March 27, 2012 - I was asked to review a paper called "Person-centered care training in long-term care settings: analysis of trainees' discourse on usefulness and facility of transfer into practice." The paper began by identifying the type of patient-centred care that is being taught in the training programs. It is called “Relationship Based Care†or RBC. This type of patient-centred care derived from the banking industry where it is called “Relationship Based Customer Care.†The idea means that individual bankers would develop a close relationship with their affluent clients in order to build loyalty. They could offer favours like a slightly higher interest rate on their GICs, intervene when there was trouble with a bank credit card, or with charges and so on.
The idea in banking extends beyond the individual customer to his or her family, while the notion of RBC described in the paper specifically excludes the patient’s family. According to the findings, family input is seen by some providers to be an intrusion into their relationship with the patient. Another goal of the model is to foster patient autonomy. This notion of autonomy is presumably meant to afford patients their own choices so not to be pushed into choices better suited to their caregivers. However, for many patients, the loss of autonomy (of capacity to make such choices independently) is exactly the reason that they have entered a long-term care facility. Presumably this aspect of their lives will not be regained, except at the margins. Often family members understand their tastes, preferences, and previous life desires and goals. It might be that family members are able to support staff with satisfying the patients’ personal preferences. But according to the paper the relationship fostered in the long-stay facility specifically excludes family members: it is a relationship between caregiver and patient.
Today as our ideas of patient-centred care develop, we are recognizing that patients generally come with family members in tow and professionals must be prepared to deal with, and support, the patient-family through the care process. Family members of demented patients can meaningfully contribute by knowing who they were and are, and by supporting the caregivers in their work. It’s no surprise that the idea of the patient described in the paper excludes the role of family members except as a possible disruption. In older nursing attitudes, the primary focus is strictly on the patient, however times are changing. I think that the paper is a valuable historical record that can be learned from and its results can help us understand the present context including the remaining difficulties.