Abstract

Religious, economic, political, social, and cultural factors influence professional autonomy in nursing, and differ from country to country. The aim of this study was to explain barriers and facilitators of professional autonomy in the experience of clinical nurses. This qualitative study was conducted on 19 clinical nurses and nursing managers selected based on purposive sampling from January 2018 to December 2019. Data were collected through semi-structured interviews, which continued until data saturation was reached. Conventional content analysis based on the Graneheim and Lundman approach was used to analyse the data. Data were categorised into 34 subcategories, 8 main categories, and two main themes, which were titled as facilitators of professional autonomy (professional, organisational, and individual factors, and effective communication) and barriers to professional autonomy (professional, organisational, and personal barriers, and inappropriate communications). The results discussed a set of facilitators and barriers faced by Iranian nurses in clinical settings. Professional organisations can play a key role by enhancing professional autonomy facilitators and increasing professional support for nurses. Another finding was the importance of training nursing staff to be competent and autonomous, beginning right from the college years.

Keywords: professional autonomy, professionalism, nurse, qualitative research

Introduction

Professional autonomy in nursing is defined as the right to make clinical and organisational judgments within a healthcare team in accordance with rules of the (nursing) discipline [1]. Professional autonomy is a vital component for healthcare professionals and an important aspect of a healthy and positive work environment for the nurse [2]. Nurses with professional autonomy exhibit management and leadership skills to provide adequate nursing services using clinical reasoning and effective professional interactions [3]. Professional autonomy among nurses can lead to better decision-making to maintain patient safety, improve the quality of patient care, reduce patient mortality, reduce stress, increase job satisfaction among nurses, and retain and attract nurses [3, 4, 5, 6].

However, despite increasing professionalism in nursing and greater emphasis on responsibility in the clinical setting, many nurses believe that their autonomy is limited [7]. This is associated with job dissatisfaction, burnout, emotional exhaustion, and a feeling of aversion towards patients, eventually leading to quitting the nursing profession [7, 8]. On the other hand, autonomous nursing practice improves patient outcomes. Further, to acquire autonomous nursing practice it is important to gain skill and competence, the trust and respect of other colleagues and physicians, and to interact well with them [9, 10, 11]. In fact, the absence of professional autonomy seems to subject nurses to stress, and thus, they may contemplate how to avoid it, and consequently change their work environments (moving to intensive care (ICUs) and administrative units), or even leaving the job altogether [12].

A set of individual and organisational factors influence the professional autonomy of nurses [2]. Traditional, religious, economic, political, social, and cultural factors influence professional autonomy in nursing, and these differ from country to country [13]. The study by AllahBakhshian et al identified two main barriers — profession-related barriers and organisational barriers. This indicates that autonomy in nursing would vary according to the situation as well as influencing factors [14]. Therefore, the present study aimed to explain the barriers and facilitators of professional autonomy in clinical settings with the experience of nurses.

Methods

We conducted a qualitative study to determine barriers and facilitators of professional autonomy in clinical nurses from January 2018 to December 2019.The study included 19 nurses with at least two years of clinical work experience, and nursing managers. This study was performed in 21 educational hospitals of some medical science universities in Iran. Participants were selected using purposive sampling and the interviews were conducted in a quiet part of the hospital where only the participants were working, belonging to different wards with different work experience and positions. The data were collected through semi-structured interviews, using an interview guide. Prior to the interview, the purpose of the research, the method of interview, and the right of the individuals to participate in the study or to refuse was explained to each participant, and they were assured that their information would be kept confidential and anonymous at all stages. Written informed consent was obtained from them. The questions ranged from general to more specific ones, such as: “Describe one day at work by emphasising what you do autonomously.”, “What factors have you experienced that were effective in gaining and maintaining your professional autonomy?”, “Have you encountered any barrier to maintaining autonomy in your career?”, and so on. Heuristic questions such as: why, how, explain more, how did you feel, give examples, etc were also used. In cases where additional information was required, a second interview was conducted with the participants. Interviews continued until we reached data saturation. A total of 21 interviews were conducted, each lasting for 30 to 60 minutes and all interviews were audio recorded. Immediately after each interview session, the interview text was written verbatim in Microsoft Word.

The conventional content analysis method based on the Graneheim and Lundman approach was used for data analysis [15].

The researcher read all the data repeatedly until data saturation was reached and a general sense of the data had been achieved. The data were then read verbatim to precisely extract the meaning units from the text, and each unit was coded according to its meaning. Next, the initial codes were divided into subcategories based on their similarities and differences, which were then grouped into main categories, and eventually, study themes were formed. This process was also reviewed several times by the research team to ensure that valuable data were not lost. MAXQDA 2010 software was used for data analysis.

To establish the trustworthiness of the qualitative research, the criteria outlined in 1985 by Guba and Lincoln were used [16]. These criteria include credibility, dependability, confirmability, and transferability. To increase the credibility of the findings, sufficient time was devoted for the study process, especially from the beginning of the interviews until the data analysis phase; the prolonged engagement principle was observed. The participants were selected from different wards with different positions. Moreover, to examine the consistency between the study findings and the experiences of the participants, three coding samples and the results of the interviews were provided to the participants so that they could express an opinion about their accuracy and consistency. To gain a broad sense of the data, all stages of the analysis performed by one researcher were provided to four other members of the research team who were experienced in conducting qualitative studies. In order to increase the acceptability of the data, the results of the analysis were provided to another expert who was not part of the research team in order to obtain complementary and critical comments.

The study was approved by the institutional ethics committee of Ahvaz Jundishapur University of Medical Sciences (reference number = IR.AJUMS.REC.1397.286).

Results

Table 1 shows maximum variation of participants. During data analysis, a total of 283 codes were obtained, which were categorised into 34 subcategories and then grouped into 8 main categories based on their similarities and differences. Finally, two main themes were identified as facilitators of and barriers to professional autonomy [Table 2].

Table 1: Characteristics of research participants

Quantitative variables (n = 19)
Variables	Range (years)	Mean (years)
Age	34 – 50	42.36
Work experience	08 – 25	17.78
Qualitative variables
Variables		Frequency (N)
Sex	Female	18
	Male	1
Marital status	Married	18
	Single	1
Educational level	Bachelor	10
	Master’s degree	7
	Ph.D.	2
Organisational  position	Clinical nurse	10
	Head nurse	3
	Supervisor	2
	Matron	2
	University Nursing Manager	2
Place of work	Clinical wards	13
	Nursing office	4
	University Nursing Management	2

Table 2: An example of an analysis process

Theme	Category	Subcategory
Facilitators of professional autonomy	Individual factors	Update knowledge and skills
		Interest in the nursing profession
		Experience of working in difficult conditions
		Use the experiences of experienced colleagues
	Professional factors	Developing a sense of autonomy in nursing students from the college years
		Well-defined laws
		Having specialised and specific job descriptions
		Development of tertiary education
		Social acceptance of the nurse’s position
	Organisational factors	Autonomy-supportive structures
		Role modelling
		Give nurse more freedom of practice
		Arrangement of human resources
		Experience in emergency and ICUs
	Communication factors	Interaction with the treatment team
		Interaction with the patient

Facilitators of professional autonomy

In this theme, four main categories were identified: professional, organisational, and individual factors, and effective communication.

Professional factors

Nurses considered a set of professional factors as facilitators of professional autonomy. They believed that written and well-defined rules could play an important role in freedom of practice and authority in nurses, and increase job security and autonomy. One matron said: “I feel that, although our nurses are very capable, they cannot demonstrate their capability sufficiently due to legal problems and its consequences.”(17P)

On the other hand, nurses believed that they could talk about professional autonomy when they have separate and specific job descriptions, which could determine the decision-making position of nurses and thus, promote autonomy. One clinical nurse said: “You can do a task when you have a specific well-defined job description.” (4P)

Participants also noted the impact of the development of tertiary education and social acceptance of the position of nurses on the power of nurses. Participants emphasised the importance of developing a sense of autonomy starting from the college years, especially through playing the professional roles of clinical educators and nurses. They believed that clinical educators and clinical nurses contributed to the development of such a sense by trusting nursing students and respecting them in the clinical setting. One of the clinical nurses said: “I experienced autonomy when I was a student, the professors were really trying to nurture self-directed students, and I feel that being autonomous is a feeling originated during the college years.”(5P)

Organisational factors

One of the points noted by nurses was the existence of an autonomy-supportive structure at work. They stated that working in educational hospitals can be helpful in enhancing their autonomy in emergency and critical life situations, and believed that the residents would give them more freedom of practice. They also stated that the existence of specific intra-organisational protocols would help them to take actions autonomously in case of absence of a medical practitioner. One clinical nurse stated: “The type of work environment and the structures in that environment are very important. For example, the defined processes, those tasks promoted the autonomous practice of nurses according to my own experience.” (4P)

Furthermore, according to the participants, one of the characteristics of the autonomy-supportive structure was conducting regular and continuous training courses for nurses to increase their scientific and practical capacity by updating their knowledge and skills. Based on their experiences, the participants felt that the existence of responsible and autonomous nursing role models throughout their career influenced their professional practice, and thus emphasised the selection of capable nursing managers. In this regard, one of them believed: “If we work under the supervision of those who are responsible people, certainly, this would have an influence on us to do the same.” (6P)

One of the issues of interest to the participants was to provide nurses the freedom to practise. They believed that the freedom to practise is achieved when the nurse is given the opportunity to make decisions at the bedside and to give value to nursing autonomy. This requires superiors to give nurses the necessary authority in proportion to the scope of the task description as well as to provide the necessary support and positive feedback following optimal practice. A nurse said: “There should be an opportunity for the nurse. We cannot have expectations of a person as long as we avoid giving him/her an opportunity and we cannot say whether she or he is an autonomous person or not.”(4P) A supervisor said: “I think nursing autonomy requires a bit of support. They should give a little value to nursing autonomy, certainly through support.” (2P)

Another effective organisational factor was arrangement of human resources based on their specialty. They believed that, given the academic promotion of nurses, it would be advisable to recruit staff in appropriate departments based on their specialty so that they could autonomously contribute to improving the quality of healthcare services by relying on their knowledge and skills. Conversely, nurses with experience in emergency and ICUs pointed to greater freedom of practice in these units considering their working conditions. One of the matrons said: “ICU staff can work a little more autonomously than other clinical departments because of the governing conditions as well as their knowledge and skills. Their autonomy is sufficient enough to allow them to take some actions.” (17P)

Effective communication

According to the nurses, communication skills were among the facilitators of professional autonomy. They considered it inevitable that nurses need to build constructive interaction with the treatment team, including nursing colleagues, physicians, nutritionists, physiotherapists, and others in order to promote autonomy. Indeed, professional intimacy and interaction can pave the way for the treatment team to trust the nurses and give them more freedom to practise as well as to exchange scientific experience with one another. Moreover, participants referred to the appropriate nurse-patient communications as one of the facilitating factors in creating confidence in the client and thus strengthening the patient’s trust in the nurse and his/her optimal cooperation with the treatment team. “A professional nurse interacts with all groups and she/he knows how to talk with staff holding different positions ranging from physicians to service staff,” said one university nursing manager. “You have to empathise with all treatment team members. You have to be able to touch their hearts so that you can tell them that, my goal is to help the patient recover and to trust you.”(10P)

Individual factors

Participants referred to a set of individual factors in nurses as facilitators of professional autonomy. They believed that an interest in the nursing profession could be one of the factors leading nurses toward professional autonomy. Also, based on their experience, nurses can take effective steps toward autonomous clinical decision-making and autonomous practice by updating their knowledge and skills, passing specialised professional courses, and being aware of professional rules. In addition, they emphasised, using the experiences of skilled colleagues, the importance of professional experience and working under difficult conditions such as staff shortages, excessive numbers of shifts, and exposure to multiple cases. Some of the nurses said: “When we update our scientific knowledge and skills, we can have more self-confidence because we are certain that we have the full knowledge and skill, so, we can handle it much more easily and accept the responsibility and consequences of what we do.” (17P); “Perhaps the staff shortage forced us to do too many tasks. For instance, when I was working alone, I didn’t have the time to tell the doctor or announce a code, so, if my patient really needed it, I initiated CPR and made sure that my patient was stable, then I went back to do the rest.” (7P)

Barriers to professional autonomy

Four main categories were identified under this theme: professional, organisational, and individual barriers, and inappropriate communication.

Professional barriers

One of the professional barriers identified was the gap between education and a clinical setting when the nurses stated that there was a mismatch between the description of nursing duties in the clinic and the training received during college years. In this regard, clinical nurses stated: “There are some tasks defined as a job description of the nurses, but necessary training has been taken into account yet, the nurses have not received the necessary training” (9P) or “they defined a job description that would limit a lot of things. This has resulted in the nurse not yet possessing that sense of autonomy.” (5P)

Organisational barriers

One of the organisational barriers experienced by the participants was that the organisation did not support autonomous nursing practice. Participants pointed out the lack of support by talking about issues such as the lack of opportunity for the nurse to make clinical decisions, lowering the authority of nurses, and being reprimanded by the system, and believed that these issues act as barriers to nurses’ professional autonomy by undermining their self-confidence. In this regard, some of the statements were as follows: “I think one of the barriers was the punishments which could be replaced with rewards, but we would be punished more than before …” (12P), and “Here, if you want to do the right thing, they will rock the boat so much that you eventually say I was wrong.” (16P)

According to the nurses, one of the challenging factors faced by them is the lack of capable nursing managers, since they often did not receive sufficient support from nursing managers due to the manager’s over-confidence. Furthermore, since some of the managers lacked clinical experience, in some cases, their views led the nurses to depart from their true professional position. One of the nurses said in this regard: “There are many staff who may not have done the clinical tasks at all, they have been in nursing management for many years and have never had any clinical experience. However, they make some decisions for us and we who work in the clinical setting know this is not feasible.”(12P)

Another barrier referred to by the nurses was the presence of medical professional dominance in the country’s healthcare system. Based on the experience of the nurses, unfortunately, some physicians neglect the views of the nurses on the patient’s clinical conditions and resist the nurse’s engagement in clinical decision-making in the present situation. Participants noted the low attendance of nurses during the visits. On the other hand, one of the main challenges was the physician-centred payment system of healthcare systems. One participant stated: “The mechanism of the Ministry (of Health), which undermines nursing autonomy, is that allowance payment system does not depend solely on the nurse’s performance, and measurement unit of such system is the physician’s performance, we must define another mechanism for it.” (13P)

Participants also considered the assignment of non-nursing tasks to the nurse as one of the barriers, and believed that this could lead the nurses to depart from their primary role at the patient’s bedside and ultimately hinder their autonomy. Participants also stated that stressful workplace, lack of facilities, and especially, the lack of financial incentives can affect their performance and motivation to pursue professional promotion.

Another interesting point was educational hospitals. Some nurses described educational hospitals as a facilitator of nurse’s autonomy, and others regarded them as a barrier and that the nurses’ freedom of practice would be limited by the constant presence of residents in these hospitals. “I can’t make a decision autonomously here due to the presence of residents and interns. But, for example, wherever they are absent, there is an increased opportunity for autonomous practice.”(4P)

Inappropriate communication

This category consists of subcategories of challenges such as nurse-patient communication, lack of unity among nursing colleagues, and distrust of the treatment team towards the nurse. Nurses stated that patients and their companions interfere with nurses’ autonomous practice in some situations. Conversely, they also complained about the lack of unity among and support from nursing colleagues. Also, one of the major barriers from their perspective was the fact that the treatment team, especially, the physicians had no trust in the abilities of nurses, which can lead to a decrease in their self-confidence and freedom of practice.

Individual barriers

Nurses referred to lack of courage in practice, lack of professional commitment, and lack of awareness of professional rules as some of the barriers to the autonomy of nurses. In fact, autonomous clinical decision-making requires courage. On the other hand, as long as the nurse is not committed to her/his profession, she/he does not pursue career promotion, one of the essentials of which is professional autonomy. Some participants also considered lack of familiarity with professional rules and fear of legal consequences as barriers to autonomous clinical interventions and the tendency to perform their duties routinely.

Discussion

Nurses who take pride in their profession, develop professional skills, and successfully carry out their professional role in various situations [17], which in turn demonstrates the importance of becoming a professional in nursing. Therefore, considering the importance of professional autonomy as one of the main criteria for professionalisation in nursing, it seems important to identify the factors influencing this concept.

The findings of the present study indicate that the professional autonomy of nurses is highly vulnerable in clinical settings.

One of the most important facilitators of professional autonomy is a clear job description and the existence of relevant, strong and clear rules. In fact, it can play an important role in nurses’ freedom of practice and authority, and to some extent leads to increased job security, self-confidence, and autonomous practice. With the specialisation in the nursing profession, there is a need to determine the scope of decision-making to increase the power of nurses. Nouri et al also referred to the need to define the discipline and its governing rules considering specialisation in the nursing profession as one of the factors affecting the autonomy of nurses [10].

The findings of our study discussed the importance of developing a sense of autonomy in nursing students from the college years, which is one of the most important tasks of clinical educators by being a role model as a professional clinical nurse for students. Some studies suggest that the autonomy in nursing is an acquired characteristics developed through life and professional experiences [18, 19]. Therefore, one of the essentials in nursing education is the selection of clinical educators with the professional capability to gradually develop the sense of autonomy in students, so that we see competent clinical nurses in the future.

Some participants from our study stated that the educational hospital is an autonomy-supportive structure, while others found it a barrier to nurses’ freedom to practice. The different types of work environments, the type of rules, and the intra-hospital processes seem to have created this contradictory perspective in the participants. However, this may also be due to the physicians’ attitudes to the professional status of nurses in each hospital.

Our findings showed that professional empowerment of nurses through specialised professional courses is also vital for achieving professional autonomy. According to the findings of a study by Baykara et al, nurses also believed that elevated training not only increases professionals’ level of knowledge, research skills, and self-confidence, but also their success, motivation, and happiness in the clinical setting [13]. Some studies have also pointed to the role of professional education and the updated nursing knowledge and skills in achieving an optimal level of autonomy [4, 5, 10]. In addition to increasing the awareness of nurses, responsible nursing role models can also have a positive effect on performance of nurses and play an important role in nurturing empowered nurses.

The present study emphasises the importance of freedom of practice and authority in providing nursing care. Nurses with professional autonomy also have the freedom to refuse duties that are ethically inconsistent with the rules of their professional conduct as this right is protected by rules of professional conduct, organisational policies as well as the courts [20].

Based on the experiences of nurses, having the freedom of action requires support from superiors. Additionally, superiors can play an important role in enhancing the self-confidence of the nursing personnel. Other studies have also highlighted the supportive role of nursing managers and organisational permissions by giving freedom to practice [5, 6, 10, 21].

In a study by Paganini et al, nurses stated that working in a stressful ICU environment is an opportunity to increase their autonomy level, and believed that the rules of the ICU ward could facilitate professional decisions [22], which is consistent with our findings. It seems that the professional ability of nurses improves gradually in the ICU and in emergency wards considering their frequent exposure to acute and critical situations, and the need for autonomous nursing interventions, which strengthen their professional experience of autonomous practice.

Our findings also demonstrated that communication skills can be one of the contributory factors to autonomy. In fact, the existence of professional interactions can lead to increased inter-professional trust and greater freedom of action for nurses, which in turn can increase the quality of care provided to the patients and increase their satisfaction. Berti et al suggested that professional autonomy is gained in a calm and intimate environment [19]. Gaining trust, support, and respect from other members of the treatment team can play an important role in promoting autonomous nursing practice [5, 10, 21].

The Participants suggested that individual factors, such as interest in the nursing profession, scientific competence and professional experience act as facilitators of professional autonomy and help them gain confidence and freedom of practice from the system because of their successful handling of workplace experiences. In this regard, participants believed that enthusiastically carrying out their professional duties and voluntarily taking on professional responsibilities would positively contribute to the development of professional autonomy [13]. Nurses interested in nursing seem to be more motivated to advance their career and to strive to enhance their abilities, both of which can enhance professional autonomy of nurses.

One of the barriers perceived by nurses was the gap between education and clinical practice. They had experiences that suggested a mismatch between the job description and the nurse’s abilities. In this regard, dos Santos et al highlighted the importance of professional training in achieving professional autonomy [4]. Nurses, however, believed that they have been deprived of freedom of practice due to the existence of a series of restrictive rules in their profession. In Baykara’s study, nurses also stated that professional regulations protect their profession in such a way that they must remain “physician-dependent”, and they referred to restriction on legal rights and authorities as a barrier to professional autonomy in nursing [13].

The Participants stated that some superiors and physicians blamed them for exercising their autonomy, and believed that these behaviours stemmed from organisational policies and could be a barrier to optimal nursing practice at the patient’s bedside. Actually, operating in a non-supportive environment can deprive staff of their freedom of action and motivation, and subsequently, reduce the quality of care provided. Nursing managers play an undeniable role in decision making, training, prioritising staffing needs, enactment of laws, and overall, improving quality of patient care and creating a healthy work environment [23]. Therefore, the existence of capable nursing managers seems to be necessary from the scientific, practical, and managerial points of view.

The Participants identified the dominance of medical professionals in the country’s healthcare system as one of the major barriers to achievement of professional autonomy in nursing. They referred to lack of engagement in clinical decisions for the patient, disregard for views of the nurses by physicians, and the physician-centred payment system as challenges to healthcare systems. The participants also believed that this could reduce self-confidence and motivation of nurses, which could eventually reduce the quality of service provided to the patient.

The Participants indicated that ineffective communication between the nurse and the members of the treatment team (including physician, other nurses, physiotherapists, etc) had a negative impact on the professional autonomy in nursing. This ineffective communication will lead to a lack of trust among the team, neglect of their professional status, lower the chances of autonomous decision-making at the patient’s bedside, and consequently, the nurse is denied support from colleagues. Berti et al in their study also referred to the contradictions between nurse-physician, nurse-nursing assistant, nurse-nurse relationships as perceived risks to nurse autonomy [19]. Therefore, it seems that nurses need to learn communication skills and establish appropriate professional communication with the treatment team and the patient.

The participants considered lack of courage and lack of knowledge of the rules as individual factors hindering the autonomy of nurses. They felt that lack of awareness of the rules can lead to fear in nurses and decrease their decision-making power and autonomous practice.

The limitations of the present study were: the area of the study was restricted to public hospitals only, and excluded private hospitals. Also caution must be exercised in generalising our findings as with all qualitative studies. Another limitation is the use of an empirical design to evaluate a normative concept.

Conclusion

The findings of this study provided a picture of the perceptions of nurses according to their real experiences in their field of work in relation to professional autonomy in nursing. The findings of the present study can help nursing policy makers and managers to promote the professional autonomy of nurses by identifying facilitators and barriers. As can be deduced from the results, by increasing the level of autonomy in nursing, a vital step can be taken to improve the quality of health services.

Conflicts of interest: None declared.

Acknowledgements: This article is based on the qualitative research study carried out for a doctoral dissertation in nursing. The research proposal was approved by the Ahvaz Jundishapur University of Medical Sciences, Iran, and conducted under the reference number U97063. For this, we thank the Ahvaz Jundishapur University of Medical Sciences in Ahvaz.

Statement of similar work:

1) We carried out another study which was a qualitative meta-synthesis that aimed at explaining the concept of professional autonomy of nurses. This has been published as: Rouhi-Balasi L, Elahi N, Ebadi A, Jahani S, Hazrati M. Professional autonomy of nurses: A qualitative meta-synthesis study. Iranian J Nursing Midwifery Res. 2020 Jul-Aug; 25(4):273-81. Available from: https://www.ijnmrjournal.net/text.asp?2020/25/4/273/287024

2) The current paper is a qualitative study of barriers and facilitators of professional autonomy where 19 clinical nurses were interviewed from January 2018 to December 2019.

3) Both these articles are the result of a PhD dissertation with the code IR.AJUMS.REC.1397.286.