Emancipatory reflection on a nursing practice-based ethical issue about nurses'paternalistic decision-making for patients

Lian-Lian Tang*

Department of Nursing Administration, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei 066000, China

Abstract: Objective: This study aimed to demonstrate and promote the skill of critical emancipatory reflection through reflecting on a nursing practice-based ethical issue about nurses' paternalistic decision-making for patients. Meanwhile, critical awareness will be developed and the underlying issues of paternalism in nursing decision-making will be analyzed. Then, by applying the procedure, improvement in nursing decision-making practice will be expected.Methods: Taylor's model of emancipatory reflection with four steps, including construction, deconstruction, confrontation, and reconstruction, is utilized to guide the author's reflection.Results: Guided by the socialization theory, the author's personal and professional socialization is seen to be associated with the formation of the value of paternalism. The theory of reflexivity is applied to unearth the related issues, including deeper personal value,work environment, as well as historical and cultural contexts. Moreover, the power derived from policy, work relationship, and nursing administration, which could induce paternalism in the author's nursing decision-making practice, was critically debated using the hegemony theory. Finally, new insights into paternalism will be achieved, which enable change in terms of how to facilitate patients'autonomous decision-making.Conclusions: The process of refection makes it clear that respecting patients' right and performing patient-centered caring are the bases to change the paternalism existing in the nursing decision-making practice currently. The reconstruction step assists the author in terms of how to value the patients' autonomy and balance patients' safety and choice, rather than being overprotective; carry out risk assessment, and search for strong evidence to counterbalance the positive and negative aspects of risk-taking; communicate with patients appropriately in a manner that they can comprehend; spend more time to explore patients' preference and choice; make every effort to elevate the patients' decision-making capacity; implement patient-centered care and shared decision-making in nursing practice; consult with other colleagues and obtain the required support when limitations or challenges exist; try to justify and avoid hidden paternalism behind policy or guidelines; deal with the power in hand well and fairly; and also positively face the powers that constrain the author.

Keywords: reflection · paternalism · critical emancipatory reflection · Taylor's model · decision-making · nursing ethical issue? Shanxi Medical Periodical Press.

1. Introduction

This paper arose from the experience of the author, a Chinese nurse who studied in Ireland and experienced the clash between Oriental and Occidental nursing assumptions. In Irish nursing education and practice, critical reflection has burgeoned over a few years.1It has been recognized as a theoretical method and process for analyzing and transforming practice.2Meanwhile, in the module of Ethics, the author encountered a fresh phrase “paternalism in nursing decision-making”, which has never been recorded in her nursing practice before. Then, a considerable amount of thinking and research were undertaken by the author. When the author comprehended the related connotation, she was shocked by her previous paternalistic style of decision-making, which actually breached patients' autonomy in work but was rationalized by her thoughts of guaranteeing patients' safety. Therefore, the author utilized the skill of critical reflection to reflect on this widespread ethical issue in Chinese health care but with little attention by Chinese nurses.

Paternalistic nursing practices, wherein nurses confer a treatment or service upon a person without his/her consent, ostensibly due to reasons of limited autonomy or diminished capacity, are widespread in the healthcare setting.3Numerous issues surround it. In this study,the author examines these issues through the medium of reflective writing and discussion.

2. Methods

The whole process of this reflection and writing will be generally guided by Taylor's model of emancipatory reflection with four steps, including construction, deconstruction, confrontation, and reconstruction.4First, in the phase of construction, the author captures the essence of paternalistic decision-making in nursing practice. Then,she deconstructs it as a detached observer through review of the related values and beliefs. The theories of socialization,5reflexivity,6and hegemony7-9are adopted to underpin the reflection and help to understand her individual practice, social context, and relationship between both. In the third phase, a critical view is taken to confront and challenge the author's own basic assumptions,even those of the society. Eventually, a new awareness is reconstructed and in the light of the remolded assumption, how to change the practice infuture is clear.

3. Results

3.1. Describe

I have been a qualified nurse for 11 years in a tertiary hospital in China. I had never realized my paternalistic behavior in nursing practice until I learned the module on ethics during my Irish course on Master of Science in Nursing (MSN). In my previous experience, it was ingrained in my mind that the responsibility for ensuring patients' treatment and recovering their health is far more important than respecting patients' autonomy.I was so overprotective that I implemented some selfrighteous safety measures on clients under the condition of interference with their liberty or autonomy. When I learned that my action is a pattern of paternalistic conduct in health-care setting10and that paternalism is an ethical concept contrary to autonomy11and is criticized by scholars, I was shocked. I perceived that my previous nursing service was filled with paternalistic behaviors. For instance, I traditionally put bedrails on the patients' beds without asking for their consent;, several studies even demonstrated that having the side rails up could not reduce falls.12,13The decision was only implemented due to my own thought that it might prevent them from the potential harm of a fall, although the incidence was identified to be very low in numerous research works. I had tried my best to persuade patients to accept some treatment even when they were not happy or could not afford it. I did not respect patients' autonomy well.

3.2. Inform

According to Taylor's guidance, I stood away from my action and looked at myself with the eyes of an interested observer to look for the stimuli4that pushed me to act with paternalism. It seemed that I acted in a paternal role due to my belief that nurses are virtuous and have authority over the patients in the ward.14I might consider that the patients are not wise in the medical field and that they often do not know what is right or which is the better choice. From this viewpoint, I felt that whatever I did for the patients from my professional experience and personal goodwill was in their best interests. I took it for granted that patients should accept my decisions. Moreover, due to my heavy workload, the time-consuming process of communication to obtain their opinion was not considered essential or it could be overlooked.

Additionally, I realized that I took the view that science came first, rather than ethics, in the health-care industry. I believed that health-care professionals should provide service according to scientific guidelines first. As for ethical principles, they are just largely a formality. This opinion also showed that I hold the diseaseoriented nursing idea. I did not look at the patient as a whole person but as a disease. Thinking deeply, I consider that my nursing work was restricted by many social factors. There may be some power to force me to act paternalistic to some extent.

3.3. Confront

I was aware that the formation of the paternalism value was associated with my socialization process, in which family was an undoubtedly essential factor.15I think it has been embedded in my head when I was a child.From my childhood to adolescence, I followed my father's advice without any disobedience. In my eyes,my father had more knowledge and life experience, and I believed his decisionfor me was wise and beneficial.16I had to respect and accept the decision that my father made for me, even if sometimes I was not happy. Moreover, in memories of my childhood, when I was ill, my family members and I obeyed all the orders of the nurse without any doubts. Once I was a patient in a hospital,I respected and complied with the words of the nurses devoutly. Thus, I was socialized in the early of my life that in a relationship, the person who is more knowledgeable has the power of making the decisionfor others, while whoever is less knowledgeable should obey the more knowledgeable ones.17It was embedded in my mind that the decision-making right of those who are considered unwise would be unappreciated. Similarly,iextended to my work the belief that patients should accept the orders and decisions made by nurses who have more professional knowledge and experience than them.

Moreover, education was another prominent attributable factor for the formation of paternalism in my professional socialization.15Socialization is a process whereby I learn to behave in accordance with social traditions and mores.15When I studied nursing in the medical college,nursing was regarded as a subject of science regardless of its philosophical nature. The modules related to science , such as biophysics, biochemistry, anatomy, and so on, comprised our main lessons; no subjects related to nursing ethics or philosophy were included, which would enlighten me and modify my professional ethical values.18I was socialized in the education paradigm that science has more power than humanity and philosophy19in the nursing field and that nursing decision and intervention should be determined by science first rather than by feelings or wishes.20,21Professional education did not guide me to respect service users' preferences and choices. Conversely, it provided paternalism a scientific mask and made me neglect the clients' feelings and wishes in my practice.3

Furthermore, my work experience, especially, the influence of my workplace, played a very important role in the process of my professional socialization5to form a paternalistic attitude. According to Rajendra and Rachana,15people can have an impact on each other through imitation, suggestion, and sympathy. Paternalism is very popular in the Chinese health-care setting.22In my workplace, most nursing work is performed in accordance with the nursing routine, such as using bedrails for every patient in the intensive care unit (ICU).3The nursing plan was usually made by the nurses without the participation of patients.23These routine actions often resulted in my neglecting the consent of patients.Moreover, owing to the limited nursing human resource,nurses are very busy at work. I would not like to spend time on communicating with patients and their families the available options to ensure that their decisions are informed. Obviously, the work of talking with patients cannot result in any direct benefits in terms of economy for the hospital. Less-informed consent work can save time cost and reduce my workload to some extent,which can promote my efficiency and earn more money for the employer.24The climate of the hospital not only fostered my paternalism assumption but also forced me to execute it.

I was aware that my disease-centered value induced my paternalistic action. The theory of reflexivity25-27provided the evidence that my paternalistic action was associated with my personal value. Disease-centered value seemed to be the strongest belief in my mind. The disease-centered belief resulted in the situation that more attention was paid to patients' health recovery and safety guarantee rather than to patients' autonomy.28,29I have never facilitated patients' choices when some limitation existed: for instance, if I judged that the patient was not very conscious, I often gave some safety measures directly without performing additional assessment or asking his/her opinion. I was overprotective in my nursing work rather than balancing patients' rights, risks,and the responsibility for both. Any strategies that are able to better cure the disease and protect the patients'safety will be adopted and the patients' opinion to disagree remains enfeebled.30Although the organization advocates patient-centered care,31the effective implementation of measures that ensure that this value is actualized was not carried out. The busyness of nursing work and a shortage of nursing staff32made me struggle to finish my tasks, with little energy remaining to make an effort to promote patients' decision-making capacity.Moreover, because of my introverted personality, I was not good at communication with others. I realized that I did not communicate appropriately with clients in a manner that they can understand and explore what is important for them, to promote their preference.30

With regard to my historical and cultural contexts,both the Chinese traditional medicine history and international nursing history played an essential role in the existence of my nursing paternalism. It is evident that modern health-care ethics in China is greatly influenced by Chinese traditional medical morality, which has a deep tradition of paternalism.16Paternalism in modern Chinese health care is the product of humanity of the Confucian ethics, from which two core typical paternalism ideas are inherited.16Firstly, health-care providers should act considering the patients' best interests and decide on behalf of the patients' benefits completely;secondly, health-care providers could make a decisionfor the patient ignoring or rejecting the autonomy of the patient. Chinese traditional medical ethics emphasizes“the healer parents heart”.16These ideas affect modern health-care philosophy and support paternalism in health-related decision-making. Likewise, some clues of paternalism also can be found in the history of nursing theory, which was once used to guide nursing practice.Peplau33originally analogized the nurse as a surrogate mother and the patient as an infant or child or adolescent, with the relationship between nurses and patients expectantly leading the patient to become an adult person. These deep historical influences prevented me from realizing what paternalism is and whether there is something wrong in acting as I did.34Conversely, I took it for granted in my nursing practice; I even considered that it was a good type of action and that I am a virtuous nurse in terms of protecting patients.

I also noticed that the national culture affected not only my belief but also patients' attitude to paternalism in health-related decision-making.11In turn, patients'attitude in the decision-making process could further affect my working manners and values.35The cultures of different countries shape different people's preferences regarding their role in health-related decisionmaking.36-38In the United States, most patients preferred to be given complete information and be involved in the decision-making process.37,39,40Only 10%-20% of patients did not like to know the details of the decision41and 9%-17% preferred to leave decisions to their family or medical professionals.37,42Nevertheless, studies among African-American, Hispanic, and Asian respondents reported more frequently that they preferred the professionals to make the final decisions.37,42A survey in Taiwan43demonstrated that 92.6% of patients did not make health-related decisions by themselves. This attitude showed that the style of health-related decisionmaking cannot be entirely patient autonomous. It is well known that paternalism is a widely refused ethical principle in health-care decision-making, especially in Western countries, but Chinese patients prefer to leave the decision-making to medical professionals.43This situation enables the survival and acceptance of paternalism,and further, paternalism becomes natural for nurses(e.g., me) in nursing practice for a long period.

Besides socialization and reflexivity, I also noticed that my paternalistic action was associated with my experience of power.7I worked in a power hierarchy that shaped my paternalism. As a nurse, on the one side, my action was under the power of policy, rules, and management, as well as under doctors. On the other side,I also have some power, which is related to the ability to care for patients,44to influence doctors and patients,to control or have autonomy,45,46and to use health-care resources.47The following will show how these kinds of power interacted with each other and shaped my paternalism.

First, my nursing practice was guided by many kinds of knowledge and rules, including medical science and technology, institutional policies, as well as professional standards, guidelines, and so on. Although it is purported that these rules are primarily guided by scientific principles, such principles are usually generated and disseminated by the health-care institutes themselves.3Therefore, these principles cannot keep off the suspicion of paternalism,48which is the way of self-interest for health-care workers with least resistance from the patients.3Moreover, health-care workers, including nurses, routinely conform to various scientific standards and guidelines to provide treatment to patients,with little care about their actual willingness. Breaching of these standards and guidelines by professionals and regulators without considering the patients' willingness is recognized as erroneous. As Hofmann said, paternalism may be hidden behind the veil of technology and science.48

Secondly, power was also involved in the relationship between patients and me.49It is apparent that medical knowledge, nursing experience, and skills made me have authority in the nursing field.50,51The psychology of common people is obedience to authority because of the patriarchal system.52Additionally, in China, nurses have a second-high reputation and status, only behind doctors in the hospital. People trust nurses and believe it would not be wrong to conform to nurses' decision in any situation.53Meanwhile, patients who want very much to get along well with doctors often need me to help them connect. As they reached for me, the patients often complied with my paternalistic decision without any complaints.54Moreover, it is true that I controlled some health-care resources, such as some health information and allocation of my own caring time.55These powers give more fertile ground for my paternalism. The patients often chose silence even when I was paternalistic to them56because they were afraid that my revenge might make me allocate less resources for them. Furthermore, with increase in my professional knowledge and experience, I was increasingly confident with my authority in the nursing field.44This resulted in intensification of my paternalism to some extent.

Thirdly, I also realized that the paternalism in my nursing decision-making cannot be separated from the doctor-nurse power relationships54,57as nurses play a mediating role between doctors and patients.52In the power hierarchy in a hospital, it is certain that the grade of doctors is higher than that of nurses.58The preferment or nurses' need for doctors' comments determined that some actions of mine did not consider patients' opinion completely but aimed for a good relationship with or appraisal from doctors. For example, when iexecuted a doctor's medicine orders, if the patients expressed some disagreement with the order, my dealing habitude was to try my best or utilize my power to make the patients accept the treatment, which is a pattern of paternalism,3instead of asking the doctor to come and explain clearly, because asking the doctor to explain or change the order is not a wise or effective conduct in doctors' eyes. Doctors expected me to deal with these“troubles” for them. Moreover, under the power of doctors, I had never questioned the paternalism involved in the doctors' orders but performed them blindly.

Finally, I felt that the power of nursing management in me also increased my paternalism.59,60As Fook,61Agger,62and Oudshoorn63stated, personal power interacts with the structural level of power.-My action was constrained by the nursing management system.63,64The evaluation system for efficiency, which was invented by the management department of my hospital, put the amount of practical nursing tasks first and foremost. In the context of the Chinese market-oriented economy, the amount of tasks and the profits that I produced determined my income and promotion.65The nursing personnel were also assigned according to the amount of practical nursing tasks,66such as injection,infusion, urine catheterization, and so on. The process of communication with patients and the informing duty had never been taken into account in the workload of nurses. Besides, they were indeed difficult to be calculated and assessed. The root cause was that those nursing operations that could generate economic benefits for the hospital while respecting the patients' rights could not produce immediate profits. With regard to evaluating the work of respecting patients' autonomy in nursing decision-making,67the patient's signature on the informed consent form is the main criterion and evidence used by the manager. This management style causes me to attach greater importance to practical tasks; I was not willing and did not have much time to provide plenty of information to patients and wait for their decision. In contrast, choosing to inform the patients of my decision directly and gaining their signatures was a better way for me to satisfy the requirement of the manager.

3.4. Reconstruct

It seemed paternalism in nursing decision-making saved some working time for me, but now I realize that it actually made me take on more responsibilities68,69for the patients' care beyond the call of my duty.10,70Although I tried my best to make a right - and the best - decisionfor patients, if there was something wrong associated with this decision, the patients and the management would blame me and ask me to face the consequence for the errors.71Hence, I should be responsible for all the negative results generated from the decision that I made for the patients.71Previously, I even thought that it was indeed my responsibility as it was caused by my inappropriate decision, but now I know that my thought was wrong. The root reason that they asked me to take the responsibility was that the decision was not made by the patients themselves and my paternalism deprived patients' autonomy at the time of decision-making.10If the decision had originated from the patients' autonomy completely, they were willing to afford and bear by themselves any consequences arising due to their own decisions.69Therefore, I realized that paternalism not only is against patients' autonomy but also brings forth nursing disputes.72

The understanding of paternalism in nursing decision-making is significant for me as a nursing practitioner because it led me to explore my outdated values and realize the necessity of transforming it. As the next step, I will need to reconstruct the understanding with my increased awareness.4I will value the patients'autonomy and respect their knowledge. I am willing to balance patients' safety and choice rather than being overprotective; appreciate patients' right to make decisions; carry out risk assessment and search for strong evidence to balance the positive and negative aspects of risk-taking; communicate with patients appropriately in a manner that they can comprehend; spend more time to explore patients' preference and choice; make every effort to elevate the patients' decision-making capacity; when I am unable to support a patient's decision, explain clearly the reasons to make them understand; implement patient-centered care and shared decision-making in nursing; and consult with other colleagues and obtain the required support when limitations or challenges exist. Moreover, I will try my best to justify the hidden paternalism first to avoid it before the utilization of nursing guidelines, routines, and policies.Furthermore, I need to deal with the power in my hand well and fairly, as well as positively face the powers that constrain me.

4. Discussion

Critical reflection is a theoretical method and a process for understanding and transforming practice. Using critical incidents, I identified my own assumptions and values, as well as those of my workplace and even nation.61A new reconstruction of my practice assumption was developed. This may also lead to changes in the embedded paternalistic value in my organizational culture. Through reflection, a useful ethical guideline that avoids paternalism in my nursing decision-making was developed. Firstly, respecting clients and avoiding prejudging should be regarded as the two antecedents necessary to sustain values and actions for caring. I certify that respecting is the guiding value and the foundation to interact with patients.73Secondly, I should be sensitive and open to the interplay between protective and empowering actions to accomplish my responsibility of ensuring patient safety and autonomy choice. A good way to promote patients' autonomy is to encourage and invite them to participate in the amendment of the daily caring plan that contributes to their convalescence, health recovery, and quality of life. Ethical principles can serve as guides to practice, but reflection is a tool that promotes my sensitivity and openness and assists me in applying these principles in practice.

5. Conclusions

Overall, the reflective process on the paternalism in my nursing decision-making, using Taylor's model of emancipatory reflection, transforms my outdated values and awakens me to the prospect of promoting patients' autonomy in decision-making. The theories of socialization,5reflexivity,6and hegemony8underpinned my reflection and guided me to effectively unearth the values involved in connecting with my experience and social context. Moreover, the paternalism in my nursing practice has been recognized to be related to personal value, history, culture, powers in the working environment, and the attitude of patients. I realized that respecting patients' rights and performing patient-centered caring are the bases of nursing practice. Reconstruction assisted me in the following: value patients' autonomy;balance patients' safety and choice rather than being overprotective; carry out risk assessment and search for strong evidence to balance the positive and negative aspects of risk-taking; communicate with patients appropriately in a manner that they can comprehend;spend more time to explore patients' preference and choice; make every effort to elevate the patients' decision-making capacity; when I am unable to support a patient's decision, to clearly explain the reasons and make them understand; implement patient-centered care and shared decision-making in nursing; and consult with other colleagues to obtain the required support when limitations or challenges exist; try my best to justify and avoid hidden paternalism in policy or guidelines; deal with the power in my hand well and fairly;and positively face the powers that constrain me. Furthermore, I also expect that my transformation in terms of recognition of paternalism and avoiding it in practice will have a related impact on the organizational culture of my hospital.

Conflicts of interest

The author declares no conflicts of interest.