Core Ethical Principles in Nursing: Key Definitions

Autonomy in Nursing Practice

Autonomy in the nursing profession emphasizes the importance of the client's role in making decisions, reflecting the nurse's advocacy for the patient (Wade, 1999, p. 310). Ultimately, this includes caring for the patient physically, mentally, and emotionally; developing a relationship with the patient that benefits his care; and actively advocating for the patient's rights and wellbeing. It is important to note that this type of autonomy is not the same as individual or work autonomy. Nevertheless, empowerment through nursing autonomy will inevitably lead to better professional and personal autonomy and should also produce increased job satisfaction (Wade, 1999, p. 310).

Typical definitions of autonomy include the idea of complete independence for the person making decisions. However, in the case of the nursing profession, the client's needs and desires must be heavily weighed and, in fact, become central to the concept of autonomy. No nursing professional can make life-and-death decisions for someone without taking the patient's beliefs and concerns into account. It is this dependence on the patient that renders professional nursing autonomy different from almost any other kind of autonomy. Once this definition is applied to nursing, it becomes easy to see how it could affect all aspects of the profession. Becoming a full advocate for a patient empowers the nurse to make the best decisions in the patient's interest while also developing a sense of personal accomplishment. Successfully advocating for a client's needs reinforces the role of the nurse as a primary caregiver.

One example of this type of advocacy and its overall effects would be the situation of a terminally ill patient who is nearing the end of life and is currently kept alive artificially. A nurse would be well positioned to contact family members and discuss their wishes alongside the patient's own. If a living will exists, it must be taken into consideration, and someone must be available to advocate on the patient's behalf. Ideally, the family would assume this role, but a nurse can often be more persuasive when dealing with medical professionals—and there is sometimes no family to advocate for the patient at all. Beyond the family's wishes, the patient's medical condition must also be taken into account. This is where the nurse can be especially effective, acting as a mediator who conveys the wishes of both the family and the medical team. It is incumbent upon the nurse to advocate for the course of action that most directly reflects the patient's ultimate wishes.

Advocacy need not be applied only in such dire circumstances. It can be as simple as pushing for a patient to receive care that may not be covered by insurance. Such advocacy can take the form of negotiating with insurance companies or lobbying doctors and hospital administrators to treat a patient regardless of ability to pay. It also serves as a guard against burnout and staff turnover, since fighting for and securing better coverage for patients benefits the overall care environment, including the hiring of more nurses and ensuring they have the proper tools to perform their jobs effectively.

While nursing autonomy has at times been characterized solely as a call for patients' rights advocacy, that does not capture the full spectrum of what it achieves. Defending a patient's rights is certainly an important component, but it is the support of the individual's overall well-being that is paramount to the concept of nursing autonomy (Gaylord & Grace, 1995, p. 11).

Informed consent is the legally recognized right of all patients to be informed about the procedures to be performed on them. This includes, but is not limited to, a clear explanation of the procedure, its benefits and risks, available alternatives, and likely outcomes—and the patient must fully understand and be able to sign an agreement authorizing the indicated procedure (White, 2004, p. 64). This legal obligation, normally associated with physicians performing medical or surgical treatments, also extends to nurses when consent for a specific nursing procedure is required. The responsibility for obtaining a patient's signature—whether for a nursing or medical procedure—typically falls to the nurse, who must also determine the client's capacity to sign such a form (White, 2004, p. 65).

Informed Consent and the Nurse's Role

The New York State Nurses Association sets out concrete recommendations for nurses when obtaining informed consent. They specify that the nurse should assume the role of patient advocate, respect the patient's decision, refrain from participating in any treatment where informed consent has not been obtained, and initiate appropriate action if informed consent is not properly processed and implemented (Position statement, 2004). The Association further holds that patients are responsible for evaluating their own healthcare, have the right to determine what will be done to them, have the right to information regarding their condition, and that the nurse should serve primarily as a witness and advocate rather than as the person obtaining informed consent (Position statement, 2004).

Informed consent is most commonly associated with surgical procedures. Before performing any medical procedure, the doctor explains the entire process to the patient, ensuring that the patient understands what is to be done along with the associated risks and benefits. While it may seem excessive to go into great detail for relatively simple treatments such as a vasectomy or endoscopy, many patients are taken aback when they learn of the inherent risks of any surgical procedure, particularly one requiring anesthesia. It can also be informative for the patient to learn about alternative treatments he may not have known existed, and a patient has the right to know the prognosis associated with any procedure.

At any point while reviewing this information, the patient may decide that the risks outweigh the benefits and choose to pursue an alternative approach. A patient who learns of significant risks associated with a heart surgery procedure may opt instead for an alternative such as angioplasty or certain medications that may help clear blockages. Of course, these alternatives carry their own risks, which should also be communicated to the patient.

For many patients, simply hearing about the risks is enough to deter them from undergoing a procedure. For others, however, their doctors seem infallible and they will follow whatever course of action is recommended. This is where the nurse becomes an important advocate—relaying the patient's concerns to the doctor and encouraging open dialogue between physician and patient. Many patients feel intimidated by their doctors but may feel more comfortable sharing concerns with a nurse, who can then relay those concerns to the physician as a professional colleague.

The nurse's role in informed consent is fundamentally one of mediator, ensuring that the patient's best interests are protected even as the doctor recommends what he or she considers the most effective treatment. There can be no informed consent if the patient is not genuinely informed, and the nurse's role in properly explaining procedures and their associated risks cannot be overstated.