Art & science
If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Managed care: a structured approach Linsley P, Morton S (2014) Managed care: a structured approach. Nursing Standard. 28, 19, 37-42. Date of submission: July 8 2013; date of acceptance: September 9 2013.
Abstract The authors developed a model of clinical nurse management based on the concept of managed care. This article, which describes the model, is intended to encourage nurses to consider their role as manager and engage in activities that support good management of clinical practice. The model presents several components that need to be monitored and controlled if best care is to be achieved. Specifying these components in the form of a model allows a visual representation of practice and supports contemporary thinking about healthcare management from the perspective of the nurse in clinical practice.
Authors Paul Linsley Principal lecturer in nursing, University of Lincoln, Lincoln. Sean Morton Senior lecturer in nursing, University of Lincoln, Lincoln. Correspondence to: [email protected]
Keywords Change management, managed care, patient-centred care, patient-focused care
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
© NURSING STANDARD / RCN PUBLISHING
MANAGED CARE IS described as a variety of systems and arrangements for planning, managing, delivering and evaluating care. In a well-functioning system of managed care, a defined group of people receive treatment services that are clinically necessary and appropriate, within defined benefit parameters, for a set amount of time, in compliance with quality standards, and with anticipated and measurable outcomes (NHS Confederation 2006). By relating services to, and developing services around, the patient, managed care can reduce duplication and cost while targeting the essential components of care and providing a timely and appropriate service for patients (Nolte and McKee 2012). Achieving a balance between the different components of managed care requires active management. Nurses, other healthcare professionals and service managers aim to achieve the highest standard of care possible within often socially constructed restraints, such as patient expectation, local commissioning arrangements and service delivery, and services that are often resistant to change (Ham et al 2011). Managed care has become increasingly complex because of changes in commissioning arrangements, the way in which services are delivered, performance management and advances in technology (Hurley and Linsley 2007). The Health and Social Care Act 2012 provides a departure from current commissioning arrangements for health and social care and constitutes a major restructuring of the health service in England, requiring nurses and others to work in a more collaborative and flexible way, and to extend their roles to meet public expectation and demands. In response to this changing environment, the authors developed a model of managed care. The model presents several components that need to be monitored and controlled if best care is to be achieved. january 8 :: vol 28 no 19 :: 2014 37
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Art & science nursing management Managed care model Nurses are increasingly expected to manage and report on the care they give, taking into account several components that, while interrelated, can at times work against each other (Figure 1). These conflicting demands require monitoring and control on behalf of healthcare professionals by the organisations for which they work to ensure high quality care. While the components of the proposed model are discussed individually, the model is best used when opposing components are viewed in one of three states: Ideal – when two or more opposing components work in unison for the benefit of the patient. For example, the delivery of quality care is enhanced when services are focused on the needs of the patient, based on best evidence and contemporary thinking, and managed and actioned in a multiprofessional framework in which each service is viewed as equal. Moderator – when one of two opposing components is viewed as moderating the other’s activity or behaviour. For example, the nurse may want to pursue a particular treatment or intervention in keeping with his or her professional thinking, but he or she may have to adapt the approach to meet the requirements of medical colleagues. Antagonist – when one of two components is working in opposition or in spite of the other.
FIGURE 1 Model of managed care
Managing expectation Maintaining and adhering to professional standards
Law and ethics Fiscal responsibility
Patientfocused care
Multiprofessional, multi-agency working
Delivering quality care Patient and family advocacy
Contemporary thinking, creativity and entrepreneurship
Managing performance
38 january 8 :: vol 28 no 19 :: 2014
Managing knowledge
Managing information
Organisational fit
For example, when the patient wants to leave the ward, but is prevented from doing so because he or she has been placed under a section of the Mental Health Act 2007. To bring about effective change in one component of the model requires careful and thoughtful management, demonstrating sensitivity to the change process and the demands this makes on staff and patients. Effective care is achieved when all components of the model are working in support of each other for the benefit of the patient. Other than meeting the needs of the patient, no single component should be considered more important than another.
Patient-focused care
The managed care model revolves around the concept of patient-focused care, or patient-centred care. For the purpose of this article, patient-focused care and patient-centred care are viewed interchangeably, reflecting the way the two terms are used in the wider literature. The term patient-focused care implies individualised care, based on and responsive to individual need. Furthermore, it is: ‘Healthcare that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care’ (Institute of Medicine Committee on Quality of Health Care in America 2001). The definition emphasises the importance of working in partnership, recognising that patient-centred care is best achieved through collaboration and joint working. Partnership is important in fostering a sense of ownership and collective responsibility that involves and reflects the views and needs of patients, healthcare staff and the wider community (Kreitzer et al 2009). Patient-focused care provides the framework and strategies to improve the experience of care, and enhance quality, safety and efficiency (Shaller 2007). Modern concepts of patient-focused care are based on research conducted by the Picker Institute and the Harvard School of Medicine, which identified seven dimensions of patient-centred care, including (Gerteis et al 1993): Respect for patients’ preferences and values. Emotional support. Physical comfort. Information, communication and education. Continuity and transition. Co-ordination of care. Involvement of family and friends. An additional dimension to patient-focused care
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proposed here is that of public health. Public health extends the aim of patient-focused care by promoting a sense of responsibility in individuals for their actions and health-related behaviours and lifestyle (Linsley et al 2011), as well as helping people to achieve good health and wellbeing. It encourages the nurse and other healthcare professionals to think about the needs of the community in which the person lives and, in turn, how the community affects an individual’s health. Public health mandates the need to work with the vulnerable in society to tackle issues such as stigma and prejudice, and act as an advocate for those who are unable to communicate their needs.
the organisation’s structure. Nurses should be encouraged to take part in qualitative initiatives by identifying improvement opportunities, collecting and analysing relevant data, formulating a planned approach for improvement and implementing suggested changes. The challenges in delivering and improving patient-focused care include finding a shared language for healthcare professionals and managers to discuss such care, identifying the most relevant measures to capture patient experience and finding ways to translate the data on patients’ experience into service improvement (NHS Institute for Innovation and Improvement 2008a).
Maintaining and adhering to professional standards
The nurse as an advocate for the patient and family has long been recognised in the literature and the role reflects a range of activities such as helping the patient and family access health care, assuring quality of care, defending the patient’s rights, and liaising between the patient and the healthcare system (Negarandeh et al 2006, Department of Health 2010, Institute for Patient- and FamilyCentered Care 2011). Providing patient-focused care involves considering the perspective of service users and setting care objectives accordingly. Nursing practice needs to be sensitive to the social environment and the needs of patients and their families, and mandates thoughtful consideration of the legal and ethical dilemmas that arise from a delivery system that is focused on the efficiencies of managed care (Hunter 2006).
With professional practice comes a responsibility to maintain professional standards by acting ethically, adhering to the profession’s code of conduct, and keeping up to date through development and training. Managing self and working within certain limitations places demands on the nurse and others to work to a defined standard of care and level of activity, and at times exceed these. Managing self should be considered the first step in managing others, because it is only by setting an example and working to the highest standards that nurses can hope to influence the behaviour and attitudes of those with whom they work.
Organisational fit
The primary responsibility of the nurse is to ensure optimum care of the patient. In achieving this, the nurse needs to ensure that he or she meets the requirements of the employing organisation while carrying out his or her duties and that he or she works and adheres to agreed policy and procedure. It is the responsibility of the organisation to provide resources, support and guidance to allow staff to undertake their duties. In promoting clinical effectiveness, the organisation and individual employer should work together to ensure that care is delivered in a timely and appropriate way. The nurse’s duty as a manager is to ensure that he or she, and those he or she supervises, remain focused on what is relevant and important to the organisation, and to ensure that work activities and individual behaviour and performance are in keeping with the requirements of the organisation.
Delivering quality care
Providing quality care should be the goal of all involved in patient-focused care. Quality is a major managerial function and there should be clear lines of responsibility and accountability in
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Patient and family advocacy
Contemporary thinking, creativity and entrepreneurship
Nurses assume many roles as they carry out their work. To perform these roles effectively, nurses must be supported by staff in their clinical practice environments who have a clear understanding of what is needed. This match must be dynamic to keep pace with rapidly changing healthcare needs, new technology and contemporary thinking. It is a challenge for nurses to support and incorporate contemporary thinking and approaches to care in clinical practice. As well as being challenged, the nurse needs to challenge accepted wisdom, contemporary issues and beliefs, and have a solution for improvement. The need to develop and use the creativity of staff finds expression in the notion of entrepreneurialism and intrapreneurship (International Council of Nurses 2004, Cooper 2005, Wilson et al 2012). Supporting teams and individuals in being creative requires an understanding of the need to ‘change with the times’ and to foster environments in which such january 8 :: vol 28 no 19 :: 2014 39
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Art & science nursing management creativity can occur. Such measures include the delegation of power; emphasising trust; giving, tolerating and incorporating criticism and feedback; and challenging existing practices and ways of working.
Multiprofessional, multi-agency working
Managed care requires greater interdisciplinary collaboration, which is based on the nurse’s clinical competence and professional self-assertion, and is balanced by a clear understanding of the care costs. Multiprofessional, multi-agency working is driven by a desire for collaborative advantage, often in terms of getting the job done. This reinforces the need to promote and support effective team working. In examining team effectiveness, the literature emphasises the need to match role with person, role with ability, role with personality and role with preferred ways of working (Watson and Gallagher 2005). Adair (1987) extended this notion of skill mix, suggesting that effective teams will comprise several members with different skills and ability. Managing and using the contribution of team members is an important task, and the challenge is to provide opportunities for shared working and decision making. Interdisciplinary working can be difficult to achieve for several reasons, particularly because of differences in disciplinary socialisation. In general, healthcare professionals tend to identify strongly with their own discipline and its language, values and practices, and to relate most effectively to other members of this discipline.
Fiscal responsibility
There needs to be recognition that health care is carried out within financial constraints and that every nurse promotes fiscal responsibility as part of his or her practice. Cost savings should be measured against nurse-sensitive outcomes, such as patient satisfaction and the extent to which planned care meets identified need. Since the NHS is required to make significant cost savings over the next five years, staff need to consider not only the ‘cutbacks’, but the entrepreneurship of nursing that can make the NHS more efficient (NHS Institute for Innovation and Improvement 2008b). Nurses are challenged to manage resources creatively to benefit the patient and the organisation for which they work. It is important to recognise that nursing does not generate income, but accounts for most of an organisation’s expenditure and budget. This puts the onus on nurse managers to manage their budgets in a responsible manner and for nurses to account for and manage supplies, equipment and time. 40 january 8 :: vol 28 no 19 :: 2014
Law and ethics
Laws promote health care and patients’ rights, while ethics ensure that health care is equitable. Nurses are expected to work within the law and behave ethically. Nurses are responsible for the evaluation of the employees they supervise and for the quality of care these individuals give. They must observe their employer’s rights and responsibilities to patients and other employees, fulfil the obligations of the contracted service, inform the employer of circumstances and conditions that impair the quality of care, and report negligent care by others (Tingle and Gribb 2007). This includes the legal duty to communicate any concerns about other healthcare professionals. Increasing patient expectation, the demand for services and the extension of the nursing role only serve to add to this pressure. Operational and organisational breakdowns resulting in litigation and court proceedings can be distressing for patients and their families, and also for healthcare staff. The psychological effect of failure exerts additional pressure on organisations that are already challenged, given that such events have the potential to demoralise staff and undermine public confidence.
Managing expectation
Perhaps the most difficult component to manage is expectation of the service. Patients will have a perceived idea about the standard of care that they are to receive and how they will be treated. Nurses need to be mindful of this, anticipate the needs and problems of patients, and seek to foster realistic expectations through patient education and communication strategies. Nurses should be proactive and open to dialogue with patients about their wishes and expectations of the service and seek to rectify shortfalls in care, in line with the NHS constitution, while being mindful that the service is facing challenging times (Prime Minister’s Commission on the Future of Nursing and Midwifery in England 2010).
Managing information
Health care requires the management and use of various sources of patient information as part of clinical practice, and that information is collected, recorded, processed and evaluated. High quality patient-focused care relies on the use of information in support of the patient journey. In turn, healthcare professionals, including nurses, require information in support of practice that is timely, relevant to their needs, in a form that they can use and open to scrutiny. Information management is concerned with
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obtaining and integrating information from many sources in support of decision-making requirements, which are often undertaken in high-pressure clinical environments. Effective channels of communication and information sharing need to be set up, maintained and reviewed periodically to ensure that they are fit for purpose and fit for practice.
Managing performance
Nurses integrate and manage all contributions to patient care (Linsley et al 2011). Managing performance is an essential part of delivering and improving health care. This extends beyond managing nurses’ and others’ performance to that of teams and organisations. Managing performance can be seen as the foundation of clinical practice since it provides the benchmark by which staff and organisations are judged, for example using performance indicators. Performance management is based on an agreement between a manager and an individual, a shared understanding of, and continuing dialogue about, an individual’s goals and the standards expected and competencies needed, together with an appreciation of the organisation’s mission, values and objectives (Torrington et al 2005). Clear performance expectations are also a crucial factor in teamwork success, and time must be given to communicating, monitoring and evaluating these. Each team member should know who is responsible for implementing decisions, and a team member should be nominated to ensure that tasks are undertaken within an appropriate timescale. Many tasks are complex, and it may be helpful to break them down into smaller components.
Managing knowledge
Knowledge management has gained significance and is driving change in the health service. The acquisition and development of healthcare knowledge is founded on evidence-based practice and is linked to emergent understandings of intellectual and human capital. The growing complexity in healthcare delivery and modern technologies requires nurses to be better educated and to demonstrate their knowledge base in support of the work they undertake. The generation of ‘usable knowledge’ is best achieved through research conducted in partnership with the users of the service, reflecting local need and concerns (McSherry and Pearce 2011). This requires active management on the part of the nurse and other healthcare professionals and willingness to try and support new ideas and ways of working.
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Change management Change in any component of the model will require management, for example a change in the patient’s treatment plan, a change of funding, or a change in policy or government legislation. To this end, change can be considered inherent to any healthcare system and something that requires careful management and sensitivity, because resistance to change is common among patients and staff. It is staying with what is known best that makes change difficult, however change management is only effective if it is challenged and always evolving. In essence, change management is an ongoing process. A vital task of any organisation is to manage change and develop the service, however it is the people in the organisation and particularly nurses who will implement this change. Change requires employers to think and behave differently while carrying out their role, and this is no longer illustrated by advances in technology, which have prompted many changes in the way that health care is delivered, accessed, recorded and measured. Changes to services need to be managed and actioned. Information, education and the joint commitment of management and healthcare staff play an important role in the successful implementation of change (Victorian Quality Council 2006).
Managing the care environment by bringing all components together It is important to ensure that the patient is the focus and that interventions and services are actioned and measured from the patient’s perspective when managing any care environment. The nursing process of assess, plan, implement and evaluate remains a solid foundation on which to develop nursing care. This, in turn, requires broad and active engagement in all aspects of the care process as well as involvement in the management and good order of the care environment. There is a need for shared decision making, requiring the involvement of patients as equal partners in their health care and collective patient and public involvement in the design and delivery of services. Due diligence on the part of healthcare professionals and a willingness to speak up when things are not working will serve to move this process along. Active management of the managed care model requires healthcare professionals to be mindful of the various components involved in a given situation and to evaluate how these might affect their work and the care of patients in terms of safety, quality and efficiency. Specific issues may january 8 :: vol 28 no 19 :: 2014 41
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Art & science nursing management need to be addressed and recourse sought. A willingness to work with others, to share good practice and adapt to new ways of working may also be required. Increasingly, healthcare professionals are being encouraged to think in terms of ‘process mapping’ and ‘system thinking’ when managing change. Process mapping refers to a range of activities that seek to identify what a service does, the way in which it does it, and to what end. System thinking recognises that staff and patients will view things in different ways, have different priorities and work to different agendas, and that this needs to be understood and taken into account when planning and organising services. When viewed together, process mapping and system thinking offer a
comprehensive representation of a service and can serve as a platform for innovation.
Conclusion The ideas and themes presented in this article are well established in health care and extend to other disciplines. However, this article offers a new way of examining these ideas and themes in a model of managed care, where the patient is the focus. The model can also be used to map the patient journey and commission services. In adopting a structured approach, the model offers a range of components that can be explored separately or in different states when coupled with other, sometimes competing components NS
References Adair J (1987) Effective Teambuilding. Gower Publishing, Burlington VT. Cooper M (2005) Becoming an entrepreneur. Canadian Nurse. 101, 4, 14-15. Department of Health (2010) Equity and Excellence: Liberating the NHS. The Stationery Office, London. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL (Eds) (1993) Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. Jossey-Bass, San Francisco CA. Ham C, Imison C, Goodwin N, Dixon A, South P (2011) Where Next for the NHS Reforms? The Case for Integrated Care. The King’s Fund, London. Hunter ND (2006) Managed Process, Due Care: Structures of Accountability in Health Care. digitalcommons.law.yale.edu/ yjhple/vol6/iss1/2 (Last accessed: December 12 2013.) Hurley J, Linsley P (2007) Leadership challenges to move nurses toward collaborative individualism within a neo-corporate bureaucratic environment. Journal of Nursing Management. 15, 7, 749-755.
Institute for Patient- and Family-Centered Care (2011) Advancing the Practice of Patient- and Family-Centered Care in Primary Care and Other Ambulatory Settings. How to Get Started… Institute for Patient- and Family-Centered Care, Bethesda, MD. Institute of Medicine Committee on Quality of Health Care in America (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington DC. International Council of Nurses (2004) Guidelines on the Nurse Entre/Intrapreneur Providing Nursing Service. International Council of Nurses, Geneva. Kreitzer MJ, Kligler B, Meeker WC (2009) Health professions education and integrative healthcare. Explore. 5, 4, 212-227. Linsley P, Kane R, Owen S (2011) Nursing for Public Health: Promotion, Principles, and Practice. Oxford University Press, Oxford. McSherry R, Pearce P (2011) Clinical Governance: A Guide to Implementation for Healthcare Professionals. Blackwell Publishing, Oxford.
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Negarandeh R, Oskouie F, Ahmadi F, Nikravesh M, Hallberg IR (2006) Patient advocacy: barriers and facilitators. BMC Nursing. doi:10.1186/1472-6955-5-3.
and Midwifery in England. Report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England 2010. The Stationery Office, London.
NHS Confederation (2006) Building Integrated Care. Lessons from the UK and Elsewhere. tinyurl.com/ p4fl6wd (Last accessed: December 12 2013.)
Shaller D (2007) Patient-Centered Care: What Does It Take? The Commonwealth Fund, New York NY.
NHS Institute for Innovation and Improvement (2008a) The Good Indicators Guide: Understanding How to Use and Choose Indicators. NHS Institute for Innovation and Improvement, Coventry. NHS Institute for Innovation and Improvement (2008b) Improvement in Pre-Registration Education: Education of Healthcare Professionals for Better, Safer Care. tinyurl.com/37khfx (Last accessed: December 12 2013.) Nolte E, McKee M (Eds) (2012) Caring for People with Chronic Conditions. A Health System Perspective. Open University Press, Maidenhead. Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2010) Front Line Care: The Future of Nursing
Tingle J, Cribb A (Eds) (2007) Nursing Law and Ethics. Third edition. Wiley-Blackwell, London. Torrington D, Hall L, Taylor S (2005) Human Resource Management. Sixth edition. Pearson Education, Harlow. Victorian Quality Council (2006) Successfully Implementing Change. tinyurl.com/84rkqu7 (Last accessed: December 12 2013.) Watson G, Gallagher K (2005) Managing for Results. Second edition. Chartered Institute of Personnel and Development, London. Wilson A, Whitaker N, Whitford D (2012) Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives. Online Journal of Issues in Nursing. 17, 2, 5.
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If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Managed care: a structured approach Linsley P, Morton S (2014) Managed care: a structured approach. Nursing Standard. 28, 19, 37-42. Date of submission: July 8 2013; date of acceptance: September 9 2013.
Abstract The authors developed a model of clinical nurse management based on the concept of managed care. This article, which describes the model, is intended to encourage nurses to consider their role as manager and engage in activities that support good management of clinical practice. The model presents several components that need to be monitored and controlled if best care is to be achieved. Specifying these components in the form of a model allows a visual representation of practice and supports contemporary thinking about healthcare management from the perspective of the nurse in clinical practice.
Authors Paul Linsley Principal lecturer in nursing, University of Lincoln, Lincoln. Sean Morton Senior lecturer in nursing, University of Lincoln, Lincoln. Correspondence to: [email protected]
Keywords Change management, managed care, patient-centred care, patient-focused care
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
© NURSING STANDARD / RCN PUBLISHING
MANAGED CARE IS described as a variety of systems and arrangements for planning, managing, delivering and evaluating care. In a well-functioning system of managed care, a defined group of people receive treatment services that are clinically necessary and appropriate, within defined benefit parameters, for a set amount of time, in compliance with quality standards, and with anticipated and measurable outcomes (NHS Confederation 2006). By relating services to, and developing services around, the patient, managed care can reduce duplication and cost while targeting the essential components of care and providing a timely and appropriate service for patients (Nolte and McKee 2012). Achieving a balance between the different components of managed care requires active management. Nurses, other healthcare professionals and service managers aim to achieve the highest standard of care possible within often socially constructed restraints, such as patient expectation, local commissioning arrangements and service delivery, and services that are often resistant to change (Ham et al 2011). Managed care has become increasingly complex because of changes in commissioning arrangements, the way in which services are delivered, performance management and advances in technology (Hurley and Linsley 2007). The Health and Social Care Act 2012 provides a departure from current commissioning arrangements for health and social care and constitutes a major restructuring of the health service in England, requiring nurses and others to work in a more collaborative and flexible way, and to extend their roles to meet public expectation and demands. In response to this changing environment, the authors developed a model of managed care. The model presents several components that need to be monitored and controlled if best care is to be achieved. january 8 :: vol 28 no 19 :: 2014 37
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Art & science nursing management Managed care model Nurses are increasingly expected to manage and report on the care they give, taking into account several components that, while interrelated, can at times work against each other (Figure 1). These conflicting demands require monitoring and control on behalf of healthcare professionals by the organisations for which they work to ensure high quality care. While the components of the proposed model are discussed individually, the model is best used when opposing components are viewed in one of three states: Ideal – when two or more opposing components work in unison for the benefit of the patient. For example, the delivery of quality care is enhanced when services are focused on the needs of the patient, based on best evidence and contemporary thinking, and managed and actioned in a multiprofessional framework in which each service is viewed as equal. Moderator – when one of two opposing components is viewed as moderating the other’s activity or behaviour. For example, the nurse may want to pursue a particular treatment or intervention in keeping with his or her professional thinking, but he or she may have to adapt the approach to meet the requirements of medical colleagues. Antagonist – when one of two components is working in opposition or in spite of the other.
FIGURE 1 Model of managed care
Managing expectation Maintaining and adhering to professional standards
Law and ethics Fiscal responsibility
Patientfocused care
Multiprofessional, multi-agency working
Delivering quality care Patient and family advocacy
Contemporary thinking, creativity and entrepreneurship
Managing performance
38 january 8 :: vol 28 no 19 :: 2014
Managing knowledge
Managing information
Organisational fit
For example, when the patient wants to leave the ward, but is prevented from doing so because he or she has been placed under a section of the Mental Health Act 2007. To bring about effective change in one component of the model requires careful and thoughtful management, demonstrating sensitivity to the change process and the demands this makes on staff and patients. Effective care is achieved when all components of the model are working in support of each other for the benefit of the patient. Other than meeting the needs of the patient, no single component should be considered more important than another.
Patient-focused care
The managed care model revolves around the concept of patient-focused care, or patient-centred care. For the purpose of this article, patient-focused care and patient-centred care are viewed interchangeably, reflecting the way the two terms are used in the wider literature. The term patient-focused care implies individualised care, based on and responsive to individual need. Furthermore, it is: ‘Healthcare that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care’ (Institute of Medicine Committee on Quality of Health Care in America 2001). The definition emphasises the importance of working in partnership, recognising that patient-centred care is best achieved through collaboration and joint working. Partnership is important in fostering a sense of ownership and collective responsibility that involves and reflects the views and needs of patients, healthcare staff and the wider community (Kreitzer et al 2009). Patient-focused care provides the framework and strategies to improve the experience of care, and enhance quality, safety and efficiency (Shaller 2007). Modern concepts of patient-focused care are based on research conducted by the Picker Institute and the Harvard School of Medicine, which identified seven dimensions of patient-centred care, including (Gerteis et al 1993): Respect for patients’ preferences and values. Emotional support. Physical comfort. Information, communication and education. Continuity and transition. Co-ordination of care. Involvement of family and friends. An additional dimension to patient-focused care
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proposed here is that of public health. Public health extends the aim of patient-focused care by promoting a sense of responsibility in individuals for their actions and health-related behaviours and lifestyle (Linsley et al 2011), as well as helping people to achieve good health and wellbeing. It encourages the nurse and other healthcare professionals to think about the needs of the community in which the person lives and, in turn, how the community affects an individual’s health. Public health mandates the need to work with the vulnerable in society to tackle issues such as stigma and prejudice, and act as an advocate for those who are unable to communicate their needs.
the organisation’s structure. Nurses should be encouraged to take part in qualitative initiatives by identifying improvement opportunities, collecting and analysing relevant data, formulating a planned approach for improvement and implementing suggested changes. The challenges in delivering and improving patient-focused care include finding a shared language for healthcare professionals and managers to discuss such care, identifying the most relevant measures to capture patient experience and finding ways to translate the data on patients’ experience into service improvement (NHS Institute for Innovation and Improvement 2008a).
Maintaining and adhering to professional standards
The nurse as an advocate for the patient and family has long been recognised in the literature and the role reflects a range of activities such as helping the patient and family access health care, assuring quality of care, defending the patient’s rights, and liaising between the patient and the healthcare system (Negarandeh et al 2006, Department of Health 2010, Institute for Patient- and FamilyCentered Care 2011). Providing patient-focused care involves considering the perspective of service users and setting care objectives accordingly. Nursing practice needs to be sensitive to the social environment and the needs of patients and their families, and mandates thoughtful consideration of the legal and ethical dilemmas that arise from a delivery system that is focused on the efficiencies of managed care (Hunter 2006).
With professional practice comes a responsibility to maintain professional standards by acting ethically, adhering to the profession’s code of conduct, and keeping up to date through development and training. Managing self and working within certain limitations places demands on the nurse and others to work to a defined standard of care and level of activity, and at times exceed these. Managing self should be considered the first step in managing others, because it is only by setting an example and working to the highest standards that nurses can hope to influence the behaviour and attitudes of those with whom they work.
Organisational fit
The primary responsibility of the nurse is to ensure optimum care of the patient. In achieving this, the nurse needs to ensure that he or she meets the requirements of the employing organisation while carrying out his or her duties and that he or she works and adheres to agreed policy and procedure. It is the responsibility of the organisation to provide resources, support and guidance to allow staff to undertake their duties. In promoting clinical effectiveness, the organisation and individual employer should work together to ensure that care is delivered in a timely and appropriate way. The nurse’s duty as a manager is to ensure that he or she, and those he or she supervises, remain focused on what is relevant and important to the organisation, and to ensure that work activities and individual behaviour and performance are in keeping with the requirements of the organisation.
Delivering quality care
Providing quality care should be the goal of all involved in patient-focused care. Quality is a major managerial function and there should be clear lines of responsibility and accountability in
© NURSING STANDARD / RCN PUBLISHING
Patient and family advocacy
Contemporary thinking, creativity and entrepreneurship
Nurses assume many roles as they carry out their work. To perform these roles effectively, nurses must be supported by staff in their clinical practice environments who have a clear understanding of what is needed. This match must be dynamic to keep pace with rapidly changing healthcare needs, new technology and contemporary thinking. It is a challenge for nurses to support and incorporate contemporary thinking and approaches to care in clinical practice. As well as being challenged, the nurse needs to challenge accepted wisdom, contemporary issues and beliefs, and have a solution for improvement. The need to develop and use the creativity of staff finds expression in the notion of entrepreneurialism and intrapreneurship (International Council of Nurses 2004, Cooper 2005, Wilson et al 2012). Supporting teams and individuals in being creative requires an understanding of the need to ‘change with the times’ and to foster environments in which such january 8 :: vol 28 no 19 :: 2014 39
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Art & science nursing management creativity can occur. Such measures include the delegation of power; emphasising trust; giving, tolerating and incorporating criticism and feedback; and challenging existing practices and ways of working.
Multiprofessional, multi-agency working
Managed care requires greater interdisciplinary collaboration, which is based on the nurse’s clinical competence and professional self-assertion, and is balanced by a clear understanding of the care costs. Multiprofessional, multi-agency working is driven by a desire for collaborative advantage, often in terms of getting the job done. This reinforces the need to promote and support effective team working. In examining team effectiveness, the literature emphasises the need to match role with person, role with ability, role with personality and role with preferred ways of working (Watson and Gallagher 2005). Adair (1987) extended this notion of skill mix, suggesting that effective teams will comprise several members with different skills and ability. Managing and using the contribution of team members is an important task, and the challenge is to provide opportunities for shared working and decision making. Interdisciplinary working can be difficult to achieve for several reasons, particularly because of differences in disciplinary socialisation. In general, healthcare professionals tend to identify strongly with their own discipline and its language, values and practices, and to relate most effectively to other members of this discipline.
Fiscal responsibility
There needs to be recognition that health care is carried out within financial constraints and that every nurse promotes fiscal responsibility as part of his or her practice. Cost savings should be measured against nurse-sensitive outcomes, such as patient satisfaction and the extent to which planned care meets identified need. Since the NHS is required to make significant cost savings over the next five years, staff need to consider not only the ‘cutbacks’, but the entrepreneurship of nursing that can make the NHS more efficient (NHS Institute for Innovation and Improvement 2008b). Nurses are challenged to manage resources creatively to benefit the patient and the organisation for which they work. It is important to recognise that nursing does not generate income, but accounts for most of an organisation’s expenditure and budget. This puts the onus on nurse managers to manage their budgets in a responsible manner and for nurses to account for and manage supplies, equipment and time. 40 january 8 :: vol 28 no 19 :: 2014
Law and ethics
Laws promote health care and patients’ rights, while ethics ensure that health care is equitable. Nurses are expected to work within the law and behave ethically. Nurses are responsible for the evaluation of the employees they supervise and for the quality of care these individuals give. They must observe their employer’s rights and responsibilities to patients and other employees, fulfil the obligations of the contracted service, inform the employer of circumstances and conditions that impair the quality of care, and report negligent care by others (Tingle and Gribb 2007). This includes the legal duty to communicate any concerns about other healthcare professionals. Increasing patient expectation, the demand for services and the extension of the nursing role only serve to add to this pressure. Operational and organisational breakdowns resulting in litigation and court proceedings can be distressing for patients and their families, and also for healthcare staff. The psychological effect of failure exerts additional pressure on organisations that are already challenged, given that such events have the potential to demoralise staff and undermine public confidence.
Managing expectation
Perhaps the most difficult component to manage is expectation of the service. Patients will have a perceived idea about the standard of care that they are to receive and how they will be treated. Nurses need to be mindful of this, anticipate the needs and problems of patients, and seek to foster realistic expectations through patient education and communication strategies. Nurses should be proactive and open to dialogue with patients about their wishes and expectations of the service and seek to rectify shortfalls in care, in line with the NHS constitution, while being mindful that the service is facing challenging times (Prime Minister’s Commission on the Future of Nursing and Midwifery in England 2010).
Managing information
Health care requires the management and use of various sources of patient information as part of clinical practice, and that information is collected, recorded, processed and evaluated. High quality patient-focused care relies on the use of information in support of the patient journey. In turn, healthcare professionals, including nurses, require information in support of practice that is timely, relevant to their needs, in a form that they can use and open to scrutiny. Information management is concerned with
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obtaining and integrating information from many sources in support of decision-making requirements, which are often undertaken in high-pressure clinical environments. Effective channels of communication and information sharing need to be set up, maintained and reviewed periodically to ensure that they are fit for purpose and fit for practice.
Managing performance
Nurses integrate and manage all contributions to patient care (Linsley et al 2011). Managing performance is an essential part of delivering and improving health care. This extends beyond managing nurses’ and others’ performance to that of teams and organisations. Managing performance can be seen as the foundation of clinical practice since it provides the benchmark by which staff and organisations are judged, for example using performance indicators. Performance management is based on an agreement between a manager and an individual, a shared understanding of, and continuing dialogue about, an individual’s goals and the standards expected and competencies needed, together with an appreciation of the organisation’s mission, values and objectives (Torrington et al 2005). Clear performance expectations are also a crucial factor in teamwork success, and time must be given to communicating, monitoring and evaluating these. Each team member should know who is responsible for implementing decisions, and a team member should be nominated to ensure that tasks are undertaken within an appropriate timescale. Many tasks are complex, and it may be helpful to break them down into smaller components.
Managing knowledge
Knowledge management has gained significance and is driving change in the health service. The acquisition and development of healthcare knowledge is founded on evidence-based practice and is linked to emergent understandings of intellectual and human capital. The growing complexity in healthcare delivery and modern technologies requires nurses to be better educated and to demonstrate their knowledge base in support of the work they undertake. The generation of ‘usable knowledge’ is best achieved through research conducted in partnership with the users of the service, reflecting local need and concerns (McSherry and Pearce 2011). This requires active management on the part of the nurse and other healthcare professionals and willingness to try and support new ideas and ways of working.
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Change management Change in any component of the model will require management, for example a change in the patient’s treatment plan, a change of funding, or a change in policy or government legislation. To this end, change can be considered inherent to any healthcare system and something that requires careful management and sensitivity, because resistance to change is common among patients and staff. It is staying with what is known best that makes change difficult, however change management is only effective if it is challenged and always evolving. In essence, change management is an ongoing process. A vital task of any organisation is to manage change and develop the service, however it is the people in the organisation and particularly nurses who will implement this change. Change requires employers to think and behave differently while carrying out their role, and this is no longer illustrated by advances in technology, which have prompted many changes in the way that health care is delivered, accessed, recorded and measured. Changes to services need to be managed and actioned. Information, education and the joint commitment of management and healthcare staff play an important role in the successful implementation of change (Victorian Quality Council 2006).
Managing the care environment by bringing all components together It is important to ensure that the patient is the focus and that interventions and services are actioned and measured from the patient’s perspective when managing any care environment. The nursing process of assess, plan, implement and evaluate remains a solid foundation on which to develop nursing care. This, in turn, requires broad and active engagement in all aspects of the care process as well as involvement in the management and good order of the care environment. There is a need for shared decision making, requiring the involvement of patients as equal partners in their health care and collective patient and public involvement in the design and delivery of services. Due diligence on the part of healthcare professionals and a willingness to speak up when things are not working will serve to move this process along. Active management of the managed care model requires healthcare professionals to be mindful of the various components involved in a given situation and to evaluate how these might affect their work and the care of patients in terms of safety, quality and efficiency. Specific issues may january 8 :: vol 28 no 19 :: 2014 41
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Art & science nursing management need to be addressed and recourse sought. A willingness to work with others, to share good practice and adapt to new ways of working may also be required. Increasingly, healthcare professionals are being encouraged to think in terms of ‘process mapping’ and ‘system thinking’ when managing change. Process mapping refers to a range of activities that seek to identify what a service does, the way in which it does it, and to what end. System thinking recognises that staff and patients will view things in different ways, have different priorities and work to different agendas, and that this needs to be understood and taken into account when planning and organising services. When viewed together, process mapping and system thinking offer a
comprehensive representation of a service and can serve as a platform for innovation.
Conclusion The ideas and themes presented in this article are well established in health care and extend to other disciplines. However, this article offers a new way of examining these ideas and themes in a model of managed care, where the patient is the focus. The model can also be used to map the patient journey and commission services. In adopting a structured approach, the model offers a range of components that can be explored separately or in different states when coupled with other, sometimes competing components NS
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