Module 5: Person and Family Centered Care

This module initiates an exploration of person centered care (PCC) in chronic illness situations.

Module Objectives:

1) Define person centered care.

2) Discuss practices associated with person centered care.

3) Analyze the relationship of informed risk with patient centered care, 4) Consider ethical principles associated with person centered care.

Key points:

· Patients and families living with chronic illness need professionals to listen and understand their illness experience.

· The  Code of Ethics for Nurses requires nurses to consider individual value systems and beliefs of individuals when planning care.

· Nursing – both as an art and a science – has a strong ‘fit’ for caring for persons and families with chronic illness.

· Patients and families need understandable information so they can make informed decisions.

· It is critical that healthcare professionals strive to understand the patient and family perception of their situation, as those perceptions are important when developing a plan of care.

· Ethical dilemmas are not uncommon in chronic illness situations.

Assigned resources:

Please watch the 32 minute video addressing Person Centered Care (linked into the module)

Agency for Healthcare Research and Quality.

Krist, A. H., Tong, S. T., Aycock, R. A., & Longo, D. R. (2020, February 3). Engaging patients in decisionmaking and behavior change to promote prevention. Studies in health technology and informatics. Retrieved November 13, 2022, from

Hsu, C., Gray, M.F., Murray, L., Abraham, M., Nickel, W., Sweeney, J.M., Frosch, D. L., Mroz, T.M., Ehrlich, K., Johnson, B., & Reid, R. J. (2019). Actions and processes that patients, family members, and physicians associate with patient-and family-centered care. BMC Family Practice, 20(1), N.PAG.

Institute for Patient and Family Centered Care.(n.d.). What is patient and family centered care?

Kunneman, M., &Montori, V. M. (2017). When patient-centred care is worth doing well: informed consent or shared decision-making. BMJ Quality & Safety, 26(7), 522–524.

Park, Giap, T.-T.-T., Lee, M., Jeong, H., Jeong, M., & Go, Y. (2018). Patient- and family-centered care interventions for improving the quality of health care: A review of systematic reviews. International Journal of Nursing Studies, 87, 69–83

Smebye, K., Kirkevold, M., &Engedal, K. (2016). Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health Services Research, 16(1).

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles &

Practice, 30(1), 17–28.

Optional

Miller, K. L. (2016). Patient centered care: A path to better health outcomes through engagement and activation. NeuroRehabilitation, 39(4), 465–470.

Graded assignment:

This synthesis and application assignment will span two modules. You will need insights and evidence from both modules five and six along with additional evidence from professional resources. Please note the due dates on your course calendar.

Synthesis and Application assignments have two separate components. Please see the information in the Synthesis and Application Assignment folder for a video and more detailed direction. Refer to the grading rubric (Appendix B in your syllabus) for how points can be earned.  Carefully note the criteria for a professional nursing journal as found in the course syllabus. 

Part 1: Choose one of the situations below. Respond to the situation you choose in the discussion forum adhering to the grading rubric in Appendix B.

Part 2:.  You will post a substantive addition to one of your peers' post. Yoursubstantive addition must address the topic/situation  other than the topic/ situation addressed in your original synthesis and application post .

Scenario One:

Bill and Sue are both in their 80s and living in their own home. Sue's was diagnosed with osteoporosis, but otherwise is in good health. Bill has been living with dementia for the last three years has fallen at least six times over the last six months without serious injury. He has had some skin tears and required stitches on his arm after one of the falls. When he falls, Sue calls one of the nearby children who come and help Bill from the floor.

1) Explore informed risk, autonomy, and beneficence as it applies to this situation.

After two more years in their own home, Bill falls, breaks his femur. He has a surgical repair but has not been able to bear weight since the fracture. His confusion increased with the hospitalization and now the move to long term care for rehabilitation.

You are the nurse admitting Bill to the long-term care center three days post operatively.

2) How would a patient and family centered approach impact the way you conduct your assessment, prioritize concerns, develop goals, and formulate interventions to reach those goals?

3) After two weeks in the long term care center, you note that Bill has lost six pounds since admission. Bill's wife Sue eats lunch with Bill almost every day and tells you that Bill is 'not a fan' of the types of food served. What approach would you take?

Situation two

Mark is a 40 year old high school chemistry teacher who has been living with Diabetes Type II for 10 years. He verbalizes a good understanding of an appropriate diet, oral antihyperglycemic therapy, and exercise. His glycosylated hemoglobin (A1C) at his last two clinic visits have been close to 9.0%. His body mass index is 30.

He tells you that he follows his diet when he can but is tired of other people telling him "what to do and how to do it". He tells you he works hard as a chemistry teacher and wants to enjoy his life. He also tells you he has many friends who eat much more than he does. His wife is concerned about Mark.

1. How would you work to provide person centered care in Mark's situation?

2. How would informed risk 'fit' with person centered care in this situation?

3. Explore at least three factors that may contribute to non-adherence to the plan in situations like this.

4. How might motivational interviewing be valuable in a situation like this? Include both your approach to assessment and care plan development.

Module Six: Adherence and Person and Family Centered Care

This module serves to review the nursing process specifically as it relates to person and family centered care. The American Nurses Association Scope and Standards of Practice and Code of Ethics for Nurses with Interpretive Statements are reviewed as they relate to person centered care.

The module continues to explore the impact of chronic illness on patients and families. Factors that impact adherence, motivation, and social determinants of health are visited. Nursing application is emphasized.

Module Objectives:

1. Review the ANA Scope and Standards of Practice, noting the emphasis on person centered care.

2. Appraise factors that impact adherence.

3. Consider the impact of individual motivation as it relates to adherence to a plan. 

4.. Examine the nurses's role in motivation and motivational interviewing.

5. Discuss social determinants of health and the impact on adherence.

Assigned readings:  

American Academy of Family Physicians. (n.d.). Social needs screening tool.Retrieved July 20, 2022, from

American Nurses Association (2015) . Code of ethics for nurses: With interpretive statements. Silver Spring, MD: ANA. (applicable portions)

Bobitt J, Aguayo L, Payne L, Jansen T, Schwingel (2019). Geographic and social factors associated with chronic disease self-management program participation: Going the “Extra-Mile” for disease prevention. Prev Chronic Disease DOI:

Cardoso Barbosa, H., de Queiroz Oliveira, J. A., Moreira da Costa, J., de Melo Santos, R. P., Gonçalves Miranda, L., de Carvalho Torres, H., Pagano, A. S., &Parreiras Martins, M. A. (2021).

Empowerment-oriented strategies to identify behavior change in patients with chronic diseases:

An integrative review of the literature. Patient Education & Counseling, 104(4), 689–702.

Healthy People 2030. (n.d.) Social Determinants of Health.

Mate, K. (2022, February 4).On the Quintuple Aim: Why Expand Beyond the Triple Aim?

Miri, Z., Rezaee, N., Faghihi, H., &Navidian, A. (2021). Effect of Cognitive-behavioral Training Combined with Motivational Interviewing on Treatment Adherence and Hemoglobin A1c in Patients with Diabetes and Depressive Symptoms. Medical-Surgical Nursing Journal

National Institute of Health. (2016, Oct.). Understanding health risks: Improve your chance for good health

Please review the videos and websites linked into the module.

Key points:

· Social relationships can either promote health or deter from health.

· Mutual goal setting is very important

· A number of factors impact adherence to a healthcare plan including: complexity of the regimen, cost, patient-provider interaction, social support, socioeconomic status, cognitive factors, health literacy, prior health behaviors, perception of relevance, cultural factors, and individual characteristics.

· Non adherence to a treatment plan also encompasses ethical issues including: rights and responsibilities of both patients and caregivers; paternalism; autonomy; and costs of non adherence to society as a whole.

Graded assignment:

This synthesis and application assignment spans two modules. You will need insights and evidence from both modules five and six along with additional evidence from professional resources. Please note the due dates on your course calendar.

Synthesis and Application assignments have two separate components. Please see the information in the Synthesis and Application Assignment folder for a video and more detailed direction. Refer to the grading rubric (Appendix B in your syllabus) for how points can be earned.  Carefully note the criteria for a professional nursing journal as found in the course syllabus. 

Part 1: Choose one of the situations below. Respond to the situation you choose in the discussion forum adhering to the grading rubric in Appendix B.

Part 2:.  You will post a substantive addition to one of your peers' post. Yoursubstantive addition must address the topic/situation  other than the topic/ situation addressed in your original synthesis and application post .

Scenario One:

Bill and Sue are both in their 80s and living in their own home. Sue's was diagnosed with osteoporosis, but otherwise is in good health. Bill has been living with dementia for the last three years has fallen at least six times over the last six months without serious injury. He has had some skin tears and required stitches on his arm after one of the falls. When he falls, Sue calls one of the nearby children who come and help Bill from the floor.

1) Explore informed risk, autonomy, and beneficence as it applies to this situation.

After two more years in their own home, Bill falls, breaks his femur. He has a surgical repair but has not been able to bear weight since the fracture. His confusion increased with the hospitalization and now the move to long term care for rehabilitation.

You are the nurse admitting Bill to the long-term care center three days post operatively.

2) How would a patient and family centered approach impact the way you conduct your assessment, prioritize concerns, develop goals, and formulate interventions to reach those goals?

3) After two weeks in the long term care center, you note that Bill has lost six pounds since admission. Bill's wife Sue eats lunch with Bill almost every day and tells you that Bill is 'not a fan' of the types of food served. What approach would you take?

Situation two

Mark is a 40 year old high school chemistry teacher who has been living with Diabetes Type II for 10 years. He verbalizes a good understanding of an appropriate diet, oral antihyperglycemic therapy, and exercise. His glycosylated hemoglobin (A1C) at his last two clinic visits have been close to 9.0%. His body mass index is 30.

He tells you that he follows his diet when he can but is tired of other people telling him "what to do and how to do it". He tells you he works hard as a chemistry teacher and wants to enjoy his life. He also tells you he has many friends who eat much more than he does. His wife is concerned about Mark.

1. How would you work to provide person centered care in Mark's situation?

2. How would informed risk 'fit' with person centered care in this situation?

3. Explore at least three factors that may contribute to non-adherence to the plan in situations like this.

4. How might motivational interviewing be valuable in a situation like this? Include both your approach to assessment and care plan development.

320.Appendix B – Synthesis and Application Assignment Remember that integrating your own thoughts with evidence from the literature is an effective to demonstrate synthesis and critical analysis. Sometimes a few short direct quotes add value to your work. But remember that long quotes generally serve to share someone else's thoughts, rather than your analysis. Please refer to the Synthesis and Application folder for a more detail and guidance.

Appendix B: Synthesis and Application Assignment Rubric.

Criterion	Excellent	Competent	Not satisfactory
Complete	All questions from one chosenscenario/topic addressed in a clear, focused manner. All responses demonstrate careful thinking. (3 points)	Not all questions addressed OR responses not clear and focused (1.5 points)	Not all required questions addressed. (0 points)
Demonstrates synthesis of assigned readings	Post demonstrates that the assigned content was appropriately reviewed, understood, and synthesized. Minimal direct quotations. (points) (6 points)	Demonstrates limited familiarity and synthesis of assigned content. (3 points)	Responses do not demonstrate synthesis of assigned readings (0 points)
Evidence based	At least two professional resources support post. Resources must be integrated, cited, and referenced per APA style. See criteria forprofessional references on p. 9of syllabus. Rare APA style errors. (3 pts)	Supported by fewer than two professional resources. Or provides evidence-based, scholarly references using incorrect APA format. Or provides non-scholarly references with correct APA format in-text. (1.5 points)	Provides no scholarly reference to support position/ideas in postings/discussion and /or uses no APA format (0 points)
Writing quality	Punctuation, spelling, spacing, capitalization, and writing mechanics errors are rare. Writing is clear, succinct, focused, organized, Easy to understand main ideas. (2 points)	Fewer than six total writing mechanics Writing is focused and organized. (1 point)	Six or more writing mechanics errors; run-on sentences. Writing lacks organization or focus (0 points)
Posted	Posted in both the discussion forum and the assignment box. (1 point)	Not posted in both the discussion forum and the assignment box (0 points)	Not posted in both the discussion forum and the assignment box (0 points)