Client Autonomy in Community Health & Nurse Safety in Community Practice Nurses involved in community nursing often face ethical and practical dilemmas, particularly with regard to the issue of patient autonomy. Community practice differs for nursing in more formal settings in that there are many complex variables that can intervene in nursing care.

they are made more complex because of the influence of the setting (isolation from nursing colleagues, role ambiguity, the shift in control, family dynamics, and the increased need to collaborate). Even something as simple as access to patients in the community cannot be assumed in the same way it can be in acute care.

(Ethical Awareness for Community Care Nurses)

Examples of this complexity are cases where access is refused by the client, even when the client is in need of urgent assistance. This presents an acute problem on an ethical level for the community nurse. As Stulginski (1993) points out. "The nurse may be the deliverer of care, but the setting is borrowed and every interaction is negotiated with respect to this." (Stulginski, 1993, p.405) Refusal of entry is only one of the issues that a community nurse might face.

In essence the problems that the community nurse faces are often of an ethical nature and need careful consideration. These may include the following examples of some scenarios that community nurses sometimes face.

How do you support a mother that you suspect of being drug dependent and who would like to breast feed her infant, which might be the best way to foster a positive mother-infant relationship, but which may not healthy for the infant?

How do you support client autonomy when you are being refused entry into a home by the elderly client who is acutely ill?

How do you respond when your client asks you to adopt her unborn infant and you are unable to become pregnant with your own child?

How do you continue to care for a patient in an unsafe environment when you are concerned about your own safety

(Ethical Awareness for Community Care Nurses)

The question of patient autonomy is a complex area for the community nurse. Community nursing, for example, implies that professional nurses should have knowledge or be cognizant of the wider cultural and social milieu in which they work. This also implies the development of a particular sensitivity to the often complex culture and social context of end-of-life patients. This aspect is also aligned to the fact that "more than 20% of the elderly population is functionally disabled and needs basic assistance in daily living; of those receiving such assistance, more than 70% continue to live in the community ... A pattern is emerging in long-term care of the elderly that will dominate health care well into the next century. (Zuckerman, M. 1990) Therefore community health care is also marked by "tensions between medical and social models of care." (ibid)

In this context one of the central issues facing the community nurse is the question of patient autonomy. An important aspect of this is the balancing act that health workers often have to achieve between the client's autonomy and the autonomy of the caregiver. Respect for the client's wishes and situation is of central concern in this regard. For example, the Canadian Nurses Association (CNA) Code of Ethics ( 2002) states that,

"Nurses should provide the desired [italics added] information and support required so people are enabled to act on their own behalf in meeting their health and healthcare needs to the greatest extent possible";

"Nurses must seek out and honour [italics added] persons' wishes regarding how they want to live the remainder of their life. Decision-making about life-sustaining treatment is guided by these considerations."

( Kikuchi, J. 2002)

In other words, the above standards stress the respect that health care workers should have for the desires and predilections of the patient or client. This would suggest that "nurses are to be guided by the business motto "the customer is always right." They should inquire about a patient's wish (es), provide the information desired by the patient, await the patient's decision and then accept and act in terms of it, unless doing so would contravene the law or their personal values." ( ibid)

However, how are these ethical and legal standards of client autonomy to be applied to the situation where a nurse is refused entry into a home by the elderly client who is acutely ill? In a case of this nature the morally correct decision would be to weigh up the situation and the imperatives of the health requirements that relate to that situation. In this sense the nurse should consider whether...

Morally speaking, the respect for patient or client autonomy should not override the necessities of the health workers professional ethics. In the above mentioned situation, where entry is refused and the patient is seriously ill, the nurse has no option but to call in assistance for the relevant medial and health authorities.
This view is underscored by the following remarks.

To determine how best to promote health in a particular situation, nurses must identify and evaluate the relevant operative health factors, including patients' choices concerning their health. Nurses cannot afford (and, it could be argued, it is immoral for them) to act without having made a professional judgment about whether a patient's health choice (informed or not) is in the patient's best interest and that of others.

( Kikuchi, J. 2002)

The above clearly states the necessity of acting in serious cases in terms of the patients needs and not only in terms of the principles of client autonomy. Hyland (2002) also endorses this view and states that, "...respect for [patient] autonomy cannot be an absolute obligation because it may conflict with the professional responsibility to act beneficently towards patients, and could thereby compromise the moral autonomy of health professionals. (Hyland, D. 2002. p 477)

In this case the principle of patient advocacy is replaced by professional advocacy. Grace ( 2001) explains this principle in terms of legal aspect.

... The nurse's function is similar to that of the lawyer: "to act solely and diligently in the interests of the client." The nurse and lawyer alike are directed solely by the client's interests. Their judgment of the rightness or wrongness of the client's action is irrelevant. Because of the injustices that can be wrought upon others when health professionals act only in terms of the client's interests, Grace suggests that the notion of patient advocacy be replaced with one of professional advocacy, wherein professionals make judgments in light of their profession's purpose, objectively defined.

( Kikuchi, J. 2002)

This view is also supported by the following statement from the British Medical Association.

No health care professional may comply with a request from a patient simply because that is what the patient wants. The practitioner must always be satisfied in his/her own judgment that the proposed course of action is appropriate and justified in terms of the likely benefit to those who may be affected.

(Theme 2 - Patient autonomy)

In terms of the second situation, i.e. where the question involves caring for a patient in an unsafe environment, many of the above ethical principles and solutions apply. Once again, the emphasis should be on a balance between patient autonomy and professional autonomy. In this case, where the patient is a palliative elderly client who is attempting to drink himself to death and falling, the principles discussed above about overriding patient autonomy are applicable. However, the element that is different is this situation is right of the nurse to protect herself in an unsafe environment.

Unsafe practice situations are defined as "particular circumstances in which the obligation of the registered nurse to provide safe, competent, ethical care cannot be fulfilled." (Professional Conduct: Nursing Practice Standards )

The rights of the patient are also balanced by the rights of the nurse to personal safety. "All nurses have the right to be safe." (Ellis. J. 2003) however this does not mean that the medical safety of the client should be ignored. As in the first situation, a nurse should call in assistance and advice from the authorities in the case where he or she feels unsafe and when the patient is in need of assistance.

Another important aspect pertaining to this situation is the unsafe environment as it relates to the patient. In this case, where the patient is aged and infirm, this environment should in itself be a source of concern for the health care worker. While it may seem that the physical surroundings of the home care situation which hinders assistance is mainly a medical issue, yet it is also an ethical one. " ... these physical restrictions actually compromise the important ethical values of autonomy and beneficence" for there patient. (Aulisio M.)

The situation that is deemed to be unsafe for the nurse may also compromise and endanger the patient and the patient's autonomy. Therefore, this factor should also be addressed by the nurse in conjunction with community and health officials.

Nurses should recognize…