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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.38 no.1 Porto Alegre  2017  Epub May 18, 2017

http://dx.doi.org/10.1590/1983-1447.2017.01.59033 

Original Articles

Professional autonomy and nursing: representations of health professionals

Érick Igor dos Santosa 

Yasmin Rayanne Alvesa 

Aline Cerqueira Santos Santana da Silvaa 

Antonio Marcos Tosoli Gomesb 

a Universidade Federal Fluminense (UFF), Centro Universitário de Rio das Ostras, Departamento de Enfermagem, Curso de Graduação em Enfermagem. Rio das Ostras, Rio de Janeiro, Brasil.

b Universidade do Estado do Rio de Janeiro (UERJ), Faculdade de Enfermagem, Departamento de Enfermagem Médico-Cirúrgico. Rio de Janeiro, Rio de Janeiro, Brasil.

ABSTRACT

Objective

To analyse the social representations of the professional autonomy of nurses and nursing for non-nursing health professionals.

Methods

This is a qualitative study based on the theory of social representations. Fifty-three non-nursing professionals of a municipal hospital participated in this study. Data were collected between March and April 2015, from hierarchical free evocations using the inductor terms, “professional autonomy of nurses” and “nursing”. The data were analysed using EVOC 2003.

Results

The most likely core of the social representation of professional autonomy were the terms care, team, and responsibility. Moreover, the likely core of nursing comprises the elements care, team, responsibility, and work.

Conclusions

The professional autonomy of nurses and nursing consists of fairly close objects of representation in the studied group, which makes them non-autonomous representations that are still sensitive to the incorporation of new elements.

Key words: Nursing; Nurses; Professional autonomy; Psychology, social

INTRODUCTION

In nursing, professional autonomy is a complex theme. The need to closely investigate this theme stems from the current configuration of nursing work in the hospital setting, which has progressively gained new contours, demands, difficulties, and technologies, and often supports practices that are still centred on the biomedical model(1-3). It is argued that nursing is characterised as an object of social representation linked to others since it generates a body of knowledge, skills, affectivities, attitudes, and practices related to nurses, their professional identity, their power of decision, and their freedom of action. Therefore, these practices are also related to their professional autonomy(4).

National(3-4) and international(5-6) production on the professional autonomy of nurses reveals the need for new studies, media interventions, and reformulations in nursing education given the urgency of self-asserting that which is central to all professions. This self-assertion explains the direct impact on the needs of society, which runs the risk of losing political power, forfeiting its range of action to other professions, and having to witness the diminished investments of public funds for its maintenance and development.

Earlier studies found that approximately 60.4% of non-nursing health workers(3), against only 6.7% of nurses(6), considered that the nurse has professional autonomy, which is considered alarming. This scenario challenges national and international higher education institutions to reflect on teaching practices that foster the acquisition of new knowledge for new nurses on the limits and potentialities that circumvent their profession.

This study is justified and grounded on the results of a recently published integrative review(4), which found that the lack of professional autonomy in nursing is still a difficult and negative factor for this profession, and a goal in the fight for the professional realisation of nurses. This lack of autonomy is based on the social knowledge of the health team on the professional autonomy of nurses with a scarcity of affective and practical dimensions, revealing that this representation is still being consolidated(3).

These considerations were used to define the guiding question: what are the social representations of nursing for non-nursing health workers? The aim was to analyse the social representations of the professional autonomy of nurses and nursing for non-nursing health workers.

This study can trigger reflection and debates on this subject. It can shed light on the social visibility of nursing, especially of nurses, their work, and the results obtained over time(5-6). Investigating the professional autonomy of nurses and nursing can increase visibility and support the transformation of care practices(7-8).

METHODS

This is a descriptive, exploratory, and qualitative study within the framework of the theory of social representations(9-11). The research was conducted in a municipal hospital in Região do Lagos, state of Rio de Janeiro, Brazil. Participant selection included all the professions (except nurses) with more than one professional since more than one subject is needed for social interaction and symbolic exchanges, a premise of social representations(10).

The criteria for inclusion were holders of a graduate degree in any area of health, hence top-level professionals, working in the area of graduation for at least six months in the study scenario, and over 18, without a maximum age group. The exclusion criteria were cognitive or communication limitations that prevent data collection, and working as a nursing professional, intern, resident or other positions without an employment bond with the institution.

The convenience sample was defined considering all the professionals by area, the criteria of inclusion and exclusion, the availability of professionals and their acceptance to participate in the research, and the minimum number of subjects required to retrieve the representations in the theoretical approach(10-11). The subjects were 9 physical therapists, 3 psychologists, 8 nutritionists, 6 social workers, and 27 physicians, totalling 53 participants. They were asked to complete a sociodemographic questionnaire for characterisation and subjected to the free evocation of words technique. Social work and psychology were considered as being linked to healthcare and, therefore, included in the sample. In the studied scenario, these professionals work as closely with nurses as the other professionals.

In compliance with the provisions of Resolution 466 of 12 December 2012, of the national health council/ministry of health (MS), the participants were asked to read the informed consent statement with the researchers and, if they agreed with the terms, asked to sign the statement. The research was submitted to the research ethics committee (“CEP”) of the Universidade Federal Fluminense (UFF) and was approved under the opinion number 924.334.

Data were collected using the free evocation of words technique at the workplace, at convenient times, previously scheduled, when the workers were available without interfering in their work. The sessions lasted 10 to 15 minutes and took place between March and April 2015. In a first moment, each participant (n = 53) was asked to evoke five words using the inductor term, “professional autonomy of nurses” and five words for the inductor term, “nursing”. The investigation was structured on the social representation of nursing to better understand and contextualise the representations of professional autonomy, starting from the hypothesis of a psychosocial construct that maintains a certain degree of semantic affinity and proximity for people who are not trained in the area.

The collected material was analysed by initially standardising the evoked terms that have the same meaning, so the employed software can join and calculate these terms as reliably as possible. Next, we used EVOC 2003 – Ensemble des programmes permettant l’ analyse des evocations. This software calculates and notifies the simple frequency of occurrence, the average frequency of occurrence of each word in the order of evocation, and weighted average of the average order of evocation (AOE) of the set of terms(10-12).

The data were presented using a four-box table containing the average frequency and order of the evocations. This table has 4 sets of elements. The top left box contains the possible nuclear elements of representation, which may be the most significant from the perspective of the study subjects. The lower left box contains the elements of the representation contrast zone, which are low frequency elements with a lower average order of evocation, that is, they are readily evoked. The upper right box contains the elements with a high frequency, although they are less readily evoked. The lower right box contains the element of the second periphery, less frequent and less readily evoked, which means they are probably the most peripheral elements and most distant from the core of the representation(11-12).

According to the theoretical premise of the structural approach of the theory of social representations, the terms that are most frequent and evoked first (readily evoked) carry the greatest importance in the social thought of the participants, and become the most likely items in the central core of the representation(11-12). In the results description and analysis, there are three representation dimensions, namely the imagery, the functional, and the normative. The imagery dimension relates to the dimension of the image in the representations as a consequence of the process of objectification and the figurative core(7); the functional dimension is the practical dimension of the representations in the everyday life of the subject, allowing control over everyday life, confronting and solving situations, and social movements in different contexts(3,7); and the third dimension refers to the cognitive work involved when the group adopts social standards to maintain the coherence of thought and the feeling of belonging in the group(7).

RESULTS

Participant profile

The participants were mostly women (75.5%), from 25 to 34 years old (41.5%), Catholics (45.5%), with a companion (62.3%), reached the top level of their studies with a specialist degree (81.1%), with average income between BRL 6,000 and BRL 11,000 (34%), without a nursing professional in the family (62.3%), and reported having already worked with the nurses in the three levels of healthcare (49.1%). Of the participants, 69.8% reported they had been attended by nurses and 56.5% had access to information about nursing outside the workplace. When asked whether the nurse has professional autonomy, 60.4% answered yes and 39.6% answered no.

Structures of the representations

For the term professional autonomy of nurses, 265 words were evoked, of which 147 were different. The minimum frequency was 4, with the exclusion of words with a lesser frequency from the four-box table. The average frequency of the other terms was 7. The average order of evocation (AOE) was 3.0, on a scale of 1 to 5. The calculations were all performed in the software based on Zipf’s law and the four-box table (Chart 1) was prepared using the parameters defined above.

Chart 1 – Analysis of the inductor term “professional autonomy of nurses” for non-nursing health professionals. Rio das Ostras, Rio de Janeiro, Brazil, 2015 

AOE < 3 Freq. AOE ≥ 3 Freq. AOE



Freq. Avg. Evoked term Evoked term
≥7 care 15 2.800 medication 7 3,286
responsibility 10 2.600
team 8 2.500

< 7 important 6 2.167 difficult 6 4.000
leadership 6 2.000 supervision 5 3.200
need 6 2.167 commitment 4 3.000
patient 5 1.600 dressing 4 3.500
respect 5 2.400 work 4 4.250

Source: Research data, 2015.

The upper left box contains the likely core elements care, team, and responsibility, indicating the strong imagery and evaluative dimensions of representation, or balance between the functional (care), normative (responsibility) and imagery (team) dimensions. The normative nature of the core is linked to the value system of the studied group. The functional nature emphasises the elements that are most important for the performance and justification of a task, that is, elements connected to an action(11-12).

The word care, which expresses the cognitive dimension of the representation, possibly originates in the classic analogy between nursing and care, as care is inherent to the epistemological pillars of nursing(8-9). The word team expresses an imagery dimension of the representation and indicates that the subjects insert the professional autonomy of nurses in the collective context rather than the individual context. In this case, the subject probably shifts the attribute professional autonomy of nurses to the nursing team, regardless of the legal framework that legitimises decisions made by the nurse on nursing care.

The term responsibility points to a normative and evaluative dimension of the representation, indicating that the subjects express the idea that the professional autonomy of nurses, in this case, is something that requires commitment. The words care and responsibility had the highest frequency among all the words mentioned, with 15 and 10, respectively.

The core has three functions: generator, organiser and stabiliser, respectively determining the meaning, the internal organisation, and the stability of the representation. The generating function attributes the meaning to the other elements of the representation(13).

The lower left box is also known as contrast zone, and encompasses evocations of a low average order of evocation (AOE), that is, words readily evoked, but with a low frequency. In this box, we identified the lexicon important, leadership, need, patient, and respect.

The terms important and need reinforce the assumed existence of a positive attitudinal dimension of the subject, and reiterates the effort of the subjects to assess the professional autonomy or nurses and position themselves in relation to the object. The word respect indicates the perception of the participants that the conquest of a greater degree of professional autonomy on the part of nurses is based on the conquest of respect in the presence of other people.

The evocation leadership, an imagery dimension, is possibly linked to the word team in the core since, by definition, the figure of the leader is always situated where there is a group of people being led, that is, a team. A new imagery dimension of the representation was identified and expressed by the term patient, who is the target of care in the hospital setting. This reveals a connection between the two terms in the four-box table. It should be noted that the evocation patient has a lower AOE, meaning that it is more readily evoked in the structure of the representation.

The first periphery consists of the term medication, revealing a new imagery dimension of the professional autonomy of nurses. The administration of medicines by nurses is apparently represented as the realisation of autonomy since this is a common procedure in the hospital environment and highly visible to other health professionals.

The second periphery, bottom right, consists of the less readily evoked terms with a lesser frequency, or the elements that are less important to the studied group. It shows the evocations, commitment, dressing, difficult, supervision, and work. The term commitment is probably associated with the term responsibility, which indicates the attributes of the professionally autonomous nurse.

The terms dressing and supervision, in association with the term medication, point to a more pragmatic and procedural autonomy, revealing the practical dimension of the representation and the technical aspects of nursing. The evocation work can indicate the condition to reach autonomy based on the ascertainment that the workload is intense in this profession. Thus, it is an evaluative dimension of the representation. Lastly, the term difficult reveals a negative attitudinal, albeit latent dimension, with a low AOE and low frequency.

In all, 265 words were evoked for the term “nursing”, of which 132 were different. The minimum frequency was 4. The average frequency was 9 and the AOE was also 3.0. The calculations were performed in the actual software, based on Zipf’s law. The four-box table (Chart 2) was created using the parameters set above.

Chart 2 – Analysis of the inductor term “nursing” for non-nursing health professionals. Rio das Ostras, Rio de Janeiro, Brazil, 2015 

AOE < 3 Freq. AOE ≥ 3 Freq. AOE



Freq. Avg. Evoked term Evoked term
≥ 9 care 27 2.296
work 13 2.385
responsibility 11 2.818
team 9 2.111

< 9 patient 7 2.571
dedication 6 2.167
profession 5 2.600 hospital 5 3.000
respect 5 2.800 help 4 3.250
white 4 1.750 love 4 3.250
important 4 2.750 medication 4 3.250
injection 4 2.000

Source: Research data, 2015.

Chart 2 shows the possibility of a representational structure for the object nursing in the reconstruction by different health professionals. The likely core of this representational structure encompasses the terms care, team, responsibility, and work. In this core, there is a balance between its functional (care and work), normative (responsibility), and imagery (team) dimensions.

Moreover, this likely core reveals a noticeably favourable attitude of the subjects with respect to the object. The term care, which points to a cognitive dimension of the representation, indicates a certain synchronism between nursing and care, in an analogy that is based on the historicity of the profession and that the profession itself, in several moments, legitimises. The high frequency of this term in the four-box table is striking, attaining 27.

The term team refers to the characteristically joint nature of the profession, at least in the dynamics of hospital work. Another word that forms the likely core is work, signalling the psychosocial development of a unique sense for nursing, in which the act of working plays a central role with regard to nursing. The element responsibility points to a normative and characteristic evaluative dimension of the representation, attributing the adjective of “responsible” to nurses.

The so-called contrast zone, or the bottom left box, has the terms white, dedication, important, patient, injection, profession, and respect. The functional dimension unfolds in this box in the lexicon patient, which is the target of nursing care and of the work of nurses and their teams. The imagery dimension refers to white, a word with a low AOE and, therefore, the most readily evoked among the healthcare professionals in their representation of nursing. White is linked to the traditional colour used by professionals, a symbol of their physical hygiene, asepsis of hospital objects, and their purity regarding suffering and death.

Furthermore, the imagery dimension is linked to the term injection that, despite being constituted as an instrument and nursing action/procedure, retrieves, in this case, one of the most widespread images of nurses in society, in magazines, fiction books, films, and cartoons, and in publicity materials of the actual profession, hospitals, and professional training schools. Finally, the lexicon profession provides the image of a particular social and institutional insertion, which is the professional aspect of nursing.

The normative dimension is revealed in the words dedication and respect, two elements that express a favourable positioning and refer to a way that nursing materialises in the everyday routine of healthcare institutions. This materialisation is rooted in the history of the profession, in its interface with the Christian religion, and in its ancestry in care provided by women to their families and children.

The term important refers to an attitudinal positive dimension of the profession by the participants of the study, whose favourable positioning has already proved evident in the likely core. The evocation patient reinforces the sense attributed to nursing since, for the study participants, this is the purpose of the work of nursing.

The terms profession and injection, strongly imagery, highlight the technical nature of nursing and indicate the connection of nursing to an instrument of its realisation. This finding reveals the overvaluation of their procedures and practice to the detriment of their other various assignments listed in the professional code of ethics and the law.

The second periphery of the representational structure encompasses the terms help, love, hospital, and medication. Help and love show a normative dimension and the affective nature of the representation of nursing. The permanence of ideas of self-denial and emotional support to others in their convalescence is historically based on the religious origins of nursing. The terms hospital and medication, the most concrete imagery elements of the second periphery, relate to one of the loci of nursing work, and to one of its most common procedures, which is the administration of medicines.

When comparing the boxes, the most frequent word in both cases is care, thus attributing notoriety to this term in the social thought of the participants. The evocation work appears in the likely core (most important) of the representation of nursing and in the second periphery (least important) in the box that refers to professional autonomy. This may mean that the professionals perceive the heavy workload as being a part of the profession itself, and not as a condition to achieve professional autonomy.

The evocation team had the lowest AOE (most readily evoked) in both likely central cores, indicating that the participants situate nursing and the professional autonomy of nurses in more of a collective context than an individual context. Of all the terms, those with the lowest AOE are patient, in the representational structure of the professional autonomy of nurses, and white in the structure of nursing. This indicates that the former term only carries meaning through the existence of patients in need of care, while the latter term is marked by the visually dominant colour of the clothing used in the profession.

DISCUSSION

The data indicate that the professional autonomy of nurses and nursing are legitimate objects of representation for non-nursing health professionals, even if these representations are essentially close and are still under development. This is because the three basic components of a representation were identified and form the representational field, the formulation of knowledge on the object, and the favourable or unfavourable positioning of the group (attitude)(12-15). Other studies identified the connection between the nursing profession and caring/care, especially among nursing professionals, users of health services approached in the doctor’s waiting rooms in healthcare units, and HIV-positive patients(14-16).

In the structure of representation, the lack of practical and affective dimensions was identified, which could mean that both objects of representation, although they have a likely central core, are still susceptible to new elements according to the context in which the involved persons are inserted and attribute meaning to nurses, nursing, and professional autonomy. Therefore, it is possible that these are non-autonomous representations since they can be linked to other objects of representation.

In the scrutiny of the social organisation of the subjects, it is possible that, in the process of creating a unique positioning on professional autonomy of nurses, the subjects turn to the appraisal of the professional practices of nurses (the most tangible expression of the profession) to subsequently deconstruct and reconstruct them through images that have some meaning to them.

The likely objectification(11,13) among healthcare professionals of the professional autonomy of nurses who provide responsible care in the nursing team challenges the higher education institutions to train professionals to understand and legitimise the epistemological bases of nursing toward ethical and humanised care. The achieve this goal, these institutions must equip nursing students with the prowess of critical and scientific thought, in accordance with the technological transformations inherent to the health sector, and prepare professionals who are aware of and promote an image of professional autonomy and govern and make care-related decisions that are compatible with current social needs(16-18).

The knowledge of the representations established by the social groups involved in nursing care can be used to reconsider the technological model of work (and education for work). Moreover, it can help establish new theoretical bases for higher education on the process of care in nursing according to the requirements negotiated between the subject and the health institutions to ensure greater positive social visibility for nursing.

Nursing education should not be immune to market requirements. The job market and university education often differ in terms of the expectations they deposit on the shoulders of newly graduated nurses. Although academia seeks the qualification of thinking professionals with a strong ability to exercise their citizenship, the interests of the job market often targets individuals with remarkable manual dexterity, speed, and accuracy when performing assigned tasks(19-20).

CONCLUSIONS

The evocations care, team, and responsibility composed the likely core of the social representation of the professional autonomy of nurses for non-nursing professionals. These evocations express strong imagery and evaluative dimensions. The likely core of the social representation of nursing contains the terms care, team, responsibility, and work. The data point to the similarity of the representations and confirm the hypothesis that nursing and the professional autonomy of nurses are configured as objects of different, albeit intimately interconnected representations. This is possibly caused by the prematurity of the identified representations, liable to modification according to shifts in the context in which the participants are inserted.

Most of the subjects acknowledged the existence of the professional autonomy of nurses, while the core of the studied representation showed that the health workers have a positive attitude toward this object. In contrast, the minority who stated the opposite are still an alarming number of workers.

The likely core of the identified representations show a certain balance between the normative, functional, and imagery dimensions. It should be noted that, in both cases, we identified aspects that are essential to a representation, namely, the imagery dimension (or representational field), the presence of knowledge about the object (cognitive dimension), and the positioning of the group (attitudinal dimension).

Although the objective was achieved, the limitations of this study are the single context with a low number of subjects, and the presence of a certain degree of social normativity, that is, the data were collected in a context that may have influenced the subjects. As a potentiality, this study can support the creation of more appropriate didactic-pedagogical tools for nursing, which is in full development, in order to consolidate their professional autonomy, especially in terms of visibility and concreteness.

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Received: October 01, 2015; Accepted: February 08, 2017

Corresponding author: Antonio Marcos Tosoli Gomes. E-mail: mtosoli@gmail.com.

DEDICATION

This paper is dedicated to the memory of Professor Érick Igor dos Santos who died on the 1st of November 2016, at the young age of 28 due to cancer complications: (1) For his tireless dedication to your academic career, for which he reached the position of professor of a federal university at such a tender age; (2) For his dedication to scientific production and dissemination, leading to the publication of more than 40 papers in indexed journals, considering his PhD defence was in July 2016; (3) For his political activity in the defence of democracy, human rights, social progress, and a better life for the people of Brazil, even when he was confined to a hospital bed until his death; (4) For the great man that he became over time, almost as a son and a good friend who contributed so much, in all his generosity, with his presence and affection toward all those who crossed his path; (5) For his courage in the face of suffering and the dying process, holding his head up high at all times, as someone who, looking at the road of life, managed to say that he completed a cycle and paved his own path, surrendering, not without a fight, to the process that led to the functional collapse of his vital organs; (6) And, finally, for his spirituality that anchored him to life for as long as possible, with insistence and beauty, but that made him so much larger than life, despite the failure of his body in accompanying such growth, allowing him to experience the unseen or what our most objective consciousness can describe, but that our heart, throughout the centuries of mankind, forever insists on telling us in every beat: life and love are stronger than death.

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