Problematising autonomy and advocacy in nursing

Patient advocacy is portrayed in the nursing literature as an essential component of the role of the nurse 1,2

and reinforced in national and international codes of conduct and standards of practice. 3–5

Popular under-

graduate textbooks and university curricula promote the notion of patient advocacy as central in nursing.

The definition of advocacy is variable depending on the context in which it is used. Traditional definitions

of advocacy arise from the legal profession where a person’s rights are defended and their cause is argued

for. 6

The need for a patient advocate is closely related to the level of autonomy a person is presumed to have.

In contemporary Western healthcare practice, including nursing, ethical practices has been guided by

biomedical ethical principles articulated by Beauchamp and Childress. 7

These principles focus on the Problematising autonomy and advocacy in nursing

concepts of autonomy, beneficence, justice and non-maleficence. 7

The principle of autonomy, supported

by the other ethical principles, is a predominant focus in Western healthcare with a key role of healthcare

understood as supporting patient autonomy, hence the centrality of patient advocacy.

To critically consider the role of advocacy in nursing, it is important to highlight and evaluate the con-

cept of patient autonomy and identify its role in the prevailing conceptualisation and promotion of the

nurse as an advocate for the patient. In particular, this article explores differing understandings of auton-

omy, contrasting liberal understandings of individual autonomy (as dominant in biomedical literature),

Corresponding author: Clare Cole, School of Health Sciences and School of Education & Arts, University of Ballarat, P.O. Box 663,

Mt Helen, Ballarat, VIC 3353, Australia. Problematising autonomy and advocacy in nursing

Email: c.cole@ballarat.edu.au

Nursing Ethics 2014, Vol. 21(5) 576–582

ª The Author(s) 2014 Reprints and permission:

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with feminist conceptions of relational autonomy, evaluating the implications of both for the practice of

advocacy in nursing. This analysis highlights and problematises some of the assumptions and influences

that surround the perceived role of nurses as advocate.

Advocacy

The idea of patient advocacy within nursing practice is embedded in nursing philosophical traditions and

reinforced in the educational preparation of nurses. In healthcare, however, advocacy has a broad range

of definitions, which are contextually based. Spence 6

highlights a range of definitions of advocacy used Problematising autonomy and advocacy in nursing

in nursing which range from acting or interceding in the best interest of the patient, protection of patient’s

rights, to ensuring protection and comfort for patients unable to communicate. The multiple interpretations

of advocacy make analysis of the role of the nurse as an advocate difficult. For the purpose of this discus-

sion, advocacy in nursing is defined as a nurse actively supporting patients in relation to their rights and

choices, clarifying their healthcare decisions in support of their informed decision-making and protecting

basic human rights such as autonomy. 8

Issues with advocacy in healthcare

Nurses have argued that they are best placed to judge a patient’s capability to make and carry out auto-

nomous decisions because they have the greatest contact with patients compared with other healthcare

professions. 2,4,9

Early work of Bird 10

recognised that nurses attend to patients in vulnerable states, and for

sustained periods of time, and that this may contribute to the nursing profession’s adoption of the role of

patient advocate. In contemporary healthcare settings, intimate, physical and emotional care for patients

is still provided continuously by nurses. Davis et al. 11 Problematising autonomy and advocacy in nursing

acknowledge this point but argue nurses also have

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an ethical obligation to be an advocate because of patient and family vulnerability in the context of the

environment and hierarchical systems of healthcare.

In cases of vulnerability, patient advocacy is seen as necessary due to the power differentials between

institutions, doctors, nurses and patients. Power distribution is unequal and nurses are arguably perceived

by patients as able to speak more effectively on their behalf than they may be able to do. 5

Under this framing

and justification of patient advocacy, the ethical obligation existing between nurses and patients is based on

patient rights and entails nurses supporting patients through their healthcare decision-making and illness

trajectory towards their achieving best outcomes for their health and autonomy. 11

Challengers to the notion of nurses as advocates have argued the role is a self-serving mechanism

adopted by nurses to position themselves for occupational advancement. 4,9,12

Mahlin 9

argued that adopting Problematising autonomy and advocacy in nursing

the position of being a patient advocate is a way to increase the power and the professional status of nursing,

without damaging long-established images of the caring nursing profession. This, Mahlin 9

suggests, is the

reasoning behind the nursing profession maintaining its proprietary claim on the advocate role.

A question that requires further clarification concerns the above-mentioned unequal power distribution

and the relation between advocacy and contextual paternalism. To begin to unravel these questions, we need

to explore the concepts that influence the patient advocate role. One of the major influences within the

healthcare environment is that of autonomy.

Individual autonomy

The concept of autonomy is predominant in contemporary biomedical and nursing literature. 13

Commonly

defined as the ability for an individual to self-rule, self-govern or self-determine, this is typically recognised

as liberal individual autonomy. 7,14–17

Taylor 18

identifies autonomy as being the property of persons rather Problematising autonomy and advocacy in nursing

Cole et al. 577

577

than non-persons, stating that persons are able to direct themselves, reflect and then make a decision. This

definition of individual autonomy assumes that each mature individual is independent and able to make deci-

sions that are rationally based (as opposed to based in emotion) and not determined by outside factors. 7,17,19,20

However, viewing autonomy with a liberal lens, Christman 19

argues, fails to recognise the fluidity and rela-

tionality of human nature that occurs as a consequence of the social circumstances in which a person finds

themselves.

Healthcare and individual autonomy Problematising autonomy and advocacy in nursing

In healthcare, this notion of individual autonomy usually drives the rules surrounding informed consent. 15

Informed consent, as a basic interpretation, requires a patient be given appropriate information so that she or

he can make a voluntary decision based on that information. 21

Informed consent also relies on individuals

displaying competence to make that decision, shown by their demonstrated understanding of the risks,

benefits and the nature of the procedure they are consenting to. 21

However, understanding autonomy purely

in terms of informed consent is unsophisticated and is focused on legal protection for healthcare profession-

als. 4 Problematising autonomy and advocacy in nursing

The giving of informed consent is not necessarily a true indication of a patient’s ability or inability to be

autonomous within the healthcare setting. In healthcare, even the patient with specialised knowledge may

not be independently autonomous due to a variety of reasons.

Goering 15

highlighted organisational hierarchies within healthcare that can potentially limit a patient’s

individual autonomy. As argued, the choices available to an individual within a healthcare environment are

constrained by several factors, which all have the potential to adversely or positively influence autonomy.

These factors can include the ability to have privacy, access to visitors and the right to come and go or com-

municate as the individual pleases. For example, the organisational structure of hospitals dictates the timing

and nature of meals and limits individual choice in eating and nutrition. This is just one example of the

institutional control over an individual, which may constrain individuals’ ability to make meaningful and

autonomous decisions. For patients, this can be seen as a loss of personal control. These factors have many

intertwining aspects to them and can be related to the clinical environment, the acuity of the patient, the

nature of the admission and length of stay. Dodds 22 Problematising autonomy and advocacy in nursing

recognised that decisions made by individuals within

the healthcare environment are constrained by institutional frameworks and policies, available resources,

education and community involvement.

This argument proposed by Goering 15

highlights the ways in which individual autonomy can be and is

frequently compromised within the healthcare environment. Issues around healthcare such as anxiety, emo-

tional issues and the entrenched ideologies surrounding healthcare also have the potential to compromise

the ability to be autonomous. 15

If we look at the operational structure of medicine in terms of individual

autonomy, the choices that patients are able to make are limited as they are constructed within a paternalistic

framework and within given environmental constraints. 22

Paternalism traditionally has characterised therapeutic relationships in healthcare. 23

Early work done by

Melia 24

defined paternalism as making choices about treatment for patients which are considered by health-

care professionals to be in the patient’s best interest. Zomorodi and Foley 25

highlighted that paternalism

from a nursing perspective occurs when the preferences, decisions and actions of the patient are denied out

of a nursing concern for the patients’ well-being Problematising autonomy and advocacy in nursing