Module 5 of 15 · 45 minutes
Standard 5: Work in a person centred way
By the end of this module you will be able to
- Explain what person centred care means in law and in practice
- Use life history and 'what matters to you' to change how care is delivered
- Identify and respond to pain and distress in people who cannot tell you
- Support choice in a way that survives a busy shift
Amara Person centred. Two words so overused I am not sure they mean anything any more. Can you give me a definition that survives an actual shift?
Nadia Here is mine. The person's own priorities decide how care is delivered. And where they cannot decide, their history, their values and their behaviour are used to work out what they would have chosen.
Amara And that is a philosophy, or a rule?
Nadia A rule. Regulation 9. Care must be appropriate, meet the person's needs, and reflect their preferences. It is the first of the fundamental standards, and everything else in care is a means to it.
Amara Where do I start on a shift, though? Because I have twelve people and four hours.
Nadia Start with life history, and stop thinking of it as a nice extra for the noticeboard. It is clinical information.
Amara That is a strong claim. Justify it.
Nadia Gladly. A man who worked nights for thirty years is not agitated at two in the morning. He is awake at his normal time. A woman widowed in a hospital side room may become distressed at the smell of alcohol gel, and nobody on shift will have the faintest idea why. Somebody who ran a household of six will not accept being fed without protest.
Amara And if we do not know any of that?
Nadia Then here is the sequence. The distress gets recorded as behaviour. The behaviour gets a medication review. And a person ends up sedated for a problem that we created at handover. That is not a hypothetical, it is one of the commonest harms in the sector.
Amara Is there a tool?
Nadia Several. This Is Me from the Alzheimer's Society, and the Getting To Know Me formats many trusts use. But the tool is not the point. The point is that somebody reads it, and that what is in it actually appears in the care plan. A beautiful life history in a folder nobody opens has changed nothing.
Amara You told me before that there is one thing in this standard that matters more than the rest. What is it?
Nadia Pain. Untreated pain is one of the commonest causes of what gets written down as challenging behaviour, particularly in advanced dementia.
Amara How would I even know, if the person cannot tell me?
Nadia They will show you instead. Resisting personal care. Striking out during transfers. Guarding a limb. Rocking. Calling out. Refusing food. Or going very quiet, when quiet is not normal for them.
Amara Quiet as a sign of pain. I would have read that as settled.
Nadia Most people do. So carry this rule into every shift instead. Assume pain until you have excluded it. Behaviour that is new, or behaviour that only appears during movement or personal care, is pain until proven otherwise.
Amara And then what? I cannot prescribe anything.
Nadia No, but you can check the boring things and you can escalate. Constipation. Urine infection. Pressure damage. Teeth. Shoes that do not fit. Then use a proper observational scale rather than a guess, the Abbey Pain Scale or PAINAD, and ask for a medical review rather than accepting the label of challenging behaviour.
Amara Right. Let me be difficult with you for a minute. All of this takes time. I am short staffed. Offering somebody a genuine choice is slower than not offering one, and everybody listening knows it.
Nadia That is a fair objection and I am not going to pretend otherwise. Two things make it survivable. The first is to offer real choices in small numbers. An open question to somebody with dementia produces anxiety and often no answer. Two options held up produces a decision in about three seconds.
Amara And the second?
Nadia Front load choice into the parts of the day that set the tone. What to wear. What to be called. When to get up. What to eat. Get those four right and you will spend less of the rest of your shift managing distress that you caused at eight in the morning. Person centred care is not slower overall. It is slower at the start and much faster by lunchtime.
Amara That is the first time anyone has made that argument to me in terms of time.
Nadia It is the only argument that survives a real rota. The dignity case is true and the time case is what gets it done.
The written material
The regulation behind the phrase
Regulation 9 requires that care and treatment is appropriate, meets the person's needs, and reflects their preferences. It is the first of the fundamental standards for a reason. Everything else in care is a means to it.
The phrase person centred is worn out through overuse, so here is a working definition that survives contact with a real shift: the person's own priorities decide how care is delivered, and where they cannot decide, their history, values and current behaviour are used to work out what they would have chosen.
Life history is clinical information
A life history is not a nice extra for the noticeboard. It is the tool that prevents distress and reduces the use of medication that would otherwise be given to manage behaviour that we caused.
A man who worked nights for thirty years is not agitated at 2am, he is awake at his normal time. A woman who was widowed in a hospital side room may become distressed at the smell of alcohol gel. Someone who ran a household of six will not accept being fed without protest, and should not have to.
Standard tools exist for this. This Is Me from the Alzheimer's Society, and the Getting To Know Me formats used by many NHS trusts, both work. What matters is that the document is read, and that what is in it appears in the care plan.
Pain and distress in people who cannot tell you
Untreated pain is one of the most common causes of what gets recorded as challenging behaviour, particularly in advanced dementia. If a person cannot say 'my hip hurts', they will show you instead: resisting personal care, striking out during transfers, guarding a limb, rocking, calling out, refusing food, going quiet when they are usually chatty.
Validated observational tools exist, and services should be using one. The Abbey Pain Scale and PAINAD are the most common in UK settings. The rule to carry into every shift is this: assume pain until you have excluded it. Behaviour that is new, or that appears only during movement or personal care, is pain until proven otherwise.
- New behaviour, or behaviour that only appears during movement, points to pain
- Check the obvious first: constipation, urinary infection, pressure damage, dental pain, ill fitting shoes
- Use a validated observational scale rather than a guess
- Escalate for a medical review rather than accepting the label of challenging behaviour
Choice when you are short staffed
The honest objection to person centred care is time. Offering a genuine choice takes longer than not offering one, and the shift is already short. Two things make it survivable.
First, offer real choices in small numbers. An open question to someone with dementia produces anxiety; two held up options produce a decision. Second, front load choice into the parts of the day that set the tone: what to wear, what to be called, when to get up, what to eat. Getting those right reduces the distress that eats the rest of your shift.
Knowledge check
The knowledge check and your certificate need a free account, so that your progress and results can be saved as evidence.
The learning itself stays free and open. You are reading all of it right now without an account.