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
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).
BRmsH JOURNAL OF NURSINO, iyy7, VOL 6, No 12
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- John WilkinsoJ
my in a variety of ways. Batey and Lewis in Nursing, Royal COIICRC
of Nurisng Institute,
(1982) identify it with self-determination, self- London
direcrinn, independence and not being con-
703
PROFESSIONAL ISSUES
The term trolleii by .111 t'xtcrn.il iij;cnt. It is also associat-
ed with tlu- control of pr.ictice (Singleton and
autonomy as N.iil, iy4), the power to act (Ward and
cited in nursing Kozakowski, 1987), independent practice
literature has a iHindshaw ct al, 1987), and control over deci-
sion-making (Owyer et al, 1992). All authors
variety of uses... associate auttuiomy in nursing practice with
autonomy involves the establishment of a professional right to
self-determination, practice nursing based on a professional agen-
da, e.g. the Code of Professional Conduct
self-direction, (UKCC, 1992a) and The Scope of Ptofessional
independence Practice (UKCC, 1992b). Botb of these docu-
and not being ments draw attention to the limits of profes-
sional autonomy, i.e. tbe nurse's autonomy is
controlled by limited by the authority of medical profession-
an external als and/or that of his/her employers.
agent. 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
704
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-
BRmsH JOURNAL OF NURSINC, 1997, VOL 6, No 12
 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
BRmiiH JOLJKNAL OF NUKiINC, 19^7, VOL 6, N o 12
to satisfy defining attribute 2), Sally, being dis- Michael does
satisfied with her inactivit)' in Andrew Brown's
as he is asked
care, refers him to a colleague. She then seeks
information on access to assertion skills train- although he
ing (satisfies defining attribute 3), disagrees with the
decision. He believes
A related case
A related case is where concepts which arc-
that the sunshine
similar to the concept in question, but which should be enjoyed
do not satisfy all the defining attributes, are not avoided. He is
exemplified. Independence, freedom and lib-
erty are synonyms of autonomy (Microsoft, unaware of the
1993), Batey and Lewis (1982) discuss the effects direct sun
interrelatedness of responsibility and authori-
light can have on the
ty, and Leddy and Pepper (1993) stress the
link between authority and accountability. skin of people
Separate concept analyses could be done on receiving
these synonyms in order to yield defining
phenothiazine
attributes and model cases which could then
be compared and contrasted with the defining medication.
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
70S
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

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