Nurse autonomy in caring for people with chronic injuries

Abstract

This study reflects on nurses’ autonomy in caring for people with chronic injuries. Nursing work is influenced by technological dimensions and defined by professional responsibility and the sharing of activities with other categories, factors that directly impact nurses’ autonomy in the treatment of chronic injuries. Therefore, it is important to recognize the skills and limitations of this professional’s work, in order to reorient conditionings. The nurse’s autonomy should not take precedence over the patient’s. Through educational actions, the heterogeneity of roles must be taken into account to ensure patient integrity and ensure therapeutic adherence, emphasizing the importance of co-responsibility in the healing process.

Wounds and injuries; Bioethics; Ethics, professional; Jurisprudence; Professional competence; Nursing care; Professional autonomy

Resumo

O presente estudo reflete sobre a autonomia do enfermeiro no cuidado à pessoa com lesão crônica. O trabalho em enfermagem é influenciado por dimensões tecnológicas e definido pela responsabilidade profissional e o compartilhamento de atividades com outras categorias, fatores que impactam diretamente a autonomia do enfermeiro no tratamento de lesões crônicas. Por isso, é importante reconhecer as competências e limitações do trabalho desse profissional, de modo a reorientar condicionamentos. A autonomia do enfermeiro não deve se sobrepor à autonomia do paciente. Mediante ações educativas, deve-se considerar a heterogeneidade de papéis para assegurar a integridade do paciente e garantir a adesão terapêutica, enfatizando a importância da corresponsabilidade no processo de cura.

Ferimentos e lesões; Bioética; Ética profissional; Jurisprudência; Competência profissional; Cuidados de enfermagem; Autonomia profissional

Resumen

El presente estudio reflexiona sobre la autonomía del enfermero en el cuidado de la persona con lesión crónica. El trabajo de enfermería está influenciado por las dimensiones tecnológicas y definido por la responsabilidad profesional y el compartir de actividades con otras categorías, factores que impactan directamente la autonomía de los enfermeros en el tratamiento de las lesiones crónicas. Por lo tanto, es importante reconocer las habilidades y limitaciones del trabajo de este profesional, con el fin de reorientar el condicionamiento. La autonomía del enfermero no debe superponerse con la autonomía del paciente. A través de acciones educativas, se debe tener en cuenta la heterogeneidad de roles para asegurar la integridad del paciente y asegurar la adherencia terapéutica, enfatizando la importancia de la corresponsabilidad en el proceso de curación.

Heridas y lesiones; Bioética; Ética profesional; Jurisprudencia; Competencia profesional; Atención de enfermería; Autonomía profesional

This study aims to reflect on nurses’ autonomy in caring for people with chronic injuries. Addressing this theme and relating it to other areas of knowledge is highly relevant given the importance of the interdisciplinary health team’s respectability and trust in nurses, who share responsibilities, duties, prohibitions and rights with this team¹ .

This is a theoretical-conceptual study based on updated references, collected from the Virtual Health Library database and official documents available online, considering a time frame of five years (2015-2020). Articles on nurses’ autonomy in relation to ethical, bioethical and legal aspects were included, specifically with regard to the care of people with skin injuries/wounds.

Nurses who act with awareness of their work environments and seek both their own satisfaction and that of the recipients of their work are considered autonomous, considering the relevance of their actions for people, work processes and health services¹ . As members of the health team, nurses play a prominent role in the development of protocols and in the assessment, selection and indication of new prevention and treatment technologies for people with wounds² , ³ . Furthermore, to assess, treat and prevent injuries effectively, scientific knowledge is needed² .

The person with chronic injury must be assisted by a multidisciplinary team consisting of a physician, a nurse, a psychologist, a nutritionist, a physiotherapist, etc.² , ⁴ . Through Resolution 567/2018⁵ , the Federal Council of Nursing (Cofen) expanded the technical role of nurses in the treatment of wounds and established standards for nursing clinics specializing in the care of patients with wounds. In addition to these legal regulations, greater demand for professional training and specialization in the areas of dermatological and surgical nursing, stomatherapy and other areas related to the treatment of skin lesions exist⁶ .

Following (associated with greater availability of therapeutic resources and support from health services), nurses’ autonomy in the prevention and treatment of chronic injuries has gained relevance⁴ . In this context, recognizing the limitations of this professional’s work is necessary to change conditionings and ensure trust and respect in the nurse-patient relationship.

Every individual, with their own opinions, thoughts and perspectives, has the right to exercise their autonomy based on morals, beliefs and personal aspirations, even if there is disagreement with social norms⁷ . It is up to the nurse to provide indispensable guidelines for decision making, without any type of persuasion or manipulation, respecting the patient, valuing their right to dignity, privacy and freedom and considering their social responsibilities⁷ , ⁸ .

In communicating with the person with a chronic injury, the nurse must fight the lack of knowledge that leads to mistaken actions, informing the patient about preventive and therapeutic methods⁹ . The therapeutic relationship must be based on ethics and health promotion, in a search that leads nurses to continuously develop professional skills.

The work of nurses is developed in health institutions, which are complex and multidisciplinary environments. All professional actions in this environment must be supported by bioethics, which involve analysis and “introversion” (that is, self-reflection), meaning “good intention” is not enough. Self-reflection allows on to understand their own frailty, the understanding of being fallible and insufficient, dependent on mutual understanding⁷ , ⁹ .

Nurse autonomy in caring for people with chronic injuries

Considered the largest organ in the human body, the skin constitutes about 16% of all body weight and fulfills various functions, such as thermoregulation and being a physical barrier between the body and the environment, preventing the penetration of microorganisms¹⁰ . Alterations in the skin structure lead to lesions, which can be caused by several factors: local and ischemic pressure, mechanical or chemical-physical trauma, involuntary or voluntary (in the case of surgery, for example).

Injuries impact public spending and reduce people’s quality of life¹⁰ , ¹¹ . They affect the population in general, without distinction of sex, age or ethnicity, and evaluating, preventing and treating them are care activities that are now almost exclusive to nursing professionals. Thus, such professionals must know the risk and anatomical-physiological factors considered essential to diagnose the type of injury and the best preventive and therapeutic approach to be followed. Prevention and treatment actions are dynamic and need to be in accordance with scientific evidence and available technology, under the Nursing Care Systematization (SAE)¹⁰ , ¹² .

SAE, based on Cofen Resolution 358/2009¹³ , leaves no doubt about the obligation to systematize care and implement the nursing process (NP) in all environments, private or public, where care is provided by nursing professionals. The NP has five interrelated, interdependent and recurrent stages: nursing data collection; nursing diagnosis; nursing planning; implementation; and nursing assessment¹³ . Nurses must use the NP in the care of patients affected by injury, aiming at qualified and individualized care⁶ .

As a theoretical support that establishes all stages of care, the NP is called “nursing consultation” when performed in outpatient health service institutions, domiciles, community associations or nursing clinics specializing in the prevention and care of patients with wounds. Thus, as a “nursing consultation”, the planning and prescription of nursing care are activities that are exclusive to nurses⁵ , ⁶ , ¹³ .

The prescription of covering is based on the pathophysiological knowledge of the injury, the ethical and legal attributions of the professional, and health surveillance standards. Moreover, the same technology may not be effective for all healing phases or for all patients² , ¹⁰ , and it is up to nurses, in their autonomy and with their knowledge, to prescribe the most suitable therapy in each phase of the process.

The prescription of medications and covering, as well as the request for exams, must be carried out according to protocols, guides, manuals and technical notes defined by public health institutions and programs, considering Law 7,498/1986, which regulates the practice of nursing³ , ⁵ . This law establishes that the Nurse in the area is responsible for participating in the assessment, design of protocols, selection and indication of new technologies in the prevention and treatment of people with wounds ⁵ . Also regarding the criteria for prescribing medications/materials for cleaning, debridement and covering of wounds, the nurse should pay attention to the list of prescription exempt medications in the Collegiate Board Resolution (RDC) 98/2016¹⁴ and RDC 107/2016¹⁵ , which deal with simplified notification drugs and related matters.

To support discussions, decisions and actions involving moral and ethical aspects in health, bioethics is based on four principles: beneficence, non-maleficence, autonomy and justice⁷ , ⁹ . Autonomy refers to self-determination, or self-government, and proclaims that each individual’s freedom must be safeguarded. This principle can only be violated when the public good takes precedence over the individual good⁷ . Nurses use bioethical principles in their professional routine when they respect the patient’s individuality, welcome their needs to direct care, offer care free of risks and physical or moral damage, and provide information about procedures, guaranteeing the patient’s right to accept or refuse the procedures.

Nurses and nursing staff can intervene in defining care priorities. The exercise of autonomy, however, is based on the individual’s beliefs and is influenced by sociocultural aspects² , ¹⁶ , an important characteristic, since living with chronic injuries is precisely an interference factor in social, labor and even family relationships. Patients with injuries become more vulnerable to situations such as unemployment, abandonment and social isolation, which affect life plans and generate feelings of sadness, anxiety, anger and shame. All of this affects the individual’s state of balance, self-image and self-esteem¹⁷ , ¹⁸ .

When trust between patient and professional is established, experiences are shared and a relationship based on respect, help and understanding of the individual’s needs is established. To take care of an injury, going beyond dressing techniques, the nursing team, led by a nurse, must recognize that every human being has their own values and free will⁹ , ¹⁷ .

The nurse’s autonomy cannot take precedence over the patient’s; as provided for in the Code of Ethics for Nursing Professionals, the person’s or their legal representative’s right to exercise their autonomy in free and clear decision-making about their health, safety, treatment, comfort, well-being must be respected, performing necessary actions in accordance with ethical and legal principles ⁸ .

It is noteworthy, however, that nurses, through educational actions, should seek to ensure therapeutic adherence, considering the heterogeneity of roles in the professional-patient relationship and emphasizing the importance of co-responsibility in the therapy process. By following these principles, nurses will be able to provide care free from harm caused by malpractice, negligence or recklessness⁸ .

Final considerations

Given the complexity of the life of a person with a chronic injury, nurses must have a broader view of the feelings that the disease arouses and intensifies not only in the patient, but also in their families and close friends. Assisting the patient in an individualized and systematic way requires both specialized knowledge and a comprehensive view of care and the human being.

It is necessary to know the patient’s anxieties and expectations. For this, nurses should improve their capacity to feel empathy and provide qualified listening, unveiling and valuing what is special and different in each person, while paying attention to the responsibilities of professional nursing practice.

Nurses’ autonomy is essential in areas related to the care of people with skin lesions. Thus, theoretical-conceptual reflections on ethics, bioethics and law become even more necessary. Such reflections are essential to ensure patient safety and well-being, offering them comprehensive, systematized and harm-free care.

Referências

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• Article originated from a final paper in the Bioethics and Health discipline of the master’s degree in Nursing and Health at Universidade Estadual do Sudoeste da Bahia.

Publication Dates

• Publication in this collection
  18 Oct 2021
• Date of issue
  Jul-Sep 2021

History

• Received
  13 Aug 2019
• Reviewed
  16 Feb 2021
• Accepted
  15 Apr 2021