Protecting client autonomy: a grounded theory of the processes nurses use to deal with challenges to personal values and beliefs

Registered nurses, while carrying out their professional roles, regularly encounter situations with ethical components. While there are research findings reporting the types of ethical challenges nurses face, their level of involvement in ethical decision-making, and reasoning processes used, how nurses actually deal with situations that challenge them personally has not been specifically explored. The purpose of this study was to investigate the psychosocial processes that can explain how registered nurses reason and make decisions when faced with ethical situations that challenge their personal values and belief systems. A grounded theory approach was used to conduct the study, allowing a substantive theory to be developed. Twenty-three nurses, currently working in metropolitan or regional areas in New South Wales, volunteered to participate in the study. Two methods of data collection were utilised, the first being semi-structured, in-depth interviews which were audio taped then transcribed. The second method used hypothetical vignettes with associated questions to which the participants were invited to anonymously return written responses. Data were managed by means of the computer program NVivo 2, while constant comparative analysis using open, axial and selective coding, as outlined by Strauss and Corbin (1998), was performed. The substantive theory which emerged from the data explains the processes used by nurses when they have to deal with ethical challenges to their personal values and beliefs. The basic psychosocial process (core category) of protecting client autonomy reveals a pattern of moral reasoning that gives priority to the clients selfdetermined choices. This subsumes the key processes (subcategories) of: (1) being self-aware, (2) determining duties to other/s versus self, (3) engaging self as protector, and (4) restoring self from tension or anguish, which link to each other and to the core category to explain the various sub-processes used when protecting client autonomy is considered a priority. Findings in the study revealed that nurses who give primacy to client autonomy believe they should not impose their own preferred choices on to clients. Yet the emphasis on client autonomy is also paradoxical, since it may come at the cost of compromise and even denial of the nurses own autonomy and their deeply held values and beliefs. When they become aware that their personal values and beliefs are being challenged, they are at times prepared to compromise their own values or beliefs, yield to constraints, or put themselves at risk in order to protect the autonomy of clients. Such actions can leave nurses experiencing ethical tension or anguish for which they need to seek support. Opportunities to find appropriate support are not always available to them in the work environment. The findings in this study have important implications for both nurses and the nursing profession. The pattern of moral reasoning shows generosity and nurses commitment to their caring and advocacy roles. However, when nurses are regularly prepared to compromise their own values or beliefs because they give priority to protecting client autonomy, there is a risk they may be left with a sense of loss to their personal worth and in their ability to be moral agents. Further, in some situations it may occur out of complacency because they simply accept that it is the clients choice, absolving the nurse of further moral responsibility. Appropriate support systems need to be available to nurses to help them deal with the consequences which may occur as a result of giving preference to clients choices, over their own.