• Registered Nurses Association of Ontario (RNAO). Client centered care supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2006 Mar. 8 p. [38 references]



• Registered Nurses Association of Ontario (RNAO). Client centred care. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Jul. 70 p. [63 references]

This is the current release of the guideline.

Any disease or condition that requires a nurse's care

Management

Family Practice
Nursing
Psychology

Advanced Practice Nurses
Health Care Providers
Nurses

To present best nursing practice guidelines for client centred care

Clients in all health sectors

Note: The term client is inclusive of individuals, families/significant others, groups, communities, and populations.

1. Embracing nursing core values and beliefs (i.e., respect; human dignity; clients are experts for their own lives; clients as leaders; clients' goals coordinate care of the health care team; continuity and consistency of care and caregiver; timeliness; responsiveness and universal access to care)
2. Practicing the core process of client centred care (i.e., identifying concerns/needs; making decisions; caring and service; evaluating outcomes)
3. Education, organization and policy approaches and strategies

Client centred outcomes, including client empowerment, client satisfaction, quality of care and quality of work life

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

A systematic literature search was conducted; Key videos depicting client centred care principles were viewed: "Through the Patient´s Eyes" (1994, 1998), "Not My Home" (1994), "Real Stories" (1995), "Finding the Way" (1996). In addition, the panel examined the values and beliefs that are the underpinning of client centered care as reflected in the Code of Ethics of both the College of Nurses of Ontario (1999) and the Canadian Nurses Association (1997). An extensive literature review was conducted comprised of research, theoretical papers, and articles concerning clinical practice and client experiences. Evidence to support the values and beliefs was identified and specific actions pertaining to nursing were gathered.

The 2006 revision panel also conducted an extensive literature search to identify new evidence.

July 2002 Guideline

Not stated

March 2006 Supplement

Twenty-six articles were retrieved for review.

Expert Consensus

Not applicable

Systematic Review

Not stated

Expert Consensus

July 2002 Guideline

In May 2000, a panel of nurses with expertise from practice, research, and academic sectors in the area of client centred care was convened under the auspices of the Registered Nurses Association of Ontario (RNAO).

The values and beliefs that are the underpinning of client centered care were articulated by the panel. Evidence to support the values and beliefs were identified and specific actions pertaining to nursing were gathered. Action statements for each value and belief statement were developed. Through a process of discussion and consensus, practice, education, and organization policy recommendations were developed.

March 2006 Supplement

RNAO has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline every three years. The revision panel members (experts from a variety of practice settings) are given a mandate to review the guideline focusing on the recommendations and the original scope of the guideline.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Clinical Validation-Pilot Testing
External Peer Review

A draft guideline was submitted to external stakeholders for review and feedback. The feedback received was reviewed and incorporated into the draft guideline; The nursing best practice guideline was pilot implemented in selected practice settings in Ontario (see "Acknowledgement" in the original guideline document for a listing of implementation sites).

Pilot implementation practice settings were identified through a "request for proposal" process conducted by the Registered Nurses Association of Ontario (RNAO).

The guideline document was further refined taking into consideration the pilot site feedback, evaluation results and current scholarship identified through a supplementary literature review.

Note from the National Guideline Clearinghouse (NGC): In March 2006, the Registered Nurses Association of Ontario (RNAO) amended the current practice recommendations for this topic. Through the review process, one recommendation was deleted and others were reworded to reflect new knowledge. The recommendations are noted below as "changed" or "unchanged."

Practice Recommendation

Recommendation 1 (Changed March 2006)

Nurses embrace the following values and beliefs: respect; human dignity; clients are experts for their own lives; clients as leaders; clients' goals coordinate care of the healthcare team; continuity and consistency of care and caregiver; timeliness; responsiveness and universal access to care. These values and beliefs must be incorporated into, and demonstrated throughout, every aspect of client care and services.

Education Recommendations

Recommendation 2

Recommendation has been deleted and incorporated as a bullet under recommendation 5.

Recommendation 3 (Unchanged)

The principles of client centred care should be included in the basic education of nurses in their core curriculum, be available as continuing education, be provided in orientation programs and be sustained through professional development opportunities in the organization. Organizations should engage all members of the healthcare team in this ongoing education process.

Organization and Policy Recommendations

Recommendation 4 (Unchanged)

To foster client centred care consistently throughout an organization, healthcare services must be organized and administered in ways that ensure that all caregivers, regardless of their personal attributes, enact this practice successfully. This includes opportunities to gain the necessary knowledge and skills to really engage with clients from their standpoint, as well as organizational models of care delivery that allow nurses and clients to develop continuous, uninterrupted, and meaningful relationships.

Recommendation 5 (Changed March 2006)

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

• Board and senior management understanding and support
• An assessment of organizational readiness and barriers to education
• Community involvement (whether in a direct or indirect supportive function) who will contribute to the implementation process
• Ongoing opportunities for discussion and education to reinforce the importance of best practices
• Opportunities for reflection on personal and organizational experience in implementing guidelines
• Initial and sustained financial support
• Members of the public

In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the "Toolkit: Implementation of Clinical Practice Guidelines", based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO nursing best practice guideline on Client Centred Care.

None provided

Recommendations were based on the evaluation of evidence from a systematic review, other quantitative studies, nursing theories, qualitative sources and client reports of their experiences. Expert consensus was utilized when scientifically formalized knowledge was not available.

• Guideline implementation is intended to help nurses provide client centred care.
• Client centred care is intended to help empower clients, improve client satisfaction, and enhance quality of care and quality of work life.
• Nurses, other health care professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools, etc.

Not stated

• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• The March 2006 supplement to the nursing best practice guideline Client Centred Care is the result of a three year scheduled revision of the guideline. Additional material has been provided in an attempt to provide the reader with current evidence to support practice. Similar to the original guideline publication, this document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This supplement should be used in conjunction with the guideline as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.

Toolkit: Implementing Clinical Practice Guidelines

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as the appropriate facilitation. In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers and administrators) has developed The Toolkit for Implementing Clinical Practice Guidelines, based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The "Toolkit" provides step by step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the "Toolkit" addresses the following key steps:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The "Toolkit" is one key resource for managing this process.

For specific recommendations regarding implementation of this guideline, refer to the "Major Recommendations" field.

At the time of the March 2006 revision of the original Guideline document, the evidence continues to support the recommendations identified with the addition of some new understanding of the successes and challenges faced during implementation. The initial pilot of the guideline in 5 organizations reaffirmed the importance of adopting all recommendations. Successful client centred care not only requires nurses to embrace the values and beliefs of client centered care but they need to do so in conjunction with the other professional team members and with the organizational support of appropriate policies and procedures.

Client centred care requires:

• A shift in organizational focus to remove 'power' barriers
• Inclusion of practice structures that allow for the sharing of power
• Advocacy within the power structures that exist
• Placement of patient and family needs at the center of the entire health team and healthcare delivery system

Adequate and continual training and resources to support the adoption of client centered practices are paramount (refer to figure A in the March 2006 supplement to the original guideline document). Rigid hospital system schedules, lack of supportive documentation tools, inadequate time to educate and care for self can create barriers to successful implementation (refer to figure B in the March 2006 supplement to the original guideline document). Procedures put in place previously may need to be challenged and assessed against the best practice recommendations for client centred care. Client centred care is a joint responsibility of the individual nurse and other healthcare providers and the organization in which practitioners work.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. A table in the original guideline document, based on framework outlined in the RNAO Toolkit: Implementation of clinical practice guidelines (2002), illustrates some indicators for monitoring and evaluation.

Educational Program

An educational program consisting of 16 classroom hours is outlined in the original guideline document.

End of Life Care
Getting Better
Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Client centered care supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2006 Mar. 8 p. [38 references]



• Registered Nurses Association of Ontario (RNAO). Client centred care. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Jul. 70 p. [63 references]

Not applicable: The guideline was not adapted from another source.

2002 Jul (addendum released 2006 Mar)

Registered Nurses' Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Revision Panel Members

Penny Nelligan, RN, BScN, MSN
Team Leader
Executive Director
Huron County Health
Clinton, Ontario

Frances Flint, RN, MN
Director Nursing Practice
Sunnybrook & Women's College Health
Sciences Centre
Toronto, Ontario

Doris Grinspun, RN, MSN, PhD(c) O.Ont
Executive Director
Registered Nurses' Association of Ontario
Toronto, Ontario

Nancy Lefebre, RN, MScN
Chief Clinical Executive, Vice President
Knowledge & Practice
Saint Elizabeth Healthcare
Markham, Ontario

Sheila Lewis, BScN, MHSc
Associate Lecturer
School of Nursing
York University
Toronto, Ontario

Dianne Martin, RPN, RN, BScN
Senior Policy Analyst
Nursing Secretariat
Ministry of Health and Long-Term Care
Toronto, Ontario

Suzanne Payeur-Grenier, RN
Clinical Manager
Niagara Health Systems
Welland, Ontario

Elizabeth Peter, RN, PhD
Associate Professor
Faculty of Nursing
University of Toronto
Toronto, Ontario

Beryl Pilkington, RN, PhD
Associate Professor
School of Nursing
York University
Toronto, Ontario

Kari Van Camp, RN, MScN. CPMHN(C), CARN-AP
Advanced Practice Nurse
West Park Healthcare Centre
Toronto, Ontario

Barb Van Maris, BSc, MSc
Vice President
NRC+Picker Canada
Markham, Ontario

Tracey Skov, RN, BScN, MSN(c)
Program Coordinator
Nursing Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

The Registered Nurses Association of Ontario (RNAO) received funding from the Ministry of Health and Long-Term Care (MOHLTC). This guideline was developed by a panel of nurses and researchers convened by the RNAO and conducting its work independent of any bias or influence from the MOHLTC.

This is the current release of the guideline.

This NGC summary was completed by ECRI on December 17, 2003. The information was verified by the guideline developer on January 16, 2004. This NGC summary was updated by ECRI on June 22, 2006.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario (2006). Client Centred Care. (rev. suppl.) Toronto, Canada: Registered Nurses' Association of Ontario.