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PROFESSIONAL ISSUES

Developing a concept analysis of


autonomy in nursing practice
Johit Wilkinson

T he ability to define and categorize


concepts is essential in order to make
sense of an issue and effectively com-
municate it to others. Batey (1977) argues
that the greatest limitation of nursing
Abstract
This article presents a concept analysis of autonomy and offers some
insights Into the quest for and operatlonallzation of autonomous nursing
practice. Recommendations are made regarding automony and nursing
research is the vagueness with which key practice at the level of the individuai practitioner. This concept is also
terms are clarified. The process of conducting examined in reiation to the context in which nursing care is deiivered. The
a concept analysis is challenging. Critical conclusions drawn as a result of this anaiysis serve as a focus for debate
thinking is a desirable quality in nursing on the challenges that nurses and those invoived in their education face.
(Kemp, 1985) and potentially leads to an
enhanced understanding of a topic. Rodgers The word is derived from the Greek words
(19S9) offers a flexible method of concept 'autos' (self) and 'nemien' (to hold sway)
analysis which acknowledges the potential (Curtin, 1987).
for subjectivity in concept definition. At a physiological level, an autonomous
In undertaking a concept analysis of auton- process is characterized by its independence
omy the author used Walker and Avant's from rhe usual processes of regulation, e.g. the
(1988) strategy as it offers a structured autonomic nervous system functions largely
approach which assists in the achievement of independently of conscious will (Marieb,
rigour in the process. 1992}. At a personal level, autonomy refers to
The issue of autonomy has received much determining and defining self, which suggests
attention in the nursing literature. The empha- liberty to select and act according to one's
sis has mainly focused on the desirabilit)' of will, independent thought and control over
autonomy for both practitioners and recipients choice (Shotter, 1975; Rogers, 1983).
of care. Indeed, the concept of autonomous The importance of regarding autonomy in
nursing practice being delivered in partnership context is highlighted when the concept is con-
with an autonomous patient/client has been sidered at a social level (Jary and jar>', 1991).
advocated as the panacea of modem profes- While acknowledging that some social out-
sional nursing (Leddy and Pepper, 1993). The comes are a direct result of the individual's
concept of autonomy appears complex and yet intended actions, a model of autonomy must
it is fundamental to human existence. The lack take account of constraining factors:
of precision in its definition makes the search
for clarity and understanding a challenge. '...to believe that man is the author of
his destiny is not to deny that he may be
A greater understanding of autonomy gives
tragically limited by his circumstances'
insight into the following questions:
(Kelly, i98i).
Is autonomous nursing practice desirable?
Is autonomous nursing practice possible? The notion of independence is the core
How may autonomous nursing practice (if theme of autonomy. In addition, it is not an
desirable and possible) be enhanced? all-or-nothing state, i.e. its variable interde-
pendence on determining factors is clear. One
USES OF THE CONCEPT is only truly autonomous when one is aware
of the extent to which one is being deter-
A typical definition of autonomy is: mined by external factors (Stevens, 1984).
The nursing literature uses the term autono- John WilkinsoJ
'...the having or making of one's own my in a variety of ways. Batey and Lewis in Nursing, Royal COIICRC
of Nurisng Institute,
laws, independence...' (1982) identify it with self-determination, self- London
(Tite Oxford English Dictionary, 1989). direcrinn, independence and not being con-

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PROFESSIONAL ISSUES

The term trolleii by .111 t'xtcrn.il iij;cnt. It is also associat- notion of independence further. Tbere appears
ed with tlu- control of pr.ictice (Singleton and to he a dissonance between tbe concept of
autonomy as N.iil, iy4), the power to act (Ward and independence .md the emphasis placed on mul-
cited in nursing Kozakowski, 1987), independent practice tidisciplinary teamwork and patient empower-
literature has a iHindshaw ct al, 1987), and control over deci- ment in modern bealtb care. Hence, this char-
sion-making (Owyer et al, 1992). All authors acteristic was not selected as a critical defining
variety of uses... associate auttuiomy in nursing practice with attribute. Self-regulation appears to be intu-
autonomy involves the establishment of a professional right to itively desirable to nursing (Batey and Lewis,
self-determination, practice nursing based on a professional agen- 1982; Singleton and Nail, 1984; Curtin, 1987;
da, e.g. the Code of Professional Conduct Quinn and Smith, 1987; Ward and
self-direction, (UKCC, 1992a) and The Scope of Ptofessional Kozakowski, 1987; Manthey, 1989;
independence Practice (UKCC, 1992b). Botb of these docu- McCloskey, 1990; Dwyer et al, 1992; Henr>',
and not being ments draw attention to the limits of profes- 1993; Kramer and Schmalenberg, 1993;
sional autonomy, i.e. tbe nurse's autonomy is McCormack, 1993). These authors associate
controlled by limited by the authority of medical profession- autonomy witb professionalism wbicb is con-
an external als and/or that of his/her employers. gruent witb self-regulation (Giddens, 1993).
agent. From a consumer perspective. The Patient's Authority to make decisions regarding the uti-
Charter (Department of Healtb (DoH), 1995) lization of professional judgment is well docu-
highlights tbat tbe autonomy of patients may mented in tbe nursing literature (Batey and Lewis,
occasionally challenge the nurse's autonomy, e.g. 1982; Singleton and NaJ, 1984; Perr>', 1986;
in relation to compliance with care. This tension Curtin, 1987; Quinn and Smith, 1987; Dw>'eret
is addressed b>' Porter (1992) who comments that al, 1992; Ward and Kozakowski, 1987; Mandiey,
nurses' professional autonomy is at odds witb the 1989; Johns, 1990; Wright, 1990; Tettersell,
increasing trend towards patient empowerment. 1992). In tbecontext of autonomy, decision-mak-
The literature suggests that: ing refers to those decisions wbich are based in a
To be truly independent is idealistic, unique and professional knowledge base.
impossible and undesirable as tbis Freedom from determining forces is incon-
impinges on the autonomy of others gruous witb autonomy. Indeed, Hollis (1977)
To be knowledgeable of determining forces suggests tbat an assumption of complete
and to act to increase reflexive awareness so agency is indicative of lack of autonomy.
that we seek to understand and, on occa- There is evidence tbat nurses work with an
sion, challenge the way we are shaped and acknowledgement of constraints (Porter,
created is realistic and desirable for nursing 1992; UKCC, 1992a; Leddy and Pepper,
in particular and mankind in general. 1993). This critical defining attribute draws
The latter of these two propositions attention to the notion that autonomous
appears highly desirable and wili be analysed nursing practice is context dependent, and as
further in order to yield clarification and sucb goes beyond an individual nurse or nurs-
enbanced understanding. ing as a whole. The critical defining attribut-
es to emerge from this analysis are that the
DETERMINATION OF DEFINING autonomous nurse:
ATTRIBUTES /. Practices within a professional context
which is self-regulatifig
The process of identifying tbe defining attributes 2. Makes decisions which are based on profes-
of autonomy involved using tbe literature to sional judgment and is able to act on these
extract representations of tbe various dimen- within his/her own sphere of practice
sions of tbe concept. Tbe process was conducted 3. Is cogniziint with deternutung forces and
in an uncritical fashion, similar to a brainstorm has the ktiowledge to judge when these
technique, to attempt to minimize any filtering should be acquiesced, and when they
or distortion of tbe elements. Following tbis shotdd be challenged.
process a list of provisional criteria was estab-
lished: independence; self-regulation; authority' ILLUSTRATIVE CASES
to make decisions; freedom from determining
forces; and knowledge of determining forces. A model case
If autonomy is conceptualized as being on a A model case is a real life example of tbe use
continuum it is inappropriate to pursue tbe of a concept. It includes all the critical defin-

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DEVELOPING A CONCEPT ANALYSIS OF AUTONOMY IN NURSING PRACTICE

ing attributes of that concept nnd excludes to satisfy defining attribute 2), Sally, being dis- Michael does
those of any otlicr concept, lt is hence a pure satisfied with her inactivit)' in Andrew Brown's
as he is asked
exemplar ot the concept, care, refers him to a colleague. She then seeks
Annie is a registered general nurse who is information on access to assertion skills train- although he
employed as a staff nurse in a coronary care unit ing (satisfies defining attribute 3), disagrees with the
(satisfies defining attribute I), She is caring for
decision. He believes
Mrs Pauline Spencer who is being treated for A related case
ischaemic heart disease. Unexpectedly, Mrs A related case is where concepts which arc-
that the sunshine
Spencer collapses into unconsciousness and her similar to the concept in question, but which should be enjoyed
cardiac monitor displays ventricular fibrillation. do not satisfy all the defining attributes, are not avoided. He is
Annie uses her professional judgment to assess exemplified. Independence, freedom and lib-
her patient and concludes that she is suffering a erty are synonyms of autonomy (Microsoft, unaware of the
cardiopulmonary arrest. She decides to initiate 1993), Batey and Lewis (1982) discuss the effects direct sun
advanced life support procedures and adminis- interrelatedness of responsibility and authori-
ters deHbrillation which is within her scope of
light can have on the
ty, and Leddy and Pepper (1993) stress the
professional practice as a specialist nurse (satis- link between authority and accountability. skin of people
fies defining attribute 2). The cardiac arrest Separate concept analyses could be done on receiving
team arrives in response to Annie's request and these synonyms in order to yield defining
advanced life support procedures continue.
phenothiazine
attributes and model cases which could then
Annie responds to medical instructions regard- be compared and contrasted with the defining medication.
ing the administration of intravenous prescrip- attributes of autonomy.
tions, but challenges the medical registrar when
he suggests pauses beuveen the administration
A contrary case
of defibrillation tocarr\'out basic life support as
A contrary case occurs when a concept is nur
she is aware of the current research (European
being represented, i.e. none of rhe defining
Resuscitation Council, 1992) which gives
attributes are present.
empirical support to the efficacy of rapid repeat-
Michael is a volunteer who helps in an
ed defibrillation (satisfies defining attribute 3).
elderly mentally ill ward (fails to satisfy defin-
ing attribute 1), The ward sister asks him to
Additional cases assist a nurse in persuading a group of
Additional cases serve to delineate the bound- patients who are sitting in the sun to move
aries of autonomy and to enhance under- into the shade. Michael does as he is asked
standing and its appropriate usage. but disagrees with the decision. He believes
that they should be allowed to enjoy che sun-
A borderline case shine. He is unaware of the effects direct sun-
A borderline case only partially reflects the light can have on the skin of people receiving
defining attributes of rhe concept and is hence phenothiazine medication, (fails to satisfy
inconsistent with its full representation. defining attribute 2). Michael complains that
Sally is a registered sick children's nurse who it is unreasonable to limit the patients' access
is employed as a staff nurse in a paediatric res- to the sun. He was unable to appreciate that
piratory clinic (satisfies defining attrihute 1), A patient safety had to he considered in con-
key component of Sally's responsibilit)' is to junction with patient enjoyment (fails to sat-
advise children and their families on health isfy determining attribute 3).
education. When her patients are motivated
and compliant Sally enioys and is confident and An invented case
skilled in this area of her work. Unfortunately, An invented case involves the transposition of
she is not very assertive and finds it difficult to a concept from its usual context into an
challenge certain parents. Andrew Brown's invented scenario to assist in the clarification
mother is a heavy smoker and in Sally's profes- of the concept. This invented scenario is out-
sional judgment passive smoking is exacerbat- side one's sphere of experience.
ing Andrew's asthma. Sally decides that this
Clarence is an angel (third class) who has
needs to be discussed with Mrs Brown, and
won his wings and as such has earned tbe right
knows that this is within her scope of practice.
to sit on the angel's council and to contribute to
However, she fails to address this issue because
the angel's charter which governs how angels
she is afraid of antagonizing Mrs Brown (fails
do their work (satisfies determining attribute

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PROFESSIONAL ISSUES

The potential 1). He sees th;U his old friend CJeorge Bailey is Decision-making is central to the critical defin-
in t r i i i i b i c nj^nin n i u l ik-citit's t o r L t i i t n t o A tovvti ing attributes in tbis study. It presents tbe option
for professional to act (ir not to act. Kvery nurse, being part of a
1)11 c.uiii called liedtord lalls to help him in
growth is dependent accordance with his skills as an angel (satisfies self-regulating profession, has the option to put
on professional defining attrihutc 2). In so doing Clarence is bim/herself forward for office or to selea those
fully aware that Ciod dues not permit direct whom hc/sbe wishes to be elected by a balloting
communication action, hut th.u it is permissible for him to system. Entering into professional debate is seen
occurring both demonstrate to George that he has a lot going as autonomous practice; not entering into pro-
through the for him in his life. Clarence has the knowledge fessional debate is therefore viewed as not
and confidence to negotiate with God the mode autonomous and as being contradictory to chal-
dissemination of of action he will take (satisfies defining lenging determining forces. It would appear,
propositional attribute 3). (With apologies to Frank Capra therefore, that communication over profession-
knowledge and (1947) US a Wonderful Life, RKO Films). al issues is a consequence of autonomy.
Tbe potential for professional growtb is
through the IDENTIFICATION OF ANTECEDENTS dependent on professional communication
acquisition of occurring botb through the dissemination of
tacit knowledge Critical defining attributes are indicative of the propositional knowledge and through the
occurrenue of autonomy. Hence, the antecedents acquisition of tacit knowledge by reflective
by reflective of the concept are circumstances which enable practice (Bolt, 1993). The current interest in
practice... the critical defining attributes to occur. clinical supervision (Faugier and Butterworth,
Consequently, to enable a nurse to practice 1994) demonstrates that nurses are required to
autonomously the following must be satisfied: make clear those factors which determine their
The nurse must satisfy the requirements to practice. The autonomous nurse must be able
enter and remain on the professional regis- to account for the professional decisions made.
ter (e.g. UKCC, 1992a, 199>). An autonomous nurse seeks role develop-
The nurse must have professional knowl- ment according to his/her personal and pro-
edge and skills (e.g. DoH, 1983) fessional agenda. The reduction in medical
The nurse must have a defined area of staffing hours can be regarded as either an
practice (UKCC. 1992b) opportunity' or an imposition for nurses. The
The nurse must have knowledge and skills autonomous nurse must decide the bound-
on which he/she can reflect in order to yield aries of bis/her practice in accordance with
tacit knowledge (Atkins and Murphy, 1993) areas of already accepted responsibility.
The nurse must desire autonomy (Ward
and Kozakowski, 1987) DEFINING EMPIRICAL REFERENTS
The nurse must have the responsibility and
authority to act autonomously (Batey and Walker and Avant (19S8) recognize tbat
Lewis, 1982) empirical referents and critical defining
Nurses must feel that tbey bave the right to attributes may be identical, and therefore the
challenge tbeir circumstances, botb indi- factors previously identified for critical defin-
vidually and collectively (Barber, 1993) ing attributes must be sougbt in practice. The
Tbe context must be supportive of, and cases generated serve as examples of how
value, professional nursing practice empirical referents may be recognized.
(Curtin, 1987) There is evidence to suggest that autonomous
The bureaucracy must be one of partnersbip nurses experience greater job satisfaction
with a bottom-up component to manage- (McCloskey, 1990; Dwyer et al, 1992; Tingle,
ment (Kramer and Schmalenberg, 1993). 1992). It would therefore be reasonable to use
tbe same data collection tecbniques used by
IDENTIFICATION OF CONSEQUENCES tbese autbors to assess nurses' perceived job
satisfaction and level of autonomy.
Identifying consequences can sbed light on: Nurse recruitment and retention has been
investigated in relation to perceived autono-
'...often neglected areas, variables or my. An association was demonstrated
relationships tbat may yield fruitful new between autonomy and the popularity of
research directions' work place (Ward and Kozakowski, 1987;
iWaliier and Avant, 1988}. McCloskey, 1990; Dwyer et al, 1992; Tmgle,

706 BumsH JOURNAL OF NURSING, 1997, VOL 6, No 12


DEVELOPING A CONCEPT ANALYSIS OF AUTONOMY IN NURSING PRACTICE

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