Autonomy of Nurse PDF
Autonomy of Nurse PDF
Autonomy of Nurse PDF
Keywords
Autonomy; nurse practitioners; acute care
setting; Dempster Practice Behaviors Scale.
Correspondence
Corazon B. Cajulis, 182-37, 80th Road,
Jamaica, NY 11432.
Tel: 917-470-8161;
E-mail: cbcajulis@msn.com
Received: September 2006;
accepted: February 2007
doi:10.1111/j.1745-7599.2007.00257.x
Abstract
Purpose: The purpose of this descriptive study was to determine the level of
autonomy of nurse practitioners (NPs) providing care to an adult patient
population in an acute care setting.
Data sources: Data were collected from 54 NPs in different specialty areas
currently working in a large metropolitan hospital. The Dempster Practice
Behaviors Scale was used to measure the autonomy of the NPs.
Conclusions: The overall mean autonomy score of 117.37 (SD = 14.55)
indicates a high level of autonomy of the NPs in this study. Forty-one percent
of the participants had very high levels of autonomy, 31.5% had extremely high
levels of autonomy, and 19% had moderate levels of autonomy. Demographic
variables of age; years worked as an NP, as an RN, and at current job; highest
educational level; basic nursing preparation; NP certification; and specialty had
no statistically significant relationship with autonomy scores.
Implications for practice: The results of this study provided preliminary
evidence of the level of autonomy of NPs providing inpatient care to adult
patients in an acute care setting. The findings could lead to future research on the
impact of NP services on patient outcomes and clinical productivity in acute care
settings.
Introduction
Autonomy has been an essential component for full professional recognition, a professional issue in nursing, and
a dominant issue in nurse practitioners (NPs) practice
(Dempster, 1990, 1994; Wade, 1999). The introduction
of the NP role in primary care and then in acute care
settings greatly improved professional autonomy in nursing practice (Brown & Draye, 2003). As the NP role
continued to evolve, the autonomy to practice to the full
extent of knowledge and skills coupled with complete
accountability for decisions and actions was necessary in
order to be regarded as important players in a reformed
healthcare system (Institute of Medicine Quality Initiative,
1995; Joel, 2002; Pruitt, Wetsel, Smith, & Spitler, 2002).
The reduction of residency and fellowship positions,
restrictions of medical residency work hours by the Bell
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Background
The NPs educational preparation, progressive education, and experience provided a base for NPs to practice
Journal of the American Academy of Nurse Practitioners 19 (2007) 500507 2007 The Author(s)
Journal compilation 2007 American Academy of Nurse Practitioners
Autonomy
Dempster (1990) defined autonomy as the state of being
independent, free, and self-directing. Kanter (1977) stated
that power is similar to autonomy and freedom of action.
Autonomy was characterized as the exercise of considered
independent judgment and the freedom to make discretionary decisions according to ones scope of practice
(Batey & Lewis, 1982; Keenan, 1999). The development
of professional nurse autonomy may exist on a continuum
in different stages (Wade, 2004). The Dempster Practice
Behaviors Scale (DPBS) was used to measure the level of
autonomy of NPs in this study. Autonomy was operationally defined as the total score obtained on the DPBS.
Nurse practitioners
This study focused on NPs working in acute care. These
NPs were educationally prepared and trained as adult
nurse practitioners (ANPs), acute care nurse practitioners
(ACNPs), geriatric nurse practitioners (GNPs), or family
nurse practitioners (FNPs). ACNPs have specialty education, training, and certification to practice in acute care
settings; however, other NPs work in the acute care setting
and function in roles based on their education, training,
and experience. The NPs extended scope of practice
included advanced nursing functions as well as medical
functions and responsibilities (Sidani & Irvine, 1999).
Expanded advanced nursing functions included education
and counseling of patients and family members, discussion
and coordination of the patient plan of care, admission, and
discharge. Medical function and responsibilities included
day-to-day medical management of patients (Sidani &
Irvine). NPs focus in acute care settings encompassed
specialized knowledge and skills to manage select patient
groups with acute and specialized healthcare needs
(Mick & Ackerman, 2000).
Studies have shown that NPs provide accessible costeffective, high-quality care (Keane & Richmond, 1993;
Mundinger, 1994, 2000; Safreit, 1992). Several studies had
indicated NPs have autonomy in primary care (Adams &
Miller, 2001; Chumbler, Geller, & Weier, 2000; Offredy &
Townsend, 2000; Pan, Straub, & Geller, 1997). A study
done by Adams and Miller showed that the majority of the
NP participants were accountable for direct client outcomes and made clinical decisions autonomously. Studies
done on NPs diagnostic and clinical decision making
indicate similarities to that of physicians; however, NPs
style of management tends to be holistic, interactive, and
inclusive of patients and colleagues (Burman, Stepans,
Jansa, & Steiner, 2002; Lamb, 1991).
Irvine et al. (2000) explored the influence of organizational factors on the ACNP role implementation in a longitudinal survey. The results revealed that ACNPs had
a relatively high level of perception of autonomy on the
job (M = 4.81, SD = 0.62) with a moderate to high level in
practice in relation to physicians (M = 4.81, SD = 0.67).
A study done by Kleinpell-Nowell (1999) found that over
a period of 1 year, ACNPs demonstrated increased independence, autonomy, and confidence in practice.
Pan et al. (1997) analyzed the impact of a restrictive
environment on NPs level of autonomy regarding prescribing selected categories of medications. Restrictive
environment was referred to as the imposed state laws
and regulations related to the NPs prescribing authority on
selected categories of medication. The study results indicated that a restrictive environment significantly reduces
NPs level of autonomy in prescribing medications: NPs in
inpatient settings were 27% more autonomous than NPs
in ambulatory settings (M = 47.51 vs. M = 37.39, respectively). NPs not working directly with a physician had the
highest level of prescriptive autonomy.
Almost and Laschinger (2002) used a predictive, nonexperimental design to test Kanters theory of organizational empowerment on NPs perceptions of workplace
empowerment, collaboration with physicians and managers, and work strain. The results indicated that NPs
perceived themselves to be moderately empowered, had
a moderately high level of collaboration with physicians,
and had a moderate collaboration with managers. The
primary care NPs perception of workplace empowerment
(M = 14.71, SD = 1.95), collaboration with managers (M =
4.03, SD = 0.76), and collaboration with physicians (M =
4.26, SD = 0.58) were higher than those of ACNPs
(M = 12.89, SD = 2.53; M = 3.51, SD = 1.13; M = 4.20,
SD = 0.80, respectively). Laschinger, Almost, and TuerHodes (2003) did a secondary analysis from three studies
(two studies pertaining to staff nurses and one study on
ACNPs) to test the link between workplace empowerment
and magnet hospital characteristics. The ACNPs reported
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Instruments
Methods
Setting
Research procedure
The study was conducted at a large metropolitan academic magnet hospital on the East Coast. As a magnet
hospital, the setting has a work environment that promotes autonomy and control over practice and fosters
positive nurse-physician relationships. The institution
has a 1000-bed capacity with 200 NPs practicing in varied
clinical areas. Eighty-six NPs practicing with adult inpatient populations in clinical areas that include general
medicine, cardiovascular, geriatrics, oncology, rehabilitation, and surgery constituted the available sample population. NPs were operationally defined as registered NPs
with a masters degree who met the inclusion criteria.
The inclusion criteria included licensed to practice in
an advanced practice role, practicing in an acute care
setting, currently working with an adult patient population either full time or part time on any work time schedule, and members of the New York State Nursing
Association (NYSNA). Pediatric NPs and those working
in the outpatient clinics, NPs working in maternal and
child health units, NPs working in psychiatric units, and
NPs who were nonmembers of NYSNA were excluded
from this study.
502
Statistical analysis
Data were entered and analyzed using the Statistical
Package for the Social Sciences 13.0. Descriptive statistics
were used to describe the demographics and the DPBS
scores; Pearson correlation coefficient was used to test the
relationship between the autonomy scores and the demographic variables of age, years worked as an RN, years
worked as an NP, years worked at current job, highest
educational level, NP certification, NP specialty, and basic
nursing preparation.
Results
There were 86 possible participants: 55 participants
(63.9%) returned completed questionnaires; however,
one participant was excluded because the participant
did not meet one of the inclusion criteria.
Frequency
Board certified (n = 54)
Yes
36
No
18
Certifying board (n = 36)a
ANCC
26
AANP
7
NP specialty preparation (n = 50)b
ANP
25
ACNP
13
FNP
11
GNP
1
Percentage
66.7
33.3
72.2
19.4
50
26
22
2
Age (years)a
<31
3140
4150
5160
>60
Gender
Female
Male
Race/ethnicityb
Caucasian
Black
Asian
East Indian
Basic nursing preparation
Diploma
Associate degree
BSN
Highest educational level
MSN
Masters in other field
Post Masters NP certificate
PhD
Frequency
Percentage
Prior to analysis of the DPBS scores, reliability assessments for this sample were obtained. The Cronbachs
alpha for the DPBS overall scale was r = .922; r = .890
4
18
22
7
1
7.7
34.6
42.30
13.46
1.92
Percentage
6
26
20
1
11.3
49.0
37.7
1.9
3
17
10
14
10
5.6
31.5
18.5
25.9
18.5
9
22
14
1
5
3
16.7
40.7
25.9
1.9
9.2
5.5
Years worked as an NP
<1
15
610
>10
Years worked as an RN
<5
510
1115
1620
>20
Years worked at current job
<1
15
610
1115
1620
>20
48
6
88.9
11.1
19
9
23
2
35.8
17
43.4
3.8
2
2
50
3.7
3.7
92.6
45
1
7
1
83.3
1.9
13
1.9
503
M (SD)
DPBS total
Readiness subscale
Empowerment subscale
Actualization subscale
Valuation subscale
117.37
41.72
24.7
38.5
12.3
(14.5)
(6.79)
(4.12)
(3.94)
(2.06)
Median
Range
118.35
41.5
25
38
12
65.50
28.5
19
19
8
Discussion
The NPs represented in this study had a slightly smaller
percentage of female NPs (89%), mean age (42.9 years), and
average years worked as an NP (5 years) compared to the
national sample of NPs in the United States. The NP workforce data survey conducted by the American Academy of
Nurse Practitioners (AANP, 2004) reported that 95% were
female respondents, with a mean age of 48 and 9 years of NP
experience. The AANP survey also reported that white females (non-Hispanic) comprised the majority of NPs in the
United States in contrast to the demographic finding that
the majority of the NPs in the present study were Asians.
All NP participants in this study were educated at a masters level in contrast to the AANPs (2004) survey, which
showed only 88%. In this present study, however, only
66.7% were NP board certified as compared to the AANP
survey of 92%. This finding may be explained by the fact
that a national NP board certification is not required for
practice in New York State. It was noted in this study that
the majority of the participants were educationally prepared as ANPs compared to the AANP survey report,
wherein FNPs were the majority of the NP population in
the United States. More than 92% of the participants had
a baccalaureate degree (BSN) as their basic nursing preparation. This result was greater than the national average
(approximately 34%) of nurses prepared with the BSN.
The overall result of the study indicated that the majority of the NPs (41%) had very high levels of autonomy and
Demographic variable
Pearsons r
Significance
(two-tailed test)
DPBS
Readiness Empowerment Actualization Valuation total
Age
Number of years as an NP
Numbers of years as an RN
Basic nursing preparation
Number of years at current job
Highest educational level
NP board certification
Type of NP/specialty
.109
.132
.104
2.030
.233
.104
.131
2.155
.443
.345
.452
.892
.093
.455
.354
.284
Not at all
1.68
true
Slightly
6.56
Moderately 24.57
Very true
45.1
Extremely 22
504
8.46
0.2
12.69
23
28
27.7
1.85
10.69
44
43.2
2.5
3
16
47.5
33.3
6
19
41
31.5
Limitations
Limitations for this study were a small sample size
(n = 54) and only one setting, a magnet-designated medical
center. The setting was a favorable work environment to
practice; thus, the study results may not represent the
average NP workforce working in an acute care setting.
Nursing implications
As more NPs are employed by hospitals, knowledge
and understanding of the levels of autonomy require
further examination. The higher the level of competence,
decision-making authority, and autonomy of NPs, the
more likely patients are provided with the best possible
care. In todays healthcare environment where health care
is characterized by financial prudence with an expectation
of quality care, NPs are in the best position to meet this
expectation. As sicker patients are admitted for inpatient
care and management, it is logical that NPs should have
high levels of competence as well decision-making skills
and autonomy to care for these patients. Although the
results of this study were primarily descriptive of the levels
of NP autonomy in an acute care setting, these findings
could generate research regarding the impact of NPs
services on patient outcomes and clinical productivity in
acute care settings.
Conclusions
Data generated from this study indicated that the
majority of the NPs had high levels of autonomy. NPs
had high levels of competence, skills, and mastery. They
were also highly empowered, accountable, and responsible. In addition, they had high levels of decision-making
skills, self-respect, achievement, and satisfaction. The
505
Acknowledgments
Thank you to Maria Vezina, EdD, RN, Senior Director for
Nursing Education and Research, Mount Sinai Hospital,
New York, NY, and Sr. Rita McNulty, DNP, RN, CNP,
Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
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