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Humanising nursing care: a theoretical model

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The first in a series of two articles about humanising care explores a theoretical framework based on eight aspects of what it is to be human. Humanising care, part 1 of 2.

Abstract

This article is the first of two exploring how nurses can humanise care. It presents a theoretical framework developed by Todres et al (2009) that explores eight central aspects of what it is to be human. The second article, published next week, looks at the role of nurse education in humanising care.

Citation: Hemingway et al (2012) Humanising nursing care: a theoretical model. Nursing Times [online]; 108: 40, 26-27.

Authors: Ann Hemingway is senior lecturer public health; Janet Scammell is associate professor; Vanessa Heaslip is senior lecturer adult nursing; all at School of Health and Social Care, Bournemouth University.

Introduction

The need to put the person at the heart of care has been raised in policy (Department of Health, 2005; 2004) and health professionals have an integral role in developing person-centred services (DH, 2010).

This article explores the framework presented by Todres et al (2009) and shows how it can be used to improve nursing care. The framework presents central aspects of what it means to be human as eight dimensions of humanisation/dehumanisation (Box 1). These can be used to identify humanising and dehumanising elements in care systems and nurse/patient interaction. Each has a practice point for reflection.

Insiderness vs objectification

To be human is to experience life in relation to how you are; the world is experienced through mood, feeling and emotion (insiderness).

An approach that focuses on patients’ abilities (skills, knowledge, motivation) rather than their problems ensures they are not treated like objects, problems, needs or diseases. For example, how often do nurses see a patient with dementia as

a list of fragmented risks and issues, instead of an individual with the potential to be involved in solving problems? This focus does not lead to a shared vision of care but a dependency upon the nurse to make decisions.

Practice Point 1: nurses must never make those we care for feel like objects.

Agency vs passivity

As humans, we make choices and are generally held accountable for our actions. We do not usually see ourselves as totally passive or determined but as having the potential to live and act within limits; seeing ourselves as having a sense of freedom appears to be linked to social, physical and mental health (Stansfeld et al, 2002).

Ensuring we maintain patients’ sense of agency offers another way of viewing individuals that helps us to make sure that choice and accountability are woven into interactions and interventions. We have to consider the possibilities that enable individuals to manage their care.

Practice Point 2: nurses need to offer and enable choice and freedom for patients.

Box 1. The dimensions of humanisation

Forms of humanisation

  • Insiderness
  • Agency
  • Uniqueness
  • Togetherness
  • Sense making
  • Personal journey
  • Sense of place
  • Embodiment

Forms of dehumanisation

  • Objectification
  • Passivity
  • Homogenisation
  • Isolation
  • Loss of meaning
  • Loss of personal journey
  • Dislocation
  • Reductionism

Source: Todres et al (2009)

Uniqueness vs homogenisation

Our uniqueness as human beings can never be reduced to a list of characteristics such as age, gender, ethnicity; each of us is unique in relation to our relationships and our context, and this is how we see ourselves.

De-emphasising uniqueness by fitting people into a group - such as diabetic, smoker or obese - can encourage a one size fits all approach to care, which separates individuals from the context of their life.

We need to consider an individual’s context, carers, friends, family and home to balance any generalisations that hide characteristics that make people who they are.

Practice Point 3: nurses need to get to know patients and their contexts to build trusting relationships and discover what is important to them.

Togetherness vs isolation

To be human is to be part of a community, while recognising others’ uniqueness. Social isolation can damage health, and negative relationships may cause harm. Social isolation is detrimental to the outcomes of chronic physical and psychological disease (Drennan et al, 2008).

Nurses need to be aware of the importance of interaction between nurses and patients, as well as between patients and carers, friends or family. Trust between nurses and patients is paramount, and central to trust is patient dignity.

Practice Point 4: nurses need to offer support to those we care for and the opportunity to build relationships and friendships.

Sense-making vs loss of meaning

To be human is to care about the meaning of events and experiences. The immediacy of the search for meaning can outweigh the significance of the search for truth.

When people are counted as a number or statistic, treatment or prevention opportunities may not make sense because what is “significant” statistically does not necessarily balance with their experience.

For example, smoking may be the way a person copes with stress or reducing their food intake. If we are going to help that person to quit, we need to find alternatives for the reason behind that behaviour. People may make sense of their wellbeing by looking at how they live rather than through official presentations of risks and problems.

Practice Point 5: nurses need to explain what is happening and ensure that patients and relatives understand fully their situation in their context.

Personal journey vs loss of personal journey

People move through time in a meaningful way, positioning themselves in terms of past, present and future. People are familiar with the past and could be ambivalent, fearful, excited or bored by the future.

Experiences of health and healthcare are only a part of life. However, interruption or threat from illness may cause distress.

An excessive emphasis on labelling our patients negatively as needy or problematic does nothing to enhance their sense of pride and engagement with past, present and future. Indeed this approach could be said to be disempowering and disabling.

Practice Point 6: patients are often in unfamiliar situations and their life has been interrupted. We need to acknowledge and value their concerns and help them to adapt.

Sense of place vs dislocation

To be human is to come from a particular place. A sense of home and place is not just a collection of objects or experiences; it offers security, comfort and familiarity.

Spaces can potentially provide an environment where connections between people can flourish (Hemingway and Stevens, 2011). Day rooms or social areas allow patients to talk to each other.

Insufficient attention may have been paid to spaces within homes and communities in relation to eating and exercise, which contribute to unhealthily lifestyles (Hemingway, 2012). The effect of place and residence on health cannot be ignored; arguably, the only way to intervene successfully is to be ready to listen to what makes a sense of home and place for individuals.

Some researchers (Martinsen, 2006) have argued that space and architecture are important preservers of human dignity, particularly within caring contexts. This could be achieved through maintaining privacy, giving time to find out the objects or tasks that give an individual comfort, and flexibility about visiting times.

Practice Point 7: healthcare environments can be frightening and depressing; we need to do the best we can to mitigate this and reduce the sense of dislocation.

Embodiment vs reductionism

We experience the world through our bodies in a positive or negative way. An individual’s biology cannot be understood without considering the psychological, social and socio-cultural aspects.

Embodiment relates to how we experience the world and this includes our perceptions of our context and its possibilities or limits. It may be affected by illness, or changes in body image or ability.

An excessive emphasis on physiology and tests, while not recognising the individual within their social context, limits our ability to respond to another human being in a caring and dignified way.

Practice Point 8: everyone is unique and valuable and nurses need to treat everyone with respect and dignity.

Conclusion

As qualified and student nurses, we have an individual and collective responsibility to maintain the best standards of care.

Focusing care on what is important to individuals as human beings enables nurses to understand and more fully appreciate the individual’s personal experience of ill health so they can better support them. Doing so, could ensure a dignified and respectful approach to care that puts the patient first.

Key points

  • Focusing on what it is to be human will help us to reflect on our practice critically
  • The eight dimensions put the individual patient at the centre of care
  • Having a clear value framework helps to ensure the best quality of care
  • This approach helps us to focus on being with other human beings rather than doing tasks
  • This different way of caring is not focused on the professional group but on us as human beings
  • Nurse and patient

    Humanising nursing care: a theoretical model

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