Responsibility and autonomous nursing practice

Ethical dilemmas in nursing documentation

BACKGROUND

Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored.

AIM

To explore ethical dilemmas in nurses' conversations about nursing documentation.

RESEARCH DESIGN, PARTICIPANTS AND CONTEXT

The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman.

ETHICAL CONSIDERATION

This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent.

FINDINGS

Ethical dilemmas were strongly present in nurses' conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients' autonomy and not causing harm, which was visible in nurses' navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses' balancing between documenting deviations and proof of nursing practice.

DISCUSSION

Ethical dilemmas in nursing documentation regarding respecting patients' autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records.

CONCLUSION

Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.

Design of a Clinical Practice Guideline in Nurse-Led Ventilator-Weaning for Nursing Training

Cardiothoracic intensive care unit (CICU) nurses have shared the role and responsibility for ventilator-weaning to expedite decision-making in patient care. However, the actions taken are based on individual's unstructured training experience as there is no clinical practice guideline (CPG) for nurses in Malaysia. Hence, this study aims to design a CPG for the process of weaning from mechanical ventilation (MV) for a structured nursing training in a CICU at the National Heart Institute (Institut Jantung Negara, IJN) Malaysia. The Fuzzy Delphi Method (FDM) was employed to seek consensus among a panel of 30 experts in cardiac clinical practice on the guidelines. First, five experts were interviewed and their responses were transcribed and analyzed to develop the items for a FDM questionnaire. The questionnaire, comprising of 73 items, was distributed to the panel and their responses were analyzed for consensus on the design of the CPG. The findings suggested that the requirements expected for the nurses include: (a) the ability to interpret arterial blood gases, (b) knowledge and skills on the basics of mechanical ventilation, and (c) having a minimum 1-year working experience in the ICU. On the other hand, the CPG should mainly focus on developing an ability to identify criteria of patient eligible for weaning from MV. The learning content should focus on: (a) developing the understanding and reasoning for weaning and extubating and (b) technique/algorithm for extubating and weaning. Also, the experts agreed that the log book/competency book should be used for evaluation of the program. The CPG for structured nursing training at IJN in the context of the study is important for developing the professionalism of CICU nurses in IJN and could be used for training nurses in other CICUs, so that decision for ventilator-weaning from postcardiac surgery could be expedited.

Professional responsibility and decision-making in the context of a disease-focused model of nursing care: The difficulties experienced by Spanish nurses

When, in 1977, nurse education in Spain was transferred to universities a more patient-centred, the Anglo-American philosophy of care was introduced into a context in which nurses had traditionally prioritised their technical skills. This paper examines the characteristics of the nurse's professional role in Spain, where the model of nursing practice has historically placed them in a position akin to that of physician assistants. The study design was qualitative and used the method of analytic induction. Participants were selected by means of theoretical sampling and then underwent in-depth interviews. The resulting material was analysed using an approach based on the principles of grounded theory. Strategies were applied to ensure the credibility, transferability, dependability and confirmability of the findings. The main conclusion is that nurses in Spain continue to work within a disease-focused model of care, making it difficult for them to take responsibility for decision-making.

Comparing nurse managers and nurses' perceptions of nurses' self-leadership during capacity building

AIMS

This paper compares the perceptions of nurse managers and nurses about self-leadership of professional nurses while taking ownership of capacity building during unit management.

BACKGROUND

The Nursing Strategy for South Africa states that the competency of nurses is dependent upon factors that lead to capacity building.

METHOD

A quantitative design was followed by conducting a survey. The target population included nurse managers and professional nurses working at an academic public hospital in the Gauteng Province of South Africa.

RESULTS

The findings indicate shortcomings in relation to advising professional nurses about self-direction while taking ownership of their daily pressures and stresses associated with unit management.

CONCLUSION

Professional nurses should develop their confidence by focusing on their self-leadership strengths when managing a unit.

IMPLICATIONS FOR NURSE MANAGERS

Recommendations are made to promote self-leadership while taking ownership of nurses during capacity building of unit management.

Career in mental health still an unlikely career choice for nursing graduates: a replicated longitudinal study

The lack of qualified mental health nurses is at critical level with the problem likely to worsen as the aging mental health nursing workforce retires. This study investigates the career preferences of undergraduate nursing students by comparing preferences at the start, middle, and end of the Bachelor of Nursing program. The comparison of the cohorts gave an indication of the change in preferences over the intervening years. It replicates research completed in 1992, 1997, and 2001, and develops a profile of nursing career preferences and the rationale underpinning those preferences in a cohort of students (n = 150) who began their Bachelor of Nursing studies in 2007 and completed in 2009. The main findings included that, like the previous studies, mental health nursing is one of the least desirable career choices for most nurses at the start of their course and remains so as they approach graduation. The reasons change but the outcome remains the same. The current system of using the Bachelor of Nursing award to produce mental health nurses in Australia does not encourage nurses to consider a career in mental health nursing. Which begs the question: where will mental health nurses in the future come from?

Nurse autonomy in cancer care

BACKGROUND

The concept of autonomy is regarded as an essential element for gaining professional status. Yet, it remains poorly defined and understood. To date, there is little research that has focused on exploring how nurses in different specialty areas perceive autonomy.

OBJECTIVE

The purpose of this research was to explore oncology nurses' perceptions of autonomy and understand how they develop and exhibit autonomy in their everyday practice.

METHODS

Using Leininger's ethnonursing method, data were collected from 15 oncology nurses using semistructured interviews. Participant observation was also carried out through job shadowing to complement interview data.

RESULTS

Three themes emerged from the findings: autonomy is an unspoken opportunity in the workplace; autonomy is developed through professional and personal growth acquired over time; and demonstrating autonomous behaviors is a conscious choice.

CONCLUSION

The findings provide insight into how oncology nurses perceive, develop, and exhibit autonomy in everyday practice and how autonomous and collaborative clinical decision making contributes to quality cancer care.

IMPLICATIONS FOR PRACTICE

Descriptions of the meaning of autonomy and its explication in a nursing specialty practice can add to nursing knowledge by clarifying nurse autonomy and its relevance to nurses' work life. Descriptive studies can identify nurse behaviors and attitudes related to autonomy that may be measurable and relevant to real life.

The meaning of autonomy in nursing practice

AIM

To illuminate the meaning of nurses' experiences of autonomy in work situations.

BACKGROUND

Professional autonomy means having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base. An understanding of autonomy is needed to clarify and develop the nursing profession in rapidly changing health care environments and internationally there is a concern about how the core elements of nursing are taken care of when focusing on expansion and extension of specialist nursing roles.

DESIGN

Qualitative study.

METHODS

This paper reports part of a project aimed at exploring the education and work qualifications required by the nursing profession. Eleven Norwegian nurses, each with 2-3 years of work experience since graduation, participated in both in-depth interviews and focus group interviews in 2006. A qualitative hermeneutic approach, inspired by Gadamer's philosophy, guided the research process and the analysis and interpretation of the transcribed interview-texts.

RESULTS

The nurses' descriptions of their experiences of autonomy in work situations emerged as four themes: 'to have a holistic view', 'to know the patient', 'to know that you know' and 'to dare'. To be knowledgeable and confident was found to be the coherent meaning of autonomy in nursing practice.

CONCLUSIONS

Authority of total patient care, the power to make decisions in a relationship with the patient and next of kin and the freedom to make clinical judgements, choices and actions seem to be connected to the meaning of autonomy in nursing practice.

RELEVANCE TO CLINICAL PRACTICE

To gain autonomous practice, nurses must be competent and have the courage to take charge in situations where they are responsible. This study shows the challenges in handling this autonomous practice.

Towards understanding the concept of risk for pregnant women: some nursing and midwifery implications

AIMS AND OBJECTIVES

This paper aims to explore the concept of risk in pregnancy.

BACKGROUND

Notions of risk and 'not knowing' have always surrounded pregnant women, although in the last two decades trends of increased consumer confidence and midwifery activism have together promoted a greater appreciation of pregnancy as a normal life event. At the same time, advances in pregnancy-related technologies have contributed new levels of concern related to an increasing ability to detect minor abnormalities by ultrasound. This, in turn, causes a concordant rise in the number of women referred to high-risk pregnancy care to monitor suspect findings. Overall, it seems likely that this increasing emphasis on abnormality detection and risk may have serious implications for women.

DESIGN

Concept analysis.

METHOD

In this paper, I undertake an exploration of the concept of risk as understood by health professionals and pregnant women. Then, using Deborah Lupton's understanding of a 'discourse of risk', I discuss the ways pregnant women both contribute to and are enmeshed in, this discourse. In the final section, I consider how nurses act informally to shield vulnerable women.

CONCLUSIONS

Health professionals and pregnant women understand risk differently. Women employ a subjective appraisal of risk, measuring it against their personal values and prior experience, while health professionals evaluate risk in an objective manner.

RELEVANCE TO CLINICAL PRACTICE

As increasing numbers of women are referred to 'at risk' care, it is important that health professionals understand and respond to maternal understandings of risk. Nurses and midwives particularly, have a role to play in assisting women to make sense of risk calculations. In this way, they can act to ameliorate the growing concept of risk for pregnant women.

Dangerousness and mental health policy

Mental health policy development in the UK has become increasingly dominated by the assumed need to prevent violence and alleviate public concerns about the dangers of the mentally ill living in the community. Risk management has become the expected focus of contemporary mental health services, and responsibility has increasingly been devolved to individual service professionals when systems fail to prevent violence. This paper analyses the development of mental health legislation and its impact on services users and mental health professionals at the micro level of service delivery. Historical precedence, media influence and public opinion are explored, and the reification of risk is questioned in practical and ethical terms. The government's newest proposals for compulsory treatment in the community are discussed in terms of practical efficacy and therapeutic impact. Dangerousness is far from being an objectively observable phenomenon arising from clinical pathology, but is a formulation of what is partially knowable through social analysis and unknowable by virtue of its situation in individual psychic motivation. Risk assessment can therefore never be completely accurate, and the solution of a 'better safe than sorry' approach to mental health policy is ethically and pragmatically flawed.

Writing place: a comparison of nursing research and health geography

The concept of 'place', and general references to 'geographies of ...' are making gradual incursions into nursing literature. Although the idea of place in nursing is not new, this recent spatial turn seems to be influenced by the increasing profile of the discipline of health geography, and the broadening of its scope to incorporate smaller and more intimate spatial scales. A wider emphasis within the social sciences on place from a social and cultural perspective, and a wider turn to 'place' across disciplines are probably equally important factors. This trend is raising some interesting questions for nurses, but at the same time contributes some confusion with regard to imputed meanings of 'place'. While it is clear that most nurse clinicians and researchers certainly understand that place of care matters to their practices and patients, many diverse uses of 'place' are found within nursing literature, and contemporary understandings of the term 'place' within nursing are not immediately clear. It is in this context that this article plans to advance the discussion of place. More specifically, the aims of this paper are threefold: to critique 'place' as it appears in nursing literature, to explore the use of 'place' within health geography, whence notions of place and 'geographies of' have originated and, finally, to compare and contrast the use of 'place' in both disciplines. This critique intends to address a deficit in the literature, in this era of growing spatialization in nursing research. The specific questions of interest here are: 'what is "place" in nursing?' and 'how do concepts of place in nursing compare to concepts of place in health geography?'

The impact of leading empowered organisations (LEO) on leadership development in nursing

PURPOSE

This study sought to evaluate the impact and sustainability of the Leading Empowered Organisations (LEO) programme on the role of G Grade Nurse Managers, their colleagues and therefore on patient care at CHS.

DESIGN/METHODOLOGY/APPROACH

A qualitative, inductive research methodology, which employed 360-degree research evaluation, was used. A purposive sample of four G Grade Nurse Managers was included. Each G Grade and eight of each of their colleagues were interviewed. Data were analysed according to the principles of thematic analysis.

FINDINGS

There was evidence of a sustained impact of the LEO programme on G Grade Nurse Managers in relation to competence, action plans, delegation, communication strategies, problem solving, risk taking, leadership and management. The study also revealed a number of significant personal and contextual factors that affected the implementation of the LEO principles. Empowerment, or a lack of it, underpinned much of what occurred in the implementation of the LEO principles by the G Grades into practice.

ORIGINALITY/VALUE

The findings indicated that both organisational and individual action is necessary to achieve leadership development. Organisations need to ensure that investment in leadership is not restricted to the LEO programme, but that it becomes a strategic priority.

Developing a pain assessment tool for use by nurses in an adult intensive care unit

Critically ill patients are particularly vulnerable to pain, patient's citing it as their second greatest ICU stressor. Pain has also been identified as a complicating factor in critical illness. Despite this, pain management is often not considered a priority by the ICU team. Effective management can only be achieved with accurate pain assessment. However, this is difficult in the critically ill as patients are often unable to communicate verbally due to the presence of endotracheal/tracheostomy tubes, sedation and paralysing agents. Nurses therefore rely on behavioural and physiological indicators in establishing the presence of pain. However, as these also occur in situations and conditions not associated with pain there is a need for a systematic, objective assessment tool. Such a tool, consisting of a numerical and verbal rating scale to facilitate documentation and audit, was developed as a result of ongoing adjustment and evaluation. The tool scores the patient's pain by incorporating behavioural and physiological indicators and is used in conjunction with the Glasgow Coma Score and the modified Sheffield Sedation Scale to achieve a comprehensive neurological assessment. As movement and intervention may exacerbate pain, assessment is carried out at rest and during procedures such as suctioning and manual handling. As an aid to pain assessment and management a flow chart and a clinical guideline have also been introduced. Although preliminary evaluation established the effectiveness of the tool as a means of estimating and recording pain levels in individual patients, it was evident that there has been no change to the way in which pain is managed. To address this issue, the level of nurses understanding regarding pain management has been ascertained and teaching sessions delivered to increase the profile of pain management in the unit.

A critical review of the arguments debating the role of the nurse advocate

AIMS OF THE PAPER

This paper critically reviews the arguments for and against undertaking the role of nurse advocate.

BACKGROUND

Advocacy has become a popular concept in nursing literature over the past two decades. By addressing issues of power and accountability, conclusions are drawn about the risks facing nurses who would practice patient advocacy.

METHODS

Review and analysis of theoretical debate.

RESULTS

Empirical evidence is sparse and philosophical arguments predominate in the field of patient advocacy. Humanistic arguments that promote advocacy as a moral imperative are compelling. However, in reality nurses appear to lack the power base to comply except by covert means. Informed consent with a knowledge of the consequences of undertaking such an intervention is as relevant to the nurse as it is to the patient.

CONCLUSION

Nurses need to be empowered first, if they are to empower their patients. There may however, be more suitable candidates for the role of patient advocate and nurses should recognize that they do not have a monopoly on ethical decision making.

Professional nurse autonomy: concept analysis and application to nursing education

Professional nurse autonomy, an essential attribute of a discipline striving for full professional status, is often confused with personal autonomy, work autonomy or aggregate professional autonomy. Using Walker & Avant's (1995) model for concept analysis, this paper presents an analysis of professional nurse autonomy. Professional nurse autonomy is defined as belief in the centrality of the client when making responsible discretionary decisions, both independently and interdependently, that reflect advocacy for the client. Critical attributes include caring, affiliative relationships with clients, responsible discretionary decision making, collegial interdependence, and proactive advocacy for clients. Antecedents include educational and personal qualities that promote professional nurse autonomy. Accountability is the primary consequence of professional nurse autonomy. Associated feelings of empowerment link work autonomy and professional autonomy and lead to job satisfaction, commitment to the profession, and the professionalization of nursing. A student-centred, process-orientated curricular design provides an environment for learning professional nurse autonomy. To support the development of professional nurse autonomy, the curriculum must emphasize knowledge development, understanding, and clinical decision making.

A concept analysis of autonomy

Clinical and policy developments in health care have recently created demand for a professional response in terms of the development of advanced roles for nurses, notably 'nurse practitioner' roles. Such roles demand the exercise of autonomy, a term which eludes succinct definition despite the fact that the preparation of practitioners for these roles relies on a clear understanding of its nature. Utilizing an approach described by Wilson, this paper undertakes a concept analysis of autonomy, each step illustrated with examples taken from clinical practice, with the ultimate aim of offering an operational definition of autonomy.

A concept analysis of autonomy

The nursing profession places a high value on the acquisition of autonomy as a requisite for professional status. Although the literature is replete with studies that examine autonomy and nurses, methods and results often are inconsistent and inconclusive. Review of the literature reveals ambiguous or absent definitions of autonomy. Nursing commonly confuses autonomy with related concepts such as authority, accountability, power, professionalism, and independence. A concept analysis of autonomy is done using Walker and Avant's modification of Wilson's analysis procedure. This highly abstract concept emerges as a discrete, empirically definable term referring to a potential human quality in an existing state. The analysis includes antecedents, consequences, defining attributes, model and borderline cases, and empirical referents.

Professional responsibility: implications for nursing practice within the realms of cardiothoracics

Through an exploration of the realms of professional responsibility this paper aims to illustrate its implications in nursing practice with particular reference to the area of cardiothoracics. Throughout the paper issues surrounding the 'Code of Professional Conduct for the Nurse, Midwife and Health Visitor' and the 'The Scope of Professional Practice' released by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (U.K.C.C.) in 1992 are considered. 'The Code' as it will subsequently be referred to, and the 'The Scope of Professional Practice' (U.K.C.C.) address issues of current change within the nursing profession and provide a focus for discussion. While recognising both current constraints to clinical practice and the complexity of professional responsibility, it is concluded that the delivery of research based, quality patient care remains central to the role of all nursing professionals. With a primary focus on others before the self, nursing professionals must continue to address issues surrounding the maintenance and development of this care.

Developing the emergency nurse practitioner role in accident and emergency: a bottom-up approach

This paper discusses how the Accident and Emergency Nursing Development Unit (NDU) in Dewsbury, UK, has developed the role of the emergency nurse practitioner. Each individual member of the Nursing Development Unit (NDU) contributed to this change in practice. Maintaining these contributions to practice development was as important as the practice itself. The NDU exists to support and facilitate a bottom-up approach. This paper will discuss the whole development process and will not therefore include all the details and results from what was a 2-year process.

Responsibility in intensive care: a critical analysis

Nursing has undergone numerous aspects of change within the last 10 years, resulting in a blurring of roles and thus responsibilities. Responsibility in nursing is an enormous, vitally important and pertinent concept. In this paper the term 'responsibility' will be described, discussed and critiqued within the context of the management of care, research and education for nurses working in an intensive care environment.

Ethics, agency and empowerment in nurse education

The ethical demands of professional nursing practice are considered, and the concept of Agency is offered as a potentially useful part of the nurses conceptual equipment for such practice. The pressures of working in large organisations are suggested to be inimical to a sense of Agency, and it is also suggested that some of the academic disciplines involved in nurse education are offering an ambiguous view of the issue of Agency. The discipline of Ethics, while also ambiguous on this issue, is presented as offering useful ways of exploring that ambiguity. Several theories of Ethics are considered in relation to human freedom and responsibility, and the issue between determinism and free will is likewise considered. It is suggested that these offer ways of helping the individual to explore and develop their own stance on freedom and responsibility, and thereby on the issue of Agency. This discussion is related to the United Kingdom Central Council (UKCC) Code of Professional Conduct, and the paradox of choice is acknowledged.