Intellectual structure of professional autonomy of nurses in latin american literature: bibliometric study

Abstract

Objective:  Map the intellectual structure on the professional autonomy of nurses in the scientific literature in journals indexed in the Latin American and Caribbean Literature in Health Sciences.

Method:  Bibliometric study conducted with articles indexed in LILACS, from 2012 to 2022, adopting the co-occurrence analysis of descriptors extracted from the articles' metadata using the VOSviewer® software.

Results:  The map consists of 70 co-occurring terms five times or more, distributed in seven clusters. The intellectual structure regarding the professional autonomy of nurses is related to the thematic fields: professional practice, nurses, health education, primary health care, education, ethics, and the history of nursing.

Conclusion:  Professional autonomy relates to the training and practice of the profession; it is contextualized in various scenarios of practice and health care, influenced by the organization and repercussions on working conditions and relationships, and it touches on the process of training and education.

Keywords:
Nursing; Professional Autonomy; Professional Practice; Bibliometrics; Science; Technology and Innovation Indicators.

HIGHLIGHTS

1. Professional autonomy is related to the training and education of professionals.

2. Professional autonomy is experienced in professional practice.

3. The professional action scenarios are related to professional autonomy.

Resumo

Objetivo:  Mapear a estrutura intelectual sobre a autonomia profissional dos enfermeiros na literatura científica em periódicos indexados na Literatura Latino-Americana e do Caribe em Ciências da Saúde.

Método:  Estudo bibliométrico realizado com artigos indexados na LILACS, no período de 2012 a 2022, adotando a análise de coocorrência de descritores extraídos dos metadados dos artigos com uso do software VOSviewer®.

Resultados:  O mapa é constituído por 70 termos coocorridos cinco vezes ou mais, distribuídos em sete agrupamentos. A estrutura intelectual sobre a autonomia profissional de enfermeiros está relacionada com os campos temáticos: prática profissional, enfermeiras e enfermeiros, educação em saúde, atenção primária à saúde, educação, ética e história da enfermagem.

Conclusão:  Autonomia profissional guarda a relação com formação e exercício da profissão; está circunstanciada em diversos cenários de prática e atenção à saúde, influenciados pela organização e repercussões nas condições e relacionamentos de trabalho, tangencia o processo de formação e educação.

Descritores:
Enfermagem; Autonomia Profissional; Prática Profissional; Bibliometria; Indicadores de Ciência; Tecnologia e Inovação.

HIGHLIGHTS

1. A autonomia profissional está relacionada com formação e educação dos profissionais.

2. Autonomia profissional é experimentada na prática profissional.

3. Os cenários de atuação dos profissionais estão relacionados à autonomia profissional.

Resumen

Objetivo:  Mapear la estructura intelectual sobre la autonomía profesional de los enfermeros en la literatura científica en revistas indexadas en la Literatura Latinoamericana y del Caribe en Ciencias de la Salud.

Método:  Estudio bibliométrico realizado con artículos indexados en LILACS, en el período de 2012 a 2022, adoptando el análisis de coocurrencia de descriptores extraídos de los metadatos de los artículos con el uso del software VOSviewer®.

Resultados:  El mapa está constituido por 70 términos coocurridos cinco veces o más, distribuidos en siete agrupamientos. La estructura intelectual sobre la autonomía profesional de los enfermeros está relacionada con los campos temáticos: práctica profesional, enfermeras y enfermeros, educación en salud, atención primaria a la salud, educación, ética e historia de la enfermería.

Conclusión:  La autonomía profesional guarda relación con la formación y el ejercicio de la profesión; está circunscripta en diversos escenarios de práctica y atención a la salud, influenciados por la organización y repercusiones en las condiciones y relaciones laborales, y toca el proceso de formación y educación.

Descriptores:
Enfermería; Autonomía Profesional; Práctica Profesional; Bibliometría; Indicadores de Ciencia; Tecnología e Innovación.

HIGHLIGHTS

1. La autonomía profesional está relacionada con la formación y educación de los profesionales.

2. La autonomía profesional se experimenta en la práctica profesional.

3. Los escenarios de actuación de los profesionales están relacionados con la autonomía profesional.

INTRODUCTION

Autonomy is understood as the self-determination of the person, the freedom of will, however it creates a tension in the person and society. It can also be established as practical freedom, in acting in the public sphere supporting the progress of society and individual freedom. Thus, autonomy is a social process, determined by the demarcation of the contradictions between the individual and society, in search of human emancipation¹. Thus, autonomy can be explored from various perspectives, such as the philosophical, legal, ethical, bioethical, and technical-scientific.

The concept in this article is the “professional autonomy of nurses” established as an essential precept for the full professional practice of the worker, as it promotes freedom, proactivity, and motivation for the performance of their profession. Therefore, regarding the professional performance of nurses, guaranteed in the interpersonal relationship of professionals or in the assistance provided to the user².

In nursing, in accordance with the general concept of autonomy, professional autonomy is a principle - interfaced with ethical, legal, technical-scientific, and theoretical-philosophical precepts - realized in the relationship with different characters. Legally, in Brazil, the professional autonomy of nurses is guaranteed by the Code of Ethics and the Law of Professional Practice.

The first defines the rights and duties for nurses to act with freedom, technical, scientific, and environmental safety, without discrimination of any kind, according to the principles and legal, ethical, and human rights assumptions³. The Law of Professional Nursing Practice, in turn, specifies the exclusive activities of the nurse, being a legal and normative instrument for achieving professional autonomy.

Nurses use diverse strategies for the establishment and consolidation of professional autonomy in the exercise of work, thus enabling the achievement of recognition, respect for professional practice areas⁴. The exercise of professional autonomy, therefore, presents nuances in different contexts and the possibilities of action for nurses, influenced by intervening factors that interfere with the exercise of autonomy of these workers.

In light of the above, the research question arises: how is the intellectual structure regarding the professional autonomy of nurses configured in the scientific literature? In seeking answers to this question, this aims to map the intellectual structure regarding the professional autonomy of nurses in the scientific literature in journals indexed in the Latin American and Caribbean Literature in Health Sciences.

Exploring a theme using the available scientific literature and metadata enables the understanding of aspects related to professional autonomy contained in the collection of journals from Latin America, in order to highlight the regional context, predominantly composed of Brazilian scientific production. Thus, this study contributes to the recognition and deepening of the thematic field investigated in the regional context.

METHOD

This is a bibliometric descriptive study that used the keyword co-occurrence analysis technique, through VOSviewer®. The co-occurrence of terms means the association between two words or pairs of keywords, representing a conceptual association between both. This type of analysis enables the identification of clusters, thus characterizing basic concepts of a specific research area.

Considering the interest in highlighting the regional context, predominantly composed of Brazilian scientific production, the Latin American and Caribbean Literature in Health Sciences (LILACS) database was chosen. LILACS is an information ecosystem, composed of methodologies and technologies for the management, storage, curation, and publication of technical and scientific documents, and contains more than a hundred specialized bibliographic databases in Health Sciences. LILACS has democratic, inclusive, decentralized, and collaborative management for coordination, feeding, and maintenance, being supported by BIREME, PAHO, and WHO⁵.

The search strategy was validated by experts and used the Health Sciences Descriptors (DeCS), (“nurses” OR “nurses and nurse practitioners”) AND (“professional autonomy”). The study was conducted in the second semester of 2023. The inclusion criteria were articles published in the last 10 years (2012-2022), a time frame justified by representing a broader range of studies on the subject, as well as encompassing an important period between studies and the adoption of scientific evidence in health decision-making available in Portuguese, English, or Spanish, that meet the objective proposed by the study. The search strategy resulted in 507 articles that were exported in RIS format to the VOSviewer® software.

The VOSviewer® is free access software, made available for free, that enables analyses of bibliometric networks, such as the analysis of co-occurrence of keywords/descriptors selected for this study⁶.

The keywords were analyzed by the software, determining which ones co-occurred the most in the bibliographic productions. The number chosen as the minimum incidence of co-occurrence was five times, considering that the software does not set a parameter as a selection criterion for the co-occurrence of terms, and this frequency resulted in a tangible quantity of co-occurrences for analysis by the study. This process resulted in the identification of 1,964 terms, of which 184 co-occurred more than five times.

From this list of words, paired normalization was carried out with the structured vocabulary of DeCS/MESH, using the bibliographic manager Mendeley®, resulting in the Thesaurus list 1. Thesaurus 1 was processed so that duplicate descriptors in other languages were represented according to their respective translation in DeCS. From this, Thesaurus 2 was obtained, which was imported into the VOSviewer® software along with the database of the 507 articles (in RIS format), resulting now in 70 descriptors that co-occurred five or more times, for further bibliographic analysis.

Finally, the bibliographic coupling map of knowledge was obtained and evaluated according to the selected method, the analysis of keyword co-occurrences. This map was then interpreted in order to understand its results in relation to the objective proposed by the study.

As a theoretical framework for the stage of interpretative procedures of the information from the knowledge map, the bibliographic map interpretation model of words based on Moore’s concept of ‘infortícula’ was used, according to Inomata’s approach⁷.

On the map, the term clusters have specific colors that allow them to be differentiated and to observe the intrinsic and extrinsic correlations between them, and therefore, it presents the thematic arrangement. This determination of colors and their interpretative sequence on the map is established by the VOSViewer® software itself, starting with the red color for the words allocated in the first cluster with the highest frequency of co-occurrences and strength of correlations.

Understanding the positional order of the terms on the map and what their arrangement means in relation to these terms, we proceed to deepen the understanding of these terms. This understanding arises from reading the terms in the contexts in which they appear and enables the identification of groupings of keywords that characterize certain basic concepts of a specific field.

Finally, the map combined with the qualitative definitions of the identified terms leads to the descriptive textual production of the intellectual structure of the bibliographic productions that revolve around the research term of this study, the professional autonomy of the nurse, which constitutes the discussion part of the work. This descriptive procedure is an attempt to descend to a greater level of detail, with the analysis of groupings and/or chains of interrelated significant terms susceptible to characterize, per se or together, a certain area of knowledge⁸.

RESULTS

The co-occurrence map of descriptors below represents the co-occurrences of words resulting from the search, composed of 70 keywords/descriptors distributed in seven clusters, Figure 1. The frequency of the co-occurrence of each term is presented in Chart 1.

Chart 1
Description of the properties of the 20 units of analysis with the most co-occurrences, extracted from articles published in journals indexed in LILACS from 2013 to 2023. Salvador, BA, Brazil, 2023

Keywords co-occurring more than 5 times	Number of occurrences	Number of relevant calls
nursing education	62	99
professional practice	53	86
nurses	37	76
nursing care	37	57
primary health care	35	65
worker's health	29	59
job satisfaction	28	57
history of nursing	24	29
human resources training in health	21	32
professional autonomy	20	36
education	19	30
nursing team	18	41
ethics in nursing	17	26
health personnel	16	32
family health strategy	16	22
professional competence	15	30
nursing students	14	30
vocational education	14	27
working conditions	13	37
patient safety	13	26

Figure 1
Co-occurrence map of descriptors extracted from articles published by journals indexed in LILACS from 2013 to 2023. Salvador, BA, Brazil, 2023

As planetary terms or groupings, the following seven clusters appeared: “professional practice”, “nursing education”, “nurses and nurse practitioners”, “ethics in nursing”, “health education”, “primary health care”, and “history of nursing”. The planetary terms co-occurred with other terms, referred to as satellite terms identified by the same colors, establishing a relationship that is represented by co-occurrence clusters.

The first cluster, cluster 1, represented by the red color, consists of eight units of analysis, showing a relationship with the other six clusters on the map. The keyword/descriptor of this grouping that stands out the most is “professional practice” with 53 co-occurrences and positioned to the left on the map. The analysis unit “professional practice” appears related to the other 16 terms of the first grouping, which are “nursing care”, “quality of health care”, “leadership”, “nursing team”, “nursing human resources”, “job satisfaction”, “working conditions”, “workplace environment”, “professional burnout”, “patient safety”, “work environment”, “worker health”, “health management”, “obstetric nursing”, and “intensive care units”.

The second grouping, in dark green, consists of eight terms and is positioned peripherally to the right of the map. The term “nursing education” is the term with the highest number of co-occurrences (62). It relates to another twelve keywords/descriptors intrinsic to the grouping itself, which are: “education”, “professional training”, “nursing educators”, “vocational education”, “scientific research and technological development”, “human resources training in health”, “postgraduate education in nursing”, “research in nursing education”, “staff development”, “single health system” and “violence against women”.

The cluster three (dark blue) has twelve items, located in the lower portion of the map. The term with the highest number of co-occurrences is “nurses” (37). This term is associated with units of analysis belonging to the grouping, are these: “professional autonomy”, “work”, “professional competence”, “curriculum”, “nursing students”, “job market”, “role of the nursing professional”, “nursing administration research”, “nursing research”, “emergency nursing”, and “social psychology”.

In the fourth grouping, yellow, eleven units of analysis related to the other six clusters occur together. This grouping is located at the top of the map. The analysis unit “health education” has 10 co-occurrences. Intrinsically to the grouping, it has interrelations with the terms “health care”, “hospitals”, “communication”, “health personnel”, “professional-family relations”, “child”, “family”, “elderly”, “oncology”, and “mental health”.

The fifth grouping, lilac color, has six terms and has an interface with 3 clusters. It is distributed lower left on the map. The term that co-occurs the most is “ethics in nursing” (17 co-occurrences). The keyword/descriptor “pediatric nursing” appears related to terms in its own cluster, such as “bioethics”, “safety management”, “occupational risks”, “coronavirus infections”, and “pandemics”.

In turn, the sixth grouping, light blue color, located at the top of the map, has six keywords/descriptors that relate to all the clusters. “Primary health care” is the unit of analysis of the grouping that co-occurs the most on the map, with 35 co-occurrences. The terms in which “primary health care” co-occurs are “family health strategy”, “family health”, “public health”, “interpersonal relationships”, and “psychological stress”.

Finally, the last grouping, cluster 7 in orange, located peripherally to the right, presents as the unit of analysis that co-occurs the most with “nursing history,” which has 24 co-occurrences. Interacts with the other four items in its grouping, the “choice of profession”, “professional identity”, “social identity”, and “socialization”.

DISCUSSION

This study aimed to map the intellectual structure on the professional autonomy of nurses in the scientific literature in Latin American journals, summarized in the co-occurrence map of descriptors (Figure 1). The discussion was structured considering the map, the groupings, the relationships between the words with relevant co-occurrence quantity (Table 1) and the concepts of the terms. It is reaffirmed that LILACS is mainly composed of journals from Latin America and the Caribbean, and Brazil alone represents more than half of the scientific production in the region.

Professional autonomy is only possible during the exercise of practical activity. In this way, it is made effective conditioned to the professionalism of nurses and implies the guarantee of access to health for society. The nursing profession, as a freelancer, with its own knowledge and credentials, participates in health care from a perspective of professional identity for society⁹.

The relevance of the terms related to professional practice was represented by the first and main grouping of the co-occurrence map. The “nursing care” stands out - the main phenomenon of the profession - associated with “working conditions” and related terms, determining the planning, management, and implementation of this care and, therefore, intervening in “professional autonomy”⁹.

Two areas of action for nurses derived from the metadata of the documentary framework on professional autonomy were the “intensive care units” (ICU) and “obstetric nursing”. The concept of “nurse autonomy in intensive care units” is related to the workforce, organizational and sociocultural conditions, and also considers the intrinsic aspects of the professional, enhancing competencies and skills, and thus affects the quality of health care and professional satisfaction¹⁰.

The specialty of obstetric nursing has been enhanced with the implementation of residency courses, which promotes a qualified and specialized professional training; thus, it creates conditions for a favorable performance in the development of the nurse’s professional autonomy, based on a practice guided by scientific evidence, with specific and ethical knowledge recognized by society, and of a multidimensional nature, based on humanistic care that mobilizes intuitive, relational, and technical competencies, promoting the satisfaction of the assisted women¹¹.

Nursing education guides discussions about the professional autonomy of nurses and spans various levels: secondary vocational education, undergraduate education, postgraduate education, and continuing and permanent in-service education. This educational process involves both the training institution and the student themselves, resulting in the knowledge inherent to the work of nursing, an essential competence for exercising autonomy in the various forms of professional practice of the nurse³.

We understand, therefore, that every educational process aims to educate people to be independent, self-directed, self-motivated, and constant learners, capable of questioning the reality in which they are inserted and inclined towards the process of constant learning. The training and education in the Nursing discipline enables the sharing of scientific knowledge, organized based on the theoretical-methodological references applied in the organization of work, teaching, research, and health management itself, substantiating professional autonomy⁹.

The nursing degree is guided and based on the National Curriculum Guidelines for the Nursing Undergraduate Course, which aim to train a nurse with a generalist, humanist, critical, reflective, and qualified education, in accordance with scientific and intellectual rigor and based on ethical principles¹². It is in it that the “nursing students” come to know more broadly the “role of the nursing professional”, build their professional identity, and recognize how the nurse can and should develop their autonomy¹³.

This continuous search for knowledge acquisition enhances the professional and intellectual autonomy of the nurse, through the achievement of “professional competence,” as it arises from the articulation of theoretical knowledge, practical skills, and attitudes. In this way, the search for the development of professional competence contributes to the opportunity for autonomy in decision-making, through the appreciation of safety and quality of care through processes of reflection and analysis of clinical practice¹⁴.

The third grouping refers to nurses and how they exercise, experience, and appropriate professional autonomy. The professional skills and abilities, along with other attributes of nursing, such as knowledge, affectivity, attitudes, practices, professional identity, decision-making power, and freedom of action, and therefore also professional autonomy, contribute to characterize nurses as objects of social representation².

Ethics and bioethics constantly coexist in the discussion about autonomy in the professional practice of nurses, as these principles philosophically solidify the support and regulation of the guarantee of this autonomy, through instruments such as legislation and resolutions. In this way, ethical and bioethical principles must coexist in symbiosis with the exercise of the nurse’s professional autonomy, since what is aimed at in care is that the health professional guides their practice by the “ethical commitment to care” and directs their actions with an attitude that goes beyond the limits of professional consciousness, bridging the gap between technical care and ethical care¹⁵.

In the scope of the period analyzed by the work, the coronavirus pandemic occurred, also derived from the bibliographic productions. COVID-19 required nursing professionals to adapt their skills and competencies to meet the demands of people affected by the disease, as well as to protect themselves from infection. These productions responded to the demands imposed by the untimeliness of transformations, requiring a sensitive look so that the exercise of professional autonomy of nurses continued to be aligned with the professional practice of nurses.

The fourth grouping addressed health education, understood as a tool for exercising the professional autonomy of the nurse, who uses knowledge, skills, and abilities to empower the population to acquire health awareness, which in turn returns autonomy to them, contributing to a critical and informed reflection on their choices regarding their health needs.

This education occurs with the nurse as the mediator of “health care,” and it is also configured as an exercise of caring. In this sense, each user must be assisted as a unique human being, with individualized needs, and have their physical and psychological well-being promoted through the holistic and humanistic view of nursing care¹⁶. The idea of promoting health through education is enhanced in primary care, which promotes a set of health actions, including the promotion and protection of health and the prevention of harm¹⁷.

The sixth grouping addresses Primary Health Care (PHC), the preferred gateway to health services and coordinator of care among the various points of attention that make up the health system, as a conducive field for the exercise of autonomy¹⁸.

The “Family Health Strategy” (FHS), responsible for guiding Primary Care, delineates an important field of action for the nurse through the practice of competencies, with managerial and assistance competencies being the most predominant, and they should coexist in a harmonious and efficient manner, just like the educational and research competencies¹⁹.

In light of the competencies performed by the nurse in relation to the Family Health Strategy (ESF), the professional autonomy of the nurse can be perceived positively regarding their independent practice, with care protocols and exclusive activities that expand their scope of action without the need for another professional to be resolutive.

The last grouping interfaces the professional autonomy of nurses with the history of nursing. Productions about the professional autonomy of nurses are permeated by the history of this profession, as a way to understand how such autonomy developed in the face of the transformations of society and the profession. One of the most common reflections is about the submissive role to other health professionals, especially to the medical category.

However, the role of nurses is distanced from professional submission, as care should be based on their own knowledge, not just on generalized knowledge without foundation, since it was previously directed solely by medical thinking²⁰. Thus, the “professional identity” is constructed and established as a result of the professionalization of nursing and its constitution as a scientific discipline, thereby strengthening professional autonomy.

This identity is developed, and subsequently its autonomy, with its consolidation as a discipline and profession, in accordance with the variables of the sociopolitical sphere, gender issues, and economic factors. Similarly, the constitution of the body of knowledge itself, embodying scientificity through its methods, technologies, and processes, such as the Systematization of Nursing Assistance, with classifications of diagnoses, interventions, and results based on its theoretical roots of care²¹.

In the Brazilian context, the Systematization of Nursing Assistance ensures professional autonomy for the organization and visibility of the work performed by nurses²². Another regulatory advance deals with the prescription of medications by nurses, enhancing the scope of action of nurses²³.

The potential reflections emerging from the study also reaffirm the limitations of the method and allow for the analysis of metadata in an aggregated manner, even enabling the analysis of large volumes of data.

CONCLUSION

The professional autonomy of the nurse is a concept endowed with complexity, allowing for reflection on the phenomena involved in professional dynamics and the enhancing and limiting aspects of nurses’ professional autonomy.

The mapping of the intellectual structure related to the professional autonomy of nurses showed the phenomenon contextualized in professional practice in various health care scenarios and different configurations of professional performance, confirming the relationship between education and the practice of the profession, for the experimentation of professional autonomy.

In this practice scenario, professional autonomy has the specificities of health care attention scenarios, how they are organized, and the repercussions on working conditions and relationships.

It is reaffirmed how professional autonomy relates to the process of training and education in nursing, that is, the training process of nurses at different levels, and the influence of building this competence. In time, health education is a space that enhances the care processes of nurses, reinforcing the role of a profession endowed with its own scientific knowledge and with autonomous practice.

The history of nursing and the continuous transformations and adaptations to new care scenarios have repercussions for the construction of the professional and social identity of the nurse and, therefore, for professional autonomy. In light of the period used as a reference for understanding the intellectual structure, it reaffirmed the influence of the COVID-19 pandemic on the work of professionals and, consequently, on professional autonomy.

• HOW TO REFERENCE THIS ARTICLE
  Batista GB, Souza VRS, Lourenço RO, da Silva GTR, Almeida LDP, Amestoy SC, et al. Intellectual structure of professional autonomy of nurses in latin american literature: bibliometric study. Cogitare Enferm [Internet]. 2025 [cited “insert year, month and day”];30. Available from: https://doi.org/10.1590/ce.v30i0.98000

ACKNOWLEDGMENTS

This study was conducted with the support of the Universidade Federal da Bahia (UFBA) - Work Plan number 42006 Notice 02/2021 - Pro-Rectorate of Research, Creation and Innovation of the Institutional Program for Scientific Initiation in Affirmative Actions.

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Edited by

• Associate editor: Dra. Luciana Puchalski Kalinke

Publication Dates

• Publication in this collection
  28 Mar 2025
• Date of issue
  2025

History

• Received
  05 Aug 2024
• Accepted
  26 Nov 2024