Organizational environment and the support of patient autonomy in nursing home care

This study examined how patient autonomy is associated with the organizational environment in nursing homes, particularly the organizational climate, organization of work and selected staff characteristics, such as age and experience of health care Staff from 13 nursing homes in the county of Stockholm, Sweden, were included The organizational climate was described by staff from two of the nursing homes that, on the basis of staff judgement, were rated as creative, and from two of the nursing homes that were rated as lacking innovation Regarding organization of work, which included the number of patients who required to be fed, together with the incidence of pressure sores and indwelling urinary catheters, there appeared to be no difference in care from both types of nursing home The statistical analyses showed that nursing homes characterized as significantly creative supported patient autonomy to a high degree, and that the staff's experience with health care was associated with the organizational climate     

When the patient asks for counselling, when the patient doesn't ask for counselling, when the patient refuses therapy

A large debate that has brought some depths changes is in action. It is on the relationship between patients and health professionals, physicians, nurses, psychologists etc. The path went through the medical paternalism to the phase of the autonomy, thin to reach the ethics of taking care. In these years, bioethics has tried to answer to urgent questions that primarily interest the private sphere of the people. Currently, by contributions of European and American philosophies, an ethics of the responsibility is delineating This, differentiates the ethics of the rights and the rules (autonomy, self-determination). The attitude of taking care postpones to a whole intellectual, affective, moral competences, that every health professional has to possess to establish relationship with people. This allows, beyond the autonomy, a fundamental moral principle that remains, to give a positive emotional answer and support the conditions and the situation of others. In this answer, the availability to be in the identification process is affirmed to, with their problems and, the desire to do the possible to assuage their suffering. If the person is set in a large net of relationships, is able to express autonomy mediating counselling process of health professionals. The client will freely choose to assume self-care responsibilities.     

Medical ethics in the 21st century: respect for autonomy in care of the elderly patient

In the 21st century, health professionals will serve an increasing number of elderly female patients. Critical care and other fields will face formidable challenges in developing the medical skill and knowledge to care for the changing patient population. At the same time, new ethical challenges will accompany demographic changes. This review critically evaluates the ethical principle of autonomy in the context of geriatric patient care. We show how the issues discussed and the theoretic perspectives adopted shift in this context. Special attention is paid to the issues of advance directives, mental health and competence, gender bias, drug therapy, and the residential settings from which elderly patients come and to which they return. Toward the end of the review, we note that autonomy occurs in the context of other medical ethical values. The task ahead is to balance these values and to fine-tune various medical ethical principles to suit the growing elderly population.     

Caring, patient autonomy and the stigma of paternalism

Caring, patient autonomy and the stigma of paternalism ¶This paper utilizes data generated during a qualitative study in palliative and maternity care settings to guide discussion of the current discourse, which emphasizes patient autonomy and derides paternalism. Data are presented which illustrate that this ideology is established in nursing practice. Respect for patient autonomy is identified as an essential element of individualized, patient-centred and ethical care but conversely, it is suggested that over-emphasis may confuse and suppress beneficent intervention. The value of ethical theory to provide an objective means to explore ethical dilemmas in practice is not debated, but exploration of the issues raised by the data suggest, that principle-based ethical theory suffers the following constraints: the predetermined balance of ethical principles in favour of respect for autonomy prevents an unbiased perspective and optimum guidance; in contrast to caring relationship, application of ethical theory does not reveal the particulars necessary to guide ethical decisions aimed at promoting good for the individual; current discourse appears to disregard the inherent inequality in the relationship between the helped and helper and practitioners' need to preserve their own moral integrity. Consequently, this paper argues that beneficence derived through caring should not be superseded uncritically and suggests that mutual nurse-patient relationship, which balances respect for patient autonomy and beneficent guidance based on practitioner's clinical expertise, protects the moral integrity of both patient and practitioner. For conciseness, the term patient will be used to indicate recipients of both nursing and midwifery care and while both nurses and midwives are not always specified, any term referring to nurses, denotes both.     

The nurse's role as patient advocate: obligation or imposition?

In order to secure professional standing, nursing has sought to discover and prove the value and uniqueness of the nursing contribution to patient well-being A prominent feature of this quest has been the assertion by nurses and nurse writers that the nurse has a specific and special function as patient advocate There is a substantial amount of literature to support this view, which is further reinforced by the United Kingdom Central Council (UKCC) for Nursing, Midwifery and Health Visiting which states that advocacy forms an integral part of the nurse's duty to patients This paper provides a critical analysis of some of the features central to advocacy in order to promote clarification of the concept These include the patient's rights and interests in health care, the moral status of patient autonomy, the obligations owed to patients by nurses and the work of independent advocacy schemes It is suggested that the literature tends to confuse advocacy with beneficence which dilutes the significance of advocacy in health care, and that nurses have no special function as patient advocate Furthermore, due to the rigorous demands of the advocate role, the UKCC neither can nor should impose such an obligation on its members, who would be better served by improved support when they endeavour to discharge the full range of beneficent obligations owed to patients within their care     

An exploration of the relationship between patient autonomy and patient advocacy: implications for nursing practice

The purpose of this article is to examine whether patient/client autonomy is always compatible with the nurse's role of advocacy. The author looks separately at the concepts of autonomy and advocacy, and considers them in relation to the reality of clinical practice from professional, ethical and legal perspectives. Considerable ambiguity is found regarding the legitimacy of claims of a unique function for nurses to act as patient advocates. To act as an advocate may put nurses at personal and professional risk. It may also be deemed arrogant and insulting to other health care professionals. Patient autonomy can be seen as a subcategory of the right of every individual to self-determination, and as such is protected by law. However, it is questionable whether the traditionally paternalistic approach to health care provision truly respects the autonomous rights of each patient. The author considers examples and cases from the literature that resulted in professional and/or personal difficulties for the nurses involved, and also reflects on an incident from her own practice where a positive outcome was achieved that demonstrated compatibility between the concepts under consideration.     

Creating an organizational diversity vision: goals, outcomes, and future directions of the International Society of Psychiatric Nurses

The aim of this article was to chronicle the development and status of a diversity vision within a psychiatric nursing organization. Organizational activities to support diversity and cultural competence, along with challenges to a full integration of these values, are presented. Psychiatric nurses need to be engaged in the process of developing personal and organizational cultural competence to eliminate barriers that contribute to disparities in effective mental health care.     

Patient‐centred care through a broader lens: Supporting patient autonomy alongside moral deliberation

Patient‐centred care (PCC) is an essential component of high‐quality healthcare and shared decision‐making is its cornerstone. Yet, integrating the principles of PCC into healthcare practice is not always straightforward and shared decision‐making can be complicated and ethically demanding. While ethicists and academics routinely debate moral aspects of clinical care, such discussion among clinicians is less overt. In this paper, we use Emmanuel et al.’s deliberative model to provide a practical framework for considering ethical aspects of PCC and shared decision‐making. The model encourages us to appreciate PCC through a broader lens and consider patient autonomy alongside other moral obligations such as justice and the equitable distribution of finite resources. The model can be used by healthcare providers, patients and caregivers to facilitate dialogue and moral deliberation regarding the merit of their preferences and values; in this way, individualised care can be delivered without compromising other important ethical obligations.     

Cultural Competence in the Undergraduate Nursing Curriculum

Although health care providers and health care systems have increasingly acknowledged the need for culture-specific care in a global society, its implementation has remained daunting. Thus, integrating cultural competence into nursing education is no longer a choice but a requirement that builds on the values of the racially and culturally diverse population of the United States for optimal health care. The need has never been greater for nurses who understand the health implications of the demographic shifts that are shaping an American society whose African American, Hispanic, Asian, and Native American constituents compose a significantly growing portion of the population and whose health care needs will need to be served in health care settings that range from their homes to health care institutions. This article provides a blueprint on how our undergraduate program integrated cultural competence education throughout the curriculum.     

Emergency Medical Practice: Advancing Cultural Competence and Reducing Health Care Disparities

In an increasingly diverse patient population, language differences, socioeconomic circumstances, religious values, and cultural practices may present barriers to the delivery of quality care. These obstacles contribute to the health care disparities observed in all areas of medical care. Increasing cultural competence has been cited as part of the solution to reduce disparities. The emergency department (ED) is an environment where cultural sensitivity is particularly needed, as it is often a primary source of health care for the underserved and ethnic and racial minorities and a place where high patient volume and acuity place the provider under demanding time pressures, yet the emergency medicine (EM) literature on health care disparities and cultural competence is limited.
The authors present three clinical scenarios highlighting challenges in providing equitable emergency care to minority populations. Using these cases as illustrations, three processes are proposed that may improve the quality of care delivered to minority populations: 1) increase cultural awareness and reduce provider biases, enabling providers to interact more effectively with different patient populations; 2) accommodate patient preferences and needs in medical settings through practice adjustments and cultural modifications; and 3) increase provider diversity to raise levels of tolerance, awareness, and understanding for other cultures and create more racially and/or ethnically concordant patient–physician relationships.     

A growing challenge: patient education in a diverse America.

Patient education is a vital part of nursing practice, but the inability to provide consistent culturally sensitive patient care to minority populations has most certainly contributed to disparities in health and healthcare. This article explores minority populations in the United States and their characteristics in relation to health and healthcare, popular cultural competence theories, and nursing school curricula, and discusses teaching strategies for developing more culturally competent nursing professionals.     

Values that matter, barriers that interfere: the struggle of Canadian nurses to enact their values.

Qualitative interviews were conducted with 20 nurses in a Canadian city to explore the moral experience of nurses in their working lives. The participants were asked what they valued in their profession and how well their work lives enabled them act on their values. Almost uniformly, they expressed commitment to the values of helping others, caring, making a difference, patient-centredness, advocacy, professional integrity, holistic care, and sharing knowledge for patient empowerment. They identified several challenges and frustrations experienced in attempting to enact these values. System-level challenges included professional hierarchies, organizational structures, issues in the health-care system, and power dynamics. Removing these barriers cannot be left to nurses alone. It requires complex, wide-ranging strategies: system change, power restructuring, and the creation of ethical climates and cultures that support values that are essential to good patient care.     

Is in-vitro fertilization for older women ethical? A personal perspective

Fertility treatments raise a range of social and ethical issues regarding self-identity for family, sexual intimacy, and the interests and welfare of potential children. Eggs and sperm are combined to produce fertilized eggs. These eggs are then implanted as embryos and grow into viable fetuses, which are carried by the original mother or a surrogate mother. This artificial form of conception can challenge religious values and family structures. In-vitro fertilization (IVF) can be considered either as a medical miracle or playing with divinity. What obligation do medical professionals have to infertile women and to what extent? The bioethical dilemma of IVF use encompasses different moral issues for all involved in the process. Ethical issues address respect for personal autonomy, access and care, and the duty of the health care provider to be compassionate to persons whose actions and moral values may be different from their own. Health care providers need to impart empathy, understanding and sensitivity towards this unique type of patient population. The conflict for those treating patients who are trying to conceive by IVF includes respect for personal autonomy, nonmaleficence, justice, utility and the ethics of care. As a registered nurse in a postpartum hospital unit, I have seen antepartum and postpartum women involved with this new technology. I have worked with mothers and their partners as they experience different levels of anxiety and hope for the future. There is an underlying psychosocial connection with patients who undergo IVF treatments. The purpose of this article is to explore the ethical use of IVF on older women. Is this type of biotechnolgy being applied for the right reasons and for the best patient population?     

An ethical case for patient self-determination

The self-determination of patients can be impeded or enhanced to a significant extent by the professionals who care for them. The autonomy of cancer patients especially is affected by their care givers. These patients often face difficult choices in the management of their illness: decisions about pain control, treatment choice, research participation, family involvement, withdrawal of treatment, and the degree to which they wish to be informed in making each of these decisions. The extent to which consent is free and informed and the autonomy of the patient not impeded, but positively enhanced, is determined by the professional. Is it fair to assign the professional so much responsibility for patient autonomy? Are patients not free to make decisions as they wish? In a technological society, serious illness is managed by professionals who incur a major share of responsibility for the degree of freedom that patients exercise. When patients are not encouraged and assisted to exercise their freedom, they cannot be autonomous. When an experience is brought under professional management, self-determination is possible only to the extent that it is both protected and promoted, or actively advocated. In the care of cancer patients, the central responsibility for advocacy belongs to the professional best situated within the framework of health care to sustain a partnership with the patient, and that professional is the nurse.     

Intrusion into patient privacy: a moral concern in the home care of persons with chronic mental illness

The aim of this study was to identify and analyse ethical decision making in the home care of persons with long-term mental illness. A focus was placed on how health care workers interpret and deal with the principle of autonomy in actual situations. Three focus groups involving mental health nurses who were experienced in the home care of persons with chronic mental illness were conducted in order to stimulate an interactive dialogue on this topic. A constant comparative analysis of the transcribed audiotaped sessions identified a central theme that concerned the moral symbolic meaning of 'home'. This reflected the health care workers' conflict between their professional role and their moral role, which they perceived as unclear.     

Autonomy and the developing role of the clinical nurse specialist

The role of the clinical nurse specialist has developed in response to social, technological and political changes that have impacted upon the delivery of health care. Nursing has traditionally been associated with femininity and in a paternalistic health structure the concept of nursing care can be devalued because autonomous nurses may threaten the balance of power. Autonomy is a multi-faceted concept and yet, if nurses have the courage to embrace both the traditional values of nursing and the expertise that their caring role brings to health care, they will be able to develop their own competence and autonomous practice. Nurses may not need autonomy in order to enhance their roles but they do need to concentrate on the concept of care as a team phenomenon. This notion is included in the UKCC's higher level of practice initiative which may direct specialist practice in the future. A negative element to nurse specialization is that nursing care can become fragmented, thus compromising the continuity and accountability of patient care.     

Respecting end-of-life treatment preferences

Most patients eventually must face the process of planning for their future medical care. However, few Americans have a living will or a durable power of attorney for health care. Although advance directives provide a legal basis for physicians to carry out treatment using a health care proxy or a living will, they also should reflect the patient's values and preferences. Family physicians are in a position to integrate medical knowledge, individual values, and cultural influences into end-of-life care. Family physicians can best respect the autonomy of patients by allowing the patient and family to prospectively identify relevant health care preferences, by sustaining an ongoing discussion about end-of-life preferences, and by abiding by the decisions their patients have made.