Fundamentals of care: Methodologies, metrics and mobilisation
Alison Kitson
Abstract
The focus of our second special edition on fundamentals of care was to stimulate discussion around the sorts of methodological challenges facing researchers interested in this phenomenon. Linked to the methodological issues were explorations of the way measures were being generated and tested and how researchers, clinicians and educators were mobilising this new or refined knowledge. As acknowledged by Richards (2020), the majority of reported studies in this issue are observational in design. Richards argues that we need to move on from this stage to designing and testing rigorous interventions to evaluate the effectiveness of fundamental care. However, this still is a challenge for a number of reasons. For example, Theys et al. (2019) describe the preliminary work they have undertaken to understand some of the preimplementation challenges facing their team in trying to introduce a previously trialed nursing intervention to improve nurse–patient communication (called the Tell-us Cards and first developed and tested by Jangland & Gunningberg, 2017). They et al's work identified five major barriers to why nurses would not use this tool. These included nurses’ reports that they needed to maintain control over care; that they were reluctant to engage in in-depth conversations; they feared being seen as unprofessional by patients; they feared repercussions from physicians and they reportedly lacked insight into the meaning of patient participation. These barriers are indeed significant and reflect a number of attitudinal, behavioural and system-related challenges that in themselves require interpretation and ways to understand what enabling strategies might be generated to mitigate them. No one would challenge the premise that effective communication between patients, their relatives and nursing staff is something to strive for, but the findings of this study reflect the multilayered complexity of actually trying to do something practical and effective about it. So, the remaining challenge is how much preparatory or preimplementation work needs to be undertaken before researchers can be confident that the interventions they are testing are themselves robust and fit-for-purpose. Another challenge identified in this special issue is the lack of consolidation or building upon other research teams’ work. This was clearly illustrated by Feo, Conroy, Wiechula, Rasmussen, and Kitson (2019) in their scoping review around the development of instruments measuring aspects of the nurse–patient relationship. Rather than there being very little literature, they discovered over 30 published tools measuring a range of elements around the nurse–patient relationship. However, they went on to note that the volume, variability, duplication and inconsistency of use and terminology of the reported tools to be significant barriers both towards building a stronger scientific base and to enabling them to be used in practice with any sort of confidence. So again, we are left with the question of how we galvanise the multiple efforts to scale up and improve our research approaches and quality to improve fundamental care. These are very common challenges in emerging disciplines. Think of the debates that have ranged in medical specialisms such as general practice (Gunn & Pirotta, 2017), primary care (Cooke, Nancarrow, Danas, & Williams, 2008) and gerontology (Zerzan & Rich, 2014) over the last decades. It is only after dedicated and long-term commitment towards research funding and capacity building that the quality of research improves in particular disciplines. So far globally, we have one example from the Netherlands (Zwakhalen et al., 2018) where there is a nationally funded research programme around fundamental (or basic) care. While enviable, the challenge for these multi-institutional teams will of course be to generate interventions that have the robust science around them in terms of demonstrating their effectiveness. And even in clinical specialisms such as continence care with a substantial body of clinical evidence to inform practice (Dowling-Castronovo, Bradway, Kitson, & Ostaszkiewicz, 2020), we know that despite the science being robust the ability of nurses and health systems to implement best practice is still not there. This is why at the International Learning Collaborative's (ILC) 11th meeting in Aalborg, Denmark, members came together to product the Aalborg statement (Kitson et al., 2019). While research investment is necessary, it alone is not sufficient to make fundamental care more valued and visible across our health and care systems. This requires concerted leadership around how we value, talk about, do, own and research fundamental care. So, what do we do from a research methodology perspective? Well, I would say we continue to refine our observational studies and aggregate them to help us understand the attitudinal, behavioural, cultural and systemic issues we need to unravel in order to understand how to develop and test robust fundamental care interventions. We have examples of novel methodologies in this special issue such as the use of videos and photography in both identifying patient care needs (Dale, Angus, Sutherland, Dev, & Rose, 2019) as well as generating ways to improve inter-rater reliability in measurement testing and refinement (van Ingen Schenau-Veldman, Niemeijer, Lamberts, & Nieuwenhuis, 2019). We also need to embed our observational studies within robust experimental methods so we can work out what is effective; how it is effective; and why it is effective. Our challenge is that we have yet to crack the research funding glass ceiling for fundamental care and unless or until we can demonstrate fundamental care's effectiveness potential, then we will not get either short-term or sustained investment. So, we need to be strategic and political in the ways we work with our healthcare partners in suggesting novel (and robust) ways to tackle some of our ongoing challenges, such as better communication, oral hygiene, continence care and personal hygiene to name but a few. Another strategy is to proactively invest in improving our research capacity and capability around fundamental care research. Through organisations such as the International Learning Collaborative ([email protected] or https://intlearningcollab.org/) we are facilitating the coming together of like-minded researchers who wish to see how their research can make a real difference to patient care. We are planning special events such as interactive workshops at other nursing conferences (e.g. the 2020 Nordic Nursing Research Conference) where we will explore the very questions posed in this editorial, that is how do we improve the quality of the research we undertake and move from observational studies to setting up robust effectiveness trials. My last reflection has been prompted by Rey et al's paper (2019). In their outline of how an RN and student nurse could work together using a systematic approach to gathering person-centred fundamental care data from an older woman with dementia and her immediate family, I had a breakthrough thought. What if the steps described in this process of engagement, assessment, action and evaluation (called the practice process, Conroy, Feo, Alderman, & Kitson, 2016) could become the basis of how a nurse generates an integrated person-centred fundamental care intervention? In the case scenario described by Rey and colleagues, we can see the particularity and uniqueness of the emerging fundamental care plan. The research question this obviously generates for me is how can we achieve this person-centredness and at the same time follow a proven systematic approach to care delivery? Importantly, it means that what we would be testing in our controlled trials of effectiveness would NOT be the same package of integrated fundamental care for all patients, but it would be the personalised package required for that particular person in that moment based on the practice process outline. So, the research question then becomes one around how clinical nurses construct and deliver person-centred fundamental care within their care setting to meet patients’ individualised needs rather than testing whether they follow a standardised protocol, care path or guideline. This conceptual breakthrough in our thinking about what constitutes an integrated fundamental care intervention is pivotal to the future of our research trajectory in this area. This is not as far-fetched an idea as you might think: consider personalised medicine where researchers are putting together “bespoke” treatments for patients rather than proceed with the “one (evidence-based) size fits all” solution. If we hang onto this brave new world that is emerging before us, we would then know that even our existing assumptions about what good intervention research looks like are going to be even more challenged. So, we do need to get our thinking and observations right before we embark on expensive trials. The nature of the phenomena we are studying is that they are interrelated and complex so our designs and underlying theoretical positions need to reflect this. This is the path that knowledge translation and implementation research is taking (Kitson et al., 2018) and it will shape the way we do research in fundamental care. Could we indeed work together to refine a fundamental care template that could clearly summarise a person's fundamental care needs as they go through a health situation or crisis? And could this be captured in a systematic way for them as an individual so it could be like their own “care passport” that they could add to as their fundamental care needs alter and change? These are just some of the many incredibly rich and important questions we need to be asking and finding answers to. And it is this curiosity that will continue to drive high-quality fundamental care research forward globally.