Autonomy and the relationship between nurses and older people

Abstract

Autonomy is considered to be one of the central ethical principles of health care practice and as such is a significantly relevant concept for health care practitioners. With the many political and ideological drivers that challenge the way health care for older people is currently delivered, it is important to consider how the autonomy of older people is facilitated in everyday practice. In this paper I challenge the dominant understanding of autonomy as 'individualism'. Through research undertaken with nurses who work with older people, it identifies the conflicts that arise between an individualistic understanding of autonomy set alongside an emphasis on 'person-centred' practice. Data were collected by recording 'naturally occurring' conversations between nurses, patients and associated practitioners. Primary nurses recorded conversations occurring between them and four patients throughout their hospital stay. In addition, a recognised expert gerontological nurse and a community nurse specialist participated as a means of testing out initial themes generated by the primary nurses. A total of 14 case studies were recorded. The data were analysed using principles of conversation analysis and thematic analysis set within a hermeneutic interpretive framework. In order to illuminate presentations of autonomy in practice, focus group discussions with nurses and older people were used as part of the interpretative process. I discuss the factors that prevented the operationalisation of an individualised rights-based concept of autonomy for older people. Issues including information-giving, the conversation style of nurses, internal and external constraints and patients' competence to decide are considered. In addition, the role of families in decision-making is addressed. The paper ends with a discussion of an alternative view of autonomy based on 'interconnectedness' in the nurse-patient relationship. This perspective is not based on either the patient or nurse being the 'final arbiter' of decisions, but is instead set within a framework of negotiation.