Scandinavian Journal of Occupational Therapy
ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
Contradictions in client-centred discharge planning: through the lens of relational autonomy Evelyne Durocher, Elizabeth Anne Kinsella, Carolyn Ells & Matthew Hunt To cite this article: Evelyne Durocher, Elizabeth Anne Kinsella, Carolyn Ells & Matthew Hunt (2015) Contradictions in client-centred discharge planning: through the lens of relational autonomy, Scandinavian Journal of Occupational Therapy, 22:4, 293-301 To link to this article: http://dx.doi.org/10.3109/11038128.2015.1017531
Published online: 24 Feb 2015.
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Date: 05 November 2015, At: 12:49
Scandinavian Journal of Occupational Therapy. 2015; 22: 293–301
ORIGINAL ARTICLE
Contradictions in client-centred discharge planning: through the lens of relational autonomy
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EVELYNE DUROCHER1,2, ELIZABETH ANNE KINSELLA3,4,5, CAROLYN ELLS6 & MATTHEW HUNT7 1
School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montréal, Québec, Canada, Centre for Interdisciplinary Research in Rehabilitation, Jewish Rehabilitation Hostpital, Laval, Québec, Canada, 3School of Occupational Therapy & Occupational Science field, Faculty of Health Sciences, Western University, 4Health and Rehabilitation Sciences Graduate Program, Faculty of Health Sciences, Western University, 5Department of Women’s studies and Feminist Research, Western University, London, Ontario, Canada, 6Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada, and 7Centre for Interdisciplinary Research in Rehabilitation, Jewish Rehabilitation Hostpital, Laval, Québec, Canada
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Abstract Background: While client-centred practice has received wide support, it remains difficult to apply in many practice settings. Identified barriers include constraints on time, resources, and services imposed by healthcare policies. Healthcare professionals’ prioritizing of client safety over (other) interests that clients may name may further restrict the application of client-centred practice. Discharge planning is one area where such considerations can conflict. Aim: This paper presents a secondary analysis of data examining the process of discharge in one Canadian rehabilitation setting. It examines how discourses of client-centred practice and of prioritizing safety were reflected in discharge planning with older adults and considers the implications of potential conflicts between these discourses. Method: Taking a critical bioethics perspective informed by relational autonomy theory, microethnographic case studies were used to examine discharge planning from the perspectives of older adult clients and healthcare professionals. Results: Healthcare professionals interpreted client-centred practice to require abiding by client wishes, as long as this was safe; furthermore prioritizing safety took precedence over other considerations in discharge planning. Conclusion and significance: Client-centred practice was not promoted in discharge planning processes in the research setting. Applying a relational autonomy lens to practice could promote approaches that better facilitate client-centred practice.
Key words: patient safety, microethnographic case studies, feminist bioethics, ethical tensions, critical bioethics
Introduction While client-centred1 practice has received wide support, it remains difficult to apply in many practice settings in which precedence is attributed to demands imposed by institutionally centred and policy-driven healthcare systems (1,2). Barriers to enacting clientcentred practice identified in the literature include constraints imposed by institutional healthcare policies, including time, resources, information
transfer, funding, and services available to clients (3-6). Additionally, there are suggestions that an unreflective prioritization of safety over other concerns may further restrict the application of clientcentred practice (3,6). This paper presents the results of a secondary analysis of data examining discharge planning in one inpatient rehabilitation setting in Canada. Discharge planning is particularly relevant to occupational therapists as it is a prominent source of ethical tension in practice (7-10). We examine how
Correspondence: Evelyne Durocher, PhD OT Reg. (Ont.), Postdoctoral fellow, School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Rabinovitch House, room 102, 3640 Rue de la Montagne, Montréal, Québec H3G2A8, Canada. E-mail: [email protected] (Received 17 December 2014; accepted 4 February 2015) ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1017531
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values prioritizing safety routinely overshadowed commitments to client-centred practice with older individuals in discharge planning. We then discuss how this resulted in practices that contradicted clinicians’ professed adherence to client-centred practice and conflicted with the intended aims of clientcentred practice as outlined in the literature.
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Background information During the 1990s, Western healthcare systems moved towards client-centred healthcare. Client-centred or shared decision-making approaches emerged in reaction to more paternalistic attitudes in order to promote collaborative decision-making between healthcare professionals and their clients (11,12). The intention was for clients to be more involved in decisions relating to their care, and for their perspectives and unique circumstances to be considered in finding options that met clients’ needs, upheld their preferences, and fitted into existing healthcare systems (11,12). Client-centred practice remains a guiding principle in professional and institutional healthcare mandates (13-16) and aligns with the World Health Organization’s concept of people-centred care (17). Challenges to realizing client-centred practice have been identified in both theoretical and empirical practice literature. These include policies limiting the amount of time healthcare professionals have to spend with clients, context-specific conventions and processes, as well as limitations to the quantity and type of services offered (3-5,18-20). Such limitations can lead to ethical tensions for practising occupational therapists who may be unable to practise in a manner that meets their clients’ needs (8-10). Beginning in the mid-twentieth century, there has been a steady rise in discourses of institutional and professional accountability, risk aversion, and patient safety promotion in healthcare institutions (21,22). These developments raise additional challenges to the application of client-centred practice when options that promote individual safety are given precedence over other considerations (3). A domain of practice in which commitments to client-centred practice and the promotion of safety often conflict is discharge planning, particularly with older adults (6). Timely and appropriate discharge planning is important in preparing individuals to leave, or discontinue use of, healthcare services. Planning discharges from inpatient care settings involves deciding where a client will live, identifying if care will be needed, and if so, arranging services to ensure that individuals’ needs will be met. For older adults being discharged, the decision to return home or move into a long-term care facility can have tremendous implications (6,23). One’s home environment has a significant impact in shaping the
social, occupational, healthcare, and personal aspects of one’s life; one’s home may hold great emotional significance and be closely related to one’s identity and sense of self (24,25). The application of clientcentred practice in discharge decisions could help to identify options that align with clients’ values (25). However, evidence suggests that sometimes safety is prioritized over client-centred practice, which can result in situations where older adults are not included in discharge decisions (6). Purpose of paper In this paper we critically examine how discourses of client-centred practice and the prioritization of safety are taken up in practice using the example of discharge planning with older adults from an inpatient rehabilitation setting. We draw on a study by the lead author that examined discharge planning (26) to highlight tensions between the definitions of client-centred practice in the literature and the understandings of clinicians. We further examine conflicts between the aims of client-centred practice articulated variously by clinicians, their professional bodies, and healthcare institutions, and discourses that prioritize safety. We argue that attending to relational autonomy has the potential to guide clinicians to practise in ways that better align with the tenets of client-centred practice. Material and methods This work is part of a larger project examining discharge planning (26). Taking a critical bioethics perspective (27,28) informed by relational autonomy theory (29,30), we used microethnographic case studies (31) to examine discharge planning processes at one rehabilitation unit in Canada. The data set comprised five case studies for a total of five discharge planning family conference observations and 22 semistructured interviews. Each case explored discharge decision-making from three stakeholder perspectives: the older adult preparing for discharge from inpatient rehabilitation, one or more involved family members, and one or more healthcare professionals involved in the individual’s discharge-planning process. In this secondary analysis, we include the six interviews with the older adults (four women and two men) and the 11 interviews with healthcare professionals (three occupational therapists, one physical therapist, two social workers, one head nurse, and one unit manager – two healthcare professionals were interviewed in relation to more than one case). Data generation and analysis occurred simultaneously to allow unforeseen topics identified as relevant in earlier case studies to be explored in subsequent case studies. The data from fieldnotes
Client-centred care and relational autonomy and interview transcripts were analysed inductively and deductively following a modified version of the process suggested by Dierckx de Casterle and colleagues (32) whereby instead of coding in the second phase of analysis as these authors suggest, two sets of questions based on the research questions and guided by the theoretical framework were asked of the data. The research was approved by research ethics boards at the University of Toronto and the partnering institution.
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Results Healthcare professionals who participated in the study interpreted client-centred practice to prioritize client preferences as long as doing so was considered safe. Healthcare professionals and clients alike valued the comfort and familiarity they associated with their home as well as the opportunities that their current home environments offered them. Despite this, prioritizing safety inevitably took precedence over abiding by client wishes in discharge planning. These three different themes will be discussed. Pseudonyms are used to maintain participant confidentiality. Healthcare professionals’ understandings of client-centred practice All healthcare professionals in the study professed adherence to client-centred practice. Understandings of client-centred practice, however, differed between participants. One healthcare professional equated client-centred practice with enabling what the client wanted “as long as it’s safe”: Interviewer: What do you think of this word [clientcentred] and how would it apply to discharge planning? Rebecca: The first person who I meet with is the client, is the patient, because obviously I want to hear what they want from their rehab stay and what they hope would be the discharge plan for them, because sometimes their kids or their grandchildren or siblings or whoever it is has a very different idea on what would be best for them. So I always like to hear what the patient wants first. I always try and be client-centred in my approach, and that’s what I do on the unit. Like I said, they’re the first people that I meet. . .. I advocate for what the patient wants as long as it’s safe. Rebecca indicated that she was client-centred in her practice because she met with the clients and found out what they wanted. Erica, another healthcare professional, described client-centred practice as balancing safety with individual wishes, while taking into consideration the individual’s capacity: I feel that client-centredness does not always mean that we go with what they want. It has to be a balance
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between honouring their wish but also maintaining safety . . . so I feel that client-centredness has to be respected, but also with the understanding that you have to look at the person’s capability and capacity to make decisions for themselves. Both practitioners vouched for what the client wanted as long as this was safe. These quotations implied that safe practice trumped client-centred practice (here associated with honouring clients’ wishes) if the two were in opposition. A different way of relating client-centred practice to doing what the client wants was evident in suggestions that recommendations were client-centred when older adults agreed with them. As Julie stated, “I think I am very client-centred, and I would say, 90 per cent of cases of discharge, the patient is in agreement with what we’re recommending”. Julie suggests that the high percentage of client agreement with the team’s recommendations validates her practice as client-centred. She went on to discuss a different understanding of client-centred practice in which clients are included or “involved” in discharge planning from the beginning even if clients do not agree with the plans made. In sum, according to healthcare professional participants, client-centred could mean different things. The most prominent understanding entailed abiding by what the client determines to be the client’s own best interests. A second understanding entailed balancing clients’ wishes with their safety and capacity (to understand the situation and to make decisions). In this formulation, healthcare professionals had to balance clients’ wishes and determination of best interests with the healthcare professionals’ duty to protect patients from potential harms. Keeping clients “involved” throughout the process was a third feature of client-centred practice reported by these participants. In practice this was interpreted to require listening to or informing clients even if clients did not agree with decisions taken. Values associated with one’s home When asked about what was important in discharge and where they lived, older adults frequently spoke of the importance of being in their own space. Maeve described that she wanted to go home “just to be in my own place”. Magan quoted the expression “There’s no place like home” and further discussed the comfort of knowing where all of one’s belongings are placed, the freedom to invite guests, and the increased function that being in one’s own space enables: The comfort of knowing where things are, what is what. It also depends how you want to live. If I want to invite you to my home for lunch, I should know where things are, my crockery, my cutlery, my
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coffeemaker, my whatever it is. So that process of inviting people to lunch or [that] kind of thing becomes simpler. Frederik and his wife Rita similarly discussed the importance of living in a place where they had frequent opportunities to play bridge, and where they could easily visit their families. Another important aspect of one’s home was the pride that individuals took in organizing and maintaining their space. Marion expressed pride in saying “That’s my castle. I have a nice home, it’s clean; it’s always clean. I look after it.” And furthermore expressing “I will not leave my home. My home is my castle. But now I have a one-bedroom, two bathrooms, a kitchen, the washer-dryer is off the kitchen I have no stairs to walk. I’m very comfortable.” For Marion, the cleanliness of her home inspired pride. She was comfortable there. She hinted at consideration of her functional limitations and the implications for her safety when she mentioned that there were no stairs in her home. (Marion had difficulty going up and down stairs on her own.) Similarly, while Sophia reported feeling pride in her garden and the cleanliness of her home, she also asserted that after a recent fall and hospitalization she was afraid of falling and that having a home free of stairs was important to her. Other than these mentions, safety did not factor in older adults’ discussions about their home or where they wished to live and therefore did not appear as a priority from the perspective of older adults in this study. When asked what they personally saw as important in their own living situations, healthcare professionals similarly listed attributes related to leisure and opportunities in the community: I’m in a place where there are a lot of things around me. . .. I want to go to Starbucks I go for a walk, I want to go to the bank, I go for a walk. . .. To have things accessible, close by, I don’t have to sit in traffic for three hours to get somewhere, I think that’s important. To be close to family I think is important. As Alison stated above and as reinforced by Julie, healthcare professionals also mentioned attributes such as being close to family. “Home to me is. . .. I always think of my family and who’s living in my house, all of those things are important to me, that’s what makes my home.” In relation to themselves, all participants reported valuing attributes of their homes related to comfort and familiarity, as well as the opportunities available to them in their preferred home environment. Healthcare professionals’ prioritization of safety The promotion of safety was prominent in all healthcare professionals’ discussions of their discharge
planning recommendations. There was a difference between what healthcare professionals viewed as important in relation to their own home or living situations and what they saw as important for older adults’ living situations upon discharge, namely safety. In relation to their own home, healthcare professionals in this study did not mention safety. In consideration of older adults’ living situations and discharge plans, however, comfort, familiarity, and opportunity for preferred occupations was secondary to the prioritization of safety. Not only did healthcare professionals in this study view safety as something to be prioritized over client preferences, but healthcare professionals also viewed safety as the most important consideration in all situations of discharge. Evidence of the prioritization of safety in healthcare professionals’ approaches came to light in discussions of what was a “good” or a “bad” discharge, which was closely linked to the safety of the discharge plan as defined by the healthcare team, the alignment of the final discharge outcome to the team’s recommendations, and the amount of discord between involved parties. All healthcare professionals indicated that a good discharge was a safe discharge. As Alison said, “A safe discharge for me is a good discharge”. Conversely, as Julie describes, unsafe or risky discharges were described as “disaster discharges”: I mean obviously it’s people’s personal choice to live at risk . . . we call them disaster discharges. There’s lots of times that there are disaster discharges where the person goes to an environment that I think is not optimal for them. According to Julie, disaster discharges were those whereby individuals chose to live at risk and not put in place the recommendations of the healthcare team – which would keep them safe. Another healthcare professional reaffirmed this idea: Rebecca: We’ve discharged patients here and it’s been a disaster – I mean it. The discharge plan is totally not what we would have recommended – at the end of the day what can you do? I mean unless they’re incapable and then you can deem them incapable and you know defer to the POA [power of attorney] or the substitute decision-maker. Interviewer: When you say that the discharge plan is a disaster, you mean like in terms of what they’ve put in place? Rebecca: In terms of them not following our recommendations and [they] leave and we’re very anxious because we know it’s not safe but that’s what they’ve decided they want to do. In these last two quotations the prioritization of physical safety was seen as the only logical or reasonable option. According to Alison, if the patient’s home was not a safe option, it was not considered:
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Client-centred care and relational autonomy So we all come up with ideas to try and get the patient home, if that’s where they want to go, but if home’s not safe, where’s another place either that is safe, and that they want to go to, or just a place that is safe, even if it’s not necessarily their first choice. Despite one acknowledgement that a client has a choice to live at risk, these healthcare professionals implied that they did not support autonomous choices that differed from their recommendations for a safe discharge. Older adults valued being comfortable in the familiarity of their own space. Yet, there was little consideration for client preferences in the healthcare professionals’ accounts, which directly contradicted their own understandings of client-centred practice and the promotion of client preferences. Taking a putatively client-centred approach to practice was therefore in effect, maximizing client safety. Discussion and implications A critical approach informed by relational autonomy theory At the heart of client-centred practice is a presumption of respect for the autonomy of clients, yet little literature in the field problematizes how the enactment of respect for autonomy in practice occurs; the results of this study point to conditions that preclude or trump its enablement. Relational autonomy theory recognizes that not everyone has equal opportunity for autonomous decision-making and action, that autonomous action is mediated through relational, social, cultural, economic, contextual, situational, and political dimensions, and that power circulates in its enactment (29,30,33). In this way theories of relational autonomy offer a means of more deeply examining how autonomous decision-making and actions of individual or groups of clients are enabled or constrained, and draw attention to circumstances that promote (in)justice for particular groups or individuals. For example, in situations where individual choices are constrained by external forces, opportunities for engagement in occupations can be impeded or coerced, which can result in occupational injustice and can have an impact on individual health and well-being (34). Theories of relational autonomy thereby contribute a critical perspective to the aim of respecting autonomy and imply a duty to promote justice as central to client-centred practice. This theoretical perspective aligns with recent literature pertaining to the influence of external forces on older adults’ decision-making processes (35,36). Ells et al. have suggested that a consideration of relational autonomy ought to be an essential component of client-centred practice (37). Being attentive to the relational aspects of autonomy has the potential to promote a more in-depth understanding of the
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values, concerns, and external forces shaping clients’ perspectives and choices and to foster increasingly client-centred discharge plans. In this research we used relational autonomy theory to: (i) focus our analysis on revealing the hidden intersections of influences on healthcare professionals’ practice in discharge planning with older adults, and (ii) augment current understandings of client-centred practice. Doing so opens a discussion of how using relational autonomy theory to frame practice may enhance and better align practice with the intended aims of client-centred practice and help clinicians to navigate ethical tensions they encounter in discharge planning, or other areas of practice. Safety and client-centred practice The importance of safety in healthcare professionals’ approaches in this setting echoes research findings from Canada, the United States, and Australia in which healthcare professionals prioritized safety in discharge planning (6,38,39). The drive to promote and maximize patient safety is also prominent in healthcare and best practice literature (40,41) and in the mandates of various professional colleges and associations (16,42,43) but may also be linked to a fear of professional or institutional liability and an impetus to manage professional and institutional risk (21,36,44). These prevalent structural drivers are reflected in the prioritization of safety in the institutional practices reported in the study. The literature shows much variability in terminology and conceptions of client-centred practice. Predominant definitions focus on considering individuals and groups within their contexts and including them in collaborative decision-making concerning their care with little or no mention of safety. For instance, in a large-scale review of the literature on client-centred practice (which included patient- and person-centred search terms), Brookman and colleagues (43) suggest that client-centred practice is based on “developing an understanding of the individual, their environment, values, relationships and social world” (p. 22). Additionally, the World Health Organization’s defining criteria for person-centred care include maintaining “respect for patients and their decisions” and the “provision of individualized care” (17). Similarly, the Canadian Association of Occupational Therapy denotes client-centred practice as a collaborative approach that that recognizes clients’ experiences and knowledge and involves clients in decision-making (16). In their seminal text, Gerteis and colleagues (44) suggest that patient-centred practice “consciously adopts the patient’s perspective” (p. 5). These authors further elaborate seven dimensions of patient-centred care: (i) Respect for patients’ values, preferences, and
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expressed needs; (ii) Coordination and integration of care; (iii) Information, communication, and education; (iv) Physical comfort; (v) Emotional support and alleviation of fear and anxiety; (vi) Involvement of family and friends; and (vii) Transition and continuity (p. 5–11). The literature focuses on developing an understanding of clients’ values and contexts in order to consider these in healthcare decision-making. This overlaps with the descriptions of client-centred practice in the data in the common concern for clients’ values. Conceptions in the literature, however, promote the inclusion of client values and preferences in the determination of care plans while practices and behaviours to honour client values and preferences did not appear in the data. The multi-dimensionality of concepts in the literature contrasts professional participants’ narrowly conceived descriptions of client-centred practice as following the clients’ wishes only if assessed as safe. The aim to prioritize safety over consideration for other aspects of clients’ lives in discharge planning can lead to ethical tensions and create moral distress for occupational therapists (8-10), which we propose may be mitigated to some extent through attention to relational autonomy within the practice of client-centred practice. Implications for practice: How relational autonomy theory might be helpful More robust conceptualizations of client-centred practice include not only consideration for individual values or preferences, but also an understanding of the person, her/his strengths, capabilities, needs, and resources, as well as her/his environment, relationships, and social networks. These aspects strongly overlap with relational approaches that consider individuals’ unique capabilities, needs, and preferences, and how these are shaped by social and political contexts (28,29,37). Framing practice through the lens of relational autonomy theory promotes practice that better enables individuals to participate autonomously in shared decision-making, a key component of client-centred practice. Through a collaborative process, clients’ values, strengths, and areas in which they need support, as well as potential influences (barriers and facilitators) on the clients’ autonomy, could be identified. Based on these features, a tailored relational approach can be taken to enable conditions that support greater recognition and uptake of clients’ contributions in collaborative decisions regarding discharge. Unsurprisingly, there were contradictions in the data between older clients’ wishes for discharge, which focused on returning home and being in their own space, and healthcare professionals’
recommendations, which focused on protecting older clients’ safety. What was surprising was the healthcare professionals’ unreflective prioritization of safety over client preferences in light of the narrow understanding of client-centred practice they exhibited (notably when client-centred practice, and perhaps respect for autonomy, was assumed to be limited to abiding by client preferences). This conflict between safety and upholding client preferences relates to what has been called “the dignity of risk” (45,46). “The concept of the dignity of risk acknowledges the fact that accompanying every endeavour is the element of risk and that every opportunity for growth carries with it the potential for failure” ( (46), p. 28). In her commentary, Nay (45) discusses healthcare professionals’ tendency to maximize physical safety at the expense of all other considerations, and the potential link to protecting the hospital from potential liability. She argues, however, that removing the freedom to take physical risks does not uphold older adults’ autonomy and can engender psychological harm. A relational autonomy perspective views individuals as having a unique constellation of circumstances and as interrelated with their contexts. Practice adopting this approach would promote addressing the discharge decision at hand, but also taking into consideration how this decision or action is related to the individual’s identity, values, and life circumstances. As Hunt and Ells (47) state, when approaching decisions between options that may involve personal risks for clients or others, “it is particularly important to probe the meaning the patient associates with the choice that is being considered, as well as to seek to understand the meaning of potential consequences that have been identified . . . and how these are incorporated in the patient’s evaluation of risk” (p. 964). Framing practice through a relational approach may thus better enable a collective determination of discharge plans that uphold individual values, are more accurately tailored to individuals’ unique intersections of needs, preferences, strengths, and resources, and that attend to considerations of various dimensions of safety. Where clients participate in decision-making, they also share in the responsibility for decisions made. Such an approach supports enriched conceptualizations of client-centred practice as outlined in the literature. Taking a relational approach also includes the added dimension of considering social, cultural, economic, and political contextual forces and how these may enable or constrain particular choices. Bringing attention to such influences has the potential to promote changes in practices and policies that disable barriers and allow for more options, thereby better enabling client-centred practice. Taking a relational approach to autonomy may furthermore decrease the
Client-centred care and relational autonomy ethical tensions and moral distress experienced by occupational therapists, by offering a more robust consideration of different dimensions informing the capacity for autonomy in the situation, as well as the potential harms, benefits, and other justifications for each option.
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Challenges to a client-centred or relational approach Practices that support a relational approach to clientcentred practice would not easily fit within the kind of “triage model” of discharge planning identified in this research (26). Identifying individuals’ preferences, values, strengths, weaknesses, and specific circumstances, and taking the time required to develop a client-centred approach to practice that maximizes client autonomy and elaborates a customized plan might be at the root of client-centred practice, but may take more time than healthcare professionals are afforded with each client. Additionally, individuals’ unique values, strengths, and preferences may be ambiguous and may not easily fit into existing frameworks such as protecting from harm and prioritizing safety, or addressing physical illness or injury, or into a theoretical framework aiming to guide “clientcentred” practice. As such, practices to identify and integrate unique client values and preferences into intervention and discharge plans may be overshadowed by more expedient practices that focus narrowly on older clients as objects of care who need to be kept safe and have their healthcare needs met. Such practices are arguably simpler as physical safety is being prioritized rather than the breadth of personal, physical, psychological, and emotional (and other) safety needs or preferences. Similar observations were made by Huby and colleagues, who asked whether risk management and patient participation in discharge planning were compatible aims (36). Considering the unique set of client preferences, values, needs, strengths, resources, and circumstances may be healthcare professionals’ intent but may not be the practice to which they resort in light of shorter lengths of stay and higher caseloads in many healthcare settings (48). Thus, while there is a systemic push to provide client-centred practice and an intrinsic pull towards it for healthcare professionals based on their training and ethics, systemic policies regulating the amount of time that healthcare professionals have to provide care and make discharge plans limit the potential for client-centred practice to be realized. Conclusion The results ofthisresearchdemonstratethat,inthestudy setting, healthcare professionals’ understandings of client-centred practice were narrowly construed as
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upholding client preferences in so far as doing so was deemed to be safe according to the healthcare team. Such a limited application does not achieve the intended aims of client-centred practice described in the literature. We argue that relational autonomy theory is not only aligned with more robust descriptions of clientcentred practice, but also has the potential to promote practice that reconciles concerns for client safety with aims to uphold client preferences. Practice guided by relational approaches can enhance clients’ capacities to participate in collaborative decision-making by creating conditions that promote the enactment and recognition of their autonomy. On a broader scale, relational autonomy theory encourages the examination of social, political, and institutional structures and consideration of the influence these may have on individuals’ autonomy, identities, perspectives, strengths, and capabilities (29,30). This examination extends to the intersection of social, political, and institutional structures that can, at times, set up situations of occupational injustice (34). The failure of healthcare professionals to politicize their actions in the interest of social justice has been highlighted as a barrier to client-centred practice (34,49). The application of a relational autonomy lens to practice could help to identify overarching social, political, and institutional structures that are intersecting to constrain client or therapists’ autonomy and create situations of injustice. Doing so could promote a discussion of how policies and practices could be reoriented away from institutionally driven values (50) or therapist-centred care (2) to better enable approaches that foster client autonomy, promote social and occupational justice, and better align with tenets of client-centred practice (34,37). 1 The authors recognize there are differing views with respect to the use of the terms “client”, “patient”, and “person” in this context. It is not our intent to address this debate in this paper. Given that the term “client-centred” is the convention in the field of occupational therapy, other than in instances where the terminology in cited texts differs, we will use the term “client”.
Acknowledgements The authors sincerely thank the research participants for their willingness to share their stories with us. They are grateful to Drs Susan Rappolt, Barbara E. Gibson, and Kathryn Morgan for their notable contributions to the development of this work. DThey thank the Ontario Graduate Scholarships programme, the Margaret and Howard Gamble Scholarships, and the Peterborough K. M. Hunter Graduate Studentships for their generous funding of Evelyne Durocher
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during the completion of this work. Matthew Hunt is supported by a research scholar award from the Fonds de Recherche du Québec – Santé. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
Contradictions in client-centred discharge planning: through the lens of relational autonomy Evelyne Durocher, Elizabeth Anne Kinsella, Carolyn Ells & Matthew Hunt To cite this article: Evelyne Durocher, Elizabeth Anne Kinsella, Carolyn Ells & Matthew Hunt (2015) Contradictions in client-centred discharge planning: through the lens of relational autonomy, Scandinavian Journal of Occupational Therapy, 22:4, 293-301 To link to this article: http://dx.doi.org/10.3109/11038128.2015.1017531
Published online: 24 Feb 2015.
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Scandinavian Journal of Occupational Therapy. 2015; 22: 293–301
ORIGINAL ARTICLE
Contradictions in client-centred discharge planning: through the lens of relational autonomy
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EVELYNE DUROCHER1,2, ELIZABETH ANNE KINSELLA3,4,5, CAROLYN ELLS6 & MATTHEW HUNT7 1
School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montréal, Québec, Canada, Centre for Interdisciplinary Research in Rehabilitation, Jewish Rehabilitation Hostpital, Laval, Québec, Canada, 3School of Occupational Therapy & Occupational Science field, Faculty of Health Sciences, Western University, 4Health and Rehabilitation Sciences Graduate Program, Faculty of Health Sciences, Western University, 5Department of Women’s studies and Feminist Research, Western University, London, Ontario, Canada, 6Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada, and 7Centre for Interdisciplinary Research in Rehabilitation, Jewish Rehabilitation Hostpital, Laval, Québec, Canada
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Abstract Background: While client-centred practice has received wide support, it remains difficult to apply in many practice settings. Identified barriers include constraints on time, resources, and services imposed by healthcare policies. Healthcare professionals’ prioritizing of client safety over (other) interests that clients may name may further restrict the application of client-centred practice. Discharge planning is one area where such considerations can conflict. Aim: This paper presents a secondary analysis of data examining the process of discharge in one Canadian rehabilitation setting. It examines how discourses of client-centred practice and of prioritizing safety were reflected in discharge planning with older adults and considers the implications of potential conflicts between these discourses. Method: Taking a critical bioethics perspective informed by relational autonomy theory, microethnographic case studies were used to examine discharge planning from the perspectives of older adult clients and healthcare professionals. Results: Healthcare professionals interpreted client-centred practice to require abiding by client wishes, as long as this was safe; furthermore prioritizing safety took precedence over other considerations in discharge planning. Conclusion and significance: Client-centred practice was not promoted in discharge planning processes in the research setting. Applying a relational autonomy lens to practice could promote approaches that better facilitate client-centred practice.
Key words: patient safety, microethnographic case studies, feminist bioethics, ethical tensions, critical bioethics
Introduction While client-centred1 practice has received wide support, it remains difficult to apply in many practice settings in which precedence is attributed to demands imposed by institutionally centred and policy-driven healthcare systems (1,2). Barriers to enacting clientcentred practice identified in the literature include constraints imposed by institutional healthcare policies, including time, resources, information
transfer, funding, and services available to clients (3-6). Additionally, there are suggestions that an unreflective prioritization of safety over other concerns may further restrict the application of clientcentred practice (3,6). This paper presents the results of a secondary analysis of data examining discharge planning in one inpatient rehabilitation setting in Canada. Discharge planning is particularly relevant to occupational therapists as it is a prominent source of ethical tension in practice (7-10). We examine how
Correspondence: Evelyne Durocher, PhD OT Reg. (Ont.), Postdoctoral fellow, School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Rabinovitch House, room 102, 3640 Rue de la Montagne, Montréal, Québec H3G2A8, Canada. E-mail: [email protected] (Received 17 December 2014; accepted 4 February 2015) ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1017531
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values prioritizing safety routinely overshadowed commitments to client-centred practice with older individuals in discharge planning. We then discuss how this resulted in practices that contradicted clinicians’ professed adherence to client-centred practice and conflicted with the intended aims of clientcentred practice as outlined in the literature.
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Background information During the 1990s, Western healthcare systems moved towards client-centred healthcare. Client-centred or shared decision-making approaches emerged in reaction to more paternalistic attitudes in order to promote collaborative decision-making between healthcare professionals and their clients (11,12). The intention was for clients to be more involved in decisions relating to their care, and for their perspectives and unique circumstances to be considered in finding options that met clients’ needs, upheld their preferences, and fitted into existing healthcare systems (11,12). Client-centred practice remains a guiding principle in professional and institutional healthcare mandates (13-16) and aligns with the World Health Organization’s concept of people-centred care (17). Challenges to realizing client-centred practice have been identified in both theoretical and empirical practice literature. These include policies limiting the amount of time healthcare professionals have to spend with clients, context-specific conventions and processes, as well as limitations to the quantity and type of services offered (3-5,18-20). Such limitations can lead to ethical tensions for practising occupational therapists who may be unable to practise in a manner that meets their clients’ needs (8-10). Beginning in the mid-twentieth century, there has been a steady rise in discourses of institutional and professional accountability, risk aversion, and patient safety promotion in healthcare institutions (21,22). These developments raise additional challenges to the application of client-centred practice when options that promote individual safety are given precedence over other considerations (3). A domain of practice in which commitments to client-centred practice and the promotion of safety often conflict is discharge planning, particularly with older adults (6). Timely and appropriate discharge planning is important in preparing individuals to leave, or discontinue use of, healthcare services. Planning discharges from inpatient care settings involves deciding where a client will live, identifying if care will be needed, and if so, arranging services to ensure that individuals’ needs will be met. For older adults being discharged, the decision to return home or move into a long-term care facility can have tremendous implications (6,23). One’s home environment has a significant impact in shaping the
social, occupational, healthcare, and personal aspects of one’s life; one’s home may hold great emotional significance and be closely related to one’s identity and sense of self (24,25). The application of clientcentred practice in discharge decisions could help to identify options that align with clients’ values (25). However, evidence suggests that sometimes safety is prioritized over client-centred practice, which can result in situations where older adults are not included in discharge decisions (6). Purpose of paper In this paper we critically examine how discourses of client-centred practice and the prioritization of safety are taken up in practice using the example of discharge planning with older adults from an inpatient rehabilitation setting. We draw on a study by the lead author that examined discharge planning (26) to highlight tensions between the definitions of client-centred practice in the literature and the understandings of clinicians. We further examine conflicts between the aims of client-centred practice articulated variously by clinicians, their professional bodies, and healthcare institutions, and discourses that prioritize safety. We argue that attending to relational autonomy has the potential to guide clinicians to practise in ways that better align with the tenets of client-centred practice. Material and methods This work is part of a larger project examining discharge planning (26). Taking a critical bioethics perspective (27,28) informed by relational autonomy theory (29,30), we used microethnographic case studies (31) to examine discharge planning processes at one rehabilitation unit in Canada. The data set comprised five case studies for a total of five discharge planning family conference observations and 22 semistructured interviews. Each case explored discharge decision-making from three stakeholder perspectives: the older adult preparing for discharge from inpatient rehabilitation, one or more involved family members, and one or more healthcare professionals involved in the individual’s discharge-planning process. In this secondary analysis, we include the six interviews with the older adults (four women and two men) and the 11 interviews with healthcare professionals (three occupational therapists, one physical therapist, two social workers, one head nurse, and one unit manager – two healthcare professionals were interviewed in relation to more than one case). Data generation and analysis occurred simultaneously to allow unforeseen topics identified as relevant in earlier case studies to be explored in subsequent case studies. The data from fieldnotes
Client-centred care and relational autonomy and interview transcripts were analysed inductively and deductively following a modified version of the process suggested by Dierckx de Casterle and colleagues (32) whereby instead of coding in the second phase of analysis as these authors suggest, two sets of questions based on the research questions and guided by the theoretical framework were asked of the data. The research was approved by research ethics boards at the University of Toronto and the partnering institution.
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Results Healthcare professionals who participated in the study interpreted client-centred practice to prioritize client preferences as long as doing so was considered safe. Healthcare professionals and clients alike valued the comfort and familiarity they associated with their home as well as the opportunities that their current home environments offered them. Despite this, prioritizing safety inevitably took precedence over abiding by client wishes in discharge planning. These three different themes will be discussed. Pseudonyms are used to maintain participant confidentiality. Healthcare professionals’ understandings of client-centred practice All healthcare professionals in the study professed adherence to client-centred practice. Understandings of client-centred practice, however, differed between participants. One healthcare professional equated client-centred practice with enabling what the client wanted “as long as it’s safe”: Interviewer: What do you think of this word [clientcentred] and how would it apply to discharge planning? Rebecca: The first person who I meet with is the client, is the patient, because obviously I want to hear what they want from their rehab stay and what they hope would be the discharge plan for them, because sometimes their kids or their grandchildren or siblings or whoever it is has a very different idea on what would be best for them. So I always like to hear what the patient wants first. I always try and be client-centred in my approach, and that’s what I do on the unit. Like I said, they’re the first people that I meet. . .. I advocate for what the patient wants as long as it’s safe. Rebecca indicated that she was client-centred in her practice because she met with the clients and found out what they wanted. Erica, another healthcare professional, described client-centred practice as balancing safety with individual wishes, while taking into consideration the individual’s capacity: I feel that client-centredness does not always mean that we go with what they want. It has to be a balance
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between honouring their wish but also maintaining safety . . . so I feel that client-centredness has to be respected, but also with the understanding that you have to look at the person’s capability and capacity to make decisions for themselves. Both practitioners vouched for what the client wanted as long as this was safe. These quotations implied that safe practice trumped client-centred practice (here associated with honouring clients’ wishes) if the two were in opposition. A different way of relating client-centred practice to doing what the client wants was evident in suggestions that recommendations were client-centred when older adults agreed with them. As Julie stated, “I think I am very client-centred, and I would say, 90 per cent of cases of discharge, the patient is in agreement with what we’re recommending”. Julie suggests that the high percentage of client agreement with the team’s recommendations validates her practice as client-centred. She went on to discuss a different understanding of client-centred practice in which clients are included or “involved” in discharge planning from the beginning even if clients do not agree with the plans made. In sum, according to healthcare professional participants, client-centred could mean different things. The most prominent understanding entailed abiding by what the client determines to be the client’s own best interests. A second understanding entailed balancing clients’ wishes with their safety and capacity (to understand the situation and to make decisions). In this formulation, healthcare professionals had to balance clients’ wishes and determination of best interests with the healthcare professionals’ duty to protect patients from potential harms. Keeping clients “involved” throughout the process was a third feature of client-centred practice reported by these participants. In practice this was interpreted to require listening to or informing clients even if clients did not agree with decisions taken. Values associated with one’s home When asked about what was important in discharge and where they lived, older adults frequently spoke of the importance of being in their own space. Maeve described that she wanted to go home “just to be in my own place”. Magan quoted the expression “There’s no place like home” and further discussed the comfort of knowing where all of one’s belongings are placed, the freedom to invite guests, and the increased function that being in one’s own space enables: The comfort of knowing where things are, what is what. It also depends how you want to live. If I want to invite you to my home for lunch, I should know where things are, my crockery, my cutlery, my
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coffeemaker, my whatever it is. So that process of inviting people to lunch or [that] kind of thing becomes simpler. Frederik and his wife Rita similarly discussed the importance of living in a place where they had frequent opportunities to play bridge, and where they could easily visit their families. Another important aspect of one’s home was the pride that individuals took in organizing and maintaining their space. Marion expressed pride in saying “That’s my castle. I have a nice home, it’s clean; it’s always clean. I look after it.” And furthermore expressing “I will not leave my home. My home is my castle. But now I have a one-bedroom, two bathrooms, a kitchen, the washer-dryer is off the kitchen I have no stairs to walk. I’m very comfortable.” For Marion, the cleanliness of her home inspired pride. She was comfortable there. She hinted at consideration of her functional limitations and the implications for her safety when she mentioned that there were no stairs in her home. (Marion had difficulty going up and down stairs on her own.) Similarly, while Sophia reported feeling pride in her garden and the cleanliness of her home, she also asserted that after a recent fall and hospitalization she was afraid of falling and that having a home free of stairs was important to her. Other than these mentions, safety did not factor in older adults’ discussions about their home or where they wished to live and therefore did not appear as a priority from the perspective of older adults in this study. When asked what they personally saw as important in their own living situations, healthcare professionals similarly listed attributes related to leisure and opportunities in the community: I’m in a place where there are a lot of things around me. . .. I want to go to Starbucks I go for a walk, I want to go to the bank, I go for a walk. . .. To have things accessible, close by, I don’t have to sit in traffic for three hours to get somewhere, I think that’s important. To be close to family I think is important. As Alison stated above and as reinforced by Julie, healthcare professionals also mentioned attributes such as being close to family. “Home to me is. . .. I always think of my family and who’s living in my house, all of those things are important to me, that’s what makes my home.” In relation to themselves, all participants reported valuing attributes of their homes related to comfort and familiarity, as well as the opportunities available to them in their preferred home environment. Healthcare professionals’ prioritization of safety The promotion of safety was prominent in all healthcare professionals’ discussions of their discharge
planning recommendations. There was a difference between what healthcare professionals viewed as important in relation to their own home or living situations and what they saw as important for older adults’ living situations upon discharge, namely safety. In relation to their own home, healthcare professionals in this study did not mention safety. In consideration of older adults’ living situations and discharge plans, however, comfort, familiarity, and opportunity for preferred occupations was secondary to the prioritization of safety. Not only did healthcare professionals in this study view safety as something to be prioritized over client preferences, but healthcare professionals also viewed safety as the most important consideration in all situations of discharge. Evidence of the prioritization of safety in healthcare professionals’ approaches came to light in discussions of what was a “good” or a “bad” discharge, which was closely linked to the safety of the discharge plan as defined by the healthcare team, the alignment of the final discharge outcome to the team’s recommendations, and the amount of discord between involved parties. All healthcare professionals indicated that a good discharge was a safe discharge. As Alison said, “A safe discharge for me is a good discharge”. Conversely, as Julie describes, unsafe or risky discharges were described as “disaster discharges”: I mean obviously it’s people’s personal choice to live at risk . . . we call them disaster discharges. There’s lots of times that there are disaster discharges where the person goes to an environment that I think is not optimal for them. According to Julie, disaster discharges were those whereby individuals chose to live at risk and not put in place the recommendations of the healthcare team – which would keep them safe. Another healthcare professional reaffirmed this idea: Rebecca: We’ve discharged patients here and it’s been a disaster – I mean it. The discharge plan is totally not what we would have recommended – at the end of the day what can you do? I mean unless they’re incapable and then you can deem them incapable and you know defer to the POA [power of attorney] or the substitute decision-maker. Interviewer: When you say that the discharge plan is a disaster, you mean like in terms of what they’ve put in place? Rebecca: In terms of them not following our recommendations and [they] leave and we’re very anxious because we know it’s not safe but that’s what they’ve decided they want to do. In these last two quotations the prioritization of physical safety was seen as the only logical or reasonable option. According to Alison, if the patient’s home was not a safe option, it was not considered:
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Client-centred care and relational autonomy So we all come up with ideas to try and get the patient home, if that’s where they want to go, but if home’s not safe, where’s another place either that is safe, and that they want to go to, or just a place that is safe, even if it’s not necessarily their first choice. Despite one acknowledgement that a client has a choice to live at risk, these healthcare professionals implied that they did not support autonomous choices that differed from their recommendations for a safe discharge. Older adults valued being comfortable in the familiarity of their own space. Yet, there was little consideration for client preferences in the healthcare professionals’ accounts, which directly contradicted their own understandings of client-centred practice and the promotion of client preferences. Taking a putatively client-centred approach to practice was therefore in effect, maximizing client safety. Discussion and implications A critical approach informed by relational autonomy theory At the heart of client-centred practice is a presumption of respect for the autonomy of clients, yet little literature in the field problematizes how the enactment of respect for autonomy in practice occurs; the results of this study point to conditions that preclude or trump its enablement. Relational autonomy theory recognizes that not everyone has equal opportunity for autonomous decision-making and action, that autonomous action is mediated through relational, social, cultural, economic, contextual, situational, and political dimensions, and that power circulates in its enactment (29,30,33). In this way theories of relational autonomy offer a means of more deeply examining how autonomous decision-making and actions of individual or groups of clients are enabled or constrained, and draw attention to circumstances that promote (in)justice for particular groups or individuals. For example, in situations where individual choices are constrained by external forces, opportunities for engagement in occupations can be impeded or coerced, which can result in occupational injustice and can have an impact on individual health and well-being (34). Theories of relational autonomy thereby contribute a critical perspective to the aim of respecting autonomy and imply a duty to promote justice as central to client-centred practice. This theoretical perspective aligns with recent literature pertaining to the influence of external forces on older adults’ decision-making processes (35,36). Ells et al. have suggested that a consideration of relational autonomy ought to be an essential component of client-centred practice (37). Being attentive to the relational aspects of autonomy has the potential to promote a more in-depth understanding of the
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values, concerns, and external forces shaping clients’ perspectives and choices and to foster increasingly client-centred discharge plans. In this research we used relational autonomy theory to: (i) focus our analysis on revealing the hidden intersections of influences on healthcare professionals’ practice in discharge planning with older adults, and (ii) augment current understandings of client-centred practice. Doing so opens a discussion of how using relational autonomy theory to frame practice may enhance and better align practice with the intended aims of client-centred practice and help clinicians to navigate ethical tensions they encounter in discharge planning, or other areas of practice. Safety and client-centred practice The importance of safety in healthcare professionals’ approaches in this setting echoes research findings from Canada, the United States, and Australia in which healthcare professionals prioritized safety in discharge planning (6,38,39). The drive to promote and maximize patient safety is also prominent in healthcare and best practice literature (40,41) and in the mandates of various professional colleges and associations (16,42,43) but may also be linked to a fear of professional or institutional liability and an impetus to manage professional and institutional risk (21,36,44). These prevalent structural drivers are reflected in the prioritization of safety in the institutional practices reported in the study. The literature shows much variability in terminology and conceptions of client-centred practice. Predominant definitions focus on considering individuals and groups within their contexts and including them in collaborative decision-making concerning their care with little or no mention of safety. For instance, in a large-scale review of the literature on client-centred practice (which included patient- and person-centred search terms), Brookman and colleagues (43) suggest that client-centred practice is based on “developing an understanding of the individual, their environment, values, relationships and social world” (p. 22). Additionally, the World Health Organization’s defining criteria for person-centred care include maintaining “respect for patients and their decisions” and the “provision of individualized care” (17). Similarly, the Canadian Association of Occupational Therapy denotes client-centred practice as a collaborative approach that that recognizes clients’ experiences and knowledge and involves clients in decision-making (16). In their seminal text, Gerteis and colleagues (44) suggest that patient-centred practice “consciously adopts the patient’s perspective” (p. 5). These authors further elaborate seven dimensions of patient-centred care: (i) Respect for patients’ values, preferences, and
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expressed needs; (ii) Coordination and integration of care; (iii) Information, communication, and education; (iv) Physical comfort; (v) Emotional support and alleviation of fear and anxiety; (vi) Involvement of family and friends; and (vii) Transition and continuity (p. 5–11). The literature focuses on developing an understanding of clients’ values and contexts in order to consider these in healthcare decision-making. This overlaps with the descriptions of client-centred practice in the data in the common concern for clients’ values. Conceptions in the literature, however, promote the inclusion of client values and preferences in the determination of care plans while practices and behaviours to honour client values and preferences did not appear in the data. The multi-dimensionality of concepts in the literature contrasts professional participants’ narrowly conceived descriptions of client-centred practice as following the clients’ wishes only if assessed as safe. The aim to prioritize safety over consideration for other aspects of clients’ lives in discharge planning can lead to ethical tensions and create moral distress for occupational therapists (8-10), which we propose may be mitigated to some extent through attention to relational autonomy within the practice of client-centred practice. Implications for practice: How relational autonomy theory might be helpful More robust conceptualizations of client-centred practice include not only consideration for individual values or preferences, but also an understanding of the person, her/his strengths, capabilities, needs, and resources, as well as her/his environment, relationships, and social networks. These aspects strongly overlap with relational approaches that consider individuals’ unique capabilities, needs, and preferences, and how these are shaped by social and political contexts (28,29,37). Framing practice through the lens of relational autonomy theory promotes practice that better enables individuals to participate autonomously in shared decision-making, a key component of client-centred practice. Through a collaborative process, clients’ values, strengths, and areas in which they need support, as well as potential influences (barriers and facilitators) on the clients’ autonomy, could be identified. Based on these features, a tailored relational approach can be taken to enable conditions that support greater recognition and uptake of clients’ contributions in collaborative decisions regarding discharge. Unsurprisingly, there were contradictions in the data between older clients’ wishes for discharge, which focused on returning home and being in their own space, and healthcare professionals’
recommendations, which focused on protecting older clients’ safety. What was surprising was the healthcare professionals’ unreflective prioritization of safety over client preferences in light of the narrow understanding of client-centred practice they exhibited (notably when client-centred practice, and perhaps respect for autonomy, was assumed to be limited to abiding by client preferences). This conflict between safety and upholding client preferences relates to what has been called “the dignity of risk” (45,46). “The concept of the dignity of risk acknowledges the fact that accompanying every endeavour is the element of risk and that every opportunity for growth carries with it the potential for failure” ( (46), p. 28). In her commentary, Nay (45) discusses healthcare professionals’ tendency to maximize physical safety at the expense of all other considerations, and the potential link to protecting the hospital from potential liability. She argues, however, that removing the freedom to take physical risks does not uphold older adults’ autonomy and can engender psychological harm. A relational autonomy perspective views individuals as having a unique constellation of circumstances and as interrelated with their contexts. Practice adopting this approach would promote addressing the discharge decision at hand, but also taking into consideration how this decision or action is related to the individual’s identity, values, and life circumstances. As Hunt and Ells (47) state, when approaching decisions between options that may involve personal risks for clients or others, “it is particularly important to probe the meaning the patient associates with the choice that is being considered, as well as to seek to understand the meaning of potential consequences that have been identified . . . and how these are incorporated in the patient’s evaluation of risk” (p. 964). Framing practice through a relational approach may thus better enable a collective determination of discharge plans that uphold individual values, are more accurately tailored to individuals’ unique intersections of needs, preferences, strengths, and resources, and that attend to considerations of various dimensions of safety. Where clients participate in decision-making, they also share in the responsibility for decisions made. Such an approach supports enriched conceptualizations of client-centred practice as outlined in the literature. Taking a relational approach also includes the added dimension of considering social, cultural, economic, and political contextual forces and how these may enable or constrain particular choices. Bringing attention to such influences has the potential to promote changes in practices and policies that disable barriers and allow for more options, thereby better enabling client-centred practice. Taking a relational approach to autonomy may furthermore decrease the
Client-centred care and relational autonomy ethical tensions and moral distress experienced by occupational therapists, by offering a more robust consideration of different dimensions informing the capacity for autonomy in the situation, as well as the potential harms, benefits, and other justifications for each option.
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Challenges to a client-centred or relational approach Practices that support a relational approach to clientcentred practice would not easily fit within the kind of “triage model” of discharge planning identified in this research (26). Identifying individuals’ preferences, values, strengths, weaknesses, and specific circumstances, and taking the time required to develop a client-centred approach to practice that maximizes client autonomy and elaborates a customized plan might be at the root of client-centred practice, but may take more time than healthcare professionals are afforded with each client. Additionally, individuals’ unique values, strengths, and preferences may be ambiguous and may not easily fit into existing frameworks such as protecting from harm and prioritizing safety, or addressing physical illness or injury, or into a theoretical framework aiming to guide “clientcentred” practice. As such, practices to identify and integrate unique client values and preferences into intervention and discharge plans may be overshadowed by more expedient practices that focus narrowly on older clients as objects of care who need to be kept safe and have their healthcare needs met. Such practices are arguably simpler as physical safety is being prioritized rather than the breadth of personal, physical, psychological, and emotional (and other) safety needs or preferences. Similar observations were made by Huby and colleagues, who asked whether risk management and patient participation in discharge planning were compatible aims (36). Considering the unique set of client preferences, values, needs, strengths, resources, and circumstances may be healthcare professionals’ intent but may not be the practice to which they resort in light of shorter lengths of stay and higher caseloads in many healthcare settings (48). Thus, while there is a systemic push to provide client-centred practice and an intrinsic pull towards it for healthcare professionals based on their training and ethics, systemic policies regulating the amount of time that healthcare professionals have to provide care and make discharge plans limit the potential for client-centred practice to be realized. Conclusion The results ofthisresearchdemonstratethat,inthestudy setting, healthcare professionals’ understandings of client-centred practice were narrowly construed as
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upholding client preferences in so far as doing so was deemed to be safe according to the healthcare team. Such a limited application does not achieve the intended aims of client-centred practice described in the literature. We argue that relational autonomy theory is not only aligned with more robust descriptions of clientcentred practice, but also has the potential to promote practice that reconciles concerns for client safety with aims to uphold client preferences. Practice guided by relational approaches can enhance clients’ capacities to participate in collaborative decision-making by creating conditions that promote the enactment and recognition of their autonomy. On a broader scale, relational autonomy theory encourages the examination of social, political, and institutional structures and consideration of the influence these may have on individuals’ autonomy, identities, perspectives, strengths, and capabilities (29,30). This examination extends to the intersection of social, political, and institutional structures that can, at times, set up situations of occupational injustice (34). The failure of healthcare professionals to politicize their actions in the interest of social justice has been highlighted as a barrier to client-centred practice (34,49). The application of a relational autonomy lens to practice could help to identify overarching social, political, and institutional structures that are intersecting to constrain client or therapists’ autonomy and create situations of injustice. Doing so could promote a discussion of how policies and practices could be reoriented away from institutionally driven values (50) or therapist-centred care (2) to better enable approaches that foster client autonomy, promote social and occupational justice, and better align with tenets of client-centred practice (34,37). 1 The authors recognize there are differing views with respect to the use of the terms “client”, “patient”, and “person” in this context. It is not our intent to address this debate in this paper. Given that the term “client-centred” is the convention in the field of occupational therapy, other than in instances where the terminology in cited texts differs, we will use the term “client”.
Acknowledgements The authors sincerely thank the research participants for their willingness to share their stories with us. They are grateful to Drs Susan Rappolt, Barbara E. Gibson, and Kathryn Morgan for their notable contributions to the development of this work. DThey thank the Ontario Graduate Scholarships programme, the Margaret and Howard Gamble Scholarships, and the Peterborough K. M. Hunter Graduate Studentships for their generous funding of Evelyne Durocher
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during the completion of this work. Matthew Hunt is supported by a research scholar award from the Fonds de Recherche du Québec – Santé. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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