Introduction
Professional autonomy plays an important role in nurses’ job satisfaction and the outcomes of patient care. A review of literature shows the presence of nurses’ dissatisfaction in regard to their professional autonomy.
Aim
To assess the Iranian nurses’ perspectives of their professional autonomy.
Materials and Methods
In this cross-divtional study, 150 nurses with bachelor or higher academic degrees and clinical experiences participated. The professional autonomy questionnaire by Blegen MA, composed of the domains of decision-making for ward’s affairs and decision-making for patient care, were used for data collection. The data was collected from November 2015 to April 2016 and analysed using descriptive and inferential statistics.
Results
The mean (SD) of professional autonomy was 152.06 (28.181). Also, the means of professional autonomy in the domains of decision-making for ward’s affairs and decision-making for patient care were 71.91 (17.687) and 80.15 (13.088), respectively. The majority of the nurses (66.7%) stated that they had high levels of professional autonomy. There were statistically significance relationships between the nurses’ age, work experience, and educational level and nurses’ professional autonomy (p<0.05).
Conclusion
The nurses had high levels of professional autonomy. Also, the nurses’ autonomy in decision-making for patient care was greater compared with decision-making in ward’s affairs. Nurses’ managers need to consider our findings for improving the condition of nurses’ autonomy in healthcare settings.
Introduction
In healthcare systems, nurses need autonomy for their activities [1,2]. Autonomy is a very abstract concept composed of the Greek word “autonomos”. It is derived from “auto” means self and “nomos” means law. Since, ancient Greece so far, this concept has found wide variations, and several theme synonyms including self-management, ability and competence, critical thinking, freedom and self-control are used [3,4,5].
There are several definitions for autonomy in the nursing literature such as control over the work, control over nursing activities, clinical autonomy, individual autonomy, work autonomy, professional autonomy and organisational autonomy, which all are used interchangeably [4-7].
Nowadays, autonomy is defined as having the right of making decisions and acting accordingly. Autonomy with regard to nurses,means doing activities within the scope of nursing practice without permission from others. Independent interventions by nurses’ means that nurses do not need to get permission from authorities for performing patients’ assessment and observation. These interventions can be beyond standard nursing activities and aim for the greatest health benefits to patients [8]. Autonomy means having the ability to choose between the best and worst conditions [9].
In recent years, the role and responsibilities of nurses in the healthcare system has changed. Nowadays, unlike the past, nurses have to be accountable for healthcare delivered to patients. At the same time, they should strive to make professional relationships with other healthcare workers [10]. All these require professional autonomy for performing nursing duties.
Therefore, nurses make efforts for achieving professional autonomy in individual and group levels [10]. Nurses put in efforts to achieve the following three goals: providing and coordinating healthcare services for patients with complex care needs, enhancing the professional image of nursing to attract young people to the profession and attract young staff for creating and maintaining professionalism [11].
Also, in recent years, many changes have occurred in health policies. The most significant changes include the shortage of nursing staff, shortening of the duration of hospitalisation, increase in emphasis on cost-effectiveness, reduction in the size of healthcare services and increase in the number of patients with chronic and complex disease. All these changes have led to the growth of autonomy in nursing [12]. All of the above-mentioned factors and the increase of nurses’ education level have led many nurses to ask for increasing autonomy in nursing practice [13,14]. Studies show that nurses are often dissatisfied with their work, and demand better job opportunities and autonomy in their work environment [14]. The loss of autonomy leads to the increase of nurses’ distress while nurses who have a higher level of autonomy have more skills competence, ability, power, accountability, decision-making abilities, self-esteem and satisfaction [15,16].
Despite all efforts, nurses have a medium level professional autonomy [6,7]. However, various factors such as the education level, gender and work experience in the critical care unit, management style, education and experience, medical staff’s perspectives, workload and the workplace affect autonomy in nursing practice [6,7,10,12].
In general, professional autonomy is a distinguishing feature of professionalism [5]. The complexity of the healthcare system has increased nurses’ professional responsibilities and they require autonomy in their activities [1]. Despite considerable efforts, achieving autonomy in nursing still faces challenges and professional research in this area is necessary. Due to a lack of knowledge about the level of autonomy in Iranian nurses, this study aimed to explore Iranian nurses’ perspectives of professional autonomy.
Materials and Methods
This was a cross-sectional study. The study environment included three hospitals of Imam Khomeini, Shahid Mostfa Khomeini and Ayatollah Taleghani in Ilam province of Iran. The sample size was estimated to be 150.
Next, the subjects were recruited using the random stratified proportion sampling method from the three general hospitals. The inclusion criteria were: having the bachelor or higher academic degrees in nursing, work experience in nursing for at least one year and willingness to participate in this study.
This study’s research proposal was approved by the research council affiliated with Ilam University of Medical Sciences that corroborated its ethical considerations (decree number: ir.medilam.rec.1394.179). After the recruitment of the subjects, they were informed of the study’s aim and method. Also, the voluntary nature of participation in this study, anonymity and confidentiality throughout the study process were ensured. Those who willingly participated in this study were asked to sign the written informed consent form. The data were analysed using descriptive and inferential statistics via the SPSS v.18 software. p<0.05 was considered statistically significant.
The demographic data form and the Blegen MA et al., professional autonomy questionnaire were the data collection tools. The former was conclude of questions about age, gender, educational level, occupation, and questions about an interest to the profession, membership in the nursing organisation, the ability to make decisions and individuals affecting professionalism. The Belgen et al., professional autonomy questionnaire [17] (supplement 1) was used to measure nurses’ perspectives about professional identity and had six questions about nurses’ knowledge in the field of professional autonomy. The autonomy questionnaire consisted of 42 items in two dimensions including decision-making for ward’s affairs (21 items) and decision-making for patient care (21 items). A five-option Likert scale (always=5, often=4, sometimes=3, rarely=2, and never=1) was used for scoring. The range of the questionnaire’s scores was from 42 to 210. Also, scoring for negative items was reverse. After the translation of this questionnaire, 10 faculty members of nursing were asked to determine its content validity without modifications of the questionnaire. The reliability of the questionnaire was estimated by test-retest method. The interclass coefficient using the alpha Cronbach’s coefficient was reported to be 0.96. The questionnaire’s reliability using the test-retest method with a 10-day interval was 0.81.
Results
More than half of the participants (52.7%) were female in the age range of 21-50 years. Their mean age was 30.09 years (SD=6.48). They were mainly bachelor degree, (91.3%) and worked in rotational work shifts (82%) and as full-time clinical nurses (78.7%). The division of labour in 61.3% and 33.3% cases was functional and team methods, respectively. Their work experience was 1-26 years with an average of 7.73 years (SD=6.27) [Table/Fig-1].
Demographic characteristics of the samples.
| Variable | Number | Percent |
|---|
| Gender |
| Male | 71 | 47.3 |
| Female | 79 | 52.7 |
| Marital status |
| Single | 80 | 53 |
| Married | 70 | 47 |
| Educational level |
| Bachelor degree | 137 | 91.3 |
| Master degree | 12 | 8 |
| Work shift |
| Morning | 21 | 14 |
| Evening | 6 | 4 |
| Rotational | 118 | 82 |
| Presence at work |
| Full-time | 118 | 78.7 |
| Part-time | 29 | 19.3 |
| Division of labour |
| Team | 50 | 33.3 |
| Functional | 92 | 61.3 |
The results of the nurses’ perspectives of professional autonomy are presented in [Table/Fig-2].
Nurses’ perspectives of professional autonomy.
| Scoring section | Mean (SD) | Mode | Range |
|---|
| Total score | 152.06 (28.181) | 153.00 | 145 |
| Decision-making for patient care | 80.15 (13.088) | 81.00 | 66 |
| Decision-making for ward’s affairs | 71.91 (17.687) | 73.00 | 81 |
To determine the level of nurses’ autonomy and knowledge about it, the scores were classified as low (0-0.33), intermediate (0.33-0.66) and high (>0.66) with higher scores indicating greater autonomy. It was found that the nurses in the domains of decision-making for patient care (78.7%) and decision-making for ward’s affairs (60.7%) had the high levels of autonomy. Also, 66.7% of participants achieved high scores for autonomy and majority of them (80%) had an intermediate level of knowledge regarding autonomy [Table/Fig-3].
| Level of autonomy | Number | Percent |
|---|
| Total score |
| Low | 1 | 0.7 |
| Intermediate | 49 | 32.7 |
| High | 100 | 66.7 |
| Decision-making for patient care |
| Low | 0 | 0 |
| Intermediate | 32 | 21.3 |
| High | 118 | 78.7 |
| Decision-making for ward’s affairs |
| Low | 4 | 2.7 |
| Intermediate | 55 | 36.7 |
| High | 91 | 60.7 |
| Knowledge of autonomy |
| Low | 3 | 2 |
| Intermediate | 120 | 80 |
| High | 27 | 18 |
The [Table/Fig-4] shows statistically significant reverse relationships between age and autonomy in decision-making for ward’s affairs and work experience and autonomy in decision-making for ward’s affairs.
Pearson correlation coefficients among variables.
| Variables | Autonomy in decision-making | Age |
|---|
| Age | -0.203* | - |
| Work experience | -0.195* | 0.919** |
*p<0.05
**p<0.001
There was a statistically significant relationship between the mean score of autonomy in decision-making for patient care and the nurses’ education level. Those nurses with master degree education had more autonomy for decision-making for patient care. No such relationship was reported between autonomy in decision-making for ward’s affairs and the education level [Table/Fig-5].
Relationship between the mean score of autonomy and nurses educational level.
| Variables | Group | |
|---|
| Bachelor | Master | 95% CI for mean difference | t |
|---|
| M | SD | n | M | SD | n |
|---|
| Autonomy in decision making for patient care | 79.36 | 12.87 | 137 | 87.2 | 12.67 | 12 | -15.54, -0.234 | -2.037* |
| Autonomy in decision-making for ward’s affairs | 71.57 | 16.80 | 137 | 74.4 | 26.73 | 12 | -19.98, 14.29 | -0.363 |
*p<0.05
In addition, no statistically significant relationships were found between the total score of autonomy and its domains, and the nurses’ knowledge, gender, marital status, presence at the work, division of labour, and employment status.
Discussion
Nurses participating in the study had a high level of autonomy. They had obtained higher scores in the domain of autonomy in decision making for patient care. Similar findings were reported in other studies too [18,19].
Cajulis CB and Fitzpatrick JJ in their study reported that 41% of nurses had high levels of autonomy [7]. Similar findings were reported by Laschinger HKS et al., [20]. This study was conducted in all nursing wards of hospitals chosen using the random sampling method. However, the samples of other studies [7,20] were nurses working in critical care units who had high levels of autonomy due to working in specialised care units.
The results of the present study showed that 80% of nurses had an intermediate level of autonomy. The definition of autonomy is one of the challenging issues related to the level of autonomy in nursing. There are several definitions of the concept of autonomy in the nursing literature [21-25]. Although, the literature shows nurses’ inclination to reach autonomy in nursing has faced challenges [21,22]. However, interviews with more than a thousand nurses in a research project carried out in 17 years showed that nurses did not know the meaning of autonomy [6]. To take independent action, a nurse must have sufficient knowledge based on research and evidence. It is clear that ongoing and systematic research in relation to the functions and activities of nursing impacts the autonomy of nurses [26,27].
In this study, reverse correlations were reported between age, work experience and autonomy in making decisions. In the study of Cajulis CB and Fitzpatrick JJ [7], no statistically significant relationship was reported between the work experience of a critical care nurse and autonomy. In the studies of Chumbler NR et al., and Kleinpell-Nowell R a direct relationship was reported [28,29]. Mrayyan MT also reported that experienced nurses had greater autonomy [30]. The increase of age and work experience empowers nurses and improves their autonomy. Experienced nurses have more autonomy in decision-making [31].
According to the present study, there was a statistically significant relationship between nurses’ autonomy in decision-making for patient care and nurses’ educational level. The findings of other studies [28,32], similarly show that sufficient knowledge and expertise not only improve nurses’ performance, but also increase their confidence in autonomy.
The demographic variables such as gender, marital status, presence at the workplace, division of labour, and employment status had no statistically significant relationships with autonomy. Cajulis CB and Fitzpatrick JJ reported similar findings [7].
Limitation
Self-reporting questionnaire for data collection and participants’ fatigue were the limitations of this study. Using the observation method for data collection can be helpful in future studies.
Conclusion
Nurses need autonomy for making decisions to establish and maintain patient safety, improving the quality of patient care, reducing mortality and stress, improving job satisfaction and retaining and attracting nurses. Autonomy is one of the important factors for the development of organisational commitment and indicates the desire of remaining in the workplace. The findings of the present study indicated nurses’ autonomy for decision-making in patient care was greater compared with decision-making for ward’s affairs. Nurses’ managers should take responsibility for improving the condition of nurses’ autonomy in healthcare settings and try to remove barriers to nurses’ autonomy.
*p<0.05**p<0.001*p<0.05
[1]. Wade GH, Professional nurse autonomy: concept analysis and application to nursing education Journal of Advanced Nursing 1999 30(2):310-18.10.1046/j.1365-2648.1999.01083.x10457232 [Google Scholar] [CrossRef] [PubMed]
[2]. Ann MT, Guide to nursing management and leadership 2009 8th edSt. LouisMosby Elsevier [Google Scholar]
[3]. Rozalinda AL, Critical Thinking and Clinical Judgment: A Practical Approach 2009 4th edSounders [Google Scholar]
[4]. Black BP, Professional Nursing: Concepts & Challenges 2007 5th edSounders [Google Scholar]
[5]. Wade GH, A model of the attitudinal component of professional nurse autonomy Journal of Nursing Education 2004 43(3):116-24. [Google Scholar]
[6]. Kramer M, Schamalenberg C, Development and evaluation of essentials of magnetism tool Journal of Nursing Administration 2004 34(7):365-76.10.1097/00005110-200407000-0001015303055 [Google Scholar] [CrossRef] [PubMed]
[7]. Cajulis CB, Fitzpatrick JJ, Level of autonomy of nurse practitioners in an acute care setting Journal of the American Academy of Nurse Practitioners 2007 19(10):500-07.10.1111/j.1745-7599.2007.00257.x [Google Scholar] [CrossRef]
[8]. Fung-Kam L, Job satisfaction and autonomy of Hong Kong registered nurses Journal of Advanced Nursing 2004 27(2):355-63.10.1046/j.1365-2648.1998.00527.x9515647 [Google Scholar] [CrossRef] [PubMed]
[9]. Maryyan MT, Nurses’ autonomy: influence of nurse managers’ actions Journal of Advanced Nursing 2004 45(3):326-36.10.1046/j.1365-2648.2003.02893.x14720250 [Google Scholar] [CrossRef] [PubMed]
[10]. Papathanassoglou ED, Tseroni M, Karydaki A, Vazaiou G, Kassikou J, Lavdaniti M, Practice and clinical decision making autonomy among hellenic critical care nurses Journal of Nursing Management 2005 13(2):154-64.10.1111/j.1365-2934.2004.00510.x15720485 [Google Scholar] [CrossRef] [PubMed]
[11]. Yoder-Wise P, Leading and managing in nursing 2007 6th edMosby [Google Scholar]
[12]. Kennerly S, Perceived worker autonomy: the foundation for shared governance Journal of Nursing Administration 2000 30(12):611-17.10.1097/00005110-200012000-0001311132350 [Google Scholar] [CrossRef] [PubMed]
[13]. Hascup V, Organizational silence: the threat to nurse empowerment Journal of Nursing Administration 2003 33(11):562-63.10.1097/00005110-200311000-0000214608211 [Google Scholar] [CrossRef] [PubMed]
[14]. Seguin D, Professional nursing council empowers staff nurses to solve clinical problems and increases RN retention Journal of Emergency Nursing 2003 29(1):78-79.10.1067/men.2003.412556841 [Google Scholar] [CrossRef] [PubMed]
[15]. Chaboyer W, Najman J, Dunn S, Factors influencing job valuation: a comparative study of critical care and non-critical care nurses International Journal of Nursing Studies 2001 38(2):153-61.10.1016/S0020-7489(00)00052-3 [Google Scholar] [CrossRef]
[16]. Finn CP, Autonomy:an important component for nurses’ job satisfaction International Journal of Nursing Studies 2001 38(3):349-57.10.1016/S0020-7489(00)00065-1 [Google Scholar] [CrossRef]
[17]. Blegen MA, Goode CJ, Johnson M, Maas M, Chen L, Moorhead S, Preferences for decision-making autonomy Journal of Nursing Scholarship 1993 25(4):339-44.Available from: https://www.ncbi.nlm.nih.gov/pubmed/828830310.1111/j.1547-5069.1993.tb00269.x8288303 [Google Scholar] [CrossRef] [PubMed]
[18]. Cook G, Gerrish K, Clarke C, Decision-making in teams: issues arising from two UK evaluations Journal of Interprofessional Care 2001 15(2):141-51.10.1080/1356182012003987411705010 [Google Scholar] [CrossRef] [PubMed]
[19]. Krairiksh M, Anthony M, Benefits and outcomes of staff nurses’ participation in decision-making Journal of Nursing Administration 2001 31(1):16-23.10.1097/00005110-200101000-00005 [Google Scholar] [CrossRef]
[20]. Laschinger HKS, Almost J, Tuer-Hodes D, Workplace empowerment and magnet hospital characteristics Journal of Nursing Administration 2003 33(7-8):410-22.10.1097/00005110-200307000-0001112909793 [Google Scholar] [CrossRef] [PubMed]
[21]. Ballou KA, A concept analysis of autonomy Journal of Professional Nursing 1998 14(2):102-10.10.1016/S8755-7223(98)80038-0 [Google Scholar] [CrossRef]
[22]. MacDonald C, Nurse autonomy as relational Nurs Ethics 2002 9(2):194-201.10.1191/0969733002ne498oa11944208 [Google Scholar] [CrossRef] [PubMed]
[23]. Rao AD, Kumar A, McHugh M, Better Nurse Autonomy Decreases the Odds of 30-Day Mortality and Failure to Rescue J Nurs Scholarsh 2017 49(1):73-79.10.1111/jnu.1226728094907 [Google Scholar] [CrossRef] [PubMed]
[24]. Kramer M, Schmalenberg C, The practice of clinical autonomy in hospitals: 20000 nurses tell their story Critical Care Nurse 2008 28(6):58-71. [Google Scholar]
[25]. Wetson MJ, Validity of instruments for measuring autonomy and control over nursing practice Journal of Nursing Scholarship 2009 41(1):87-94.10.1111/j.1547-5069.2009.01255.x19335682 [Google Scholar] [CrossRef] [PubMed]
[26]. Lewis FM, Soule ES, Autonomy in Nursing Ishikawa Journal of Nursing 2006 3(2):1-6. [Google Scholar]
[27]. Kramer M, Maguire P, Schmalenberg CE, Andrews B, Burke R, Chmielewski L, Excellence through evidence structures enabling clinical autonomy The Journal of Nursing Administration 2007 37(1):41-52.10.1097/00005110-200701000-0000717172971 [Google Scholar] [CrossRef] [PubMed]
[28]. Chumbler NR, Geller JM, Weier AW, The effects of clinic decision-making on nurse practitioners’ clinical productivity Evaluation and the Health Professions 2000 23(3):284-304.10.1177/0163278002203461511067192 [Google Scholar] [CrossRef] [PubMed]
[29]. Kleinpell-Nowell R, Longitudinal survey of acute care nurse practitioner practice: Year 1 AACN Clinical Issues 1999 10(4):515-20.10.1097/00044067-199911000-0001210865536 [Google Scholar] [CrossRef] [PubMed]
[30]. Sabiston JA, Laschinger HK, Staff nurse work empowerment and perceived autonomy. Testing Kanter’s theory of structural power in organizations The Journal of Nursing Administration 1995 25(9):42-50.10.1097/00005110-199509000-000097674044 [Google Scholar] [CrossRef] [PubMed]
[31]. Papathanassoglou EDE, Karanikola MNK, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW, Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses American Journal of Critical Care 2012 21(2):e41-e52.10.4037/ajcc201220522381995 [Google Scholar] [CrossRef] [PubMed]
[32]. Sheer B, Reshaping the nurse practitioner image through socialization Nurse Practitioner Forum 1994 5(4):215-21. [Google Scholar]