Nursing and midwifery care: event report

Excellence in Care: Keynote

Professor Brendan McCormack

Seeking A Person-Centred Culture

Professor Brendan McCormack has an international reputation as an expert in person-centred practice, gerontological nursing and practice development, all of which have a direct connection with care assurance. In addition to being head of the Department of Nursing at Queen Margaret University, he also holds visiting professorships at the University of Aberdeen and institutions in Australia, Norway and South Africa.

Having taken up post in Edinburgh just 14 months ago, his perspective on care assurance and its implications for Scotland was eagerly anticipated by participants at the event.

Brendan told them there has been a huge surge in care assurance systems across the world, and the initiatives being progressed in Scotland put it in a prime place to take a strong leadership role. "I really think the work that has started in Scotland is phenomenal, and it would be a great pity if we did not capitalise on that," he said.

Brendan believes, however, that there are complexities in the way care assurance systems are currently being taken forward in Scotland. "We can see conflict in some of the processes being followed between compliance and engagement, criteria-led versus principles-led approaches, and whether what we are doing should be about performance or setting the conditions in which people can thrive," he said. "I believe this event should be about positioning where we stand in relation to these conflicts."

The last 30 years or so have seen a big shift in what is important in evaluation, as Box 1 shows. Brendan believes, however, that healthcare and nursing evaluation has become very firmly stuck at Move 1 - "Positivist and outcome-oriented".

"We've become very input- output orientated - we forget everything in between the two and wonder why the output doesn't seem to match the input," he said. "Areas like education, social work and community development are looking much more at Move 3, which is about using evaluation to bring people together on a common footing.

"Rather than evaluation coming from on high and producing data that is disconnected from people, data becomes part of everyday life. It means that people are engaged and involved from the point of conception through to reporting the data. This leads us towards person-oriented evaluation, which is Move 4."

Brendan's ground breaking work on person-centredness shows four overarching outcomes that are important to patients and nurses. "Patients and nurses want a good experience of care, and it's important that we understand the experience of both," he said. "Involvement with care is also critical - again, not just patient involvement, but staff involvement too. Action research I'm involved in is identifying examples of units where healthcare support workers are not involved in shift handovers and are instead given lists of tasks to do. Yet these are the people who are providing most of the direct care. It's an indictment of us all that this situation still exists in this day and age."

Feelings of wellbeing is the third factor, and the last is creating a healthful culture. "A healthful culture is a culture of practice that helps us feel well, that doesn't drain us and put us on a journey towards burnout," Brendan explained. "It helps us maintain our health - morally, spiritually and physically.

"I believe we should be aiming to develop a system that reflects these four overarching outcomes, but that can't happen if we remain stuck in Move 1 mode - it will only happen if we are in a genuinely engaged and participatory mode of evaluation."

Brendan recalled a recent event at which Don Berwick, the leading authority on patient safety and quality, had spoken. "Berwick emphasised that measurement and compliance do not change practice," he said. "Instead, they create a culture of fear, which restricts innovation and creativity. He argued very strongly for person-centred services - when I made that call a year before at a major international conference, the reaction was not particularly positive, so we have made a big shift in just 12 months. And he said that only if we learn through practice can we create sustainable cultures of quality - and I think everyone in this room knows that already."

Brendan's current work with Professor Jan Dewing is looking at developing a model that focuses on promoting people's vitality and absorptive capacity and capability. "You need to have a balance," he said. "High levels of vitality and absorptive capacity and capability take you closer to a person-centred culture, but if you focus too much on issues like compliance and performance, you get what we call 'person-centred moments' rather than a full person-centred culture - people only occasionally delivering person-centred care because they are so focused on performance and the next set of evaluations coming their way.

"A genuine person-centred culture is one that promotes innovation and in which people are engaged and passionate about what they do. This is critical to our journey in Scotland - if we go for something that focuses primarily on performance and compliance, we are not going to get the outcomes the CNO is seeking. We will get elements of it, but it will not be sustainable. We need to prioritise what we want to drive this work."