian3 Author information Copyright and License information Disclaimer This article has been corrected. See Iran J Nurs Midwifery Res.

Nurses’ policy influence: A concept analysis

Akram Arabi,1 Forough Rafii,2 Mohammad Ali Cheraghi,3 and Shahrzad Ghiyasvandian3
Author information Copyright and License information Disclaimer
 
 
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Abstract

Background:

Nurses’ influence on health policy protects the quality of care by access to required recourses and opportunities. This is a new and important concept for nursing; however, research studies on policy influence of nurses in health care sector are lacking a basic conceptual understanding of what this concept represents. The aim of this paper is to clarify the concept of nurses’ policy influence and to propose the definition of this concept, considering the context of Iran.

Materials and Methods:

The eight stages of Walker and Avant approach was used to guide this concept analysis. Various databases and internet engines were searched to find all related information about the concept. Textbooks were also searched manually. English language literature reports published between 1990 and 2012 were reviewed.

Results:

Based on the analysis undertaken, nurses’ policy influence is nurses’ ability in influencing decisions and affairs related to health through political knowledge, effective communication, and collaboration with other members of the health team, which results in the improvement of nurses’ job environment and increases patient outcomes. This is a dynamic process situated on a spectrum and is accompanied with nurses’ knowledge, competency, power, and advocacy, and also their ability to change.

Conclusions:

Nurses have individual views on health care issues and influence health care policies in different ways. With a common understanding of nurses’ policy influence as a concept, nurses will recognize the importance of policy making in the health sector and their influence on this process and also on patients’ outcomes.

Keywords: Advocacy, concept analysis, health policy, influence, Iran, politics, power
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Introduction

Health systems are rapidly developing and changing. Nurses, as a part of this system, should move forward along with these changes.[1] For this purpose, nurses need to influence the formulation of health policies rather than just implementation of them. Then, they need to be active in the development of health policies to be better able to control their practice.[2] In this process, nurse leaders have a very important role. They need to acquire policy-making skills in order to address professional challenges.[3] Because of their values, professional ethics, advocacy skills, and experiences, nurse leaders have unique and valuable views toward health policies.[2] There has been increasing growth toward nurses’ presence, role, and influence in health policies during recent decades. Nurses are expected to identify the issues deliberately and work with other decision makers to advance health care policies. They should understand the levels of power, and know who controls the resources of health services in their organizations.[4] Therefore, we can go ahead and say that nurses have to be involved in policies which affect patients, families, themselves, and the whole health care system.[5]

Nurses’ influence in health polices protects patient safety, increases quality of care, and facilitates their access to the required resources and promotes quality health care.[4,6] Accordingly, the concept of policy influence in nursing is a new and important concept, but there is lack of conceptual clarity with regard to what this concept really represents. Dowswell et al. (2002) in their study showed that most primary care groups in primary care centers consulted with local nurses about the key fields in care services and they believed that consultation with nurses had been effective.[2] On the other hand, results of a survey about the health managers’ and authorities’ perceptions of the effect of various health professions on revision of health affairs reveal that nurses are in the sixth (the last) grade with a dominant point interval in comparison to other health professionals.[7]

There is an ambiguous point here whether or not what Dowswell et al. (2002) reported as consultation with nurses in local fields really represents nurses’ policy influence. It seems that the extent of applying this concept is wide and not clearly addressed in literatures. On the other hand, we should state that health systems’ policies settle within three levels: Micro, macro, and meso. In the micro level, policies are just for especial parts, fields, or groups, and have not been made essentially by the government, whereas in the macro level, policies are for the whole country and have been made essentially by the government.[8] The meso level policies settle between micro and macro levels and have usually been made by official organizations.[9] Now can we call what happens in all these three levels as policy influence? So, clarifying and defining this concept in order to develop it, especially in different levels of nursing management is essential. By clarifying this concept, we can reach a common language and help to increase the credibility of future studies.

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Materials and Methods

This study was carried out using concept analysis approach, by which an abstract concept is defined and clarified and differentiated from similar concepts.[10] We used the eight-stage Walker and Avant approach, which is a clear and systematic method of concept analysis and also the most common one. Table 1 shows Walker and Avants's eight stages method for concept analysis. This method is especially useful for novice concept analysts,[11] and had been successfully applied in previous analysis of the concepts.

Table 1

Walker and Avants’ eight stages method for concept analysis

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One probable concern about using Walker and Avant approach is insufficient conceptual clarification[12] due to the context-free nature of this approach.[11] Concepts may have different meanings in different theoretical contexts. While conceptual clarification should be achieved through referring to different existing theoretical contexts, some analysts have commitment that the concepts’ own theoretical context should be highlighted. Thus, they suggest that if there is no theory or theoretical framework for the concept in literatures, this should be stated explicitly by the analysts.[12] In the present concept analysis, we have considered this concern. While there is not any direct theory that represents the concept of nurses’ policy influence, we have referred to relevant theories with both nursing and management context. In the “Discussion” section, we have addressed the concept's relevance with existing theories.

In the process suggested by Walker and Avant, the first and second stages are identifying a suitable concept for analysis and then determining its purpose.[10] As mentioned earlier, the extent of using nurses’ policy influence as a concept has not been determined clearly. This means it is not clear whether we can address consultation with nurses from operational levels of nursing care about health and nursing issues as influencing the policies or this is a concept that just addresses high levels of nursing management and leadership. It is not clear which one of activities carried out in these extended levels can be introduced as policy influence. Thus, this is a new and valuable concept for nurses. The principal purpose of this concept analysis is to clarify and develop the concept and to propose a definition for it, through which nurses can better understand the importance of policies in health care system and the necessity for their involvement in policies and to have their influence on them.

The third stage is review of literature. According to Walker and Avant, review of literature should not be limited to nursing literatures to prevent bias in understanding the concept.[12] In the search strategy, we searched various databases including PubMed, Science Direct, Elsevier, CINAHL, and also Google Scholar as an internet search engine, using relevant key terms, “nursing AND policy involvement,” “nursing AND policy influence,” “nursing AND policy making,” and “nursing AND decisional involvement.” Only English articles published between 1999 and 2013 were reviewed. Finally, 24 articles related to nurses’ policy influence were selected. We also searched English dictionaries, the textbooks about nursing management, and nurses’ guide to health policies manually. Here is a summary of this review:

Looking back at the nursing background in the 19th century, we find nurse leaders such as Florence Nightingale, Sojourner Truth, Lillian Wald, and Margaret Sanger who have had extraordinary roles in the development of policies, especially in women's, newborns’, school children's, and environmental health.[4] In 1991, the American Association of College of Nursing (AACN) announced that it is necessary to add health policy education to the field of nursing at Master's level.[5] We also found nursing courses with the content of policies in baccalaureate degree programs after the year 2000.

Therefore, it seems that nurses should be knowledgeable about all issues related to health system, and not just caring issues. Certainly, days of just carrying out the prescribed orders are over for nurses globally. Now it is time for nurses to be health legislators and develop practical policies.[13] Kowalik and Yoder point to health care organizations which have identified the importance of nurse leaders’ participation in decisional affairs. They believe that the outcomes of having strong voice in the fields of decision making will enhance the quality of patients’ care.[14]

However, the managerial roles of nurse leaders, such as decision making, analyzing, control, and budgeting, are still considered as less valuable from the viewpoint of health system managers.[15] Nurses should know that the political ideology of health care system and policy-making process will shape nursing leadership, whether it is a political, clinical, academic, or management leadership.[16]

There are two words in the lexicon (2006) including “policy” and “politics,” which need to be defined. Although these two words are different, because of their similar tone, they infer same concepts and are usually used interchangeably. In order to wildly define these two words, both as a general and as a management and health concept, analysts have referred to dictionaries, articles, and books with the approach of nursing policy and nursing management.

The word “policy” comes from “politia” which is a Latin word. Policies are decisions which are made by people who have power and authority. On the other hand, policy sometimes means regulations for how to behave.[17] Thus, we can define policy as, “practical ways or principles accepted or suggested by a government, group, profession, or an individual.”[18] Meanwhile, Mason, Leavitt, and Chaffee are nurses who define policy as, “choices of society or a part of society or organization, with consideration of purposes, health priorities, and ways of resource supply in order to reach purposes.”[19] In management books, policies are guidelines for procedures and helping people for decision making. What is important for management's authorities is to understand how policies can support effective leadership.[20]

The word “politics” is derived from “politica,” a Greek word which means “related to citizens.” In fact, this word has been driven from Aristotle's book named “Citizen Affairs” which is about government and how to govern. For the first time in 1430, this word with the title of “politiqu” was imported to English, and in 1520, was changed to “politics”. Politics is the art and science of governing. Politics refers to people's affairs and authority of government. As we see, polities is always related to organizational process and government function, while policies sometimes are principles and acts for how to behave. Finally, politics refers to the ways and techniques for regulation and using policies.[17] Mason et al. define politics as the art of influence to supply rare resources such as money, time, personnel, and materials.[19] From management point of view, “politics” is the art of influencing others; it is a means to get ends.[20]

To better clarify the concept of policy influence, we also need to define the concept of “influence.” In Webster's dictionary (1977), influence is defined as affecting others without any force or pressure.[21] As previously mentioned, some authorities of management define politics as the art of influence. Thus, the words “influence” and “politics” or “influence” and “policy” are very much related to each other. In fact, without influence, many wise policies are operationally unusable. For example, imagine a person who has a lot of important and consistent views and opinions about one of the patient care issues, but the people working with him/her think contrary. Here, we should ask the questions of how we can influence others to make them come in our direction and what kind of power we can use.[20] Also, the concept of influence has a very near association with the concept of power. We will discuss about it more in this article.

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Results

Attributes

The fourth stage is clarifying attributes. According to Walker and Avant (2005), attributes are characteristics which are with the concept or related to it.[10] Review of literature helps us to find these attributes. Instead of using many attributes which are less related to the concept, it is better to use less attributes with more relations.[12] Policy influence is accompanied with the following attributes: the spectrum of policy influence, power, and advocacy. Before explaining these attributes, let us first discuss the concepts with a close meaning to policy influence. These are concepts which have some, but not all of the attributes of the concept. These are decisional involvement, policy making, political influence, and policy involvement. The concept of decisional involvement was analyzed by Kowalik and Yoder. They stated that decisional involvement is affecting a judgment or a result.[14] Thus, decisional involvement is a means for policy making and achieves policy influence. Policy making is one of the activities which are done during the process of policy influence. Political influence refers to governmental persons who have points of authority and power. Most of the times, for individuals to be influential in polices, they require to be politically influenced. Policy involvement may have very close meaning to the concept of policy influence.

Like policy influence which can be considered on a spectrum, policy involvement has three levels. According to Boswell et al., policy or political involvement entails the use of activities and behaviors to have an effect on governmental and legislative strategies. In the first level, the individual will just be a voter. At the second level, the individual goes beyond just voting and will take a hard look at personal values, beliefs, and world views. These stimulators will make them as being an adherent for a group of individuals. In the final level, the individual reaches a level of commitment that involves the development of health policies.[22]

The attributes to policy influence have been described below.

Policy influence is moving on a spectrum which begins from policy literacy, moves forward to policy acumen, and then continues to policy competence and finally to policy influence. Policy literacy was first introduced by Malon (2005). For nurse beginners, there are two ways to practice policy literacy. One way is referring to policy documents and asking these questions: What is the problem? When was the process begun? How many are affected? And who are the stakeholders?[23] Another way is to participate in especial political courses.[16,24]

When the abilities of beginners are developed, they can involve in policy acumen. Policy acumen is the ability to analyze policies, and when nurses acquire policy acumen, they can actively analyze organizational process and health care services. Policy competence is related to management in health care. Managers who have acquired policy competence can direct their organizations in response to the challenges and opportunities related to political situations and also make policies which have desirable effects on their organizations. Finally, we have reached policy influence which refers to the nurses who are able to give especial consultation to governments about nursing issues and have important roles in development, implementation, and evaluation of government policies about health care.[23]

The second attribute of policy influence is power. Power is the ability to achieve goals. On the other hand, power is the inherent ability to influence others. Potential factors for maximum influence will be achieved by strengthening the basis of power. Power is an essential aspect for leadership. Thus, nurses should acquire enough information about the presence and place of power fields. What nurses need and should know about power is “power with others” instead of “power on others.” Indeed nurses need power as one attribute of policy influence to protect the quality of care and to change organizations.[20]

The third attribute of policy influence is advocacy. Nurses have long been known as patient advocates. An advocate should be active in political process of his/her country (i.e. by voting). Without involvement in policies, advocating role of nurses will be ineffective.[22] Nurses as advocates should know that when they want to influence decision makers, they need to understand that they are working in an “open system,” so they are affected by many factors. An advocate should ensure that everything influencing decision makers for developing a plan has been understood and considered.[24] They need to recognize conflicts as important components to success and manage them effectively.[25]

Model case

The fifth stage is presenting a model case. Model cases are valuable for better clarification of abstract concepts in nursing and should have all the attributes of a concept.[10] A model case of Iranian nurses policy influence is presented here. Iranian Nursing Organization (INO) was established in December 2001 after years of work for counseling, mentoring, and lobbying. INO is the most active nursing organization and the largest one in Iran which has been established by Iranian nurse activists. This is a non-governmental organization (NGO) according to Iran's constitution. The main mission of this organization is to improve nursing profession in Iran by protecting and supporting nurses’ rights, improving their knowledge, skills, and on-the-job education, and introducing nursing to society.[26]

If we look at the pathway that Iranian nurse activists paved to establish this organization, we can find the attributes of policy influence. First of all, Iranian nurse activists searched and investigated for similar constructions in the world, such as American Nursing Association (ANA), and in this way, they increased their policy literacy. Then, they started to analyze the findings and reached a consensus on the establishment of this organization as their policy acumen developed. Iranian nurse leaders who were well educated, together with other nurse activists facilitated the process as policy competent people. They put the primary plan in writing and sent it as a statement to Islamic consultative parliament. The statement was assessed during numerous agendas and the needed amendments were proposed. Finally, when all amendatory acts were accomplished, the establishment of INO was approved and the statement changed to a law. In this way, policy influence occurred.

Although the legislation system of Iran is centralized and all the health policies are made in the Ministry of Health, INO has the authority and power to act for the improvement of Iranian nurses’ welfare and patients’ rights.

According to the World Health Organization (WHO), there are some domains in which NGOs like INO are required to advocate and, therefore, be involved in political actions such as influencing on workplace policy procedures, funding allocation decisions, practice models, setting of standards, and also special licensure and credentialing.[25]

Antecedents

In the sixth stage, antecedents of the concept should be identified. According to Walker and Avant, antecedents are events or factors which come before the occurrence of the concept.[10] Antecedents are related to the social context in which the concept has been used.

Antecedents of policy influence in nursing which were identified in this analysis are listed and discussed as follows.

  • 1)
    Strengthening political knowledge through especial educational programs in nursing[23]: There are a number of formal programs to increase the political knowledge of nurse leaders in Iran. These are Leadership for Change (LFC) and Leadership for Development (LFD), which are conducted similar to International Council of Nursing (ICN) and Eastern Mediterranean Region Office (EMRO) Nursing Advisor.[27] Meanwhile, there are a number of such programs in the United States with emphasis on this issue. One wonderful program is New York State Nurses Association's Lobby Day (NYSNA’S Lobby Day), which is an exciting dynamic course for baccalaureate nursing degree programs.[28] The well-known program in the UK is Royal College of Nursing Political Leadership Program (2005). This program corresponds to the needs of leaders, students, and other related groups, and is presented as workshops and active learning sessions.[29]
  • 2)
    Communications: Policy and politics have a very close relationship with communication skills. Nurses’ communication skills increase their influence on policies. Nurses are well experienced on how to communicate with people and how to attract their interest in order to meet different institutional needs and achieve their goals.[5]
  • 3)
    Teamwork: Policy making is teamwork and needs support and hard work, which is only possible through effective decision making by groups.[22] Teamwork in policy affairs is very creative and active because many people are involved who support each other. There are two important aspects for teamwork in policy influence: One of them is nursing coalitions in the framework of associations and organizations and the second one is inter-disciplinary participation.[5] INO, Iranian Scientific Nursing Association (ISNA), Iranian Nursing Association (INA), and Iranian Cardiac Nursing Association (ICNA) are four nursing coalitions in Iran that provide the required framework for policy influence in nursing.
  • 4)
    Strengthening public mental image: Policy is related to perceptions and images. For policy influence, nurses need to strengthen mental images. Nurses’ ability to influence policies depends on others’ images of nursing and also their own images of themselves.[18] In this regard, media plays an important role. Increasing visibility of nurses in media would enhance their participation in public health discussions.[30]

Consequences

The seventh stage of this concept analysis is identification of consequences of the concept. Consequences are events or outcomes which occur as a result of the concept. As for antecedents, consequences depend on the social context in which the concept has been used.[10] According to the findings of this analysis, the consequences of nurses’ policy influence are as follows.

  • 1)
    Adequacy of nurse workforce size: Nursing workforce is an important problem in the health care system of Iran. Maintaining nursing workforce by recruitment of more new nurses will have significant effects on health system outcomes.[31] Some of these effects are: Increased presence of nurses in the bedside, listening to patients more, and better maintenance of patients’ munificence.[32] Although during recent years, some policies have been applied for compensating nurse workforce shortages in Iran, such as training nurse assistants through short-term courses, recruitment of undergraduate nursing students as part-time staff, and receiving agreement to recruit 23,000 nurses in governmental health centers,[26] nursing shortage is still the most important problem which needs policy making.
  • 2)
    Modification of nursing duties and organizing nursing care systems: Evidence indicates that most part of the nurses’ time is spent for official works and not for direct care of the patients.[33] In Iran, traditional functional system of nursing and weak relationship patterns still are destroying nursing work environments and need to be handled by effective policies.
  • 3)
    Improving nursing education congruent with social needs: Along with the changes in lifestyle and health care systems, there is a serious need to improve nursing education and expand nurses’ roles.[34] In Iran, constructive changes have been made in nursing education, especially in Master's degrees, during recent years. For example, because of population aging, rise in survival rate of neonates, and also high levels of road accidents, new educational programs such as geriatric nursing, intensive care nursing, and neonate intensive care nursing have been recently developed. But we still need effective policies to expand nurses’ roles in some fields like cancer and diabetes in the community.
  • 4)
    Job satisfaction and job retention: According to Mangold et al., effective participation of nurses in career-related decisions will increase their job satisfaction.[35] Meanwhile, in institutions with active participatory management and power distribution, job retention will be enhanced.[14]
  • 5)
    Improvement of patient outcome: The final product of nurses’ policy influence is improvement of patient outcome, and in this way, health systems can claim that they have achieved their mission.[33] Table 2 shows antecedences, defining attributes, and consequence of nurses’ policy influence.

    Table 2

    Antecedents, defining attributes, and consequences of nurses’ policy influence

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Finally, all of the above consequences can be summarized as making change in health care strategies.

Empirical referents

In the eighth and the last stage of this kind of concept analysis, the empirical referents of the concept should be presented. Because of high abstraction level of concepts, their existence in real situations and also the way they have been measured should be determined.[10]

Although no instrument has been developed to directly measure nursing policy influence and its attributes, “Political Astuteness Inventory” (PAI) can measure some aspects of this concept indirectly. PAI measures the level of political astuteness and identify conceptual factors contributing to organizations, awareness of health policy issues, knowledge of the officials, and involvement in the political process. It is a 40-item tool, and it takes about 70 min to be completed. Each item answered with yes is worth one point. Based on the total score, four levels of political astuteness are categorized: 0-9 points, totally unaware; 10-19 points, slightly aware; 20-29 points, beginning political astuteness; and 30-40 points, politically astute. Although PAI just measures political astuteness and not direct policy influence of a person, it defines awareness, understanding, and evaluation of policy influence.[24] There are also a number of qualitative studies which have focused on nursing influence and its wide effects on patients and nurses. For example, Gebbie et al. described the ways nurses can be influential in the development of health policy and its barriers.[36] In the United States, Byrd et al. introduced a series of learning experiences which have been designed to make students engage in policy involvement process.[24] Finally, Fyffe (2009) introduced strategies for nurses to be influential in policies.[30]

Definition

Based on this analysis, the concept of nurses’ policy influence would be defined as “nurses’ ability to have an effect on decisions and affairs related to health care using power, advocacy, and policy competence, which is acquired by policy awareness, effective communication, teamwork, and strengthening images and will result in improvement of nurses’ and patients’ outcomes.” Accordingly, policy influence is the highest level of involvement in policies which are just carried out by high level of nursing management. Therefore, activities such as consultation with nurses about health issues will not adequately address this concept.

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Discussion

Explaining precise and specific meaning of a concept through various theoretical contexts with emphasis on the favorite context is sufficient.[12] The concept of policy influence at all and nurses’ policy influence, in particular, has not been adequately addressed in various theoretical contexts. But there are many theories with relevant to these concepts. In this section, our analysis has been compared with theses theories.

Kingdon's theory (1995) of policy streams proposes presence of some streams in the process of policy making before agenda setting and policy formulation take place. Kingdom believed that in spite of the dominant effect of governmental agents in progression of an agenda setting, some interest groups also may have a key role in acceptance or obstruction of an agenda setting through formation of a coalition. Kingdom, according to Dohler (1991), states that a united and constant coalition increases the chance for victory in policy streams.[37] The results of current concept analysis of policy influence also forebode the significance of communication and teamwork as two important antecedents for policy influence. As mentioned before, policy activists need to work together as a team and have an acceptable level of communication.

Margaret Newman's theory of “health as expanding consciousness” can be seen as related to raising political awareness. Her theory emphasizes that all people, of any health status and from any circumstance, are a part of the process of expanding consciousness.[28] Her theory defines consciousness as the capacity of the system to interact with the environment. Some of the dimensions of this interaction are exchanging, communicating, relating, choosing, moving, perceiving, and knowing.[38] In summary, expanding consciousness is a metaphor for the changing health systems. Nurses’ awareness of policies will assist expanding consciousness and change health systems.[28] In the present study, we have achieved attributes such as policy literacy, policy acumen, policy competence, and also strengthening political knowledge as antecedents, all of which build policy awareness. These are concepts which can be abstracted from some of Newman's dimensions of interaction with environment, i.e. knowing and perceiving. Meanwhile, other dimensions of Newman, i.e. exchanging, communicating, and relating, can be accommodated to other antecedents of policy influence, i.e. communication and teamwork, in this study. Finally, choosing and moving are Newman's dimensions which are related to making change in health care strategies as overall consequence of policy influence in the present study.

The other theories which the results of current concept analysis are related to are philosophical theories of nursing advocacy. Advocacy as a concept had been considered by nurse theorists, and each of them has a unique definition of nursing advocacy. For example, Gadow (1983) propounded the concept of existential advocacy. She has a moral view of advocacy and believes that the ultimate goal of advocacy is to increase patient outcomes.[39] Kohnke (1980) propounded a model of functional advocacy, in which nurses are agents who inform patients and support patients’ decisions.[19] The results of the current concept analysis are pertinent for Gadow's and Kohnke's theories, since we postulated advocacy as an attribute of policy influence and an inseparable part of the role of nurses as health care providers.

It is notable that the role of advocacy is not limited to patient advocacy, but rather it is allocated to professional advocacy too. Nurses as professional advocators are concerned about nursing workforce, nurse — patient ratio, prevention of malpractice, and the expansion role of nurses.[39] In the present study, we have also introduced pertinent activities such as adequacy of nurse workforce size and improving nursing education, congruent with social needs, as the consequences of policy influence, all of which address professional advocacy.

The aim of this article was to clarify the concept of policy influence associated with nursing management, leadership, and practice in the context of Iran. In this unique analysis, attributes of the concept, such as advocacy, power, and policy competence, were identified. Nurses have the ability to affect health policies. This effect is impossible without the required knowledge of health care system as a whole. Nurses need to be aware of policy agendas, policy makers, and political backgrounds. They are advocates for improvement of the quality of care, but many of them do not have adequate organizational and personal power for advocating patients’ rights. In fact, for nurses to be in a state of empowering patients, it is first essential for them to be empowered.[40] Their expertise, judgment, and policy influence, all together help them to achieve their goals and to facilitate the professional process and the efficacy of health care system. We hope this concept analysis addresses a clear definition of nurses’ policy influence for all nurses and encourage political influence, especially for nurse leaders. In summary, results of this concept analysis indicate that although there are some theories about policy-making process and its facilitators and barriers, there is still lack of nurses’ theories in which the main concepts are involving them or their influence in health policies. However, these are stepping stones in nursing discipline, as we can see them in Newman's model and advocacy models which have been developed by nurses’ theorists.

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Conclusion

Considering the state of nurses’ policy involvement in reports and research papers identified that this involvement has various levels but not all levels indicates influencing in policies. Our definition of this concept may represent a broad theoretical understanding of this concept and may discriminate between similar or related concepts. This analysis will potentially inform nurses about how they could be really influence in policies and what they need to achieve for this purpose. Moreover nurse researchers may use this definition to increase clarity in their research. The identified antecedents, attributes and consequences of policy influence may also give guidance to nurse administrators and managers to achieve high level of leadership step by step to be influence in policies. Finally this paper may offer a theoretical framework to guide future work on this concept.

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Acknowledgments

The authors would like to thank the INO for its sincere cooperation in providing some documents for this study. This article was written based on the first investigator's PhD dissertation at the Faculty of Nursing and Midwifery, Tehran University of Medical Sciences (TUMS); therefore, the financial support from the TUMS is also acknowledged.

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Footnotes

Source of Support: Tehran University of Medical Sciences.

Conflict of Interest: None declared.

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10 important healthcare policies for your facility Ensure compliance and best practices in your healthcare facility with our comprehensive guide on the 10 important types of healthcare policies for your facility. December 22, 2020 12 Minute Read T

10 important healthcare policies for your facility

Ensure compliance and best practices in your healthcare facility with our comprehensive guide on the 10 important types of healthcare policies for your facility.

December 22, 2020

 

 12 Minute Read

To create and sustain high-quality patient care, healthcare facilities rely on effective guidance from a variety of results-driven, health-related policies and procedures. These policies provide a framework for employees by outlining expected standards for day-to-day operations and help facilities meet the many health, safety, and legal regulatory requirements in a high-risk industry.

The ultimate goal? To provide safe, high-quality patient care, achieve quality goals, efficiently use resources, and lessen risk in the process.

Written policies and procedures help healthcare facilities in a number of ways.

They help mitigate risk by ensuring facilities comply with ever-changing rules and regulations, guiding employees with best practices in care delivery, securely handling sensitive documents, protecting staff from potential harm, and working to avoid costly lawsuits.

They improve compliance to industry standards by requiring healthcare organizations to meet complex accreditation requirements, and federal, state, and local laws and regulations.

And they improve internal communication by ensuring that staff members have the information they need to do their jobs well, which makes operations run smoothly and fosters better patient care.

If you’re wondering where to start, it might help to see some examples of important types of healthcare policies that facilities commonly put into place to follow best practices and mitigate risk.

1. Patient care policies

The first place to start with health policy examples covers those designed for patient care. A one-size-fits-all set of patient care policies will not work, as every facility’s needs are different based on the type of care it provides.

Whether your facility is a multi-state hospital, a small podiatry practice, or a regional rehab center, you should have facility-specific policies that cover the way in which your facility cares for patients.

For example, effective policies should address what types of procedures your facility performs, what types of illnesses and injuries your facility treats, when to refer patients to other facilities, and when to transfer them. More specifically, your patient care policies should explain how to handle particular medical situations, such as exposure to bodily fluids or medical emergencies.

Regardless of your organization’s size or type of care provided, a good first step with patient care policies involves asking key questions that relate to your specific facility.

While some of this may seem obvious, it is better to err on the side of caution by including potential issues and areas of concern in the beginning rather than coming across a problem later. It really means taking a more proactive rather than reactive approach.

Learn more about developing patient care policies for your facility.

2. Workplace health and safety policies

With patients at the heart of your health-related policies, it makes sense then to include a variety of policies that cover your biggest asset – namely, employees.

As the number one resource of any healthcare facility, employees need (and deserve) policies that look out for their health and safety on the job. This holds especially true because healthcare professionals face much greater health risks compared to most other industry professions.

Depending on your specific healthcare facility, you might need employee policies that cover issues such as personal protective equipment (PPE) (i.e., when do they need to wear gloves, masks, or more); exposure to substances like chemicals, infectious agents, or drugs; and any physical hazards in and around your facility. Your policies and procedures can help make employees aware of these hazards and protect their health.

But beyond that, do not overlook the overall wellness of your staff. Do you have programs or policies to promote and protect their wellness?

Just as in other industries, your wellness policies should address concerns like weight loss, work stress, healthy eating, and even on-the-job breastfeeding. All of these contribute to a healthy workforce, which research continues to prove is a more effective workforce.

Learn more about workplace health and safety policies.

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3. Information security policy 

The issue of security is becoming an increasingly important one for healthcare facilities of all sizes. Even for smaller organizations that lack a dedicated security team, how will they handle suspicious persons or situations? When do they sound an alert and to whom?

Whether your facility maintains a security team or not, your health-related policies should clearly explain that security, like compliance, is everyone’s responsibility.

You need to equip employees at every level with the right information and procedures so they can handle security-related situations that might arise.

Learn more about the benefits of an information security policy, and get resources for writing your own.

4. Data privacy and IT security

Increasingly, data privacy and IT security are connected in terms of hospital policies and procedures. The more technology you incorporate into your facilities, the more risks you face for data leaks or privacy breaches.

At the core of these leaks? Primarily, human error falls at the crux of these breaches. That is why it is crucially important to put in writing these security and privacy policies. They can help your facility avoid a costly error.

For example, the consequences of not complying with HIPAA could mean losing your tax-exempt status by failing to comply with new requirements from The Patient Protection and Affordable Care Act. Or noncompliance could mean facing a stiff fine.

According to HIPAA Resolution Agreements from the Department of Health and Human Services (HHS) Office for Civil Rights (OCR), HIPAA fines can be up to $1.5 million per incident per year.

Learn more about writing your patient data privacy policy and how to create effective HIPAA policies and procedures.

5. Drug handling

What procedures and safeguards are you putting around drug handling? Many facilities do not carry medicines in-house, while others only carry over-the-counter drugs, and still more carry very controlled and regulated drugs.

Regardless of where you fall on the spectrum, you need very clear policies on how you administer medication, how you record and chart it, and what to do if an error occurs or inventory goes missing.

6. Administrative and HR policies

Another category of health policy examples includes administrative and HR policies. These cover all of those aspects of running the facility from a business and personnel perspective.

While caring for patients and helping them heal drives the mission of healthcare facilities, it is important to remember that they are still a business and need to operate effectively.

And, like any other business, these facilities also need policies that address general HR issues such as dress code, vacations, sick days, and shift-changes. Plus, these policies should address more health-related administrative issues such as patient visitation and bed capacity.

These seemingly mundane policies and procedures can help streamline many of the questions and concerns and help administrative staff more efficiently run the operational side of things.

7. Social media policies

The lure of Facebook and Twitter can pose some complex challenges when it comes to social media and healthcare. What are employees allowed to post when at work? What about when they are off duty but talking about things that happened at your facility?

A fine line exists between protecting the interests of the facility, the patients’ privacy, and the employees’ First Amendment rights. That is why you need a written policy that clearly spells out what is and isn’t allowed by employees.

A well-crafted social media policy in healthcare should touch on employee access, use of official accounts, online conduct, security requirements, disclaimers, and engagement.

Outlining these details can help your facility proactively prevent scandals such as an employee tweeting something offensive from an official hospital account or a staff member sharing confidential facility information online.

A social media policy can also help you effectively address and defuse problems that do arise before they do too much damage.

8. BYOD policy

Common health-related policies often include a bring-your-own-device (BYOD) policy, which can be very simple and straightforward depending on your facility’s needs.

Everyone owns a smartphone these days. These personal devices, while helpful, also carry their own unique risks, especially when it comes to accessing sensitive work information. This doesn’t necessarily have to mean patient information; it could also mean work emails and communications or internal files and documents.

The lines between work and home are blurred these days, so creating a BYOD policy helps define what your organization does and does not allow on personal devices.

It doesn’t have to be overly complicated, but your BYOD policy should focus on those areas that pose the biggest potential risks to your facility.

9. Infectious disease policy

An infectious disease policy is the set of guidelines, rules, and regulations that establish the importance of disease control and how to prevent an outbreak.

Healthcare workers have a higher risk of contact with infectious diseases than most other industries. It comes with the territory.

An infectious disease policy keeps your employees prepared and informed on best practices and regulations. This prevents diseases from spreading, keeps healthcare workers safe, and protects your organization from liability.

According to SHRM, “Employers are legally liable for both employees and nonemployees infected in the workplace."

There are several key steps to developing your infectious disease policy:

  1. Identify known risks
  2. Plan for unknown risks
  3. Create a communication plan
  4. Assign roles
  5. Comply with regulations
  6. Train your employees

To learn more about developing your policy, visit our article Infectious disease policy in healthcare.

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10. Code of ethics

With healthcare being such a complex, high-risk, evolving industry, you will never be able to write enough health-related policies to cover every situation. Therefore, adopting a code of ethics policy will help determine the type of principles, behaviors, and ethics you want employees to demonstrate in every circumstance.

This organizational culture is not something you can mandate in a written document. However, you can codify and put words to a culture of respect, honesty, fairness, accountability, and compliance that your facility aims to develop.

Creating a culture of accountability in your healthcare facility starts with leadership and trickles down throughout the organization to employees at every level.

It helps you focus on your shared purpose and makes employees aware of expectations. And it fosters open communication from top to bottom. This empowers everyone to understand your organization’s goals, your mission, and the values you want every employee to demonstrate.

How to manage it all

Armed with this list of healthcare policies (10 of many different types), you can now identify the policy work that might still need to happen at your facility. And you might even feel a bit overwhelmed at needing to keep up with all of these policies not to mention the cost if you printed them all out. These days, there’s a better way.

Forget the paper-based system of the past, as it is inefficient in keeping up with the compliance demands of today’s healthcare environment. Instead, you need a policy management solution, like PowerDMS, to help keep everything organized and up to date.

A modern but easy-to-use solution like PowerDMS provides benefits for both the administrative side and the workforce. For admins, our cloud-based solutions helps them be more efficient in how they host, distribute, and track all these policies, saving both time and money. For employees,

PowerDMS helps provide them with better access to the information they need to perform their jobs. This boosts their confidence that what they find is up to date and improves their ability to quickly search for and find what they need.

Schedule a free demo today, or if you'd like some tips on writing effective policies, download the guide below.

What is the definition of multimorbidity? What is the difference between comorbidity and multimorbidity? What is multimorbidity in general practice? Who is multimorbidity most common in? Feedback https://apps.who.int/iris/bits

Multimorbidity refers to the presence of 2 or more long-term health conditions, which can include. Defined physical and mental health conditions such as diabetes or schizophrenia. Ongoing conditions such as learning disability. Symptom complexes such as frailty or chronic pain.14 Jul 2022
https://www.nature.com/articles/s41572-022-00376-4%23:~:text%3DMultimorbidity%2520refers%2520to%2520the%2520presence,as%2520frailty%2520or%2520chronic%2520pain.&ved=2ahUKEwimrN6n8LaAAxV8VKQEHQu-CdAQFnoECB4QAw">

Multimorbidity | Nature Reviews Disease Primers

 
Nature Journal
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