Learning Objectives
By the end of this section, you will be able to:
- Explain the elements of autonomy
- Describe why restrictions might be placed on the autonomy of a person with a mental health diagnosis or symptoms
- Discuss power sharing in the therapeutic relationship
The concepts of autonomy (ability to make decisions) and independence (ability to function without assistance) are often discussed together. While autonomy is related to the right to make one’s own decisions with minimal interference from others, independence encompasses the client’s ability to do things on their own, without any assistance from others (Toledano-Gonzalez et al., 2019). For instance, a client may need assistance with ADLs, but continue to have the ability to make informed decisions in a meaningful way.
In mental health care, clients may need assistance in making decisions, due to the severity of mental health symptoms, so it might compromise autonomy. If thought processes are impaired and clients are unable to interpret reality, or if clients are at risk for behaviors dangerous to self or others, it may call for restriction of autonomy and independence therapeutically or legally. Personal power can be restored as mental health is restored and the nurse-client relationship is instrumental in this process.
Defining Autonomy for Mental Health Clients
One of the fundamental ethical principles in health care, and often at the heart of nursing care, is freedom for clients to make decisions for themselves (ANA, 2015). In mental health care, individuals may be unable to make decisions for themselves perhaps until they have received treatment, which can become complicated when an individual is unable to make the decision to receive the treatment. Clients may enter the mental health system demonstrating an inability for self-care due to the exacerbation of their diagnosis. For example, a client with bipolar disorder in their euphoric state may demonstrate the lack of ability to make appropriate decisions related to spending money.
Freedom is a component of autonomy and when individuals are restricted for their safety, for example, court-ordered into treatment, it limits autonomy. One argument in favor of such limitation is that the disease process itself has already altered the person’s autonomy; therefore, protections are indicated (SAMHSA, 2019).
The Influence of Autonomy on Behavior
The ability to exercise autonomy allows the client to demonstrate responsibility, integrity, dignity, individuality, and self-knowledge (Liu et al., 2022). Mental health clients can lose this ability with an exacerbation of their disease, creating the need for someone to be responsible for making decisions for them.
Agency
The term agency, according to Wheeler (2020), means feeling control over one’s decisions and well-being. It is the component of autonomy that involves individuals being in control of what happens to them. In mental health recovery, agency plays a large role as the client begins to regain an ability to be in charge of their lives and become the owner of their thoughts, feelings, and actions.
Restrictions on Autonomy and Independence
There are certain circumstances under which restrictions on a client’s autonomy are justified legally, medically, and ethically. Nurses should be aware of these instances, should understand the appropriate ways to limit autonomy in the least restrictive means necessary, and should work with clients to implement interventions that will help them to regain autonomy as quickly as possible. When a client is in an impaired state—for example, in pain, emotionally traumatized, or unable for any reason to make an informed decision—the client’s autonomy may be restricted.
Nurses are bound by their ethical duty to keep clients’ confidentiality, respect clients’ right to refuse treatment, and ensure that clients receive emergency and continuous care. All this within the condition that if harm would ensue to the client or to others, the nurse may be in a position to modify some of these aspects of care. Careful documentation and consultation are essential for such restrictive nursing action in relation to restrictions on autonomy and independence for the client.
Independence
Independence represents an individual’s ability to perform activities of daily living without assistance. Included are things like bathing, dressing, eating, ambulating, housework, and managing medication. With independence comes the ability to live alone. Often the mental health client temporarily loses the ability to live independently until they are returned to their pre-exacerbation level of functioning. For some individuals, however, they may come to a point where loss of independence is permanent and long-term arrangements must be made.
Rationality
According to Pugh (2020), autonomous decision-making is based on a person’s concept of what options they have. Therefore, if an irrational thought process drives a chosen action, the action may be inappropriate, illegal, or harmful. In that situation, the autonomous decision may actually have been involuntary (Pugh, 2020). Another name for guidance of reason is rationality. This is in contrast to rationalization, which is a defense mechanism used in attempts to explain experiences that prompt unacceptable feelings. As a short-term defense against anxiety, rationalization can be a coping mechanism. However, when used frequently or if preventing emotional resolution, it can be unhealthy. With mental illnesses, it can prevent the client from accepting truth and delay a return to their previous level of functioning.
Clinical Safety and Procedures (QSEN)
Client-Centered Care: Autonomy
The QSEN competencies provide a framework for nursing education and practice, emphasizing the importance of client-centered care, safety, quality improvement, teamwork, and evidence-based practice. Advocacy in psychiatric-mental health nursing aligns closely with several QSEN competencies:
Client-centered care: Advocacy in psychiatric nursing involves prioritizing the needs, preferences, and rights of clients. Nurses advocate for client-centered care by ensuring that treatment plans are individualized, respecting clients’ autonomy and self-determination, and actively involving clients in decision-making processes regarding their care and treatment options.
Safety: Advocacy in psychiatric-mental health nursing also encompasses ensuring the safety and well-being of clients. Nurses advocate for safety by assessing and managing risks, such as suicidal ideation or aggression, and implementing appropriate interventions to prevent harm while promoting client autonomy. This may involve collaborating with interdisciplinary teams, implementing de-escalation techniques, and advocating for the use of least restrictive interventions.
Teamwork and collaboration: Effective advocacy in psychiatric-mental health nursing often requires collaboration with interdisciplinary teams, including psychiatrists, psychologists, social workers, and other health-care professionals. Nurses advocate for clients by collaborating with team members to develop comprehensive care plans, ensuring that clients’ needs are addressed holistically and that their voices are heard in the care process.
Evidence-based practice (EBP): Advocacy in psychiatric-mental health nursing is informed by EBP, which involves integrating the best available evidence with clinical expertise and client preferences. Nurses advocate for evidence-based interventions and practices that promote client autonomy, recovery, and well-being. This may include advocating for the implementation of psychoeducation, cognitive behavioral therapy, and other evidence-based therapeutic modalities.
Quality improvement: Advocacy in psychiatric-mental health nursing also involves participating in quality improvement initiatives aimed at enhancing client outcomes and safety. Nurses advocate for quality improvement by identifying areas for improvement in the delivery of psychiatric care, such as reducing stigma, improving access to mental health services, and promoting client empowerment and self-advocacy. By participating in quality improvement efforts, nurses contribute to the enhancement of psychiatric nursing practice and the delivery of high-quality, client-centered care.
Informatics: Technologies such as electronic medical records (EMRs) and medication distribution systems help to promote client safety, preventing harm and promoting client autonomy.
By incorporating advocacy into psychiatric-mental health nursing practice in alignment with QSEN competencies, nurses can effectively promote the rights, well-being, and recovery of individuals experiencing mental illness while contributing to the delivery of safe, high-quality care in psychiatric-mental health settings.
The client-centered care competencies of knowledge, skills, and attitudes (KSAs) are expected of the student nurse as they transition to practice as a licensed nurse. The table serves as a resource to guide curricular development in formal academic nursing programs.
Power Sharing in the Therapeutic Relationship
The power to change and recover belongs to the client, and nurses share in the client’s success. The therapeutic relationship is a helping relationship wherein a space is created for nursing interventions and client response. Goals of treatment are developed with the client and adjusted as care progresses; therefore, power is shared from the beginning. Allande-Cussó et al. (2022) assert that the nurse-client relationship is the foundation of nursing care, nursing skill, and nursing intervention simultaneously.
Nurse-client relationships function with respect and mutual decision-making, which promote independence and self-care for the client (Akpotor & Johnson, 2018). Nurse appreciation of the client experience enhances client participation. In focus group research, Beyene et al. (2018) found that clients may need differing levels of support to participate in care planning, even relying on nursing to make decisions. Nurses must respect this process of balancing responsibility with power, as this balance is essential in order to provide safe and optimal care (Beyene et al., 2018).
Challenges in Power Sharing
Nurses may view clients as incapable of participating in their own care due to their illness. Nurses may consider clients lacking in sufficient knowledge, motivation, or energy to resolve their own problems, especially if clients enter the health-care system frequently. Unfortunately, nurses may blame clients for their health-care needs.
Nurses may approach client care from a rescue perspective, believing that the nurse is the one to heal the client. If nurses approach client interactions with these concepts in mind, there could be an implied message of the nurse’s greater power in the relationship. As mentioned, clients may present as dependent and be mindful of the imbalance in power between the client and the nurse. In these cases, nurses’ attitudes may be reinforced and a cycle of imbalanced power results.
Application of Power-Sharing Techniques
Nurses must look honestly at their own beliefs before power-sharing skills can be acquired.
The practice of trauma-informed care (TIC) means that nurses realize the far-reaching effects of trauma in people’s lives and refine nursing care accordingly in a manner that helps to share the power in the relationship through recognizing the needs of the client. The strategies in Table 12.1 utilize concepts of TIC from the Substance Abuse and Mental Health Services Administration (SAMHSA, 2023).
| Concept | Technique/Example |
|---|---|
| Safety | Manage the physical environment and provide information Example: The nurse ensures lighting and comfort for the interaction and explains what the conversation or procedure will be about. |
| Trust | Use open communication, transparency, and advanced notice Example: The nurse introduces self and invites the client to share. The nurse informs the client of scheduled activities. |
| Supportive others | Include family members and peers Example: The nurse acknowledges the client’s supportive others. |
| Partnering | Level power differences between staff and client Example: The nurse speaks of staff members as collaborating to assist the client. |
| Empowerment | Build upon client’s strengths and experience Example: The nurse assists the client with strengths identification. The nurse acknowledges the client’s experience. |
| Cultural and gender issues | Move beyond stereotypes and bias Example: The nurse examines own values, is nonjudgmental of client’s beliefs, and considers the client’s perspective and incorporates it into mutual decision-making. |