Autonomy

Autonomy is fundamental to nursing practice and it is one of the most essential characteristics of the profession. Autonomy is defined as the authority to use professional knowledge and judgment to make decisions and take action (Skår, 2009; Traynor, Boland, & Buus, 2010). Skår (2010) further defines nursing autonomy as “Authority of total patient care, the power to make decisions in a relationship with the patient and next of kin and the freedom to make clinical judgments, choices and actions …” (p. 2233). Autonomy is also referred to as self-determination, self-direction, independence, and self-governance.

Skår (2009) found the following four themes from her research on finding the meaning of autonomy in nursing practice:

to have a holistic view
to know that you know
to know the patient
to dare (an expression of personal ability)

Types of Autonomy

Weston (2008) defines two types of autonomy in nursing practice:

Clinical autonomy: The authority, freedom, and discretion of nurses to make judgments about patient care
Control over practice: The authority, freedom, and discretion of nurses to make decisions related to the practice setting, such as the organizational structure, governance, rules, policies, and operations

Skår (2009) studied the meaning of nurses’ experiences of autonomy in practice and found knowledge and confidence were the two major requirements for independent decision-making. Nurses begin exercising their clinical autonomy as their knowledge improves through experience and collaboration within the interprofessional team. As clinical competence improves, nurses gain the necessary confidence needed to make decisions about care.

Regardless of advanced knowledge and experience, nurses are bound to find themselves in a position where they are unprepared to complete a task. Skår (2009) found nurses will rely on their personal capabilities and confidence to figure out what they need to know and how to proceed. In addition, Skår (2009) found it takes personal courage to act, stating, “The nurses’ confidence in knowing that they know as well as knowing that they dare is important for making autonomous clinical judgements and decisions” (p. 2232). In other words, nurses pull from their depth of knowledge and experience and use their courage to complete the task.

An example of clinical autonomy for a nurse who has begun to develop some competencies and advanced knowledge may start to question physician orders or share ideas about treatment options with the provider. The nurse may reflect on a conversation with a peer or recall a patient from the past that offers guidance and relevant information about care options. As Skår (2010) points out, patient care decisions are based on knowledge and confidence, therefore, as nurses develop their competencies and gain additional knowledge, independent decision-making will grow. The longer a nurse practices and acquires more competencies (i.e. wound care certificate), and new knowledge (i.e. specialty certification, advanced degrees), practice will continue to become more autonomous over time.

Nurses make autonomous decisions all the time, sometimes without realizing it. Consider the following practice examples nurses make on a regular basis in regard to clinical autonomy:

Administer prn pain medication
Raise the head of bed when a patient is short of breath
Seek out the physical therapist to discuss advancing ambulation
Request a dietician referral when assessments find poor wound healing
Delegate aide to assist with ambulation
Check blood sugar due to confusion and weakness

In order for nurses to exert control over their practice, they need to question whether the environment allows for autonomous practice. Below are some examples of how nurses can demonstrate control over their practice:

Does the current policy on assessing tube feeding placement rely on current evidence-based practice?
The supply room is always short of supplies. The nurse will inquire about the procedure for stocking the room and suggest ideas for improvement.
Unit policies and procedures change without input from nursing staff. The nurse will speak with the manager about organizing a shared-governance approach for the unit, and possibly institution-wide.

Standards of Professional Practice

American Nurses Association (ANA, 2010c) explains the role of autonomy in nursing practice:

All nursing practice, regardless of specialty, role, or setting, is fundamentally independent practice. Registered nurses are accountable for nursing judgments made and actions taken in the course of their nursing practice, therefore, the registered nurse is responsible for assessing individual competence and is committed to the process of lifelong learning. Registered nurses develop and maintain current knowledge and skill through formal and continuing education and seek certification when it is available in their areas of practice (p. 24, para. 2)

In order for nurses to acquire a fully autonomous practice, one must subscribe to lifelong learning to maintain and develop one’s knowledge. Nurses are unable to make accurate and timely independent decisions without meeting the competencies of Standard 13: Education, such as:

“Participates in continuing professional development activities related to nursing and inter-professional knowledge bases and professional topics.”
“Commits to lifelong learning through critical thinking, self-reflection and inquiry for personal growth and learning” (ANA, 2021, pp. 98-99)

In addition to improving quality, hospitals must also improve patients’ perceptions of their hospital experience. Patients’ perception of care, known as patient satisfaction, is tied to hospital reimbursement from Medicare through the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) scores (Agency for Healthcare Research and Quality, 2017). Patients receive a HCAHPS survey about their hospital experience in the mail after discharge.

Due to potential implications of reduced reimbursement, nurses and the entire healthcare system must focus care on practices that positively impact the patient experience. The list below shares some of the HCAHPS topics where nurses are can positively impact the patient experience through autonomous practice:

Communication with nurses
Responsiveness of hospital staff
Pain management
Communication about medication
Discharge information
Cleanliness of the hospital environment
Quietness of the hospital environment (Centers for Medicare and Medicaid [CMS], 2018)

Depending on the work setting, nurses may not have decision-making authority in all aspects of care. Authority to make certain patient care decisions depends on allowances made by the employer (Rau, Kumar, & McHugh, 2017). For example, a nurse may want to make an independent decision about an intravenous catheter, though the employer may have processes in place that overrule the nurse’s decision. Often times such processes are in place to improve quality.

The ANA (n. d.-c) created the Magnet Recognition Program for healthcare organizations who strive for nursing excellence. The program designates Magnet Recognition to organizations worldwide whose nurse leaders have successfully transformed their nursing goals to improve patient outcomes. Magnet Recognition offers nurses education and professional development, leading to greater autonomy in nursing practice. The ANA (n. d.-c) has identified 14 characteristics of Magnet Recognition, known as Forces of Magnetism. Force 9 is Autonomy, which reads:

Autonomous nursing care is the ability of a nurse to assess and provide nursing actions as appropriate for patient care based on competence, professional expertise and knowledge. The nurse is expected to practice autonomously, consistent with professional standards. Independent judgment is expected within the context of interprofessional approaches to patient/resident/client care (ANA, n. d.-c, para. 11).

Autonomy is an essential characteristic of the nursing profession; therefore, it is imperative nurses understand the importance of autonomy, and the factors that enhance or reduce autonomy in one’s practice. The ability to make independent decisions about care has a multitude of benefits on health outcomes, the patient experience, financial reimbursement, job satisfaction, and the health and well-being of the nurse. These topics are discussed below.

Benefits of Nursing Autonomy

Since nurses represent the largest percentage of healthcare providers, they play an important role in transforming healthcare. When nurses make autonomous decisions about care, they are questioning the status quo, they are looking to find ways to improve the healthcare system, improve health outcomes, reduce adverse events, improve patient satisfaction, and quality. While providing quality care has always been paramount, quality of care is under particular scrutiny in the current healthcare system. Hospitals and healthcare providers are expected to deliver patient-centered and value-based care (Rau et al., 2017), otherwise healthcare organizations are negatively impacted with financial penalties (CMS, 2018).

Rau et al. (2017) studied nurse autonomy and its impact on quality of care and 30-day mortality rates. Research found hospitals with higher levels of nurse autonomy had reduced 30-day mortality rates. Another study (Maurits, Veer, Groenewegen, & Francke, 2017) found higher rates of autonomy in the home care setting led to improved job satisfaction for BSN prepared nurses. The following is a summary of the benefits of autonomous nursing practice:

Sense of professional satisfaction by developing quality, responsive, and humanized care, essential for patient survival (Weston, 2008)
Job satisfaction (Weston, 2008)
Feelings of pleasure and appreciation of providing care (Weston, 2008)
Reduced 30-day mortality rates (Rau et al., 2017)
Enhanced job satisfaction (Weston, 2008)
Improved quality of nursing performance (Weston, 2008)

Impact of Low Levels of Nurse Autonomy

The lack of nursing autonomy negatively impacts nurses, patients, other members of the team and the organization as a whole. When nurses do not have the freedom to use their knowledge and skills to provide care, nurses can suffer from physical and psychological harm, eventually leading to reduce quality of care, and ultimately reduced reimbursement. Papathanassoglou et al. (2012) shares the following adverse effects of low levels of nursing autonomy:

Lack of motivation
Physical illness
Moral distress
Depersonalization
Professional and personal devaluation
Depression

Papathanassoglou et al. (2012) studied how autonomy impacted nurses’ level of moral distress and collaboration with physicians. The study found nurses with lower levels of autonomy had higher rates of moral distress and lower levels of nurse-physician collaboration. Nurses who inconsistently made independent decisions collaborated less often, which puts patients at risk for poorer quality of care. If providers do not collaborate with nurses, they are missing important information about patient needs and vital nursing insight. Sollami, Caricati, and Sarli (2015) found teamwork and nurse-physician collaboration improved quality of care, decreased work conflicts, and improved team motivation. The lack of collaboration will eventually lead to poorer outcomes and quality care.

Level of autonomy and collaboration with physicians must be evaluated when quality of care, nurse distress, and poor team motivation are present. Nurses must make efforts to identify how team processes and policies impact autonomy and collaboration. The following section reviews factors that enhance and inhibit autonomy.

Factors Known to Enhance Autonomy

Strapazzon Bonfada, Pinno, and Camponogara (2018) found the following factors enhanced nurses’ autonomy in the hospital setting:

Effective communication with members of the interprofessional team
Positive interpersonal relationships with coworkers
Organization and documentation of patient care
Technical and scientific knowledge
Leadership
Cultural knowledge
Professional experience
Professional appreciation
Policies that support autonomous decision-making

Specialty certification offers nurses an advanced knowledge base and enhanced competencies, skills, and qualifications. Nurses who have earned a certification benefits from enhanced autonomy in practice, empowerment, higher level of professionalism and improved interprofessional collaboration (Fritter & Shimp, 2016).

Skår (2009) found nurses who established a relationship with their patients led to a better understanding of the patient’s situation. Nurses were better positioned to advocate for their patient’s needs. As a result, Skår (2009) found a stronger nurse-patient relationship gave nurses the opportunity to provide holistic care and act autonomously.

Factors Known to Inhibit Autonomy

Lack of technical-scientific knowledge
Hierarchy
Authoritarian leadership (oppressive, domineering)
Physical and emotional exhaustion (work overload)
Negative working conditions (bureaucracy, compliance with regulations, hierarchy)
Lack of human (i.e. nurses/nursing shortage) and material resources
Lack of communication with managers (Strapazzon Bonfada et al., 2018)

Skår (2009) found nurses who had a lack of control over their environment had restricted autonomy. For example, charge nurses with limited decision-making power and inability to confer with the physician or other nurses struggled to make autonomous decisions. These are examples of where nurses need evaluate their work environment and create a plan on how to gain more control over their practice. Nurses can take it upon themselves to create ways to empower the charge nurse role, suggest innovative processes for communication with the team. Exploring ways to transform the work environment to one that values communication and collaboration is an essential step towards autonomous practice.

Strategies to Improve Autonomy

As previously discussed, knowledge and confidence are the two key factors to autonomous practice. Actions taken to advance knowledge and confidence will lead to improving a nurse’s ability to make independent decisions about clinical practice. Keep in mind that nurses may have the personal ability (knowledge and confidence) to make autonomous decisions, though it does not mean such decisions can be made. Nurses must continually evaluate their work setting and environment to ensure they have the freedom to make independent decisions. Investigating policies and processes that restrain nursing autonomy is an essential step for improving autonomy (control over one’s practice).

Level of nursing autonomy is largely influenced by the relationship with medical providers. Autonomy can be negatively impacted when nurses have no recourse or input about patient care, or they are completely reliant on the doctor to perform care. Establishing a professional and collegial relationship with providers is an important step in gaining their trust and respect. Nurses need to be assertive and advocate for their patients by offering the provider and the team ideas, relevant literature, and professional insight on best practices.

Another way nurses can improve their knowledge and develop skills and competencies is through participation in professional nursing organizations. Membership offers nurses a multitude of educational opportunities:

Specialty certification
Networking
Mentoring
Peer-reviewed journal subscriptions
Continuing education modules, webinars
Discounts on attending conferences

Involvement in scientific and nursing-related conferences, and other healthcare forums, strengthens professional identity, thus allowing nurses to reach higher levels of autonomy in their practice (Roshanzadeh, Aghaei, Kashani, Pasaeimehr, & Tajabadi, 2018). A comprehensive review of the benefits of joining professional nursing organizations can be found in week 7 resources.

Shared governance is an organizational/decision-making model where managers share the power of decision-making on patient care issues with nurses (Church, Baker, & Berry, 2008). When nurses have the opportunity to share their opinions and ideas concerning decisions that impact patient care, this type of authority promotes nurses’ autonomy (Hoying & Allen, 2011). Nurses are able to make more independent decisions as a result of having input on how care should be provided. See the chapter on Nursing Accountability for more information about shared governance.

Managers play a pivotal role in improving nurses’ confidence by supporting and encouraging nurses to make autonomous decisions (Roshanzadeh et al., 2018). In order to support nurses, managers must examine unit and hospital policies that support nursing autonomy and create opportunities to reinforce nurse-physician collaboration. Actions that bring team members together to share knowledge and expertise with each other support a patient-centered care focus.

Nurses have been chosen number one for the most honest and ethical profession for many years (Brenan, 2017). Maintaining this positive public image is essential for a strong professional identity and movement towards a more autonomous practice (Strapazzon Bonfada et al., 2018). Nurses can advocate for a more autonomous profession by seeking out more influential positions within healthcare organizations. Papathanassoglou et al. (2012) discusses how expanding professional nursing roles can improve autonomy by giving nurses more decision-making power. In order to expand roles, nurses need to reflect on their career goals and create a personal nursing philosophy and a professional development plan. See Week 2 resources for a comprehensive review of career goals and planning.

Considering all the members of the healthcare team, nurses spend the most time with patients. Nurses know their patients and family well, learning about their needs, wants, and goals. Consequently, nurses are eager to advocate for their patients, and want to make decisions they know will meet their patient’s goals and lead to positive outcomes. When nurses work in an environment where they can make independent decisions based on patient needs, everyone benefits. Nurses meet their goals of providing patient- and family-centered care, and the patient receives the safe, quality care they deserve.

In order to transform the delivery of care, nurses must exercise their autonomy. It’s through autonomous practice that nurses are able to use their critical thinking skills, experience, and specialized knowledge to provide exceptional nursing care.

Chapter 1