Nursing literature in the US contains a plethora of studies relating to autonomous decision-making in nursing practice. The expert views expressed on the subject tend to vary, often widely, according to whether the field of study concerns hospital practice, community practice or nurse education. There is much less literature in the UK.
The present article explores community nurses' willingness, or sometimes their lack of willingness, to make an autonomous practice decision. The author examines both the liberating opportunities of doing something ‘off one’s own bat’ and also the limits that can, and sometimes should, be imposed on such freedom. The law does come into play now and again, but not as frequently as practitioners might think.
Basic meanings of ‘autonomy’
To do something autonomously is to do it unbidden by others. Autonomy has shades of independence and self-governance, of not being interfered with in the making of a decision and even, in some cases, of not being pressed or even prevailed upon to make a particular choice. That is to state the matter in the most general terms. However, autonomy is a value that takes on a real meaning only when used in a specific context. As said, this context could be as a nurse practitioner in a hospital, or in the community, or as a student—as well as in many more practice settings.
This article naturally focuses on autonomy in community nursing, but it makes reference, when appropriate, to other healthcare practice contexts when a comparison or a contrast is useful.
Autonomy in general
The word ‘autonomy’ can have many different meanings in a whole variety of contexts. For example, Hong Kong is an autonomous region of the People's Republic of China, though how self-governing it is remains to be seen in the light of recent events. The Isle of Man is not part of the UK, but is a Crown Dependency. It makes many of its own laws, through Tynwald, its parliament, independently of the Westminster legislature.
Health professionals are autonomous to the extent that their various professional practices are not at the beck-and-call of the government that funds them, nor at the instruction and command of those to whom healthcare services are delivered. Are they autonomous, is each an island unto itself ? In a mental healthcare team treating a patient with a mental disorder, is the clinical psychologist autonomous in the sense that they are entitled to make decisions, and to put such decisions into practice, independently of the psychiatrist member of the treating team? Does the mental health nurse member of the team act autonomously in regard to the other two?
These questions are actually meaningless without full knowledge and appreciation of the respective roles played by all the team members, according to legally accepted and professionally acceptable professional practice.
It takes but a moment's reflection to realise that unfettered autonomy of each from the other could, and probably would, lead to chaos.
Autonomy, independence and choice
All three of these notions are themselves interdependent. Interdependence is not the same as independence. In fact, they can mean the very opposite of each other in the context of healthcare practice. Members of a treatment team are interdependent. At the same time, they are independent professionals, each making a different contribution to the treatment that is proposed and given. They play different roles in the team, much as a football team comprises forwards, halfbacks fullbacks and a goalkeeper. Eleven goalkeepers would not make for much of a football match.
What has the law got to do with autonomy?
Not a lot, actually, in terms of the sheer volume of practical considerations that should be brought to bear on any treatment decision. However, where it does bear on autonomy in professional healthcare practice, a proper appreciation of applicable legal parameters can be vital. No one is above the law, and so there are, by definition, limits to the autonomy of an individual in any sphere of activity.
Contrary to widespread belief across healthcare professions, legal rules and regulations in the context under discussion are there for one reason only. In the context of professional healthcare regulation, they are there to empower, not to prohibit or to restrict. It is the function of the criminal law to say what acts are not allowed and to prohibit them.
In the context of healthcare, there are indeed restrictions and prohibitions, such as the obvious example of inventing or misstating a qualification when applying for a job. But that sort of prohibitory regulation is as far as it goes for the present purposes. Not even the law relating to the award of compensation (damages) for negligence in professional practice is there to prohibit negligence. It simply says what should happen when negligence occurs, by way of monetary compensation. The law of compensation for harm negligently caused is, in a real sense, an ‘after-the-event’ law. Criminal law is, by contrast, a before-the-event law that tells us what not to do in the future.
The law does not tell a community nurse when to make an autonomous decision nor when not to make one. In the context of teamwork, it might look for a collaborative decision or even for an act dictated, or at least advised by, a practitioner more senior in the hierarchy (if there is one) or one with more detailed knowledge of the case history. In the most extreme instances, it might be negligent of that other person not to give such information, even if it were effectively to take the form of an instruction.
On the other hand (but in none but the most extreme instances), it could be negligent not to request further and better particulars by the practitioner who had reason to believe that such information might exist. In the latter instance, it could be said, perhaps perversely, that the person seeking such information was in fact making an autonomous choice to do so. A fancy way of recognising this is to be found in the term ‘evidence-based practice’. Since when have the decisions of healthcare practitioners not been based on evidence?
Autonomy: the positives and negatives
There may be occasions when a healthcare practitioner wishes to do precisely the opposite of making an autonomous decision. There may be any number of reasons for this. One might be simple inexperience, at least of the type of situation in which a clinical decision is to be made. The desire—perfectly proper in many circumstances—not to act autonomously may incorporate a legitimate desire to depend on the greater or more detailed experience of another practitioner or practitioners, whether these be from the same or another healthcare profession.
Perversely, it could correctly be said that such a decision is itself an exercise of autonomy. It is a recognition of insufficient knowledge or experience of the totality of the case in point, and none the worse for that. The law of negligence says that if a person takes on a task for which they are ill-equipped and causes harm to another as a result of so doing, they are to be judged according to the level of skill they have, in the event unwisely taken upon themselves. Harsh though this may seem at first, it is only sensible that a patient should benefit from the best available expertise.
Or it could be that, according to the multidisciplinary makeup of a particular team, decision or a particular part of a decision, a nurse feels that on the basis of professional experience, there are circumstances that indicate that the decision should be made by another. Again, that could be a wise decision that accords with the law relating to ‘duty of care’ in the law of negligence. Further, it may again be an exercise in autonomy. These are not motives for inaction; rather, they are positive reasons for choosing to play a particular role in the decision-making process.
Such motives for action are entirely positive. A wholly negative reason for choosing to avoid an autonomous decision would be an ill-advised and wrongly informed fear of adverse legal repercussions. Such an outlook is by no means confined to the nursing profession. It can be, or at least has been, found in all healthcare professions. A wrongheaded fear of the law can lead to defensive practice or ‘defensivism’—being defensive against a perceived but unreal foe. Imagine having to practise under the suspended Sword of Damocles, expecting it to drop on you at any time. Not good for the patient, certainly, and not good for the practitioner.
More importantly from the legal point of view, a decision to do something or not to do something that was based on unfounded fear of ‘legal repercussions’ could itself, were it to cause harm, amount to negligence. Unfounded paranoia is not accepted by the law.
Autonomy: pecking order and decision-making
Should there be a ‘pecking order’ in a team? Certainly not, if that were to mean a hierarchy of different healthcare professions, the order being there for its own sake and for no legitimate reason.
It has been the author's observation that the view that the profession of nursing is, in some undefined way, inferior to or less than some others is irritating and without any sensible basis. For too long, certain advocates of the value of good nursing care have been almost apologetic for the role that nurses play. Perhaps, in the antediluvian times of ‘doctor knows best’, certain members of the medical profession have managed to browbeat other healthcare practitioners into believing they play a lesser role.
Conversely, a team leader is by definition one who takes a lead in a clinical decision and the way to put it into practical effect. Why have a team leader if not for that? But this is not to say that a team leader is the sole decision-maker. Otherwise, why have a team? This brings us naturally to ‘consensus decisions’.
Consensus decisions
The very term ‘consensus decisions’ is suspect. Clinical decisions do not arise out of the wobbles. They are made by someone. ‘Consensus’ does not mean ‘unanimous’, at least when people are being honest with each other as well as with themselves. Majority rule is a fine thing in some circumstances, but not in others. How many of us have found ourselves in a meeting when the chairman says, ‘I think we are all agreed…’. Either we swallow our pride, or we upset the apple-cart. Back to pecking order, pronounced demagoguery.
Fine in politics, maybe, but not in healthcare decision-making. However, unfortunately, it does happen.
Conclusion
Nurses should not be browbeaten, and they should stand up for their professional, considered and experienced point of view. Equally, though, they should not hesitate to accept and even invite the views of others, to let those views colour their own and to colour the views of others. That is what teamwork is. It benefits interdisciplinary working, it benefits the patient and it benefits the health professional. That is true autonomy.