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Gómez-Torres D, Hernández-Cortés GG, González-Santana A. [Nursing process as developer of professional autonomy]. Rev Enferm Inst Mex Seguro Soc. 2016;24(3):183-9.

Nursing process as developer of professional autonomy

Danelia Gómez-Torres,¹ Gabriela Guadalupe Hernández-Cortés,² Araceli González-Santana²

¹Universidad Autónoma del Estado de México, Facultad de Enfermería y Obstetricia, Toluca; ²Instituto Mexicano del Seguro Social, Hospital General Regional 251, Metepec. Estado de México, México

Correspondence: Danelia Gómez-Torres

Email: gomezdanelia@usa.net

Received: April 24^th 2015

Judged: November 25^th 2015

Accepted: March 8^th 2016

Abstract

Introduction: The autonomy of the profession based on the nursing process (NP) is addressed therefore its epistemological construction is reviewed, projecting the topic in two perspectives: centrality in the nurse and in the patient.

Objective: To show the construction of the professional autonomy through the Nursing Process. The study scenario was a tertiary hospital; four nurses participated applying the process.

Methodology: Combining qualitative approach, action research and case study method of Mckernan was used applying the twelve steps rigorously.

Results: The nursing process is a developer of professional autonomy, as the clinical judgment and proactive defense to the patient were fundamental bases being present as components in various stages.

Conclusions: The NP generated in the participants a change in the perception of the process itself, enabling them to act in partnership with the patient, being able to transpolar from a basic level of attention to the construction of a more complex and committed attention. It also led nurses to stop inferring in the use of medical diagnosis.

Keywords: Nursing process; Professional autonomy; Hospital care; Clinical nursing research

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Introduction

The approach to and construction of the concept of professional autonomy with an epistemological basis, reflects the complexity of the study of autonomy, as the diversity of concepts brings opposing views, and bears fruit in research. The topic can be projected on the centrality of the nurse. Nurse autonomy¹ is the faculty that a person has to determine their own rules within their profession to control their professional activities in the field. To the extent that the nurse has taken charge of care as their primary intention, there are theoretical arguments able to shape their autonomous and non-delegatable function.

To describe autonomy in the areas: decision making, independence, clinical judgment and responsibility, Kramer² analyzes the components of professional autonomy and sees the proactive defense of patients. They see care as an interdependent, nurse-patient relationship. Clinical judgment is significantly linked, and thanks to this, nurses act independently among other disciplines. The profession seeks to collaborate with different disciplines to benefit the patient. Similarly, clinical judgment paves the way in making clinical decisions to support the responsibility of the nursing staff.

In recent years, Mexican hospitals have managed the integration and application of the nursing process (NP). As a result, weaknesses have been identified in its execution, perhaps because it is viewed with a high degree of complexity. With an epistemological view of the nursing profession, there is a proposal to use the NP, with its scientific basis founded by the International NANDA, the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC), to show how nurse autonomy is constructed during patient care and to discover the most relevant obstacles to implementing the NP in the clinical setting.

Methodology

The research was conducted with a qualitative approach from the particular observation of theoretical generalization to solve everyday or immediate problems, improve specific practices, and focus on providing information in decision making for programs, processes and structural reforms.¹ With support from McKernan's case study,³ which uses twelve stages, this type of method is to learn about a complex instance, based on its comprehensive understanding as a whole and its context, using data and information obtained by descriptions and extensive analyis.⁴

To tacitly reflect the development path of the investigation, the first part is about what distinguishes the author, followed by the application of the research method, as shown below:

• Define the unit or case:  nursing and service staff on the fourth floor, in the women's area of the study hospital, were chosen to participate.
• Define the nature of behavior:  to identify autonomy exercised by the group of nurses in the workplace with the application of the NP, taking into consideration the characteristics that define professional nursing autonomy.
• Characterization:  The team was composed of four nurses. The criteria for participation were:  nurse directly attends to patients. To comply with the anonymity required by law, they were assigned names E-1, E-2, E-3 and E-4. E-1 is the department head, a specialist in psychiatry and management, with 24 years' experience and 2 years in the department. E-2 is an operating general nurse with 20 years of experience, currently enrolled in an undergraduate nursing degree program. E-3 is an acting nurse researcher, and E-4 is a nurse researcher, interviewer and observer.
• Exemplary case studies read in advance:  Among the previous studies are Castillo⁵ and Arenas Fernández,⁶ who are characterized by trying to discover, understand, interpret, analyze, report, evaluate, diagnose and resolve a specific topic. These studies also make use of the research-action model and aim to improve a particular practice.
• Admission into research environment:  Access to the unit was officially authorized, following the requirements established by the institution. The research protocol was approved by the nurse coordinator at the teaching hospital in question. Collaboration of operational service staff was on a voluntary basis, which appears in the informed consent document, so it complies with the ethical conditions that Ley General de Salud Mexicana for Research, Chapter One, Article 14, Fraction V, and Article 13 lay out:  in any investigation in which humans are the subject, respect for dignity and the protection of their rights and welfare shall prevail.
• Development of a research plan:  The research plan was implemented over a period of two months as follows:
  • Presentation of the research project to nurses E-1 and E-2 for approval and views on their participation.
  • Presentation of the proposed study on NP implementation to a patient, in order to approach the professional autonomy of nursing.
  • Project implementation with the nursing team applied NP methodology with attachment to the NANDA taxonomy, NIC and NOC to a staff member with new entry; E-4 used an observation guide and field diary to record and analyze the elements that make up the two types of autonomy: patient-central and nurse-central (both discussed in this research).
  • Action or application by NP:  When the data for analysis were obtained and the type of autonomy generated by the nursing team (with the implementation of the NP) was determined, the data were discussed.
  
  
• Approach of the hypothesis:  Three conductive questions were raised. What kind of autonomy did the nursing team exercise (with the application of NP attention to a staff member)? What are the main difficulties encountered by the NP practicing in the clinical setting? What are the easy things about the NP practicing in the clinical setting?
• Review of related publications:  The concept of autonomy in nursing in 1999 Wade⁷ points to an autonomy based on the centrality of the client. Years later, MacDonald⁸ points to a relational autonomy, which relates the nurse's autonomy to the patient and other professionals. Both authors relate nurse autonomy to the patient.
  However, Mulero,⁹ in 2003 highlights the autonomy of nursing as an independent act, assuming control over their work. In 2005, Tapp, Stanfield and Stewart¹⁰ conceptualized it as an indicator of professionalism, which is directly related to staff satisfaction. Jara,¹¹ in 2009, portrays it as that degree of effectiveness of control the nurse has over their practice. Clearly the authors’ approach is focused on the actions of the nurse, in contrast the approaches of Wade and MacDonald.
• Enumerate research methods:  The use of the nursing process was proposed to search through professional autonomy exercises in nursing, so the stages of assessment, diagnosis, planning, implementation and evaluation of the NP were made with strict adherence to the NANDA, NIC and NOC taxonomy. User/staff member focus was on teams. A working folder was drawn up, where documents evidencing non-participant observation and application of the NP were filed.
• Data collection and systematic recording:  An observation guide structured by four items was used. The first consists of seven variables with the components of the two types of autonomy, each with its own characteristics. The second item is the narrative explanation or speculation presented in the episode. The third item is the account of other involved professionals' arguments. The fourth item is for collecting data and additional research. E-4 was responsible for handling the instrument, as well as recording all of the data in the record of institutional identification and registration of episodes of the participants in the place of observation. The guide is complemented by the field diary, which captured feelings and beliefs at the time they occurred, thus providing a mood dimension to the human action.³
• Start of formal data analysis:  Professional autonomy was analyzed and discussed according to Gorajek-Jozwik’s¹² centrality of the nurse as well as Wade’s patient centrality,⁷ each according to their components -- professional  autonomy and centrality in the nurse; centrality in the patient, clinical judgment; responsibility; independence; decision making; care in the nurse-patient relationship; making responsible, discreet decisions; interdependence among colleagues; and proactive patient defense.
• Provisional case report:  The report is built based on the results, deriving considerations to improve autonomy in the discipline, showing a portrait of autonomy in practicing nursing staff, as well as aspects that favor or hinder the practice of nurse autonomy.

Results and discussion

The nursing process is considered the proper method to make explicit the essence of nursing. Its scientific bases, technologies and humanist concepts encourage critical thinking and creativity, allowing practical problem solving.¹³ This method was associated with the following results:

Care, nurse-patient relationship

Also called relational work,¹⁷ it exists as a general rule, establishing itself as good, and not valued as the process of skill and efficiency. However, Defrino¹⁴ and Daza¹⁵ agree that today there is a departure from professionals’ vision of care as a nurse-patient relationship.

With the application of the nursing process, this relationship was built, at all stages, as this example shows:  Before the assessment interview begins, the head nurse, operating nurse, and nurse researcher, and the user did a team-building exercise.

The operating general nurse says that a form is quite extensive. We must work in the interest of the patient so they do not get bored, to obtain more data. We answer questions from the patient, as she looked interested, we requested the opinion on her habits and health problems.

At the end of the assessment with the patient Romina, she recognizes the operational nurse (E-4) and the research nurse as helping people. E-1, E-2 and E-3, performed direct interventions with the patient. Romina identifies nurses as "helping me with my anxiety."

Both the nurse and the patient play an active role in comparing the actual responses of the patient to the desired result, because between the two, they identified the responses. The participant recounts the relationship with the patient in the evaluation process; analysis of the results with the patient worked with self-analysis to recognize the progress that happened or did not (E-4).

As there is patient participation, nurses associate it with interventions, no longer seeing the patient as an end. Therefore, care is characterized by the ratio of aid to the individual, family and community groups in order to promote health, prevent disease, promote rehabilitation and pain relief.¹⁵

With interventions related to the issue of relational nursing work, a reality that exists is articulated, but not seen. It is the consciousness of this reality that leads to the discovery that nurses have professional power. The application of the NP not only promoted care as a nurse-patient relationship, but nurse autonomy also became evident, since it reflected the relational work when they achieved therapeutic results, which coincide with the idea that knowledge of this reality leads to the discovery that nurses have professional power.¹⁴

Making discrete, responsible decisions

This is found in all stages of NP, but the planning, implementation and evaluation stages have significant evidence, as recounted below:

Considering the pharmacotherapy prescribed by the psychiatrist, nurses plan a teaching intervention:  prescribed medication (5616), and carry out activities to inform the patient of the drug name, prescribed dose, dose schedule, administration method, side effects, importance of therapeutic monitoring, and care in handling.

The planned intervention is carried out with the patient and responsible guardian. The information provided to the responsible guardian included the results for which no improvement was achieved, and it was explained that they would have to make changes in the care plan (E-4).

Interdependence among colleagues

Another feature of autonomy is where nurses must meet their professional role together with the rest of the multidisciplinary team, achieving benefits for the patient, because the position of relative power between medicine and nursing has changed, articulated as a colleague relationship.¹⁶

Evidence of interdependence among colleagues is described by the following: E-2 and E-3 both associate misperceptions with delirium. The psychiatrist also detects delirium associated with misperceptions. The psychologist noted: "The nurse records provide depth and a base of very useful comprehensive data" (observation).

The doctor prescribes sennosides AB for a diagnosis reported by nursing, with risk of constipation, and nurses choose to include constipation management and intestinal training in the intervention plan. Among the nurses and the doctor, they decide to first follow the nursing plan, and if the problem persists, proceed with the prescription (observation).

In the performance of the health team, records report for the NOC indicator: managing anxiety levels, nurses work with relaxation techniques (laughter therapy); the psychiatrist manages anxiety pharmacotherapy (Clonazepam 4 mg in 24 hours) and psychotherapy; the psychologist, with confrontational therapy (observation).

Nurses assessed improvement in the response of anxiety self-control, because as the indicator absence of manifestations of anxiety behavior initial value was 1 (never shown) and the result achieved was 4 (often shown). The psychiatrist assessed the improvement in patient anxiety and reduced the Clonazepam dose to 2 mg daily. (E-4)

In all stages of NP, synchrony was shown in the nursing interaction with other health personnel, as well as interdependent work to fulfill their professional role, as patient outcomes emerge from a collaboration between disciplines complemented by a common goal. It is true collaboration as part of an ongoing process, and not an event, which must be built over time, the result of a work culture in which communication and joint decision-making between nursing and other disciplines becomes the norm.¹⁷

Proactive patient advocacy

The nurse is in the ideal position among health professionals to experience the patient's humanity, with individual strengths and beliefs, and to use this position to intervene in favor of the pacient.¹⁸ Proactive patient advocacy is outlined below:

The nursing sheet is the guide to include in the assessment of the patient's preferences. For example, in the coping/stress tolerance pattern, it was ascertained that the patient is interested in reading and music, so she asked for help with these activities during hospitalization (E-4).

The same patient is accused of aggression directed toward another staff member. The psychiatrist prescribed medication and four-point restraint. The operating nurse argues with these orders: "I firmly believe that it was not her, as I observed how she controls impulses. Before she has been bothered, and she does not respond to provocations." Before following the order, the nurse proposes that the doctor examine the patient, who denies having assaulted the staff member, and later the staff administrator confirms this version, upon which the prescription is suspended (observation).

The nursing team dealt with exploring wishes and preferences, in addition to identifying problems and health risks, to act for the patient. As a result of this process in the implementation phase, and this component is highlighted and clarified:  analysis of the episode, the nurse observed, evaluated the results in the patient, and took action. They had elements to defend their position with the doctor. Here their relationship is revealed, human responses can be identified, and we can assess how the nurse improved the circumstance. As an ethical foundation, the duty of care is a principle of autonomy, so it was decided to dig deep before taking an unsuitable action. However, that autonomy directed at the proactive defense of patient could be threatened by a hostile hospital environment to the detriment of rights.

Evidence with the nursing process

The implementation of the nursing process is denoted in the execution stage during the praxis of planned care. The professional relationship with the health team is established, and the interest shown by nursing care in joint treatment decisions with the psychiatrist and the psychologist, who in turn formed a relationship with the patient based on affection and trust.

What distinguished the personnel involved was that the patient identified the nurses for their care actions. In turn, the nurses felt a satisfaction with their commitment to the patient and their work, as reported by the nurse: "I maintain that I did what I had to do.”(E-2). As far as the ability to manage the NP, they had to redouble efforts to meet the requirement of the method, and invest non-work time to understand, correct, and study the instrument.

In the area of clinical nursing, difficulty was seen in the development of NP, specifically in the use of diagnosis, because historically they work with and know about medical diagnoses, not the NANDA taxonomy, as confusion was observed on several occasions in the construction of nursing diagnoses.

Other obstacles are related to the professional approach to nursing and responsibilities in the institution, because they are not directed towards the implementation of the method, and implementing it caused difficulties in the records. Finally, nurses recognized that the implementation of NP offers theoretical support, security, and confidence, and projects professionalism.

Conclusions

Professional autonomy was demonstrated through NP implementation, where clinical judgment and proactive patient defense were the pillars of autonomy in decision-making, because clinical judgment links and gives rise to components of the two perspectives, proactive defense is the result of a combination of the other components.

Moreover, research-action was a flexible method, because it allowed us to identify the problem and then gave us the flexibility to test the proposed change. In its spiral form, each cycle allows the use of research results to provide continuity with new goals, resulting beneficial not only in planning the action that will solve the problem, but in implementing and assessing the impact obtained from the designed proposal.

The participants learned that when applying NP with a base of knowledge to make decisions and take actions, it gave them the possibility to act with the patient and strengthen autonomy, instead of using predetermined interventions. The application of the NANDA taxonomy led the nurses to stop inferring with medical diagnostics and exercise professional care and clinical judgment, evidence of person-centered nursing.

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