BACHELOR OF NURSING SCIENCE WITH HONOURS (BNS)

CLUSTER OF APLLIED SCIENCES ( CAS )

MAY/ 2018

NBHS1204

PROFESSIONALISM AND ISSUES IN NURSING

NO. MATRIKULASI : 901029025948001

NO. KAD PENGNEALAN : 901029-02-5948

NO. TELEFON : 011-26447905

E-MEL : iqmalirfamimi@oum.edu.my

PUSAT PEMBELAJARAN : KEDAH LEARNING CENTRE ( ALOR SETAR)

TABLE OF CONTENT PAGE

Table of Content 2

Introduction 3

Significance of autonomy 4

Current Trend of Autonomy 5-7

Strategies to Enhance Autonomy 8-12

Conclusion 12

References 13-15

INTRODUCTION
 Lately, nurses in Malaysia seem to have lost their autonomy when every practice that nurses
should have done has been taken over by doctors. Not only that, the autonomy of nurses can also
be lost if there is intervene from the patient as well. If we examine the autonomous word itself
shows it is something that affects a nurse's career. Autonomy is not something that cannot be
changed, but autonomy can be achieved when a nurse takes some steps to increase its
autonomous powers. Here are some autonomy definitions in nursing fields. To be an autonomous
a person should be able to formulate and implement his or her own plans or policies. While the
second feature the person should be able to administer one's behavior with rules or values. It
directly shows that to become autonomous is needs to control in one ’s life instead of someone is
personally involved with self-governing individuals and should behave in a rational way and able
to control his or her own freedom and independence ( Downie & Calman,1994). Autonomy also
was known as a self- determination when someone is able to understand in a situation thus make
a plans and choices to achieve goals (Brown et al,1992). Meanwhile, autonomy can be
approached as the way we think and directly act on the situation that we thought how to solve
and we are free in making a decision without involving others (Gillon,1986).

There is two feature of autonomy. First autonomy refers to someone mean to a person while
the second refers to an attitude, mean it is referred to the way we decide and making own
decision. Nursing is undergoing constant stress in many countries. Furthermore, the nurse's
autonomy is linked to socioeconomic, legal and political factors. But today's nurse is
underestimated by the society and the health system. Values placed on nurses are autonomous
pillars. If this value increases then a nurse's autonomy level is also increased. Many nurses now
complain that they are often underestimated. This leads directly to the nurse with no high level of
confidence, mental imbalance, and physical symptoms. Problems in this workplace cause
discomfort in working with nurses and they are inclined to park If this situation persists,
autonomy is not obtained and therefore they will work in a stressful situation. Even the quality of
patient care is also affected.

SIGNIFICANCE OF AUTONOMY
 It is not unusual to know that nursing positions have been reduced and replaced by non-
nursing, generic workers, or nurse-to-patient ratio climbing. Support in various aspects of nurses
is needed to ensure that their working environment not only enables them to practice but also the
resources that are appropriate in doing their job well. It is very important. There are some signs
of autonomy in the nursing profession. Through full control over autonomy in nursing, the level
of job satisfaction among nurses will increase as well as better patient care quality can be
given. Not only that through full autonomy control, nurses will produce a healthy work
environment where satisfaction of work can be achieved (Mark, Lindley & Jones,2009).
Autonomy means the ability of a person to act on the basis of a person's knowledge and therefore
the quality of the care will be given in full scope as specified by the nurse with certain rules and
organizational rules (Westorn,2008). In general, autonomy is required as a compulsion to explain
the relationship between the hospital magnet and the positive effect on the patient (Aiken,
Smith & Lake,1994). After all, autonomy is also linked to the cause of job satisfaction as well as
the retention of the nurse itself (Kramer & Schmalenberg,2004). As stated by Aiken et, al,2008

“When controlling for nurse staffing and education, hospitals with better care environment those
by having more nurses autonomy were found to be associated with significantly lower mortality
rates.”

Increase the quality of

Produce healthy work
Increase patient care
care environment

Achieve satisfaction
Lower mortality rate
of work

CURRENT TREND
 Nowadays there are some examples of current trends that corroborate the autonomy of
nurses. The first trends are that nurses are no longer allowed to make blood transfusion
procedures. This procedure has been taken over by a doctor. When such a situation occurs, then
all the practices practiced by nurses and the procedure goes away. The nurse becomes
incompetent and less confident if it is necessary to re-apply the practice. This practice is one of
the most common autonomy violations among nurses. If we examine the nurse's duty is to take
care of the patient and always be with the patient. If the practice of blood transfusion is done by
the doctor then there will be negligence in the procedure because the patient needs to be closely
monitored during the process the blood transfusion. The doctor also cannot always be on the side
of the patient because it is obliged to treat other patients. It thus clearly shows that in addition to
autonomy violations, the patient's life is also a bet.

Secondly, we find that most nurses are not given priority in interpreting ECG.This is why
doctors underestimate the ability of nurses.For them,the task of interpreting ECG is only feasible
to be done by a doctor to make decisions in treating patients. Most doctors also do not believe
every what the nurse is inform them regarding ECG reading through phones but they are more
likely to come and see with their own eyes about ECG results.It directly drops the level of nurse
confidence as well as assesses the nurses at an inconsistent level. They also consider nurses are
not comparable to them.

Thirdly, the installation of branula is also not given priority to the nurse. We find that
most hospitals do not place priorities for branula installations for nurses. This task is taken over
by housemen and doctors. When admission happens, the nurse's job is to complete the admission
and wait for the doctor to If the condition continues like this, the nurse will lose their skills. The
sooner the job is given priority to the nurse. The doctor can help the doctor in the event of a
condition where the doctor comes late for case clerking. If the doctor does not have time to make
the installation, the nurse can also help and further implement any care plan that has been
directed by the doctor.
 Fourth, autonomy in making decisions to administer inotrope. Patient which are critical
in the medical ward and ICU are always given inotrope. In Malaysia, nurses do not get autonomy
in raising or lowering the number of inotrope readings given to patients looking at the current
situation of the patient. This situation is very different compared to the nurses working in Saudi
Arabia where they are given priority in making decisions whether to raise or lower according to
the condition of the patient. In Malaysia this kind of duty is only performed by doctors and
nurses is just as instructed by the doctor in performing each action. If this condition continues the
nurse cannot think critically about making results according to the patient's situation.

Fifth, autonomous examples in overseas midwifery. They play a role in assisting pregnant
women to decide on how to give birth to their child. However, the situation is where the mother's
autonomy is lost because there is a policy which did not justify their birth by water birth who
refuse to make HIV or hepatitis b and c tests (Magillcuerden,1996). However, there is an
acknowledgment of the growing need for patients to be empowered by their midwives to decide
on childbirth. The midwife needs to face the challenge The problem is that the midwife has little
power to become autonomous in the health profession as they have no confidence in their skills
to give their patient choices. They also face the difficulty of playing their role as an advocator
because of the power struggle between midwifery and obstetricians. If she wants her patient
to decide, the midwife should have an autonomic level first.

Sixth, another example of a nurse's autonomy is taken over by family members or

patients themselves. One of the scopes of the nurse's job is to care for patients to achieve good
health and to provide quality care services. In this case, nurses are entitled to decide how and
how to treat patients. Not all decisions and methods are agreed upon by family members or
patients themselves. For example, patients do not want to take medicines that have been
instructed by the doctor. The nurse helps in giving the medication either through oral or
injection. There are also patients who refuse to treat.In addition, family members also play a role
in disrupting the autonomy processes of nurses. They often do not follow instructions for
example when in ICU. They are in default and continue to visit mass patients. every act of nurses
to conduct the job is in ICU or in the medical ward. Thus, this kind of thing can disturb the nurse
as long as they do the job. So the nurses do not get satisfaction in working and the quality of
patient care is also affected.

The last example is the situation where a nurse thinks deeply to make a decision. For
example, the situation in CCU (coronary care unit). There is an ischemic heart disease patient
and the nurse cares for and treats the patient. The patient is unconscious and collapse and cardiac
monitor show ventricular fibrillation. As a professional nurse, the nurse uses her professional
level to assess the patient and decides that the patient is suffering from cardiac arrest. The nurse
also makes a decision to provide an advanced life support procedure such as CPR and put the
defibrillator as the scope of his assignment as a trained nurse who specializes in the field. Then,
the cardiac arrest team arrived due to the nurse's request and the patient's rescue procedures were
continued. The nurse followed the doctor's instructions in the intravenous prescription but a
barrier occurs when a medical registrar proposes to stop during the defibrillator process to
continue the rescue of patients with CPR as he is aware of the current situation (European
Resuscitation Council,1992).

STRATEGIES FOR ENHANCING AUTONOMY AND CONTROL OVER NURSING

PRACTICE
 Strategies For Strategies For Enhancing
Enhancing Control Over Nursing
Autonomy Practice

Clarify Expectation About Clinical

Autonomy
- Describe expected behaviors
- Embedded nursing knowledge into clinical
practice processes
- Recognize and reward autonomous practice
-Role model expected behaviors
-Provide manager support for autonomous
process
Enhance competence in
practice
-Create a learning environment
-Enable formal and informal
educational practice
Establish Participative Decision
Making
-Used an organized structure for
nurse participation in decision
making
-Ensure authority for clinical
decision making resides with direct
care nurses
-Include nurses on organizational
comittees
-Minimize bureaucracy
-Support involvement by nurses on
comittees and workgroups
-
Enhance Competence In Decision
Making
-Teach nurses about decision
making process
-Coach and support nurses
through early decision
-Teach facilitation skills to leader

STRATEGIES FOR BOTH AUTONOMY AND CLINICAL NURSING PRACTICE

 Create strong,visible,nurse leader
Ensures that nurses in supervisory
position are encouraging autonomy
and clinical nursing of practice
Encourage new and innovative
ideas

Ensure Strong Nurse

Influence Leader
social,political and
economic factors

Work Publicly
Upstream
expertise
describe nursing's unique
and contributiom
Acknowledge nurses contribution
in all roles and practice settings

The first strategy is to explain the expectations for clinical autonomy. Professional and
organizational bodies support in the application of nurse knowledge and skills that specialize in
patient care by enhancing the autonomy of nursing practice (Kramer & Schmalenberg,2003).
Autonomy can enhance if the nurses practice clearly communicate and organize their work
properly. Thus this can ensure the nurses have a freedom when act on the nursing decision and
clinical judgment.T his will encourage nurses to make a decision by describing the expected
behavior and encourage them to make an action based on the science and the art of nursing
besides,nurses also should be an independent when making a decision within the scope of
nursing practices.Nursing practice has two feature which is an independent and interdependent
action that need the nurses to identify response based on a situation that needs the nurses to apply
an action that helps in the process (Steward,Standsfield & Tapp,2004).For examples, nurses can
make an identification regarding outlining the expectation of physician order through verbal
make a protocol when it comes to over the counter medicine. Moreover, Even the degree of
autonomy in clinical practice can affect the quality of patient care with the knowledge used. For
example, a nurse is given an autonomy to provide patient care and to make a round during the
ward. This is directly the nurse knows the person's personality and strength. Not only that the
relationship between the nurse and the patient can also be improved (Manojlovich,2007). There
is also a study conducted where support in nursing practice from the nursing community can
increase the level of a nurse's autonomy. For example, nurses working in major hospitals are
more likely to receive nurse supervisors who provide much support in clinical decision-making
than nurses working at district hospitals (Upenieks,2003). Due to the support is given to the
nurse in making decisions then it is possible to be risky but it is safe at the same time
encouraging nurses to practice innovative and autonomous practices can also be improved.

Secondly, need to increase the level of competence in nursing practices. By developing a

strong clinical assessment level in autonomous practice it is imperative that a combination of
knowledge and prolonged experience skills (Jasper,1994). Therefore, by seeking a strategy by
increasing the level of competence required by creating a learning environment, it can create
autonomy among nurses. According to them, it is reported that autonomy can be formed by
enhancing competence and confidence through several strategies including conducting round
teaching, continuous formal learning, and learning based on inquiries in daily nursing practice
(Steward, Standfield & Tapp,2004). Furthermore, encouraging practice assessment continuously
can contribute to the assessment of autonomous presence in the nurse as they make decisions.
This is because by practicing evidence-based practices it can help in the development of
autonomy. By creating an atmosphere of formal and informal learning can enhance the
autonomous in clinical practice (Blegen et al.,1993). Furthermore, there is a study that nurses
who have skills in a particular area or area of specialty form high skills when performing their
duties in patient care. These skills are very helpful to develop skills and competencies in
supporting autonomous practice (Fricsson, Whyte & Ward,2007). As stated in Mryyan's study,
support from management, education, and experience are three key factors that contribute to
increased autonomy in patient care as well as surgical units (Mryyan,2004).

Third, nurses need to take part in decision making. Most nurses act as employees by
following certain instructions can directly affect their practice (Hess,2004). To have full control
over their practices, nurses need to have both these important elements of the right and authority
in making decisions in their overall practice. Nurses should also create and use decision-making
structures in an organization, group work and practice with practice professional level. In
addition, the nurse's participation in the decision-making structure goes hand in hand with the
communication process as well as contributing to the move to improve nursing practice (Kramer
& Schmalenberg,2003). Usually, nurses act as workers with a broad structure and the health field
itself. Nurses need to have a formal structure in joining systems and organizations when making
decisions. For example, nurses need to be included with physicians and doctors as a team in
developing patient care policies and procedures. Such expectations should also be given to
nurses in expressing their opinions and they are also responsible in making decisions on patient
care (McKay,1983). In addition, through other organizational structures as well as nurses can
make programs and resource-making decisions without going through bureaucratic layers that
make implications such as innovation and implementation. So to control the practice of nurses
should have an influence on the proper resources and have policies for their practice
(Hess,2004). Therefore, nurses need to ensure that they and their colleagues can influence both
where and at the time when key decisions are made that will affect the scope, nature, and context
of their practice.

Fourth is to increase the level of competence in making decisions. Competency in decision

making can be achieved by nurses if they are constantly given ongoing education. Not only that,
there are also nurses who continue their education to a high level and thus increase their
autonomy in decision making. Head nurses regardless of any part such as management, clinical,
learning or research positions can be taught about facilitation skills to enhance their ability to
form discussions that contribute to the identification of the group which is efficient without
dominating discussions and making decisions. Even so by teaching a leader to issue opinions can
also help in finding solutions to a problem. Hence nursing practices can enhance the strategy by
ensuring the participation of nurses that are key in organizational structure. This is because most
nurses have less experience so continuing education can increase autonomy among nurses.
 Lastly, the role of the Head of Nurse is needed as a step towards enhancing autonomy
among nurses. The head should be visible nursing leadership in the nurses' section to increase the
level of autonomy (Hinshaw,2002). This is because they show influence affecting nurses in
decision making (Taunton, Boyle, Woods, Hansen & Bott, 1997). There is a clear study stating
that nurses are only a doctor's handmaiden (Buresh & Gordon 2000). They also do not consider
nurses to have a high value in contributing to healing the patient( Gordon,2005). Hence the role
of the chief nurse should be played in order for others to look at the nursing profession. When a
nurse is on par with a doctor, the doctor will not dare to discriminate between the nurses and the
nurse's autonomic powers cannot be taken over by them. Nurse Manager should always support
and support each other.

CONCLUSION

In conclusion, autonomy is the power of the nurse, it is also not an authority to be dominated
by some other parties. Autonomy in the field of nursing is also full of unique knowledge and
competencies for patients and an organization. These two complement the practice of nursing by
giving a positive impact on the quality of patient care. By establishing a strong nursing
organization, it can improve nurse's autonomous power and also have a significant impact on
many nurses on their nursing practices as well as health and work environment are in good stages
as well as work satisfaction is also attainable. Thus, all nurses should do something to improve
their autonomy by practicing the above strategies because through autonomy people will respect
nurses and value nurses is the best caregiver to patient.

(2945 words)

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