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A concept analysis of autonomy
A Concept Analysis of Autonomy KATHRYNA. BALLOU,MSN, RNC, CNA*
The nursing profession places a high value on the acquisition of autonomy as a requisite for professional status. Although the literature is replete with studies that examine autonomy and nurses, methods and results often are inconsistent and inconclusive. Review of the literature reveals ambiguous or absent definitions of autonomy. Nursing commonly confuses autonomy with related concepts such as authority, accountability, power, professionalism, and independence. A concept analysis of autonomy is done using Walker and Avant's modification of Wilson's analysis procedure. This highly abstract concept emerges as a discrete, empirically definable term referring to a potential human quality in an existing state. The analysis includes antecedents, consequences, defining attributes, model and borderline cases, and empirical referents. (Index words: Autonomy; Governance; Decision making; Professional status)J Prof Nurs 14:102-110, 1998. Copyright © 1998 by W.B. Saunders Company
HE CONCEPT of autonomy related to profesT sional nursing practice has been visible in the nursing literature for a number of years. The assumption in most nursing literature related to autonomy is that autonomy is desirable. Toward that end, nurse administrators have sought to establish practice environments that increase the perception of autonomy in staff nurses. Nurse researchers have studied autonomy from a variety of theoretical and methodological perspectives. Throughout the nursing literature the meaning of autonomy is laden with differing assumptions, defined inconsistently, and measured using variable and inconsistent theoretical constructs (Blanchefield & Biordi, 1996; Blegan et al., 1993; Maas, 1989; McCloskey, 1990; Pinch, 1985; Schoen, 1992; Schutzenhofer & Musser, 1996; Young, 1985). The author believes that the concept of autonomy has been used ambiguously and often inaccurately in nursing literature. This misuse has contributed to *ClinicalInstructor,Schoolof Nursing, Universityof MissouriKansasCity, KansasCity, MO. Address correspondenceand reprint requests to Ms Ballou: University of Missouri-Kansas City, School of Nursing, 2220 HolmesSt, KansasCity, MO 64108. Copyright© 1998 by W.B. SaundersCompany 8755-7223/98/1402-0011 $03.00/0 102
inefficient delivery system changes, construct validity problems in research methodology and instrument development, and a general tone of doom related to acquisition of autonomy in nursing. Autonomy is a very abstract concept. In nursing it is confused with concepts of professionalism, power, image, control, authority, accountability, and independence. Its true meaning in the nursing literature is obscure. A wide variety of definitions of the concept of autonomy are evident in the nursing literature (Blanchfield & Biordi, 1996; Holden, 1991; McCloskey, 1990; Schutzenhofer, 1983, 1987; & Wood, Tiedje, & Abraham, 1986). Several authors do not even provide explicit definitions (Carmel, Yakubovich, Zwanger, & Zahcman, 1988; Henry, 1993; Holden, 1991; Keenan, Hoover, & Hoover, 1988; Keenan & Schoen, 1992; Perry, 1986; Pinch, 1985; Schoen, 1992; Young, 1985). Batey and Lewis analyzed the concept of autonomy in 1982 using literature from nursing and organizational sociology. Their analysis produced a definition very similar to the one that this author will present; however, the range of literature they used was relatively narrow, and defining attributes were not identified. The analysis presented in this article encompasses a broad range of sources and timespan. Using Walker and Avant's (1995) modification of Wilson's concept analysis procedure, the concept of autonomy was analyzed to appreciate greater clarity and accuracy of meaning. Relevance of the Concept to Nursing
The nursing literature on autonomy primarily relates to three areas: the discipline's desire for professional status, the impact of socialization of women and nurses, and the relationship of autonomy to job satisfaction within bureaucracies. In all cases, the literature reflects nursing's desire for and difficulties achieving autonomy. Most authors agree that autonomy is a coveted requisite for professional status in nursing (Dachelet & Sullivan, 1979; Holden, 1991; Mundinger, 1980; Schutzenhofer & Musser, 1994). Freidson (1970) asserted that all other elements defining professional-
Journal of ProfessionalNursing,Vol 14, No 2 (March-April), 1998: pp 102-110
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ism derive from autonomy and referred to autonomy as "the prize sought by virtually all occupational groups" (p. 15). Before industrialization, nursing functioned independently by virtue of context of practice and the simplicity of health care delivery (Dachelet & Sullivan). The advent of hospitals in the 1930s brought bureaucracy and patriarchy that subverted the independence of nurses and the perception of autonomy among nurses (Church, 1990). Nursing's quest for autonomy has been evident since that time. Difficulty in achieving autonomy in nursing relates to role socialization of women (Scearse, 1989; Schutzenhofer, 1983, 1987). For centuries women have been expected to be nurturing, self-sacrificial, and other-centered. Expression of these qualities has been within a world primarily controlled and directed by men and often within a subservient role. As a predominantly female profession, nursing is a metaphor for women and their roles. Roberts (1996) eloquently illustrated the effects of oppression on nurses' behavior. The entire health care system as it operates today depends on the oppressed group status of nurses: a group easily controlled by others. The attitude that others control nursing's full expression and practice connotes a passive role in individual acquisition of autonomy. This attitude assumes that achievement of autonomy is contingent on major changes in external structures. And it assumes that others, primarily those in formal power, can give autonomy to nurses. The majority of the body of nursing literature on autonomy related to increasing staff nurse autonomy and job satisfaction reflects this assumption (Blegen et al., 1993; Kramer & Schmalenberg, 1993; McCloskey, 1990; Schoen, 1992). Re-examination of the concept will demonstrate that autonomy in its truest form is contingent on the desiring person's own actions and that autonomy evolves internally. Analysis of the Uses of the Concept in Disciplines and Other Literature
The concept of autonomy derives from the Greek word "autonomos" or auto (self) and nomos (law); hence, self-law. The dictionary definition is "the quality or state of being self-governing; the right of self-government; self-directing freedom and esp. moral independence," (Merriam-Webster's Collegiate Dictionary, 1996, p. 79). In contrast, heteronomy is "subjection to something else; esp. a lack of moral freedom or self determination," (p. 545).
The concept's earliest documentation is in the history of ancient Greece and the relation between Athens and her allies in the Delian League in 5th century BC. The term "autonomia" referred to "a state that is free to determine the norms by which it wants to live." (Ostwald, 1982, p. 10) Autonomia was used by weaker states in opposition to despotism. It described the qualities of states or individuals that exist in the shadow of a superior power but still enjoy self-determinism, even if it results in death. Autonomia referred to the quality of an individual or agent who lives by their own law. The Greeks used the term "agency" to refer to a state or person who is an effective producer of intended effects. Greek writings suggest that the agent's ability to prepare for the protection of their own integrity is the hallmark of a state that is autonomous (Ostwald). Thus, autonomy is political in origin. Since the time of the ancient Greeks, the concept has evolved extensively. On investigation of its evolution, several recurring themes emerge. They are selfgovernance within a system of principles, competence or capacity, decision making, critical reflection, freedom, and self-control. Each theme will be explored separately, although there is much overlap between themes.
Theme of Self-Governance Within a System of Principles
The notion of self-governance and self-rule is found throughout contemporary literature on autonomy as well as in the ancient Greek usage. Self-governance is the core of autonomy and is based on a system of principles and laws. Kant's philosophical work Groundwork on the Metaphysics of Morals (cited in Wolff, 1974) postulated the classic explication of autonomy: "The will is therefore not subject to the law; but is so subject that it must be considered as also making the law for i t s e l f . . . " (p. 178). Kant believed that one must be moral to be autonomous, governing oneself in accordance with universally valid moral principles and laws through his or her own actions. In analysis of this view, Wolff concurs that "the autonomy of the rational agent is legislating through his independent choice a system of principles to which he is rationally bound" (p. 228). Others have referred to governance as the right and responsibility to establish conditions and make decisions pertinent to one's professional practice to main-
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tain control over practice, self, and working conditions (Aydelotte, 1983; Dayani, 1990; Susman, 1976). Theme of Ability, Capacity, and Competence The attributes of ability, capacity, and competence are another recurring theme in autonomy. Psychologist and philosopher Haworth (1986) asserted that "competence is the foundation of autonomy. A person strives to be able to produce intended effects and to become able to expand his repertoire of skills that underlies that ability" (p. 2). The contemporary philosopher Young (1985) stated that "the autonomous person's capacities, beliefs, and values will be identifiable as integral to him and be the source from which his actions spring" (p. 1). Autonomy hinges on one's ability and competence and is expressed in one's actions. Ability or competence include knowledge and the capacity for self-control. Aydelotte (1983) stated that " . . . knowledge is essential to self-governance. It opens the door to power and authority" (p. 832). Leddy and Pepper (1985) further reinforced the necessity of knowledge by stating that professional autonomy is achieved when "one can perform one's total professional function on the basis of one's own knowledge and judgment and further, that one is then recognized by others as having the right to do so" (p. 196). Several nurse authors also have correlated competence and knowledge base with the achievement of autonomy (Blanchfield & Biordi, 1996; Kramer & Schmalenberg, 1993; Maas, 1989; Pankratz & Pankratz, 1974; Perry, 1986; Schutzenhofer & Musser, 1994). Thus, competence is critical to the meaning of autonomy. Theme of Decision Making Decision making also is a central theme in the concept of autonomy. Two components arise that are critical to the idea that decision making is an attribute of autonomy. One is that agents have the freedom to choose how best to achieve an end or satisfy a preference. The other is that agents have the freedom to act on their choices. Batey and Lewis (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" (p. 15). Leddy and Pepper (1985) stated that "the autonomous person is capable of 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" (p. 47). Philosopher Young (1985) reinforced the notion of individual decision making with "those who themselves determine what they will decide and do, rather than have these dictated to them by circumstances or others, are autonomous" (p. 8). Haworth (1986) suggested that autonomy develops psychologically and is made evident through decision making activities. The necessity of this attribute to autonomy is borne out through the predominance of decision making as a variable in research on autonomy (Batey & Lewis, 1982; Blegan et al., 1993; Carmel et al., 1988; Katz, 1968; Pinch, 1985; Schutzenhofer, 1987). Theme of Critical Reflection Closely connected with decision making in autonomy is the attribute of critical reflection. If autonomy reflects one's life being one's own, then independence must proceed from decisions reflecting one's own judgment. Obedience to laws and principles, as a part of the autonomous person's system, must stem from reflection on those laws and principles and on reason. Therefore (as Kant described), the autonomous person believes in and is bound to critically reflected upon laws accepted as their own.
Closely connected with decision making in autonomy is the attribute of critical reflection.
Haworth (1986) described reflection as being "sensitive to thought and to being guided by i t . . . acting on reason, reflecting on impulses and outside influences. One adopts standards, values, and principles after having critically reflected on them. Autonomy is the carrying out of reflectively endorsed purposes" (pp. 2, 23). Kant (as cited in Haworth, 1986) believed that actions based on desire lead to heteronomy. Kant's critics disagree by asserting that if one critically reflects on one's desires, one avoids heteronomy by assuring that one's choices are one's own. Thus, the concept of autonomy involves the idea of authoring one's own world without being subject to the will of others-through reflection and decision making and within a system of endorsed beliefs and principles.
CONCEPT ANALYSIS OF AUTONOMY
Theme of Freedom
Throughout the literature, autonomy expresses a condition of freedom and independence worth fighting for and achieving. Reference to this notion began as freedom of a state to make it's own laws. This idea evolved to the search for individual freedom. Nursing references to freedom and autonomy are laden with the assumption that freedom to act autonomously, at least partially, derives from external sources (Carmel et al., 1988; Lewis & Batey, 1982; Maas, 1989). Classical and philosophical literature reflects a much different notion. The Romantics viewed autonomy as an independence of consciousness, and their literature examines the balance between the self and its context (Garber, 1982). Rousseau and other Romantic writers of the time viewed perfected autonomy as a state of completely fulfilled desire. Not a state that comes easily but rather one that one that is fought for and made by oneself, in opposition to the pressures for subservience coming from external sources (Garber, 1982). Poets and authors of such literary works as "TellTale Heart," Moby Dick, the "Grand Armanda," and "Pappacini's Daughter" write of the paradox between one's vision of autonomy and the cost of its attainment. These literary works refer to autonomy as self-won, self-generated, and free of external inducements (Garber, 1982). Haworth (1986) reiterated this directional correlation between autonomy and freedom. He stated that "the positive connotation of independence is one actually ruling oneself, and that self-rule doesn't automatically follow from freedom and independence, but only guarantees the possibility" (p. 11). If autonomy is viewed as a self-generated condition that is free from external inducements, two connotations may be implied. First, that freedom for something is a consequence of autonomy. Second, that autonomy is the capacity of an individual to express his or her freedom from. In describing positive liberty, Young (1985) stated that "people are not independent from" (p. 5). Instead, we exist within the realities of social structure and "that those structure's arrangement may undermine autonomy but adjustments will not confer it" (p. 8). Thus, autonomy is a character ideal or virtue, synonymous with the ability to self-direct according to a life plan that conforms to the individual's long-term nature and interests. The notion of an unobstructed environment or a domain of autonomy is therefore not necessary for the condition of being autonomous, as so many nursing
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authors have suggested (Batey & Lewis, 1982; Blanchfield & Biordi, 1996; Blegan, et al., 1993; Dachelet & Sullivan, 1979; Kramer & Schmalenberg, 1993; Maas, 1989). Autonomy is not given or taken away; it is a personal quality that hinges on individuals' a priori inherent potential to choose a course of action. Truly autonomous individuals know and live what they believe to the extent that external forces cannot control or adversely influence them. As Mundinger (1980) expressed, autonomy is not an issue for authentically autonomous individuals because they are already autonomous. Theme of Self-Control
The theme of self-control is common to discussions of autonomy (Erikson, 1963; Holden, 1991; McCloskey, 1990; Schutzenhofer, 1983, 1987). These authors and others discussed the impact of self-control and its relation to constraints in the environment on the exercise of autonomy. Autonomous individuals receive domains of autonomy in recognition of their developed capacity for an autonomous life' Otherwise, freedom to act with no constraints whatsoever would result in anarchy. Autonomous persons demonstrate capacity through "full rationality and unrestricted critical competence expressed in a continuously expanding creative life that is fully one's own" (Haworth, 1986, p. 55). This notion connotes an existing awareness of responsibility for self and the ability to control oneself. Autonomous people act with deliberation and self-discipline while acknowledging limitations and the need for the support and love of others (Fromer, 1981). Impulsive behavior is the antithesis of deliberate self-discipline. It implies the absence of a welldeveloped internal system of beliefs and principles and thus invites external control. Thus, to the degree that one exercises self-control, one's domain of autonomous expression expands (Holden, 1991). Definitions
In the process of separating this complex concept from its antecedents, consequences, and related concepts, the core meaning of autonomy is now definable. The theoretical definition is "the quality or state of being self-governing." More specifically, autonomy is "the capacity of an agent to determine its own actions through independent choice within a system of principles and laws to which the agent is dedicated."
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Defining Attributes Especially useful in a concept analysis is the explication of defining attributes. These attributes, or characteristics, signal the true presence of the concept (Walker & Avant, 1995). The critical attributes of the theoretical definition of autonomy based on this analysis are (1) the agent is able to determine his or her own actions, (2) the agent is able to competently act on his or her determinations, (3) actions and decisions are based on critical reflection, (4) actions and decisions are consistent with the agent's own internally endorsed system of principles to which he or she is dedicated, and (5) decisions are made independent of external control.
Antecedents and Consequences These definitions and their corresponding attributes derive from the development of the concept of autonomy as a potential human quality in an existing state. The definitions and their attributes as stated here are devoid of antecedents, consequences, and related concepts. A frequent barrier to understanding of this abstract concept has been its confusion with the related concepts of freedom, power, control, authority, responsibility, independence, and professionalism. All of these concepts are found in nursing literature related to autonomy. In one way or another, these concepts reflect the professions struggle with issues related to practice, education levels, and nursing's relationship to other health care professionals and health care bureaucracies. Antecedents derived from a concept analysis can be extremely useful in clarifying areas for intervention. Antecedents are the events or states that must exist or occur before the concept can occur (Walker & Avant, 1995). In contrast to the sweeping assumption that nursing and nurses must be provided with a contextual environment of a certain nature for autonomy to occur, autonomy actually is contingent on a culmination of personal factors explicated as antecedents. These personal factors hinge on both inherent personal characteristics as well as exposure to knowledge and ideas that can be cultivated and supported in a nurturing environment (Table 1). Thus, if nursing wishes to advance the level of autonomy among its practitioners, interventions must focus on assessment, development, and measurement of these antecedent conditions. The antecedents of autonomy as gleaned from this analysis demonstrate
TABLE 1. Antecedents Inherent intellectual capacity Morality Exposure to systems of beliefs, laws, standards, and principles Knowledge sufficient to develop competence Knowledge of personal values and beliefs Ability to reason Ability to control self
the necessity of careful selection of candidates for the profession. They also point the way toward basic formal educational content as well as postgraduate retraining and reinforcement. Consequences may reflect the context surrounding a concept (Walker & Avant, 1995). In this case, autonomy emerges as a term often used in a colloquial manner to refer to a state that more accurately reflects the consequences of autonomy (Table 2). As a student recently remarked in response to the author's questioning on the meaning of autonomy, "it's when someone finally takes notice of my work and makes me feel valued" (M. Payne, personal communication, October 14, 1996). The word autonomy has been used to mean the consequences of autonomy, such as recognition and status, as described by the nursing student. Although erroneously described, the consequences reflect very real needs that can only be attained by possessing autonomy. The astounding revelation arising from this analysis of the concept of autonomy is that the actual stated desires and needs of the profession are reflected in the consequences of autonomy, not the true state of autonomy itself. Individual autonomy must in fact precede the desired state that nursing has described as autonomy. An even more astounding realization is that achievement of true autonomy does not spring from an external set of conditions (consequences of autonomy such as authority and an autonomous domain) but rather through the development and nurturing of internal human qualities (antecedents such as ethical knowledge and critical thinking) that are most certainly within the control of nursing.
TABLE 2. Consequences Individual professional status Freedom for Authority and power Recognition by others as competent Personal satisfaction Expansion of domain of autonomous expression
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Model Case
Another useful strategy in the analysis of an abstract concept is the presentation of a model case. As Walker and Avant (1995) described, the model case is one in which all of the defining attributes of the concept are present. The model case is a pure example of the analyzed concept. Mary is a registered nurse who graduated from a diploma school in 1981 at the top of her class. She completed her bachelor's of science in nursing in 1987, and graduated with honors. Mary has been employed at a large tertiary-level hospital on a busy medical-surgical unit since 1984. Mary is knowledgeable regarding her hospital's policies and her state practice act. She has developed expertise in her practice, and uses theory and research. She believes in and follows the American Nurses Association (ANA) Codefor Nurses and Standardsfor Clinical Practice. She developed her philosophy of nursing based on holism, advocacy, and critical problem solving. In both learning and professional situations, she often questions tradition and authority, reflects on new information, and thoughtfully integrates that which she endorses as rational and sound into her philosophy and base for practice. She regularly attends seminars and continuing education. Her managers always rate her performance as excellent. Today she is working evening shift and is the primary nurse for a 34-year-old man admitted yesterday with viral pneumonia. Mary gets report that his temperature has been greater that 102°F since admission, that he has a dry, hacking cough, and that he is very restless. His doctor had ordered intravenous fluids, continuous oxygen, and acetaminophen as needed. On assessment of her patient, Mary found a very agitated, pale, diaphoretic man in a weakened state with a hacking cough, a temperature of 104°F orally, and an apical pulse of 68. He stated that he feels scared and nauseated. His family was at the bedside and pleaded with Mary for help. After assuring the patient's safety and reassuring the family, Mary went to the chart. The temperature graphic indicated a 24-hour zigzag pattern of rising temperatures with falling pulses and vice versa. The chart indicated that staff on day shift had notified the doctor of the patient's condition. He responded with orders to continue present treatment and noted that the patient was "doing well." Mary knew that that her patient's condition was deteriorating and that his symptoms were not indica-
tive of a simple viral pneumonia. She consulted with the shift supervisor, informing her that she planned to call the doctor and request a stat pulmonary or infectious disease consultation. She stated that she believed that her patient had been improperly diagnosed and treated. Her supervisor told Mary she was overreacting and advised her not to call the doctor at home because it was late at night and the situation could wait until the morning. Mary decided to call the doctor against the advice of the supervisor. She knew that her code of ethics required responsible competent practice based on informed judgment and that she is first accountable to her patient for the provision of safe care. She placed the call, described the patient's condition and her concerns, and requested a consultation order. After some encouragement, the doctor agreed. She called a pulmonary doctor, who arrived on the unit one half hour later. The doctor quickly diagnosed the patient and immediately began treatment for Legionnaire's disease. Extraction and Justification of the Attributes Via Empirical Referents Within the Model Case
Extraction and justification of the attributes is helpful in the analysis of a highly abstract concept. The ability to measure autonomy is enhanced using empirical referents from the model case.
• . . a g e n c y refers to o n e w h o is an effective p r o d u c e r o f i n t e n d e d effects•
THE AGENT IS ABLE TO DETERMINE HIS OR HER OWN ACTIONS
To reiterate, agency refers to one who is an effective producer of intended effects. That an agent is able to determine something therefore implies the capacity to make intentional decisions. Mary demonstrated this attribute in several referents. She decided on a career, nursing, and the manner in which she obtains her education. She decided to remain knowledgeable both formally and informally. She decided to develop a philosophy of nursing onto which to base her practice. Mary, in caring for this patient, demonstrated the ability to decide on her manner of delivery of care, to consult her supervisor, and to go against advice and call the doctor.
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This attribute closely relates to the first one. In number one, the focus is decision making. Here the essence is the capacity to intentionally act on one's decisions with competence. Mary's case illustrated this attribute through the following referents: that a state licensed her, that her hospital employed her, and that her success in both school and practice demonstrated knowledge, competence, and an authority to act. Her capacity to act on her decisions also is founded on her theory- and research-based knowledge and practice and in her 6 years of experience, including the care of patients with viral pneumonia. Her knowledge of the state nursing practice act and the institution's policies also bolstered her competency and gave credence to her actions. She also demonstrated competent action in her management of her patient's care by acknowledging herself of his condition, calling her supervisor, and calling the doctor. She based her actions on her philosophy and standards, her knowledge, her legal capacity, and on her history of sound decisions developed through use of the nursing process. ACTIONS AND DECISIONS ARE BASED ON CRITICAL REFLECTION
Critical reflection refers again to deliberation, reason, and choice rather than acting on impulse or outside influence, thus making one's decisions, actions, and laws one's own. Mary overtly and covertly demonstrated this attribute in the following referents: she believes in the ANA Code for Nurses and the Standards of Clinical Practice, referring to more than mere acceptance. In her learning and practice situations she reflects upon orders, policies, authoritative mandates, and tradition and carefully assesses new information. She exhibited reason and critical reflection in deciding that her patient's condition was incongruent with his diagnosis and the doctor's most recent assessment. She critically reflected on her supervisor's advice, choosing instead to call the doctor. ACTIONS AND DECISIONS ARE CONSISTENT WITH AGENT'S OWN INTERNALLY ENDORSED SYSTEM OF PRINCIPLES TO WHICH HE OR SHE IS DEDICATED
As an agent critically reflects on information and chooses the components of its philosophy, values, and laws, he or she must also demonstrate that internally accepted system in his or her actions if the agent is
truly autonomous. Mary does this often in the model case. She has a solid system of principles developed over time. They include her practice skills based on theory and research, her belief in a code of ethics and professional standards, her philosophy of nursing, and her knowledge of her institution's policies and state practice act. She demonstrated incorporation this system into her practice through her continuing education, assessment of her patient's condition based on her knowledge, and her caring activities toward her patient. She practiced her philosophy of client advocacy by acting in opposition to formal authority and calling the doctor with a request for a consultation with a specialist. She used the nursing process in her care of the patient.
DECISIONS ARE MADE INDEPENDENT OF EXTERNAL CONTROL
This attribute refers to the demonstration of an agent's willingness to act on his or her decisions. It does not imply an environment free of constraints but rather an autonomous agent who enacts his or her freedom to choose no matter what exists in the environment. The two overt referents in this case include the following. Mary did not wholly rely on information from external sources, including the chart and report, but chose instead to make her own assessment of the situation based on her own system of principles, knowledge, and experience. Also, she decided to call the doctor against the supervisor's advice, once again demonstrating freedom to control her own decision making.
Borderline Case
Borderline cases are useful when analyzing a concept that is both abstract and frequently misused and misunderstood. A borderline case is a case in which some, but not all, of the defining attributes are present (Walker & Avant, 1995). Using the previous model case, everything remains the same in the borderline case except for the following: When Mary hears her supervisor's instruction not to contact the doctor, she is upset and feels that the advice is wrong. But she has been reprimanded before for questioning authority, so she reluctantly chooses not to contact the doctor, feeling angry that once again "the system" has used its power over her. Two defining attributes of autonomy (nos. 4 and 5)
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are skewed or absent in this case. First, had Mary's actions and decisions been consistent with her own internally endorsed system of principles to which she is dedicated, she would have called the doctor as in the model case. Also, Mary did not demonstrate independent decision making despite external control. She chose not to call the doctor because she believed that there was more powerful external control. Essentially, she gave her autonomy away. Autonomous agents would analyze the situation and act on their critically reflected-on decision based on their internally endorsed system of beliefs and principles despite constraints from external sources.
Significance The concept of autonomy is abstract and complex. Its meaning in the nursing literature encompasses many related concepts. Formal analysis of this concept clarifies meaning and encourages semantically proper usage. This analysis should be useful in a number of ways. The cultivation of true autonomy is essential if nursing is to reduce the likelihood of consequences of borderline autonomy, such as patient suffering and death, nursing dissatisfaction, burnout, and attrition. Knowledge of defining attributes of autonomy as well as the antecedents could facilitate development of curricular models and educational content. The focus should be increasing and enhancing development of autonomy in professional nurses within the formal educational process. Educators have a responsibility to assure that students are adequately immersed in formal professional standards and values. Students must fully identify and develop their philosophy of nursing and insure knowledge of personal beliefs. Characteristics such as morality, ability to reason, self-discipline, and accountability must be assessed and supported within the educational process. Appropriate risk-taking behavior must be viewed by faculty as a positive quality to be encouraged and developed rather than suppressed. And finally, nursing must come to grips with the fact that knowledge level does indeed correlate with competence and therefore au-
tonomy. Maas (1989) and others assert that there is a strong connection between educational level and the exercise of autonomy. Singleton and Nail (1984) intimated that the issue of autonomy is not a matter of how organizations should provide nurses with autonomy but of how much autonomy nurses freely choose to exercise. This analysis shows that the core meaning of autonomy is that of a positive potential human quality arising from within the individual agent. Thus, the focus of systems research related to autonomy should reflect this clarification. Defining attributes and antecedents might be useful in the development of accurate role differentiation within health care organizations and in the profession as well as in retraining and reinforcing to enhance and support autonomous practice. Construct validity is essential in the development and use of research instruments. Without operational definitions and defining attributes, conceptual measurement is futile. Schutzenhofer (1987) and Scearse (1989) called for identification of personal and behavioral characteristics of autonomy and for clarification of this loosely defined term. The global analysis contained herein will enable measurement of characteristics in a variety of populations of nurses within a variety of settings. Use of a formal concept analysis for the development of research instruments measuring autonomy should result in meaningful and more consistent outcomes. Autonomy and the importance of its acquisition have continued to be a vital issue within the profession of nursing. If nursing is to successfully achieve this state, it must have an absolutely clear and consistent understanding of its meaning and its empirical measurement. Otherwise we will continue to be "Like one that stands upon a promontory and spies a far-off shore where he would tread, wishing his foot were equal with his eye" (Shakespeare, "King Henry VI," Part III).
Acknowledgment The author thanks Sue Popkess-Vawter, PhD, RN, professor, University of Kansas, Kansas City, KS, for her invaluable assistance with the preparation of this manuscript.
References American Nurses Association. (1985). Code for nurses with interpretive statements. Kansas City, MO: Author. American Nurses Association. (1991). Standards of clinical nursingpractice. Kansas City, MO: Author.
Aydelotte, M. K. (1983). Professional nursing: The drive for governance. In N. L. Chaska (Ed.), The nursing profession: A time to speak (pp. 830-843). New York: McGraw-Hill.
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Batey, M. V., & Lewis, E M. (1982). Clarifying autonomy and accountability in nursing service: Part 1. Journal ofNursingddministration, 12(9), 13-18. Blanchfield, K. C., & Biordi, D. L. (1996). Power in practice: A study of nursing authority and autonomy. NursingAdministration Quarterly,20(3), 42-49. Blegan, M. A., Goode, C., Johnson, M., Maas, M., Chen, L., & Moorehead, S. (1993). Preferences for decision making autonomy. Image--The Journal of Nursing Scholarship, 25, 339-344. Carmel, S., Yakubovich, I. S., Zwanger, L., & Zaltcman, T. (1988). Nurses' autonomy and job satisfaction. Social Scienceand Medicine, 26, 1103-1107. Church, O. M. (1990). Nursing's history: What it was and what it was not. In N. L. Chaska (Ed.), The nursing profession: Turningpoints (pp. 3-8). St. Louis: Mosby. Dachelet, C. Z., & Sullivan, J. A. (1979). Autonomy in practice. NursePractitioner, 4(2), 15-22. Dayani, E. (1990). Professional and economic selfgovernance in nursing. In E. C. Hein & M. J. Nicholson (Eds.), Contemporary leadership behavior (pp. 357-362). Boston: Little, Brown. Erikson, E. (1963). Childhood and socie~ New York: Norton. Freidson, E. (1970). Profession of medicine. New York: Dodd Mead. Fromer, M. (1981). Ethicalissuesin health care. St. Louis: Mosby. Garber, F. (1982). The autonomy of the selffrom Richardson to Huysmans. Princeton, NJ: Princeton University Press. Haworth, L. (1986). Autonomy:An essayin philosophical psychologyand ethics. New Haven, CT: Yale University Press. Henry, B. (1993). Professional autonomy in nurses. NursingAdministration Quarterly, 17(2), 81-83. Holden, R. J. (1991). Responsibility and autonomous nursing practice.Journal ofAdvancedNursing, 16, 398-403. Katz, E E. (1968). Autonomy and organization. New York: Random House. Keenan, M. J., Hoover, P. S., & Hoover, R. (1988). Leadership theory lets clinical instructors guide students toward autonomy. Nursing and Health Care, 9(2), 82-86. Kramer, M., & Schmalenberg, C. (1993). Learning from success: Autonomy and empowerment. Nursing Management, 24(5), 58-64. Leddy, S., & Pepper, M. (1985). Conceptual bases of professionalnursing. Philadelphia: Lippincott. Maas, M. L. (1989). Professional practice for the extended care environment: Learning from one model and its implementation. Journal of ProfessionalNursing, 5, 66-76. McCloskey, J. C. (1990). Two requirements for job
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contentment: Autonomy and social integration. Image-TheJournal of Nursing Scholarship,22, 140-143. Merriam-Webster'sCollegiateDictionary (10th ed.). Springfield, MA: Merriam-Webster. Mundinger, M. O. (1980). Autonomyin nursing. Germantown, MD: Aspen. Ostwald, M. (1982). Autonomia: its genesis and early history. Chico, CA: Scholars. Pankratz L., & Pankratz, D. (1974). Nursing autonomy and patients' rights: Development of a nursing attitude scale. Journal of Health and SocialBehavior, 15, 211-216. Perry, G. R. (1986). Myth or reality: Autonomy of RNs. Nursing SuccessToday,3(9), 23-24. Pinch, W. (1985). Ethical dilemmas in nursing: The role of the nurse and perceptions of autonomy. Journal of Nursing Education, 24, 372-376. Roberts, S. J. (1996). Breaking the cycle of oppression: Lessons for nurse practitioners? Journal of the American Academy of Nurse Practitioners, 8(5), 209-214. Scearse, E (1989). Autonomy: Where are we going? Journal ofProfessionaINursing, 5, 176, 237. Schoen, D. C. (1992). Nurses' attitudes toward control over nursing practice. NursingForum, 27(1), 27-34. Schutzenhofer, K. K. (1983). The development of autonomy in adult women. Journal of PsychosocialNursing and Mental Health Services,21, 25-30. Schutzeuhofer, K. K. (1987). The measurement of professional autonomy. Journal of ProfessionalNursing, 3, 278-283. Schutzenhofer, K. K., & Musser, D. B. (1994). Nurse characteristics and professional autonomy. Image--The Journal of Nursing Scholarship, 26, 201-205. Singleton, E. K., & Nail, E C. (1984). Autonomy in nursing. NursingForum, 2•(3), 123-130. Susman, G. I. (1976). Autonomy at work. New York: Praeger. Young, W. B. (1985). The competition approach to understanding occupational autonomy: Expansion and control of nursing service.Journal of ProfessionalNursing, 1, 283-292. Walker, L. A., & Avant, K. C. (1995). Strategiesfor theory construction (3rd ed.). Norwalk, CT: Appleton & Lange. Wilson, J. (1963). Thinking with concepts. New York: Cambridge University Press. Wolff, R. P. (1974). The autonomy of reason:A commentary on Kant'sgroundwork of the metaphysicsof morals. New York: Harper & Row. Wood, J. E., Tiedje, L. B., & Abraham, I. L. (1986). Practicing autonomously: A comparison of nurses. Public Health Nursing, 3(3), 130-139.
The nursing profession places a high value on the acquisition of autonomy as a requisite for professional status. Although the literature is replete with studies that examine autonomy and nurses, methods and results often are inconsistent and inconclusive. Review of the literature reveals ambiguous or absent definitions of autonomy. Nursing commonly confuses autonomy with related concepts such as authority, accountability, power, professionalism, and independence. A concept analysis of autonomy is done using Walker and Avant's modification of Wilson's analysis procedure. This highly abstract concept emerges as a discrete, empirically definable term referring to a potential human quality in an existing state. The analysis includes antecedents, consequences, defining attributes, model and borderline cases, and empirical referents. (Index words: Autonomy; Governance; Decision making; Professional status)J Prof Nurs 14:102-110, 1998. Copyright © 1998 by W.B. Saunders Company
HE CONCEPT of autonomy related to profesT sional nursing practice has been visible in the nursing literature for a number of years. The assumption in most nursing literature related to autonomy is that autonomy is desirable. Toward that end, nurse administrators have sought to establish practice environments that increase the perception of autonomy in staff nurses. Nurse researchers have studied autonomy from a variety of theoretical and methodological perspectives. Throughout the nursing literature the meaning of autonomy is laden with differing assumptions, defined inconsistently, and measured using variable and inconsistent theoretical constructs (Blanchefield & Biordi, 1996; Blegan et al., 1993; Maas, 1989; McCloskey, 1990; Pinch, 1985; Schoen, 1992; Schutzenhofer & Musser, 1996; Young, 1985). The author believes that the concept of autonomy has been used ambiguously and often inaccurately in nursing literature. This misuse has contributed to *ClinicalInstructor,Schoolof Nursing, Universityof MissouriKansasCity, KansasCity, MO. Address correspondenceand reprint requests to Ms Ballou: University of Missouri-Kansas City, School of Nursing, 2220 HolmesSt, KansasCity, MO 64108. Copyright© 1998 by W.B. SaundersCompany 8755-7223/98/1402-0011 $03.00/0 102
inefficient delivery system changes, construct validity problems in research methodology and instrument development, and a general tone of doom related to acquisition of autonomy in nursing. Autonomy is a very abstract concept. In nursing it is confused with concepts of professionalism, power, image, control, authority, accountability, and independence. Its true meaning in the nursing literature is obscure. A wide variety of definitions of the concept of autonomy are evident in the nursing literature (Blanchfield & Biordi, 1996; Holden, 1991; McCloskey, 1990; Schutzenhofer, 1983, 1987; & Wood, Tiedje, & Abraham, 1986). Several authors do not even provide explicit definitions (Carmel, Yakubovich, Zwanger, & Zahcman, 1988; Henry, 1993; Holden, 1991; Keenan, Hoover, & Hoover, 1988; Keenan & Schoen, 1992; Perry, 1986; Pinch, 1985; Schoen, 1992; Young, 1985). Batey and Lewis analyzed the concept of autonomy in 1982 using literature from nursing and organizational sociology. Their analysis produced a definition very similar to the one that this author will present; however, the range of literature they used was relatively narrow, and defining attributes were not identified. The analysis presented in this article encompasses a broad range of sources and timespan. Using Walker and Avant's (1995) modification of Wilson's concept analysis procedure, the concept of autonomy was analyzed to appreciate greater clarity and accuracy of meaning. Relevance of the Concept to Nursing
The nursing literature on autonomy primarily relates to three areas: the discipline's desire for professional status, the impact of socialization of women and nurses, and the relationship of autonomy to job satisfaction within bureaucracies. In all cases, the literature reflects nursing's desire for and difficulties achieving autonomy. Most authors agree that autonomy is a coveted requisite for professional status in nursing (Dachelet & Sullivan, 1979; Holden, 1991; Mundinger, 1980; Schutzenhofer & Musser, 1994). Freidson (1970) asserted that all other elements defining professional-
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ism derive from autonomy and referred to autonomy as "the prize sought by virtually all occupational groups" (p. 15). Before industrialization, nursing functioned independently by virtue of context of practice and the simplicity of health care delivery (Dachelet & Sullivan). The advent of hospitals in the 1930s brought bureaucracy and patriarchy that subverted the independence of nurses and the perception of autonomy among nurses (Church, 1990). Nursing's quest for autonomy has been evident since that time. Difficulty in achieving autonomy in nursing relates to role socialization of women (Scearse, 1989; Schutzenhofer, 1983, 1987). For centuries women have been expected to be nurturing, self-sacrificial, and other-centered. Expression of these qualities has been within a world primarily controlled and directed by men and often within a subservient role. As a predominantly female profession, nursing is a metaphor for women and their roles. Roberts (1996) eloquently illustrated the effects of oppression on nurses' behavior. The entire health care system as it operates today depends on the oppressed group status of nurses: a group easily controlled by others. The attitude that others control nursing's full expression and practice connotes a passive role in individual acquisition of autonomy. This attitude assumes that achievement of autonomy is contingent on major changes in external structures. And it assumes that others, primarily those in formal power, can give autonomy to nurses. The majority of the body of nursing literature on autonomy related to increasing staff nurse autonomy and job satisfaction reflects this assumption (Blegen et al., 1993; Kramer & Schmalenberg, 1993; McCloskey, 1990; Schoen, 1992). Re-examination of the concept will demonstrate that autonomy in its truest form is contingent on the desiring person's own actions and that autonomy evolves internally. Analysis of the Uses of the Concept in Disciplines and Other Literature
The concept of autonomy derives from the Greek word "autonomos" or auto (self) and nomos (law); hence, self-law. The dictionary definition is "the quality or state of being self-governing; the right of self-government; self-directing freedom and esp. moral independence," (Merriam-Webster's Collegiate Dictionary, 1996, p. 79). In contrast, heteronomy is "subjection to something else; esp. a lack of moral freedom or self determination," (p. 545).
The concept's earliest documentation is in the history of ancient Greece and the relation between Athens and her allies in the Delian League in 5th century BC. The term "autonomia" referred to "a state that is free to determine the norms by which it wants to live." (Ostwald, 1982, p. 10) Autonomia was used by weaker states in opposition to despotism. It described the qualities of states or individuals that exist in the shadow of a superior power but still enjoy self-determinism, even if it results in death. Autonomia referred to the quality of an individual or agent who lives by their own law. The Greeks used the term "agency" to refer to a state or person who is an effective producer of intended effects. Greek writings suggest that the agent's ability to prepare for the protection of their own integrity is the hallmark of a state that is autonomous (Ostwald). Thus, autonomy is political in origin. Since the time of the ancient Greeks, the concept has evolved extensively. On investigation of its evolution, several recurring themes emerge. They are selfgovernance within a system of principles, competence or capacity, decision making, critical reflection, freedom, and self-control. Each theme will be explored separately, although there is much overlap between themes.
Theme of Self-Governance Within a System of Principles
The notion of self-governance and self-rule is found throughout contemporary literature on autonomy as well as in the ancient Greek usage. Self-governance is the core of autonomy and is based on a system of principles and laws. Kant's philosophical work Groundwork on the Metaphysics of Morals (cited in Wolff, 1974) postulated the classic explication of autonomy: "The will is therefore not subject to the law; but is so subject that it must be considered as also making the law for i t s e l f . . . " (p. 178). Kant believed that one must be moral to be autonomous, governing oneself in accordance with universally valid moral principles and laws through his or her own actions. In analysis of this view, Wolff concurs that "the autonomy of the rational agent is legislating through his independent choice a system of principles to which he is rationally bound" (p. 228). Others have referred to governance as the right and responsibility to establish conditions and make decisions pertinent to one's professional practice to main-
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tain control over practice, self, and working conditions (Aydelotte, 1983; Dayani, 1990; Susman, 1976). Theme of Ability, Capacity, and Competence The attributes of ability, capacity, and competence are another recurring theme in autonomy. Psychologist and philosopher Haworth (1986) asserted that "competence is the foundation of autonomy. A person strives to be able to produce intended effects and to become able to expand his repertoire of skills that underlies that ability" (p. 2). The contemporary philosopher Young (1985) stated that "the autonomous person's capacities, beliefs, and values will be identifiable as integral to him and be the source from which his actions spring" (p. 1). Autonomy hinges on one's ability and competence and is expressed in one's actions. Ability or competence include knowledge and the capacity for self-control. Aydelotte (1983) stated that " . . . knowledge is essential to self-governance. It opens the door to power and authority" (p. 832). Leddy and Pepper (1985) further reinforced the necessity of knowledge by stating that professional autonomy is achieved when "one can perform one's total professional function on the basis of one's own knowledge and judgment and further, that one is then recognized by others as having the right to do so" (p. 196). Several nurse authors also have correlated competence and knowledge base with the achievement of autonomy (Blanchfield & Biordi, 1996; Kramer & Schmalenberg, 1993; Maas, 1989; Pankratz & Pankratz, 1974; Perry, 1986; Schutzenhofer & Musser, 1994). Thus, competence is critical to the meaning of autonomy. Theme of Decision Making Decision making also is a central theme in the concept of autonomy. Two components arise that are critical to the idea that decision making is an attribute of autonomy. One is that agents have the freedom to choose how best to achieve an end or satisfy a preference. The other is that agents have the freedom to act on their choices. Batey and Lewis (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" (p. 15). Leddy and Pepper (1985) stated that "the autonomous person is capable of 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" (p. 47). Philosopher Young (1985) reinforced the notion of individual decision making with "those who themselves determine what they will decide and do, rather than have these dictated to them by circumstances or others, are autonomous" (p. 8). Haworth (1986) suggested that autonomy develops psychologically and is made evident through decision making activities. The necessity of this attribute to autonomy is borne out through the predominance of decision making as a variable in research on autonomy (Batey & Lewis, 1982; Blegan et al., 1993; Carmel et al., 1988; Katz, 1968; Pinch, 1985; Schutzenhofer, 1987). Theme of Critical Reflection Closely connected with decision making in autonomy is the attribute of critical reflection. If autonomy reflects one's life being one's own, then independence must proceed from decisions reflecting one's own judgment. Obedience to laws and principles, as a part of the autonomous person's system, must stem from reflection on those laws and principles and on reason. Therefore (as Kant described), the autonomous person believes in and is bound to critically reflected upon laws accepted as their own.
Closely connected with decision making in autonomy is the attribute of critical reflection.
Haworth (1986) described reflection as being "sensitive to thought and to being guided by i t . . . acting on reason, reflecting on impulses and outside influences. One adopts standards, values, and principles after having critically reflected on them. Autonomy is the carrying out of reflectively endorsed purposes" (pp. 2, 23). Kant (as cited in Haworth, 1986) believed that actions based on desire lead to heteronomy. Kant's critics disagree by asserting that if one critically reflects on one's desires, one avoids heteronomy by assuring that one's choices are one's own. Thus, the concept of autonomy involves the idea of authoring one's own world without being subject to the will of others-through reflection and decision making and within a system of endorsed beliefs and principles.
CONCEPT ANALYSIS OF AUTONOMY
Theme of Freedom
Throughout the literature, autonomy expresses a condition of freedom and independence worth fighting for and achieving. Reference to this notion began as freedom of a state to make it's own laws. This idea evolved to the search for individual freedom. Nursing references to freedom and autonomy are laden with the assumption that freedom to act autonomously, at least partially, derives from external sources (Carmel et al., 1988; Lewis & Batey, 1982; Maas, 1989). Classical and philosophical literature reflects a much different notion. The Romantics viewed autonomy as an independence of consciousness, and their literature examines the balance between the self and its context (Garber, 1982). Rousseau and other Romantic writers of the time viewed perfected autonomy as a state of completely fulfilled desire. Not a state that comes easily but rather one that one that is fought for and made by oneself, in opposition to the pressures for subservience coming from external sources (Garber, 1982). Poets and authors of such literary works as "TellTale Heart," Moby Dick, the "Grand Armanda," and "Pappacini's Daughter" write of the paradox between one's vision of autonomy and the cost of its attainment. These literary works refer to autonomy as self-won, self-generated, and free of external inducements (Garber, 1982). Haworth (1986) reiterated this directional correlation between autonomy and freedom. He stated that "the positive connotation of independence is one actually ruling oneself, and that self-rule doesn't automatically follow from freedom and independence, but only guarantees the possibility" (p. 11). If autonomy is viewed as a self-generated condition that is free from external inducements, two connotations may be implied. First, that freedom for something is a consequence of autonomy. Second, that autonomy is the capacity of an individual to express his or her freedom from. In describing positive liberty, Young (1985) stated that "people are not independent from" (p. 5). Instead, we exist within the realities of social structure and "that those structure's arrangement may undermine autonomy but adjustments will not confer it" (p. 8). Thus, autonomy is a character ideal or virtue, synonymous with the ability to self-direct according to a life plan that conforms to the individual's long-term nature and interests. The notion of an unobstructed environment or a domain of autonomy is therefore not necessary for the condition of being autonomous, as so many nursing
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authors have suggested (Batey & Lewis, 1982; Blanchfield & Biordi, 1996; Blegan, et al., 1993; Dachelet & Sullivan, 1979; Kramer & Schmalenberg, 1993; Maas, 1989). Autonomy is not given or taken away; it is a personal quality that hinges on individuals' a priori inherent potential to choose a course of action. Truly autonomous individuals know and live what they believe to the extent that external forces cannot control or adversely influence them. As Mundinger (1980) expressed, autonomy is not an issue for authentically autonomous individuals because they are already autonomous. Theme of Self-Control
The theme of self-control is common to discussions of autonomy (Erikson, 1963; Holden, 1991; McCloskey, 1990; Schutzenhofer, 1983, 1987). These authors and others discussed the impact of self-control and its relation to constraints in the environment on the exercise of autonomy. Autonomous individuals receive domains of autonomy in recognition of their developed capacity for an autonomous life' Otherwise, freedom to act with no constraints whatsoever would result in anarchy. Autonomous persons demonstrate capacity through "full rationality and unrestricted critical competence expressed in a continuously expanding creative life that is fully one's own" (Haworth, 1986, p. 55). This notion connotes an existing awareness of responsibility for self and the ability to control oneself. Autonomous people act with deliberation and self-discipline while acknowledging limitations and the need for the support and love of others (Fromer, 1981). Impulsive behavior is the antithesis of deliberate self-discipline. It implies the absence of a welldeveloped internal system of beliefs and principles and thus invites external control. Thus, to the degree that one exercises self-control, one's domain of autonomous expression expands (Holden, 1991). Definitions
In the process of separating this complex concept from its antecedents, consequences, and related concepts, the core meaning of autonomy is now definable. The theoretical definition is "the quality or state of being self-governing." More specifically, autonomy is "the capacity of an agent to determine its own actions through independent choice within a system of principles and laws to which the agent is dedicated."
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Defining Attributes Especially useful in a concept analysis is the explication of defining attributes. These attributes, or characteristics, signal the true presence of the concept (Walker & Avant, 1995). The critical attributes of the theoretical definition of autonomy based on this analysis are (1) the agent is able to determine his or her own actions, (2) the agent is able to competently act on his or her determinations, (3) actions and decisions are based on critical reflection, (4) actions and decisions are consistent with the agent's own internally endorsed system of principles to which he or she is dedicated, and (5) decisions are made independent of external control.
Antecedents and Consequences These definitions and their corresponding attributes derive from the development of the concept of autonomy as a potential human quality in an existing state. The definitions and their attributes as stated here are devoid of antecedents, consequences, and related concepts. A frequent barrier to understanding of this abstract concept has been its confusion with the related concepts of freedom, power, control, authority, responsibility, independence, and professionalism. All of these concepts are found in nursing literature related to autonomy. In one way or another, these concepts reflect the professions struggle with issues related to practice, education levels, and nursing's relationship to other health care professionals and health care bureaucracies. Antecedents derived from a concept analysis can be extremely useful in clarifying areas for intervention. Antecedents are the events or states that must exist or occur before the concept can occur (Walker & Avant, 1995). In contrast to the sweeping assumption that nursing and nurses must be provided with a contextual environment of a certain nature for autonomy to occur, autonomy actually is contingent on a culmination of personal factors explicated as antecedents. These personal factors hinge on both inherent personal characteristics as well as exposure to knowledge and ideas that can be cultivated and supported in a nurturing environment (Table 1). Thus, if nursing wishes to advance the level of autonomy among its practitioners, interventions must focus on assessment, development, and measurement of these antecedent conditions. The antecedents of autonomy as gleaned from this analysis demonstrate
TABLE 1. Antecedents Inherent intellectual capacity Morality Exposure to systems of beliefs, laws, standards, and principles Knowledge sufficient to develop competence Knowledge of personal values and beliefs Ability to reason Ability to control self
the necessity of careful selection of candidates for the profession. They also point the way toward basic formal educational content as well as postgraduate retraining and reinforcement. Consequences may reflect the context surrounding a concept (Walker & Avant, 1995). In this case, autonomy emerges as a term often used in a colloquial manner to refer to a state that more accurately reflects the consequences of autonomy (Table 2). As a student recently remarked in response to the author's questioning on the meaning of autonomy, "it's when someone finally takes notice of my work and makes me feel valued" (M. Payne, personal communication, October 14, 1996). The word autonomy has been used to mean the consequences of autonomy, such as recognition and status, as described by the nursing student. Although erroneously described, the consequences reflect very real needs that can only be attained by possessing autonomy. The astounding revelation arising from this analysis of the concept of autonomy is that the actual stated desires and needs of the profession are reflected in the consequences of autonomy, not the true state of autonomy itself. Individual autonomy must in fact precede the desired state that nursing has described as autonomy. An even more astounding realization is that achievement of true autonomy does not spring from an external set of conditions (consequences of autonomy such as authority and an autonomous domain) but rather through the development and nurturing of internal human qualities (antecedents such as ethical knowledge and critical thinking) that are most certainly within the control of nursing.
TABLE 2. Consequences Individual professional status Freedom for Authority and power Recognition by others as competent Personal satisfaction Expansion of domain of autonomous expression
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Model Case
Another useful strategy in the analysis of an abstract concept is the presentation of a model case. As Walker and Avant (1995) described, the model case is one in which all of the defining attributes of the concept are present. The model case is a pure example of the analyzed concept. Mary is a registered nurse who graduated from a diploma school in 1981 at the top of her class. She completed her bachelor's of science in nursing in 1987, and graduated with honors. Mary has been employed at a large tertiary-level hospital on a busy medical-surgical unit since 1984. Mary is knowledgeable regarding her hospital's policies and her state practice act. She has developed expertise in her practice, and uses theory and research. She believes in and follows the American Nurses Association (ANA) Codefor Nurses and Standardsfor Clinical Practice. She developed her philosophy of nursing based on holism, advocacy, and critical problem solving. In both learning and professional situations, she often questions tradition and authority, reflects on new information, and thoughtfully integrates that which she endorses as rational and sound into her philosophy and base for practice. She regularly attends seminars and continuing education. Her managers always rate her performance as excellent. Today she is working evening shift and is the primary nurse for a 34-year-old man admitted yesterday with viral pneumonia. Mary gets report that his temperature has been greater that 102°F since admission, that he has a dry, hacking cough, and that he is very restless. His doctor had ordered intravenous fluids, continuous oxygen, and acetaminophen as needed. On assessment of her patient, Mary found a very agitated, pale, diaphoretic man in a weakened state with a hacking cough, a temperature of 104°F orally, and an apical pulse of 68. He stated that he feels scared and nauseated. His family was at the bedside and pleaded with Mary for help. After assuring the patient's safety and reassuring the family, Mary went to the chart. The temperature graphic indicated a 24-hour zigzag pattern of rising temperatures with falling pulses and vice versa. The chart indicated that staff on day shift had notified the doctor of the patient's condition. He responded with orders to continue present treatment and noted that the patient was "doing well." Mary knew that that her patient's condition was deteriorating and that his symptoms were not indica-
tive of a simple viral pneumonia. She consulted with the shift supervisor, informing her that she planned to call the doctor and request a stat pulmonary or infectious disease consultation. She stated that she believed that her patient had been improperly diagnosed and treated. Her supervisor told Mary she was overreacting and advised her not to call the doctor at home because it was late at night and the situation could wait until the morning. Mary decided to call the doctor against the advice of the supervisor. She knew that her code of ethics required responsible competent practice based on informed judgment and that she is first accountable to her patient for the provision of safe care. She placed the call, described the patient's condition and her concerns, and requested a consultation order. After some encouragement, the doctor agreed. She called a pulmonary doctor, who arrived on the unit one half hour later. The doctor quickly diagnosed the patient and immediately began treatment for Legionnaire's disease. Extraction and Justification of the Attributes Via Empirical Referents Within the Model Case
Extraction and justification of the attributes is helpful in the analysis of a highly abstract concept. The ability to measure autonomy is enhanced using empirical referents from the model case.
• . . a g e n c y refers to o n e w h o is an effective p r o d u c e r o f i n t e n d e d effects•
THE AGENT IS ABLE TO DETERMINE HIS OR HER OWN ACTIONS
To reiterate, agency refers to one who is an effective producer of intended effects. That an agent is able to determine something therefore implies the capacity to make intentional decisions. Mary demonstrated this attribute in several referents. She decided on a career, nursing, and the manner in which she obtains her education. She decided to remain knowledgeable both formally and informally. She decided to develop a philosophy of nursing onto which to base her practice. Mary, in caring for this patient, demonstrated the ability to decide on her manner of delivery of care, to consult her supervisor, and to go against advice and call the doctor.
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108 THE AGENT IS ABLE TO COMPETENTLY ACT ON HIS OR HER OWN DETERMINATIONS
This attribute closely relates to the first one. In number one, the focus is decision making. Here the essence is the capacity to intentionally act on one's decisions with competence. Mary's case illustrated this attribute through the following referents: that a state licensed her, that her hospital employed her, and that her success in both school and practice demonstrated knowledge, competence, and an authority to act. Her capacity to act on her decisions also is founded on her theory- and research-based knowledge and practice and in her 6 years of experience, including the care of patients with viral pneumonia. Her knowledge of the state nursing practice act and the institution's policies also bolstered her competency and gave credence to her actions. She also demonstrated competent action in her management of her patient's care by acknowledging herself of his condition, calling her supervisor, and calling the doctor. She based her actions on her philosophy and standards, her knowledge, her legal capacity, and on her history of sound decisions developed through use of the nursing process. ACTIONS AND DECISIONS ARE BASED ON CRITICAL REFLECTION
Critical reflection refers again to deliberation, reason, and choice rather than acting on impulse or outside influence, thus making one's decisions, actions, and laws one's own. Mary overtly and covertly demonstrated this attribute in the following referents: she believes in the ANA Code for Nurses and the Standards of Clinical Practice, referring to more than mere acceptance. In her learning and practice situations she reflects upon orders, policies, authoritative mandates, and tradition and carefully assesses new information. She exhibited reason and critical reflection in deciding that her patient's condition was incongruent with his diagnosis and the doctor's most recent assessment. She critically reflected on her supervisor's advice, choosing instead to call the doctor. ACTIONS AND DECISIONS ARE CONSISTENT WITH AGENT'S OWN INTERNALLY ENDORSED SYSTEM OF PRINCIPLES TO WHICH HE OR SHE IS DEDICATED
As an agent critically reflects on information and chooses the components of its philosophy, values, and laws, he or she must also demonstrate that internally accepted system in his or her actions if the agent is
truly autonomous. Mary does this often in the model case. She has a solid system of principles developed over time. They include her practice skills based on theory and research, her belief in a code of ethics and professional standards, her philosophy of nursing, and her knowledge of her institution's policies and state practice act. She demonstrated incorporation this system into her practice through her continuing education, assessment of her patient's condition based on her knowledge, and her caring activities toward her patient. She practiced her philosophy of client advocacy by acting in opposition to formal authority and calling the doctor with a request for a consultation with a specialist. She used the nursing process in her care of the patient.
DECISIONS ARE MADE INDEPENDENT OF EXTERNAL CONTROL
This attribute refers to the demonstration of an agent's willingness to act on his or her decisions. It does not imply an environment free of constraints but rather an autonomous agent who enacts his or her freedom to choose no matter what exists in the environment. The two overt referents in this case include the following. Mary did not wholly rely on information from external sources, including the chart and report, but chose instead to make her own assessment of the situation based on her own system of principles, knowledge, and experience. Also, she decided to call the doctor against the supervisor's advice, once again demonstrating freedom to control her own decision making.
Borderline Case
Borderline cases are useful when analyzing a concept that is both abstract and frequently misused and misunderstood. A borderline case is a case in which some, but not all, of the defining attributes are present (Walker & Avant, 1995). Using the previous model case, everything remains the same in the borderline case except for the following: When Mary hears her supervisor's instruction not to contact the doctor, she is upset and feels that the advice is wrong. But she has been reprimanded before for questioning authority, so she reluctantly chooses not to contact the doctor, feeling angry that once again "the system" has used its power over her. Two defining attributes of autonomy (nos. 4 and 5)
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are skewed or absent in this case. First, had Mary's actions and decisions been consistent with her own internally endorsed system of principles to which she is dedicated, she would have called the doctor as in the model case. Also, Mary did not demonstrate independent decision making despite external control. She chose not to call the doctor because she believed that there was more powerful external control. Essentially, she gave her autonomy away. Autonomous agents would analyze the situation and act on their critically reflected-on decision based on their internally endorsed system of beliefs and principles despite constraints from external sources.
Significance The concept of autonomy is abstract and complex. Its meaning in the nursing literature encompasses many related concepts. Formal analysis of this concept clarifies meaning and encourages semantically proper usage. This analysis should be useful in a number of ways. The cultivation of true autonomy is essential if nursing is to reduce the likelihood of consequences of borderline autonomy, such as patient suffering and death, nursing dissatisfaction, burnout, and attrition. Knowledge of defining attributes of autonomy as well as the antecedents could facilitate development of curricular models and educational content. The focus should be increasing and enhancing development of autonomy in professional nurses within the formal educational process. Educators have a responsibility to assure that students are adequately immersed in formal professional standards and values. Students must fully identify and develop their philosophy of nursing and insure knowledge of personal beliefs. Characteristics such as morality, ability to reason, self-discipline, and accountability must be assessed and supported within the educational process. Appropriate risk-taking behavior must be viewed by faculty as a positive quality to be encouraged and developed rather than suppressed. And finally, nursing must come to grips with the fact that knowledge level does indeed correlate with competence and therefore au-
tonomy. Maas (1989) and others assert that there is a strong connection between educational level and the exercise of autonomy. Singleton and Nail (1984) intimated that the issue of autonomy is not a matter of how organizations should provide nurses with autonomy but of how much autonomy nurses freely choose to exercise. This analysis shows that the core meaning of autonomy is that of a positive potential human quality arising from within the individual agent. Thus, the focus of systems research related to autonomy should reflect this clarification. Defining attributes and antecedents might be useful in the development of accurate role differentiation within health care organizations and in the profession as well as in retraining and reinforcing to enhance and support autonomous practice. Construct validity is essential in the development and use of research instruments. Without operational definitions and defining attributes, conceptual measurement is futile. Schutzenhofer (1987) and Scearse (1989) called for identification of personal and behavioral characteristics of autonomy and for clarification of this loosely defined term. The global analysis contained herein will enable measurement of characteristics in a variety of populations of nurses within a variety of settings. Use of a formal concept analysis for the development of research instruments measuring autonomy should result in meaningful and more consistent outcomes. Autonomy and the importance of its acquisition have continued to be a vital issue within the profession of nursing. If nursing is to successfully achieve this state, it must have an absolutely clear and consistent understanding of its meaning and its empirical measurement. Otherwise we will continue to be "Like one that stands upon a promontory and spies a far-off shore where he would tread, wishing his foot were equal with his eye" (Shakespeare, "King Henry VI," Part III).
Acknowledgment The author thanks Sue Popkess-Vawter, PhD, RN, professor, University of Kansas, Kansas City, KS, for her invaluable assistance with the preparation of this manuscript.
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