INTRODUCTION

In clinical practice, the concept of autonomy is daily applied when trying to refer to person independence¹. Autonomy is a multidimensional concept that contains the cognitive state, emotional intelligence, the social situation, and the intellectual and physical condition ². Therefore, it is understood that a person is autonomous if she is able to satisfy the conditions previously described, demonstrating decisional autonomy, relational autonomy, and executional autonomy³. Independence is understood as the competence in performing daily life activities and self-care without the help of third parties⁴. Like this, the transition processes between dependence and independence are recognized for being in the domain of autonomy⁵.

Since there are different versions of both concepts, in the professional speeches, the nursing should search "change your lenses to see in a new way and appreciate some of your beauty, art and humanity, as well as your science", since this "requires its own description, has its own phenomena, and needs its own method for clarifying its own concepts, meanings, relationships and contexts”⁶, allowing the implementation of different nature interventions.

We know that the nursing affirmations passes, necessarily by the clarification and application of their own knowledge⁷. Therefore, being the nurse the professional with greater proximity to the patient and being him the holder of knowledge, able to satisfy their needs, is his function to understand what involves and surrounds the independence, in a way to materialize its effectiveness without the possibility of bias in its interpretation. After realizing this disparity in clinical practice, a preliminary research was realized in the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, CINAHL, in PubMed and Scopus, without identifying any revision about the theme in the consulted literature.

Concerning the objectives, this study intended to map the existing evidence on the concept of independence and analyze the concept according to its application in the most diverse areas of knowledge, using the recommended model to conceptual analysis from Walker e Avant⁷. It is intended to understand in a significant and coherent as possible way the concept in the study, outlining their involvement, contributing, this time, for a better understanding from the health professionals, namely the nurses, which have a leading role in promoting the person's independence.

MATERAL AND METHODS

The synthesis of evidence through the realization of a systematic revision is a central point of the practice based on the evidence⁸. A scoping review was carried out for being a kind of revision, which has as essential objectives: map the existing evidence relating to a research area and identify possible gaps in existing evidence⁹.

Therefore, this is a scoping review that looks to map in the existing bibliography thoroughly, the application of the concept of independence, to obtain the subsidies needed to analyze this concept. Currently, this research method assumes crucial importance, insofar as it allows incorporating into nursing practice, the scientific evidence, gathering data from developed studies according to different methodologies¹⁰. The study followed all the phases suggested by the Joanna Briggs Institute⁹.

Regarding the analysis of the concept of independence, assumptions of the method of analysis of the concept of Walker e Avant were used, once this is the most used and appropriate concept analysis method for the professional are of nursing⁷.

The concept analysis followed the recommended steps by the model itself, such as: concept selection; determination of the analysis objectives and purposes; identify all the possible uses of the concept; determine the definition attributes; identify the case model; identify borderline, related, contrary, invented and inappropriate cases; identify antecedents and consequences, define empirical references⁷.

Taking into account the knowledge that was intended to synthesize, the revision had as a starting point the following question: "What is the scope of the application of the concept of independence, in the existing bibliography, in the most diverse areas?"

Making use of the strategy participants, concept e context (PCC), was included in the scoping review studies that: a) as to the type of participants, approach the sick person; b) as to the concept, approach the concept of independence of the person; c) as to the context, it will be contemplated all the contexts, in the most diverse areas of knowledge; d) as to the study types, it will be contemplated qualitative and quantitative studies and all the kinds of literature revision.

The research strategy includes published studies, being performed in three steps: 1) Initial research in the databases Scopus, MEDLINE (via PubMed) and CINAHL (via EBSCO), then performing an analysis of words of texts in the titles and abstracts and the index terms used in the article description; 2) Second research making use of the keywords and index terms identified, in the databases included (Table 1); 3) The bibliographic references of the identified articles were examined to identify added studies. Studies wrote in English, Spanish, and Portuguese were considered for inclusion in this review, regardless of the year of publication.

Table 1.  Search strategy applied by database and the respective results 

The article pertinence for the revision was examined by two independent reviewers, using the title and abstract literature. The complete articles have been recovered when the inclusion criteria were fulfilled. Two reviewers analyzed, in an independent way, the articles in full text, to ascertain if these, fulfilled the defined inclusion criteria. In case of disagreements, between the two reviewers, they have been resolved, making use of the discussion with a third reviewer. The investigators developed an instrument aligned with the objectives, with the starting question and with the questions of conceptual analysis, for data extraction.

RESULTS

Such as it is introduced in figure 1, the research identified 1586 articles with potential relevance to the present study. Of these, 67 were excluded for being in duplicate, from the remaining 1519 articles, 1173 articles were excluded after reading the title and summary, 244 articles were excluded for not meeting the inclusion criteria after reading the full text. After the described selection, there were 102 articles included in this revision.

Figure 1.  Flowchart PRISMA (adapted) of the study selection process 

Once the mapping was realized in a systematized form, of the studies that meet the defined inclusion criteria, a concept analysis was carried out.

According to the results from the analysis of the concept of independence and following the recommended model by Walker e Avant⁷, as regards:

Concept selection - In providing nursing care, we highlight the importance of the recovery/maintenance of the person independence, since in most situations that motivate hospitalization, this may be compromised. It is recognized that the first cause of functional declination, mainly in the elderly person is the hospitalization, in which they lose an average of 30 to 60% of their independence in carrying out self-care and other activities of daily living¹¹. In clinical practice, independence is directly associated with the physical capacity of the person for self-care realization and daily living activities^5,12.

Determination of the analyze objectives - The health professionals, namely the nurses are daily faced with the need to work on the people's independence they care for, as a result of disease processes or even the vulnerability that is advancing age causes, there is a need for the implementation of interventions that respond to the promotion or maintenance of independence.

Identification of the possible uses of the concept - from the data analysis, the investigators identify the areas that approach the concept, being these areas more practical, where there is direct contact between the professional and the patient. Between these areas, we found nursing¹³, medicine^4,5, phycology^14,15, physiotherapy¹⁶, pharmaceutical sciences^12,17, occupational therapy^18,19, health sciences^20)(21)(22, physical education²³⁾ and sociology^24,25. Other areas such as engineering, despite not working directly with the patient, they invest in research and in the realization of adaptive means/strategies, capable of responding to independence²⁶⁾⁽²⁷. From the cited articles, the majority makes reference to the concept as being the capacity for self-care and the performance of daily life activities. Therefore, it involves physical capacity. Although, in minority, some authors refer to the concept of independence, as when it comes to autonomy^14,15. Perhaps, this is since the concept of autonomy comprises several capacities, namely physical capacity.

Determination of the attributes that define the concept and definition of the empirical references of the concept - After analyzing all forms of using the concept of independence, it was possible to determine its features.

According to the results, independence refers to the patient's physical capacity for self-care and daily life activities realization¹²⁾⁽²². In nursing and other areas of health, it is essential, diagnosis and implementation of targeted actions, understanding the concepts are essential. The data contributed to the understanding of the concept of independence, allowing it to outline its attributes, antecedents, and consequences, as shown in table 2. Regarding the antecedents, all aspects addressed in the consulted bibliography were highlighted, even if only referenced in one or a few articles.

Table 2.  Presentation of the attributes, antecedents and consequences of the concept of independence. 

Identification of a case for nursing practice - Victim of a road accident, a person becomes quadriplegic, therefore, physically dependent for the realization of daily life activities and for self-care, however, have the capacity of decision, being, except for physical, autonomous capacity. Another patient is confused, but with the physical capacity to perform self-care and daily activities, being this patient considered independent, but not autonomous, as autonomy comprises other areas, as previously mentioned^13).

DISCUSSION

It's perceived in the different areas of knowledge, indeed, some confusion between the concepts of autonomy and independence. However, most authors define the concept of independence as the capacity for self-care and for carrying out their daily life activities, without third-party help¹²⁾⁽²². The authors define the concept of autonomy as a multidimensional concept, which involves the physical, cognitive, intellectual, social capacity and emotional intelligence². Thus, independence is a part of autonomy²⁸.

The concept of independence is more approached by the scientific areas, which directly contact with patients, such as nursing, medicine, psychology, physiotherapy, pharmaceutical sciences, occupational therapy, health sciences, physical education and sociology, although, the engineering, namely biomedical engineering, also pronounce on the concept. The latter do so, insofar as they too, through their research and in the performance of their duties, contribute to independence, with the construction of adaptive strategies, to meet needs in this area. Some authors refer to independence as the financial capacity¹⁴, capacity to maintain social relations²⁹, cognitive capacity²⁹, capacity to solve problems²⁹ and capacity to make decisions²⁰. Hence the confusion that exists between both of the concepts. Some of these aspects concern the concept of autonomy and financial capacity, it is not a personal capacity.

Thus, as Beaucham and Childress point out, independence allows the person to put into practice the right of freedom and authority arising from their autonomy¹⁸.

The nursing, especially rehabilitation nursing, while a great independence promoter³⁰, it needs to analyze the concepts to examine its practices and reflect on them.

More studies should be realized in this ambit to clarify the concepts used. In this review, we only included studies published in Portuguese, English and Spanish, which may have been a limitation.

CONCLUSION

From this review and analysis, it was possible to identify the essential components of the concept. Independence includes the ability to perform self-care and daily living activities. The concept of autonomy involves the concept of independence, and therefore, concerning the provision of care, professionals must meet the needs of each person and identify which of the concepts will need their intervention and prescribe and implement interventions aimed at their satisfaction. This analysis allows, the nurses in general and the specialist nurses in rehabilitation nursing in particular, to direct their care in an effective way, allowing to highlight in the care processes the interventions that promote independence. Thus, further studies must be carried out on the concepts used in the field of nursing.