Autonomy concept

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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

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Introduction

The concept has been used to give various meaning, concept defined as an “a complex

mental formulation of experience” (chine & Kramer, 1995).In addition, the concept is a word

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

intangible and uncertain concept in nursing field (Chine & Kramer, 1995).

Autonomy as a concept in nursing profession is confused with other concepts such as:

independence, power, control, professionalism, accountability, image, responsibility,

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.

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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

and efficiently of quality of health care services .

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

important concepts related to autonomy concept: self­governance (Beauchamp; Childress,

1994; Mill, 1985), actual autonomy (Agich, 1993) and self­realization (Miller, 1981; Taylor,

1991). Furthermore, health professionals recognized three dimensions of autonomy:

independence, self­care, and self­determination (Proot et al., 2000a).

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Moreover, the majority of body nursing literature on autonomy related to job

satisfaction, job performance, nursing retention and increasing staff nurse autonomy (Blegan

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.

Linguistically, Oxford English Dictionary (1994) defined autonomy clearly as

“independence”. Mosby's Medical, Nursing and Allied Heath Dictionary (1994) defined

autonomy as“the quality of having the ability to function independently”. Also autonomy was

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,

self­government, independence and sovereignty (Kipper, 1992).In contrast, heteronomy is

“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

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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.

Consequently, nursing literature held many definitions of autonomy, a lot of nursing

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

or maintained. Moreover, Keenan (1999) provides an operational definition of autonomy as

“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”.

Further more; recently the concept of autonomy has been differently defined as power over

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labor (Scott J, Sochalski J, Aiken L., 1999; Sims HP; Szhagyi AD; Keller RT., 1976), or

liberty to take action (Kennerly S., 2000; and Kramer M, and Schmalenberg C, 1993).

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

accountable”. In addition, according to the perspective of Beauchamp and Childress (1994)

the autonomy concept has obtain meanings as various as liberty, freedom of will, privacy,

independency, individual choice, self­governance, rights, governing one’s behavior, and

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

believe themselves to be free to exercise judgment in decision­making process, and provide

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

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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

related literature of the autonomy concept many attributes are put forward:

• 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.

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• 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

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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

interdependence relationships with individuals are necessary to achieve autonomy.

• Judgment, person must be able to make judgment based on knowledge and experience

which lead to making good decision to become autonomous.

Related concepts

There are many concepts which give the same meaning of autonomy, according to

Kathryn A., (1998) the related concepts of autonomy are:

1. Control.

2. Freedom.

3. Authority.

4. Power.

5. Independence.

6. Responsibility.

7. Professionalism.

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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.

8. Finally, the Individuals also must have a good knowledge to develop competence

and fully exposure to systems of laws, principles, standards, and believes.

Consequences

Consequences refer to product or outcomes of the autonomy process. According to

(Kathryn.et al., 1998) the outcomes of autonomy process include the followings:

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

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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,

polices, regulations and his state practice act. He developed his experience in nursing based

on support, critical problem solving, encouragement, and participation with health care

providers, patients, and patients families. At all time, he makes integration between his

knowledge (education and experience) and practice. Also he has empowered from his nurse

managers, for all time his manager's say "Ashraf is a typical professional nurse and mostly

his performance is excellent".

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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.

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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

thighs utilized as a graft. However once the patient is under­operation, the surgeon state his

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

autonomy such as: control, authority, power, independence, responsibility, and

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.

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