Scott Chisholm Lamont, RN.

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This is a paper I wrote in my first year of doctoral coursework for a nursing theory class. It was challenging to write, and I got some good feedback on it. My plan is actually to re-write it, based on the feedback I've received, and then re-post it.

A concept analysis of professional autonomy

November 6, 2002

By Scott C. Lamont, BSN, RN.

Organized nursing and individual nursing practitioners have arguably sought professional autonomy within the domain of their practice for well over a century. This effort has not been without controversy and cannot be characterized as a universal drive or desire amongst registered nurses (Melosh, 1982). To this day, the issue of securing professional autonomy remains no less pressing or conflicted. Moloney (1992) argues that “for nursing to achieve full professional status, the concept of autonomy must be understood and diligently sought by all professional nurses. If autonomy is power, then nursing should continue its struggle to achieve it.” (p. 230, italics original). An assumption inherent in this statement is that both professional status and autonomy will benefit nurses and the society nurses serve (Kelly, 1985).

Professional autonomy has several uses in the literature and is frequently cited in a circular motif: autonomy is noted not only as a significant criteria for conferment of professional status upon an occupation (which in this context means the broader concept of any compensated organized work), but also as a goal of professionalism, which when achieved validates the occupation’s professional status. Therefore it would appear that professional autonomy is “the most strategic (and cherished) distinction between a profession” and other occupational groups (Kelly, 1985, p. 353). Kelly lists several key nursing issues that are connected to autonomy, including maintenance of ethical standards, accountability for practice, nursing education, support and expansion of nursing research, and credentialing. Additional issues raised in more recent literature include the impact of professional autonomy on the retention and recruitment of nurses, and the impact of nursing’s professional autonomy on patient outcomes. These linked issues demonstrate the relative importance of autonomy for the nursing profession, thus highlighting the need to understand the concept more completely.

The aim of this concept analysis is to clarify the meaning of this frequently cited term for use in a specific program of research investigating the relationship between nurses’ independent clinical decisions and patient outcomes. The method used for this analysis is the modified Wilson method as presented in our seminar readings (N202A course reader). Following the selection of the concept to be analyzed and the determination of the aim of the analysis, the literature was reviewed for the uses of the terms ‘professional’ and ‘autonomy’ both independently of each other and together as a single concept. Defining attributes were identified, and then model, borderline, and contrary cases were constructed. Antecedents and consequences were identified, along with empirical referents, the latter being most critical to the research program proposed.

A CINAHL search revealed almost 1000 citations of the key term “professional autonomy” published since 1982 in all languages available. Only slightly more than 260 citations were available in English and published after 1995, the majority of which were not available through the UCSF library. A remarkable proportion of these citations were theses and dissertations. Many of the available resources for review were text books that dealt specifically with professional issues in nursing, but none were published within the past 5 years. The list of sources utilized in this paper can in no way be construed as exhaustive.

Profession is a concept that despite repeated attempts does not have a consensus definition (Styles, 1982), although many authors select a definition or synthesize one from several sources (see, for example, Styles’ summary on p. 47). Funk & Wagnalls (1989) dictionary definition of profession is as follows:

Profession: 1) An occupation that properly involves a liberal, scientific, or artistic education. 2. The collective body of those following such occupations. 3. The act of professing or declaring; declaration. 4. That which is avowed or professed; a declaration.

In this context, professing, declaring, and avowing (items 3 and 4 above) are important, as they speak to the occupation publicly stating the claim to society that it holds special and necessary knowledge which warrants special privileges not conferred upon other occupations. Early authors such as Flexner included college professors amongst the groups that were indisputably professions, an interesting point as the title professor has the same root as profession, and means someone who publicly avows special knowledge which can be studied and taught.

Flexner, cited by Moloney (1992, p. 8), listed what he considered to be the characteristics of a profession. His list included 6 items:

1. it (the profession) is basically intellectual, carrying with it high responsibility
2. it is learned in nature, because it is based on a body of knowledge
3. it is practical rather than theoretical
4. its technique can be taught through educational discipline
5. it is well organized internally
6. It is motivated by altruism

Leddy & Pepper (1993) condensed the characteristics of a profession into the categories of intellectual, personal and interpersonal, commitment to service to society, autonomy, and shared personal values. Both Styles (1982) and Martin (1986) note the importance of standards of conduct and codes of ethics in the definitions of professions they chose to highlight.

Autonomy is a concept that has meaning transcending the sociology of work. For example, it “is a basic ethical principle” (Leddy & Pepper, 1993, p.14). Funk & Wagnells (1989) dictionary definition of autonomy and autonomous are:

Autonomy: 1. The condition or quality of being autonomous (defined separately as: Independent; self-governing); esp., the power or right of self-government. 2. A self-governing community or group.

Leddy & Pepper (1993) state that “autonomy means the freedom and the authority to act independently” (p. 11) but note this does not mean control over another individual. They mention accountability and responsibility, tying the concepts together, which other authors also do (Holden, 1991; Styles, 1982). Accountability and responsibility are therefore suggested as consequences of autonomy (Moloney, 1992), and represent aspects of the social contract between the public and a profession. This autonomy is contrasted to what Melosh (1982) referred to as “worker control”, which she has suggested as what the majority of working nurses are interested in. Kelly (1985) calls this “job content” autonomy, noting that it is the freedom to determine methods and means, but not to define the boundaries of the problem. Stated another way, it is control over tasks within a setting, rather than control over determining and managing a domain of practice. Unions have typically been more interested in the former aspect of control in specified work settings, but have shied away from the latter concept and the responsibility (individual and collective) that it entails.

The term “professional autonomy” incorporates both the concept of an occupational group with special and socially relevant knowledge and the concept of independent action tempered by accountability. Several of the sources reviewed provided a definition for professional autonomy. Kelly (1985) states that “professional autonomy has been defined as the right of self-determination and governance without external control” (referring to professions as groups). This definition may be over-stating the case, as evidenced by the societal reciprocation that both empowers professions and controls them through legal institutions. Leddy and Pepper (1993) in referring to autonomy as a characteristic of a profession, offer this definition: “Autonomy means that practitioners have control over their own functions in the work setting”. These definitions suggest autonomy that extends in both the social dimension (such as self-regulation) and the occupational dimension (the work setting), involving both the individual practitioner and the collective group of practitioners.

Based on this analysis, the following definition of professional autonomy is offered: The socially conferred freedom of action and self-governance afforded to occupational groups (or to individuals within said groups) possessing highly specialized knowledge and skill critical to public well-being. This freedom occurs within the domain of practice claimed by the group by virtue of the body of knowledge it controls. In consideration for this freedom, the group accepts accountability and responsibility for all aspects of the knowledge-based services it provides to the society.

Defining attributes of professional autonomy were found to be: 1) a mandate or impetus for action that is largely internal rather than external, 2) action informed by mastery of a unique body of knowledge and selected though an intellectual process of problem solving, 3) action motivated by a sense of altruism and social concern, 4) freedom to act in the work setting and in the social setting without significant outside control, 5) internal and peer constraints upon action guided by a code of ethics which have been set by the group as a whole, 6) societal sanction for independent and collective action and activity, and 7) a cohesive subculture that supports and expects independent and accountable action from its members.

Model Case: A registered nurse notes that a 6 year old post-operative child she is responsible for is having difficulty with deep breathing and coughing, is restless in bed, and has a depressed affect. She is concerned about the child’s comfort and the potential for complications. Drawing upon Roy’s adaptation theory to refine the child’s plan of care, she assesses the child’s interests, the safety of the environment and the child’s clinical stability. The nurse updates the child’s care plan using interventions supported by current nursing research, setting specific goals to improve the assessed findings. She guides the child in progressive physical and distraction activities that are of interest to the child, resulting in the child being up in a chair blowing bubbles and laughing at jokes from a book. When performed in conjunction with blowing bubbles, the nurse notes that the child’s measured deep breaths have improved significantly. Her colleagues on the floor congratulate her for being able to successfully mobilize the child so quickly.

Borderline Case: An experienced critical care nurse notes that his patient is experiencing a dangerous dysrythmia. He assesses that the patient is pulseless, and intervenes with the nationally accepted clinical interventions. As there is no physician present, he follows the hospital’s guidelines and takes charge of the resuscitation, treating the patient using the accepted national standards as standing orders. This guideline has been accepted by all attending physicians, who have agreed to treat the protocols as if they were orders signed by their hand. Upon arrival of the resident physician, the nurse reports the patient’s condition, current therapies implemented, and responses. The physician takes over the management of the patient and directs the nurse to implement additional medical therapies. The physician and the unit nurses compliment him on his effective and knowledgeable leadership.

Contrary Case: A patient appeals to his registered nurse for additional pain medication. The nurse informs him that he has had all that has been ordered by the physician and will have to wait until it is time for another dose. She does not offer any alternative interventions in the interim. The family complains to the unit manager.

Antecedents include a favorable organizational setting, availability of a large and complex knowledge base within a defined domain, completion of formal education sufficient to support independent decision making, socialization to an independent role, peer support, social agreement regarding the appropriate role and domain of the profession, and personal attributes. The consequences include an obligation to take action or to set an agenda (both at an individual and a collective basis), responsibility and accountability for acting when appropriate, acceptance of consequences for errors in judgment or action, and high social expectations. Empirical referents include observable actions that are dependent on internalized factors (knowledge, problem solving, social concern) rather than external direction, overt or implicit statements that the actions were initiated by the practitioner based on their own judgment, and statements or actions that indicate acceptance of responsibility for actions. These latter items are of the greatest concern for the purpose of the proposed research program. Unlike previous studies, which have largely addressed the perception of autonomy, often in a work place context with professional satisfaction as the phenomenon of concern (see, for example, Sabiston & Laschinger, (1995)), this program intends to study empirically observable autonomous action and the related patient outcomes.

Reference List

Funk & Wagnalls standard dictionary (1989). (1st ed.) New York: Signet.

Holden, R. J. (1991). Responsibility and autonomous nursing practice. Journal of Advanced Nursing, 16, 398-403.

Kelly, L. Y. (1985). Dimensions of professional nursing. (5th ed.) New York: Macmillan Publishing Company.

Leddy, S. & Pepper, J. M. (1993). Conceptual bases of professional nursing. (3rd ed.) Philadelphia: J.B. Lippincott Company.

Martin, C. E. (1986). A sociological perspective on professions: Other entry dilemmas. In Looking beyond the entry issue: Implications for education and service (pp. 21-39). New York: National League for Nursing.

Melosh, B. (1982). “The Physician’s Hand”: Work culture and conflict in American nursing. Philadelphia: Temple University Press.

Moloney, M. M. (1992). Professionalization of nursing: Current issues and trends. (2nd ed.) Philadelphia: J.B. Lippincott Company.

Sabiston, J. A. & Laschinger, H. K. S. (1995). Staff nurse work empowerment and perceived autonomy: Testing Kanter's Theory of Structural Power in Organizations. Journal of Nursing Administration, 25, 42-49.

Styles, M. M. (1982). On nursing: Toward a new endowment. St. Louis, MO: The C.V. Mosby Company.

Cite as: Lamont, S.C. (2002). A concept analysis of professional autonomy. Available on-line at: http://www.thuntek.net/~sclamont/nursescott/essays/prof autonomy concept analysis.htm. Retrieved: [date].