9 Practice Breakdown
Professional Responsibility and Patient Advocacy
INTRODUCTION: PROFESSIONALISM AND AGENCY
Professionals are socially constructed agents (Benner, Hooper-Kyriakidis, & Stannard, 1999; Buchanan, 1996) whose justification derives from the benefits they contribute to society that exceed the social costs (Buchanan, 1996). The function of a professional is to serve interests beyond the professional’s own self-interest (Hazard, 1996). Professionalism is defined further to include two elements: self-regulation and agency.
SELF-REGULATION
Self-regulation refers to “effective, collective self-regulation by the professional group, including specification of standards of competence for the profession, measures for inculcating in individual members the commitment to these standards, and sanctions for ensuring compliance with them” (Buchanan, 1996, p. 107). (This may also include expulsion from the professional group.) Generally speaking, the question of regulating a professional group’s activities arises only where the activity has the potential for seriously affecting the interests of others who are not in a position to protect themselves adequately, such as those involved in a health care professional patient relationship (Buchanan, 1996). The health care profession is much broader than the profession of medicine or physicians and includes many other healing professions, such as nursing, clinical psychology, and pharmacology.
AGENCY
An agent is considered to be one authorized to act or decide on behalf of a principal (Hall, 1996). Agency relations are created because principals recognized that they are incapable of choosing or executing the correct course of action as successfully as were their designated agents, owing to some special expertise of the agent or some disability of the principal. The nurse-patient relationship, like other principal-agent relationships, is characterized by an asymmetry of knowledge and capabilities. The patient as principal is dependent on the nurse as agent because the nurse has knowledge and/or capabilities that he/she lacks. This asymmetry of knowledge or capabilities introduces a risk that the agent would use his or her superior knowledge and ability to pursue his or her own interests or the interests of others at the principal’s expense. Therefore some sort of regulation is necessary to provide adequate protection to the principal (Hall, 1996).
NURSE-PATIENT ADVOCACY
PROFESSIONAL RESPONSIBILITY AND ADVOCACY
A socially organized practice such as nursing has notions of good internal to the practice (Dunne, 1993; MacIntyre, 1984). By notions of good that are “internal to the practice,” MacIntyre means that these notions of what it is good to do are shared and upheld by practitioners—in this case, nurses. Nurses, patients, and their families have a responsibility to protect the vulnerabilities of patients during an illness and hospitalization. If a nurse is dismissive of a patient’s concerns about his or her clinical condition, then a breakdown in nursing professional responsibility or advocacy has already occurred. If the nurse is too hurried or too task oriented to notice the patient’s and the family’s experience, then the level of disclosure on the part of the patient/family will be constrained, and this failed attentiveness will limit the possibility of patient advocacy on the part of the nurse.
Human beings dwell in human worlds constituted by care, relying on others, and the human lifeworlds that they both constitute and are, in turn, constituted by. The knower and the known are intertwined. The intertwining of self and world is so pervasive that it resides in the taken-for-granted background. Often we fail to see and thus forget the concerns that daily suspend us in the webs of care that make up our worlds. Without networks of care or concern, we lack the structures in which to ground our actions and choices. Advocacy is a central moral mandate of excellence in nursing care. Once a particular need for care is recognized, the nurse is responsible for advocating that that care need is met (Benner & Wrobel, 1989).
PROBLEM ENGAGEMENT AND INTERPERSONAL SKILLS
When practicing nurses begin to learn differentiated emotional responses that are appropriate to a situation, they can become attuned to the demands and concerns inherent in the clinical situation. They do this through a sense of salience that they have learned experientially as well as through skills of attunement that are specific to the situation. At the competent stage of skill acquisition in nursing, clinical learners can safely pay attention to vague or global emotional responses as a sign that they do not fully understand in the situation because they now recognize a wider array of situations (Benner, Tanner, & Chesla, 2009). At this point, they have a developing sense of when they do or do not have a good clinical grasp of the situation.
PATIENT AUTONOMY
Much has been written about the importance of patient autonomy in biomedical ethics (Beauchamp & Childress, 2001). However, it is understood that during illness, injury, childhood, or old age, impairments occur that limit the patient’s ability to be autonomous. This is yet another reason why the nurse must advocate for patient/family concerns—to augment and support, not usurp, patient autonomy.

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