Autonomy and autonomy competencies: a practical and relational approach

Understanding the Significance of Listening to Older People's Life Stories in Whole Person Care-An Interview Study of Nurses in Gerontology

Aim: The purpose of this study was to explore the significance of performing a life story interview for gerontological nursing students. Method: The study had a qualitative exploratory design, focusing on hermeneutical understanding using thematic analysis. Seven nurses in older people nursing were interviewed. Findings: Two main themes emerged from the analysis: "Engaging fellowship" and "Understanding the importance of life stories." The participants experienced increased engagement and fellowship with their patients after the life story interview; the change in their perspective was characterized by renewed interest, connection, and recognition of the individual person. The participants also gained a deeper understanding of the significance of listening to an older person's life story narrative, and this was expressed through them gaining an understanding of people's actions, achieving an altered mindset, gaining a greater generational understanding, and integrating a life story focus in their everyday professional life. Conclusion: Knowledge of human life and stories makes older people's situations easier to understand; this insight affects how we as nurses think about others. Seeing each patient as an individual and unique person and being aware of this in daily care is essential for nursing.

The Weakness of Will: The Role of Free Will in Treatment Adherence

Chronic disease prevention and management requires a lifelong commitment and adherence to lifestyle modifications, monitoring of symptoms, medication use, and other forms of therapy. Treatment adherence is a crucial and complex concept in patient care provision, and it requires the voluntary active involvement of patients for the best possible outcome. Multiple factors, which may or may not be under the patient's control, can influence treatment adherence. However, adherence or non-adherence to a certain treatment is predominantly influenced by one's sense of agency, values, beliefs, attitudes, and willpower. It is evident that mental states appear to influence patients' decision-making, and the best treatment outcome occurs when a patient identifies their goals, needs, and desires and exercises their decision-making and free will during the course of receiving care. The role of healthcare providers is critical in promoting treatment adherence, thereby enhancing patient outcomes. Thus, this paper highlights the importance of promoting a sense of agency and integrating patients' values, beliefs, attitudes, and intentions during the provision of healthcare. It is indispensable to recognize the individual's ability and initiative to control and manage their illness in the face of challenging socioeconomic and cultural reality. On logical grounds, it is not enough to appreciate the value of free will and mental states, it is also essential to empower and cultivate an individual patient's willpower to make a well-informed, free decision based on their mental state for the most optimal treatment outcomes.

"Sometimes it feels like thinking in syrup" - the experience of losing sense of self in those with young onset dementia

Purpose: To explore and describe the experience of people having young-onset dementia.Methods: This was a qualitative study that used semi-structured interviews to collect data from nine persons with young-onset dementia (aged 47-65; five men and four women). Data were collected in the spring of 2018. All interviews were conducted at the participants' choice and in their own homes by one interviewer. The collected data were analysed using the six-stage process of reflexive thematic analysis model.Results: The analysis revealed three themes: Dementia causing loss of control over oneself; becoming a burden to the family while sense of self disappears; and fearing a humiliating future.Conclusions: The experience of having and living with young onset dementia affected the persons' thoughts and memory and was experienced through the persons' loss of personality and sense of self. Thoughts about the future were associated with fear, and the risk of changing their personalities to something different from the one which they had experienced as humiliating throughout most of their lives.

Ethical Dilemmas of Participation of Service Users with Serious Mental Illness: A Thematic Synthesis

Mental health professionals are expected to stimulate the participation of service users with serious mental illness. This not only changes what is expected from service users and professionals, it also changes the values underlying their relationship. The value of autonomy becomes more important as a result. This raises potential ethical dilemmas. This paper reports the findings of a thematic synthesis of 28 papers on the views of service users, professionals and family members on the care relationship in inpatient, outpatient and community services for people with serious mental illness. It puts forward various perspectives on participation of service users, foregrounding differing values, which in turn can lead to ethical dilemmas for professionals. The key implications for mental health professionals and future research are discussed.

Self-care as care left undone? The ethics of the self-care agenda in contemporary healthcare policy

Self-care, or self-management, is presented in healthcare policy as a precursor to patient empowerment and improved patient outcomes. Alternatively, critiques of the self-care agenda suggest that it represents an over-reliance on individual autonomy and responsibility, without adequate support, whereby 'self-care' is potentially unachievable and becomes 'care left undone'. In this sense, self-care contributes to a blame culture where ill-health is attributed to personal behaviours or lack thereof. Furthermore, self-care may represent a covert form of rationing, as the fiscal means to enable effective self-care and supplement, or replace, self-care capacities, is not provided. This paper explores these arguments through a contemporary ethical analysis of the self-care agenda. The terms self-care and self-management are used interchangeably throughout whereby self-management is understood as a point in the wider self-care continuum.

Attunement and Involvement: How Expert Nurses Support Patient Autonomy

In this essay, I argue that the daily practice of expert nurses goes far toward enacting the kind of patient autonomy feminist bioethicists envision. Nursing theorists often utilize philosophical theories in their work, but bioethicists have not paid much attention to nursing theory and what it means to be an expert nurse. This is unfortunate because expert nurses do much in their daily practice to make the ideals for autonomy put forth by feminist bioethicists a reality. With this in mind, I bring these two literatures together in what I hope is a fruitful dialogue.

Perceived resident-facility fit and sense of control in assisted living

The concept of resident-facility fit has largely been used to illustrate whether a residential care facility and a resident are together able to meet requirements set by only the hampering functional abilities of the latter. The purpose of this paper is to study how assisted living residents perceive resident-facility fit. The data were gathered ethnographically from both observations and resident interviews in a sheltered home in Finland during 2013-2014. Perceived resident-facility fit is based on several relational factors that connect to both the residents as individuals and their surroundings. This fit seems also to be partly conditional and indeed depends on residents' trust in having their own potential to act. Good resident-facility fit results in feeling at home in a facility, whereas poor fit can even result in residents' feeling imprisoned. Care providers can thus utilize our results to affirm residents' quality of life in residential facilities.

Free choice in residential care for older people - A philosophical reflection

OBJECTIVE

Free choice in elderly care services is a debated issue. Using the theoretical support of philosophers of free will, this paper explores free choice in relocation to residential care. The three dominant perspectives within this field of philosophy, libertarianism, determinism and compatibilism, are applied from the perspective of the older individual to the process of moving.

METHOD

Empirical data were collected through qualitative interviews with 13 older individuals who had recently moved into residential care.

RESULTS

These individuals had made the choice to move following either a health emergency or incremental health problems. In a deterministic perspective they had no alternative to moving, which was the inevitable solution to their various personal problems. A network of people important to them assisted in the move, making the choice possible. However, post-move the interviewees' perspective had changed to a libertarian or compatibilist interpretation, whereby although the circumstances had conferred little freedom regarding the move.

CONCLUSIONS

The interviewees reported a high degree of self-determination in the process. It appeared that in order to restore self-respect and personal agency, the older individuals had transformed their restricted choice into a choice made of free will or freer will.

Intergenerational Perspectives on Autonomy Following a Transition to a Continuing Care Retirement Community

The study evaluated the concept of autonomy from the perspective of older adults and their adult children following a transition of the older adult to a continuing care retirement community (CCRC). Overall, 70 interviews (with older adults and their adult children; 34 dyads) were analyzed, using a line-by-line open coding, followed by dyadic analysis. Autonomy was not portrayed as a uniform, homogenous construct, but rather encompassed four different domains: (a) the focus of one's attention or concerns: on others, on self, or not at all; (b) the ability to exercise decisions and make independent choices; (c) the degree of physical functioning and ability of the older adult; and (d) the financial ability of the older adult. The duality in the relationships between older adults and their adult children is discussed in relation to the give and take of autonomy that occur following a transition to a CCRC.

COMPETENCE, VOLUNTARINESS, AND OPPRESSIVE SOCIALIZATION: A FEMINIST CRITIQUE OF THE THRESHOLD ELEMENTS OF INFORMED CONSENT

Abstract

Feminists have argued that oppressive socialization undermines the liberal model of autonomy. We contend that this argument can also be employed effectively as a challenge to the standard bioethical model of informed consent. We claim that the standard model is inadequate because it relies on presumptions of procedural autonomy and rational choice that overlook the problem of how agents are often socialized so that they adopt and internalize oppressive norms as part of their motivational structure. The argument that oppressive socialization undermines liberalism’s view of autonomy is most relevant to what Beauchamp and Childress call the threshold elements of informed consent—competence and voluntariness. We show how these elements fail to account for morally relevant factors such as oppressive socialization.

Older people’s experiences of their free will in nursing homes

Background:

Older people in institutional care should be allowed to live a meaningful life in a home-like environment consistent with their own free will. Research on actualisation of older people’s own free will in nursing home context is scarce.

Objectives:

The purpose of this study was to describe older people’s experiences of free will, its actualisation, promoters and barriers in nursing homes to improve the ethical quality of care.

Research design:

Fifteen cognitively intact older people over 65 years in four nursing homes in Southern Finland were interviewed. Giorgi’s phenomenological method expanded by Perttula was used to analyse the data.

Ethical considerations:

Chief administrators of each nursing home gave permission to conduct the study. Informants’ written informed consent was gained.

Findings:

Older people described free will as action consistent with their own mind, opportunity to determine own personal matters and holding on to their rights. Own free will was actualised in having control of bedtime, dressing, privacy and social life with relatives. Own free will was not actualised in receiving help when needed, having an impact on meals, hygiene, free movement, meaningful action and social life. Promoters included older people’s attitudes, behaviour, health, physical functioning as well as nurses’ ethical conduct. Barriers were nurses’ unethical attitudes, institution rules, distracting behaviour of other residents, older people’s attitudes, physical frailty and dependency.

Discussion:

Promoting factors of the actualisation of own free will need to be encouraged. Barriers can be influenced by educating nursing staff in client-orientated approach and influencing attitudes of both nurses and older people.

Conclusion:

Results may benefit ethical education and promote the ethical quality of older people’s care practice and management.

Concept analysis: patient autonomy in a caring context

AIM

This paper is a report of an analysis of the concept of patient autonomy

BACKGROUND

Many problems regarding patient autonomy in healthcare contexts derive from the patient's dependent condition as well as the traditional authoritarian position of healthcare professionals. Existing knowledge and experience reveal a lack of consensus among nurses regarding the meaning of this ethical concept.

DESIGN

Concept analysis.

DATA SOURCES

Medline, CINAHL, The Cochrane Library and PsycINFO were searched (2005-June 2013) using the search blocks 'autonomy', 'patient' and 'nursing/caring'. A total of 41 articles were retrieved.

REVIEW METHODS

The Evolutionary Method of Concept Analysis by Rodgers was used to identify and construct the meaning of the concept of patient autonomy in a caring context.

RESULTS

Five attributes were identified, thus creating the following descriptive definition: 'Patient autonomy is a gradual, time-changing process of (re-)constructing autonomy through the interplay of to be seen as a person, the capacity to act and the obligation to take responsibility for one's actions'. Patient vulnerability was shown to be the antecedent of patient autonomy and arises due to an impairment of a person's physical and/or mental state. The consequences of patient autonomy were discussed in relation to preserving control and freedom.

CONCLUSION

Patient autonomy in a caring context does not need to be the same before, during and after a care episode. A tentative model has been constructed, thus extending the understanding of this ethical concept in a caring context.

Managing threats against control in old age: a narrative inquiry

BACKGROUND

The desire to retain personal control over self and life circumstances continues into old age; it exists in tension with late-life vulnerabilities.

OBJECTIVES

This article investigates how older adults respond to threats against control in light of changes surrounding health and identity.

METHODS

Community-dwelling African American (n = 10) and European-American older adults (n = 10), aged 70 years and older, with varied self-reported health statuses were qualitatively interviewed. Open-ended interviews explored older adults' perceptions of control and threats to control in older age.

RESULTS

Three themes linked older adults' responses to threats to control. Older adults (a) proactively monitored physical and mental health, (b) maintained roles that shaped important aspects of identity, and (c) fostered personal growth and development by generative practices. Responses of participants who had difficulty countering threats to control are also offered.

DISCUSSION

This study shows that the construct of control is not abstract; it is interpreted and applied by older adults in the contexts of everyday life. Respondents used personal resources honed throughout the life course to respond to threats to control. Older adults viewed control as a cultural construct with nuanced meanings that recalled past roles and current changes that occur with age. Suggestions are offered for how health professionals can assist older adults with the cognitive and emotional tasks required to deal with threats to personal control surrounding health and identity.

Community-dwelling older adults' perceptions of dignity: core meanings, challenges, supports and opportunities

Dignity is a universally important issue for all people, and particularly vital for older adults who face multiple losses associated with ageing. In the United States of America and beyond, the maintenance of dignity is a key aim of policy and service provision for older people. Yet surprisingly little research has been conducted into the meaning of dignity to community-based older adults in the context of everyday life. As life expectancy continues to increase worldwide, unprecedented numbers of people are living longer than ever before. The majority of older adults will face declining health and other factors that may impact dignity in the course of ageing in their communities. This paper reports on a study that explored older people's understandings and experiences of dignity through focus groups and a survey. Three key components of dignity are identified: autonomy, relational and self-identity. In addition, the paper discusses a range of factors that can facilitate or inhibit a sense of dignity for older people, including long-term health issues, sensory deficits and resilience to life events. Finally, the implications of these findings for policy and practice are considered in the context of American social structures and values.

Patient autonomy and choice in healthcare: self-testing devices as a case in point

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility.

Relational Autonomy in Assisted Living: A Focus on Diverse Care Settings for Older Adults

Consistent with Western cultural values, the traditional liberal theory of autonomy, which places emphasis on self-determination, liberty of choice, and freedom from interference by others, has been a leading principle in health care discourse for several decades. In context to aging, chronic illness, disability, and long-term care, increasingly there has been a call for a relational conception of autonomy that acknowledges issues of dependency, interdependence, and care relationships. Although autonomy is a core philosophy of assisted living (AL) and a growing number of studies focus on this issue, theory development in this area is lagging and little research has considered race, class, or cultural differences, despite the growing diversity of AL. We present a conceptual model of autonomy in AL based on over a decade of research conducted in diverse facility settings. This relational model provides an important conceptual lens for understanding the dynamic linkages between varieties of factors at multiple levels of social structure that shape residents' ability to maintain a sense of autonomy in this often socially challenging care environment. Social and institutional change, which is ongoing, as well as the multiple and ever-changing cultural contexts within which residents are embedded, are important factors that shape residents' experiences over time and impact resident-facility fit and residents' ability to age in place.

Nursing Students' Perceptions of Self-Determination in Elderly People

The purpose of this study was to compare nursing students' perceptions of self-determination in elderly patients before and after clinical training in long term care institutions as a part of their course in gerontological nursing. A pre- post-test design was employed. The data were collected by questionnaires completed by students at one nurse education organization college in Finland (pre-test n ± 120, response rate 95%; post-test n ± 115, response rate 91%). The students' perceptions of elderly patients' self-determination were more positive after their clinical training period concerning to what extent elderly patients are able to control their treatment and what kind of support they received from nurses to exercise their self-determination. The students' perceptions remained stable concerning how important self-determination is to elderly patients, and how willing and knowledgeable they are about using their self-determination. Ethics teaching, together with high quality clinical training placements, should be assured early during nursing studies.

Nurses practice beyond simple advocacy to engage in relational narratives: expanding opportunities for persons to influence the public space

In practicing existential and human advocacy, or engaging in a relational narrative, nurses may assist persons who experience health inequalities to clarify their values, and, in becoming more fully their authentic selves, community members who ordinarily feel powerless in the public space may act with confidence in influencing the distribution of health-care resources. In this paper, the writers describe research characterizing nurses’ advocacy practices and review the concepts of respect and self-interpretation as a foundation for arguing that nurses who engage in relational narratives with the persons they serve may encourage continuing acts of self-understanding. Investigators indicated that nurses characterized their practices as a therapeutic endeavor, and that their practices were grounded in respect. Practicing nurses may need self-awareness to habitually convey respect for human dignity, in addition, nurse educators ought to attend to the professional development of student nurses, providing opportunities for the formation of character traits or qualities.

Ethical and conceptual aspects of capacity assessments in psychiatry

PURPOSE OF REVIEW

To search the literature on conceptual and assessment issues of patient capacity.

RECENT FINDINGS

Current literature shows that many instruments have been developed in the last decade to measure patient capacity. Although these measures provide a rank-ordered scale of capacity, they cannot categorize patients into competent and incompetent, which relies heavily on the concept of authentic autonomy. The latter, however, should be carefully examined after considering the patient's cultural and subcultural background, and the quality of the doctor's communication skills.

SUMMARY

Academic and clinical psychiatry are posed with such questions as to how to categorically classify capacity and incapacity as well as to evidence the admissibility of measuring instruments when used in a civil commitment.