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Commentary on Skår R (2010) The meaning of autonomy in nursing practice. Journal of Clinical Nursing 19, 2226–2234

2010; Wiley; Volume: 19; Issue: 17-18 Linguagem: Inglês

10.1111/j.1365-2702.2010.03350.x

1365-2702

John Rowe,

Interprofessional Education and Collaboration

Autonomy is usually described as the state of being independent or self-governing, but the meaning is more broadly defined in ethical discourse, healthcare and nursing. The result is that, although there is some clarity about what autonomy means in the ethical literature, in nursing the issue becomes more complex with a lack of consistency when defining autonomy (McParland et al. 2000). This commentary on the paper by Skår (2010) seeks to contribute to the discussion by suggesting that the term autonomy in nursing is sometimes misapplied; used when words such as ‘confidence’ and ‘competence’ are more appropriate, but also identifies the beginnings of a model for the pursuit of nursing autonomy. According to Dworkin (1988) and McParland et al. (2000), nurses can attain autonomy with the ability to make independent choices, freedom from coercion, rational and reflective thought, and adequate information and knowledge. When applied to professional practice, MacDonald (2002) referred to autonomy as control over practice and the exercise of judgment. The autonomous nurse would, therefore, have substantial control over their practice in addition to significant room for clinical judgment. The number and types of decisions made by nurses are related to the work environment, and the perceptions of their operational autonomy (Thompson et al. 2004). The study reported by Skår (2010) aimed to illuminate the meaning of nurses’ experience of autonomy in work situations. It addresses the topic of autonomy head on with an informed discussion on what constitutes autonomy when applied to nursing practice. Four themes were identified: ‘to have a holistic view’, ‘to know the patient’, ‘to know that you know’, and ‘to dare.’ The first three themes refer to the gradual acquisition of practice skills and knowledge, but not to the extent that they meet the definitions of autonomy given by McParland et al. (2000) or MacDonald (2002). They do, though, begin to outline a model for pursuing autonomy in practice. The theme ‘to have a holistic view’ was expressed as knowing how nursing is organised, tasks, routines and interdisciplinary work. It is not so much about acting autonomously as ‘learning the ropes’ and organisational culture. It does also suggest the first step on a model for pursuing autonomy as it recognises patients’ needs with the nurse realising what jobs require attention. The theme, ‘to know the patient,’ is related to knowing what is best as the nurse has responsibilities for patient care. Again this suggests adequate information and knowledge to care in a familiar clinical situation and can be viewed as the second step on a model for pursuing autonomy. In the third theme, ‘to know what you know’, nurses proclaimed the need for knowledge about the patient’s medical condition and to be confident about their assessments and interventions, but as the third step on a model for pursuing autonomy it also introduces the concept that sometimes nurses do not know what to do, but have to ‘handle new tasks’ (Skår 2010, p. 6). As Tschudin (2003, p. 70) put it, ‘When nurse are aware of what they can and could do, they also become aware of what they cannot do.’ These first three themes are not so much related to nursing autonomy (as exercising judgment or having substantial control over practice), but refer to organisation, responsibility and knowledge. Therefore, although participants attempt to identify the meaning of autonomy, they misapply the term and actually describe the acquisition and development of the knowledge and skills needed to practice confidently and competently in familiar clinical situations. It is with the fourth theme, ‘to dare’ that nurses begin to understand the meaning of autonomy and take the fourth step on a model for autonomy in practice. They ‘express their personal endeavours in new and challenging situations where ‘there are no standards or routines to follow’ (Skår 2010, p. 6). They have to rely on personal resources to deal with situations that are outside their experiences. At the personal level, nurses who ‘dare’ are liberated to act, able to think independently and with control over their decisions. As one participant put it, ‘there are no standards or routines to follow’ (Skår 2010, p. 6). It is here that they can move to exercising autonomy, having what MacDonald (2002) described as substantial control over their practice and significant room for clinical judgment. But there are also restrictions on their efforts to be autonomous; these restrictions are on their ability to make decisions about their course of action and to act on those decisions in unfamiliar clinical situations. At the social level, there are constraining factors that further help define autonomy. For nurses they include legislation, policies and codes of conduct such as in the United Kingdom where the Code (NMC, 2008) governs nursing practice through standards for conduct, performance and ethics. These constraining factors help define autonomy as they hold nurses responsible and accountable for their actions (Hugman 2005). Skår’s (2010) paper reported on research involving participants who had 2 or 3 years postqualification experience. Examining the perspectives of nurses with limited practice experience led to the misapplication of the term autonomy, but illuminated the development of confidence and competence in familiar clinical situations. In doing so, Skår has contributed to the debate on the development of nursing roles and the pursuit of nursing autonomy.