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• W1875884807 abstract "The role of nurses in advocating for patients and their relatives is well documented (Jamerson et al., 1996; Tammelleo, 2002; Bundgaard et al., 2011) and entrenched in their code of professional conduct by nursing regulatory bodies in several countries (e.g. Council for Nurses and Midwives, 1997). This responsibility is even more pronounced in the critical care setting that poses situations of considerable patient vulnerability invoked by the acute illness itself and compounded by the technology-dominated alien environment which allegedly introduces barriers and reinforces the power imbalance between patients and health professionals (Happ, 2000; Pryzby, 2005; O'Keefe-McCarthy, 2009; Eriksson et al., 2010). The considerations that follow were triggered by reflecting on some of the findings emerging from a grounded theory doctoral research project exploring the factors associated with nurses' decisions to seek help from doctors in a Maltese intensive care unit. Data were collected through 20 h of preliminary non-participant observation; 50 h of participant observation accompanied by informal interviews; 15 h of formal semi-structured interviews with 10 critical care nurses selected by purposive and theoretical sampling; and two 2-h focus group sessions aimed at enhancing theoretical sufficiency and verification (Trapani, 2014). The study findings affirm that nurses feel duty-bound to act and speak on behalf of patients and their relatives, which manifested itself in forwarding patients' or their relatives' questions and concerns to medical practitioners; explaining treatment modality decisions to patients or their relatives; and giving their input, influencing and at times correcting treatment modality decisions on the basis of what they perceive to be the patients' best interest. In other words, by acting as their patients' agents, nurses have the potential to counteract critically ill patients' ‘voicelessness’ (Happ, 2000, p. 1250) and mediating their perceived and actual power asymmetry with respect to health providers (Silver and Winland-Brown, 2000; Porter, 2002; Blanchard and Alavi, 2008). Yet, the study also revealed that nurses' ability to act as their patients' intermediaries is significantly affected, and at times hindered, by their relationship with medical practitioners, most notably consultants. Maltese nurses' constant mindfulness about their institutional requirements to seek authorization for their decisions from members of the medical profession, underpinned by their deferential decision-making power relative to doctors, establishes an agent relationship with their medical colleagues holding equal weight to that of their role as agent for the patient. In other words, nurses implement a dual agency role as they need to act concurrently as an agent to two different principals, namely the medical practitioner and the patient, a situation which is potentially morally distressing as it occasionally impedes nurses from implementing what they consider to be best options for their patients. Subsequently, nurses' decisions about whether, when and to whom they make referrals were not exclusively determined by their aim of improving patient outcomes. Rather, their desire to prevent conflict with medical practitioners, and subsequently their reluctance to express dissent to consultants' decisions indicate that they also give due consideration to the additional anxiety imposed on the self when making such referrals. Thus, although nurses feel strongly motivated to act as their patient's agent, their dual agency role implies that several other factors impinge on their actions, because of which the patient is not their only, and at times their utmost, concern. This is worrying when considering the negative consequences on patient safety and on the public's trust in the health system arising from the relegation of patients' welfare below other competing interests, as eloquently portrayed in two recent inquiries undertaken in the UK into the delivery of care in certain parts of the NHS (Francis, 2013; Keogh, 2013). How, then, does one shift the balance in the favour of patient advocacy? How can nurses' dual agency relationship with doctors and patients be balanced in a manner that fosters inter-professional collaboration without compromising patient advocacy? The study suggests that nurses' moral agency is severely challenged by institutional constraints, most notably their deferential decision-making power and the positional authority of medical consultants. Subsequently, nurse leaders and educators should continue endeavouring to facilitate not only the academic and intellectual growth but also the moral development of nursing students and qualified nurses in order to place them in a better position to address moral challenges, particularly that of concurrently acting as an agent to both the critically ill patient and the medical practitioner. Training in decision-making and moral positioning should aim at instilling, with even greater intensity, ‘a relentless focus on the patient's interests and the obligation to keep patients safe and protected from substandard care’, even when this involves health care providers having to place patients' interests before their own (Francis, 2013, p. 66). The latter point is congruent with the current vision and strategy document of the Chief Nursing Officer for England, which identifies courage as one of the core values for nurturing a culture of compassionate care (NHS England, 2012). The findings also suggest that nurses occasionally failed to contest medical decisions on behalf of their patients because of their concern that this might tarnish doctors' trust in their ability to act as their agent. This somewhat resonates with the conclusions of the Mid Staffordshire NHS Foundation Trust Public inquiry – which reported a ‘culture of fear in which staff did not feel able to report concerns’ (Francis, 2013, p. 10) – and the review into the quality of care and treatment provided by 14 hospital trusts in England – in which ‘staff did not feel empowered to take action when they had identified an issue’ (Keogh, 2013, p. 29) – with negative effects on patient outcomes in both scenarios. In view of nurses' role in safeguarding critically ill patients, it is indispensable that hospital managers promote and maintain a clinical atmosphere, which provides nurses with ‘the psychological safety to speak up if something has gone wrong’ through the adoption of collegial, rather than hierarchical, attitudes (Gordon, cited in Larson, 2011, p. 2). Similar recommendations have been proposed in the frequently cited To Err Is Human document by the Commission on Quality of Health Care in America (Kohn et al., 2000); in the Institute of Medicine's Keeping Patients Safe document (Page, 2004); and, more recently, in the NHS inquiries by Keogh (2013) and Francis (2013). The latter report, in particular, recommended that the oppressive ‘culture of fear…[is replaced] by a culture of openness, honesty and transparency, where the only fear is the failure to uphold the fundamental standards and the caring culture’ (Francis, 2013, p. 75). What is particularly significant is the fact that in the present study this recommendation is based on data indicating that nurses' effectiveness at, and at times willingness to, contribute to decisions affecting the patient were considerably affected by the perceived or actual reaction of doctors to their input, which is of concern given their well-documented responsibility to ‘rescue’ their patients from the complications of care during hospitalization (Clarke and Aiken, 2003; Department of Health and Human Services, 2007; Thompson et al., 2008; Matthew, 2010; Jones et al., 2011). Health administrators should, therefore, introduce, encourage and sustain opportunities for organizational and peer support for all ICU health care providers, particularly those who, similar to the nurses in the present study, are vulnerable to moral distress due to frequent instances of being constrained from implementing what they consider best for their patients. Holding regular forums in which physicians and nurses can share unpleasant experiences related to collaboration and attempt to resolve differences (Tang et al., 2013) could be a step in the right direction. One tangible way in which inter-professional collaboration could be enhanced is through the nature of the ICU ward round. In the UK, physicians have acknowledged that ‘nurses provide the hub of patient care, and their involvement in the daily bedside clinical review is central to the effectiveness of the ward round’ (Royal College of Physicians and Royal College of Nursing, 2012, p. 12). Yet, nurses' input, and sometimes even their presence, in ward rounds is inconsistent (Weber et al., 2007; Liu et al., 2012). In particular, data from this study indicated that although critical care nurses were invariably present at the bedside during ward rounds, the nature and extent of their participation varied substantially depending on the consultant's characteristics. Subsequently, hospital managers should facilitate nurses' (and other health professionals') input in ward rounds and ensure that opportunities are in place for such contribution to be given consistently rather than haphazardly. Only in this way can ward rounds become truly multidisciplinary and fulfil their ‘crucial communicative purpose’ (Moroney and Knowles, 2013, p. 28). Nurse educators should also expand their efforts at equipping current and future nurses with effective interpersonal skills. In Malta, undergraduate nurse education programmes appear to focus on developing and enhancing communication techniques that aid nurse-patient interaction, particularly in terms of informing, educating, listening to, and empathizing with patients and their relatives. While it is unquestionably essential to master these skills, there is room for improvement in the training of nursing students and qualified nurses in communicating effectively with members of their own and other professions, including persons who are considered higher in the hierarchy. Special attention should be given to the manner in which nurses' unique information about their patients is communicated to other members of the health care team, and the strategies they adopt to assert their input in treatment modality decisions. This should facilitate nurses' ability to fulfil the dual nature of their concurrent agency relationship with critically ill patients and medical practitioners. In conclusion, the notion of dual agency contributes to the current debate about factors that potentially distract nurses from providing quality compassionate and safe care, and proposes that these are partly explained by the interconnected nature of nurses' relationship with medical practitioners and patients. Rather than studying the relationship between medical and nursing practitioners in isolation, therefore, future research should explore inter-professional collaboration in full view of its effects on nurses' effectiveness in safeguarding patient outcomes." @default.
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• W1875884807 date "2014-08-17" @default.
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• W1875884807 title "Critical care nurses as dual agents: enhancing inter-professional collaboration or hindering patient advocacy?" @default.
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