The Practice of Clinical Autonomy in Hospitals: 20 000 Nurses Tell Their Story

How can autonomous practice affect nurses’ professional job satisfaction?In a previous article,1 we described how staff nurses, managers, and physicians working on units with confirmed healthy work environments judged “competent performance of nurses.” Although related to all of the essentials of a healthy work environment,2 competent performance is a sine qua non for autonomous decision making, the essential professional work process we discuss in this article.Autonomy has long been cited as 1 of the 3 cornerstones of excellent, magnetic work environments.3 Progress in identifying organizational structures and best practices that enable clinical autonomy has been inhibited by widespread confusion, lack of precise definition of clinical autonomy, and failure to distinguish between organizational and clinical autonomy. The following excerpt4 from groups of staff nurses illustrates this confusion:In 2001, staff nurses in 14 magnet hospitals identified 8 essentials of a healthy (ie, job satisfying and professionally productive) work environment,2 1 of which is clinical autonomy. Six studies related to the 8 essentials of magnetism have been conducted (Table 1). In both the 2001 study2,4–7 on the dimensions of magnetism and the 3 studies1,10–16 to identify structures, interviewees provided hundreds of examples and descriptions in response to requests and questions such as the following:Through constant comparative analysis,18 we generated grounded theories from which we constructed the magnet hospital staff nurses’ definition of autonomy and the items for the Clinical Autonomy subscale of the Essentials of Magnetism (EOM) tool. In the 2 psychometric studies8,9,17 summarized in Table 1, respondents from both magnet and comparison hospitals completed the EOM; the construct validity of the EOM was established by comparing the scores of nurses in these 2 groups of hospitals. Nurses in magnet hospitals consistently reported healthier work environments, including opportunity and support for autonomous clinical practice, than did staff nurses in comparison hospitals.8,17This article is not based on a single research study. It is a synthesis of the results from 6 studies1,2,4–17 on the essentials of magnetism conducted from 2001 to 2007 as they pertain to clinical autonomy and the results of an informal survey at the 2006 National Training Institute in Anaheim, California, of critical care nurses about their perceptions of autonomous practice. Unless noted otherwise, all excerpts are from interviews with staff nurses in the 2001 study2,4–7 or in the 2004 to 2007 structure-identification studies.1,10–16 All the speakers are staff nurses unless noted otherwise. Suggestions offered are specifically addressed to clinical nurses and what these nurses might do to improve their work environment with respect to autonomous practice.Staff nurses perceive and report that they feel that they should practice autonomously, that it is expected of them, but that they receive little support for doing so.19 In the 15 years from 1974 to 1991, nurses reported only low to moderate autonomy scores.19,20 Part of the problem may be due to inadequate, faulty, inconsistent measurement. When autonomy is measured by means of items such as “Nurses need more autonomy in their daily practice,”21 it is impossible to know which of the 34 different definitions of autonomy in the literature is being used as a referent.12 Hence, the results cannot be interpreted accurately. However, when results from 3 different studies19,22,23 by 3 different investigating teams of 3 different samples of staff nurses, some of whom were nurses in magnet hospitals, in which the same instrument22 was used to measure autonomy were compared, the level of autonomy was only moderate; there was little change in level of autonomy during 20 years and little support for autonomous practice. This moderate level and lack of support for autonomous practice were also evident in a 2001 interview study2,4 of 279 staff nurses in 14 magnet hospitals. When we asked nurses to describe a situation in which they functioned autonomously, 39% provided examples and descriptions indicating limited, unsanctioned, unsupported, or no autonomy.4 By 2004, more than 100 hospitals, 80% of them magnet hospitals, had been tested by using the EOM containing the Clinical Autonomy subscale. Although autonomy scores in magnet hospitals were significantly higher than those in comparison hospitals, the scores still were only moderately high.12 In 2003, the mean autonomy score for magnet hospitals was 78.59, 70% of the total possible score; in 2006, the mean score was 76.38, 68% of the total possible score.8,17No word engenders more misunderstanding, confusion, and differences in conceptualization than does the word autonomy. Six different descriptors—clinical, job/work, professional, individual, practice, and organizational—are used, and, to add to the confusion, autonomy is dynamic; it changes over time. As an experienced nurse said, “In the 1980s, refusing to give a patient a contraindicated drug was an act of heroism; in the 1990s, it was an example of autonomy; today, it’s standard practice.”Staff nurse interviewees had a clearer and more consistent understanding of what constitutes clinical autonomy than what is indicated by the descriptions and definitions in the literature.4,12 They demonstrated this by their high similarity in examples of autonomy, descriptions of steps and components of the autonomy process, and illustrations of impediments to autonomous practice. When staff nurses use the word autonomy, they mean clinical autonomy; sometimes, clinical autonomy is also termed practice or professional practice autonomy. Staff nurses do not group clinical autonomy with control of practice and ability to self-govern as was done by directors of nursing in 1982 and has continued in much of the literature today.24 Today’s magnet hospitals staff nurses and their Canadian counterparts25 clearly distinguish the self-determination, self-regulation, control of practice characteristics of a profession from the autonomy characteristic, that is, “the freedom to make decisions about the service needs of clients” as defined by Flexner.26The following definition of autonomy was constructed through constant comparative and thematic analysis18 and from the grounded theory of autonomy generated from the examples and descriptions provided by staff nurses interviewed in hospitals all across the United States:Autonomous practice includes both types of decision making—independent and interdependent.Understanding the concept of unique and overlapping (U/O) spheres of practice and their relationship to type of decision making (independent or interdependent) is essential for safe, effective autonomous practice. U/O spheres may also be termed separate and combined. The knowledge and activities of nurses and the knowledge and activities of physicians or other health professionals can be envisioned as 2 or more partly intersecting spheres (see FigureF1). The more discrete and separate knowledge and activities of each professional are indicated by the parts of the sphere that do not intersect. Those that are shared are indicated by the overlapping areas.27 Usually health maintenance, prevention, and caring dominate nurses’ unique sphere, whereas curative, diagnostic, and prescriptive functions dominate the physicians’ unique sphere. Professionals make independent, patient-centered decisions in their unique spheres of practice. Nurses may seek counsel and advice from peers, but the decision making is individual and independent, as is the accountability for decisions made. Decision-making responsibility and accountability are interdependent and relational in the overlapping sphere.The first of the following excerpts illustrates autonomous action in the nursing-unique sphere; the second exemplifies autonomous decision making and action in the overlap sphere of practice.Although U/O spheres of practice and the corresponding types of decision making have long been heralded in the literature,24,27–30 only recently has adoption of the concept in nurses’ professional practice become evident. In a 1980 classic book on autonomy, Mundinger28 emphasized that autonomous practice is not a nurse providing medical care without medical supervision or a nurse practicing medicine without a license; rather it is a nurse providing nursing therapy that complements and at times overlaps medical therapy. In the same year, the American Nurses Association and the American Medical Association combined commission on collaborative practice recognized the U/O spheres of practice and called for “the formal development of Scope of Practice documents.”29 In their 1980 Social Policy Statement, the American Nurses Association emphasized that clinical autonomy and collaborative relationships between nurses and physicians are true partnerships in which power is held and valued by both participants with recognition and acceptance of separate and combined spheres of activity, responsibility, and accountability.30 In the 1983 original magnet hospital study,31 all of the autonomy examples cited were in the nursing-unique sphere of practice, for example, preadmission programs for children, counseling for pregnant adolescents, and support services for senior citizens. The overlap sphere was alluded to when it was noted that in settings without a house staff, nurses perceive themselves as having greater autonomy and responsibility in decision making and in management of patient care. The current magnet program of the American Nurses Credentialing Center defines autonomy as “independent judgment exercised within a multidisciplinary approach to patient care.”32 This somewhat contradictory definition does not address U/O spheres of practice or corresponding types of decision making, nor are these addressed in either the Forces of Magnetism or in the suggested sources of evidence.32Despite the overt approval by national professional nursing and medical organizations, no evidence of widespread, consistent use of the concept of U/O spheres of practice was reported until 2001, when staff nurses in 14 magnet hospitals were interviewed.4 When asked to describe a situation in which they practiced autonomously, many nurses inquired, “Do you want me to describe a patient care or a nursing care decision?” Interviewees’ descriptions indicated that autonomous patient care actions were decisions that “extend beyond the usual parameters of nursing to other disciplines,”2,4 essentially the same as decisions made in the overlapping sphere of practice. Nursing care decisions were independent actions focused in the nursing arena only, the same as the nursing-unique sphere of practice. Scope of practice emerged as 1 of the 3 dominant themes when the examples and descriptions of autonomy were categorically analyzed; frequency of action and organizational sanction for autonomous practice were the other 2. A total of 43% (n=117) of the nurses cited autonomous patient care actions; 17% (n=47) cited nursing care actions.2Tracking the performance of several research samples (Table 1) on the U/O item of the Autonomy sub-scale of the EOM provides further evidence of the power and use of this U/O spheres concept as a critical element in autonomous practice in magnet work environments. The Autonomy subscale of the EOM II contains this item: “On this unit, nurses make independent decisions within the practice sphere of nursing and interdependent decisions in those spheres of practice where nursing overlaps with other disciplines such as medicine and respiratory therapy.” Not only do nurses in magnet hospitals consistently score significantly higher on the total Autonomy scale than do their counterparts in nonmagnet hospitals,8,17 but the percentage of staff nurses in magnet hospitals who responded affirmatively to the U/O item increased from 83% of 279 nurses in 200133 to 90.2% of 3602 nurses in the 2003 study8 to 94% of 3510 nurses in the 2006 autonomy structure-identification study.12,13 The percentage of positive responses in comparison hospitals has remained low, decreasing from 38% in 2003 to 29% in 2006.8,17The results of the autonomy structure-identification study12,13 provide additional evidence of increased recognition and use of the concept of U/O spheres of practice. When presented with 8 of the 34 definitions of autonomy found in the literature, 60% of the 267 staff nurses, nurse managers, and physicians interviewed selected 1 of the following 2 definitions as representative of their understanding of the concept of autonomy.12 Both definitions recognize the concept of U/O spheres of practice.A total of 31% of the 267 interviewees selected 1 of the 2 following literature definitions to represent their understanding of autonomy. Both of these definitions acknowledge mainly or only the overlap sphere.The U/O concept and corresponding different types of decision making are not included in the American Nursing Credentialing Center definition of autonomy for magnet designation.32 Not all magnet hospitals score at the level noted in the previous samples, nor do all nonmagnet hospitals score low. The percentage of nurses in magnet hospitals who respond affirmatively to the item on U/O spheres of practice is sometimes as low as 37%, and in some comparison hospitals, as many as 85% of nurses respond affirmatively to this item.The differences in scores occur because in some hospitals, approval and sanction from the leadership create the interest, excitement, and security for clinical nurses to practice autonomously. One staff nurse remarked as follows:Several nurses from a single unit who came to the 2006 interviews as a group had this to say:Executive-level nurses, managers, and staff nurses in the 8 magnet hospitals that participated in the autonomy structure-identification study13 provided considerable evidence of the support present in their hospitals for autonomous practice. The following are examples:If the risk involved is so great, why should staff nurses make autonomous decisions? Such decisions are essential for patients’ safety, nurses’ job satisfaction, and nurse retention.2,3,12,19,28,33 Nurses want to make decisions that promote quality patient care. They perceive autonomy as an, if not the, essential component of professional practice.12,15 Physicians rated autonomous decision making as the highest indication of competent performance of staff nurses.1 Most recently, the Institute of Medicine34 recommended that a higher level of clinical autonomy be given to staff nurses and that they be trusted and supported in using the outcomes of evidence-based practice initiatives to make decisions about patients’ patient needs and are the for autonomous In the autonomy structure-identification we inquired, or patient needs you staff to autonomous described examples that 6 Table 2 each of these with or patient of the were in the overlap or combined sphere of practice. to and patient for highest with physicians more need to and nurses more patient decisions by unit and to be unit these included to the and for care and the of for or with who had several physicians and sometimes to the and autonomy are not overlap Although all can be present on clinical unit, patients’ needs to by The and need to are more in critical care units than in other and are needs of in and units but are also to a in critical care. different and Most autonomous practice with quality of patient care and nurses’ job satisfaction, if unit and included of the made autonomous decisions on the unit and the knowledge and to make those of which clinical units do nurses report the autonomous In the autonomy structure-identification we selected interviewees from those clinical units in the 8 magnet hospitals in which staff nurses had confirmed that they and did autonomously. unit in the 8 hospitals high on the Autonomy subscale of the EOM to be selected for individual interviews with staff nurses, managers, and All of the units had high but only of the 8 hospitals had such units and only 1 had the highest care units were in the unit only 8 of 34 units in the 8 hospitals reported autonomous practice as measured by the Autonomy score on the from the autonomy structure-identification is not the only evidence for this of units with respect to of reported autonomous practice. the same unit was found in the 2006 essentials structure-identification on units in 8 other magnet hospitals. units reported the highest scores for autonomous in were and combined were from the of in the unit is and because nurses report a greater need for and score higher in autonomy than do nurses in other did nurses in some of report more autonomy than did nurses in other this we conducted informal of individual and groups of nurses during the 2006 American Association of Nurses National Training Institute in the and asked the nurses for their and as to why this might have A dominant was that the increased use of and having physicians present all the the need for autonomous decision making in the overlap was that autonomy in the nursing-unique sphere was so much a of practice in the that nurses did not it or report it as autonomy. In a different Canadian nurses reported a for why nurses may have low autonomy The following related to by an experienced what nurse from a about the of decisions and actions in the nursing-unique sphere of 267 staff nurses, nurse managers, and physicians working on the units in 8 magnet hospitals who had high scores in autonomy in the autonomy structure-identification described structures and best practices that staff nurses to make autonomous structures and best practices that have for clinical nurses are in the following cannot be and with accountability without an understanding of the U/O spheres of practice by staff nurses, and other This of autonomy cannot be done without about what clinical autonomy is and how it is to be at on each unit and in each Staff nurses can leadership in this They can the to a staff They can their to describe their understanding of the concept of autonomy. They can discuss the and The definitions provided may be a to Staff nurses can discuss the differences between independent decision making and interdependent decision making that from other can and should nurses do if their and that patients’ needs are not by current or action nurses’ current of As a said, that and impediments to autonomous practice not make them clinical nurses, those in magnet hospitals, have the and responsibility do about the autonomy not only in the where they work but also with their and with the American Nurses Credentialing and with professional nursing Nurses can what were they about clinical autonomy in their nursing have they professional practice, and what they to the in the of nursing they The original Forces of Magnetism from interviews with staff nurses and directors of nursing in the original magnet hospitals. than professional nurses in magnet hospitals to the American Nurses Credentialing Center about the current practice of clinical autonomy and evidence to support that The American Association of Nurses is the only professional that U/O spheres of practice as essential for autonomous more impediments to autonomous practice are by critical care nurses than by nurses on other critical care nurses need to of this not only in and in the hospitals but also in of their the of practice has been termed on knowledge and responsibility to patient performance of beyond professional or and to of practice is in the overlapping sphere of practice. in the autonomy structure-identification study12,13 identified 3 or of autonomous decision making and The do and is based on a and between physicians and nurses and is the autonomous action in the overlapping sphere of second level of autonomous until the patient what or the same other the of or not to an or a that the nurse to be for this patient in this The second about the patient with in the is an example of this type of autonomous The following is interdependent decision making the level of autonomous practice. The following from an nurse in an autonomy illustrates this of of practice also in unit or as a of such as are in medical and or in to and nurse collaborative practice critical and response It is through the process of and the of and that of what decisions and activities are best for quality patient care both nurses and were about with such as or for all in a were as and of little in autonomous decision making because they provided little for judgment and for individual a does not this at this in this of clinical nurses in all of this is to for and identify what is In the nursing-unique sphere of practice, of practice is by best in the or and is a of The overlap sphere and the 2006 autonomy structure-identification interviewees identified and support as a best practice staff nurses to make autonomous This is not This same best practice was 1 of the 3 themes that emerged from the of the hundreds of examples and descriptions of autonomous practice provided by the 279 staff nurses interviewed in can not and not practice if have at the support and approval of nurse noted that if a nurse did not have this the only was do it or as their Canadian counterparts said, to in the and with the risk that you may on for to do the best you can for interviewees remarked that the only support they for autonomous decision making was from their or from structures and best practices were identified by interviewees or through an of and from each of the 8 hospitals as of the autonomy structure-identification The cited structures were evidence-based practice and practice autonomously, a nurse have knowledge by research and evidence-based practice teams the knowledge which and critical are The effective teams were evidence-based practice teams of nurses, and patient care second practice sanction was the of in the for programs or in the for a All 8 hospitals in the autonomy structure-identification study12,13 had some type of professional the for on or leadership in or research activities or on or practice the 8 hospitals that had the highest autonomy scores of more 100 hospitals tested with the 2 based all or a of their on the steps and components of autonomy, specifically the type of decision making, sphere of practice, and risk as In 6 of the 8 hospitals, spheres of practice and related decision making were in Scope of of and of that sanction and support for autonomy is performance of the 8 hospitals cited this type of In 3 of the hospitals, of practice spheres and types of decision making were as and in of practice with physicians and other was cited as an staff nurse in all independent and interdependent decision making were defined and as of a professional The that only of these 8 magnet hospitals cited sphere of practice and type of decision making in their performance and that in of the 8 hospitals were these expected of nurses, staff nurses’ that autonomous decision making is rather than or standard nursing nurses can action to the support for autonomous practice. Nurses for the they have an to make their a nurse to practice and feel that need and the best that the nurse can or that clinical autonomy be and included in performance and in clinical Nurses the to practice nurses are made to feel that they do not have the support of leadership management in making autonomous decisions in the best of experienced nurse related the these are and to the of management and clinical nurses if they are or are not expected to nurses in magnet hospitals describe autonomy as the freedom to act in the best of to make independent decisions in the nursing sphere of practice and interdependent decisions in those spheres in which other disciplines overlap with practice is essential for and quality patient care and for nurses’ job Nurses on and units report more autonomous practice than do nurses on other Six of autonomy based on patients’ needs were many of these are unit the work environment so that nurses can is a responsibility of both leadership and clinical Clinical nurses can leadership by autonomy, at for their unit or the of practice and support and sanction do much to work environments.