Journal of Advanced Nursing, 1999, 29(3), 556562

Nursing theory and concept development or analysis

A concept analysis of autonomy

Jan Keenan
RGN MSc

Lecturer/Practitioner, Cardiac Medicine, Oxford Radcliffe Hospitals NHS Trust and Oxford Brookes University, Oxford, England

Accepted for publication 29 May 1998

KEENAN J. (1999)

Journal of Advanced Nursing 29(3), 556562 A concept analysis of autonomy Clinical and policy developments in health care have recently created demand for a professional response in terms of the development of advanced roles for nurses, notably `nurse practitioner' roles. Such roles demand the exercise of autonomy, a term which eludes succinct denition despite the fact that the preparation of practitioners for these roles relies on a clear understanding of its nature. Utilizing an approach described by Wilson, this paper undertakes a concept analysis of autonomy, each step illustrated with examples taken from clinical practice, with the ultimate aim of offering an operational denition of autonomy. Keywords: autonomy, nursing, independent practice, nurse practitioner, concept analysis

INTRODUCTION
Clinical and policy developments in health care have recently created demand for a professional response in terms of the development of new roles for nurses, the most notable of which have come to be known as nurse practitioner roles. Alongside these developments have arisen the need for and provision of education and training of practitioners, heavily reliant on a professional understanding of what is meant by the concept of autonomy. As yet, an operational denition of the concept of autonomy is at best elusive, the concept apparently poorly understood. The purpose of this paper, utilizing Wilson's (1969) framework for concept analysis, is to arrive at an operational denition of autonomy. Chinn & Kramer (1995 p. 58) dene a concept as `a complex mental formulation of experience'. Concepts range from the empirical (directly measurable) to the abstract (more mentally constructed) on a continuum. As a concept, one could place autonomy quite rmly at the abstract end of such a continuum; clearly it is intangible and therefore complex to dene. Chinn & Kramer (1995)
Correspondence: Jan Keenan, 16 Janaway, Sandford on Thames, Oxford OX4 4SY, England.

add that mentally constructed concepts relate least well to perceptible reality. Walker & Avant (1988) argue that concepts contain within them the dening characteristics or attributes that permit us to decide which phenomena are good examples of the concept and which are not. Concept analysis `allows us to examine the attributes or characteristics of a concept' (Walker & Avant 1988 p. 35) and is useful to clarify overused vague concepts that are prevalent in nursing practice. One would nd it difcult to deny that `autonomy', through common usage has emerged as a popular term; by the very nature of its popularity, its meaning has become more vague with the passage of time. Walker & Avant (1988) suggest the use of a step-by-step approach to concept analysis proposed by Wilson (1969, see Table 1) in which each step of concept analysis is explicated to provide a very useful framework upon which to build the analysis. This framework is additionally attractive due to its clear popularity with other writers undertaking a similar task (for example Teasdale 1989, Hokanson Hawks 1991). The use of a framework to provide an operational denition of a concept has the added advantage that the emergent denition by its very nature has construct

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Nursing theory and concept development or analysis

Table 1 Steps of concept analysis (Wilson 1969) Step One Two Three Four Five Six Seven Eight Stage of analysis Select the concept Determine the aims or purposes of analysis Identify all uses of the concept that can be discovered Determine dening attributes Construct a model case Construct borderline, related, contrary, invented and illegitimate cases Identify antecedents and consequences Dene empirical referents

Concept analysis of autonomy drance'. Gillon's denition also implies deliberate action, and expands on the notion of independence in stating that action must occur `without hindrance'. This can be further extended to include the concept of freedom and the capacity for rational thought. This view is afrmed by Abramson (1985) who, writing in the context of social work practice, has a similar philosophical stance in that `autonomy' is seen as a `form of personal liberty of action where the individual determines his or her own course of action in accordance with a plan chosen by himself or herself'. In this view, freedom (liberty) as well as the capacity to make a choice are important. In the statement `to respect autonomy is to perceive the other person as having unconditional worth.' Abramson (1985) is clearly discussing individual autonomy. The views of Abramson (1985) and Gillon (1995) relate to a rights-based, moral/ethical notion of autonomy as a characteristic of individuality respected by one individual of another. However, particularly in relation to nursing, discourse has additionally centred on autonomy as an attribute of a profession. Styles (1982) argues that writers on `professions' tend to enumerate the characteristics of professions as a group, rather than offer a discrete denition of what is a profession. Lists of criteria for an occupational group to be identiable as a profession contain `multiple variations in expression, format and priority (but) seldom stray from the universal themes', one of which is autonomy (Styles 1982 p. 47). Because Styles refers to professions, rather than professionals, there is clear reference in her statement to the autonomy of a profession as a whole, i.e. group autonomy. Particularly this is evidenced in her use of the `spirit and form of collegiality' which carries the implication of group advocacy. Styles asserts that the sole characteristic differentiating professionals from other occupational groups is autonomy, which is described as a `key value' having two aspects: job content and job context. It is the former which is essential to professionalism; thus the profession decides the nature of the profession's work. Rather than relating to individualism, however, this appears to be more directly related to the self-government of a group with similar interests. Writing of the medical profession, Kenny & Adamson (1992) view that autonomy is exercised over its own work, which is `not subject to direction and evaluation by other health professionals'. Further there is implicit evidence that autonomy arises from internal control over a profession, by the profession itself. This relates well to the earlier identied characteristic of autonomy, selfdetermination, but also to the rights-based notion of autonomy outlined above. However, the two appear to be subtly different in that self-determination of the individual is held to be a moral and ethical right, which might be passively exercised in that it is `allowed'. Selfdetermination of a professional group, such as medicine,

validity; that is, it will accurately reect its theoretical base (Walker & Avant 1988). The constructed analysis which follows is therefore built upon the process outlined in Table 1.

AUTONOMY A CONCEPT ANALYSIS Selection of the concept

The concept of autonomy is of particular interest from a clinical practice perspective. Advancing clinical developments frequently demand a professional response in terms of the development of new roles for nurses, the most recent of which have come to be known as nurse practitioner roles. As such roles demand the exercise of `autonomy', it is useful to examine the concept in order that its use can be claried in relation to practice.

Aims of the analysis

To utilize the approach of concept analysis to provide an operational denition of autonomy.

Uses of the concept

Dictionary denitions of autonomy are succinct and straightforward, which contradicts the notion that autonomy is indeed used in different contexts. For example, the Oxford English Dictionary (1994) denes `autonomy' simply as `independence'. Mosby's Medical, Nursing and Allied Health Dictionary (1994) goes one step further, stating that autonomy is `the quality of having the ability to function independently'. What is important in this denition is the statement that, to have autonomy, one must have the ability `to act'. That is, one must be either capable of, or allowed, autonomy; to `act' implies deliberate, or conscious effort. Gillon (1995 p. 60), a philosopher with an interest in medical ethics, states that autonomy `is the capacity to think, decide, and act on the basis of such thought and decision freely and independently and without hin-

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J. Keenan presents a view of autonomy in a more active, deliberate sense in that autonomy, in this respect, is `taken'. This view is fundamentally awed, however, in that, in the instance of a professional group, society grants autonomy on the basis of other professional characteristics, such as possession of a vital resource (knowledge) and the trust society places in altruism (Maas et al. 1975, Parkin 1995). Discussion regarding the characteristics of a profession gives rise to a further use of the concept. Moore (1970) believes that, in the pursuit of autonomy, `collective autonomy and individual autonomy may turn out to be inconsistent goals'. Writing of the status of occupational groups, Moore infers that individual autonomy of a professional is possible and perhaps more likely than autonomy of an occupational group. Additionally, Moore (1970) writes of individual autonomy in a context that is not rights-based. Adamson et al. (1995) are among other writers (for example Leach 1993, Parkin 1995) who believe that recent developments in nursing are aimed at increasing both individual and collective autonomy for nurses. For example, Adamson et al. (1995) argue that individual nurses are developing new roles in independent community practice outside medically dominated hospitals and away from medical domination. Whilst the use of the concept in relation to individual professionals implies self-determination, Weins (1990) argues of nurses that `autonomy does not mean the nurse will have total control, but the autonomous nurse is free to choose when control should be abdicated or retained'. Thereby a distinction is made between autonomy and `control', or autocracy. It is felt important to make this distinction in the light of discussion about the exercise of autonomy in relation to control over one's work, or the work of others. Friedson (1984) additionally draws this distinction by conceptualizing medical dominance over the work of allied health professions as separate from the manner in which autonomy is exercised by the medical profession. Partridge (1957) adds that `autocracy and autonomy are occasionally confusedF F F X The meaning of autocracy is absolute government (by an individual or paramount authority); of autonomy, the right of the institution to govern itselfF F F ', hence clearly separating the notions of control and self-determination. In summary, there appear to be three related but distinct uses of the concept of autonomy:  A rights-based notion; utilized in the context of patients, or clients of health services.  Professional (group) autonomy; utilized in the context of describing characteristics of a professional group and relating to work individual.  Occupation-related autonomy; utilized in the literature relating to the discussion of the work context of nurses. Although there are three distinct uses of the concept identied, there are attributes of the concept, known as critical or dening attributes, which apply to each use.

Dening attributes
The purpose of identifying the dening attributes of a concept is to provide a basis for its occurrence as a phenomenon as differentiated from another similar or related one. The following are attributes which apply to each use of the concept, and are therefore identied as the dening attributes of autonomy:  Independence Where independence is taken to mean `freedom of will' (Lloyd 1982), this applies clearly to all three uses of the concept. It is taken that independence as an attribute can apply to professional groups as well as to individuals.  Capacity for decision making Where autonomy is used in the context of self-determination or control over one's work, it is implied that one has the capacity to make a choice.  Judgement In addition to the capacity for decision making, to exercise one's autonomy as a group or individual, one must be able to discriminate, i.e. to make a judgement, based on knowledge, which leads to making a conscious decision. Further, it could be argued that one must be able to make a judgement based on the evaluation of its likely consequences.  Knowledge In all three uses of the concept it is implicit that active, deliberate decision-making will occur, which will require the utilization of a knowledge base, whether scientic, personal, professional or experiential.  Self-determination As an attribute of autonomy, selfdetermination appears repeatedly in the literature reviewed. This takes independence one stage further in that it implies active, rather than passive, exercise of free will.

Model cases
Model cases offer `real life' examples of a concept and include all the critical attributes, i.e. are a paradigmatic example (Walker & Avant 1988). The following cases are examples which serve to illustrate the use of the concept in clinical practice. In each construction, two cases are illustrated. The rst represents a rights-based notion of individual autonomy in relation to a patient; the second represents the exercise of individual occupational autonomy in relation to the practice of a health care professional.

A young man has undergone cardiac surgery and has made an uneventful recovery. He is visited by a rehabil-

Autonomy as a right

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Nursing theory and concept development or analysis itation nurse and, presented with all the information he requires, exercises his right not to participate in an education and exercise-based rehabilitation programme. The rehabilitation nurse respects his decision and moves on to the next patient. The young man goes home and writes later to thank the ward staff for their help in his recovery from surgery, telling them he has returned to work. In this instance, the young man makes an independent decision, based on available knowledge (provided by members of the health care team) and makes a calculated judgement that he will recover from his surgery without the need to attend a formal rehabilitation programme. The rehabilitation nurse respects his right to self-determination.

Concept analysis of autonomy In this instance, the patient has reached a decision based on the knowledge available to him, and independent judgement. This time, the rehabilitation nurse, by attempting to persuade him otherwise, does not respect his right to self-determination.

A nurse is caring for a patient following coronary angioplasty. Being restricted to lying at as a result of femoral arterial cannulation, the patient is in constant pain due to an old back injury. Because the arterial cannula is occluded and the patient has small veins from which venepuncture is difcult, it is impossible for the nurse to obtain a blood sample to assess his clotting status following an infusion of heparin, which was discontinued 2 hours previously. To make the patient more comfortable, the nurse removes the cannula, following which the patient is able to change his position in the bed, thereby relieving his discomfort. In this situation, the nurse makes an independent clinical decision based on empirical and experiential knowledge relating to the patient's condition and anticoagulation therapy. The nurse uses independent, clinical judgement to determine the most appropriate action to take, and acts accordingly.

Individual occupational autonomy

A patient suffering a large myocardial infarction is admitted to the coronary care unit. Before reaching hospital, he collapsed and hit his head, suffering an open wound which, on close examination, was not supercial. The registrar, in a hurry to act in the patient's interest, prescribes a thrombolytic agent. The nurse caring for the patient repeatedly contends the decision to use the thrombolytic, afraid the patient would suffer cerebral haemorrhage, thus drawing on empirical and experiential knowledge that the risk to the patient may be greater than the potential benet. Ultimately the agreement is reached that the thrombolytic agent will be given, and the nurse documents the detail and outcome of the discussion. In this instance, the nurse independently uses knowledge and judgement to reach a decision that the risk to the patient is likely to be greater than the benet. The nurse succeeds in persuading the doctor to consider the decision more carefully by questioning, but tentatively administers the drug in spite of her beliefs. As a result of the existing balance of power between the professions, and the doctor's right to prescribe, the nurse is unable to act on her decision. Whilst the doctor respects that decision, it is over-ruled.

Individual occupational autonomy

Related cases
A patient about to undergo cardiac surgery has expressly refused to have his radial arteries utilized as bypass grafts. The surgeon is aware of this, as are the nursing staff of the ward and the operating theatre. However, once the patient is under anaesthetic, the surgeon states his intention to defy the patient's wishes, and remove his radial arteries. The anaesthetist and theatre staff refuse to support the surgeon's decision to go against the wishes of the patient, and the surgeon ultimately agrees to abide by the patient's wishes. In this instance, it could be argued that the patient had acted autonomously in reaching his decision. However, under anaesthetic he is unable to exercise his right to self-determination, and has to rely on the intervention of health care professionals to carry out his wish on his behalf. Therefore, he is able to act autonomously only up to a point; his right to selfdetermination is respected by some, but not all members of the health care team.

Autonomy as a right

Additional cases
Additional cases are constructed in order to provide examples of what is not the concept, and in order to clarify understanding of what the concept is about. These include borderline cases, which may contain some but not all of the attributes, related cases which contain none of the attributes, and contrary cases, which are clear examples of `not the concept'.

Borderline case
Consider the rst example offered as a `model' case, with a slight change in scenario. In this instance, the rehabilitation nurse, believing strongly in the benet of the service offered, attempts to change the patient's mind. Ultimately the patient accepts that to attend the rehabilitation group would be in his best interests, and agrees to attend.

Autonomy as a right

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Consider the above case. A second important player is the anaesthetist who, by refusing to support his colleague's intention, could be said to be acting autonomously. However, autonomy in this sense implies a clash of powerful opinions; because conict occurs, there is no respect of the other's self-determination. Therefore the case may be used to illustrate, but is not an example of, autonomy.

Independent occupational autonomy

Contrary case
Following investigation into coronary disease, a patient is approached by a cardiologist who, without preamble, announces clearly to the patient `You need an operation'. Clearly shocked, the patient begins to question whether there may be any alternative. The cardiologist interrupts him, saying `If you don't have an operation, you'll be dead by Christmas'. The above is an example of paternalism. As Walker & Avant (1988) suggest, a contrary case illustrates that, whatever the concept is, the contrary case is not an example of it.

Autonomy as a right

A nurse attempts to discuss with a physician whether a patient's central venous line should be removed following the receipt of an abnormal blood clotting screen. The physician states `Just do it. Please'. The latter is clearly an example of autocracy, not autonomy, in that the physician does not acknowledge the right of the nurse to utilize knowledge gained through experience to challenge the appropriateness of the action.

Individual occupational autonomy

Having identied that knowledge is an attribute of autonomy, then the source of knowledge must then become the antecedent. Largely this can be expressed in terms of education, or experience, both of which imply the passage of time. This view would seem to be upheld by the ndings of a study undertaken by Kenny & Adamson (1992) in which they discovered that health care workers' perceptions of their level of autonomy were related significantly to the length of time they had been employed in their current profession, as well as the seniority of their position in the organization. Although the study was based on a total sample of only 90 health care workers, it could be argued that length of time in employment and seniority relate to education and experience, and are therefore sufcient to support such an observation. In relation to a rights-based notion of autonomy, education could simply refer to the information offered; experience can relate to life, rather than solely professional experience. In order to act autonomously, one must particularly be able to discriminate and prioritize aspects of knowledge relevant to a situation. To make a judgement, one must also be capable of self-discipline. In support of this view, Holden (1991) states that impulsive behaviour `implies the lack of personal autonomy due to the absence of self discipline combined with an inability to prioritise desires'. Therefore the following are offered as antecedents to the exercise of autonomy:       Experience, gained over an unspecied length of time. Education, gained formally or informally. Ability to prioritize. Ability to discriminate. Self-discipline. Acceptance of responsibility.

ANTECEDENTS TO, AND CONSEQUENCES OF, AUTONOMY

Walker & Avant (1988) believe that the antecedents to, and consequences of, a concept `may shed considerable light on the social contexts in which the concept is generally used'. They identify that both are events or incidents, implying that some occurrence must take place prior to, or as a consequence of, the concept. Equally, events or incidents can be the development of values or attributes which are necessary for, or result from the exercise of the concept.

Consequences of autonomy
Maas & Jacox (1977) argue that `accountability for behaviour is a corollary of autonomy. Accountability means responsibility and answerability to authority for one's actions'. It can be seen that, if an individual is prepared to act autonomously, the individual must be prepared to accept that they must be answerable for their actions. This is particularly true in the case of the health care professional where others are affected by that action, but also true of a rights-based notion of autonomy where the individual may only be accountable to themselves for their action. It is through discussion of this issue in relation to nursing that May (1995) warns against nurses promoting patient autonomy, which the patient may not wish to exercise, as this in a sense does not respect the patient's right not to be autonomous. At this point it is necessary to differentiate between the different contexts in which the concept is used, as it is difcult to identify the consequences of a rights-based

Antecedents
What is difcult to identify is whether antecedents themselves are integral to the concept, rather than prerequisites of it, or even both. Therefore the discussion outlines the basis on which antecedents to autonomy may be derived. Before one is able to exercise independent judgement, one requires knowledge on which to base that judgement.

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Nursing theory and concept development or analysis notion of autonomy over and above an increase in accountability. Therefore the remainder of the discussion, in accordance with discussion relating to the development of `advanced' nursing roles, centres principally around the use of the concept in relation to occupation-related autonomy. Because discussion about autonomy is closely linked to discussion relating to professionalization, particularly in nursing literature (e.g. Adams & Rentfro 1991, Parkin 1995), it would be foolish not to question at this point, or at least to offer an opinion, as to whether professional status can actually arise from an increase in professional autonomy. Full discussion of this issue is far beyond the scope of a concept analysis, though it seems that the ability to reach professional status extends far beyond the need to accumulate the characteristics said to be those of professionals (Styles 1982). Parkin (1995) argues that `professionalization is a political process and issues of power and control are central to it'. Nursing has an historical lack of power vis a vis the medical profession and, in such a situation, Parkin (1995) argues that `full professional status cannot be achieved'. Job satisfaction was identied in a study by Kenny & Adamson (1992) as being related to increased autonomy. It is not clear, however, whether any attempt had been made to differentiate this from the relationship between perceived autonomy and experience. Therefore although the writer's observation that increased work satisfaction is likely to result through autonomy, the relationship is as yet tentative. Thus the only clear consequence identiable for the concept of autonomy is accountability.

Concept analysis of autonomy presents them are also attitudinal, they are not observable phenomena. One could, however, attempt to measure attitudes related to autonomy, though it seems the concept may be more than the sum of it's identied parts. It is therefore beyond the writer to suggest any true empirical referents which may highlight the presence, or exercising, of the concept.

CONCLUSION
This analysis has been a complex and difcult process compounded by frustration on reaching the nal section and discovering that, after a lengthy exercise in mental agility, there seems to be no way in which to directly observe autonomy. However, as stated at the outset, the purpose of this analysis was to attempt to provide an operational denition of autonomy; this is still possible: Autonomy:
The exercise of considered, independent judgement to effect a desirable outcome.

References
Abramson M. (1985) The autonomypaternalism dilemma in social work practice. Social Casework 66(7), 387393. Adams R.A. & Rentfro A.R. (1991) Strengthening hospital nursing. An approach to restructuring care delivery. Journal of Nursing Administration 21(6), 1219. Adamson B.J., Kenny D.T. & Wilson-Barnett J. (1995) The impact of perceived medical dominance on the workplace satisfaction of Australian and British nurses. Journal of Advanced Nursing 21, 172183. Boughn S. (1995) An instrument for measuring autonomy-related attitudes and behaviours in women nursing students. Journal of Nursing Education 34(3), 106113. Chinn P.L. & Kramer M.K. (1995) Theory and Nursing: A Systematic Approach (4th edn), Mosby, St Louis. Friedson E. (1984) Professionalism as model and ideology. In Professionalism Reborn: Theory, Prophecy and Policy (Friedson E. ed.), Polity Press, London, pp. 169183. Gillon R. (1995) Philosophical Medical Ethics. Wiley Medical, London. Hokanson Hawks J. (1991) Power: a concept analysis. Journal of Advanced Nursing 16, 754762. Holden R.J. (1991) Responsibility and autonomous nursing practice. Journal of Advanced Nursing 16, 398403. Johns C. (1995) Achieving effective work as a professional activity. In Towards Advanced Nursing Practice; Key Concepts for Health Care (Schober J.E. & Hinchcliff S.M. eds), Arnold, London, pp. 252280. Kenny D. & Adamson B. (1992) Medicine and the health professions; issues of dominance, autonomy and authority. Australian Health Review 15(3), 319334. Leach M.K. (1993) Primary nursing: autonomy or autocracy? Journal of Advanced Nursing 18, 394400. Maas M. & Jacox A.K. (1977) Guidelines for Nurse Autonomy/ Patient Welfare. Appleton Century Crofts, New York.

Empirical referents
Identifying empirical referents of an abstract concept is a complex process. As Walker & Avant (1988) state, empirical referents `provide the clinician with clear, observable phenomena with which to ``diagnose'' the concept'; thus it is worthwhile postulating how this may be done. Johns (1995) refers to `structural autonomy', i.e. that which may be dened in job descriptions which set boundaries or limits to discretionary decision-making. One could assess from such documentation whether one has occupational autonomy, and possibly to what degree it exists. Additionally Johns (1995) discusses `attitudinal autonomy'; one could measure an individual's perception of how much autonomy they have. However, these are tentative suggestions and are subjective criteria by which autonomy could be measured. More useful would be observable attributes of autonomy; aspects of behaviour which would evidence its existence. Boughn (1995) devised an instrument for measuring autonomy-related attitudes and behaviours. Again, however, because the characteristics of autonomy as Boughn

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Maas M., Specht J. & Jacox A. (1975) Nurse autonomy; reality not rhetoric. American Journal of Nursing 75(12), 22012208. May C. (1995) Patient autonomy and the politics of professional relationships. Journal of Advanced Nursing 21, 8387. Moore W. (1970) The Professions: Roles and Rules. Russell Sage Foundation, New York. Mosby's Medical Nursing and Allied Health Dictionary (1994) Mosby's Medical Nursing and Allied Health Dictionary. Mosby, St Louis. Oxford English Dictionary (1994) Oxford English Dictionary. Oxford University Press, Oxford. Parkin P.A.C. (1995) Nursing the future: a re-examination of the professionalisation thesis in light of some recent developments. Journal of Advanced Nursing 21, 561567. Partridge (1957) Usage and Abusage 5th edn. Penguin, Aylesbury. Styles M.M. (1982) On Nursing: Towards a New Endowment. Mosby, St Louis. Teasdale K. (1989) The concept of reassurance in nursing. Journal of Advanced Nursing 14, 444450. Walker L. & Avant K. (1988) Strategies for Theory Construction in Nursing. 2nd edn. Appleton Century Crofts, Norwalk. Weins A.G. (1990) Expanded nurse autonomy; models for small rural hospitals. Journal of Nursing Administration 20(10), 15 22. Wilson (1969) Thinking with Concepts. Cambridge University Press, New York.

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