In this essay we will take a critical look at the concept of autonomy and whether it is possible to maintain autonomy at the nursing and patient levels. For our purposes we will first discuss the concept of autonomy, autonomy within the nursing and medical profession and whether complete autonomy to nursing professionals is feasible.
Conceptually autonomy indicates something independent or not dependent on anything else. According to the self-determination theory proposed by Ryan and Deci (2000) autonomy is referred by contrasting autonomous support and control and hypothesizes that autonomy-supportive social contexts tend to facilitate self-determined motivation, healthy development, and optimal functioning. Considering this, it is only expected that increased autonomy in decisions taken by nurses or patients can increase motivation, improve work culture and can prove to be very effective for general enhanced functioning of the clinical setting. Autonomy is also seen as a learning opportunity as individuals learn from their experience and learning contexts whch help to raise their awareness of their potentials and strategies to enabe them to take better advanatge of their situations.
Autonomy Issues in Nursing?
There are two aspects of autonomy, from the perspective of nurses and the perspective of patients. We will discuss autonomy issues within nursing, discussing in brief some concerns and necessities of patient autonomy perspectives as well. In this study we discuss the case of 55-year old patient Mr. J with respiratory failure who has been subjected to artificial life supporting ventilator. Mr. J’s case is a challenging one for the nursing profession considering social, legal and ethical issues and issues of both patient and nurse autonomy. We discuss some relevant studies below to support our case.
Proot et al (2002) discuss a relevant study in which 27 health care providers from three different nursing homes were interviewed about autonomy issues concerning stroke patients in rehabilitation wards. This study is mainly focused on nurses perceptions of patient autonomy and a core category of changing autonomy was developed identifying the process of stroke patient regaining their autonomy with dimensions such as self determination, independence and self care. The factors affecting this process are the conditions or circumstances, the strategies of patients, strategies of care providers and families and the strategies and policies of the nursing home. The authors suggest that only a team-based approach can increase patient autonomy and this can be aided by education and guidelines, as well as coordination of the process of changes in patient autonomy.
Indirectly pointing out to the autonomy of nurses in making decisions and involving patients rather than doctors in these important decisions, Brier-Mackie (2001) argues that nurses are being increasingly faced with situations where they may have to take important decision along with the patents on issue such as withdrawal treatment or prolongation of life. Nurses play a central role in the care of dying people and they may also find themselves powerless by medical paternalism and continue to remain ill equipped in decision-making process in end of life situations of terminally ill patients. Brier-Mackie examines the ethical relationships between patient autonomy and medical paternalism for end of life care in terminally ill or incurable patients. The nurse has a unique role as the voice, support and advocate of the patient although the important issue of patient autonomy as opposed to doctors’ orders cannot be ignored. The paper tends to question whether nurses are able to overcome doctors commands and medical paternalism to voice out patients opinions and help doctors to listen. There may be considerable differences of nurse and doctor perception s far as patient autonomy is concerned.
In Mr. J’s case, whether the ventilator system supporting the patient should or should not be removed depends on nurses’ perception and opinions on end of life decisions and care. 55 year old Mr. J is terminally ill, has suffered from several cardiac arrests that paralyzed him completely, and his condition is incurable. In this condition, his physician’s decision to remove life support and ventilator systems ay have t be weighed long with Mr. J ‘s own wish to live or die. Within the nursing perspective, as we have seen from studies already discussed, nurses face the increasing social and ethical challenge of understanding patients’ wishes on one hand and listening to doctors’ decisions on the other. In this condition, it is important to consider the features of nursing practice that make autonomy a necessity.
A general respect for autonomy in nursing practice is required as suggested by van Thiel ad van Delden (2001). They point out that respect for autonomy is a core element of normative views on enhanced care services offered. The general research focus on autonomy is on independence and self-determination when it comes to clinical decision-making. However the authors argue that this is too narrow an interpretation of autonomy in the clinical setting and care in the nursing homes are subject to other definitions and influences. The authors indicated form their findings that caregivers in nursing homes seemed to value different notions of respect for autonomy under different situations. They point out that no significant differences have been noted in the opinions of doctors and nurses or between male and female hospital staff. So a necessity for a multidimensional understanding of autonomy considering several related factors and an open-minded attitude to the principle of autonomy are basic factors in the theory for respect to personal autonomy.
Considering a team based approach, a circumstantial approach or the importance of nurses’ perception in delineating patient autonomy, it is also important to keep in mind that autonomy within the nursing practice is itself a growing and important area of study.
Madsen (2005) explores the role of the untrained nurse and argue that despite the increased prevalence and need of trained nurses, the number of nurses without any formal nursing training whatsoever continue to increase in hospitals. Although untrained nurses were given primary private duties initially, things are being changed increasingly as more and more untrained nurses are working under the supervision of trained nurses. This adds to the historical evolution of the nursing profession as autonomy of untrained nursing professionals are being dramatically decreased. However with the improvement in professional standards of nursing drastically in the last few decades, we have to examine whether the reverse is true and whether autonomy for trained nurses has increased considerably.
In certain areas of medical practice, the expanded role of nurses and their new powers of prescribing drugs or performing surgery may be seen as increased levels of autonomy in which the nurses do not have to consult the physicians before administering drugs to a patient or performing an operation.
Increased autonomy and professional judgment of nurses has bee taking up importance in recent research studies and Flynn and Sinclair (2005) emphasizes that nursing practice no longer relies on tradition or rituals and is based on empirical evidence and research. Evidence based practice or nursing, reflective practice, standardization of nursing practice and production and maintenance of nursing protocols, policies and guidelines are the various important aspects of nursing care that have direct relevance to nursing autonomy. A careful examination of nursing theory, policies and the actual practice provides significant insights into the experiences of the nurses in relation to the policies and highlights how nurses perceive and adapt to these guidelines and whether they see these as hindering or favoring autonomy and independence within their practice.
In Mr. J’s case, several social issues are being considered and these include:
1. Mr. J’s own wishes regarding life support or specific wishes on death or life
2. The decision of Mr. J’s family, their desires on whether doctor recommended life support system should be removed
3. A proper consensus to be reached between health care tea of professional, doctors and nurses and Mr. J’s family, relatives and the patient’s own wishes.
4. Nurses face the challenging role of mediators who conveys patients and family wishes to doctors.
5. Costs incurred by the healthcare department to support a terminally ill patient have to be considered
The ethical issues in removing Mr. J’s life support system are many and span
1. Questions on life and death and whether natural death should be preferred as opposed to forced death
2. whether it is ethical to keep an incurable patient in a persistent vegetative yet painful state
3. or whether it is ethical to remove life supporting system s to hasten death in patients
Consideration of patient and patent’s family members’ wishes may be given priority
As there are several legal issues involved
1. Human rights or right to live is one of the arguments given by human rights group who oppose euthanasia
2. most legal opponents of forced death may however suggest patient autonomy and completely independent decision making by the patient as to whether e want to live or die as the only legal criteria for justifying such acts. However patent autonomy might not work in many cases as in most cases, terminally ill patients on life support systems may not be able to decide for themselves.
Brewster has discussed the implications of nurse prescribing for stoma care patients and other studies suggest the possibility and actual practice of extrapolating nurse expertise in several previously physician controlled domains. Shermann (2005) points out that the expanded role of nurses with increased responsibilities are only preparing nurses as future leaders of the clinical setting as they continue to remain the major force behind care and treatment schedules of patients. The need for strong nurse leaders has been emphasized in the study.
In this essay we discussed the case of Mr. J who has been terminally ill and suffers from respiratory problems following several cardiac arrests and in his condition the wish to die or live by removing or maintaining life support systems is an important decision that has to be taken by M. J, his family, his physicians and nurses. Mr J’s condition highlights successfully the legal, ethical and social issues that surround and shape both patient and nurse autonomy as patient’s decision on important treatment issues may be conveyed by nurses to doctors and the nurses in turn, with increasing autonomy and independence can also help the patient in taking decision. Both patient and nurse autonomy are examined as closely related and influencing nursing practice than possibly any other singular aspect of the nursing profession. However as we have seen, there are many controversies on patient and nursing autonomy that adds to the complications of the situation.
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