Clarifying autonomy and accountability in nursing service: part 2. Bourne L (2019) Respecting the ethical principle of autonomy in end of life care decisions. The third is job or work autonomy, which describes unit-level-group decision making for the purpose of organising the work day and setting priorities among tasks. The definition and indicators were refined into a conceptually and clinically coherent outcome. Removing the NHS blame culture around mistakes is essential to improving patient safety [32]. Both are critical to empowering nurses and motivating their job satisfaction and retention. Although, she was aware that her decision was against the Trust’s policy, she took responsibility for her action in the best interest of the patient: ...the policy should be we take the cannula out… I thought I would rather send them with a cannula because he's a very difficult patient to cannulate and he’s on 6 hourly antibiotics, so if he comes back late (within the 6 hours he’ll be back)… they are struggling to put in a cannula and he’ll miss his dose and he really needed his antibiotics because he was a vascular patient. Doctors have an ethical and legal duty to respect patient confidentiality. Likewise, [1] emphasised that performing tasks is an essential part of autonomous nursing practice. Nurses are important participants in that decision-making process. Offredy M, Vickers P. Developing a healthcare research proposal. All interviews were transcribed verbatim and analysed using the five-step descriptive phenomenological analytical method described by Giorgi, Giorgi, and Morley [16]. In addition to the discussion of the skills and knowledge required for autonomy, participants considered the importance of decision making either on a day-to-day basis or in emergency situations. Springer Nature. I don’t like to say hierarchy but in the nursing management scheme…my junior nurses I would expect to seek advice from the junior sister that is on. (P23 WM:28y). Interpretation is the adoption of a non-given factor to help account for what is given in experience such as a theoretical stance, a hypothesis, or an assumption. Dressings they do, that’s autonomous, but obviously they must have the knowledge to be able to choose the right dressings. Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Twenty-six registered nurses were interviewed from hospital A and 22 from hospital B. Enabling patients to decide how information about them is disclosed is an important element in autonomy and helps patients engage as active partners in their care. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Core values of nursing include altruism, autonomy, human dignity, integrity, honesty and social justice . Participants identified confidence as being connected with autonomous practice. There appears to be no set definition of autonomy and interpretations of autonomy were found to be diverse. Hospital B is a general hospital which serves a population of about 400,000 and has approximately 600 beds. Labrague LJ, McEnroe-Petitte DM, Tsaras K. Predictors and outcomes of nurse professional autonomy: A cross-sectional study. Keegan [33] equated accountability to responsibility and answerability to authority for one’s actions. 1997 Jun 26-Jul 9;6(12):703-7. doi: 10.12968/bjon.1997.6.12.703. Article  Gagnon L, Bakker D, Montgomery P, Palkovits JA. Findings further indicate that autonomy was practiced occasionally, rather than incorporated into practice. The importance of education in supporting and enhancing autonomous practice was highlighted. Recommendations are made regarding automony and nursing practice at the level of the individual practitioner. Article  Fields, Bronwyn E.; Whitney, Robin L.; Bell, Janice F. AJN, American Journal … © 2020 BioMed Central Ltd unless otherwise stated. The complex technology of health care creates situations in which difficult decisions need to be made by patients and their families. Fielding N, Thomas H. Qualitative interviewing. The above opinion was supported by a staff nurse who described autonomy in relation to the staff nurse taking a lead role in decision making and assuming more responsibility on weekends when there was no senior member of staff to offer support. Clipboard, Search History, and several other advanced features are temporarily unavailable. Teddlie C. Mixed methods sampling: a typology with examples. It is suggested that the nursing profession in England should adopt a more participative decision-making style, similar to that of America, where nurses emphasise involvement in hospital level committees. We express our profound gratitude to Professor Elizabeth West for offering the initiative in conducting the study, and for her supervision of the study. Confidentiality was assured, and participants were also informed that they could stop or discontinue with the interview at any time without prejudice. boundaries): They say they were going to collect the patient at 8 o’clock…10 o’clock the ambulance said... ‘I don’t think we will be able to get your patient as soon as possible now, maybe if you wait for us, book her in an hour,’ and then I said ‘Well I am not happy at all for my patient to go at that time’ so obviously I had to cancel the discharge. Phenomenology seeks to understand people’s everyday life experiences [12] by revealing what lies ‘hidden’ in them [13]. Get the latest research from NIH: https://www.nih.gov/coronavirus. https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf. An interview schedule containing four questions was developed in response to the aims of the study and was used to guide the interviews (Table 1). Whilst some nurses understood autonomy as working independently, others viewed it as working in a team. As a result of autonomy being expressed through everyday tasks, participants revealed how autonomy is implied rather than overtly expressed. In other cases, it is an independent decision such as giving the patient oxygen. A more junior staff nurse reinforced this view stating: “I’d say it’s very good that we get all the responsibility, but I think in some cases that blame is a bit of a problem... so if things go wrong they just blame you even though... while you were making it, your decision was supported, but when something went wrong they say ‘Oh, you did this?’” (P10 SN:8 m). Participants discussed boundaries related to autonomy as policies and guidelines that are intended to advise people on how something should be done. For instance, typical descriptions of autonomy included comments such as: “being able to work independently” (P6 SN:3½y) and “autonomy is working on your own” (P5 WM:43y). With an increasing internationally mobile work force, discrepancy between conceptualisations of autonomy held locally and by non-local nurses have the potential to impact the delivery of patient care. Importantly, when nurses talked about autonomy, they did not relate it to the achievement of professional status; rather, nurses were clinically focused and limited their discussions of autonomy to the ward team, implying a need for the NHS to adopt a participative decision-making style wherein staff nurses will be more involved in hospital-level decision making. The participants mentioned the corollary to working independently which is that one is then accountable for the actions taken and responsible for the results. One of the extracted factors, Restriction of Decision-making, suggested that Chinese nurses experience prohibitions on autonomous decision-making. One of the participants highlighted the need for acknowledgement as a factor that supports the development of autonomy. 2003;51:13–9. They have their BNF [British National Formulary] if they need back-up. 2001 The inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary London , The Stationary Office The need for clear, shared understanding of the meaning and an understanding of the empirical measurement of autonomy is critical. Allah Bakhshian M, Alimohammadi N, Taleghani F, Nik AY, Abbasi S, Gholizadeh L. Barriers to intensive care unit nurses' autonomy in Iran: A qualitative study. The authors declare that they have no competing interests. We have presented five ethical principles (i.e., nonmaleficence, beneficence, autonomy, justice, and privacy/confidentiality) that can help nurses to examine the ethical pros and cons of interstate nursing practice and regulation for the 21st century. It also involves nurses understanding their needs, failings, and capabilities in patient care, as can be gathered from the following comments: “....that you act within your own boundaries” (P38 WM:16y), “but also knowing their limitations and when to get help” (P43 WM:10y), and the “…need to consider our limitations as well, especially with the patient care” (P17 SN:3y). She maintained that autonomous practice was something that nurses do automatically without actually thinking about it: I feel that they [nurses] probably don't have that full understanding of what it means. PubMed Google Scholar. Online Journal of Issues in Nursing: great resource for ethics. Matua GA, Van Der Wal DM. This statement was corroborated by other participants who perceived autonomy as: “making my own clinical judgements” (P44 SR:18y), or when “I am making decisions based on my clinical judgement and my experience” (P35 WM:15y). Several respondents mentioned working within their own boundaries and limitations which involve a degree of self-knowledge. Aim: Epub 2009 Jul 23. Specifically, the study asked: RQ1: How do registered nurses in England understand the concept of autonomy in practice? 2000;23:334–40. It has been argued that as long as another unit of the organisation legitimately can veto power, autonomy cannot exist [28]. Quality in Health Care. NLM NIH Terms and Conditions, COVID-19 is an emerging, rapidly evolving situation. This study shows the challenges in handling this autonomous practice. These were then used to clarify and interpret the raw data. Five authors who were specialised in qualitative research independently went through the transcripts, confirmed the accuracy of the meaning units, as well as the transformed expressions. 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. Nursing is a profession rooted in professional ethics and ethical values, and nursing performance is based on such values. In addition to teamwork, participants emphasised the skills and knowledge required for autonomy. The subtheme ‘Working within boundaries’, explored the determinants or hindrances to autonomy, such as the hierarchy and organisational structure in the NHS. The overarching goal of this qualitative study was to explore how nurses in England conceptualise autonomy and how they put the concept into practice. This gave them the ‘support and backing’ to be autonomous practitioners. Relevance to clinical practice: (P13 WM:29y). An American study [4] of 570 acute care hospitals found that patients receiving care within hospitals that promote nurse autonomy have lower risk for, and complications leading to, death within 30 days. 2010 Feb;30(2):132-6. doi: 10.1016/j.nedt.2009.06.012. A table was created (Table 2) where the first column represents the meaning units using the language of the participants. EW, SN, FK, RC, BB, and TOO were responsible for the critical revision of the paper. Some nursing work is routine, as described above, but the patient’s condition can quickly deteriorate requiring the nurse to take action. (P38 WM:16y). Jones, H. 1996 Autonomy and Paternalism: partners or rivals British Journal of Nursing 5(6) 378 – 381 Google Scholar Kennedy, I. Participants described clinical judgement as one of the skills nurses draw upon while making clinical decisions. To illuminate the meaning of nurses' experiences of autonomy in work situations. This staff nurse emphasised the lack of recognition for nurses’ ability to make autonomous decisions as a hindrance to the development of autonomy, because such a situation may make nurses feel undervalued: “they [nurses] want to be recognised as being able to make decisions” (P33 SN:3½y). 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. Bai, Hsu, and Zhang [8] explored the psychometric proprieties of the EOMII scale. J Adv Nurs. Participants recognised the need for training: “…the more training you have like to back you up, it’s very good” (P31 SN:8y). Giorgi A, Giorgi B, Morley J. Conflict of interest. Comments such as: “Staff having the confidence and experience and knowledge…” by P7(WM:33y); and “…it’s nurses using their own knowledge and experience to manage patient care” (P43 WM:10y) exemplify this finding. For example, one ward manager reflected that: ...autonomous practice is working independently and being accountable for your own actions... They’re doing it on their own back if they’re not being told what they need to do first. The second dimension is control over nursing practice autonomy, or organisational autonomy, which relates to the regulation and the development of policies for nursing by nurses. Please enable it to take advantage of the complete set of features! In: Bowling A, Ebrahim S, editors. J Clin Nurs. Online ahead of print. Nurses' Clinical Judgment Development: A Qualitative Research in Iran. Manage cookies/Do not sell my data we use in the preference centre. Analysis and discussion of developments in Evidence-Based Nursing. The interviews took place in quiet rooms on the wards. Some participants linked autonomous nursing practice to working without supervision or using self-directed guidance. In summary, this theme described the various ways in which junior nurses were supported by senior nurses in making autonomous decisions in practice. Registered nurses' perceptions and experiences of autonomy: a descriptive phenomenological study. Background: Care is the essence of the nursing role and is closely related to the concept of professional autonomy. However, the presence of a blame culture is one of the limitations the participants perceived was associated with autonomous decision making. One of the participants gave an example of how decisions are made in practice based on nursing knowledge. For instance, P15(SR:5y) commented: “...they [autonomous practitioners] are responsible and having the confidence to do things on your own without having to constantly seek help and advice from others or relying on others to do it for you”. Issues for nurses regarding elder autonomy. Participants comprised 13 ward managers, 11 ward sisters, two charge nurses and 22 staff nurses with different levels of nursing experience and different grade levels in nursing. Sometimes it’s not the ward manager or the ward itself, it’s those outside like those in managerial positions that force pressure onto the nurses. The most significant results indicated that freshmen were less likely to select the autonomous model … Article  2002;9:472–82. Wiley: Chichester; 2016. The study received ethics approval from London-Surrey Borders National Health Service (NHS) Research Ethics Committee, study reference number 11/LO/1329. The study was conducted in two National Health Service (NHS) Trusts in the South East of England. Many of the participants perceived autonomy as working and making decisions within the context of a team, with typical comments such as: “...you’re working, obviously as part of a team” (P10 SN:8 m); and “…making my own decisions, obviously within the context of everyone I am working with, as being part of the team” (P9 SN:23y). Kramer M, Schmalenberg C. Magnet hospital staff nurses describe clinical autonomy. This article has been subject to external double-blind peer review and checked for plagiarism using automated software. Cookies policy. Kramer and colleagues [2] delineated three dimensions of autonomy in clinical practice settings. Similarly, a ward manager described boundaries in terms of nurses having had nursing training that provided them with the capability to look after patients within that remit: That the nurse is being seen to be their own individual professional and have had training as such and therefore they should be able to look after patients within that remit… the training would help you to be an autonomous professional. Professional autonomy is a key concept in understanding nurses’ roles in delivering patient care. https://www.nursingtimes.net/keen-calls-for-end-to-nhs-blame-culture/5001010.article. Nurs Res. 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. Nurses also perceived that autonomy could be turned off and on rather than comprising an integrated aspect of nursing. They had different levels of nursing experiences and were of different grade levels in nursing. Health organisations are responsible for providing necessary means for nurses to act autonomously by formulating clear roles, responsibilities and behaviours, and enhancing competence in practice and decision-making [5]. Control over practice: The authority, freedom, and discretion of nurses to make decisions related to the practice setting, such as the organizational structure, governance, rules, policies, and operations Skår (2009) studied the meaning of nurses’ experiences of autonomy in practice and found knowledge and confidence were the two major r… Nurses' moral strength: a hermeneutic inquiry in nursing practice. A descriptive phenomenological analysis of data from 48 semi-structured interviews with registered nurses from two National Health Service (NHS) hospitals (purposive sample) was used to explore the concept of autonomy. Participants highlighted the development of confidence in the junior nurses, enabling them to make autonomous decisions when they receive affirmation or confirmation before or after making their decisions. The Sage Handbook of Qualitative Research in Psychology, 2nd ed. Their findings suggested that the Dutch respondents used different definitions of autonomy which could have affected the way they answered items in the clinical autonomy subscale. Based on these findings, it is suggested that current nursing education should provide opportunities for personal and professional development which would promote autonomous practice in students. 2001; Supplement 2: ii32–7. The concept of autonomy has been an important topic of study in the nursing profession for many decades and has given rise to a range of definitions. Own palliative care, continuous professional developmental courses focussing on clinical skills, autonomy, continuous professional developmental courses on... 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