The policy discourses of patient autonomy in home care and the re-shaping of nurses’ professional work and identities

Abstract

Introduction: Over the last decade, new health care policies are transforming healthcare practices towards independent living and self-care of older people and people with a chronic disease or disability within the community. For professional caregivers, such as nurses, this requires a shift from a caring attitude towards the promotion of patient autonomy. The aim was to explore how nurses in home care deal with the transformation to fostering patient autonomy. The research questions included: How do community nurses perceive the required changes in professional knowledge, skills and attitudes in promoting self-management of patients and their families? What challenges or dilemmas do they encounter and how do they cope with these? Answering these questions provides insight into the changes in professional work practices and professional identities and the ways practitioners cope with these changes, learn from and develop their own practices. Methods: A qualitative case study was conducted in community care Yin, 2013. The ‘case’ was a professional development project for community nurses, funded by ZonMW, aiming to increase nurses’ professional knowledge, skills and attitude to support autonomy of clients and their social system. Data were collected by the researcher as participant observer of the four meetings of one professional development group. Reflective notes of the observations were taken before, during and after learning circle meetings. A narrative analysis Riessman, 2008 was conducted on these data and three main themes constructed. Theory: The theoretical notion of ‘relational agency’ Edwards, 2010 and the moral concept of ‘practices of responsibility’ Walker, 2007 were used to conduct a narrative analysis on the nurses’ stories about patient autonomy. Findings: Three main themes expressed the moral demands experienced and negotiated by the nurses: adapting to the person; activating patients’ strengths; and collaboration with patients and informal caregivers. The overarching challenge the nurses face, is creating an equal partnership with clients and family members. Discussion: On a policy and organisational level, the moral discourse on patient autonomy gets intertwined with the instrumental discourse on health care budget savings. This is mirrored in the nurses’ ‘stories of ambiguity’: the turn towards autonomy in healthcare raises moral questions about responsibilities for care. Conclusion: Each of these tasks has troublesome elements and presents challenges and ethical dilemmas for the nurses, resulting in shifts in professional identity and practice. Promoting patient autonomy should be a collaborative endeavour and deliberation of patients, professional and informal caregivers together. Lessons learned: The ‘relational turn in expertise’ Edwards, 2010 requires long-term coaching of individual practitioners as well as teams, and a culture change in healthcare practice. Co-education of nurses, patients and informal caregivers is needed to achieve this goal of promoting patient autonomy. Limitations and suggestions for future research: additional in-depth interviews could have added to the insight into dilemmas and tensions in practice and in nurses’ coping strategies. More research is needed into the conversations and co-actions within patient-family-practitioner partnerships: the relational dynamics of making decisions, establishing connections and breaking them, negotiating responsibility and creating trust or mistrust.