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Patient autonomy in care: A theoretical framework for nursing
Patient
Autonomy
in Care: A Theoretical for Nursing
ARLENE
G.
WIENS,
Patient autonomy has increasingly become an issue in a health care system that often promotes dependence in decision making. The complex technology of health care creates situations In which difficult decisions need to be made by patients and their families. Nurses are important participants in that decisionmaking process. Models available for deveioplng a theoretical approach to patlent autonomy traditionally have been limited to ethics literature. A more recent approach to personal autonomy is Meyer’s philosophical feminist perspective. Any philosophical approach to patient autonomy must be congruent with other critical nurslng concepts. In addltion, a model of patient autonomy for nursing must be useful for persons who operate at varlous functional levels. The model, Patient-Autonomy in Care, based on the Meyer’s model, was developed to incorporate the special vulnerability and functional needs of patients in the health care system. (index words: Decision making; informed consent; Patient autonomy; Patient control; Truth telling) J Prof Nurs 9:95-103, 7992. Copyright 0 1993 by W.B. Saunders Company
N
RN,
dependence
rather
than
autonomy
for
patients.
autonomy
Questions
Nursing nation.
definitions
one’s life (Quinn
of autonomy
include
Autonomy
& Smith,
self-determination
1987),
(Payton,
(Gadow,
1979), 1980;
1988), and the patient’s
of
& Allen,
right to decide
1987; Moskowitz
1986).
The concept of patient autonomy is evident in nursing thought and practice. For example, Orem’s (1985) Self Care model promotes patient involvement in decision making and encourages the use of patient education to improve the patient’s self-control and ability
to make decisions.
on promoting nursing
Patient
self-determination
interventions
education for patients.
focus on promoting
over their lives,
which
is based Many patients’
have been altered
by
disease or disability. Nursing diagnoses such as powerlessness focus on interventions that provide a milieu that enhances
autonomy
for the patient.
Often patient
work for the discussion
by the need for
over
subject
the right
Otte
Before further discussion, it is important eate several assumptions that will provide
is subsumed
basi-
control
not being
Within this system nurses organize their duties to maintain order so that their work can be completed. autonomy
but
of self-determi-
as having
or freedom of choice (Otte & Allen, & Moskowitz,
will be introvary,
the right
is defined
to the will of another 1987; Reeder,
in nursing
for research will be suggested.
cally all of them
control URSING is largely practiced within the structure of a health care system that promotes
MSN*
work for patient duced.
Framework
of patient
autonomy
to delina framein nurs-
order and task completion. An increased concern by nurses about the lack of patient autonomy is evi-
ing. First is the assumption that the nurse-patient relationship is such that autonomous behaviors of the
denced
patient are potentially jeopardized. Autonomy expression is threatened in settings in which persons lack
tient
by the growing autonomy
number
in the nursing
of writings
about pa-
literature.
However,
the discussion of patient autonomy to nursing ethics literature.
is limited
chiefly
control
or knowledge.
Patients
in the health care sys-
This article will expand the concept of patient autonomy beyond the current ethics focus in nursing. A
tem are particularly vulnerable to external control because of the parentalism of the system and the dependence of the patient on the expertise of professionals.
philosophical approach scribed. The compatibility
to autonomy will be deof this concept with other
Intimate activities to which the patient is exposed and the emotional vulnerability of persons who are in dis-
will be addressed. Using a philoas a foundation, a conceptual frame-
comfort due to emotional or physical suffering threaten the patient’s self-perception. When selfperception is altered, it is more difficult to exercise behaviors that express autonomy. Consequently, health care professionals may impede patients’ auton-
nursing concepts sophical approach
*Assistant Professor of Nursing, Eastern Mennonite College, Harrisonburg, VA. Address correspondence and reprint requests to MS Wiens: 1520 N College Ave, Harrisonburg, VA 22801. Copyright 0 1993 by W.B. Saunders Company 8755..7223/93/0902-0008$03.00/O
Jourtzu:Z of Professsional Nursing,
Vol 9, No 2 (March-April),
omous behaviors. A second assumption is that an organismic world view most accurately encompasses nursing’s holistic 1993: pp 95-103
95
96
ARLENE G. WIENS
approach. thing
An organismic
as connected
1980).
perspective
to everything
An organismic
and contextuality.
spective,
phenomena
enon is studied a controlled
within setting.
From
parts.
as complex
Therefore,
its environment Organismic
claim to be value free; rather,
perrather
a phenom-
rather than in
science
does not
values are seen as part of
The inclusion
of these assumptions
choices in identifying autonomy.
a compatible
to autonomy,
affects nursing
philosophical
Diana Meyers,
and Personal Choice (1989),
approach
the care concept
of autonomy,
presents
base
in Self, Society, a philosophical
which she calls the care con-
Meyers
persons as those (1989, p. 46) d escribed autonomous who “are able to match their conduct to their selves within
the constraints
cumstances
afford.”
sons, within
of the opportunities
the constraints
able to exercise behaviors times
enlarge
their
of life.
that they perceive persons
opportunities;
“they
are
coincide
can someexercise
as anyone
as
can.” All
in some way by the circumstances
Autonomous in making
per-
of their life situation,
much power over their destinies persons are limited skilled
that cir-
In other words, autonomous
with who they are. Autonomous
the context.
for patient
Within
interactive
a contextual
are perceived
isolated
The Care Concept of Autonomy
“every-
else” (Merchant,
view emphasizes
processes
than as discrete
views
persons,
decisions
however,
are more
that are compatible
with
cept of autonomy. The author will argue that Meyers’ view is particularly useful to nursing in describing patient autonomy in the nurse-patient relationship.
who they perceive themselves to be. In that sense, they have more control over who they become.
First, a brief overview of the care concept of autonomy
Meyer’s concept
will be provided.
Fig 1 and are further
Environment,
Autonomy Competency Repertory of skills
Several
concepts
are important
of autonomy. described
to understanding
These are outlined here.
Social Structure, Mores
Life Plan Includes values, emotional ties, personal ideals A
Meshes with the selfztrait
Self-correction
Self-Definition
Self-referential
Does the decision fit?
Decision making Rational Deliberative and Affective
Figure 1.
-Memory -Imagination -conversation -reason =-volition
with others
Care concept of personal autonomy.
in
PATIENT AUTONOMY:
I. Lifeplan:
97
A MODEL FOR NURSING
This is a conception
of intent.
Life plans
around
group
are usually
of values
organized
or emotional
clude specific personal of the kind of person plans are schematic include
According
of who a person
wants to be in life; it is a projection ties;
ideals;
a
they in-
it is an image
one wishes to be. Life
and dynamic;
to Meyers,
ideal within
they do not
self-referential,
is the repertory
skills that allow people to control It is a decision-making consults wants,
process in which one
the self and asks what needs,
of
their lives.
cares about,
one really
or values.
The
skills that enable people to make this enquiry and to carry out their decisions competency. the ability directive,
is autonomy
The repertory of skills to be self-referential, self-defined,
cover one’s self. a. Self-referential: reading
and to be able to dis-
potential
This
is a process
of self-
to life situations.
to use emotions
such as
frustration or pride as affective cues to guide one’s judgments. For example, if persons whether
are frustrated they may ask the trouble stems from a condi-
tion they can avoid or whether a major change in their life plan is required. b. Self-direction: This is to express one’s self in ways worthy
that
one considers
fitting
of one’s self; it is an episodic
An overview
a situation,
is not an all-or-nothing
diagram
in Fig 1. to the care concept
asks what he or she
themselves
and
their environment. People can, however, examine their socialization to better understand themselves and to increase their control over the future. Introspection and memory are important, albeit limited tools in self-discovery. e. Self-portraits: This is the conception sons have of themselves; it is their
phenom-
exist.
of the care concept
in Fig 1. The discussion
of
of autonomy
is
below follows
the
of autonomy
is the in-
personality with a realistic, accurate selfThe integrated personality is made possible
through the life plan and autonomy competency. Environment, social structures, and mores impact on the of socialization.
competency;
Through
they are products
the skills of autonomy
com-
petency persons can carry out their life plan. As the skills of autonomy competency are used, they serve to adjust
the life plan and/or
plan provides
direction;
the self-portrait.
to be autonomous,
The life one must
have a life plan. Autonomous persons develop the resources available to them.
life plans relative to They establish stan-
dards they can realistically hope to attain although they do not always do so. Autonomous persons are not denied to other people. Autonomous persons, according to Meyers, “Possess and exercise skills that main-
c:. Self--definition: Persons with self-definition know their true selves and act in accordance with their true selves. People cannot be fully d. Self-discovery: about
the sofor more
does the socialization
provided
tegrated portrait.
skills
and
yields.
concept.
Autonomy
than
with
offered
wants or can do with respect to it, and than enacts the decision this deliberation
knowledgeable
behaviors
For example,
them
and
programmatic directing of one’s life. Episodic self-direction occurs when a person confronts
autonomy.
of men equips
enon; various degrees of autonomy
Central
to be
However,
of some persons offers them a greater
for optimal
women.
social experience.
life plan and autonomy
one’s responses
It is the ability
include self-
through
the socialization
an all
to be autonomous,
but they learn how to confer with themselves,
autonomous 2. Autonomy competency: This
is more than
She assumes that virtually
people are born with the potential
cialization
all possibilities.
autonomy
our society.
perself-
a unique
view
tain a fluid interaction
of their
between
inner
selves that
their traits,
their feel-
ings, their beliefs, their values, their extended their current possibilities for realizing these and their conduct”
(p. 55). These standards
is
plans, plans,
and skills
allow autonomous persons greater control over life events than is experienced by nonautonomous persons. The life plan allows this control to occur.
A key component of autonomy competency is decision making. Autonomy competency, according to Meyers, aids in the process of developing autonomy; it allows persons to carry out their life plan. A key component of autonomy competency is decision making. Decision making is a self-referential process of autonomy competency.
98
ARLENE G. WIENS
Decision affective
making
(Fig
is both rational
1). Rational
based on ethical principles, formal decision ling persons tions.
to revert
most persons
values,
to their
decision
than is rational
making
has many
reason, memory,
imagination,
with others, Often
find plausible
deliberation.
explanations
Either
terpretation
for
Affective
components,
including
spontaneous.
AutonoSome-
the person’s
self-
can be adjusted,
or
that he or she has erred.
In-
competency
is present self emerges
competency.
by social experience
choice. The authentic self-chosen
identity
feelings
to the critical
the social-
compe-
over their lives. in the authentic through
the ex-
The authentic
self is
as well as by individual
self, according rooted
to Meyers,
in the individual’s
and firmest perspective
the
convictions,
autonomy
is “a most
yet subject
competency
af-
fords” (p. 61).
by others may be useful in this
who they want to be. That is, they adjust This self-correcting
process
A useful conceptualization of patient autonomy must be consistent with a care rather than a cure approach to nursing.
their self-
maintains
con-
gruency between the self-portrait and the life plan. Decision making within autonomy competency entails a self-referential process, self-discovery, direction, and self-definition. The self-referential cess of decision
Although
persons can use the degree autonomy
Autonomy
process. Decision making is a self-correcting process. As people make changes they believe in, they adjust portrait.
conduct.
varies with a person’s
tency they have to exert some control
abiding
recognizes
how persons can gain con-
and their
for autonomy
ercise of autonomy
in a search to
for their responses.
do not match
provided
ization,
competency
it explains
trol of themselves potential
shaped
the self-portrait
may decide
1989). Because autonomy self as dynamic,
self, and the authentic
verbal communication
are largely
the decisions
the person
and inclina-
is more common
mous persons reflect on these decisions times
compel-
and volition.
decisions
portrait.
are
or rules. However
feelings
making
and
decisions
rules are often inapplicable,
Affective
decision
deliberative
deliberative
making
aids in self-discovery.
selfpro-
As per-
Several aspects of the care concept
sons read their feelings, the process enables them to gradually identify integral segments, propensities,
particularly helpful tonomy competency
values,
skills
and goals (Meyers,
1989).
Self-direction
aids
that
will
of autonomy
are
for nursing. The concept of auoffers hope that persons can learn
offer them
some control
over life’s
in maintaining congruency between persons’ decision and their life plan. Self-directed persons are able to
circumstances; it does not totally trap an individual in his or her socialization. Decision making as both ra-
resist
tional and affective is attractive for nursing. Nurses deal with many persons who have made decisions that
unwarranted
pressure
from other
individuals.
They have the resolve to act on their own judgments. As persons act on the options of their choice, they
appear
irrational.
Meyer’s
model,
which
recognizes
reinforce or weaken different aspects of their personality. Through these choices people define who they
the affective aspect of decision making, describes a decision-making process that is useful in nursing. In
are (self-definition, Meyers, 1989). Autonomy competency will atrophy with disuse. Social interactions can inhibit or encourage the use of
addition to these aspects, it is important to address the overall compatibility of the care approach to autonomy with current nursing thought.
the skills of autonomy
competency.
The function
autonomy competency is to secure an integrated sonality. Integrated persons are satisfied with
of
pertheir
traits and how they find expression. Meyers maintained, “The autonomous individual is engaged in a dynamic process of meshing the self-portrait with a life plan that provides
for an integrated
personality”
(p. 84). Autonomy competency alone cannot account for people’s control in broad circumstances. The personal ideal of the life plan fills this gap by counterbalancing the pull of immediate circumstances and by providing guidelines for a broad range of circumstances (Meyers,
Compatibility of Concepts With Nursing Dworkin (1989) described criteria for a satisfactory theory of autonomy that are useful in evaluating the care concept of autonomy for nursing. These will be addressed in the form of questions. In addition, the last two questions address the congruency of the philosophical view with the assumptions presented at the beginning of this article. Is the approach logically consistent with other nursing concepts? The care concept of autonomy is congruent with an organismic approach. The care concept is a
PATlENT AUTONOMY:
contextual
99
A MODEL FOR NURSING
view of autonomy;
it looks at the whole
A useful must
conceptualization
be consistent
approach available
with
to nursing.
experiencing
of autonomy a resource
a cure
offer care for persons
by helping
patients
mobilize their prob-
the nurse is one of the resources. autonomy
is helpful
in revealing
by enhancing,
for the patient’s
then,
that nurses can be or substi-
competency.
Is the approach empirically possible? Autonomy care concept of autonomy ple evidence spective.
is empirically
in the peo-
from this per-
of nurses in providing
tient care, nurses observe patients
who evidence
pamany
levels of autonomous behaviors. 1s t$e concept valued? Is being autonomous desirable? The direct and indirect
emphasis
in nursing
literature
on patient autonomy indicates that autonomy is valued by nursing. Part of the same question is whether the specific
view
of autonomy
is compatible
with
nursing’s other values. In this respect the care concept reflects other values in nursing such as caring and holism. Additional evaluation of this view should clude questions more specific to patient autonomy the nurse-patient
patient autonomy? The
would lead nurses to assess for au-
competency
in patients.
tained that patients capacity
When
it is ascer-
either do not have the skills or the
to carry out autonomous
would then act to aid the patient
behaviors,
nurses
at the point of his or
her need. In summary,
the care concept
knowledge
However,
in relation
the care concept
areas that are important is not particularly ers should
with
offers
autonomy.
does not address
for nursing.
helpful
intervene
of autonomy to patient
several
The care concept
in describing patients
how caretak-
who have a low
degree of autonomy competency. In addition, the problem of power dynamics in unequal professional relationships
is inadequately
use. The care concept
addressed
of autonomy
for nursing’s
does offer a philo-
sophical approach that is generally congruent with other nursing concepts. In the remainder of this article the care concept is used to develop a framework patient
autonomy
in the nurse-patient
for
relationship.
Concept of Patient Autonomy in Care: A Conceptual Framework for Nursing
nursing knowledge about
social perspective
of the care
nature of decision making, the concept of rhe in relation to the life plan, and the idea of
self-portrait autonumy
tonomy
inin
concept of autonomy is congruent with the idea of a nurse-patient relationship. The care concept of autonomy expands knowledge for nursing through the interactive
The care approach
relationship,
Does the perspective augmnt
in how professionals
relationships.
autonomy in persons whose self is threatened through illness?
expanded
possible,
various levels of autonomy
In the experience
In
the care concept
supplementing, autonomy
clarification
relate in unequal
Does the approach offw expanded knowledge related to
autonomy than
resources to help them transcend
the sense of patient
tuting
of patient a care rather
Nurses
difficulty
lems. Sometimes
cept offers minimal should
rather than the article.
Patient trol,
truth
is addressed
telling,
and informed
conceptual
framework
consent
litcon-
(Cassidy
within
&
the nurse-
used to fill in the gaps left by the care concept
of
autonomy. NURSE-PATIENT
Does the approach speak to the inherently unequal nurse-
of autonomy
of patient
patient relationship. Because of its congruence with nursing concepts, the care concept of autonomy is used in developing the model. Other sources will be
as nurses interact with pa&s, both will have shifting spheres of autonomy.
patient relationship? The care concept
in the nursing
in discussions
Odi, 1986; Curtin & Flaherty, 1982; Payton, 1979; Reeder, 1988). These areas, along with the nursepatient relationship, will be used to organize a patient autonomy
competency.
autonomy
erature most frequently
ex-
pands knowledge as to how injustice occurs and offers hope for transcending it to some extent. Autonomy competency provides a framework for ascertaining areas where control can be attained in unjust situations, even though the control may be small. The concept of autonomy competency offers expanded understanding of nurse-patient interactions. However, the care con-
Patient
autonomy
RELATIONSHIP
in the nurse-patient
relationship
is a relational phenomenon. Rosenbaum (1986) described a relational notion of autonomy in which the actual range of a participant’s social autonomy is mostly a function of his ‘role’ relatedness to other participant(s). Accordingly, as the relations between participants change, it is likely that a corresponding modification in their respective and reciprocal ranges of autonomy will occur also (Rosenbaum, 1986, p 107).
100
ARLENE G. WIENS
Therefore,
as nurses
will have shifting experience
interact
spheres
role trajectories
dent to independent,
with
patients,
of autonomy. from being
the autonomous
both
As patients totally
depen-
actions of both
self-referential to adjust
process.
However,
The culture to promote
a milieu
that encourages
autonomous
times this leaves the nurse with great power over the
trinsic
and will not be greatly
patient.
professionals,
and
the nurse
Coercion
unopposed
change.
is always a possibility
the role of patient
to the knowledge Consequently,
and opinions
patients
are expected
to listen
indicates
the health
this role enactment continues to persist.
ingrained
the reference
and assorted
Patients
patient
role and forego autonomous
and controlling.
dating
have an aptitude
persons
whereas
reserved
role. The culture certain patient ingrained
bill of
Certainly,
ist for the patient tomary practices
persons
Congenial,
for the patient
Impediments
to autonomous
tients
autonomous
behaviors
to the self that occur with illness. must
confront
choices
erected
by
by the onslaughts During
about
while they are under considerable
illness pa-
basic
emotional
interests and phys-
ical strain. Nurses may need to decide whether patients have the resolve for autonomous action. Illness to assaults
to autonomous
ac-
tion.
role,
enforces a practices,
expectations
ex-
role (Cassidy & Odi, 1986). CUSinclude having professionals in
of patient
gratitude
for the
skills of health care personnel, Even though formal displays of autonomy promotion, such as the Patient Bill of Rights, offer individuals the freedom to expand the patient role, few patients do so. Perhaps they fear informal sanctions. Role enforcement compels patients to separate what they really want from what is really prudent (Meyers, 1989). However either the nurse or the patient may perform outside their typical role enactment. Patients may reject the passive role that is often expected of them and demand control. Nurses may relinquish their caring role and behave rudely in their interactions with patients. Either of these groups may be acting in manners incongruent with their selfEach will need to engage
ltfness can decrease resistance to assaults to autonomous action.
for the
include believing that health care personnel know what is best for the patient. Standardized expectations
portrait.
and fosters
that
for patients.
the health care system are reinforced
accommo-
have less aptitude
and standardized
the exhibition
It is the
for the role. For ex-
charge who make decisions for the patient, frequently without consulting the patient. Ingrained attitudes
include
autonomous
af-
with the
action.
desire
is to this passive
of the health care system role enactment. Customary
attitudes,
may choose to compromise
respects
ample, persons who are passive obviously have less diffculty with the patient role than do persons who are confrontive
is strongly
actions
role with diverse per-
aptitudes
of action
fected.
can decrease resistance
Persons come to the patient sonalities
affected by health care
but autonomy
Those
has changed somewhat, but it When speaking about the patient
role in this section, patient role.
than in-
desire is in-
to pro-
this role per-
care system.
rather
Autonomous
to create an environment
advice are then
The need for a patient
how deeply
is within
advice.
action.
nurses’ responsibility
of expert professionals.
and act on the professional’s
labeled as noncompliant. ception
when power is
is one of submission
who choose to not follow the given rights
At certain
because persons have few resources.
Classically,
fessionals
will
to the other.
of the health care system can be altered
hibits
the patient
each also will need
his or her sphere of autonomy
in his or her own
Deci and Ryan (1987) described proach
to autonomy
nurses
can promote
that
assists
autonomy
an organismic in describing
aphow
in the nurse-patient
relationship. Deci and Ryan hypothesized that autonomy-suppoctive behaviors are those that maintain oc enhance intrinsic motivation. In reviewing studies, they
found
that
external
threats and deadlines, creased intrinsic
events
evaluation,
motivation.
such
as rewards,
and surveillance
External
events
de-
such as
these are often used as institutional restraints. Positive feedback was found to enhance intrinsic motivation when it affirmed competence, but it did so only when the sense of competence was accompanied by the experience of self-determination, In addition, Deci and Ryan reported chat There is indication that when contextual factors function to support autonomy rather than to control, people tend to be more intrinsically motivated, more creative, more cognitively flexible, more trusting, more positive in emotional tone, and more healthy; they tend to have higher self-esteem, perceived competence, and preference for choice; their behavior tends to be less controlling; and they project less aggression (p. 1030).
PATIENT AUTONOMY:
Finally,
101
A MODEL FOR NURSING
in considering
prescriptive
to predict
whether
controlling, contextual
events are autonomy
cannot
meaning
(Deci & Ryan,
behaviors supporting
supportive
is likely to be given.
factors
psychological vidual
it is possible
this is based on the significance
event or context
1987).
or in predicting behaviors,
each patient-nurse
or
that an
However,
be disembodied
ascribed
on occasion
formulations,
Deci and Ryan offer a caveat. Although
these
from
action
are coercion
enhance
Therefore, responses
it is essential
in assessing to autonomy-
that nurses view
holistically
of the nurse-patient
and indi-
of patient
relationship autonomy
shown in Fig 2. The nurse and patient with diverse personalities
action
that block
and surveillance.
autonomous
of the paautonomous
Nurses
action by offering opportunities
PATIENT
to them by the indi-
interaction
framework
of activities
back and providing
Within
can also
positive
for patient
feed-
control.
in the in care is
come to each
and roles. They
CONTROL
the concept of patient
of choice,
control
is the matter
which
involves
decision
making.
Within
the care concept,
patients’
decision
making
is based
on such things as feelings, ideas of others,
An outline
interaction
Examples
the
vidually. conceptual
block the autonomous
tient.
what they can imagine,
and on the ability
may be made based on deep emotional to others. tients
Often
nurses
arrive at certain
formation
commitment
fail to understand decisions,
that the patient
the
to reason. Decisions why pa-
considering
was given.
With
the intheir lim-
then enact their roles, sometimes as expected, other times not as expected. The nurse, who is usually in
ited exposure to patients, nurses’ understanding of the affective role in patient decision making is superficial.
the independent
On the other hand,
role, cannot
block the patient’s
au-
tonomous desire. However, because of their superior position in the nurse patient relationship, nurses can
making
although
choices
patients
nurses can aid patients they do not fully
make.
For example,
in decision
understand
the
patients
may
Patient: Diverse personalities Assorted aptitudes for roles
. Nurse action Coercion Threats to self Surveillance
Autonomous
1 7
1
action
Figure 2.
Patient-nurse
Rewards Threats Deadlines Evaluation
Positive feedback in the presence of competence if self-determined; remove controlling factor; provide opportunities for patient control
roles. Nurse and patient with shifting spheres of autonomy.
ARLENE
102
need to decide
whether
nurse can help patients
to take chemotherapy. imagine
may mean for them by describing
their actual personalities
experience
they can tolerate? patients
have experienced
reflections
Through
must
accept
this kind
in the nurse-patient
tion for obstructing
in this as valid
through
decision
relationship
making
ternatives
by helping
and by listening
Not all patients omy competency, grees of control
is given
However,
in
the al-
defense
mecha-
to the reality of
skills are not a justifica-
persons attempts
at self-control.
to enact autonomy
the self, parentalism
is justiability
to
the self may happen in several ways. The
extreme case is to make decisions
for a suicidal person. decisions.
so some will abdicate
patient’s
de-
autonomy
However, a decision.
there are less obvious compromised
But the family
or nurse
desires from the past,
A person
and unable
to make
may know
the
and they may safely
make a decision knowing they are carrying out what the patient would have desired. Another case could be
auton-
omy competency may be compromised. Sometimes control desired by patients is beyond the capability of
Patient control through decision
through
are blinded
need to assess each person’s
may be cognitively
certain
people,
to
(Cassidy &
the self and then offer help accordingly.
Protecting
to their concerns.
In some patients
resemblance
and achievements
filters,
to protect
Nurses
protect
possess the same degree of auton-
to caretakers.
limited
when persons are unable
competency
retain control through
them to consider
Other
Compromised
of
decisions
control
1986).
Meyers noted that many
bear
their lives.
fied.
of patient
self-portraits
nisms or cognitive
In patients
competency
their
Fig 3. Nurses can help patients decision
Odi,
Did
of the self.
A summary making
memories.
can make decisions.
who are able to use autonomy nurses
what
nausea in the past? If so, how? Is it an
discussion,
competency.
what happens,
it. The nurse can draw on the patients’
manner,
their autonomy persons’
it feels like, and how other patients they experience
The
what chemotherapy
G. WIENS
the person with an ileostomy
who denies
its perma-
making
I Nurse helps consider alternatives, listens -> to concerns
If exercise autonomy competency, nurse accepts decision as valid
If autonomy skills are _ compromised
Assess ability to protect the self
Less autonomy competency -> abdicates control
Self-portrait incongruent with autonomy competency
I
I
Defense mechanisms and cognitive filters interfere with autonomy competency I
Nurse needs to aid in protection of the self as needed. This may range from enhancing autonomous action to parentalism. Figure 3.
Patient control in the nurse-patient
relationship.
PATIENT AUTONOMY:
103
A MODEL FOR NURSING
nence and refuses to care for it. It would be appropri-
the patient.
ate for the nurse
of this sort.
to intervene
care of the ileostomy
or to work‘with
help him or her understand
for
the patient
to
that physical
care need not
Autonomy Within
is antithetical
to parentalism
the care concept
of autonomy,
persons grow as they use their competency not within
the prerogative
skills.
It is
of the health care provider
to use benevolent
control
from the realities of life. The truth should be shared in
ing patient
is then largely a process of facilitat-
decision
when the patient When
arrange
to permanence.
be related Patient
and either
making.
the patient
autonomy
is unable
nurse aids through the pati.ent
Nurses respect decisions
is exercising support
or intervention
a kind and caring
manner.
the use of autonomy
competency.
to act independently,
manipulation
the
to protect
come more skillful The conceptual care advances
.
Informed
consent
also involves
decision
making,
Nurses
framework
encourage
patients
for patient
knowledge
will
be-
autonomy
in
in several ways. It
way to look at patient
omy and solicits
new questions.
tions
is the nature
autonof ques-
of the nurse-patient
autonomous
action? Do pa-
tients
prefer a passive role enactment?
How does the
exercise their autonomy competency, the nurse must provide information that enables the person to use it. Information can be offered in many ways, and nurses
nurse
decide
informa.tion;
must
is on the person with the technical
in this case it is the nurse. For patients
be careful
not to deliver
nipulative manner. Some informed
consents
information
are more
in a ma-
complex
than
others. Informed consents that require an adjustment in a person’s self-portrait are difficult for patients. For example, if a treatment will result in a change in one’s life-style,
it requires
an adjustment
in the
self-
that enhances
Examples
to
but the emphasis
relationship
patients
as they use their skills.
nursing
are: What
should
competency,
offers nurses a different INFORMED CONSENT
to protect
whether
a patient
has the resolve
for
autonomous action? How does the nurse recognize a compromised autonomy competency? How can nurses aid patients in the exercise of autonomy competency skills? How can nurses assist patients in decision making when their illness affects their self-portrait
or in-
terferes with their life plan? Patients who experience varied role trajectories, which involve shifting spheres of autonomy, would autonomy research. Many
be suitable
perspectives
on autonomy
subjects
for patient
are available
for
portrait. If the change is permanent, it may also require a change in one’s life plan. In this case, nurses
nursing
are a resource needed by patients to help them imagine how their options fit into their life plan.
is uniquely helpful in expanding nursing knowledge. A concept of patient autonomy in care is offered as a conceptual
TRUTH TELLING
Truth
telling
becomes
researchers.
an issue when an expert
in
an area such as health care decides what information a patient should have without discussing the issue with
Meyer’s care concept of autonomy
framework
for patient
autonomy
in nurs-
ing. The concept of patient autonomy within this framework is consistent with an organismic world view, with holism, ing.
and with other concepts
in nurs-
Moskowitz, L., & Moskowitz, S. Autonomy critically ill patient. Heart Lung, 15, 520-524.
and the
REFERENCES Cassidy, V., & Odi, L. (1986). Legal and ethical aspects of informed consent. Journal of ProfesJionaINursing, 2, 343349. Curtin, L., & Flaherty, M. (1982). Nursing ethics: Tbeovies and pragmutics. Bowie, MD: Brady. Deci, E., & Ryan, R. (1987). The support of autonomy and the control of behavior. Journal of Personalityand Social Psychology, 53,
1024 1037.
Dworkin, G. (1989). The concept of autonomy. In Christman, J. (Ed.), The inner citadel (pp. 54-62). New York: Oxford
University
Press.
Gadow, S. (1980). Existential advocacy: Philosophical foundation of nursing. In S. Spicker & S. Gadow (Eds.), Nursing image and id&s (pp. 79- 10 1). New York: Springer. Merchant, C. (1980). The death of nature: Women, ecology and the scientific revolution. New York: Harper & Row. Meyers, D. (1989). SeIJ society,andpersonal choice(p. 46). New York: Columbia University Press.
Orem, D. (1985). York: McGraw Hill.
Nursing concepts and pa&e.
New
Otte, D. & Allen, K. (1987). Ethical principles in the nursing care of the terminally ill patient. Oncology Nurse Forum, 14, 87-91. Payton, R. (1979). Information control and autonomy: Does the nurse have a role? Nursing Clinics of North Amwica,
14, 23-33. Quinn C., & Smith, M. (1987) The professional commitment in nursing. Philadelphia: Saunders. Reeder, J. (1988). Should patients always be told the truth? AORN J, 47, 1306-1310. Rosenbaum, A. (1986). Coercionand autonomy: PhilosophicaI foundations, issues, and practices (p. 107). New York: Greenwood.
Autonomy
in Care: A Theoretical for Nursing
ARLENE
G.
WIENS,
Patient autonomy has increasingly become an issue in a health care system that often promotes dependence in decision making. The complex technology of health care creates situations In which difficult decisions need to be made by patients and their families. Nurses are important participants in that decisionmaking process. Models available for deveioplng a theoretical approach to patlent autonomy traditionally have been limited to ethics literature. A more recent approach to personal autonomy is Meyer’s philosophical feminist perspective. Any philosophical approach to patient autonomy must be congruent with other critical nurslng concepts. In addltion, a model of patient autonomy for nursing must be useful for persons who operate at varlous functional levels. The model, Patient-Autonomy in Care, based on the Meyer’s model, was developed to incorporate the special vulnerability and functional needs of patients in the health care system. (index words: Decision making; informed consent; Patient autonomy; Patient control; Truth telling) J Prof Nurs 9:95-103, 7992. Copyright 0 1993 by W.B. Saunders Company
N
RN,
dependence
rather
than
autonomy
for
patients.
autonomy
Questions
Nursing nation.
definitions
one’s life (Quinn
of autonomy
include
Autonomy
& Smith,
self-determination
1987),
(Payton,
(Gadow,
1979), 1980;
1988), and the patient’s
of
& Allen,
right to decide
1987; Moskowitz
1986).
The concept of patient autonomy is evident in nursing thought and practice. For example, Orem’s (1985) Self Care model promotes patient involvement in decision making and encourages the use of patient education to improve the patient’s self-control and ability
to make decisions.
on promoting nursing
Patient
self-determination
interventions
education for patients.
focus on promoting
over their lives,
which
is based Many patients’
have been altered
by
disease or disability. Nursing diagnoses such as powerlessness focus on interventions that provide a milieu that enhances
autonomy
for the patient.
Often patient
work for the discussion
by the need for
over
subject
the right
Otte
Before further discussion, it is important eate several assumptions that will provide
is subsumed
basi-
control
not being
Within this system nurses organize their duties to maintain order so that their work can be completed. autonomy
but
of self-determi-
as having
or freedom of choice (Otte & Allen, & Moskowitz,
will be introvary,
the right
is defined
to the will of another 1987; Reeder,
in nursing
for research will be suggested.
cally all of them
control URSING is largely practiced within the structure of a health care system that promotes
MSN*
work for patient duced.
Framework
of patient
autonomy
to delina framein nurs-
order and task completion. An increased concern by nurses about the lack of patient autonomy is evi-
ing. First is the assumption that the nurse-patient relationship is such that autonomous behaviors of the
denced
patient are potentially jeopardized. Autonomy expression is threatened in settings in which persons lack
tient
by the growing autonomy
number
in the nursing
of writings
about pa-
literature.
However,
the discussion of patient autonomy to nursing ethics literature.
is limited
chiefly
control
or knowledge.
Patients
in the health care sys-
This article will expand the concept of patient autonomy beyond the current ethics focus in nursing. A
tem are particularly vulnerable to external control because of the parentalism of the system and the dependence of the patient on the expertise of professionals.
philosophical approach scribed. The compatibility
to autonomy will be deof this concept with other
Intimate activities to which the patient is exposed and the emotional vulnerability of persons who are in dis-
will be addressed. Using a philoas a foundation, a conceptual frame-
comfort due to emotional or physical suffering threaten the patient’s self-perception. When selfperception is altered, it is more difficult to exercise behaviors that express autonomy. Consequently, health care professionals may impede patients’ auton-
nursing concepts sophical approach
*Assistant Professor of Nursing, Eastern Mennonite College, Harrisonburg, VA. Address correspondence and reprint requests to MS Wiens: 1520 N College Ave, Harrisonburg, VA 22801. Copyright 0 1993 by W.B. Saunders Company 8755..7223/93/0902-0008$03.00/O
Jourtzu:Z of Professsional Nursing,
Vol 9, No 2 (March-April),
omous behaviors. A second assumption is that an organismic world view most accurately encompasses nursing’s holistic 1993: pp 95-103
95
96
ARLENE G. WIENS
approach. thing
An organismic
as connected
1980).
perspective
to everything
An organismic
and contextuality.
spective,
phenomena
enon is studied a controlled
within setting.
From
parts.
as complex
Therefore,
its environment Organismic
claim to be value free; rather,
perrather
a phenom-
rather than in
science
does not
values are seen as part of
The inclusion
of these assumptions
choices in identifying autonomy.
a compatible
to autonomy,
affects nursing
philosophical
Diana Meyers,
and Personal Choice (1989),
approach
the care concept
of autonomy,
presents
base
in Self, Society, a philosophical
which she calls the care con-
Meyers
persons as those (1989, p. 46) d escribed autonomous who “are able to match their conduct to their selves within
the constraints
cumstances
afford.”
sons, within
of the opportunities
the constraints
able to exercise behaviors times
enlarge
their
of life.
that they perceive persons
opportunities;
“they
are
coincide
can someexercise
as anyone
as
can.” All
in some way by the circumstances
Autonomous in making
per-
of their life situation,
much power over their destinies persons are limited skilled
that cir-
In other words, autonomous
with who they are. Autonomous
the context.
for patient
Within
interactive
a contextual
are perceived
isolated
The Care Concept of Autonomy
“every-
else” (Merchant,
view emphasizes
processes
than as discrete
views
persons,
decisions
however,
are more
that are compatible
with
cept of autonomy. The author will argue that Meyers’ view is particularly useful to nursing in describing patient autonomy in the nurse-patient relationship.
who they perceive themselves to be. In that sense, they have more control over who they become.
First, a brief overview of the care concept of autonomy
Meyer’s concept
will be provided.
Fig 1 and are further
Environment,
Autonomy Competency Repertory of skills
Several
concepts
are important
of autonomy. described
to understanding
These are outlined here.
Social Structure, Mores
Life Plan Includes values, emotional ties, personal ideals A
Meshes with the selfztrait
Self-correction
Self-Definition
Self-referential
Does the decision fit?
Decision making Rational Deliberative and Affective
Figure 1.
-Memory -Imagination -conversation -reason =-volition
with others
Care concept of personal autonomy.
in
PATIENT AUTONOMY:
I. Lifeplan:
97
A MODEL FOR NURSING
This is a conception
of intent.
Life plans
around
group
are usually
of values
organized
or emotional
clude specific personal of the kind of person plans are schematic include
According
of who a person
wants to be in life; it is a projection ties;
ideals;
a
they in-
it is an image
one wishes to be. Life
and dynamic;
to Meyers,
ideal within
they do not
self-referential,
is the repertory
skills that allow people to control It is a decision-making consults wants,
process in which one
the self and asks what needs,
of
their lives.
cares about,
one really
or values.
The
skills that enable people to make this enquiry and to carry out their decisions competency. the ability directive,
is autonomy
The repertory of skills to be self-referential, self-defined,
cover one’s self. a. Self-referential: reading
and to be able to dis-
potential
This
is a process
of self-
to life situations.
to use emotions
such as
frustration or pride as affective cues to guide one’s judgments. For example, if persons whether
are frustrated they may ask the trouble stems from a condi-
tion they can avoid or whether a major change in their life plan is required. b. Self-direction: This is to express one’s self in ways worthy
that
one considers
fitting
of one’s self; it is an episodic
An overview
a situation,
is not an all-or-nothing
diagram
in Fig 1. to the care concept
asks what he or she
themselves
and
their environment. People can, however, examine their socialization to better understand themselves and to increase their control over the future. Introspection and memory are important, albeit limited tools in self-discovery. e. Self-portraits: This is the conception sons have of themselves; it is their
phenom-
exist.
of the care concept
in Fig 1. The discussion
of
of autonomy
is
below follows
the
of autonomy
is the in-
personality with a realistic, accurate selfThe integrated personality is made possible
through the life plan and autonomy competency. Environment, social structures, and mores impact on the of socialization.
competency;
Through
they are products
the skills of autonomy
com-
petency persons can carry out their life plan. As the skills of autonomy competency are used, they serve to adjust
the life plan and/or
plan provides
direction;
the self-portrait.
to be autonomous,
The life one must
have a life plan. Autonomous persons develop the resources available to them.
life plans relative to They establish stan-
dards they can realistically hope to attain although they do not always do so. Autonomous persons are not denied to other people. Autonomous persons, according to Meyers, “Possess and exercise skills that main-
c:. Self--definition: Persons with self-definition know their true selves and act in accordance with their true selves. People cannot be fully d. Self-discovery: about
the sofor more
does the socialization
provided
tegrated portrait.
skills
and
yields.
concept.
Autonomy
than
with
offered
wants or can do with respect to it, and than enacts the decision this deliberation
knowledgeable
behaviors
For example,
them
and
programmatic directing of one’s life. Episodic self-direction occurs when a person confronts
autonomy.
of men equips
enon; various degrees of autonomy
Central
to be
However,
of some persons offers them a greater
for optimal
women.
social experience.
life plan and autonomy
one’s responses
It is the ability
include self-
through
the socialization
an all
to be autonomous,
but they learn how to confer with themselves,
autonomous 2. Autonomy competency: This
is more than
She assumes that virtually
people are born with the potential
cialization
all possibilities.
autonomy
our society.
perself-
a unique
view
tain a fluid interaction
of their
between
inner
selves that
their traits,
their feel-
ings, their beliefs, their values, their extended their current possibilities for realizing these and their conduct”
(p. 55). These standards
is
plans, plans,
and skills
allow autonomous persons greater control over life events than is experienced by nonautonomous persons. The life plan allows this control to occur.
A key component of autonomy competency is decision making. Autonomy competency, according to Meyers, aids in the process of developing autonomy; it allows persons to carry out their life plan. A key component of autonomy competency is decision making. Decision making is a self-referential process of autonomy competency.
98
ARLENE G. WIENS
Decision affective
making
(Fig
is both rational
1). Rational
based on ethical principles, formal decision ling persons tions.
to revert
most persons
values,
to their
decision
than is rational
making
has many
reason, memory,
imagination,
with others, Often
find plausible
deliberation.
explanations
Either
terpretation
for
Affective
components,
including
spontaneous.
AutonoSome-
the person’s
self-
can be adjusted,
or
that he or she has erred.
In-
competency
is present self emerges
competency.
by social experience
choice. The authentic self-chosen
identity
feelings
to the critical
the social-
compe-
over their lives. in the authentic through
the ex-
The authentic
self is
as well as by individual
self, according rooted
to Meyers,
in the individual’s
and firmest perspective
the
convictions,
autonomy
is “a most
yet subject
competency
af-
fords” (p. 61).
by others may be useful in this
who they want to be. That is, they adjust This self-correcting
process
A useful conceptualization of patient autonomy must be consistent with a care rather than a cure approach to nursing.
their self-
maintains
con-
gruency between the self-portrait and the life plan. Decision making within autonomy competency entails a self-referential process, self-discovery, direction, and self-definition. The self-referential cess of decision
Although
persons can use the degree autonomy
Autonomy
process. Decision making is a self-correcting process. As people make changes they believe in, they adjust portrait.
conduct.
varies with a person’s
tency they have to exert some control
abiding
recognizes
how persons can gain con-
and their
for autonomy
ercise of autonomy
in a search to
for their responses.
do not match
provided
ization,
competency
it explains
trol of themselves potential
shaped
the self-portrait
may decide
1989). Because autonomy self as dynamic,
self, and the authentic
verbal communication
are largely
the decisions
the person
and inclina-
is more common
mous persons reflect on these decisions times
compel-
and volition.
decisions
portrait.
are
or rules. However
feelings
making
and
decisions
rules are often inapplicable,
Affective
decision
deliberative
deliberative
making
aids in self-discovery.
selfpro-
As per-
Several aspects of the care concept
sons read their feelings, the process enables them to gradually identify integral segments, propensities,
particularly helpful tonomy competency
values,
skills
and goals (Meyers,
1989).
Self-direction
aids
that
will
of autonomy
are
for nursing. The concept of auoffers hope that persons can learn
offer them
some control
over life’s
in maintaining congruency between persons’ decision and their life plan. Self-directed persons are able to
circumstances; it does not totally trap an individual in his or her socialization. Decision making as both ra-
resist
tional and affective is attractive for nursing. Nurses deal with many persons who have made decisions that
unwarranted
pressure
from other
individuals.
They have the resolve to act on their own judgments. As persons act on the options of their choice, they
appear
irrational.
Meyer’s
model,
which
recognizes
reinforce or weaken different aspects of their personality. Through these choices people define who they
the affective aspect of decision making, describes a decision-making process that is useful in nursing. In
are (self-definition, Meyers, 1989). Autonomy competency will atrophy with disuse. Social interactions can inhibit or encourage the use of
addition to these aspects, it is important to address the overall compatibility of the care approach to autonomy with current nursing thought.
the skills of autonomy
competency.
The function
autonomy competency is to secure an integrated sonality. Integrated persons are satisfied with
of
pertheir
traits and how they find expression. Meyers maintained, “The autonomous individual is engaged in a dynamic process of meshing the self-portrait with a life plan that provides
for an integrated
personality”
(p. 84). Autonomy competency alone cannot account for people’s control in broad circumstances. The personal ideal of the life plan fills this gap by counterbalancing the pull of immediate circumstances and by providing guidelines for a broad range of circumstances (Meyers,
Compatibility of Concepts With Nursing Dworkin (1989) described criteria for a satisfactory theory of autonomy that are useful in evaluating the care concept of autonomy for nursing. These will be addressed in the form of questions. In addition, the last two questions address the congruency of the philosophical view with the assumptions presented at the beginning of this article. Is the approach logically consistent with other nursing concepts? The care concept of autonomy is congruent with an organismic approach. The care concept is a
PATlENT AUTONOMY:
contextual
99
A MODEL FOR NURSING
view of autonomy;
it looks at the whole
A useful must
conceptualization
be consistent
approach available
with
to nursing.
experiencing
of autonomy a resource
a cure
offer care for persons
by helping
patients
mobilize their prob-
the nurse is one of the resources. autonomy
is helpful
in revealing
by enhancing,
for the patient’s
then,
that nurses can be or substi-
competency.
Is the approach empirically possible? Autonomy care concept of autonomy ple evidence spective.
is empirically
in the peo-
from this per-
of nurses in providing
tient care, nurses observe patients
who evidence
pamany
levels of autonomous behaviors. 1s t$e concept valued? Is being autonomous desirable? The direct and indirect
emphasis
in nursing
literature
on patient autonomy indicates that autonomy is valued by nursing. Part of the same question is whether the specific
view
of autonomy
is compatible
with
nursing’s other values. In this respect the care concept reflects other values in nursing such as caring and holism. Additional evaluation of this view should clude questions more specific to patient autonomy the nurse-patient
patient autonomy? The
would lead nurses to assess for au-
competency
in patients.
tained that patients capacity
When
it is ascer-
either do not have the skills or the
to carry out autonomous
would then act to aid the patient
behaviors,
nurses
at the point of his or
her need. In summary,
the care concept
knowledge
However,
in relation
the care concept
areas that are important is not particularly ers should
with
offers
autonomy.
does not address
for nursing.
helpful
intervene
of autonomy to patient
several
The care concept
in describing patients
how caretak-
who have a low
degree of autonomy competency. In addition, the problem of power dynamics in unequal professional relationships
is inadequately
use. The care concept
addressed
of autonomy
for nursing’s
does offer a philo-
sophical approach that is generally congruent with other nursing concepts. In the remainder of this article the care concept is used to develop a framework patient
autonomy
in the nurse-patient
for
relationship.
Concept of Patient Autonomy in Care: A Conceptual Framework for Nursing
nursing knowledge about
social perspective
of the care
nature of decision making, the concept of rhe in relation to the life plan, and the idea of
self-portrait autonumy
tonomy
inin
concept of autonomy is congruent with the idea of a nurse-patient relationship. The care concept of autonomy expands knowledge for nursing through the interactive
The care approach
relationship,
Does the perspective augmnt
in how professionals
relationships.
autonomy in persons whose self is threatened through illness?
expanded
possible,
various levels of autonomy
In the experience
In
the care concept
supplementing, autonomy
clarification
relate in unequal
Does the approach offw expanded knowledge related to
autonomy than
resources to help them transcend
the sense of patient
tuting
of patient a care rather
Nurses
difficulty
lems. Sometimes
cept offers minimal should
rather than the article.
Patient trol,
truth
is addressed
telling,
and informed
conceptual
framework
consent
litcon-
(Cassidy
within
&
the nurse-
used to fill in the gaps left by the care concept
of
autonomy. NURSE-PATIENT
Does the approach speak to the inherently unequal nurse-
of autonomy
of patient
patient relationship. Because of its congruence with nursing concepts, the care concept of autonomy is used in developing the model. Other sources will be
as nurses interact with pa&s, both will have shifting spheres of autonomy.
patient relationship? The care concept
in the nursing
in discussions
Odi, 1986; Curtin & Flaherty, 1982; Payton, 1979; Reeder, 1988). These areas, along with the nursepatient relationship, will be used to organize a patient autonomy
competency.
autonomy
erature most frequently
ex-
pands knowledge as to how injustice occurs and offers hope for transcending it to some extent. Autonomy competency provides a framework for ascertaining areas where control can be attained in unjust situations, even though the control may be small. The concept of autonomy competency offers expanded understanding of nurse-patient interactions. However, the care con-
Patient
autonomy
RELATIONSHIP
in the nurse-patient
relationship
is a relational phenomenon. Rosenbaum (1986) described a relational notion of autonomy in which the actual range of a participant’s social autonomy is mostly a function of his ‘role’ relatedness to other participant(s). Accordingly, as the relations between participants change, it is likely that a corresponding modification in their respective and reciprocal ranges of autonomy will occur also (Rosenbaum, 1986, p 107).
100
ARLENE G. WIENS
Therefore,
as nurses
will have shifting experience
interact
spheres
role trajectories
dent to independent,
with
patients,
of autonomy. from being
the autonomous
both
As patients totally
depen-
actions of both
self-referential to adjust
process.
However,
The culture to promote
a milieu
that encourages
autonomous
times this leaves the nurse with great power over the
trinsic
and will not be greatly
patient.
professionals,
and
the nurse
Coercion
unopposed
change.
is always a possibility
the role of patient
to the knowledge Consequently,
and opinions
patients
are expected
to listen
indicates
the health
this role enactment continues to persist.
ingrained
the reference
and assorted
Patients
patient
role and forego autonomous
and controlling.
dating
have an aptitude
persons
whereas
reserved
role. The culture certain patient ingrained
bill of
Certainly,
ist for the patient tomary practices
persons
Congenial,
for the patient
Impediments
to autonomous
tients
autonomous
behaviors
to the self that occur with illness. must
confront
choices
erected
by
by the onslaughts During
about
while they are under considerable
illness pa-
basic
emotional
interests and phys-
ical strain. Nurses may need to decide whether patients have the resolve for autonomous action. Illness to assaults
to autonomous
ac-
tion.
role,
enforces a practices,
expectations
ex-
role (Cassidy & Odi, 1986). CUSinclude having professionals in
of patient
gratitude
for the
skills of health care personnel, Even though formal displays of autonomy promotion, such as the Patient Bill of Rights, offer individuals the freedom to expand the patient role, few patients do so. Perhaps they fear informal sanctions. Role enforcement compels patients to separate what they really want from what is really prudent (Meyers, 1989). However either the nurse or the patient may perform outside their typical role enactment. Patients may reject the passive role that is often expected of them and demand control. Nurses may relinquish their caring role and behave rudely in their interactions with patients. Either of these groups may be acting in manners incongruent with their selfEach will need to engage
ltfness can decrease resistance to assaults to autonomous action.
for the
include believing that health care personnel know what is best for the patient. Standardized expectations
portrait.
and fosters
that
for patients.
the health care system are reinforced
accommo-
have less aptitude
and standardized
the exhibition
It is the
for the role. For ex-
charge who make decisions for the patient, frequently without consulting the patient. Ingrained attitudes
include
autonomous
af-
with the
action.
desire
is to this passive
of the health care system role enactment. Customary
attitudes,
may choose to compromise
respects
ample, persons who are passive obviously have less diffculty with the patient role than do persons who are confrontive
is strongly
actions
role with diverse per-
aptitudes
of action
fected.
can decrease resistance
Persons come to the patient sonalities
affected by health care
but autonomy
Those
has changed somewhat, but it When speaking about the patient
role in this section, patient role.
than in-
desire is in-
to pro-
this role per-
care system.
rather
Autonomous
to create an environment
advice are then
The need for a patient
how deeply
is within
advice.
action.
nurses’ responsibility
of expert professionals.
and act on the professional’s
labeled as noncompliant. ception
when power is
is one of submission
who choose to not follow the given rights
At certain
because persons have few resources.
Classically,
fessionals
will
to the other.
of the health care system can be altered
hibits
the patient
each also will need
his or her sphere of autonomy
in his or her own
Deci and Ryan (1987) described proach
to autonomy
nurses
can promote
that
assists
autonomy
an organismic in describing
aphow
in the nurse-patient
relationship. Deci and Ryan hypothesized that autonomy-suppoctive behaviors are those that maintain oc enhance intrinsic motivation. In reviewing studies, they
found
that
external
threats and deadlines, creased intrinsic
events
evaluation,
motivation.
such
as rewards,
and surveillance
External
events
de-
such as
these are often used as institutional restraints. Positive feedback was found to enhance intrinsic motivation when it affirmed competence, but it did so only when the sense of competence was accompanied by the experience of self-determination, In addition, Deci and Ryan reported chat There is indication that when contextual factors function to support autonomy rather than to control, people tend to be more intrinsically motivated, more creative, more cognitively flexible, more trusting, more positive in emotional tone, and more healthy; they tend to have higher self-esteem, perceived competence, and preference for choice; their behavior tends to be less controlling; and they project less aggression (p. 1030).
PATIENT AUTONOMY:
Finally,
101
A MODEL FOR NURSING
in considering
prescriptive
to predict
whether
controlling, contextual
events are autonomy
cannot
meaning
(Deci & Ryan,
behaviors supporting
supportive
is likely to be given.
factors
psychological vidual
it is possible
this is based on the significance
event or context
1987).
or in predicting behaviors,
each patient-nurse
or
that an
However,
be disembodied
ascribed
on occasion
formulations,
Deci and Ryan offer a caveat. Although
these
from
action
are coercion
enhance
Therefore, responses
it is essential
in assessing to autonomy-
that nurses view
holistically
of the nurse-patient
and indi-
of patient
relationship autonomy
shown in Fig 2. The nurse and patient with diverse personalities
action
that block
and surveillance.
autonomous
of the paautonomous
Nurses
action by offering opportunities
PATIENT
to them by the indi-
interaction
framework
of activities
back and providing
Within
can also
positive
for patient
feed-
control.
in the in care is
come to each
and roles. They
CONTROL
the concept of patient
of choice,
control
is the matter
which
involves
decision
making.
Within
the care concept,
patients’
decision
making
is based
on such things as feelings, ideas of others,
An outline
interaction
Examples
the
vidually. conceptual
block the autonomous
tient.
what they can imagine,
and on the ability
may be made based on deep emotional to others. tients
Often
nurses
arrive at certain
formation
commitment
fail to understand decisions,
that the patient
the
to reason. Decisions why pa-
considering
was given.
With
the intheir lim-
then enact their roles, sometimes as expected, other times not as expected. The nurse, who is usually in
ited exposure to patients, nurses’ understanding of the affective role in patient decision making is superficial.
the independent
On the other hand,
role, cannot
block the patient’s
au-
tonomous desire. However, because of their superior position in the nurse patient relationship, nurses can
making
although
choices
patients
nurses can aid patients they do not fully
make.
For example,
in decision
understand
the
patients
may
Patient: Diverse personalities Assorted aptitudes for roles
. Nurse action Coercion Threats to self Surveillance
Autonomous
1 7
1
action
Figure 2.
Patient-nurse
Rewards Threats Deadlines Evaluation
Positive feedback in the presence of competence if self-determined; remove controlling factor; provide opportunities for patient control
roles. Nurse and patient with shifting spheres of autonomy.
ARLENE
102
need to decide
whether
nurse can help patients
to take chemotherapy. imagine
may mean for them by describing
their actual personalities
experience
they can tolerate? patients
have experienced
reflections
Through
must
accept
this kind
in the nurse-patient
tion for obstructing
in this as valid
through
decision
relationship
making
ternatives
by helping
and by listening
Not all patients omy competency, grees of control
is given
However,
in
the al-
defense
mecha-
to the reality of
skills are not a justifica-
persons attempts
at self-control.
to enact autonomy
the self, parentalism
is justiability
to
the self may happen in several ways. The
extreme case is to make decisions
for a suicidal person. decisions.
so some will abdicate
patient’s
de-
autonomy
However, a decision.
there are less obvious compromised
But the family
or nurse
desires from the past,
A person
and unable
to make
may know
the
and they may safely
make a decision knowing they are carrying out what the patient would have desired. Another case could be
auton-
omy competency may be compromised. Sometimes control desired by patients is beyond the capability of
Patient control through decision
through
are blinded
need to assess each person’s
may be cognitively
certain
people,
to
(Cassidy &
the self and then offer help accordingly.
Protecting
to their concerns.
In some patients
resemblance
and achievements
filters,
to protect
Nurses
protect
possess the same degree of auton-
to caretakers.
limited
when persons are unable
competency
retain control through
them to consider
Other
Compromised
of
decisions
control
1986).
Meyers noted that many
bear
their lives.
fied.
of patient
self-portraits
nisms or cognitive
In patients
competency
their
Fig 3. Nurses can help patients decision
Odi,
Did
of the self.
A summary making
memories.
can make decisions.
who are able to use autonomy nurses
what
nausea in the past? If so, how? Is it an
discussion,
competency.
what happens,
it. The nurse can draw on the patients’
manner,
their autonomy persons’
it feels like, and how other patients they experience
The
what chemotherapy
G. WIENS
the person with an ileostomy
who denies
its perma-
making
I Nurse helps consider alternatives, listens -> to concerns
If exercise autonomy competency, nurse accepts decision as valid
If autonomy skills are _ compromised
Assess ability to protect the self
Less autonomy competency -> abdicates control
Self-portrait incongruent with autonomy competency
I
I
Defense mechanisms and cognitive filters interfere with autonomy competency I
Nurse needs to aid in protection of the self as needed. This may range from enhancing autonomous action to parentalism. Figure 3.
Patient control in the nurse-patient
relationship.
PATIENT AUTONOMY:
103
A MODEL FOR NURSING
nence and refuses to care for it. It would be appropri-
the patient.
ate for the nurse
of this sort.
to intervene
care of the ileostomy
or to work‘with
help him or her understand
for
the patient
to
that physical
care need not
Autonomy Within
is antithetical
to parentalism
the care concept
of autonomy,
persons grow as they use their competency not within
the prerogative
skills.
It is
of the health care provider
to use benevolent
control
from the realities of life. The truth should be shared in
ing patient
is then largely a process of facilitat-
decision
when the patient When
arrange
to permanence.
be related Patient
and either
making.
the patient
autonomy
is unable
nurse aids through the pati.ent
Nurses respect decisions
is exercising support
or intervention
a kind and caring
manner.
the use of autonomy
competency.
to act independently,
manipulation
the
to protect
come more skillful The conceptual care advances
.
Informed
consent
also involves
decision
making,
Nurses
framework
encourage
patients
for patient
knowledge
will
be-
autonomy
in
in several ways. It
way to look at patient
omy and solicits
new questions.
tions
is the nature
autonof ques-
of the nurse-patient
autonomous
action? Do pa-
tients
prefer a passive role enactment?
How does the
exercise their autonomy competency, the nurse must provide information that enables the person to use it. Information can be offered in many ways, and nurses
nurse
decide
informa.tion;
must
is on the person with the technical
in this case it is the nurse. For patients
be careful
not to deliver
nipulative manner. Some informed
consents
information
are more
in a ma-
complex
than
others. Informed consents that require an adjustment in a person’s self-portrait are difficult for patients. For example, if a treatment will result in a change in one’s life-style,
it requires
an adjustment
in the
self-
that enhances
Examples
to
but the emphasis
relationship
patients
as they use their skills.
nursing
are: What
should
competency,
offers nurses a different INFORMED CONSENT
to protect
whether
a patient
has the resolve
for
autonomous action? How does the nurse recognize a compromised autonomy competency? How can nurses aid patients in the exercise of autonomy competency skills? How can nurses assist patients in decision making when their illness affects their self-portrait
or in-
terferes with their life plan? Patients who experience varied role trajectories, which involve shifting spheres of autonomy, would autonomy research. Many
be suitable
perspectives
on autonomy
subjects
for patient
are available
for
portrait. If the change is permanent, it may also require a change in one’s life plan. In this case, nurses
nursing
are a resource needed by patients to help them imagine how their options fit into their life plan.
is uniquely helpful in expanding nursing knowledge. A concept of patient autonomy in care is offered as a conceptual
TRUTH TELLING
Truth
telling
becomes
researchers.
an issue when an expert
in
an area such as health care decides what information a patient should have without discussing the issue with
Meyer’s care concept of autonomy
framework
for patient
autonomy
in nurs-
ing. The concept of patient autonomy within this framework is consistent with an organismic world view, with holism, ing.
and with other concepts
in nurs-
Moskowitz, L., & Moskowitz, S. Autonomy critically ill patient. Heart Lung, 15, 520-524.
and the
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Dworkin, G. (1989). The concept of autonomy. In Christman, J. (Ed.), The inner citadel (pp. 54-62). New York: Oxford
University
Press.
Gadow, S. (1980). Existential advocacy: Philosophical foundation of nursing. In S. Spicker & S. Gadow (Eds.), Nursing image and id&s (pp. 79- 10 1). New York: Springer. Merchant, C. (1980). The death of nature: Women, ecology and the scientific revolution. New York: Harper & Row. Meyers, D. (1989). SeIJ society,andpersonal choice(p. 46). New York: Columbia University Press.
Orem, D. (1985). York: McGraw Hill.
Nursing concepts and pa&e.
New
Otte, D. & Allen, K. (1987). Ethical principles in the nursing care of the terminally ill patient. Oncology Nurse Forum, 14, 87-91. Payton, R. (1979). Information control and autonomy: Does the nurse have a role? Nursing Clinics of North Amwica,
14, 23-33. Quinn C., & Smith, M. (1987) The professional commitment in nursing. Philadelphia: Saunders. Reeder, J. (1988). Should patients always be told the truth? AORN J, 47, 1306-1310. Rosenbaum, A. (1986). Coercionand autonomy: PhilosophicaI foundations, issues, and practices (p. 107). New York: Greenwood.