Client Autonomy and Nurse Safety in Community Health Practice

Introduction: Ethical Complexity in Community Nursing

Nurses involved in community nursing often face ethical and practical dilemmas, particularly with regard to the issue of patient autonomy. Community practice differs from nursing in more formal settings in that many complex variables can intervene in the delivery of care.

As one professional resource notes, these dilemmas "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 include cases where access is refused by the client, even when that client is in urgent need of assistance. This presents an acute ethical problem 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" (p. 405). Refusal of entry is only one of the issues a community nurse might face.

In essence, the problems community nurses face are often ethical in nature and require careful consideration. These may include scenarios such as the following:

How do you support a mother whom you suspect of being drug-dependent and who would like to breastfeed her infant — which might be the best way to foster a positive mother-infant relationship, but which may not be healthy for the infant? How do you support client autonomy when you are being refused entry into a home by an 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 yourself? 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 implies that professional nurses should have knowledge of — 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 cultural and social context of end-of-life patients.

This aspect is further underscored by demographic realities: "more than 20 percent of the elderly population is functionally disabled and needs basic assistance in daily living; of those receiving such assistance, more than 70 percent continue to live in the community" (Zuckerman, 1990). Community health care is consequently marked by "tensions between medical and social models of care" (Zuckerman, 1990).

The Question of Client Autonomy

In this context, one of the central issues facing the community nurse is the balancing act between client autonomy and the professional autonomy of the caregiver. Respect for the client's wishes and situation is of central concern. For example, the Canadian Nurses Association (CNA) Code of Ethics (2002) states that:

"Nurses should provide the desired 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," and "Nurses must seek out and honour 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, 2002)

In other words, these standards stress the respect that healthcare workers should have for the desires and preferences 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." (Kikuchi, 2002)

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 an elderly client who is acutely ill? In a case of this nature, the morally correct decision requires weighing the situation against the imperatives of the patient's health needs. The nurse should consider whether the patient is in serious danger or in a life-threatening situation and act so as to prevent the situation from worsening. Morally speaking, respect for patient or client autonomy should not override the necessities of the health worker's professional ethics. In the situation where entry is refused and the patient is seriously ill, the nurse has no option but to call in assistance from the relevant medical and health authorities.

This view is underscored by the following observation:

"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, 2002)

This clearly establishes the necessity of acting in serious cases according to the patient's needs and not solely according to the principles of client autonomy. Hyland (2002) also endorses this view, stating 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" (p. 477).

In such cases, the principle of patient advocacy is replaced by professional advocacy. Grace (2001) explains this principle in terms of its legal dimension, drawing a parallel between the nurse and the lawyer:

When Patient Autonomy Must Be Overridden

"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, 2002)

This view is also supported by the British Medical Association, which states: "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 scenario — caring for a patient in an unsafe environment — many of the ethical principles discussed above apply equally. Once again, the emphasis should be on a balance between patient autonomy and professional autonomy. Where the patient is a palliative elderly client who is, for instance, attempting to drink himself to death and is at risk of falling, the principles discussed above about overriding patient autonomy remain applicable. However, what distinguishes this situation is the nurse's own right to protection 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 must also be balanced against the nurse's right to personal safety. "All nurses have the right to be safe" (Ellis, 2003); however, this does not mean that the medical safety of the client should be ignored. As in the first scenario, a nurse should call in assistance and advice from the appropriate authorities in cases where he or she feels unsafe and the patient is simultaneously in need of care.

Another important dimension of this situation concerns the unsafe environment as it relates to the patient. Where the patient is aged and infirm, the home environment itself should be a source of concern for the healthcare worker. While it may appear that the physical conditions of the home care setting are primarily a medical issue, they carry ethical weight as well. Physical restrictions "actually compromise the important ethical values of autonomy and beneficence" for the patient (Aulisio, n.d.). The situation deemed unsafe for the nurse may therefore also compromise and endanger the patient and the patient's own autonomy, making it an issue that must be addressed in partnership with community and public health officials.

Conclusion: Balancing Rights and Professional Responsibility

Theme 2 — Patient autonomy. (n.d.). British Medical Association. Retrieved May 16, 2005, from

Zuckerman, M. (1990). The ethics of home care: Autonomy and accommodation. The Hastings Center Report, March 1, 1990.