Nursing Autonomy Part 2: How can Nurses Enhance their Autonomy?

Nurses can promote and expand their autonomy and the control over their own practice by publicly identifying their unique expertise in health and client care in easily understandable terms in a way that shows the value of their nursing expertise.  

Nurses need to communicate that their work involves an exclusive knowledge base and skill set that is different from and even unknown by physicians. Nurses must to be able to articulate nursing practice and fully understand their scope of practice to show nursing as a distinct and critical profession.

But how do we enhance our autonomy?

Encouraging continuous examination of practice allows nurses to reflect on the degree of autonomy in their decision making. By creating and fostering environments that support continuing educational opportunities and learning provides for autonomous clinical practice (through establishing and ensuring an evidence-based practice approach).

Supportive management, education, and experience are the three most important factors in enhancing autonomy over client care. Part of the dilemma is that most nurses practice as employees, the result being that nurses must structure their work within imposed rules, at the discretion of their employer rather than based on the critical judgement of the nurse. Unlike other health professions nurses do not usually have a discrete client base and it is therefore, more difficult to establish control over decision-making and determining client care. This of course has a profound effect on nursing practice.

Nurses need to foster understanding with other professions, with employers and the public, that nursing practice involves both direct clinical care and management of the context in which care is delivered. 

Nurses are not merely automatons, performing the tasks delegated to them by the physician in rote response. Nurses are autonomous yet interdependent practitioners who case manage complex care by; providing direct care, by collaborating with and seeking advice from other key health professionals and by negotiating components of that care that are the purview of other practitioners. 

Nurses are ground zero, from which all care occurs.

 Further, nurses are often under-represented on management and/or governance issues (issues that determine autonomy) and therefore their Influence on cultural change limited.Clinical nurses more likely to participate in clinical care decisions/policies but not organisational decisions/policy. Nurses must understand and engage with health service policy beyond clinical practice as decisions about autonomy and control over professional decision making are made at  level organisational governance and operational management levels. Nurses need to demand clarification of the rationale behind policy decisions affecting their practice and expose assumptions made in relation to their scope of practice.

Developing autonomy in nursing practice also requires a shift in communication styles and practice. Development of skills related to communication, interdisciplinary teamwork, and negotiation can assist nurses to master the skills necessary to advocate for their clients and demonstrate their autonomy. Our communication skills and the information and way we communicate can help articulate our autonomy to other professions. This may require a level of professional confidence to seek out feedback and critical review without being defensive.

Nurse Leaders

There is no one linear leader/ship. Leaders operate at all levels and evenly distributed throughout the whole organisation. They are characterised by being strong, visible and influential across the whole of the workforce, and may not hold management positions but lead through their this strength and their ability to engage with and address issues.  

Nurses should actively seek out and support nursing leaders who role model promoting autonomy and control over their own practice.This acts to create and shape culture and 

influence change in practice and policy.

Nurse Managers are well positioned to promote conditions to promote nurse autonomy and influence decision-making that supports control over nursing practice. There is evidence to support that Nurse Managers who are (1) informed about current nursing practice,  
(2) support staff to develop autonomy, and (3) communicate effectively with executive management about this practice, enhance professional autonomy. (Kramer & Schmalenberg, 2002;Upenicks, 2003).

Nursing Executive to need to promote and represent nursing staff/practice. A Nursing Executive who (1) advocates for a strong, influential nursing presence in the organisation, (2) is open and communicative and (3) supports participative management,is associated with a professional environment that includes autonomous clinical practice and nursing control over

practice (Hinshaw, 2002). Our Nursing Executive is our direct link to rest of executive team and nurses should expect and demand that nursing management and executive accurately and proactively represent current nursing best practice and advocate for professional autonomy.

Each and every nurse can:

• Clarify expectations about clinical autonomy – expected practice
• Enhance competence in practice – foster clinical case analysis and critiquing
• Establish participative decision making – within policy and governance structure
• Enhance competence in decision making – educate nurses about policy/decision making and how to contribute effectively
• Identify, foster and support nurse leaders – engage with nurse leaders at all levels
• Work upstream – seek to influence social, politician and economic factors in practice
• Articulate nursing practice – to other nurses, other health professionals clients and the public

My advice...

Tell everybody what you do and how you do it....without you there is no care.

See Nursing Autonomy Part 3

Reference:

Kramer, M., & Schmalenberg, C. (2004). Essentials of a magnetic work environment: Part 2. Nursing, 34(7), 44–47.

Upenieks, V. V. (2003). The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager, 22(2), 83–98.

Hinshaw, A.S. (2002). Chapter 4. Building magnetism in health organizations. In M.L. McClure & A.S. Hinshaw (Eds.), Magnet hospitals revisited: Attraction and retention of professional nurses (pp. 83–102). Washington, DC: American Nurses Association.

Nursing/Midwifery Documentation…what is its real purpose?

You didn’t become a nurse or midwife to sit in front of a computer (or written health record) to write notes all day.  You don't have time either. The more time writing repetitive notes, the less time you have to actually provide the care! You were always told to be clear, concise and accurate but no one really ever showed you how to write it! Everyone seems to use a different system and/or different terminology!  You find that you are often writing something merely for the purpose or writing something….if it isn’t written it didn’t happen.

You don’t really want to do it and you certainly don’t enjoy it but….. 

                                               …. in reality, documentation is part of client care.

It may not feel that important today…but in 2 years time when you find yourself before a disciplinary or legal investigation….will your documentation set you in good stead to defend your actions and provide inconclusive evidence of the care you provided?

It is interesting (and concerning) that there are at present, no nursing or midwifery professional standards in Australia (correct me if I am in error) outlining something as imperative as professional documenting.  (Note: there are government and industry based standards (in each state and territory) for record keeping and client health files but these rarely outline or define nursing and midwifery documentation best practice).   

Yet documentation is a vital component of safe, ethical and effective nursing and midwifery practise regardless of the context of care or the form or purpose of the documentation. It provides an account (your professional account) of critical thinking and professional judgement you used in and across all aspects of the nursing process (ie assessment; diagnosis; planning; intervention and evaluation) and partnership between the midwife and the woman.

Documentation…

·      reflects the application of nursing knowledge, skills, and expertise

·      reflects your judgement and establishes your accountability and responsibility

·      is a legal record of events

·      is a source of evidence

·      is a permanent record

·      preserves facts and corroborates and clarifies your recollection/s

·      records the unique contribution of nursing and midwifery to health care 

A Definition

Nursing/Midwifery Documentation refers to any and all forms of documentation by a nurse or midwife recorded in a professional capacity in relation to the provision of nursing or midwifery care. It includes written and electronic health records, audio and video tapes, emails, facsimiles, images (photographs and diagrams), observation charts, check lists, communication books, shift/management reports, incident reports or any other type or form of documentation pertaining to that care.  It may be clinical data, management or educational information or research analysis.   It may also include anecdotal notes or personal reflections by the nurse or midwife.  Willis nbsa 2005 (rescinded)

Refers to written or electronically generated information about a client, describing the care of services provided to that client (eg charting, recording, nurses’ notes or progress notes). In other words, documentation is an accurate account of events that have occurred and when they occurred. Clinical documents are defined as legally authenticated (ie attested or signed) and persistent entries in a client’s health record. Nurses may document information pertaining to individual clients or groups of clients.  Registered Nurses Association of British Columbia 2003

So What is the Purpose of Professional Documentation?

1. Client Care

The permanence of health records makes them a primary client care tool.

Information increases likelihood client will receive consistent/informed care or service.

Particularly in relation to providing necessary information to ensure consistency/continuity of clients’ care.

Encourages health professionals to assess clients’ progress over time, determine effectiveness of interventions, and identify required changes to care plans.

2. Communication

Ensures all involved in a client’s care have access to reliable, pertinent, and current client information upon which to plan and evaluate interventions.

Provides clarity for other health practitioners and reduces duplication of intervention, facilitates multidisciplinary team processes/practices.

Source of information within and across professional groups and teams.

Communicate assessments about status of clients, interventions carried out and results of these interventions.

3. Accountability

Demonstrates the practitioner’s accountability and records their professional practice.

Meets requirement to comply with professional standards, organisational protocols, govt policy.

Demonstrates practitioner has applied knowledge, skills and judgement according to professional standards/best practice.

Reflects/honours ethical concepts of sound practice

Respects client’s privacy, confidentiality, information and circumstances.

May be used in relation to:

·      performance management

·      internal inquiries

·      regulatory proceedings

·      legal proceedings

·      Freedom Of Information (FOI) requests.

4. Legal Record of Evidence

Its importance cannot be overemphasised.

Thorough, accurate, timely documentation is one of the best defences against legal claims.

Can be used as evidence in court of law, coroner’s inquest, regulatory investigations, disciplinary proceedings.

Documentation can be used as evidence in legal proceedings as a measure of nursing care against

·      Standards/Guidelines…

·      Best practice/evidence based practice

·      A ‘reasonable and prudent’ nurse or midwife…..

5. Risk Management

Promotes highest quality of care through quality assurance/improvement.

Risk management processes are used to identify, assess and reduce risk to clients, visitors, staff and assets (eg financial, equipment, human).

Designed to promote safety by reducing incidence of preventable accident/incident/injury.

It may be used for audits, ethical and disciplinary reviews, accreditation surveys, legislated inspections, critical incident review and ongoing risk management analysis.

More readily able to evaluate client/groups progress, identify client care issues and recommend changes/improvements to practice.

A conceptual process to evaluate professional practice.

6. Research Evidence/Analysis

Serve as a valuable/major source of data for nursing and health related research (eg statistical trending helps to prevent or minimise specific developments such as an increase in infection rates).

Identify long term trends/issues for health services/models/resource needs

used in health research to assess nursing interventions, evaluate client outcomes, and determine the efficiency and effectiveness of care.

The type of research made possible through the information in health records can enable nurses to further improve nursing practice.

Precise, clear and complete documentation is essential to ensure accurate research data.

7. Resource/Workforce Management

Provides a valuable source of evidence and rationale for funding and resource management.

Used for workforce measurement data/projections.

Used to measure/determine client classification systems.

Used for skillmix/workload data and funding /resource allocation.

Source of evidence for funding/resource submissions/grants.

I recommend referring to a number of excellent Nursing Documentation Standards from Canada (the best I've seen). Note: They are equally relevant for Enrolled Nurses (Div 2).

Documenting Care: Standards for Registered Nurses Nurses Association of New Brunswick

Practice Standard: Documentation  Nurses Association of New Brunswick

Documentation Guidelines for Registered Nurses College of Registered Nurses of Nova Scotia

Nursing Documentation College of Registered Nurses of British Columbia