Editorial

Person-Centeredness Enhances Public Health Approaches to Combat COVID-19

The first fundamental canon of the Code of Ethics published by the National Society of Professional Engineers of the United States is, “Engineers, in the fulfillment of their professional duties, shall hold paramount the safety, health, and welfare of the public” (emphasis added) (NSPE 2019). In contrast, the United Kingdom Nursing and Midwifery Council’s Code of Ethics holds that the first principle of nursing practice is to “prioritise people” by putting their interests first, by making their care and safety the main concern of the nurse and by ensuring that the person’s dignity is preserved, they are treated with respect and their rights are upheld (NMC 2015). As the community of health-care professionals—including nurses and engineers—address the ongoing pandemic of the coronavirus disease 2019 (COVID-19) and prepares for the inevitability of future global pandemics and disasters, the purpose of this editorial is to propose that environmental engineers should “build back better” (BBB) (United Nations 2015) by enhancing public health research, education, practice, and policy by promoting the benefits of person-centered practice, which keeps the person in the center of decision-making.

Problem with How We Have Flattened the (Epidemic) Curve

In seven months, between the declaration of a pandemic by the World Health Organization (WHO) on March 11, 2020 (Roxby 2020) and the public announcement of an available vaccine on November 9, 2020 (Gallagher 2020), the number of global cases of COVID-19 rose exponentially from just over 100,000 to approximately 50 million. Throughout much of 2020, many within the global community of health-care professionals encouraged policy makers—from local health departments to national agencies—to adopt a variety of measures to “flatten the (epidemic) curve” until a vaccine could be developed (Oerther and Watson 2020). As described previously, nonpharmaceutical interventions (NPIs)—including face coverings, handwashing, physical distancing, screening, travel restrictions, quarantine, contract tracing, lockdown, and engineering controls—have been employed individually and collectively in an effort to prevent transition of the virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Oerther and Shattell 2020). Although current scientific evidence generated through systematic reviews and meta-analyses do not show strong statistical support for the effectiveness of NPIs to prevent the spread of COVID-19, nonetheless, public health officials have been urged to take “measured gambles, based on circumstantial evidence …” and “… to take action even when evidence is uncertain (or not of the highest quality), particularly when the harms and costs of such action are likely limited” (Soares-Wesier et al. 2020). And while these NPIs are well grounded within the historical command-and-control approach to public health practice, the widespread implementation of these NPIs may fail to recognize the uniqueness of individuals and the importance of personalized care (Coulter and Richards 2020). For example, in the clinical environment an important concern includes widespread restriction of visitors “… that have prevented parents from staying with their children in hospital, barred fathers from labour wards, stopped families from visiting sick or dying relatives, and inhibited much needed comfort and support for those with physical or learning disabilities, mental health problems, or dementia” (Coulter and Richards 2020). In other words, holding paramount the safety, health, and welfare of the public runs roughshod over health-care professionals showing compassion and sensitivity to understand and care for the needs of the individual person.

What Is Person-Centered Practice in the Era of COVID-19?

Over the past 20 years, the concept of person-centeredness has become prominent in the delivery of quality health care, and especially in nursing practice in the United Kingdom and beyond (McCormack and McCance 2006). As described in Fig. 1(a), person-centeredness recognizes the autonomy of the individual disaggregated from the average of the public. Person-centeredness includes the importance of the health-care professional developing a clear understanding of and respect for the values of the patient. Person-centered practice also pays attention to the situation of the health-care practitioner, ensuring that the same values of respect for the personhood of all persons is enshrined in our ways of working, engaging, and relating. It is through this understanding and respect that a dialogue occurs wherein decision-making is negotiated between practitioner and patient. These negotiations are supported and enhanced through the process of engagement, which includes the establishment and maintenance of relationships of mutual respect and trust. Outcomes from person-centered practice apply to patients and staff and include a good care experience, feeling involved in care, a feeling of well-being, and the generation of a practice culture that sustains person-centered practices.

Throughout much of 2020, an ongoing failure to provide clear, consistent, and concise risk communication has contributed to confusion and engendered a lack of trust among the public (Oerther and Watson 2020). For example, rather than achieving near universal use of face coverings as a means of helping to prevent the spread of SARS-CoV-2, many in the public now view face coverings as a sign of political affiliation—with those in the United States who wear a face covering called mindless “sheeple” or those who do not wear a face covering called selfish “covidiots” (Economist 2020). Currently throughout the United States, it is common to observe individuals wearing a face covering while driving alone in a personal automobile where no transmission should be occurring, or to observe individuals refusing to wear a face covering in a crowded indoor venue with activities known to promote transmission such as the creation of droplets and aerosols while singing during a religious service (personal communication). The ongoing failure to adopt person-centered practices including the failure to act with intentionality to cultivate an understanding of and respect for the beliefs of the individuals who make up the public should be addressed by environmental engineers both during the current COVID-19 pandemic as well as in efforts to prepare for inevitable future pandemics.

How Can Environmental Engineers Build Back Better Ahead of the Next Pandemic?

Environmental engineers have limited experience considering traits of individuals as part of public health protection. For example, as part of the Safe Drinking Water Act (SDWA), the process for proposing national primary drinking water regulations that include maximum contaminant levels should consider “… the effects of the contaminant on the general population and on groups within the general population such as infants, children, pregnant women, the elderly, individuals with a history of serious illness, or other subpopulations that are identified as likely to be at greater risk of adverse health effects due to exposure to contaminants in drinking water than the general population,” (US Congress 1996). This explicit identification of vulnerable or susceptible subpopulations reflects the Cartesian dualism of modern medicine, where individuals are reduced to a mechanistic understanding of the chief illness and the body is separated from the mind (Guignon 1983; Leder 1992). Because person-centeredness emphasizes the importance of developing a clear understanding of and respect for the values of the person, the value system that resides in the mind (i.e., their lived experiences in the world) of the person must be considered equally alongside the chief illness documented in the body of the person. To do so has the potential to develop much stronger connections between individuals’ beliefs and values in general and the public health requirement to maximize safety concerns.

To the environmental engineering community, COVID-19 represents a major modern disaster that has resulted in a temporary disruption of sustainable development. As part of the community of health-care professionals, environmental engineers are contributing to solutions to the current pandemic such as treating N95 respirators for emergency reuse (Rockey et al. 2020) and developing low-cost indoor air cleaners for homes (Eldred 2020). Beyond responding to the current pandemic, environmental engineers have an opportunity and an obligation to build back better in anticipation of future pandemics. As described in Fig. 1(b), BBB means that recovery after future disasters is more rapid. The concept of BBB was defined formally by the Japanese delegation to the Third UN World Conference on Disaster Risk Reduction as using “… the disaster as a trigger to create more resilient nations and societies than before … through the implementation of well-balanced disaster risk reduction measures, including physical restoration of infrastructure, revitalization of livelihood and economy/industry, and the restoration of local culture and environment” (United Nations 2015).

In the case of enhancing the practice of public health protection, environmental engineers should incorporate person-centeredness to complement the current approach to protecting vulnerable or susceptible populations. The framework for person-centered practice developed by McCormack and McCance (2019) provides a whole systems approach to planning and delivering person-centered activities at all levels of the public health system, with the ultimate goal of “creating healthful cultures.” These kinds of cultures nurture caring relationships, facilitate engagement of all persons, engender trust in the individual, and maximize the autonomy of citizens (McCormack and McCance 2017). Opportunities to make this happen can be seen in, for example, the switch to online instruction in response to COVID-19. This provides a window of opportunity for professors of environmental engineering to improve the empathetic listening skills of students through exercises such as think-pair-listen (Oerther and Peters 2020b). Exercises that improve listening skills may be viewed as part of a larger pedagogical emphasis on affective domain instruction with the ultimate aim of improving the overall emotional intelligence of future environmental engineers (Oerther and Peters 2020a). As described previously, the profession of environmental engineering “… care[s] deeply about answers to the ‘why’ questions, because caring deeply is a hallmark trait of our profession” (Oerther and Peters 2020a). As environmental engineers are working to hold paramount the safety, health, and welfare of the public, we can also lead the broader engineering and scientific community to show compassion and sensitivity to understand the care for individual needs, including through collaboration with caring professions such as nursing.

Conclusion

Environmental engineers have an opportunity to contribute to building back better as the public health system is improved in the aftermath of the COVID-19 pandemic. One way to integrate person-centeredness into an improved public health system is through selection of modeling approaches that capture the behaviors of individuals (Kelly et al. 2013). For example, agent-based modeling has been demonstrated for a range of public health applications, including contamination of water distribution systems (Shafiee and Zechman 2013), evacuating disabled individuals from crowded airports (Manley et al. 2011), and regulating agricultural nitrogen and related impacts on crop production and water quality (Happy et al. 2011). Agent-based modeling approaches have been introduced as a tool to improve epidemiology, including how features of the built environment impact health (Auchincloss and Diez Roux 2008). Teachers of environmental engineering have an opportunity to educate future practitioners and to offer continuing education to current practitioners in the use of modeling techniques (Oerther 2019). The development of models to describe public health systems that incorporate the behaviors of individuals is one example of the way environmental engineers should enhance public health approaches using person-centeredness.

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