The Fundamentals of Care Framework PDF

The Fundamentals of Care Framework as a Point-of-Care Nursing Theory Alison L. Kitson Background: Nursing theories have attempted to shape the everyday practice of clinical nurses and patient care. However, many theories—because of their level of abstraction and distance from everyday caring...

The Fundamentals of Care Framework as a Point-of-Care Nursing Theory Alison L. Kitson Background: Nursing theories have attempted to shape the everyday practice of clinical nurses and patient care. However, many theories—because of their level of abstraction and distance from everyday caring activity—have failed to help nurses undertake the routine practical aspects of nursing care in a theoretically informed way. Objective: The purpose of the paper is to present a point-of-care theoretical framework, called the fundamentals of care (FOC) framework, which explains, guides, and potentially predicts the quality of care nurses provide to patients, their carers, and family members. Discussion: The theoretical framework is presented: person-centered fundamental care (PCFC)—the outcome for the patient and the nurse and the goal of the FOC framework are achieved through the active management of the practice process, which involves the nurse and the patient working together to integrate three core dimensions: establishing the nurse–patient relationship, integrating the FOC into the patient’s care plan, and ensuring that the setting or context where care is transacted and coordinated is conducive to achieving PCFC outcomes. Each dimension has multiple elements and subelements, which require unique assessment for each nurse–patient encounter. Implications: The FOC framework is presented along with two scenarios to demonstrate its usefulness. The dimensions, elements, and subelements are described, and next steps in the development are articulated. Key Words: fundamentals of care  nurse–patient relationship  nursing  nursing theory  point-of-care Nursing Research, March/April 2018, Vol 67, No 2, 99–107 ''...theorizing itself presupposes prior theoretical aware- from their everyday practice, then it would follow that nursing ness...the privileged and habitual intercourse with empiri- theories and new insights would be handicapped by a dearth cal reality carried on in a practice discipline often within ¯ the bounds of rote-like or carefully specified procedures is of empirically derived “practical wisdom.” This is the over- ¯ a rich source of preconceptual awareness.'' (Dickoff & James, arching premise of this article: Nurses at the point-of-care are 1968, p. 199) not encouraged nor have been enabled to reflect on their prac- A tice in ways that generate new insights into nursing practice. s Dickoff and James (1968, p. 199) observed, the con- This has consequently led to a dearth of theoretically informed cept of “practical wisdom’” fits with the traditional insights and subsequent actions that help healthcare systems way nurses learned their craft: passed on often by understand and improve the direct nursing care provided to word of mouth or through an apprenticeship system where patients and the management of the nursing workforce. Strat- the regularized patterns of behavior created a body of egies used to explain deficits in (nursing) care therefore tend “accepted practice, if not a body of knowledge in some other to be derived from other disciplines such as the quality and sense.” The potential nuggets within nursing that could in- safety movement (Institute of Medicine, 1999), the patient- form theory were the “abundance of written sources…which centered care movement (Australian Commission on Safety could constitute a veritable gold mine of ‘incipient theory re- and Quality in Health Care, 2011), or broader theories around coverable and refinable given appropriate tools, energies healthcare management and organizational theory (Weick, and aims.” Nursing theory, it would seem, has been limited 1995). What is required to inform and balance these prevailing by the profession’s ability to systematically document the influences is a theoretical framework, which explains, guides, complexity and richness of what happens when nurses and and predicts nursing interactions with patients, carers, and patients (and their carers) interact. their families at the point-of-care. The fundamentals of care However, if practicing nurses neither have the time nor (FOC) theoretical framework has been generated to do this. the inclination, nor are encouraged to generate new insights Over the last 50 years, nursing theories have consistently Alison L. Kitson, BSc(Hons), PhD, RN, FRCN, FAAN, FAHMS, is Vice President and emphasized the centrality of the nurse–patient relationship Executive Dean, College of Nursing & Health Sciences, Flinders University, Adelaide, Australia. (Boykin & Schoenhofer, 2013; Peplau, 1952; Swanson, 1999; Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Turkel & Ray, 2000; Watson, 1985) and the importance of DOI: 10.1097/NNR.0000000000000271 the nurse working with the patient, their carers, and family Nursing Research www.nursingresearchonline.com 99 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 100 Person-Centered Fundamental Care www.nursingresearchonline.com members in ways to mitigate risk and optimize recovery, well- Of course, these failures need to be put into perspective being, and independence (McCormack & McCance, 2006). and considered in the light of all the care that is provided effi- Despite the consistency in such theoretical perspectives, there ciently, effectively, and with compassion and kindness. The is much less evidence that such instructions are being trans- theoretical and practical questions are as follows: Do we know lated into practice at the point-of-care. Indeed, there is growing what makes the difference between care that meets patients’ debate internationally that failures in nursing care are directly fundamental needs in a compassionate, respectful manner related to nurses’ inability to provide compassionate care and care that fails to do this? Do we know what happens at to patients (Francis, 2010)—despite the evidence indicating the point-of-care to nursing actions and decisions that prior- that nursing interventions promoting compassionate care itize some aspects of care over the more holistic personal care are poorly described and inconsistently evaluated (Blomberg, experience? Such theoretical and practical questions seek Griffiths, Wengström, May, & Bridges, 2016). Other commen- greater insight and understanding of what actually happens tators point to the way nursing is constrained by a “checklist” (or should happen) between nurses and patients at the mil- mentality where “getting through the task” is more highly lions of points-of-care and derive theoretically informed per- regarded than being able to engage meaningfully with patients spectives on how nursing care can best be transacted in (Feo & Kitson, 2016). these moments. In addition, researchers investigating such phenomena as nursing burnout and the reasons why nurses leave the profes- OBJECTIVE sion indicate that it is often due to nurses feeling profoundly It was this growing realization, along with mounting criticism dissatisfied that they cannot provide the personalized care of nursing care in the United Kingdom in the wake of the Mid they want to and that the health systems in which they work Staffordshire events (Francis, 2013), that a group of nursing reward “task and time” nursing rather than personalized care leaders came together to think about how they could improve (Aiken, Rafferty, & Sermeus, 2014). Despite such growing evi- fundamental care in acute hospital settings. The first meeting dence around the importance of nursing education level and of the International Learning Collaborative (ILC; www. skill mix as factors that affect patient morbidity and mortality intlearningcollab.org) took place in Oxford in 2008, hosted in U.S. and European acute hospital settings (Aiken, Clarke, by Green Templeton College, University of Oxford. It included Sloane, Sochalski, & Silber, 2002; Aiken et al., 2012), it is still international nursing leaders (clinicians, executive leaders, re- not clear exactly what these RNs do at the point-of-care and searchers, policy leads, and educationalists) from a number of how they construct their daily interactions with their patients. academic health systems. The group’s aim was to understand A series of patient safety incidents in the United Kingdom what was causing nursing care to fail in these advanced health- in the mid-2000s led to a government inquiry around failures in care systems, despite the investment in safety, quality, and patient care in one health system (Francis, 2010, 2013). The re- other professional development activities. ports criticized the nursing profession for its failure to pro- The FOC framework (Kitson, Conroy, Kuluski, Locock, & vide fundamental care to patients. Patients had been found Lyons, 2013) was generated from these meetings using an dehydrated and malnourished in soiled beds, with nursing staff inductive, collaborative, expert-informed approach (Feo et al., seemingly unaware or unable to attend to such basic or funda- 2017). It captures the complexity and multidimensionality of mental care needs. The Francis report focused on nursing atti- nursing practice by describing the practical everyday actions tudes and suggested the profession had lost its core caring of caring and nursing. It does this in a way that integrates them values of compassion and kindness. In the United Kingdom, to generate meaningful encounters for both the nurse and the this has led to a series of policy initiatives around strategies to patient using language and concepts that are familiar to carers improve nurses’ compassion and caring abilities (Department and patients. At its heart, the FOC framework focuses on the of Health & NHS Commissioning Board, 2012; NHS Commis- routine, everyday, physical, psychosocial, and relational needs sioning Board, 2013; NHS England, 2013). of patients—which form the bedrock of any caring encounter. The initiatives are important and necessary, but not suffi- In addition to emphasizing the importance of the nurse– cient to solve the problems described by Francis (2010, 2013)— patient relationship, the framework focuses on the practical which continue to be exposed in other health systems (Bureau acts of caring: helping patients manage their fundamental care of Health Information, 2014; Groves, Thomson, McKellar, & needs, such as going to the toilet, personal hygiene, mobility, Procter, 2017). Equally, reports from the U.K. Care Quality sleep, rest, comfort, feeling safe, being respected, and having Commission (2011) and other national quality and safety a choice. These elements of the caring encounter are essential agencies show how failures in basic or fundamental aspects in order to meet patients’ unique caring and safety needs. of care constitute significant risks for patients (Jeffs, Saragosa, Merkley, & Maione, 2016). Therefore, it would seem to be the DISCUSSION case that what health systems and governments are doing is still The primary objective of the FOC framework is to present not sufficient to change what’s happening at the point-of-care. a pragmatic point-of-care theory that explains, guides, and Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Nursing Research March/April 2018 Volume 67 No. 2 Person-Centered Fundamental Care 101 potentially predicts practice around person-centered funda- information to set goals but also to be aware of when the nurse’s mental care (PCFC). PCFC is the goal to which the nurse own knowledge and skills are not sufficient to manage the situa- and patient work. It is the outcome that is generated by virtue tion. The final part is to evaluate the quality of the relationship of the relationship that has been established between the and decide if and where changes are needed and that both nurse and the patient to achieve optimum independence (all) parties are involved in this real-time, ongoing process. and in meeting physical, psychosocial, and relational needs, Establishing a relationship with a patient is not a one-time taking account of the context or setting where care is carried event; it requires the ability to authentically engage in rapid out. As shown in Figure 1, the FOC framework comprises moments and to be able to create a safe and secure environ- three interrelated dimensions: relationship, integrated FOC, ment over time. Once trust is established, it is maintained by and context. engaging in interactions that continually build and reinforce that trust. The cumulative effect of missing small caring actions (such as not actively listening to a patient, not asking them Relationship what they would like to be called, or failing to return to them The nurse–patient relationship is the core of the FOC frame- after having promised to do something) undermines trust— work and the foundation upon which high-quality fundamen- not just for the individual nurse, but it can jeopardize the pa- tal care is built. According to the FOC framework, establishing tient’s trust in the whole nursing team. Likewise, being able a positive relationship with a patient requires five elements: to keep focusing on the patient, anticipating their needs at dif- developing trust with the patient, focusing and giving the ferent times throughout the care encounter, and evaluating patient undivided attention, anticipating their needs, knowing the quality and outcomes of the relationship are intellectually enough about the patient to act appropriately, and evaluating and emotionally challenging skills to master. This range of char- the quality of the relationship. acteristics is similar to Benner’s (1984) domains of practice The relationship starts through establishing trust—the nurse (particularly the helping role and the teaching and coaching needs to be trustworthy and trusting (moral qualities outlined in function) and is described in Feo et al. (2017) and validated many other nursing theories such as Peplau, 1952; Swanson, in an umbrella review of research on effective nurse–patient 1999; Watson, 1985). Once trust is established, the nurse must relationships (Wiechula et al., 2016). be able to focus on the patient (and their family) to establish their needs and to diagnose and assess the situation; following this, the nurse must be able to anticipate likely patient needs so that the Integrated FOC patients are and feel safe (physically, psychologically, and emo- The second dimension of the FOC framework focuses on how tionally); to get to know them and their unique issues—using this patients’ individual fundamental care needs (elements) are FIGURE 1. The fundamentals of care adapted from Conroy, Feo, Alderman, and Kitson (2016). Used with permission. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 102 Person-Centered Fundamental Care www.nursingresearchonline.com addressed and the importance of the nurse–patient relation- physical action; know something about ensuring dignity and ship to recognize and manage these complex needs. Despite respect for the patient; and interact with the patient in a terms such as basic, essential, or fundamental care being used way that reflects empathy, care, and compassion. This triad in nursing for many years, no agreement has been reached on of knowledge—physical, psychosocial, and relational—forms what constitutes these elements or indeed how they are man- the basis of the integrated FOC approach. aged and combined. One of the first exercises to be under- Challenges to conceptualizing care in this integrated way taken by ILC members was to review nursing seminal texts include the disaggregated way personal care is often managed to look for definitions of fundamental nursing care (Kitson, in the acute care setting; nursing activities are often graded Conroy, Wengstrom, Profetto-McGrath, & Robertson-Malt, according to complexity of technical task rather than provid- 2010). Results found variation in the range of elements identi- ing holistic care experiences for patients (Bridges et al., 2013; fied and the way they were described. An FOC list was subse- Kitson et al., 2014). Medical orders are based on a set of tasks quently generated (Kitson, Conroy, et al., 2013) and has been rather than an understanding or appreciation of the need to used in a number of empirical studies to explore how patients integrate the experience for the patient and their family with different clinical conditions view the FOC (Jangland, (Detsky & Krumholz, 2014; Krumholz, 2013), and the rapidity Kitson, & Muntlin Athlin, 2016; Kitson, Dow, Calabrese, with which patients move through acute care settings tends Locock, & Muntlin Athlin, 2013). What emerged from this to creates a dissonance or disconnect between what is hap- work was the interdependence of physical, psychosocial, pening to the patient and how they are making sense of it and relational elements of fundamental care (Kitson & Muntlin (Ball et al., 2016). There is very little time either to build Athlin, 2013). This interdependency had not been articu- up a rapport with the patient or carer or to assess their under- lated in previous studies around essentials or FOC (Depart- standing and confidence around fundamental care activities ment of Health, 2010;Government of Wales, 2015) or in (as they have been affected by an acute episode of illness). conceptual frameworks that described nursing responses to These challenges necessitate different ways of thinking and activities of living (Henderson, Nite, & Harmerp, 1978; Roper, acting around the effective meeting of patients’ fundamental Logan, & Tierney, 1996). care needs. The FOC therefore refers to the essential and practical Surprisingly little evidence exists around how nurses go elements of care, involving the integration of physical, psycho- about integrating a patient’s fundamental care needs (van social, and relational aspects that are required by every person Achterberg, 2014). The studies that have attempted to in- within any care setting regardless of, but influenced by, their vestigate this phenomenon include research around nursing clinical condition and level of dependence–independence in orders (Englebright, Aldrich, & Taylor, 2014; Turkel, Ray, & performing such self-care activities (Orem, 1991). Meeting Kornblatt, 2012), and more recent attempts to investigate such these fundamental care needs is essential for well-being, safety, nursing interventions as personal care bundles (Vollman, 2013) recovery, and positive experiences in any healthcare setting and acute abdominal pain experiences (Jangland et al., 2016). (Vollman, 2013). Increasing research shows that patients connect their ex- Context periences of respect, dignity, comfort, and support with how The final dimension of the FOC framework (the outer circle in physical aspects of care are performed. In a secondary analysis Figure 1) refers to the context of care. In attempting to un- of the experiences of fundamental care encounters of stroke cover the reasons behind the documented failures in funda- survivors, Kitson, Dow, et al. (2013) found that these people mental care, some scholars, clinicians, and policymakers are still retained vivid and occasionally distressing memories of looking to the environments in which healthcare takes place, how they were cared for immediately after their acute stoke attributing staff shortages, poor skills mix, and funding cuts phase. Independent of the clinical outcome, stroke survivors for nurses’ inability to attend to fundamental care (Aiken et al., would recollect encounters with nursing staff where they felt 2014; Needleman, 2016; Needleman, Buerhaus, Mattke, Stewart, respected, valued, and cared for and other events where they & Zelevinski, 2002). Another approach has been to “medical- felt ignored, humiliated, and unsafe. Such experiences con- ize” the problem. The term “posthospital syndrome” has been nected to practical, often physical, activities such as going to coined to explain the high readmittance rates to hospital the toilet, getting dressed, or walking. It was from this and within 30 days due to in-hospital care (Krumholz, 2013). other studies (Jangland et al., 2016) that the importance of According to this argument, hospitalization represents a period the integration of the physical, psychosocial, and relational of generalized risk for adverse health events, including sleep elements of the encounter was identified. disturbances, malnourishment, pain and discomfort, altered The practical reality of this means that each time a nurse cognition due to medication, and physical deconditioning due undertakes a (so-called relatively simple) fundamental care to bed rest. These events are seen to create physiological im- activity (e.g., helping a person to the bathroom), they need balance and increase susceptibility to a range of acute medical to be mindful of the underlying evidence informing the problems (Detsky & Krumholz, 2014). It is interesting that, in Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Nursing Research March/April 2018 Volume 67 No. 2 Person-Centered Fundamental Care 103 this debate, the increased risk was not conceptualized as be- to integrate the dimensions and elements in a personalized ing linked to or mitigated by nursing care. care plan for their patient. The summary representation is The outer dimension of the framework recognizes that not intended to be a static or rigid descriptor. What is essential the systems and organizations in which nurses work play a cru- to realize is that for every patient or care encounter, the dimen- cial part in helping or hindering the delivery of quality funda- sions and elements could be very different. The worked exam- mental care. The FOC framework outlines the system and ples will help to explain this. policy requirements needed to support the delivery of funda- The FOC framework can be presented as PCFC = PP mental care. Systems requirements include resources (e.g., (R + i-FOC + C), where physical resources such as equipment and human resources), PCFC = person-centered fundamental care is the goal/outcome culture (the values and norms of the system), leadership (lead- of the nurse–patient encounter/relationship where the actions ership styles, how roles are defined and supported, and how and interactions between the nurse and the patient maximize staff are mentored), and evaluation and feedback (processes the patient’s independence and recovery, keeping them safe at individual, team, and organizational levels that provide con- and secure; structive feedback). Policy requirements include financial re- PP = the practice process that describes how the nurse assesses what care is needed and what the nurse does in partnership sources, quality and safety agendas, governance processes with the patient, carers, and/or relatives and other members and accountability, and regulation and accreditation. of the multidisciplinary team to meet the patient’s fundamental These elements are in themselves vast, and considering care needs in the context of their presenting clinical condition; any one would in itself be a significant task. Yet, what the the assessment process is continuous and draws on multiple sources of knowledge, framed by the three main domains: rela- framework is suggesting is that the nurse—who is providing tionship (R), integrated FOC (i-FOC), and context (C); integrated FOC to their patient—will need to have the ability R = the relationship between the nurse and the patient, which to work out what resources (physical and human) they will is key to the successful delivery of PCFC; the first step in the re- need to do this effectively, how the prevailing culture of the lationship is establishing trust; i-FOC = integrated fundamentals of care, which is the system- unit or hospital might influence the way fundamental care is atic and ongoing evaluation of the patient’s need for and ability delivered, whether the nursing leadership is supportive of a to provide their own self-care around each of the physical, psy- person-centred approach to care or whether by default the chosocial, and relational FOC; the i-FOCs are contingent on fac- care is task focused, and how quality is measured. Such skills tors such as life cycle, culture, clinical condition, cognitive and abilities reflect what many nursing theorists have de- level—to name but a few; and C = the context or setting where care is transacted. Context scribed as organizational and work-role competencies (Benner, can be positively or negatively influenced by such factors as 1984) and translational mobilization capabilities (Allen, 2014). physical layout, resources, legislative frameworks, and culture. The FOC framework posits that this contextually aware level of thinking and critical reflection is required to deliver person- Lapse in Fundamental Care centered fundamental care. The following two scenarios illustrate typical nurse–patient– To date, the focus of the FOC framework has been on fun- relative–carer encounters, drawn from the author’s work, illus- damental care transacted in acute care settings. There is noth- trating how the FOC framework could be used to explain ing to suggest that the framework cannot be used in other care what was happening in the nurse–patient encounter to shape settings, such as community care, rehabilitation, residential, fundamental care. Table 1 describes a scenario that reflects and homecare. The FOC framework also hypothetically can less than optimal patient care, as described by the patient’s cover all types of clinical conditions because the focus is on family member. The nursing approach could be described fundamental care, not underlying pathology. Of course, the as “task-and-time” related (Kitson et al., 2014), with nurses challenge for the nurse is to have the confidence and compe- seemingly adhering to rules around risk assessment and safety tence to manage the fundamental care needs of the patient in issues at the expense of establishing any sort of construc- the light of the clinical condition, drawing on their knowledge, tive relationship with the patient or his family member. skills, and experience, and building up patterns of knowing There did not seem to be any relationship established be- and paradigm cases (Benner, 1984). tween any of the attending nursing staff and the patient and/or his daughter. IMPLICATIONS: OPERATIONALIZING THE FOC FRAMEWORK From the point of view of using the FOC expression to de- The FOC framework presented in Figure 1 still does not reflect scribe the care, it seems that patient goals around fundamental the dynamic, multidimensional nature of the reality of funda- care were not articulated. There was no evidence that the mental care assessment and delivery. In trying to represent nurses actively engaged in a personalized assessment of the pa- the core dimensions, a summary representation was used for tient’s needs; the consequence was that a relationship had not two reasons: (a) it indicates to the nurse what core dimensions been established, and therefore, no trust, focusing, anticipat- need to be considered in each encounter, and (b) it helps guide ing, knowing, or evaluation was likely to be happening. The the thinking and critical reflections of the nurse around how FOC around mobility, eating and drinking, toileting, social Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 104 Person-Centered Fundamental Care www.nursingresearchonline.com TABLE 1. Lapse in Fundamental Care (Scenario 1) Dorothy and Bill’s story FOC framework interpretation Dorothy’s 94-year-old father (Bill) was found unconscious and incontinent Bill’s personal history indicated that he was an active and independent lying on the kitchen floor of his home. Up until this event, he had been a 94-year-old who, no doubt, would want to recover his optimal fit, active, independent person who loved gardening. He was taken to independence. the local Emergency Department (ED) where he was diagnosed as The admitting nurse who undertook the initial assessment should have having suffered from heat exhaustion and acute dehydration, which ascertained this and generated a care plan that would optimize precipitated the fainting attack. His daughter, who lived several hundred recovery and communicate this effectively to all other nurses caring miles away, was contacted and was informed that Bill was being admitted to for Bill. hospital for observation and further assessment. When Dorothy saw Bill in the ward, she was surprised that he seemed From Dorothy’s account, it was not clear which nurse(s) had assessed disorientated. He told her he was not allowed to get out of bed because he and was/were actively managing her father’s PCFC needs (PP). was a “falls risk” and he said he was embarrassed about having to go to the Given Bill’s former independence and the acute episode, the toilet at the bedside. During her first visit, Bill indicated that he needed treatment plan ought to have been rapid re-ablement and getting the bathroom. Dorothy pushed the call bell; eventually a nurse came into the Bill back to as high a level of independence as possible (PCFC). room. Dorothy asked the nurse if she could help her father walk to the toilet, The confusion over his mobilization, toileting, eating, and drinking as he wanted some exercise. The nurse said “No, it is against hospital rules demonstrated that none of the nursing staff had prioritized these for relatives to walk patients; he must use the bedside toilet.” The nurse as nursing responsibilities, nor had they chosen to involve either Bill or left the room and did not return with the commode. Dorothy rang the call bell Dorothy (R) in the care plan (i-FOC). again and another nurse came into the room. The nurse switched off the call bell light and commented brusquely that Bill was always ringing the bell and that a commode had been provided an hour earlier so he didn’t need one now. (Dorothy had been sitting with Bill so she knew this had not happened). A commode was eventually brought to Bill. Dorothy was not invited to share in This would seem to suggest that from the point of view of setting the the care. PCFC of achieving optimal recovery and independence around FOC, Bill was getting anxious about having to stay in bed but each time Dorothy this was not done. There was little evidence of any nursing staff raised this with any of the nurses, they told her he was a “falls risk”; having undertaken an assessment using the (PP) elements: no therefore, they could not move him. She also noticed that no one checked evidence of a therapeutic relationship being established (R); no on how much food or fluid Bill was eating and drinking. evidence of an integrated plan around Bill’s physical, psychosocial, One group of staff would deliver the trays and fluids, and another would take and relational needs (i-FOC); and no evidence of the wider them away. She often worried about how much her father was eating and context (resources, the medical team, or other aspects of care) drinking when she wasn’t there to encourage him. being used (C). The final challenge occurred when Dorothy noticed that her father’s fingernails It seemed to Dorothy that the nurses were using the rules around were long and dirty. She asked a nurse to cut her father’s nails. The nurse managing risk and safety (C) as ways of not actively engaging with said it could not be done unless Bill asked and that Dorothy—although her father (R). Note: this recognized as having financial and legal power of attorney—was not able to account is from the relative’s perspective and no data were collected make decisions on behalf of her father’s self-care. Dorothy looked at the from the nurses who cared for Bill. nurse incredulously. Note. C = context; FOC = fundamentals of care; i-FOC = integrated fundamentals of care; PCFC = person-centered fundamental care; PP = practice process; R = relationship. stimulation, dignity, and choice were not articulated, nor psychosocial well-being of the patient and concerns about on- was the context (environmental factors such as physical re- going caring responsibilities for the patient’s husband with de- sources or policy) being utilized; for example, consider the mentia. The nurse was also able—through negotiation with claim that the nurse could not cut the patient’s fingernails medical and other members of the healthcare team—to re- because he had not asked the nurse to do it, despite his schedule the patient’s discharge date in order to ensure that daughter’s request). the right contextual factors were in place for a safe and suc- cessful return home. Effective Fundamental Care It is important to note that the FOC framework not only ac- Table 2 describes a very different nurse–patient–relative–carer knowledges and builds on existing nursing theories around the encounter. The nurse recounts a recent episode with a patient importance of the nurse–patient relationship but also takes who was admitted for a series of diagnostic tests. It is clear into account what Allen (2014) referred to as the essential inte- from the nurse’s account that a trusting relationship with the grative and coordinating roles of nursing. Allen referred to patient was established and that the style of assessment these capabilities as “translational mobilization,” which refers reflected the elements of focusing on the patient, anticipating to four core elements of nursing work: understanding patient immediate and longer-term needs, getting to know them and need (what would be termed PCFC) and in particular the their situation, and evaluating how the care encounter is ability to establish the relationship (R) and to manage the going. The nurse’s assessment of FOC focused on the patient’s fundamental care needs (i-FOC), converting trajectory Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Nursing Research March/April 2018 Volume 67 No. 2 Person-Centered Fundamental Care 105 TABLE 2. Effective Fundamental Care (Scenario 2) Mary and Albert’s story FOC framework interpretation Mary was an active 85-year-old who was the primary carer for her husband, Mary’s personal history indicated that she was an active 85-year-old, with Albert. They’d been together for over 60 years, and it was quite sad for primary caring responsibilities. Mary to see how dementia was robbing her of the husband she had The admitting nurse who undertook the initial known and loved. She was quite annoyed one afternoon when she took assessment ascertained this and generated a care plan that optimized really bad pains in her chest and a neighbor phoned for an ambulance. recovery and enabled Mary to continue to care for her husband on She was admitted to hospital for tests and was found to have atrial discharge. fibrillation. The nurse specialist who was caring for her explained what this was and The nurse specialist picked up Mary’s primary goal—to be well enough reassured her that it could be managed and that she would not have to to keep caring for Albert at home (PCFC). The nurse knew that in the worry. The nurse told her she would just have to slow down a bit and immediate post hospital discharge phase she would need additional make sure she didn’t do anything too strenuous. support (C) to ensure both she and Albert were okay. The nurse was Mary’s demeanor changed at this point and she started to cry. The nurse able to find this information out because he knew how to establish a then discovered that she was Albert’s main carer and that she was trusting relationship with Mary (R) and to assess both her physical and worried she would not be fit enough to manage him at home. All of this psychosocial capabilities not only to manage her own care but how information came spilling out at the end of the investigation so the nurse she was going to continue to care for her husband (i-FOC). reassured Mary that he would follow up with the relevant teams how they were going to pull together a care package that would give her the support she needed to continue to look after her husband at home. The nurse took charge of Mary’s case; he knew that her own health and The nurse negotiated with the hospital discharge team and bed manager for mental resilience were fragile and that unless they provided a broader two additional days in hospital for Mary and liaised with other teams and package of support for her they would potentially have two patients agencies to get her the support she needed (C). coming through the Emergency Department doors. Mary was discharged two days later than originally planned—that was to All in all, the nurse not only managed Mary’s fundamental care needs but also ensure that all the requisite support was available. One month later Mary helped her to continue to do the same for her husband Albert. Note: this and Albert were doing well. account was from the nurse specialist’s perspective and no data were collected from the patient or relatives involved. Note. C = context; i-FOC = integrated fundamentals of care; PCFC = person-centered fundamental care; R = relationship. narratives (PCFC plans) into formats that align with the informa- early on within systems that can anticipate likely outcomes tion needs of providers (multiple stakeholders within, be- for patients. What is more difficult to achieve is the change in tween, and across systems), integrating trajectory elements behavior at the point-of-care. Unfortunately, there are, as yet, for optimal effectiveness (knowing how to generate and keep no standardized data elements for measuring or documenting momentum around PCFC across the care system), and recon- fundamental care; ILC members are pursuing this avenue ciling patient needs with available resources (knowing how of investigation. best to deliver PCFC within different contexts). Unfinished Work and Future Directions Further Development of the FOC Framework More work on the FOC framework is needed. The emerging An international Delphi study has been conducted (Feo et al., empirical evidence to demonstrate the impact of the FOC in press) to develop a standardized definition for fundamental framework at the point-of-care will help to refine the dimen- care and the physical, psychosocial, and relational elements sions, elements, and emerging subelements. The positive re- making up the integrated FOC dimension of the FOC frame- sponses from practitioners and consumers to date provide work. Teams from several countries will be evaluating the early indication that this way of thinking and conceptualizing cross-national applicability of the FOC framework. fundamental care resonates with nurses and patients alike. A The predictive qualities of the FOC framework are specu- second area of work is to ensure that the ideas around this lative at this stage of development. The framework could be framework are shared with the whole healthcare team so that used to predict when patients are at risk of harm in systems physicians, allied health professionals, managers, and all mem- that have not paid sufficient attention to establishing the rela- bers of the team understand what nursing does for and with tionship and identifying PCFC goals. Lack of information about patients around FOC and how nursing influences clinical out- a patient’s integrated fundamental care needs could be early comes. A third area of work will be the systematic critiquing warning signs—which would then require the nurse leader of this point-of-care nursing theory with other existing theo- to follow up on the personalized care plans for a patient. As ries. Finally, activities relate to describing the impact of chang- we have seen in the wake of the Mid Staffordshire investigation ing patient profiles, timing issues, and attitudes toward caring (Francis, 2010, 2013), patterns of behavior can be detected and the role of the nurse are being actively explored. Of most Copyright © 2018 Wolters Kluwer Health, Inc. 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