Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Jordan University of Science and Technology
Faculty of Nursing
Concept Analysis Paper: Autonomy
Prepared by:
Ashraf Ali AlSmadi
Advised by:
Dr.Yaseen Hayajneh RN, PhD
1
Autonomy concept
Introduction
The concept has been used to give various meaning, concept defined as an “a complex
or label used to explain a phenomenon or a group of phenomena. (Melies, 1991).
The concept of autonomy is particular interest from health care providers exclusively
among health care managers because dynamism of health care setting frequently requires a
specialized response in terms of improving and supporting health care providers roles and
these roles for all time need to apply autonomy in actions. The researchers have been studied
autonomy for many years and explained it from different methodological and theoretical
perspectives and described it by various disciplines; including: political science, education,
psychology, sociology and nursing. Furthermore, Autonomy concept is recently used in
different settings, such as: regional autonomy, teacher autonomy, individual autonomy, and
family autonomy, autonomy of groups, clinical autonomy, patient's autonomy and autonomy
of nurses. From reviewing the related literature of the concept in the nursing, autonomy is
Autonomy as a concept in nursing profession is confused with other concepts such as:
empowerment and authority. (Kathryn A., 1998).
The true meaning of autonomy concept in the nursing still unclear because there is no
specific or universal definition of autonomy, the definition mainly depends on the writer
believes and the context. The purpose of this analysis paper is to describe and examine the
attributes or characteristics of an autonomy concept, antecedents, consequences, and clarify
the meaning of autonomy in nursing profession to add benefits, improving nursing
knowledge base and practice.
2
Autonomy concept
The assumption related to analysis of autonomy concept paper is that autonomy is
enviable, today most of the chief nurse officers and other health administrators have
desirability to create professional practice environment that increase the awareness of
autonomy to their followers to build professionalism and improve productivity, affectivity
Literature review
From the literature of autonomy, autonomy is considered to be culturally dependent
(Gracia, 1993). In addition, it is difficult to be found as a separate concept since it is linked
with other concepts, such as: professional nurse autonomy, woman's autonomy, structural or
work autonomy, and attitudinal autonomy. A lot of researchers and theories of the autonomy
concept mentioned that there is a lacking to find a unified definition for autonomy (Hertz,
1996). Furthermore, autonomy is a vital character for attaining professional status that exists
on either individual or group level (Moloney, 1992).
Autonomy is a complex and multidimensional phenomenon (kipper, 1992).and it is
described as a “dynamic process demonstrating varying amounts of independent, self
governed, not controlled, or not subordinate behaviors and sentiments related to readiness,
empowerment, actualization, and valuation for autonomous performance” (Dempster, 1994).
Beauchamp & Childress (1994) stated that autonomy is one of the most important principles
that lead ethical practice in their work on medical ethics. Biomedical ethics offer three
1994; Mill, 1985), actual autonomy (Agich, 1993) and selfrealization (Miller, 1981; Taylor,
independence, selfcare, and selfdetermination (Proot et al., 2000a).
3
Autonomy concept
Moreover, the majority of body nursing literature on autonomy related to job
et al., 1993; McCloskey, 1990; Sochen, 1992).
The concept of autonomy derived from the Greek word “autonomos” or auto (self)
and nomos (law); hence it is a selflaw. Autonomy has been examined by various sciences
and many definitions were put forward.
“independence”. Mosby's Medical, Nursing and Allied Heath Dictionary (1994) defined
defined in (MerriamWebster's Collegiate Dictionary, 1996) as “the quality or state of being
selfgoverning; the right of selfgovernment; selfdirecting freedom and esp. moral
independence”, and (MerriamWebster's, 2002) also defined autonomy as “a. the quality or
state of being independent, free, selfdirecting; b. independence from the organism as a whole
in the capacity of a part for growth, reactivity, or responsiveness”. Moreover, Dictionary of
The English Language (2006), defined autonomy as “self government with respect to local or
internal affairs; granted autonomy to national minority or a selfgoverning state, community,
or group”. A synonym of autonomy includes freedom, liberty, selfdetermination, selfrule,
“subjection to something else; esp. a lack of moral freedom or self determination” (Merriam
Webster's Collegiate Dictionary, 1996).
Sociologically, individual autonomy is seen as a type of individual freedom of action
where the personal decides his or her own line of action in agreement with a plan chosen by
himself or herself (Abramson, 1985).Furthermore, woman’s autonomy has been defined as a
woman's “ability or lack thereof to make decisions in the household” (Hindin, 2000b).
Additionally, autonomy support is defined as a social influence construct proposed by self
4
Autonomy concept
determination theory that reflects nonpressuring forms of social influence (Deci & Ryan,
1985). And Gillon (1995) stated the autonomy is the ability to do, believe, think, choose, and
decide on the basis of such knowledge or ideas and decision freely and independently and
without obstacles.
The psychological literature of autonomy points out that the improvement of
autonomy differs for male and female, male improvement emphasizes on control and
separation, but female improvement occur within the context of relationships and the ethics
of caring. (Kurtines, 1978; Gilligan, 1982; Schutzenhofer, 1987; Boughn, 1995).and
Haworth (1986) suggested that autonomy improves psychologically and is manifest through
decision making activities.
administrators described or defined autonomy as “the liberty to perform, capability to self
govern., and selfdetermination in decision making and nursing” (Lewis FM and Batey MV.,
1982). Additionally, most of nurses explained autonomy as the power or authority to
determine what requirements to be complete in providing patient health care, to perform on
assessments, and to accept accountability for decisions (Mundinger M., 1980).
In Other hand, Weins (1990) explained that autonomous nurses not need to have full
managed or control, but they need to choose independently when control should be abdicated
“the exercise of considered, independent judgment to effect a desirable outcome”. Batey and
Lewis's (1982) defined autonomy as “the freedom to make discretionary and binding
decisions consistent with one's scope of practice and freedom to act on those decisions”.
Laschinger HKS. et al, (1999) defined autonomy as “Freedom from bureaucratic restraints”.
5
Autonomy concept
labor (Scott J, Sochalski J, Aiken L., 1999; Sims HP; Szhagyi AD; Keller RT., 1976), or
Furthermore, Clifford (1990) defined autonomy based on Israel nurses perspective
related to organizational and professional autonomy as the chance to work in healthcare
setting free from policies, rules and regulations that have little to do with patient health care.
And defined clinical autonomy as the “scope of clinical practice for which a nurse is
the autonomy concept has obtain meanings as various as liberty, freedom of will, privacy,
being one’s own person. McKay (1983) defined autonomy as “both independent and
interdependent practice related decision making based on a complex body of knowledge and
skills”. Furthermore, in the process of explaining autonomy concept Kathryn A. (1998)
defined autonomy as “the capacity of an agent to determine it is own actions through
independent choice within a system of principles and laws to which the agent is dedicated”.
Hall's (1968) classified professionalrelated autonomy to the attitudinal and structural
components: Structural or work autonomy exists when professional individuals are expected
to use their judgment to make decisions or to determine the provision of client services in the
context of their work and work requirements. Attitudinal autonomy exists for individuals who
the way of people feel and view the work of the profession.
The disagreement among authors and researchers about specific definition of
autonomy as a concept reflected in the instruments which were developed to measure
autonomy among nurses. Certain instruments were developed, each instrument composed of
certain subscale items and concepts to measure autonomy such as: selfgovernance, decision
6
Autonomy concept
making, competence, critical reflection, freedom, and selfcontrol (Kramer & Schmalenberg,
2003).
Presence of certain instruments which used to measure autonomy lead to increase the
ambiguity of the components of this concept because there was a big difference between the
components of these instruments. In her, critique for the instruments of autonomy
measurements; Kennerly concluded that: a) Most instruments were lack of face validity, b)
Do not differentiate between clinical autonomy, professional autonomy, or control over
nursing practice, c) Many scales items do not particularly measure autonomy, d) when
autonomy is measured quantitatively; all scale items took an equal weight and importance
(Kramer & Schmalenberg, 2003).
In summary, from my perspective as a nursing management student, autonomy in nursing
management is an essential feature arises through giving trust, power, authority, and liability
to followers to help them to increase their selfconfidence, accountability and to improve
their abilities to control or lead, problem solving skills, decisions making skills to achieve job
satisfaction and job performance that will lead to improve quality of nursing care services.
Attributes of autonomy
The purpose of the recognizing or identifying attributes of the concept is to differentiate
and distinguish autonomy from other related or similar concepts. From reviewing the existing
· Selfgovernance is the heart of autonomy and is depend on a method of laws and
principles, some writers referred to governance as the right, liability and capability to
establish or create environment and make decisions applicable to one's professional
practice to keep control over self, working conditions and practice (Aydelotte, 1983;
Dayani, 1990; Susman, 1976).
· Independence it is essential attribute reflect freedom of individuals.
7
Autonomy concept
· Selfcontrol, autonomous individuals must have ability to do freely without any
competence restriction exhibited in constantly increasing creative life that is fully
one's own, this idea brings an existing awareness of liability for self and ability to
controlself. (Haworth, 1986).
· Freedom, Garber (1982) view autonomy as a selfgenerated, selfwon, and free from
external inducements. Therefore, autonomy is a feature ideal, the same with the
ability to selfdirect according to life plan that matches to the personals long term
interests and nature. (Kathryn .A, 1998).
· Decision making also is a vital attribute in the concept of autonomy, because
individual ability to become autonomous depends on his/her capability or capacity to
make choice among alternatives. Leddy and Pepper (1985) stated that “the
autonomous person is capable for making rational and unconstrained decisions and
acting on those decisions. An individual is to be considered rational when he is
capable of choosing the best means to some end”.
· In addition, one of the most directly associated attribute with decision making
attribute is the critical reflection. Haworth (1986) described reflection as being
“sensitive to thought and being guided by it, autonomy is the carrying out of
reflectively endorsed purpose”.
· Knowledge, capacity, ability, competence are others attributes of autonomy. The
significance of knowledge is demonstrated in Kramer and Schmalenberg's (1993)
unsophisticated definition of autonomy as “the freedom to act on what you know”.
Moreover, Haworth (1986) state the competence is the cornerstone of autonomy.
Therefore, Person autonomous must have knowledge base, capacity, and competence
to be able to create effect and to be able to increase his scope of skills that motivate
8
Autonomy concept
that capability. Also some nurse writers have associated knowledge base and
competence with the attainment of autonomy.
· Selfdetermination, a lot of nurse writers suppose that selfdetermination is significant
attribute to achieve autonomy in effective method.
· Interdependence, some nursing authors such as Holland, G. (1999) believe the
· Judgment, person must be able to make judgment based on knowledge and experience
Related concepts
There are many concepts which give the same meaning of autonomy, according to
1. Control.
2. Freedom.
3. Authority.
4. Power.
5. Independence.
6. Responsibility.
7. Professionalism.
9
Autonomy concept
Antecedent
Antecedents are the conditions or events that must required or occurred before the
autonomy process begins, from the literatures of autonomy (Kathryn A., 1998; Gail H., 1999;
Jane K., 1999) proposed that the antecedents of autonomy are:
1. The Individuals must have the abilities to prioritize part or aspect of knowledge of
personal believes and values related to circumstances.
2. The Individuals must have experience to act perfect autonomously.
3. The Individuals must have education to act as individuals autonomous.
4. The individuals must also have abilities or capabilities to selfdiscipline to act
autonomously, and to make judgment.
5. The individuals or groups must have morals, and ability to reason and critical
thinking skills to act autonomously.
6. The individuals must also have abilities to distinguish or discriminates their
knowledge either experiences or educational levels related to conditions.
7. The Individuals must accept or agree to their scope of responsibilities to act
autonomously.
and fully exposure to systems of laws, principles, standards, and believes.
Consequences
Consequences refer to product or outcomes of the autonomy process. According to
1. Accountability, it is the most obvious consequence identifiable for the
autonomy concept. It defined as the answerability and responsibility to power
or authority for person actions, when person develop into ready to act
autonomously the person must be prepared to accept responsibility and
10
Autonomy concept
answerability for his/her actions. Maas and Jacox (1977), argue that
“accountability for behavior is corollary of autonomy”.
2. One of the consequences of autonomy is improved or achieved individual
professional status.
3. As a result of autonomy process, individuals autonomous will have power,
authority, commitment and freedom to do actions based on scope of their
responsibilities, and personal satisfaction.
4. Finally, autonomy process will lead to achieve individuals or groups
empowerment that will lead to improve trust, selfawareness, and self
efficiency among individuals and improve ability of individuals to change
their work environment and assist them to create more satisfied environment
under name professional practice environment.
Application to nursing
Model case
Ashraf is a registered nurse who graduated from Jordan University of science and
technology; he completed his bachelor's of science in nursing in 2004 and graduated with
honors. Ashraf has been employed at a King Abdullah University Hospital on a pediatric
intensive care unit. Ashraf is expertise and knowledgeable concerning the hospital rules,
on support, critical problem solving, encouragement, and participation with health care
providers, patients, and patients families. At all time, he makes integration between his
managers, for all time his manager's say "Ashraf is a typical professional nurse and mostly
his performance is excellent".
11
Autonomy concept
Today he is working Nshift, responsible for a 13yearold female patient post External
Ventricular Drainage (E.V.D) insertion, a neurosurgery for insert a tube to drain cerebral
spinal fluid to reduce intracranial pressure in encephalitic patient, on assessment of his
patient, Ashraf found that the tube drain fresh blood instead of cerebral spinal fluid,
according his experience he know that the fresh blood only drained for a first 15 minute post
operation from the incision of surgery and started to disappear after that , but in his case the
blood continue draining.
Ashraf know that his patient status was getting worse he documented that directly and
informed resident physician and asked him to informed the specialist, the resident told Ashraf
that it is a normal situation and do not require the specialist consultation, but fresh blood still
draining, Ashraf reinformed resident and again he refused to call the specialist.
Ashraf decided to call the specialist against the advice of the resident; he knew that
nursing ethics need liability competent practice based on knowledgeable decision and that he
is primary accountable to his patient for the providing of safe care. He called the specialist
and described the patient status and his concerns, who arrived to the PICU and reassess the
patient status, and urgently decided to prepare the patient for operation.
Contrary case
One day in the PICU at the time of medication administration, Ashraf checked the
femoral canula for his patient and found abnormal clotting and that it is need to be changed,
Ashraf announce the physician to assess the canula, but the physician ordered ashraf "leave it
as it is".
This case is an example of autocracy not as autonomy case, because the physician does
not build his decision on the knowledge and experience.
12
Autonomy concept
Related case
One day in PICU, patient post RTA (Road Traffic Accident) was admitted and during
assessment by the specialists' consultant, they informed his father that his son need to plastic
surgery and a graft from thighs should be placed in his face; the father refused to have his son
intention to not follow the father decision. The anesthetist and nurses staff refused to support
the surgeon's decisions to go against the father decision; eventually the surgeon agrees to
follow the father decision.
In this situation, it could be argued that the patient's father had acted autonomously in
reaching his decision. However under operation the father is not present and he is unable to
use his right to self determination. Consequently, his decision is respected by some health
care providers but not all.
Conclusion
The meaning of autonomy as a concept in nursing field still ambiguous. Autonomy is a
complex and multidimensional. Autonomy which involve many subconcepts such as: self
governance, self control, freedom, decision making. Also, there are many related concepts of
professionalism. As a result of this fact, there is no specific instrument that could be used to
measure autonomy among nurses.
Finally, autonomy in nursing field is an important phenomena to be studies, and
enhancement the level of nurses autonomy should be taken in consideration from nursing
administrators and leaders, because this will lead to enhance individual and groups
empowerment, improve trust, self awareness, and enhance the level of nurses job satisfaction
and job performance which that lead to improve quality of nursing care services.
13
Autonomy concept
References
Abramson M. (1985). The autonomypaternalism dilemma in social work practice. Social
Casework 66 (7), 387393.
Agich, G.J., (1993). Autonomy and Longterm Care. Oxford University Press, Oxford.
American Heritage® Dictionary of the English Language (2006), Fourth Edition.
Aydelotte, M.K. (1983). Professional nursing: the drive for governance. In N.L. Chaska (Ed),
The nursing profession: A time to speak (pp. 830843). New York: McGrawHill.
Batey M.V & Lewis F.M (1982) Clarifying autonomy and accountability in nursing services:
part 1. Journal of Nursing Administration 12 (9), 1318.
Beauchamp T. & Childress J. (1994). Principles of Biomedical Ethics. 4th edn. Oxford
university press, Oxford.
Blegan, M.A., Goode, C., Johnson, M., Maas, M., Chen, L., & Moorehead, S. (1993).
Preferences for decision making autonomy. The Journal of Nursing Scholarship, 25,
339344.
Boughn S. (1995) An instrument for measuring autonomyrelated attitudes and behaviors in
women nursing students. Journal of Nursing Education 34, 106113.
Clifford J, ed. Advancing professional nursing practice. New York: Springer; 1990. p. 334.
Dayani, E. (1990). Professional and economic selfgovernance in nursing. In E.C. Hein & M.J.
Nicholson (Eds), Contemporary leadership behavior (pp. 357362).
Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and selfdetermination in human
Behavior. New York: Plenum.
14
Autonomy concept
Dempster J.S. (1994) Autonomy: a professional issue of concern for nurse practitioners. Nurse
practitioner forum 5, 227234.
Garber, F. (1982). The autonomy of the self from Richardson to Huysmans. Princeton, NJ:
Princeton University Press.
Gilligan C. (1982) In a Different Voice: Psychological Theory and Women's Development.
Gillon R. (1995) Philosophical Medical Ethics. Wiley Medical, London.
Gracia D., (1993). The intellectual basis of bioethics in southern European
countries.Bioethics 7(2/3): 97–107.
Hall R.H. (1968) Professionalization and bureaucratization. American Sociological Review 33,
92104.
Ct: Yale University Press.
Hertz J.E, (1996). Conceptualization of perceived enactment of autonomy in the elderly. Issues
in Mental Health Nursing 17: 261–273.
Hindin, M. J. (2000b). Women’s autonomy, women’s status and fertilityrelated behavior in
Zimbabwe. Population Research and Policy Review, 19(3), 255–282.
Holland G., (1999). Professional nurse autonomy: concept analysis and application to nursing
education. Journal of Advance Nursing, 30(2), 310318.
Kathryn A.,(1998). Aconcept analysis of Autonomy: Journal of Professional Nursing, Vol 14,
No 2:pp 102110.
Keenan, J. (1999) A concept analysis of autonomy. Journal of Advanced Nursing 29 (3):
556–562.
15
Autonomy concept
Kenny D. & Adamson B. (1992) Medicine and the health professions; issues of dominance,
autonomy and authority. Australian Health Review 15 (3), 319334.
Kipper B.A. (1992). Roget's 21st Century Thesaurus in Dictionary Form. Dell, New York.
Kramer, M., & Schmalenberg, C. (1993). Learning from success: autonomy and empowerment.
Nursing Management, 24(5), 5864.
Kramer M, Schmalenberg C. (2003).Staff nurses identify essentials of magnetism: what are
“good” RN/MD relationships?
Kurtines W.M. (1978) A measure of autonomy. Journal of Personality Assessment 42, 253257.
Laschinger HKS, Wong C, McMabon L, Kaufmann C. (1999). Leader behavior impact on staff
nurse empowerment, job tension, and work effectiveness. Journal of nursing
administration, 29:2838.
Leddy, S., & pepper, M. (1985). Conceptual bases of professional nursing.
Lewis FM, Batey MV. Clarifying autonomy and accountability in nursing service, part 2.
Journal of nursing administration 1992; 12:1015.
Maas M., Specht J. & Jacox A. (1975) nurse autonomy; reality not rhetoric, American Journal
of Nursing 75(12), 22012208.
McCloskey, J.C. (1990). Two requirements for job contentment: Autonomy and social
integration. The Journal of Nursing Scholarship, 22, 140143.
McKay P.S (1983) Interdependent decision making: redefining professional autonomy. Nursing
Administration Quarterly 7(4), 2130.
Meleis, A.,(1991). Theoretical nursing development and progress (2nd edn.).
MerriamWebster's Medical Dictionary, © 2002 MerriamWebster, Inc Mill, J.S., (1985). On
Liberty. Penguin Books, Harmondsworth.
16
Autonomy concept
MerriamWebster's collegiate Dictionary 1996, (10th ed). Spring field, MA: MerriamWebster.
Miller, B.L, (1981). Autonomy & the refusal of lifesaving treatment. Hastings Cent. Rep. 11,
2228.
Moloney M.M., (1992). Professional of Nursing: Current Issue and Trends. Lippincott,
Philadelphia.
Mosby's Medical Nursing and Allied Health Dictionary (1994). Mosby's, St Louis.
Mundinger M. Autonomy in nursing. Germantown (MD): Aspen; 1980.
Oxford English Dictionary (1994) Oxford English Dictionary. Oxford University Press, Oxford.
Proot, I.M., Huijer Abusaad H., van Oorsouw, G.G.J., Stevens, J.J.A.M. (2000a). Autonomy in
stroke rehabilitation: a model based on interviews with health professionals in
nursing homes (submitted).
Schoen, D.C. (1992). Nurses attitudes toward control over nursing practice. Nursing forum,
27(1), 2734.
Schutzenhofer K.K. (1987) The measurement of professional autonomy. Journal of Professional
Nursing 3, 278283.
Scott J, Sochalski J, Aiken L. Review of magnet hospital research. Journal of nursing
administration 1999; 29:919.
Sims HP, Szhagyi AD, Keller RT. The measurement of job characteristics. Cad Manage J 1976;
19:195512.
Susman, G.I. (1976). Autonomy at work. New York: Praeger.
Taylor, C. (1991). The Malaise of Modernity. Stoddart, Don Mills. Republished as: The Ethics
of Authenticity (1992). Harvard University press, Cambridge.
17
Autonomy concept
Weins A.G. (1990) expanded nurse autonomy; models for small rural hospitals. Journal of
Nursing Administration 20(10), 1522.
18