Person-centred care as a technology of compliance: A critical investigation of how nurse navigators care for people with complex conditions

The incidence of chronic disease is increasing across the globe, and therefore, healthcare costs are rising. To meet the growing health needs of individuals and communities, governments are seeking new ways to deliver care that is centred on reducing hospital presentations and promoting self-efficacy in individuals. Health services have introduced the concept of person-centred care as a method of working with the person and their family, ensuring that their care needs are met, with the view of translating this care into reduced hospital presentations. One new model of care which aims to support those with chronic care needs is the Queensland Health nurse navigator service. The role of the nurse navigators is to provide integrated care to people who are frail and have complex care needs, many of whom have multiple chronic conditions, to work between multiple services, public and private health systems, and across both short-and-long term timeframes, to meet the complex health needs of individuals referred to the service. Currently, individuals are eligible for navigation if they meet certain hospital usage markers such as repeated admissions, emergency department presentations and fail to attend appointments. As per the Nurse Navigator Toolkit, person-centred care is the first key role principle of the nurse navigator service. While person-centred care appears to offer individuals and families more choice, respect and integration of care, the concept is philosophical in nature. It remains rhetorical, with nurses reporting a tension between the tasks they must achieve, and the care they want to provide. The fragmented and complex nature of the health systems translates to reduced access and engagement of vulnerable populations, leaving them at risk of poor-quality care, separation from healthcare services and a reduced voice in their care. Despite the promise of person-centred care, care that centres on the medical, psychosocial, and social needs of the person has not been realised. This research applies a Foucauldian philosophy to the task of critically interrogating the concept of person-centred care. It applies Fairclough’s Critical Discourse Analysis, investigating levels of healthcare discourse, and exploring the hierarchy of power in relation to people with chronic complex disease. Discourse across the micro, meso and macro levels is critiqued, including, but not limited to, interviews with nurse navigators, media reports, hospital policies economic data, hospital usage data, national and international policies and frameworks and parliamentary Hansards. This discourse was chosen to understand the individual and system level factors which contribute to how individuals are moulded, or in this case, responsibilised. Text is examined for its relational, experiential, and expressive features, investigating social relations and world views. Through exploring the concept and ideology of person-centred care, this research uncovers how the concept is discursively positioned to meet the agenda of health services, rather than vulnerable people. The findings clearly show that person-centred care exists within a complex matrix of power relations and government agendas, living alongside the ideals of new public management efficacy, productivity, and efficiency. Person-centred care is one of several discursive strategies in place to promote individual compliance, whereby the individual is moulded into the ideals of the rational citizen, thus a technology of government. Furthermore, nurse navigators have been made responsible for the provision of person-centred care yet have little autonomy and authority to inform wider system changes that are required to enact it. Nurses themselves are subjected to fiscal management and rationing. The outcome of this research encourages health services to view person-centred care as having benefits beyond fiscal outcomes. Nurse navigators are well placed to inform wider system changes necessary to better support the needs of people with multimorbidity, therefore enacting person-centred care at the meso and macro levels.