Autonomy

1. AUTONOMY, ACCOUNTABILITY AND
ASSERTIVENESS, VISIBILITY OF
NURSES, LEGAL CONSIDERATIONS
Submitted by
Pooja
M.Sc. Nursing 1st year
College Of Nursing
AIIMS, Jodhpur

2. AUTONOMY
INTRODUCTION
It’s derived from a Greek word.
“Autos” means “self”
“Nomo’s” means “laws”
The ability to make your own decisions
without being controlled by anyone else.

3. DEFINITION:
It’s the ability to make discretionary &
binding decisions consistent with ones
scope of practice & freedom to act on
those decisions.
(Lewis & Batey)

4. AUTONOMY IN NURSING PRACTICE:
Higher
level of
educatio
n
Independent
roles

5. RESULTS OF AUTONOMY IN NURSING
PRACTICE:
Increased
productivity
Higher
retention
Collaborative
practice
Greater client
satisfaction

6. BARRIERS OF NURSING AUTONOMY:
1.Lack of recognition
2.Inability to raise concerns about treatment plan
3.Interruptions in accessing resources for patient care
4.Relationship with colleagues that undermine
collaboration & shared decision making.

7. ENHANCING AUTONOMY IN NURSING:
Medical &
teaching rounds
Protocol for
decision of
procedures
Unique situations
that evoke issues
Supporting
continuing
education
Mutually
respectful
relationships

8. ACCOUNTABILITY
Introduction:
 According to Webster, ‘Account’ means ‘subject to
giving an account, answerable.’
 It provides the opportunity to evaluate nursing
practice within healthcare & is a means of clarifying
the significance of nursing to society.

9. DEFINITION:
Accountability is being responsible for one’s actions &
accepting the consequences of one’s behaviour. It is not a
vague feeling or an obscure concept. It is a clear obligation
which must be manifested as a structured component of
nursing practice, based on responsibility, authority &
autonomy.
(Sullivan & Deekan)

10. ACCOUNTABILITY & RESPONSIBILITY;
Are they
Synonyms?

11. ACCOUNTABILITY &
RESPONSIBILITY;
• Although the terms are often used interchangeably,
they are not the same.
• According to Lewis” defined responsibility as a
“change for which one is answerable whereas
accountability consist of answering in relation to
fulfilment of defined responsibility,”

12. HIERARCHY OF ACCOUNTABILITY:
Hierarchy
Individual
Professional
Societal
Institutional

13. LINES OF ACCOUNTABILITY:
Upward • 1
Lateral • 2
Downward • 3

14. TYPES OF NURSING ACCOUNTABILITY:
• Relevance
• Quality
• Procedures
• Financial
Fiscal Process
Priorities
Program

15. ELEMENTS OF ACCOUNTABILITY:
Clarity
Commitment
Consequences

16. ACCOUNTABLE FOR WHAT?
According to Lewis & Vailey;
You can only be accountable for which you are
responsible, & you can only be responsible for those
things which are clearly designated as accepted as
your responsibility.

17. FOR EXAMPLE;
• safe & therapeutic environment.
• Maintaining adequate supplies.
• Protecting client’s legal rights & privacy.
• Maintaining accurate records & reports.
• Working within ethical boundaries.
• Delivering the care as per standards.
• Delegating responsibility appropriately.
• Contributing to development of the profession.

18. ACCOUNTABLE TO WHOM?
• Nurses are accountable to nursing council.
• according to roll or register in which your name is entered.
• The nursing council’s code of conduct for nurses & midwives in
terms of ethics.
• Professional actions are explainable to your clients & your
employer (Health care institutions)
• Ultimate accountability for nursing practice & its outcomes must be
provided its recipients within society.
• Nurse, physicians & institutions are equally accountable for their
specific functions, within healthcare delivery.

19. ROLE OF ACCOUNTABILITY IN NURSING:
Make nurses responsible for own actions.
Report errors and take necessary actions to prevent &
minimize harm.
Take actions in situations where client safety is compromised.
Exercise reasonable judgement in practice. .
Understands & promotes the values & beliefs in the code of
ethics .
Contributes to a safe& professional practice environment.

20. WAYS FOR ENHANCING ACCOUNTABILITY
IN NURSING
• Well defined duties & job description.
• Written policies, protocols & procedures.
• Proper delegation of responsibilities.
• Proper training & education of self.
• Periodical evaluation of each individual’s nursing practice.
• Refine & modify outdate policies & procedures.
• Conducive working environment.

21. ASSERTIVENESS
Introduction;
It is a tool for expressing ourselves confidentially and a way
of saying yes or no in an appropriate way.
It is considered as healthy behaviour for all people against
personal powerlessness and results in personal
empowerment.
Ex. Say ‘I won’t be able to’ instead of ‘I am not sure if I can’

22. BENEFITS OF ASSERTIVENESS:
•Creating health, meaningful relationship
Less friction and conflicts
Increased self-respect
self-esteem is enhanced
overall sense of wellbeing
Emotional and physical health improves

23. AIMS OF ASSERTIVENESS:
•To find the best possible solution for all the people
•It sees everyone as equal with equal right and responsibility
•It increases the change our needs being met
•It allows as to remain in control
•It brings greater self confidence
•Assertive people have more friend
•Reduce stress

24. ASSERTIVENESS MODEL:
A • Ask for help
S • State the problem
E • Express yourself
R •Request change & feedback
T • Talk it out

25. TECHNIQUES FOR BEING ASSERTIVE:
• Identify your personal rights, wants and needs
• Identify how you feel about a particular situation
• Be direct
• Own your message
• Avoid assumptions
• Ask for feedback

26. CONTD..
• Stop apologising all the time
• Act confident even you don’t feel confident
• Get your emotions under control
• Choose ideal time and place to communicate
• Feel free to say ‘NO’ ‘I DON’T KNOW’ ‘I DON’T
UNDERSTAND’ etc

27. ASSERTIVENESS & NURSING:
• Nurses have recognized need for assertiveness in
quality nursing care
• Nurses everyday confront with challenges such as
communication issues and high stress level
• Nurses need to adjust their behaviour in order to
develop a career and to increase confidence

28. CONTD..
• To make exercise effectively nurses should choose a
situation which they may have to deal with in future
• Nurses have to be assertive in order to meet the
challenges and to win the cooperation from others.

29. VISIBILITY OF NURSING
VISIBILITY:
The way a person appears to others or in the case of
a profession, the way that profession appears to
other discipline and to the general public- the
consumer of the health care.

30. CURRENT VISIBILITY OF NURSING:
• PUBLIC VIEW OF NURSING
Based on personal experiences
Consumer not recognise the nurses
Public values nurses
Not know about the education needed

31. CONTD..
• NURSE’S VIEW OF THEMSELVES
Response of nursing towards the changes
Not taking the leading role
What is wrong with taking credit

32. FACTORS AFFECTING VISIBILITY OF
NURSING:
External Factors
Hand maiden role
Hierarchial structure
Percieved Authority
Hospital Policy
Threat of
disciplinary action
Internal Factors
Role Confusion
Fear
Lack of confidence
Insecurity
Inferiorty

33. IMPORTANCE OF VISIBILITY IN NURSING:
•Recruitment of students
•Enhance public view
•Funding for nursing
•Relationship with administrators
•Relationship with government agencies
•Profession self-identity

34. HOW TO INCREASE VISIBILITY:
•Advertising nursing
•Role of media
•Raise the voice campaign
•Institute of medicine quality reports
•Power and empowerment
•Assertiveness
•Advocacy

35. LEGAL ASPECTS IN NURSING
Introduction:
In the beginning , we learned what is wrong and right
behaviour from our parents, teachers and authority figures.
Most of that was shaped by religious beliefs and philosophies,
but with time we learnt a personal set of ethics to guide our
behaviour in our daily life.
Every profession including nursing has a set of ethics usually
called a code. It will state responsibilities towards their
profession and society as a whole.

36. TERMINOLOGY
ETHICS: the principles of conduct governing one’s
relationship with others, basic beliefs about right and
wrong.
LAW: the body of rules that guides human action.
ACT: it is a written law. When the law is passed in
assembly and is approved by government.

37. CONTD..
LEGAL RESPONSIBILITIS: the way in which one is
obliged to obey the laws in the professional activities.
LEGISLATION: it is the process of making laws.
Legislation is a method of improving public services.

38. IMPORTANCE OF LAW IN NURSING:
•Protects rights of patients
•Prohibits unlicensed individual to work
•Updates the knowledge of individual about legal controls
•Prevent a nurse who is below the standards set by the code
•Protects the nurse who is falsely accused of wrong doing
Used as a guide when legal action has to be taken in lawsuit

39. LAWS APPLICABLE TO NURSING PRACTICE:
• Right to sue for fees
• Right to refuse to treat a patient except in a emergency
situation
• Right to add tittle and description to the name
• To exercise the reasonable skill and knowledge in treating
patient
• There is an obligation to attend the patient once relationship
is established unless patient request withdrawal

40. CONTD..
• A practitioner must give personal attention to the cases
• Children must be protected from harming themselves
• Special precautions must be taken in patients, who are
incapable of taking care of themselves
• The Indian panel code demands that poisonous drugs be
kept in separate container, properly labelled and marked

41. CONTD..
• The patient record must be treated as confidential unless the
practitioner is called upon to give evidence in the court
• Dangerous cases must be recorded
• Nurses are responsible for their own professional acts
irrespective of the employment authority

42. TORT
INTRODUCTION:
It is a civil wrong committed against a person or
persons property.
It derived from the French, are acts which unlawfully
violate a persons right by law and for which the
appropriate remedy is a common law action for
damages by injured party.

43. 1.NON-INTENTIONAL TORT
Negligence
Negligence denotes conduct
lacking in due care.
Thus, it equates with
carelessness, a deviation
from the standard of care that
a normal person would use in
a practical set of
circumstances.
Malpractice
Malpractice is a more specific
term and looks at
professional standards of
care as well as the
professional status of care
giver.

44. ELEMENTS OF NEGLIGENCE & MALPRACTICE
• Duty owed the patient- falling to monitor the patient
• Breach of the duty owed the patient- falling to report a
change in patient situation
• Foreseeability- falling to report another health care
providers in competence
• Causation- falling to provide for the patient’s safety
• Injury- allowing a patient to burn
• Damage- using equipments incorrectly

45. 2. INTENTIONAL TORT:
• ASSAULT- action that places another person in
apprehension for being touched in a manner that is
offensive, insulting or physical injury without consent.
• BATTERY- intentional touching of another’s body without
consent, injuries not required.

46. CONTD..
• CONVERSION OF PROPERTY- when practitioner
interferes with the right of possession of patient’s property.
• TRACEPASS TO LAND- unlawful interference with
another’s possession of land.
• INVASION OF PRIVACY- when confidentiality of the client
is not maintained.

47. CONTD..
FALSE IMPRISONMENT- the unjustifiable detention of a
person without legal warrant to confine any person.
DEFAMATION OF CHARACTER- act of holding a person to
ridicule, scorner, contempt with in the community.
There are two types;
slander(spoken), libel(written).

48. CONTRACTS IN NURSING SERVICES:
IMPLIED
EXPRESS
INFORMAL
FORMAL

49. LEGAL RESPONSIBILITIES OF NURSES:
•Responsibility of appointing and assigning
•Quality control
•Equipment
•To protect public
•Record keeping and reporting
•For the death and dying
•Knowledge regarding institutional rules and policies

50. LEGAL SAFEGUARD IN NURSING PRACTICE:
Licensure
Rapport
Contract
Confidence
Documentation
Self-
discharge
Reporting
Pt’s
Property
Drug
Maintenance
Standing
order
Correct
Identity
Good
Samaritan
Law

51. RESEARCH
Awareness of Nurses on Legal and Ethical Aspects of Nursing in
Selected Hospitals of Lalitpur
Sarju Maharjan, Mamta Thapa, Bijay Maharjan
A descriptive cross-sectional study was conducted in Sumeru,
Sumeru City & Ganeshman Singh Memorial Hospital of Lalitpur
district on 168 nurses.The semi-structured questionnaire was self-
administered to collect the data.Around 40% of the respondents had
inadequate knowledge of ethical and legal aspects of nursing. The
present knowledge level of nurses emphasizes the need for making
aware of these topics.

52. CONCLUSION:
As we have discussed, that autonomy, accountability &
assertiveness are the essential characteristics that a nurse
should have in herself/himself. As assertiveness is simply
saying yes or no to anything & autonomy is so relative that itself
means taking your own decisions are equally important so that
we can take responsibility for our actions as it comes under
accountability.

53. CONTD..
If we compare the historical perspective with the present image of
nursing, it is quite impressionable that this profession has Changed
its image towards self & others. And if we view ourselves as an
important part of the health care delivery system then nobody else
can make us feel less important. The legal rights of the patients &
the health care professionals are equally important to study & be
knowledgeable about. If we know our rights & responsibilities well
then we can make the future visibility of nursing even better than
today.

54. REFERENCE:
• Brar NK, Rawat HC, Textbook of Advance Nursing Practice 1st ed., Jaypee Bros, The Health Sciences
Publisher: page no.28-58.
• Dubnick, Melvin (1998). Clarifying Accountability: An Ethical Theory Framework. In Charles Sampford; Noel
Preston; C. A. Bois (eds.). Public Sector Ethics: Finding And Implementing Values. Leichhardt, NSW, Australia:
The Federation Press/Routledge. pp.68–81.
• Moreno, Ivan, Sánchez J, Alejo A, Maximino. Invisibility assessment a visual perception approach. Journal of
the Optical Society of America. (2014), A; 31 (10): 2244-2248.
• Retrieved from Bibcode:2014JOSAA..31.2244M. doi:10.1364/josaa.31.002244. PMID 25401251.
• Maharajan S, Thapa M, Maharajan B (2021). Awareness of Nurses on Legal and Ethical Aspects of Nursing in
Selected Hospitals of Lalitpur. Available from:
https://www.researchgate.net/publication/350598394_Awareness_of_Nurses_on_Legal_and_Ethical_Aspects_
of_Nursing_in_Selected_Hospitals_of_Lalitpur