Accountability and Nursing Practice

Article

Problematising autonomy and advocacy in nursing

Clare Cole, Sally Wellard and Jane Mummery University of Ballarat, Australia

Abstract Customarily patient advocacy is argued to be an essential part of nursing, and this is reinforced in contemporary nursing codes of conduct, as well as codes of ethics and competency standards governing practice. However, the role of the nurse as an advocate is not clearly understood. Autonomy is a key concept in understanding advocacy, but traditional views of individual autonomy can be argued as being outdated and misguided in nursing. Instead, the feminist perspective of relational autonomy is arguably more relevant within the context of advocacy and nurses’ work in clinical healthcare settings. This article serves to highlight and problematise some of the assumptions and influences around the perceived role of the nurse as an advocate for patients in contemporary Western healthcare systems by focusing on key assumptions concerning autonomy inherent in the role of the advocate.

Keywords Advocacy, autonomy, nursing, relational autonomy

Introduction

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

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.

Email: [email protected]

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

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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

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

acknowledge this point but argue nurses also have

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

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

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

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

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

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. Komrad 23

and Melia 24

identified the link between auton-

omy and paternalism as reciprocal; when autonomy is considered to be diminished, then paternalism is said

to be needed to care for the individual’s interests.

Waltho 26

identifies paternalism and its potential coercive treatment of patients as being of ethical

concern in healthcare. The narrow perception of healthcare professionals as acting in patients’ best interest

does not incorporate contextual and social influences that surround decision-making and autonomy. This can

also be linked to the liberal definitions of individual autonomy, which are not sufficient to understand and

578 Nursing Ethics 21(5)

578

demonstrate the complexities associated with decision-making. 15

When interpreting the social nature that con-

stitutes being human and the healthcare environment, it is evident that traditional liberal definitions of

individual autonomy are inadequate. Looking at the literature, a more appropriate definition of autonomy that

can be applied to the healthcare environment is that of relational autonomy.

Relational autonomy

Human beings are intertwined in and constructed through both social and cultural relationships. 27

In this

sense, social relatedness and interdependence are not coherently able to be excised from the capacity for

autonomy, 28

rather the capacity to be autonomous is constitutively informed by social connections and

power relations, both of which inform the individual’s sense of self and reality. 27

Within the healthcare

context, considering the ability to be autonomous solely in terms of the concept of informed consent, also

neglects the intricate and complex social behaviours that may have the potential to both support and hinder

the process of individual autonomy.

Relational autonomy is a collective word derived from feminist arguments used to describe the social rela-

tionships and social context of individuals that inform an individual’s autonomous decision-making. 17,19,28–30

There is a focus on the social values, relationships and power structures in which an individual is embedded,

and recognition that these values, relationships and structures inform an individual’s decision-making. 22,28

Further defining relational autonomy, it can be viewed as the recognition that people who are important

within an individual’s social context influence decision-making. Important people can include but are not

limited to family, friends and professionals. It is within these social contexts and groups that an individual’s

identity is shaped. 17,31–33

Intersecting social determinants such as race, class, gender and ethnicity also

shape decision-making. 33

Therefore, relational autonomy describes an individual’s autonomy as being shaped by the social contexts

in which an individual is raised and live. 33

It involves the explicit recognition that autonomy can only be

defined and pursued within a social context and that this social context significantly influences the oppor-

tunities a person has to develop or express the necessary skills to be autonomous. 30

In the concept of rela-

tional autonomy, there is a close connection between the human interactions that occur in the social

environment that influence decision-making abilities. 28

Relational autonomy in the healthcare setting

Examining the relational aspects of being autonomous, we can begin to discover that social circumstances

and the skill and competency of the social individual also matter in the healthcare environment. Relational

autonomy still supports an individual’s ability to make and participate in healthcare choices 22

but recog-

nises the role of that individual’s social context. An example of this relationality of autonomy in the health-

care setting may be observed with the patient with cognitive decline or impairment. These patients rely on

the support of family to assist in the healthcare decision-making process. Relational autonomy also requires

the acknowledgement that healthcare providers and practices themselves contribute to the development and

shaping of an individual’s capacity to make autonomous decisions. 22

Relational autonomy highlights the role that healthcare professionals play in socialising individuals to

the specific context of the healthcare setting. 22

This can be clearly seen in maternity units where expectant

parents are given a tour of the ward facilities before the birth, which is an important socialisation of the

individuals to the environment. Walker 34

describes this as orientating information and that it is intended

to produce predictability and reduction of psychological distress. Such practices also support recognition

of relational autonomy.

Cole et al. 579

579

The social conditions recognised and supported within relational autonomy provide individuals with

reflective opportunities about the choices that they make. 31

But if we consider the points made above, the

choices available to patients are already limited by the institutional healthcare structures. Without the ability

to reflect on choices, the limitations placed on the autonomy of individuals become constraining and

oppressive.

Discussion

The dominance of a liberal conceptualisation of individual autonomy, where individuals are positioned as

needing to function without interference from outside influences, has been instrumental in supporting the

current views of the role of nurses as patient advocates in healthcare settings. Accordingly, when a person

becomes identified by nurses as unable to make autonomous decisions, then that person becomes reliant on

the nurse advocate to help them make decisions and to stand up for their views and beliefs. Advocates in

these circumstances act in a temporary capacity to assist patients to regain their independence and auton-

omy. In this context, patient advocacy arguably acts as a supportive mechanism for individual autonomy.

Patients in a healthcare setting are, however, at a disadvantage and potentially vulnerable because the envi-

ronment is foreign. Nurses have the benefit of intimate familiarity with the environment and its usual rules and

operation. 35

This disparity of knowledge and understanding of the environment can contribute to a patient’s

feelings of vulnerability associated with hospitalisation. Such feelings can occur due to deconstruction of the

social self, loss of autonomy and feelings of subordination and domination. 36

In many cases, although health-

care systems purport to support individual autonomous decision-making, a patient’s capacity for decision-

making may be limited by the context of the setting, putting them at risk of de-individualisation, increased

vulnerability and reduced autonomy. 36

A relational definition of autonomy introduces a broader view that can challenge both such de-

individualisation and the conventional view of advocacy in nursing practice. Humans are social in nature;

therefore, it is unimaginable that social contexts have no influence on a person’s autonomy. Feminist perspec-

tives of relational autonomy argue that the social context of the individual must be accepted as part of their

ability to be autonomous and to make autonomous decisions. Therefore, if we based our understanding of

autonomy on a relational view, then the potential role of a nurse advocate becomes substantially broader.

Viewing patients as relationally autonomous requires acknowledging the advocacy role of nurses as

being more complex and intricate than previously suggested. Under a relational conception of autonomy,

individuals are reliant on their social experiences and relationships to influence the healthcare decisions

that they make. Within healthcare settings, the focus shifts from simply assessing whether patients have

compromised autonomy and then taking on an advocacy role, to involving people who form part of the

social context of patients in the decision-making processes. This in turn supplies a new set of problems

regarding a patient’s healthcare experience, which influence the potential role of patient advocate. For

example, issues such as patient engagement in their decision-making, confidentiality and tensions that may

arise between caregivers and patients all become pertinent to the patient advocate role.

A relational autonomy perspective creates a challenge for how individuals are supported in decision-

making while in healthcare settings. Rather than an automatic assumption of the nurse being the advocate

of patients, there is need to develop an understanding that others in the patient’s relational world can also

actively contribute to advocacy for the patient where reduced autonomy is identified. The current emphasis

on individual autonomy may result in too easily assuming vulnerability and diminished capacity and blind

nurses to alternative ways of assessing and supporting decision-making for patients. Perhaps, the role of

advocacy for nurses is broader than currently espoused and could include advocating for the patient’s support

system as key in supporting patients.

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Conclusion

Although nursing literature supports nurses undertaking a patient advocacy role, this role remains poorly

defined, and the expectations of such a role are varied and inconsistent. The role for nurses as patient advo-

cates in contemporary nursing practice is not only confusing, and potentially paternalistic, based as it is on

an individualistic view of autonomy, it needs further investigation and exploration. Arguably, a relational

view of autonomy suggests the need for a broader-based assessment and support system to assist patients

where needed in decision-making about their care.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit

sectors.

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