Autonomy in Nursing - 石川県立看護大学

石川看護雑誌 Ishikawa Journal of Nursing Vol.3(2), 2006
Autonomy in Nursing
Frances Marcus Lewis, R.N., M.N., Ph.D., F.A.A.N.
Elizabeth Sterling Soule Professor of Nursing,
University of Washington
Autonomy is the freedom to make discretionary and binding decisions that are consistent
within one’s scope of practice and the freedom to act on those decisions. There are 3 purposes to
this paper:
1. To analyze the concept of autonomy and its relevance to nursing.
2. To identify the structural, not merely personal, attributes of autonomy.
3. To identify the unique challenges in Japan for advancing autonomy in nursing.
Analysis of Concept of Autonomy
Autonomy is the freedom to make discretionary and binding decisions consistent with one’s
scope of practice.
Discretionary and binding decisions mean that the nurse has control over the knowledge
needed to make the decision. She or he does not need to turn to others in order to know or
understand. Instead, the training and education of the nurse has provided him or her with the
requisite information and understanding to make the decision. For example, a nurse is educated
to know how to assess vital signs and patient symptoms. These include deciding if a patient’s blood
pressure is elevated beyond a normal range; it also includes judging whether a patient is excessively
perspiring or hyperventilating.
Such assessments are part of a nurse’s knowledge and
Discretionary and binding decisions mean that no one “above” the nurse needs to give
approval or permission for the nurse to take action on an assessment or observation. If an act
requires permission or approval from someone else, the act is not discretionary and the nurse is not
acting with autonomy. An example of a discretionary and binding decision includes a nurse’s
decision to reposition a patient in order to maximize chest excursion and reduce cardiac work.
Another example of a discretionary and binding decision is a nurse’s decision to measure input and
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石川看護雑誌 Ishikawa Journal of Nursing Vol.3(2), 2006
output on a patient whose level of hydration is of concern to the nurse. Both decisions are within
the nurse’s scope of practice knowledge and no one needs to make these decisions for the nurse.
Rather, the nurse is able to independently make these decisions and all of them are within his or her
scope of practice.
Autonomy includes the freedom to act on the binding decisions the nurse makes. The
nurse does not need to obtain permission from others to carry out actions she has decided on.
Instead, the nurse’s education has prepared her to enact the decisions. For example, a nurse can
decide to initiate an educational teaching plan with a new mother who is trying to initiate breast
feeding her newborn but who is not being consistently successful. No one needs to give the nurse
permission to do this education with the mother. For example, a nurse can initiate a teaching plan
for a caregiver at home who does not understand when or how to interpret the patient’s symptoms
or does not know when to decide to administer a medication. Again, the nurse can carry out these
teaching plans and no one needs to give him or her permission to do them.
Autonomy as Attitude and Structure
Autonomy has both a personal or attitudinal dimension as well as a structural dimension.
Both are important.
Autonomy is part of a nurse’s attitude and is reflected in statements like these, “This nurse
has a high personal sense of autonomy, “ and, “This nurse is committed to an autonomy of practice,”
and “This nurse values autonomy of practice.” Each of these statements reflects nurses who value,
want, or embody an attitude of autonomy. If a nurse is to practice with autonomy, he or she must
perceive and value the freedom to do so and be willing to exercise autonomy. If a nurse does not
value autonomy or does not perceive the freedom to carry out autonomous acts, then the nurse will
not be autonomous.
Autonomy involves structure. Structure includes the structure of a health care agency,
the scope of practice that is described in nurses’ practice literature, nurses’ license laws, nurse
organization’s professional practice standards, advanced practice certifications, and knowledge
development within nursing science. Each will be briefly considered.
The structure of a health care agency reflects the degree of autonomy of nurses. Agencies
vary enormously on the extent to which a nurse is encouraged, hired to do, and positively rewarded
for carrying out discretionary and binding decisions and actions. If a nurse must seek permission
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石川看護雑誌 Ishikawa Journal of Nursing Vol.3(2), 2006
for practice acts that are within his or her educational training before she or he carries them out,
there is essentially no autonomy allowed by the agency. If, however, a nurse is promoted, given
merit pay increases, and valued when she or he carries out discretionary and binding decisions for
patient care, then the agency’s structure supports and encourages autonomy.
Autonomy is affected by the scope of practice that is described in nurses’ practice literature,
license laws, and practice standards. These documents are essential for advancing and supporting
autonomy in nursing. If the practice literature emphasizes non-discretionary and non-binding
decisions, they are not supporting autonomy. One could even argue that they are holding back
autonomy. Nurses’ license laws should clarify the domains of knowledge and skills over which the
nurse can make discretionary and binding decisions. Clear laws should reflect clarity on the
nurse’s assessment responsibilities, on binding decision-making responsibilities, and on delegated
responsibilities. The literature should be examined and evaluated for text that discourages
autonomy or encourages nurses’ dependency on others for making most of the decisions for nurses.
What do the license laws state about nursing actions? A review of these laws can be illuminating.
The text of these laws may include language that works against autonomy in nursing.
example, if the text of the practice law states that nurses must seek pre-approval to initiate patient
care plans, the law is working against autonomy. If the law states that nurses serve patients at the
discretion of the physician, the law is working against autonomy. Functioning with autonomy as
nurses is different than functioning collaboratively with physicians.
Nurses do function
collaboratively with physicians, but that does not preclude them from functioning autonomously
within their scope of practice. These two issues should not be confused with each other.
Collaboration with physicians works very well with autonomy in nursing.
Standards of practice in nurses’ professional organizations should include those actions
over which the nurse has autonomy. These practice standards should ideally distinguish between
entry-level and advanced level standards. Such standards can act as a vision for the profession.
Autonomy is enabled by research that is conducted by nurse scientists. As nurse scientists
continually examine the effects of nurses’ practice and actions, autonomy will be further enhanced.
For example, if nursing science discovers that certain types of daily exercise and ambulation with
patients with cancer improves depression, then nurses will be in an informed position to teach and
counsel newly diagnosed patients about the importance and frequency of daily walking, even during
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chemotherapy. Such a recommendation would be the opposite of what many nurses would have
recommended a few years ago.
By conducting scientific studies in areas of nursing practice,
nursing science adds to the nurse’s ability to act autonomously on the basis of best evidence.
Challenges to Autonomy in Japan
Japan is a country rich in heritage and deeply rooted values that include harmony,
respectfulness, deference, gentleness, and modesty. None of these values need to be changed in
order for nurses to function with autonomy. Autonomy does not conflict with these values. But
autonomy does require that a nurse carry out discretionary professional acts based on the authority
of knowledge and license. Furthermore, autonomy does not cause disharmony with physicians or
elders. Autonomy includes acts that are concordant with harmony.
Do not confuse respectfulness with inappropriate deferral or modesty.
Autonomy in
nurses’ practice contributes to the well-being of patients and adds to the quality of services and care
that patients receive.
Functioning with others in harmony does not require that a nurse is meek
as a mouse. When autonomy is effective, the nurse’s acts are focused on the patient and the
patient’s well-being. As such, autonomy brings out the BEST of nursing practice to the patient.
Autonomy is never focused on the self.
There is a “growth pain” in evolving structures and laws that encourage nurses’ autonomy.
Tension will naturally come from working through and generating new working relationships and
structures. This is a good, natural tension as nurses and other health care workers talk about,
plan, and work through new and better ways of working together for the benefit of patients.
Differing expectations can be made clear. For example, if nurses were historically expected to not
initiate patient teaching plans or counsel patients but now claim such activities as part of their
autonomy, others will need to have such actions interpreted. If the acts of autonomy are clearly
focused on the well-being of patients, tension will be easily managed or avoided. Again, autonomy
is never focused on the self or on personal power. It is instead focused on carrying out acts that
benefit patients.
Concluding Remarks
Florence Nightingale’s Pledge is the essence of nursing and reminds us of the importance
of both autonomy and collaboration with physicians:
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石川看護雑誌 Ishikawa Journal of Nursing Vol.3(2), 2006
“I solemnly pledge myself before God and in the presence of this assembly, to pass my life
in purity and to practice my profession faithfully.
I will abstain from whatever is deleterious and mischievous, and will not take or
knowingly administer any harmful drug.
I will do all in my power to maintain and elevate the standard of my profession, and will
hold in confidence all personal matters committed to my keeping and all family affairs coming to my
knowledge in the practice of my calling.
With loyalty will I endeavor to aid the physician, in his work, and devote myself to the
welfare of those committed to my care.”
Begin and end each day’s work by asking yourself, “Did I function autonomously on behalf
of my patients?” Put priority on functioning both as a collaborator with physicians and as an
autonomous nurse. The journey of an autonomous nurse is not a solo journey; it is a journey for
both nurses and physicians and health care agencies. Ultimately, autonomy will benefit your
patients, medicine and the nursing discipline. In nursing, your work is your honor.
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