Relationship Between Autonomy And Action

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Relationship Between Autonomy And Action

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Autonomy (overview)

Another criticism of the hierarchical model is the Regress or Incompleteness Problem. According to Frankfurt and Dworkin, an agent is autonomous with respect to his or her first order desires as long as they are endorsed by second-order desires. However, this raises the question of the source of the second-order volitions; if they themselves rely on third-order volitions, and so on, then there is the danger of an infinite regress in determining the source of the autonomous endorsement see Watson If the second order desires are autonomous for some other reason than a higher-order volition, then the hierarchical model is incomplete in its explanation of autonomy.

However, the choice of terminating the series is itself arbitrary if there no reason behind it Watson To stop at this point is, Frankfurt argues, hardly arbitrary. The criterion of wholeheartedness and unified agency has been criticized by Diana Meyers, who argues for a decentered, fivefold notion of the subject, which includes the unitary, decision-making self, but also acknowledges the functions of the self as divided, as relational, as social, as embodied, and as unconscious Meyers The ideal of wholeheartedness has also been criticized on the grounds that it does not reflect the agency of agents from oppressed groups or from mixed traditions. Edwina Barvosa-Carter sees ambivalence as an inescapable feature of much decision-making, especially for mixed-race individuals who have inherited conflicting values, commitments, and traditions Barvosa-Carter Marina Oshana makes a similar point, with reference to living within a racist society Oshana In any case, it is a puzzle how decisive commitments or higher-order desires acquire their authority without themselves being endorsed, since deriving authority from external manipulation would seem to undermine this authority.

A related objection to the Regress Problem is that this hierarchical account seems to give an unjustified ontological priority to higher versions of the self see Thalberg In order to give a procedural account that would avoid these objections, Friedman has proposed an integration model in which desires of different orders ought to be integrated together, rather than being constructed in a pyramid Friedman Part of the appeal of understanding autonomy is not simply in explaining how we make decisions, but because the idea of autonomy suggests something about how we identify ourselves, what we identify with. For Frankfurt, we identify with a lower level desire if we have a second order volition endorsing it.

An agent has a preference if he or she holds a certain first level desire to be good; it is similar to a second order volition for Frankfurt. A self, then, is a particular character with certain beliefs and preferences which have been endorsed in a process of self-reflection, and the ability to reshape those beliefs and preferences in light of self-evaluation. The true self includes those beliefs and preferences which cohere together; that coherence itself gives them authorization. Michael Bratman develops a similar account, arguing that our personal identity is partly constituted by the organizing and coordinating function of our long-range plans and intentions Bratman , 5.

Our decisions are autonomous or self-governing with respect to these plans. But it should be enough to make clear the way in which theorists offering these accounts strive to ensure that no particular view of what constitutes a flourishing human life is imported into their accounts of autonomy. Autonomy is just one valued human property amongst others, and need not do all the work of describing human flourishing Friedman Some doubt, however, that proceduralist accounts are adequate to capture autonomous motivation and action, or to rule out actions that or agents who we would hesitate to call autonomous.

Substantive accounts of autonomy, of which there are both weak and strong varieties, set more requirements for autonomous actions to count as autonomous. Whether weak or strong, all substantive accounts posit some particular constraints on what can be considered autonomous; one example might be an account of autonomy that specifies that we might not autonomously be able to choose to be enslaved. We do not need to be metaphysically responsible for ourselves or absolutely self-originating, but as agents we are morally responsible, and capable of revising ourselves according to our moral reasoning Wolf Contemporary Kantians such as Thomas Hill and Christine Korsgaard also advocate substantive accounts of autonomy.

Korsgaard argues that we have practical identities which guide us and serve as the source of our normative commitments Korsgaard This identity generates universal duties and obligations. Just as Kant called autonomy our capacity for self-legislation, so too Korsgaard calls autonomy our capacity to give ourselves obligations to act based on our practical identities. Since one of these is a universal moral identity, autonomy itself thus has substantive content. Autonomy, for Hill, means that principles will not simply be accepted because of tradition or authority, but can be challenged through reason. He acknowledges that in our society we do not experience the kind of consensus about values and principles that Kant supposed ideally rational legislators might possess, but argues that it is still possible to bear in mind the perspective of a possible kingdom of ends.

Human dignity, the idea of humanity as an end in itself, can represent a shared end regardless of background or tradition Hill , Substantive accounts have been criticized for conflating personal and moral autonomy and for setting too high a bar for autonomous action. Does arguing that agents living under conditions of oppressive socialization have reduced autonomy help set a standard for promotion of justice, or does it overemphasize their diminished capacity without encouraging and promoting the capacities that they do have? This interplay between our socialization and our capacity for autonomy is highlighted in the relational autonomy literature, covered below.

In order to come to some middle ground between substantive and procedural accounts, Paul Benson has also suggested a weak substantive account, which does not specify any content, but sets the requirement that the agent must regard himself or herself as worthy to act; in other words, that the agent must have self-trust, self-respect Benson Feminist philosophers have been critical of concepts and values traditionally seen to be gender neutral, finding that when examined they reveal themselves to be masculine see Jaggar , Benjamin , Grimshaw , Harding and Hintikka , and Lloyd Autonomy has long been coded masculine and associated with masculine ideals, despite being something which women have called for in their own right.

There has been some debate over whether autonomy is actually a useful value for women, or whether it has been tarnished by association. The ideal of the autonomous individual could only be created by abstracting from the relationship of dependency between men and women. The relationships which people require to nurture them are considered private, and not truly relationships with outside others.

Thus the other is reduced to an appendage of the subject — the mere condition of his being — not a being in her own right. The individual who cannot recognize the other or his own dependency without suffering a threat to his identity requires the formal, impersonal principle of rationalized interaction, and is required by them. Benjamin , Benjamin ultimately argues that the entire structure of recognition between men and women must be altered in order to permit an end to domination. Neither Gilligan nor Benjamin addresses the possibility of reformulating the notion of autonomy itself, but each sees it as essentially linked with individualism and separation. Most feminist criticism of autonomy is based on the idea that autonomy implies a particular model or expectation of the self.

Marilyn Friedman and John Christman, however, point out that the proceduralist notion of autonomy which is the focus of contemporary philosophical attention does not have such an implication, but is metaphysically neutral and value neutral Friedman , ; Christman It addresses the challenge of balancing agency with social embeddedness, without promoting an excessively individualistic liberal atomism, or denying women the agency required to criticize or change their situation. The feminist work on relational autonomy attempts to capture the best of the available positions.

It is worth noting first, for clarity, that there are two levels of relationality at work within relational autonomy: social and relational sources of values, goals, and commitments, and social and relational commitments themselves. While all acknowledge that relationality at both levels is not incompatible with autonomy, not all accounts of relational autonomy require that we pursue social and relational commitments.

However other relational autonomy theorists are skeptical about neatly separating the two, because they note that even our unchosen relationships still affect our self-identity and opportunities. They argue that while we need not pursue relationships, we cannot opt out entirely. Anne Donchin demonstrates this with regard to testing for genetically inherited disease Donchin In general, on relational autonomy accounts, autonomy is seen as an ideal by which we can measure how well an agent is able to negotiate his or her pursuit of goals and commitments, some of which may be self-chosen, and some the result of social and relational influences. The primary focus of most relational autonomy accounts, however, tends to be less on procedure and more on changing the model of the autonomous self from an individualistic one to one embedded in a social context.

The value of autonomy can be seen in its social and political context. The idea that our decisions, if made autonomously, are to be respected and cannot be shrugged off, is a valuable one. It concerns the legitimacy of our personal decisions in a social, political, and legislative context. Discussions about the value of autonomy concern the extent of this right, and how it can be seen as compatible with social needs. Kant described the protection of autonomy at the political level as encapsulated in the principle of right: that each person had the right to any action that can coexist with the freedom of every other person in accordance with universal law Kant , On his view, this right prohibits paternalism, or restrictions or interference with a person of mature age for his or her own benefit.

In the part which merely concerns himself, his independence is, of right, absolute. The question is then how high the bar ought to be set, and thus what individual actions count as autonomous for the purposes of establishing social policy. Because of this, there is a strong connection between personal and political autonomy. Further, there is also a connection between political liberalism and content-neutral accounts of autonomy which do not require any predetermined values for the agent to be recognized as autonomous. The framework of seeing the value of political autonomy in terms of protecting individual choices and decisions, however, has been criticized by those who argue that it rests on an inadequate model of the self.

Communitarians such as Michael Sandel criticize the model of the autonomous self implicit in liberal political theory, arguing that it does not provide an adequate notion of the human person as embedded within and shaped by societal values and commitments. Procedural accounts of autonomous decision-making do not adequately recognize the way our relational commitments shape us. We do not choose our values and commitments from the position of already being autonomous individuals; in other words, the autonomous self does not exist prior to the values and commitments that constitute the basis for its decisions.

Feminist scholars have agreed with some of the communitarian criticism, but also caution that the values and commitments that communitarians appeal to may not be ones that are in line with feminist goals, in particular those values that concern the role and makeup of the family Okin and Weiss Another criticism of the dominant model of autonomy within political theory is made by Martha Fineman, who argues for the need to rethink the conceptions of autonomy that undergird legal and governmental policies in order to better recognize our interdependence and the dependence of all of us upon society Fineman , While not drawing on the philosophical literature on personal autonomy or relational autonomy, but rather drawing upon sociological theories and accounts of legal and government policy, she traces the historical and cultural associations of autonomy with individuality and masculinity, and argues the need to see that real human flourishing includes dependency.

Recognizing the different levels of autonomy at play within the political sphere as a whole can help to clarify what is at stake, and to avoid one-sided accounts of autonomy or the autonomous self. Rainer Forst outlines five different conceptions of autonomy that can combine into a multidimensional account Forst Even though this is an interpersonal norm, it is relevant to the political, argues Forst, because it promotes the mutual respect needed for political liberty.

Legal autonomy is thus the right not to be forced into a particular set of values and commitments, and is neutral toward them. California took another step toward its goal of ridding the state of all gas-powered engines thanks to a new bill signed by Gov. Gavin Newsom on Saturday. Wisconsin dismisses RB Jalen Berger from the football program. Tom Brady's yard touchdown pass to Antonio Brown against the Dolphins was yet another example of his greatness. How much money do NBA referees make? Heres a look at salaries and more for NBA officials. Experts are making their picks for the CFP with plenty of time left in the regular season.

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With nursing input, more diverse solutions can be explored, patient care planning is more robust, interdisciplinary communication is improved, and care coordination can provide for more effective implementation of plans. Recognizing autonomous practice can reinforce verbally communicated expectations. For example, acknowledging exemplary performance by having nurses share clinical examples that highlight autonomous practice provides a venue for displaying sanctioned autonomous practice.

In addition, emphasizing expected behaviors through recognitions and rewards outlines for nurses the realm of autonomous actions. Clinical ladder programs formally reward and recognize clinical practice, further delineating expected autonomous actions. Novice nurses quickly observe the nature of clinical judgment and autonomous nurse actions demonstrated by more senior colleagues Role modeling expected behaviors also reinforces autonomous clinical practice. Novice nurses quickly observe the nature of clinical judgment and autonomous nurse actions demonstrated by more senior colleagues and use these observations to identify accepted levels of independent and interdependent decision making. Clinical nurse leaders and clinical nurse specialists in the practice setting can engage in behaviors reflective of autonomy and serve as an ongoing resource for role modeling, coaching, and mentoring excellence in clinical practice.

A component of coaching for autonomous behavior includes addressing when behaviors are not within the range of expected actions. For example, if nurses are not making the expected autonomous decisions, coaches can compare actual with expected actions to show how to make the expected nursing contributions and behaviors more explicit. Addressing inappropriate actions using constructive feedback can guide autonomous nursing practice. If nurses take clinical actions that are not appropriate or not successful, constructive feedback can redirect their practice patterns.

Studies have suggested that creating a climate that is supportive of nursing practice will augment the level of autonomous practice. For example, nurses working in Magnet hospitals perceived that managers were more supportive of their independent clinical decision making than did nurses working in non-Magnet hospitals Upenieks, Because of perceptions of support, nurses in Magnet hospitals may be more willing to assume the risk for making autonomous patient care decisions. Building trust in the clinical setting by supporting nursing actions that may be risky, yet are safe, encourages innovative practice and enhances autonomy.

The establishment of the sound clinical judgment needed for autonomous practice requires a foundation of nursing expertise. Although difficult to define, nursing expertise is a combination of knowledge and skill along with extensive experience Jasper Thus, implementing strategies to increase the competence of nurses by creating a learning environment can foster autonomy.

Stewart, Stansfield, and Tapp reported that autonomy can be fostered by enhancing competence and confidence through strategies such as teaching rounds, formal continuing education, and a climate of inquiry in everyday practice. Also during staff meetings, clinicians can share complicated patient scenarios that have challenged their autonomous decision making to both exemplify excellence in practice and receive feedback on how to further enhance patient care. Promoting evaluation of autonomous practice in this way allows for unique variation in culture and norms between units. Encouraging the continuous examination of practice allows nurses to reflect on the degree of autonomy present in their decision making.

In addition, establishing an evidence-based practice approach may develop and enhance autonomy. By identifying and evaluating relevant research while simultaneously assessing and incorporating information about patient preferences into their plans, nurses have the opportunity to make autonomous patient care decisions. Further, development of skills related to communication, interdisciplinary teamwork, and negotiation can assist nurses to master the skills necessary to advocate for their patients. Creating an environment that supports both formal and informal continuing educational opportunities and learning provides for autonomous clinical practice.

Baccalaureate-prepared nurses have reported a higher preference for both clinical autonomy and CONP Blegen et al. Further, Ericsson, Whyte, and Ward found that nurses with specialty nurse certification and specific clinical training demonstrated higher levels of expertise. Tuition reimbursement and support for returning to school can enhance the development of skills and competence needed to support autonomous practice.

The importance of the culture of learning cannot be stressed enough. For example, while nurse managers at non-Magnet hospitals focused on adequate staffing as a critical element, managers at Magnet hospitals emphasized educational opportunities and an autonomous climate as being a vital factor for nurse satisfaction Upenieks, In the Mrayyan study supportive management, education, and experience were identified as the three most important factors in enhancing autonomy over patient care and unit operations. In summary, autonomy can be increased by strategies that incorporate the unique knowledge and expertise of nurses into clinical patient care.

Clarifying the expectation that valuable nursing knowledge should be applied in the practice setting provides the framework for enhancing clinical autonomy. Professional enrichment and education build the clinical knowledge and competence that is a necessary foundation for nurse autonomy. Most nurses practice as employees, and as a result must structure their work within imposed rules that have a profound effect on their practice Hess, To truly control their practice, nurses must have both the right and the power to make decisions affecting the rules surrounding their practice.

Nurses must create and use decision-making structures at the workgroup, organizational, and professional levels of practice. Historically the concepts of empowerment and participatory management have been laden with a paternalistic tone of people in positions of authority allowing staff to provide input and participate in some operations.

An organized structure for nurse participation in decisions, along with an explicit communication processes contribute to enhancing CONP. Kramer and Schmalenberg b have shared that nurses in organizations with high levels of CONP describe an operative structure that is in place, one that is recognized as authoritative by others. The representatives in the structure are known and some input is sought and expected from all nurses.

In addition, staff nurses have responsibility and accountability for the issues and solutions discussed within the structure. The classic example of such a structure is a shared governance council with nurses actively managing decisions related to their practice. The importance of nurses having responsibility and accountability for professional and practice issues cannot be stressed enough. The structure for CONP is one in which the responsibility for nursing care of patients is placed with staff nurses Hinshaw, Fundamentally, this is where many shared governance programs go awry.

In these situations, although an organizational structure is established and nurses are permitted to provide input into key decisions, the ultimate authority for the decision making continues to reside with managers and administrators. Because nurses typically work as employees within a larger structure and within the healthcare system itself, nurses must have a formal structure for participating in organizational and system decisions.

For example, within employment settings, nurses should be included along with physicians and administrators on key organizational committees that establish patient care policies and procedures. The expectation should be set that nurses will share a full and equal voice in, and responsibility for making patient care decisions McKay, Not only does this foster strong, productive nurse-physician and nurse-administrator relationships, it also contributes to necessary interdisciplinary richness Hinshaw, ; Ponte, Whatever organizational structure is used, nurses should be able to make program and resource decisions without going through layers of bureaucracy that stifle innovation and implementation. In addition, to be involved, nurses must be active on hospital and professional committees.

Nurses can maximize the opportunity for colleagues to attend meetings or complete committee work by adequately staffing for patient care. Fundamentally, nurses need to foster the understanding that their work involves both the direct clinical care of patients as well as the management of the context in which that care is delivered. As a result, both clinical patient care and organizational and committee work are within the realm of nursing practice. Nurses cannot effectively practice without the right resources including an appropriate amount and mix of caregivers, supplies, and supporting systems or without the necessary evidence-based policies and practices.

To control practice, nurses must have some influence over necessary resources and policies for their practice Hess, To do so, nurses must ensure that they and their colleagues are well-represented and able to be influential whenever and wherever key decisions are being made that will impact the nature, scope, and context of their practice. Although it is important that clinical nurses serve on committees, they are generally underprepared to do so; hence they are challenged in representing their needs.

Studies find that clinical nurses participate to a greater extent in decisions related to clinical patient care decisions than to unit or organizational decisions Anthony, ; Blegen et al. As a result, investing in teaching nurses about the decision-making process, coaching them through early decision making, and supporting both successful and unsuccessful decisions will foster an environment for increasing autonomy and also CONP.

Expecting nurses to participate without allowing opportunities to acquire prerequisite skills will result in either frustration or apathy Hess, Ensuring that nurses develop the skills to manage meetings, gather and analyze existing evidence, explore alternatives, and make sound decisions will support CONP. In this way, nurses will have the knowledge and ability to not only make recommendations but also be empowered to enact decisions. Nurse leaders, whether in management, clinical, educational, or research positions, can be taught facilitation skills to enhance their ability to garner discussion that leads to identification of group expertise without dominating the discussion or decision making.

Naturally, during decision making, creative tensions will emerge by exposing differences in perspectives and gaps between organizational visions and current realities Burns Teaching leaders to pose questions that expose assumptions and challenge sacred cows can help to illuminate tensions and paradoxes, thus ultimately fostering creative new solutions. In summary, CONP can be increased by strategies that ensure nurse participation in key decisions within the organizational and professional structure.

Establishing the structures and processes for active nurse input and decision making provides the framework for enhancing CONP. Because many nurses have little such experience, investing in teaching and supporting decision making related to the context of nursing care is necessary to build competence for CONP. Nurse managers in particular are instrumental in producing the conditions for autonomy and CONP. Although leadership can come from any nurse, designated leaders remain extremely influential for enhancing both autonomy and CONP.

Consistently the recommendation is made to create strong, visible nursing leadership in the nursing department and at the unit level to increase autonomy and CONP Hinshaw, In a qualitative study, seven staff-nurse focus groups identified and rank ordered the skills needed by a nurse manager to effectively manage a patient care unit. The top three management skills in descending order were effective communication, remaining available to staff, and involving staff in decision making Maceri, Supervisor support was positively correlated with nurses reporting more control over their work and higher satisfaction Hall, Nurse manager actions, specifically those encouraging nurses to communicate openly with other healthcare team members, supporting nurses to resolve conflicts, and encouraging leadership, were associated with increased nurse participation in patient care and conditions of work decisions Mrayyan, In addition to the critical role of the nurse manager, executive leadership is critical to creating an environment that is supportive of autonomy and CONP.

Organizationally, a visionary nurse executive who trusts and values nursing staff is essential for creating the context for high levels of autonomy and CONP. A chief nurse executive who a advocates for a strong, influential nursing presence in the organization; b is open and communicative; and c supports participative management is associated with a professional environment that includes autonomous clinical practice and nursing control over practice Hinshaw, Upenieks reported that when the entire executive team, and not just the nurse executive, offered support of nursing, a climate was established that endorsed autonomous nursing practice. Thus, the role of formal nurse leaders is powerful in establishing the context for autonomy and CONP.

In contrast to the traditional command-and-control management style that results in stabilization of practices, enhancing autonomy and CONP involves leadership that encourages and fosters new ideas and innovation. In addition to addressing autonomy and CONP at the individual and organizational levels, nurses have real opportunities to shape the social, political, and economic factors that influence their practice within the healthcare system. Whereas nurses describe autonomy in terms of clinical practice, sociologists describe autonomy as the right of a profession to control its own work free from the influence or power of others Freidson,

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