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Keywords:

  • hospital;
  • Iran;
  • nurses;
  • professional autonomy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

This study aimed to determine the autonomy level of nurses in hospitals affiliated to Zanjan University of Medical Sciences, Iran. In this descriptive cross-sectional study, 252 subjects were recruited using systematic random sampling method. The data were collected using questionnaire including Dempster Practice Behavior Scale. For data analysis, descriptive statistics and to compare the overall score and its subscales according to the demographic variables, t-test and analysis of variance test were used. The nurses in this study had medium professional autonomy. Statistical tests showed significant differences in the research sample according to age, gender, work experience, working position and place of work. The results of this study revealed that most of the nurses who participated in the study compared with western societies have lower professional autonomy. More studies are needed to determine the factors related to this difference and how we can promote Iranian nurses’ autonomy.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

The concept of autonomy as a general term is defined in different forms and because its structure is complex, there are different opinions about it and there is no agreement on its definition.[1] Some define it as directing the personal life and the ability of decision making about their own affairs.[2] Others interpreted it as having liberty or being independent from the external controls.[1] Beauchamp and Childress in their book (p. 58) wrote: ‘Virtually all theories of autonomy agree that tow conditions are essential for autonomy: (i) liberty (independence from controlling influences) and (ii) agency (capacity for intentional action)’.[3] Despite, nurse researchers paid attention to this concept since 1970, but no comprehensive definition has been provided for it yet. Anyway, autonomy in nursing literature was introduced as having ability in a profession,[4] being independent,[5, 6] having control over work-related activities[7] and self-directing.[5]

Nowadays, nurses have a critical role in patient care but most of countries including Iran face with the shortage of qualified nurses.[8, 9] The existing data about nurse's job satisfaction in Iran and other countries indicate their dissatisfaction.[4, 10, 11] In Iran as an example, in a study by Mirzabeigi et al., dissatisfaction of nurses was reported as 65.7%.[10] In another study by Nehrir et al., only 28.8% of the nurses were satisfied with their job.[11] International studies reported the dissatisfaction of nurses between 17% and 41%.[12] Comparing the rates of job dissatisfaction among nurses in Iran, with nurses from other countries, indicates that the dissatisfaction of Iranian nurses with their jobs is substantially higher.

It should be noted that one of the most important factors related to nurses’ job satisfaction is their ability to function independently in the ranges of their duties.[6, 13] Therefore, autonomy has become more important property of nursing profession to attract students to nursing programmes and maintain experienced and competent nurses in the profession.

In addition, nurses who work with low level of autonomy might experience a variety of unpleasant personal and professional feelings such as deprivation, dissatisfaction,[14] sense of lack of commitment[15] and lack of motivation.[16, 17] Autonomy also can influence the service quality,[18] patient's outcome,[19, 20] care safety,[20] professional identity,[21] levels of burnout,[22] recruitment and retention of nurses in the profession,[6, 15, 18, 19] care costs, nursing morals,[19, 23] and nurse's physical and mental health.[16]

A review of the literature shows that the level of perceived autonomy in nurses in different communities with different working conditions and different institutional environments has been in ranges of low,[14] medium[24-26] and high.[18, 27-29] In Iran, there was no direct report about the Iranian nurses’ sense of autonomy, but in some of the qualitative research, the ‘lack autonomy’ and ‘lack of power’ have been reported as two main themes in Iranian nurses’ experiences.[30, 31] Therefore, this study has been aimed at determining the autonomy level of nurses in hospitals affiliated to Zanjan University of Medical Sciences, Iran.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

Sample

In this descriptive cross-sectional study, from among 1029 all nurses working in teaching hospitals in Zanjan, Iran, sample size based on the formula: n = Nz2δ2/z2δ2 + (N − 1) d2. With δ = 1.3 (based on pilot study), Z = 1.96, n = 1029, d = 0/15 were determined 223 nurses, for deal with the possible loss of completed questionnaires, 260 copies of the questionnaire were distributed among them and 252 valid questionnaires were completed that were entered into the analysis. Nurses were recruited using systematic random sampling method.

Ethical considerations

The study protocol was approved by Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences. The subjects gave informed consent and participants’ anonymity should be preserved.

Data collection process

The data were collected using questionnaire. The first section of the questionnaire was designed to gather variables such as age, sex, career, education, department of workplace, work satisfaction and working position in the unit or hospital. The second section of the questionnaire evaluated the nurses’ autonomy. This part of the questionnaire was a translation of Dempster Practice Behavior Scale (DPBS) that was translated and used after obtaining permission from its developer. This scale has been designed and developed in 1990 and has 30 questions with 5-point Likert scale. The scale score ranges from 30 to 150. A higher score of a participant shows higher autonomy.

DPBS explains the overt and covert behaviour in relation to the nurses’ autonomy and its underlying fields and has four subscales: (i) Readiness; (ii) empowerment; (iii) actualization; and (iv) valuation.[5] The subscale readiness has 11 items and measures the subjects of competence, skills and mastery. The subscale of empowerment has seven questions and evaluates the legitimacy of the performer. The actualization subscale has nine items that determine decision making, responsibilities and accountability; and the valuation subscale has three questions to measure worth, value, merit and usefulness.[27] In order to assess the level of these four subscales, the boundaries were defined according to Maylone et al.;[32] for the subscale of readiness with 11 questions, a score between 11 and 25 was defined as low readiness, from 26 to 40 as medium readiness and from 41 to 55 as high readiness. For the empowerment subscale, the scores from 7 to 16 indicated low empowerment, 17–26 medium empowerment and score between 27 and 35 was considered as high empowerment. The actualization subscale from 9 to 20 was low sense of actualization, 21 to 32 was medium and 33 to 45 was high actualization. The valuation score between 3 and 7, 8–11 and 12–15 was considered low, medium and high valuation sense, respectively.

Content validity, factorial validity, construct validity and the reliability of DPBS were reported to be at acceptable level by its designer.[5] To determine the validity of the instrument in Iran, it was first translated into Farsi. Then it was back-translated into English, and the two versions of scale (Farsi and English form) were compared and the similarity of them was approved. Next, it was sent to 15 experts, and the requested changes that were mostly edit-related were applied. The reliability was determined by the internal consistency and also test–retest method. To achieve this purpose, the questionnaires were filled in two different occasions (to the 10-day interval) by 20 participants, and the correlation between the two sets of scores obtained 0.87, and the Cronbach's alpha coefficient obtained was 0.83, indicating internal consistency was sufficient.

Statistical analysis

For data analysis, descriptive statistics were used. In order to compare the overall score and its subscales according to the demographic variables, t-test and analysis of variance test were used. P < 0.05 was considered as the statistical significant level.

Result

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

Details of the participants are presented in Table 1. Most of the participants were female (83.3%) and married (75%) and about half of them (46.4%) were < 30 years of age. Most of them (73.4%) had bachelor degree with < 10 years of working experience (67.1%). About half of them (49.2%) worked in internal and surgical units and most of them (59.1%) were nurses and had changing shifts (89.3%).

Table 1. Descriptive details of the nurses (n = 252)
Descriptive detailsn%
Gender  
Female21083.3
Male4216.7
Marital status  
Married18975
Single6325
Age (years)  
< 3011746.4
30–409236.5
> 404317.1
Education  
Diploma3643.3
Associate degree259.9
Bachelor's degree18573.4
Master's degree62.4
Years worked at current job  
< 1016967.1
10–205521.8
> 202811.1
Requirement types  
Official9939.3
Experimental72.8
Contract6827
Fixed7831
Practice setting  
Critical7430.3
Noncritical12049.2
Operation room218.6
Burn wards2911.9
Appointment level  
Nurse manager259.9
Staff nurse16866.6
Nurse assistant5923.4
Shift  
Only day shift2710.7
All combinations22589.3

According to Table 2, DPBS score of participants ranged between 45 and 121 with average of 90.3 ± 1.33 (Mean ± standard deviation), and nurses had a medium score in subscales. Comparison of participants’ scores on the DPBS based on demographic variables revealed that males were significantly more independent than females and subjects in 30–40 years of age had higher autonomy in comparison with the other age groups (Table 3), and comparison of Participants’ scores on the DPBS based on work related characteristics demonstrated nurses with more than 10 years working experience and those who were head nurses had higher mean score. There were no statistically significant differences in terms of the other occupational characteristics (Table 4).

Table 2. Participants’ scores on the Dempster Practice Behavior Scale
ScaleRangeFrequency (%)Mean ± SD
  1. DPBS, Dempster Practice Behavior Scale.

Total DPBS45–121 90.7 ± 13.3
Readiness subscale  32.1 ± 6.3
Low11–2542 (16.7) 
Moderate26–40187 (74.2) 
High41–5523 (9.1) 
Empowerment subscale  19.2 ± 3.2
Low7–1644 (11.5) 
Moderate17–26206 (81.7) 
High27–352 (0.8) 
Actualization subscale  29.8 ± 5.0
Low9–2011 (4.4) 
Moderate21–32178 (70.6) 
High33–4563 (25) 
Valuation subscale  53.4 ± 19.5
Low3–744 (17.5) 
Moderate8–11157 (62.3) 
High12–1551 (20.2) 
Table 3. Comparison of participants’ scores on the Dempster Practice Behavior Scale based on demographic variables
Demographic variablesDPBS scoredfTest statisticsP value
  1. DPBS, Dempster Practice Behavior Scale.

Gender    
Female89.96250t = −2.080.038
Male94.59   
Marriage stat    
Married88.11250t = −1.820.07
Single91.6   
Age (years)    
< 3087.85(2, 249)F = 5.420.005
30–4092.97   
> 4093.81   
Table 4. Comparison of participants' scores on the DPBS based on work-related characteristics
Work-related characteristicsDPBS scoredfTest statisticsP value
  1. DPBS, Dempster Practice Behavior Scale.

Education
Diploma89.33(3248)F = 1.150.331
Associate degree87.4   
Bachelor's degree91.6   
Master's degree86.33   
Years worked at current job
>1094.22(2249)F = 5.530.004
10–2095.36   
>2095.36   
Requirement types
Official93.05(3248)F = 1.790.149
Experimental87.57   
Contract89.88   
Fixed88.82   
Practice setting
Critical92.38(3248)F = 2.450.064
Non-critical89.83   
Operation room94.52   
Burn wards 85.79   
Appointment level
Nurse manager101.28(3248)F = 7.30.001
Staff nurse94.31   
Nurse assistant88.52   
Shift
Only day shift93.37250t = 1.090.275
All combinations90.41   

Finally, the mean score of men's actualization subscale was more than women. Participants aged more than 40 years gained higher score in readiness and valuation subscales. Subjects with 10–20 years career duration in actualization and valuation subscale had also higher score. The head nurses had higher mean score in all the subscales except empowerment. Although the head nurses had higher score in this subscale, the difference was not statistically significant.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

The aim of the presented study was to investigate the autonomy level of a group nurses in Iran. The results demonstrated that the mean and standard deviation of DPBS was 90.7 ± 13.3 in nurses. In the study of Bahadori and Fitzpatrick, it was 127 ± 10.2 in nurses practitioners in USA.[27] In another studies, it was 117.3 ± 12.5[29] and 123 ± 12.7.[32] The authors of these studies announced that the scores showed the high autonomy level. The nurses in this study had lower professional autonomy than the nurse practitioners in the USA, but this difference is expected with regard to the duties and potential authority of nurse practitioners in the USA. Furthermore, the studies conducted during the years 2001 and 2004 in USA and three other western countries revealed that the nurses’ autonomy level was medium.[18, 28] The existing differences in the autonomy score of nurses in this study with studies elsewhere could be explained by the barriers of the nurses’ professional autonomy such as hospital rules and traditional mode of supervision and control,[18] hierarchical relations between physicians and nurses, and high workload in Iran's health-care systems.[30, 33, 34] Some factors such as convenient and attractive work environment (such as magnet hospitals) have an important role in increasing the autonomy[35]- circumstances that Iran's hospitals lack.

Most of the participants had medium score in subscales of readiness (74.2%), empowerment (81.7%), actualization (70.6%) and valuation (62.3%) that were lower in comparison with the previous studies involving nurse practitioners.[27, 29, 32] Findings about readiness subscale showed that the participating nurses had medium levels of skill, mastery and competence in performing their duties. In relation to these findings, it can be stated that nurses who participated in the study did not have the required preparation before attending the clinic, or they have not adequately self-confidence for decision making and performing independently. The mean score of empowerment in this study was the same as that of the previous studies by Bahadori and Fitzpatrick,[27] Cajulis and Fitzpatrick,[29] Maylone et al.[32] and Irvine et al.[36] The mean score reported here is lower in comparison with the other subscales.[27, 29, 32, 36] This means that the nurses in the present study do not perceive that they have enough power nor receive an adequate amount of support and probably they feel barriers in obtaining their rights or they have a lower legal authority. The findings related to actualization subscale revealed that the participants’ decision making, responsibility and accountability were lower in comparison with the other studies.[27, 29, 32]

Although the scores in the valuation subscale was medium in this study and similar to the other subscales, in concordant with studies by Bahadori and Fitzpatrick,[27] Cajulis and Fitzpatrick,[29] Maylone et al.,[32] the mean score of this subscale was higher than other subscales, in other words comparison with the other subscales within the current study here were higher in value, worth, merit and usefulness associated with autonomy. However, the subscale scores reported here compared with other studies indicate that the score of the participating nurses in this study was lower.

Overall, the mean score of males was significantly higher than that of women. However, in most of the studies on autonomy levels, such differences have not been reported.[27, 29, 32] We propose that the cause of men's higher autonomy level in comparison with women in the present study is due to the gender role socialization in Iran.

Nurses in the age range of 30–40 and those with working experience of more than 10 years had higher autonomy. This difference might be due to the decision-making ability of the nurses with more work experience as previously emphasized in the studies by Hooi et al.[37] and Chumbler et al.[38] Inconsistent with the study by Hooi et al.,[37] there was a significant difference in the level of autonomy between working positions in the units.

The nurse managers had higher autonomy level compared with other personnel; this finding is consistent with studies by Schutzenhofer & Musser,[39] and Wade.[40] It might be thought that having more authority than nurses increases nurse managers’ autonomy. It is noted, in Iran, in addition to the general qualifications, nurse managers are chosen based on three characteristics which, these features’ relationship with the perceived autonomy, are revealed in previous studies. These are: (i) High skills and knowledge in the clinical practice;[24, 41] (ii) having a acceptable working experience;[24, 37, 38, 42] and (iii) having high/effective communication skills;[43] this can be lead to independence feeling by creating a sense of control on clinical practice.[41]

In this study, the nurses working in the operation room or intensive care units had a significantly higher mean score than the nurses from other units. This difference could be due to the specific requirements of these units, different type and nature of the labour division, relation and working environment.

A few studies have been done in the field of nurses’ autonomy in the intensive care units, and their results are not consistent, for example, based on Varjvs et al. study, intensive care unit nurses in Finland have feeling more autonomy.[42] Contradictorily, the study of Papathanassogloue et al. revealed a moderate amount of autonomy in the intensive care units nurses,[24] and even one study demonstrated low level autonomy among these nurses because work overload and the medically driven task-oriented care.[44]

Take into consideration that nurses and medical staff has close relationships in operating room, their relations become more social than professional,[45] and implicit hierarchy governs the team.[46] Therefore, in this situation, people would feel more independent.[47] In addition, nurses in the intensive care units need to have specialized knowledge and skills that are effective factors to achieve greater autonomy.[48]

Finally, the findings of this study demonstrated that men have higher feeling of accountability, responsibility and decision making when compared with women. Nurses with more than 10 years of working experience had higher feeling of being valuable, useful, competent, skilful and control over work. Nurse managers gained higher scores in the above fields when compared with other nurses. Due to the fact that no previous research studied subscales of DPBS, we cannot compare our findings in these subscales.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

This study revealed that most of Iranian nurses in this study compared with western societies have lower perceived autonomy. This group of nurses based on DPBS scores report having also medium competency, skill, mastery, achievement, self-respect, satisfaction and decision-making skills. From the medium score of subjects in valuation subscale, it also can be inferred that in Iran, there are not enough opportunities to promote nursing as profession (professionalism) and nurses do not deliver service in appropriate working environments. Further studies are suggested to investigate the factors that strengthen and undermine the autonomy of nurses.

Recommendations for Clinical Practice

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

According to the study findings, we think that following recommendations partly can lead to improve the perceived autonomy of the Iranian's nursing staff: Implementing participatory management systems, arranging workshops to enhance nurses’ skills especially regarding communication, decision making, caring practices and so on.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References

This study was funded and supported by Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences (TUMS), Grant no; 16757. The authors also would like to express special thanks to all the nurses who participated in this study.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Result
  6. Discussion
  7. Conclusion
  8. Recommendations for Clinical Practice
  9. Acknowledgements
  10. References