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 patient advocacy are central to the nursing role. As noted in the chapters on attentiveness, surveillance, and monitoring, if patient staffing drops too low, nurses will be unable to observe their patients sufficiently to be effective patient advocates. Patient advocacy is the positive, proactive professional stance of a nurse. As a patient advocate, the nurse aligns with the patient to ensure that the patient’s concerns are heard and that the patient’s well-being is protected. All professionals hold similar social contracts to protect the best interests of their clients/patients, especially when they are unable to adequately protect themselves because of impairment or lack of knowledge. In the judicial system this is called a fiduciary responsibility to the client to ensure that the client’s legal rights and best interests are served.

PROFESSIONAL RESPONSIBILITY AND ADVOCACY

Nurse staffing is a situation in which professional responsibility and advocacy are challenged. For example, if a nurse has adequate staffing and support during high demand times (e.g., additional help during a patient crisis on a care unit), he/she has the opportunity to establish the patient’s concerns and needs. If this does not occur and he/she does not attend to these patient concerns or well-being, a breakdown in the nurse’s social contract of advocating for the patient has occurred.

Another situation involves notification of the provider if the patient’s condition changes. A nurse discovers a significant clinical change in the patient’s condition, but chooses not to alert the physician in order to follow an informal policy, such as “allow a physician to sleep” or prevent the “physician from being angry about being awakened.” In this instance, a serious breakdown has occurred in the nurse’s professional responsibility and advocacy.

In one example, a nursing supervisor mandated that no phone calls would be made to physicians during the night. The nurse in charge of caring for a diabetic patient did not overrule this irresponsible and dangerous mandate, and the patient suffered serious harm as a result of a delay in attending to a high blood sugar.

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.

As noted earlier, attentiveness (not neglect) and recognition practices (not depersonalization) are notions of good internal to the practice of nursing. They are commonly agreed on and upheld by nurses. A nurse educated to be an excellent nurse can recognize, in most instances, good and poor nursing care, even though it would be impossible to formally list all the precise behaviors and comportments of excellent nursing care.

When nurses recognize substandard care, they carry the professional responsibility to report and/or address substandard care in some manner. For example, in the extremes of the technical worlds of neonatal intensive care units (NICUs), parents, nurses, and physicians struggle with the quality of the environments created for premature neonates. It is never a question of whether an infant can make it on its own.

Astute discernment (phronesis) is required to address three major interrelated goals. The first priority in a NICU setting is to meet and assess the particular infant. Discerning the infant’s maturity and capacities is crucial since maturation rates vary among infants and are more than just a product of size and intrauterine time. The second goal based on this discernment is to place the infant in a particularized technical/human environment that will support the infant while minimizing technological hazards. The third goal is to foster the social, human birthing of the infant. For example, managing discomfort and pain in these technical environments requires judiciously introducing and teaching human comfort and solace in concert with the infant’s ability to tolerate these. Overstimulation can be dangerous. However, social birthing is arrested if the infant does not learn to respond to human touch, comfort, and voice. Introducing these depends on the infant’s capacities and readiness. Physiologic demands exist in concert with the demands that the body/social/world relations are adequate for the baby’s well-being. Thus the premature infant’s survival and flourishing depend on both the human and technical support, just as they do for each full-term newborn infant.

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

The skills of problem engagement and interpersonal involvement require experiential learning and are essential to effective patient advocacy. For example, clinicians talk about problems of overidentifying with the patient and becoming flooded with feelings in ways that disrupt their perceptual skills. Clinicians must learn skills of involvement that prevent overidentification and emotional flooding over patient problems. However, it is also a problem if the clinician walls off feelings so that the possibilities of attunement are blunted or shut down.

The beginning nurse can feel a generalized anxiety over the demands of learning or the fear of making errors. At this beginning stage, dampening emotional responses can lower anxiety and improve performance. But with the gaining of competency, emotional responses become more differentiated. The practitioner begins to feel comfortable and “at home” in familiar situations and uneasy when the situation is unfamiliar. Learning appropriate emotional responses geared to effective nursing care is central to the formation of character and skills of being a professional nurse or learning any professional practice.

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.

A sense of salience, tacit memories of similar situations, and skills of attunement are the sources of discovery and early warnings of changes in patients. Emotional responses and communication skills play a key role in perceiving the other’s plight and in offering skillful responses. Thus professional responsibility and patient advocacy require prior patient attentiveness and engagement and assertiveness on the nurse’s part to make sure that the patient’s needs are attended to in a timely manner.

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.

Informed consent is one procedure developed to enhance the patient’s autonomy. In addition to using formal consent procedures, nurses often coach and teach the patient about the implications and potential outcomes of health care interventions. Informed patient consent is yet another example of the advocacy role of nurses.

Ignoring patients’ requests, abandoning patients by leaving the patient care area without notice, or providing substitute care for patients in the nurse’s absence constitute breakdowns in professional responsibility. Nurses are responsible for assessing when their patient care assignments are unsafe either because too many patients are assigned to one nurse or because of a patient care assignment for which the nurse has no specific preparation (e.g., use of new technology or equipment without orientation). Likewise, it is inappropriate for a nurse to delegate a medical or nursing responsibility to unlicensed assistive personnel if such an assignment is beyond their safe and/or legal scope of practice. These are difficult areas for nurses employed by institutions that may request or even demand patient care assignments that are unsafe for a particular nurse or even for any nurse to perform alone. In investigating such areas of professional responsibility, it is essential to inquire about the nurse’s actions to avoid or to identify whether a patient care assignment is unsafe.

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