Patient autonomy in care: a theoretical framework for nursing

Maternity care and Human Rights: what do women think?

BACKGROUND

A human rights approach to maternal health is considered as a useful framework in international efforts to reduce maternal mortality. Although fundamental human rights principles are incorporated into legal and medical frameworks, human rights have to be translated into measurable actions and outcomes. So far, their substantive applications remain unclear. The aim of this study is to explore women's perspectives and experiences of maternal health services through a human rights perspective in Magu District, Tanzania.

METHODS

This study is a qualitative exploration of perspectives and experiences of women regarding maternity services in government health facilities. The point of departure is a Human Rights perspective. A total of 36 semi-structured interviews were held with 17 women, between the age of 31 and 63, supplemented with one focus group discussion of a selection of the interviewed women, in three rural villages and the town centre in Magu District. Data analysis was performed using a coding scheme based on four human rights principles: dignity, autonomy, equality and safety.

RESULTS

Women's experiences of maternal health services reflect several sub-standard care factors relating to violations of multiple human rights principles. Women were aware that substandard care was present and described a range of ways how the services could be delivered that would venerate human rights principles. Prominent themes included: 'being treated well and equal', 'being respected' and 'being given the appropriate information and medical treatment'.

CONCLUSION

Women in this rural Tanzanian setting are aware that their experiences of maternity care reflect violations of their basic rights and are able to voice what basic human rights principles mean to them as well as their desired applications in maternal health service provision.

Patients' perceptions of self-determination as expressed in the context of care

AIM

The aim of this study was to describe patients' perceptions of how self-determination finds expression in the context of care.

BACKGROUND

Self-determination is an important concept within health care as well as an important patient right. New legislation on patient rights in Sweden and Europe is aimed at increased patient self-determination.

DESIGN AND METHOD

Data were collected through semi-structured, tape-recorded interviews with 17 strategically chosen patients within somatic care and analysed using a method inspired by phenomenography.

RESULTS

The analysis found three descriptive categories of the informants' perceptions: trusting, accepting and a feeling of powerlessness. The patients expressed a great sense of trust and confidence in the care provided and they accepted the health care procedures. At the same time, they expressed a feeling of powerlessness because of not being part of decision-making, as well as lacking knowledge and information about treatment strategies. The patients wished to have the right of more self-determination but lacked the strength and knowledge to be able to influence their own care.

CONCLUSIONS

Patients' perceptions of self-determination suggest that, in their encounters with the professional care, knowledge is expressed as power. The feeling of a lack of self-determination can be reduced by help and support from a nurse who allocates time for communication in order to learn the patient's needs and reach a mutual understanding.

Nurses' perspectives of encouraging clients' care-of-self in a short-term rehabilitation unit within a long-term care facility

This article presents a study conducted on a short-term rehabilitation unit in a long-term care facility. The purpose of the study was to explore, through qualitative methods, nurses' perspectives of encouraging clients to care for themselves. Although the literature suggested that encouraging self-care does not occur, the findings of this study showed that nurses have a broader view than what is currently known in nursing as "self-care." Potential impediments to nursing practice were overcome by the development of nurse-client relationships through which the nurses encouraged clients in what is described throughout this study as "care-of-self." Rehabilitation nurses play an important role in helping clients to integrate and reclaim the care of their emerging new selves. Care-of-self may be critical to clients not only in reaching their outcome goals for discharge but also in maintaining outcomes beyond discharge.

Chinese elderly patients' perceptions of their rehabilitation needs following a stroke

Stroke is the third leading cause of death and disability among Chinese elderly patients in Hong Kong and yet the rehabilitation needs of these patients are rarely explored. The aim of this study was to identify the rehabilitation needs of Chinese elderly patients following a stroke. The study adopted an ethnographic approach, information being gathered by the researcher through interviews with 15 key informants selected by purposive sampling. The perceptions of patients as to their own needs were sought at three stages of recovery - in the acute and rehabilitation settings and at 1 month following discharge. Ethical approval was gained from the Chinese University Faculty of Medicine ethical committee and access agreed by the hospital authorities. Verbal approval was gained from the patients before each interview, following confirmation of the voluntary nature of participation and assurance of confidentiality and anonymity. The researcher's role was also clearly stated. Analysis of the interview data produced five categories of patient need at the three stages of recovery, namely informational, physical, psychological, social and spiritual. The most frequently stated, but largely unmet, need in all settings was the need for information, particularly information about the reasons for stroke and about the activities that promote recovery. In the acute and rehabilitation settings patients' responses indicated a need to be respected as individuals, to be addressed by name and to be provided with privacy. Although the Barthel Index administered during interviews charted recovery at different rates, nurses did not always make links between the level of functional ability and the help needed with physical tasks. They also failed to recognize the relationship between physical and psychological needs and the equal importance of both in recovery from stroke. As Chinese elderly patients tend to take a passive role in seeking help and information, nurses play a significant role in the identification of individual rehabilitation needs. Implications for nursing practice are discussed.

Patient decision support intervention: increased consistency with decision analytic models

BACKGROUND

Patient Decision Support (PDS) tools assist patients in using medical evidence to make choices consistent that are with their values and in using evidence about consequences of medical alternatives.

OBJECTIVE

To evaluate a PDS intervention for perimenopausal hormone replacement therapy. We assessed the impact of the PDS on (1) consistency between the decision to take estrogen replacement therapy (ERT) or progesterone/estrogen replacement therapy (PERT) and the expected utility of treatment and (2) likelihood to take ERT and PERT pre- and postintervention.

DESIGN

Content of the PDS was standardized. Randomized trial of three intensities of intervention: (1) brochure; (2) lecture/discussion; and (3) active decision support.

SUBJECTS

Participants were perimenopausal community volunteers between the ages of 40 and 65 (n = 248).

MEASURES

(1) Consistent with values (correlation between expected utility (EU) and likelihood of taking hormones); and (2) Likelihood to take hormone replacement therapy.

RESULTS

(1) The brochure group was less consistent with the decision analytic model than the lecture/discussion and active decision support groups. (2) Influence on decisions: PDS tools increased the number of women certain about whether or not to take hormones. There were no differences among experimental groups. Of 99 women uncertain about ERT pre-PDS, 65% changed. Twenty-one (32%) decided against ERT and 44 (68%) decided for ERT. (3) More intensive interventions produced modest gains in a normative direction.

CONCLUSIONS

PDSs using any of 3 formats reduce uncertainty and assist women to make informed decisions. Increased consistency with decision analytic models appears to be driven by better estimates of likelihood of outcomes.

Informed consent in a multicultural cancer patient population: implications for nursing practice

Obtaining informed consent, an ethical obligation of nurses and other health care providers, occurs routinely when patients make health care decisions. The values underlying informed consent (promotion of patients' well-being and respect for their self-determination) are embedded in the dominant American culture. Nurses who apply the USA's cultural values of informed consent when caring for patients who come from other cultures encounter some ethical dilemmas. This descriptive study, conducted with Latino, Chinese and Anglo-American cancer patients in a large, public, west-coast clinic, describes constraints on the informed consent process in a multicultural setting, including language barriers, the clinical environment, control in decision making, and conflicting desired health outcomes for health care providers and patients, and suggests some implications for nursing practice.

Iowa nurses' knowledge of living wills and perceptions of patient autonomy

The principle of patient autonomy is well recognized in the nursing profession. This study extends the exploration of patient autonomy by examining nurses' knowledge about living wills. The questions addressed in this study included the following: (1) Were Iowa nurses aware of the living will statute? (2) What sources of information did nurses use to learn about this legislation? (3) What were nurses' perceptions of patients' rights? (4) What were nurses' perceptions of nurses' role involving living wills? (5) Were living wills followed? (6) If not followed, which factors contributed to the failure to honor a living will? and (7) Which communication mechanisms were used to alert nurses to a living will? A questionnaire was mailed to 10,000 actively licensed nurses in Iowa. Approximately 3,000 Iowa nurses responded to the questionnaire regarding Iowa living wills. Seventy per cent of the nurses knew that Iowa had living will legislation. No single educational source was a predominate choice for targeted information about the living will statute. Nurses were reluctant to suggest to patients that they should consider writing a living will. Nurses were also more willing to assume a passive role of suggesting that patients talk with relatives about the need for a living will but were less likely to be suggest that a patient write a living will for future health care treatment decisions. The majority of the nurses favored the patient having some control in health care treatment decisions. Three major factors were pertinent to the failure to follow a living will: family request, treating physician's refusal, and lack of information that the living will existed. The medical record was the primary means of communication regarding a living will. To enhance patient efforts at self-determination, nurses must recognize the advance directive legislation is available in their state and the potential impact that their nursing care may have on the implementation of the document.