Department of Ophthalmology State University of Medicine and Pharmacy “Nicolae Testemitanu”, Republic of Moldova
Received date: January 03, 2017; Accepted date: April 27, 2017; Published date: May 04, 2017
Citation: Paduca A (2017) Reflection Paper on Person-Centered Approach in Health Care and Research in Strabismus Field. J Pat Care 3:129. doi:10.4172/2573-4598.1000129
Copyright: © 2017 Paduca A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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This paper reflects a personal conclusions on person-centred care practice, based on my own research in strabismus field. Theoretical and practical considerations of the person-centred approach are discussed. Health services struggle to ensure health care in a “person-centered” way, but the general concept also called personcentered care is an ethical one: patients should be treated as “persons.” Person-centred practice needs to be well facilitated in order to flourish the healthcare framework. However, the literature is sometimes unclear about the nature of these person-centred actions and questions remain about how to provide and measure clinical outcomes of personcentred care while being engaged with others in real health practice contexts.
Person-centred care; Person-centred approach; Research; Strabismus
People plan their lives in different ways according to their preferences, tasks and targets. Being involved in daily practice and dealing with big variety of patients I came to the idea about the importance of person-centered care in my own primary activity. So this is the basic reason why I started to pay attention to this problem. The relation between health care workers and possible patients are fundamental in diagnosis, treatment and later collaboration. In this paper I will reflect the philosophy and theory of person-centeredness and how they interfere with my research project about strabismus. So, I am highly motivated to show the interrelation between the proper behavior of the managers, doctors, nurses and patients’ satisfaction.
Health systems and health care institutions are among the most complex and interdependent entities known to society. Without a good integration at various levels, all aspects of health care performance suffer. Patients get lost, required services fail to be delivered, or are delayed and patient satisfaction decline . Traditionally, health workers demand that their patients be compliant and to follow their instructions. The provider/practitioner takes the lead of the person and makes the decision for the person regarding what medication the person will ingest and/or what short term and long term treatment the person will undergo. Clients, therefore, usually do not expect that their concerns will come first, or even be seriously addressed. This attitude, though changing, has infiltrated health care until now. The continuous development of the health care system imposed the necessity to move beyond the traditional medicine from disease-centered approach (focusing mostly on diseases) and staff-centered to some new approaches oriented to serve first of all the needs and interests of the people who use these services. Often, “ health care does ‘to’ or ‘for’ people rather than ‘with’ them, gets it difficult to include people in taking decisions, and views people’s goals only in terms of particular clinical outcomes” [2-4]. Nowadays one of approaches which are in great demand among health worker leaders is person-centred approach. Providing a personcentred care requires fundamental changes about how health services are delivered and the roles of health care professionals and patients, the relationships between patients and health care professionals teams.
The person-centred approach has the roots in the concepts of “humanistic psychology” . Studying the literature I realized that despite many definitions of person centred and their differences one thing is common for all of them: is that the patient should be treated as a “human being”/“person”/“individual” [5-10]. Person-centered therapy, which is also known as client-centered, non-directive or Rogerian therapy based on phenomenological approach to personality and on the idea that each individual is a skilled expert for himself and that people are able to find their own solutions to their own problems [11,12]. Patients often must pass through a fragmented health care system and adapt to the procedures established by health care organizations and professionals, rather than receiving care designed to focus on the individual patient’s preferences and values. Nowadays, Person-centered care is widely considered to be a “key component of effective illness management” . Altogether, in the domain of healthcare, there are gaps in knowledge about how something might work better and ideas for improvement. That is why a very important aspect of healthcare system has always been the research. Science today is changing rapidly and becoming more and more complex. Scientific research plays a very important role in maintaining health, avoiding and combating diseases. Research helps us get new knowledge and develop new and proper tools for the use of existing one. The world around us does not give up its secrets easily and some subjects required us to go beyond our personal knowledge and experiences. It is very hard to discover and sometimes even harder to prove our hypothesis and beliefs. So, all these staff made me begin my own research on one of the topic which is a challenge for me-strabismus. Moreover the proper research stretches my mind and involves also collaboration with different specialists. Rogers  went further by saying that science is based upon the subjective experience of a person, and the knowledge we gain from science depend upon our values and how we chose to understand, interpret and use the knowledge.
The goal of my PhD project is to obtain detailed histological knowledge of the receptors of the human extraocular muscles and to seek evidence of developmental or structural anomalies associated with the different types of strabismus.
Binocular vision anomalies caused by strabismus affect a large number of people in Europe, their prevalence vary from 2-5%, where the highest rates are found in the western region of Europe . The majority of individuals who suffer from strabismus report problems associated with double vision, motion detection, depth perception, balance, orientation and mobility. In particular by impacting appearance, strabismus has negative effects on not only self-image and self-esteem but also social prejudice that may affect career opportunities [16-19]. The main aim of strabismus management is to restore normal ocular alignment and reduce diplopia, if present, allowing the patient to carry out normal daily activities. Alignment of the eyes, which is a prerequisite for binocular vision, relies on a complex network of neurons and their ability to send the correct motor command to the muscles responsible for eye rotations. While the motor innervation of extraocular muscles is very well known, the sensorial innervation is still database. Detailed knowledge of these receptors and their function is hence of both scientific and clinical interest, especially since the current medical procedure for treatment of strabismus is based on surgical manipulation of the muscles and their associated receptors. As my research work is going to be conduct on people with different type of strabismus aged 1,5-75 years old, both gender, who will require surgical treatment for strabismus correction and the ways of obtaining data are questioning responders and participating observation, surgical treatment, pre- and post-surgical evaluation applying the Personcentred approach will be an inevitable thing, even if it is at a background level. During my research work I have to ensure that my patients will be equal partners with health care professionals, with whom I intend to work, in assessing, identifying options for and delivering the most appropriate care, in order to get the most correct and real result for my research.
I often ask myself why these people with strabismus have such big psychosocial problem. Can you imagine that if they have lost their physical attributes and look different can they lose the status of person and be excluded from the community? In this case I wonder: “What does it a “person” mean and which criteria (if there are some) must be used in order to call one “person?” I asked some people trying to find their opinion. According to some “Person” can be someone with emotions, others sustain that a person is a whole Universe; person is a body and soul, with good and bad features. Basically, the word “person” for me is a mixture of physical, intellectual, emotional features and moral values. Kripkean refers this word to “names”. “Individuals” is relevant to Eric Olson; “memories” are relevant to the view of Lockean; “beliefs” go to Parfit . Looking at my patients through Kitwood definition of person centeredness which is dependent on other recognition of their status as a person which only exist in relationship with the other I understand that their decision to be operated on for strabismus is the only option for improving their “self being”. But it arise a question: Does only the physical appearance matter for people around? Taking these psychological problems of my patients in consideration if I want to achieve good results during my work (healthcare and research) I have to give the patient the opportunity to present her/himself as a person which is the starting point for building a collaborative partnership that encourages and empowers patients to take part actively in solutions finding to their problems which finally is my “fiduciary duty” to establish a relation of confidence and trust [9,13,21]. I resonate with the fact that in person-centeredness it is crucial that all practitioners remember that although each person is unique, each person also has invaluable worth. I believe that treating each person with value enables the person to feel worthy and in turn empowered and connected, the way the person deserves to feel. I have to be sure that the client is at the centre of any plans that I am going to make and that my assessment will take account of the ‘whole person’ (not simply symptoms and disease but mind and body which are integrated and inseparable) social needs as well as medical, in conclusion to use a holistic approach. So in order to deliver the best care to my patients, I need to understand them very well and to try to “see the illness through the patient’s eyes” [21,22].
There are many different aspects of person-centred care, which I consider to be very useful and important to apply during my research work: to be responsive; respecting people’s values and placing people in the center of care; taking into account people’s preferences and needs, providing communication, information; assuring physical and emotional support; emphasizing freedom of choice; involving family members and friends. Person-centred medicine promotes the idea of an “egalitarian doctor-patient relationship” differing fundamentally from the conventional paternalistic relationship based on physician professional authority and were the preferences of the patients were avoided that lead to many conflicts. Later in the 1950, the paternalistic model was replaced by a new one. This model supposes doctors to treat patients as an autonomous agent, able to make decisions according to his own personal beliefs and values [23,24]. Allowing the clients to participate in care decisions concerning treatment suggests that individuals have input into their own care . The person who is the one who understands his/her own journey best of all is encouraged to walk his/her own path. I consider that patient’s values, preferences, needs and beliefs can give us clear pictures of what the patient cares in life and the received information will help us, the care workers, to find the best decision. But engagement during person centred approach is something that applies to everyone, including those who receive services and not only health workers .
I realize that establishing a psychological relationship with a client may be sometimes difficult, especially for those who had a bad experience of therapy or face difficulties in speaking with other people about the issues they may have. Patient non-compliance and dissatisfaction with care services can be attributable to some failure on the part of doctors including in providing adequate information and explanation or even in trying to reach consensus through negotiation . Even if I am a healthcare professional, first of all I am a human being and like all human beings sometimes errors and incidents during work can occur. In our personal and working lives we all make mistakes in the things we do, but the impact of these is absent or minor and do not creates inconvenience. However, in healthcare there is always the underlying chance that the consequences could be catastrophic. It is this awareness that often prevents such incidents as we purposefully increase our attention when we have to face the situation we perceive to be risky. Risks in life can be faced everywhere, while crossing the road or driving a car or taking a medicine. Just through risks we learn to walk or ride a bike, to swim or to climb Everest, etc. in order to improve our lives. When an individual uses a care service, their right to take risks is high that’s why I have the responsibility to support this right. Although it is true that as doctors we must act responsibly and in a way that safeguards the clients, assessment is a process that can help find the best solution, especially when potential disagreement could appear . I have to be aware of my responsibilities that I have towards my patients. I have realized that, health workers, sometimes may forget that patient’s abilities to participate in their care depend on appropriately supportive relationships with health professionals and those interactions and relationships with health professionals can have harmful as well as beneficial implications for patients’ contributions to their own care, as well as their identities and broader well-being . Given the fact of human diversity and that the life events can affect people in different way I must not judge the patients according to the first impression and assumption and to take each patient’s life experiences seriously and be careful to avoid damaging personal identities that they value. I agree with Somnath et al.  statement that stereotyping and making assumptions about patients are the main barriers of a proper communication. When a researcher tries to know some personal details of the participants’ lives he has to deal with opening some of their old emotional wounds. I must not forget the ethical principles of non-maleficence which stipulate preventing intentional harm and minimizing potential one. But at the same time if we (health care staff) “tend to equate personcentered care by doing according to the patients preference, the deep value base and intrinsic worth of the concept (as well as its complexity) can be lost” . When patients appear to be making irrational or harmful decisions, for example, not complying with medication or refusing to be operating on when is vital the professional’s response is to work harder to convey the risks and I agree that sometimes it could even take a form of a “negotiation approach” between practitioner and patient . Often, actions planned by physicians are not as successful as actions planned by the individuals themselves. When we, people, participate in make choices, we feel that we are more valued and have more control over the created situation. That is why, it is important that we, health workers, support empowerment of the individuals we work with in treatment decision taking. Only in this case I consider both, doctors and patients will be responsible for the process and health care outcome. Becoming a person centred practitioner I have to be also able to deal with unexpected feedback from my clients, to accept it and to be able to work with this feedback through critical reflection. I realize that it can be difficult to accept any kind of critic from patients in our address, to hear things that we do not like about ourselves but at the same time it could be the only way to change/improve our attitude towards the clients and became a better practitioner. Our care decision will depend mostly on our ideas about what it is good for clients. That’s why I think that people should be treated more complexly. In children cases firstly I would specify the relationship with the family but, also, the relationship with the child himself should not be dismissed. Family members see the person and the situation from their own perspective [29,30]. As an example can be the adult’s strabismus that is usually a childhood onset strabismus never or insufficiently treated and they had experience of being told nothing about the disease, of being passed from one doctor to another. Everything could lead to creating concerns about the health care system as a non-reliable one. A vital priority for health care services is to sustain values and strengthen people’s family connections .
I think that empathy, unconditional positive acceptance and congruence - the core conditions provided in Person- centred care are essential to any human relation, in general and especially in relationships between the client or patient in order to enhance client’s personal growth and healthy self [12,31]. But I disagree with Roger statement that these qualities of therapist are more important than therapeutic skills . I consider that to be a good doctor a combination of all these important things are required. I want to affirm that the Rogerian theory offers the ‘illusion of simplicity’. Being professionals we hold all power due to access to resources (knowledge, technics, etc.) and to our status that give us a feeling of superiority. Everything seems easy till we try to apply it into practice.
How much should I confess myself to one client? I think the main aim of transparency and openness is communicating helpful information to clients and of course a certain amount of censoring is necessary.
How should be unconditional positive regard expressed? Can unconditional positive regard overwhelm the clients?
Can I be involved in emotional empathic process after a fatigue and stressful work schedule? It is possible for some therapist to be more vulnerable to “emotional distress and compassion fatigue” who can lead to development of emotional exhaustion and a low result. We can lose our objectivity and become overwhelmed by the emotions of the patients in their care [22,32]. Empathic responses can be influenced by a number of variables like personality, gender, interpersonal style, culture, social confidence, environment and the level of communication skills that have been learnt . That is why I agree with Gleichgerrcht and Decety statement that since personal and theoretical bases are unavoidable, it is impossible for a therapist to be consistently nondirective. Person-centred is a value based method. Buetow suggested that virtue is person-centred whereby duty is patientcentred [32,33]. It is a duty and an important aspect in collaborating in person-centred healthcare to for me to know myself especially when I interact in a clinical setting and with my research project . To me, consciously knowing the self includes personal values, morals, biases, cultural beliefs that effect decisions and lifestyle on a daily basis. “It is through an understanding of the ‘self ’ as an emotional being that we can respond effectively to the emotional behaviors of others” . Reflexology entails how I see myself is reflective in how others see me. I would like to be seen as a partner with my patients and health worker team that I work with in my project and vice versa. Being a partner includes sharing information. Beauchamp mentioned: “People need to be fully informed in healthcare, including research” . Creatively thinking about how the participant will react to the demands of the study and how the participant would feel about what is being done with the research will assist me as the researcher with best ethical practices. My aim is that the participants have a positive experience. I envision relishing on a condition where the people involved (users) in the project will flourish. As I have noticed already, the different person centred values are connected, work together and none stand alone. Our individuality and choice is associated with our independence. Our choice, from my point of view, is closely linked to dignity and respect. Certainly, all these values give us the power to take as much control as possible in order to promote our wellbeing and to live a fulfill life.
Finally my working goals of person-centred practice are to facilitate client’s trust to get to know him well in order to be able to provide a better and a more specific care to their needs; to promote client’s engagement and responsibility in taking treatment decision in order to achieve their well-being, satisfaction; and to improve the sense of professional worth . As a researcher I have to focus my research work for the good of mankind and for expanding the frontiers of scientific knowledge, to have the freedom of thought and expression, and the freedom to identify methods by which problems are solved, according to recognized ethical principles and practices. I am aware of this freedom limitations to that could arise during my work. Such limitations should not, however, be seen of the opposites of ethical principles which I have to follow: beneficence/no maleficence, utility, respect human dignity; justice and confidentiality [36-39].
“Person centeredness is not a fixed or static unidimensional concept but instead is multifaced, multidimensional and dynamic process” Mc Cormack and McCance. The Person centred approach can be implemented by different specialist with different patients in different ways. However, this ways must always be consistent with the basic philosophy and the nature of the conditions themselves. There are some freedom but there are some limits too . With an open heart and an open mind, we can experience the opportunities life has to offer. When we are really engaged in a person-centred relationship allowing others to know who we are, our hopes and desires, what values matters for us and what kind of life we choose to live, through communication, arguments, negotiation, evaluations, reflections and agreements the person centred process will progress, and even flourish.