topic on autonomy

PROFESSIONAL ISSUES

Developing a concept analysis of autonomy in nursing practice Johit Wilkinson

The 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 research is the vagueness with which key terms are clarified. The process of conducting a concept analysis is challenging. Critical thinking is a desirable quality in nursing (Kemp, 1985) and potentially leads to an enhanced understanding of a topic. Rodgers (19S9) offers a flexible method of concept analysis which acknowledges the potential for subjectivity in concept definition.

In undertaking a concept analysis of auton- omy the author used Walker and Avant's (1988) strategy as it offers a structured approach which assists in the achievement of rigour in the process.

The issue of autonomy has received much attention in the nursing literature. The empha- sis has mainly focused on the desirabilit)' of autonomy for both practitioners and recipients of care. Indeed, the concept of autonomous nursing practice being delivered in partnership with an autonomous patient/client has been advocated as the panacea of modem profes- sional nursing (Leddy and Pepper, 1993). The concept of autonomy appears complex and yet it is fundamental to human existence. The lack of precision in its definition makes the search for clarity and understanding a challenge.

A greater understanding of autonomy gives insight into the following questions: • Is autonomous nursing practice desirable? • Is autonomous nursing practice possible? • How may autonomous nursing practice (if

desirable and possible) be enhanced?

USES OF THE CONCEPT

A typical definition of autonomy is:

'...the having or making of one's own

laws, independence...' (Tite Oxford English Dictionary, 1989).

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 practice at the level of the individuai practitioner. This concept is also examined in reiation to the context in which nursing care is deiivered. The conclusions drawn as a result of this anaiysis serve as a focus for debate on the challenges that nurses and those invoived in their education face.

The word is derived from the Greek words 'autos' (self) and 'nemien' (to hold sway) (Curtin, 1987).

At a physiological level, an autonomous process is characterized by its independence from rhe usual processes of regulation, e.g. the autonomic nervous system functions largely independently of conscious will (Marieb, 1992}. At a personal level, autonomy refers to determining and defining self, which suggests liberty to select and act according to one's will, independent thought and control over choice (Shotter, 1975; Rogers, 1983).

The importance of regarding autonomy in context is highlighted when the concept is con- sidered at a social level (Jary and jar>', 1991). While acknowledging that some social out- comes are a direct result of the individual's intended actions, a model of autonomy must take account of constraining factors:

'...to believe that man is the author of his destiny is not to deny that he may be tragically limited by his circumstances' (Kelly, i98i).

The notion of independence is the core theme of autonomy. In addition, it is not an all-or-nothing state, i.e. its variable interde- pendence on determining factors is clear. One is only truly autonomous when one is aware of the extent to which one is being deter- mined by external factors (Stevens, 1984).

The nursing literature uses the term autono- my in a variety of ways. Batey and Lewis (1982) identify it with self-determination, self- direcrinn, independence and not being con-

John WilkinsoJ in Nursing, Royal COIICRC of Nurisng Institute, London

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PROFESSIONAL ISSUES

The term autonomy as

cited in nursing literature has a variety of uses... autonomy involves self-determination, self-direction, independence and not being controlled by an external agent.

trolleii by .111 t'xtcrn.il iij;cnt. It is also associat- ed with tlu- control of pr.ictice (Singleton and N.iil, iy«4), the power to act (Ward and Kozakowski, 1987), independent practice iHindshaw ct al, 1987), and control over deci- sion-making (Owyer et al, 1992). All authors associate auttuiomy in nursing practice with the establishment of a professional right to practice nursing based on a professional agen- da, e.g. the Code of Professional Conduct (UKCC, 1992a) and The Scope of Ptofessional Practice (UKCC, 1992b). Botb of these docu- ments draw attention to the limits of profes- sional autonomy, i.e. tbe nurse's autonomy is limited by the authority of medical profession- als and/or that of his/her employers.

From a consumer perspective. The Patient's Charter (Department of Healtb (DoH), 1995) highlights tbat tbe autonomy of patients may occasionally challenge the nurse's autonomy, e.g. in relation to compliance with care. This tension is addressed b>' Porter (1992) who comments that nurses' professional autonomy is at odds witb the increasing trend towards patient empowerment.

The literature suggests that: • To be truly independent is idealistic,

impossible and undesirable as tbis impinges on the autonomy of others

• To be knowledgeable of determining forces and to act to increase reflexive awareness so that we seek to understand and, on occa- sion, challenge the way we are shaped and created is realistic and desirable for nursing in particular and mankind in general.

The latter of these two propositions appears highly desirable and wili be analysed further in order to yield clarification and enbanced understanding.

DETERMINATION OF DEFINING ATTRIBUTES

The process of identifying tbe defining attributes of autonomy involved using tbe literature to extract representations of tbe various dimen- sions of tbe concept. Tbe process was conducted in an uncritical fashion, similar to a brainstorm technique, to attempt to minimize any filtering or distortion of tbe elements. Following tbis process a list of provisional criteria was estab- lished: independence; self-regulation; authority' to make decisions; freedom from determining forces; and knowledge of determining forces.

If autonomy is conceptualized as being on a continuum it is inappropriate to pursue tbe

notion of independence further. Tbere appears to he a dissonance between tbe concept of independence .md the emphasis placed on mul- tidisciplinary teamwork and patient empower- ment in modern bealtb care. Hence, this char- acteristic was not selected as a critical defining attribute. Self-regulation appears to be intu- itively desirable to nursing (Batey and Lewis, 1982; Singleton and Nail, 1984; Curtin, 1987; Quinn and Smith, 1987; Ward and Kozakowski, 1987; Manthey, 1989; McCloskey, 1990; Dwyer et al, 1992; Henr>', 1993; Kramer and Schmalenberg, 1993; McCormack, 1993). These authors associate autonomy witb professionalism wbicb is con- gruent witb self-regulation (Giddens, 1993).

Authority to make decisions regarding the uti- lization of professional judgment is well docu- mented in tbe nursing literature (Batey and Lewis, 1982; Singleton and NaJ, 1984; Perr>', 1986; Curtin, 1987; Quinn and Smith, 1987; Dw>'eret al, 1992; Ward and Kozakowski, 1987; Mandiey, 1989; Johns, 1990; Wright, 1990; Tettersell, 1992). In tbecontext of autonomy, decision-mak- ing refers to those decisions wbich are based in a unique and professional knowledge base.

Freedom from determining forces is incon- gruous witb autonomy. Indeed, Hollis (1977) suggests tbat an assumption of complete agency is indicative of lack of autonomy.

There is evidence tbat nurses work with an acknowledgement of constraints (Porter, 1992; UKCC, 1992a; Leddy and Pepper, 1993). This critical defining attribute draws attention to the notion that autonomous nursing practice is context dependent, and as sucb goes beyond an individual nurse or nurs- ing as a whole. The critical defining attribut- es to emerge from this analysis are that the autonomous nurse: /. Practices within a professional context

which is self-regulatifig 2. Makes decisions which are based on profes-

sional judgment and is able to act on these within his/her own sphere of practice

3. Is cogniziint with deternutung forces and has the ktiowledge to judge when these should be acquiesced, and when they shotdd be challenged.

ILLUSTRATIVE CASES

A model case A model case is a real life example of tbe use 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 those of any otlicr concept, lt is hence a pure exemplar ot the concept,

Annie is a registered general nurse who is employed as a staff nurse in a coronary care unit (satisfies defining attribute I), She is caring for Mrs Pauline Spencer who is being treated for ischaemic heart disease. Unexpectedly, Mrs Spencer collapses into unconsciousness and her cardiac monitor displays ventricular fibrillation. Annie uses her professional judgment to assess her patient and concludes that she is suffering a cardiopulmonary arrest. She decides to initiate advanced life support procedures and adminis- ters deHbrillation which is within her scope of professional practice as a specialist nurse (satis- fies defining attribute 2). The cardiac arrest team arrives in response to Annie's request and advanced life support procedures continue. Annie responds to medical instructions regard- ing the administration of intravenous prescrip- tions, but challenges the medical registrar when he suggests pauses beuveen the administration of defibrillation tocarr\'out basic life support as she is aware of the current research (European Resuscitation Council, 1992) which gives empirical support to the efficacy of rapid repeat- ed defibrillation (satisfies defining attribute 3).

Additional cases Additional cases serve to delineate the bound- aries of autonomy and to enhance under- standing and its appropriate usage.

A borderline case A borderline case only partially reflects the defining attributes of rhe concept and is hence inconsistent with its full representation.

Sally is a registered sick children's nurse who is employed as a staff nurse in a paediatric res- piratory clinic (satisfies defining attrihute 1), A key component of Sally's responsibilit)' is to advise children and their families on health education. When her patients are motivated and compliant Sally enioys and is confident and skilled in this area of her work. Unfortunately, she is not very assertive and finds it difficult to challenge certain parents. Andrew Brown's mother is a heavy smoker and in Sally's profes- sional judgment passive smoking is exacerbat- ing Andrew's asthma. Sally decides that this needs to be discussed with Mrs Brown, and knows that this is within her scope of practice. However, she fails to address this issue because she is afraid of antagonizing Mrs Brown (fails

to satisfy defining attribute 2), Sally, being dis- satisfied with her inactivit)' in Andrew Brown's care, refers him to a colleague. She then seeks information on access to assertion skills train- ing (satisfies defining attribute 3),

A related case A related case is where concepts which arc- similar to the concept in question, but which do not satisfy all the defining attributes, are exemplified. Independence, freedom and lib- erty are synonyms of autonomy (Microsoft, 1993), Batey and Lewis (1982) discuss the interrelatedness of responsibility and authori- ty, and Leddy and Pepper (1993) stress the link between authority and accountability. Separate concept analyses could be done on these synonyms in order to yield defining attributes and model cases which could then be compared and contrasted with the defining attributes of autonomy.

A contrary case A contrary case occurs when a concept is nur being represented, i.e. none of rhe defining attributes are present.

Michael is a volunteer who helps in an elderly mentally ill ward (fails to satisfy defin- ing attribute 1), The ward sister asks him to assist a nurse in persuading a group of patients who are sitting in the sun to move into the shade. Michael does as he is asked but disagrees with the decision. He believes that they should be allowed to enjoy che sun- shine. He is unaware of the effects direct sun- light can have on the skin of people receiving phenothiazine medication, (fails to satisfy defining attribute 2). Michael complains that it is unreasonable to limit the patients' access to the sun. He was unable to appreciate that patient safety had to he considered in con- junction with patient enjoyment (fails to sat- isfy determining attribute 3).

An invented case An invented case involves the transposition of a concept from its usual context into an invented scenario to assist in the clarification of the concept. This invented scenario is out- side one's sphere of experience.

Clarence is an angel (third class) who has won his wings and as such has earned tbe right to sit on the angel's council and to contribute to the angel's charter which governs how angels do their work (satisfies determining attribute

Michael does as he is asked

although he disagrees with the decision. He believes that the sunshine should be enjoyed not avoided. He is unaware of the effects direct sun light can have on the skin of people receiving phenothiazine medication.

BRmiiH JOLJKNAL OF NUKiINC, 19^7, VOL 6, N o 12 70S

PROFESSIONAL ISSUES

The potential for professional

growth is dependent on professional communication occurring both through the dissemination of propositional knowledge and through the acquisition of tacit knowledge by reflective practice...

1). He sees th;U his old friend CJeorge Bailey is in t r i i i i b i c nj^nin n i u l ik-citi t 's t o rL t i i tn t o A tovvti

1)11 c.uiii called liedtord lalls to help him in accordance with his skills as an angel (satisfies defining attrihutc 2). In so doing Clarence is fully aware that Ciod dues not permit direct action, hut th.u it is permissible for him to demonstrate to George that he has a lot going for him in his life. Clarence has the knowledge and confidence to negotiate with God the mode of action he will take (satisfies defining attribute 3). (With apologies to Frank Capra (1947) US a Wonderful Life, RKO Films).

IDENTIFICATION OF ANTECEDENTS

Critical defining attributes are indicative of the occurrenue of autonomy. Hence, the antecedents of the concept are circumstances which enable the critical defining attributes to occur. Consequently, to enable a nurse to practice autonomously the following must be satisfied: • The nurse must satisfy the requirements to

enter and remain on the professional regis- ter (e.g. UKCC, 1992a, 199>).

• The nurse must have professional knowl- edge and skills (e.g. DoH, 1983)

• The nurse must have a defined area of practice (UKCC. 1992b)

• The nurse must have knowledge and skills on which he/she can reflect in order to yield tacit knowledge (Atkins and Murphy, 1993)

• The nurse must desire autonomy (Ward and Kozakowski, 1987)

• The nurse must have the responsibility and authority to act autonomously (Batey and Lewis, 1982)

• Nurses must feel that tbey bave the right to challenge tbeir circumstances, botb indi- vidually and collectively (Barber, 1993)

• Tbe context must be supportive of, and value, professional nursing practice (Curtin, 1987)

• The bureaucracy must be one of partnersbip with a bottom-up component to manage- ment (Kramer and Schmalenberg, 1993).

IDENTIFICATION OF CONSEQUENCES

Identifying consequences can sbed light on:

'...often neglected areas, variables or relationships tbat may yield fruitful new research directions' iWaliier and Avant, 1988}.

Decision-making is central to the critical defin- ing attributes in tbis study. It presents tbe option to act (ir not to act. Kvery nurse, being part of a self-regulating profession, has the option to put bim/herself forward for office or to selea those whom hc/sbe wishes to be elected by a balloting system. Entering into professional debate is seen as autonomous practice; not entering into pro- fessional debate is therefore viewed as not autonomous and as being contradictory to chal- lenging determining forces. It would appear, therefore, that communication over profession- al issues is a consequence of autonomy.

Tbe potential for professional growtb is dependent on professional communication occurring botb through the dissemination of propositional knowledge and through the acquisition of tacit knowledge by reflective practice (Bolt, 1993). The current interest in clinical supervision (Faugier and Butterworth, 1994) demonstrates that nurses are required to make clear those factors which determine their practice. The autonomous nurse must be able to account for the professional decisions made.

An autonomous nurse seeks role develop- ment according to his/her personal and pro- fessional agenda. The reduction in medical staffing hours can be regarded as either an opportunity' or an imposition for nurses. The autonomous nurse must decide the bound- aries of bis/her practice in accordance with areas of already accepted responsibility.

DEFINING EMPIRICAL REFERENTS

Walker and Avant (19S8) recognize tbat empirical referents and critical defining attributes may be identical, and therefore the factors previously identified for critical defin- ing attributes must be sougbt in practice. The cases generated serve as examples of how empirical referents may be recognized.

There is evidence to suggest that autonomous nurses experience greater job satisfaction (McCloskey, 1990; Dwyer et al, 1992; Tingle, 1992). It would therefore be reasonable to use tbe same data collection tecbniques used by tbese autbors to assess nurses' perceived job satisfaction and level of autonomy.

Nurse recruitment and retention has been investigated in relation to perceived autono- my. An association was demonstrated between autonomy and the popularity of work place (Ward and Kozakowski, 1987; McCloskey, 1990; Dwyer et al, 1992; Tmgle,

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DEVELOPING A CONCEPT ANALYSIS OF AUTONOMY IN NURSING PRACTICE

1992; Hall, 1993). The findings of these stud-

ies could be used as a hasis to demonstrate

the incidence ot autonomy.

CONCLUSION

Autonomous nursing practice, as demonstrated

by the constructed cases, is essential to the deliv-

ery of complete nursing care. However, is it pos-

sible? If autonomy lies along a continuum

then there is an opportunit>' for nurses to move

up and/or down it. They can monitor where

they are by partaking in constant reflexive

scrutiny to self-monitor status. The

antecedents to autonomy identified in this arti-

cle suggest that nurses need to criticaily exam-

ine their actions and the context in which they

practice. The challenge for nurses and nurse

educators is to question the barriers to

autonomous nursing practice. It is necessary

for nurses to develop a stronger sense of group

professional identit)' so that nurses from alt

levels can contribute to shape modern nursing.

Given that autonomous nursing is both desir-

able and possible, how can it be enhanced? The

answer to this is through empowerment.

Initiatives such as collaborative case manage-

ment and primar)- nursing present opportunities

for nurses to put their unique skills into practice.

This may, in turn, help to fend off challenges

from other disciplines who seek to adopt ele-

ments of the traditional nursing role.

The suggested consequences of autono-

mous nursing are seductive and highly desir-

able. Thus, the quest to achieve this goal is

worthy of attainment. UU3

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KEY POINTS

A concept analysis is a way of clarifying phenomena and generating debate around an issue.

Autonomy in nursing is associated with empowerment in decision-making and a professional knowledge base.

An autonomous nurse is one who: practices within a self-regulating professional environment; makes decisions based on professional judgment, and has the ability to execute these in his/her own practice; and is cognizant with the bio-, psycho-, and social determining forces and has the knowledge to judge when these should be accepted or challenged.

To strive for and exercise autonomous practice is a challenge facing nurses and those involved in the education and management of nurses.

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