AC U T E C A R E C O LU M N

Levels of autonomy of nurse practitioners in an

acute care setting
Corazon B. Cajulis, DNP, APRN, BC, CCRN (Clinical Nurse Manager)1 & Joyce J. Fitzpatrick, PhD, RN,
FAAN (Elizabeth Brooks Ford Professor of Nursing)2
1 Department of Nursing/Medical Services, Mount Sinai Hospital, New York, New York
2 Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio

Column Editor: Ruth M. Kleinpell, PhD, RN, FAAN, FAANP, FCCM

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
500

Commission, and the impact of the Balanced Budget Act

provided opportunities for the role of the NP in acute care
settings (Griner, 1995; Knaus, Felten, Burton, Fobes, &
Davis, 1997). Since the introduction of this NP role, NPs
in acute care settings have been growing in numbers
(Rosenfeld, McEvoy, & Glassman, 2003). The literature
has shown important contributions of NPs in the provision
of high-quality and cost-effective care. To date, limited
information was found on the NPs level of autonomy in
acute care settings. Thus, this study was designed toward
a goal of providing preliminary evidence of the levels of
autonomy among NPs in acute care.

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

C.B. Cajulis & J.J. Fitzpatrick

autonomously. According to Almost and Laschinger (2002),

NPs need autonomy to make timely care decisions. The
development of autonomy in medical diagnosing and decision making was vital in the provision of effective and timely
care (Mick & Ackerman, 2000). Kramer and Schmalenberg
(1993) asserted that competence is a necessary precursor
for autonomy and empowerment. Therefore, autonomous
individuals have competence to think, decide, and act
independently (Dworkin, 1988; Keenan, 1999; MacDonald,
2002). Autonomy to practice ones skills is the exercise of
considered independent judgment and the freedom to make
discretionary decisions, actions, and plans according to
ones scope of practice, which requires that practitioners
be self-directed, intellectually flexible, responsible, and
accountable for their own actions (Batey & Lewis, 1982;
Cullen, 2000; Dempster, 1994; Keenan; McKay, 1983).

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).

NP autonomy in acute care

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
501

NP autonomy in acute care

higher ratings of both work empowerment (M = 20.96,

SD = 3.08) and workplace magnet hospital characteristics (M = 3.20, SD = 0.46) than those of the sample of
staff nurses.
Ulrich, Soeken, and Miller (2003) studied predictors of
autonomy of NPs affiliated with managed care systems.
The results indicated high NP autonomy scores (M = 124.2,
SD = 14.3); however, the higher the health maintenance
organization penetration rates, the higher the percentage
of managed care enrolled clients, and the higher the ethical
concerns, the lower the NP perception of autonomy.
In summary, the evolving role of the NP in acute care
settings is a recent opportunity for NPs to expand their scope
of practice (Howie & Erickson, 2002; Shapiro & Rosenberg,
2002) and a recent focus in research. Multiple studies have
shown evidence of autonomy of NPs in primary care settings. In contrast, limited studies were found on autonomy
of NPs in acute care settings. Work environments that
provide greater access to structures of power increase autonomy and organizational effectiveness (Laschinger, Finegan,
Shamian, & Wilk, 2001). While the literature supports that
NPs exhibit autonomy, data are lacking regarding levels of
autonomy of NPs working in acute care settings. Therefore,
the purpose of this study was to determine the levels of
autonomy of NPs who provide inpatient care to adult
populations in an acute care setting.

C.B. Cajulis & J.J. Fitzpatrick

Instruments

Methods

The instruments used in this study were the background

data form and the DPBS questionnaire. Dempster (1990)
developed the DPBS in 1990 to measure the extent to
which autonomous behaviors occur in nursing practice
in any setting. The DPBS is a 30-item instrument in a Likerttype format with five possible responses for each item
ranging from 1 = not at all true to 5 = extremely true. A total
score can range from 30 to 150, with higher scores indicating greater autonomy. Five items of the DPBS are
reverse scored. There are four subscales in the DPBS: (a)
Readiness, (b) Empowerment, (c) Actualization, and (d)
Valuation. Readiness measures elements of competence,
skill, and mastery. Empowerment measures the legitimacy of ones practice (legal status, rights, and privileges).
Actualization measures components of decision making,
accepting responsibility, and accountability of actions.
Valuation measures self-respect, value, worth, achievement, and satisfaction. Reliability analysis was evidenced
by a Cronbachs alpha of .95 for the 30-item instrument with
overall inter-item correlation mean of .39 (Dempster, 1990).
A background data form was used to collect personal,
educational, professional, and work-related characteristics
of the sample. Work-related characteristics also included
work shift, practice status, and union membership. One
question in the background data form was used to obtain
information about the NPs perception of physicians support of NP autonomy.

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.

Institutional Review Board approvals from the university

and the hospital were obtained prior to data collection. Data
were collected in meetings through face-to-face contact.

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.

NP autonomy in acute care

C.B. Cajulis & J.J. Fitzpatrick

Demographic characteristics of NPs

Table 2 Professional characteristics

Of the 54 participants, the majority (42.3%) were

between 41 and 50 years old and female. The majority
(43.4%) were Asians, followed by Caucasians (35.8%).
These data are elaborated in Table 1.
All NPs in this study were certified to practice in the State
of New York as a condition of practice at this hospital;
however, four participants left this item blank. Certification in specialties included ANPs (50%), ACNPs (26%),
FNPs (22%), and GNPs (2%). More than 66% of the
participants reported that they had NP board certification
in a specialty. These data are included in Table 2.
Years of NP experience ranged from 5 months to 11 years
with a mean of 5 years. Six participants (11.32%) indicated
that they worked less than 1 year to a year. Only one
participant (1.88%) indicated greater than 10 years
(11 years) experience. Years worked at current job ranged
from 3 days to 25 years (M = 5.98, SD = 5.41). Years of
experience as RNs ranged from 1 to 30 years (M = 14.74,
SD = 7.44) with 18.5% (n = 14) indicated as having worked
for more than 20 years. These data are included in Table 3.
An additional question on the demographic form
assessed the NPs perception of support from their collaborating physicians regarding NP autonomy using a Likerttype format. There were five possible answers ranging

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

Two participants were certified by both the American Credentialing

Center (ANCC) and the AANP.
b
Four responses were missing.

from 1 = not at all true to 5 = extremely true. Scores ranged

from 2 (slightly true) to 5 (extremely true) with a mean of 3.74
(SD = 0.85), demonstrating that the NPs perceived a high
level of support for NP autonomy from their collaborating
physicians. There was a statistically significant positive
relationship (r = .421, p = .002) between autonomy scores
and NPs perceptions of physicians support of NP autonomy at the .01 level (two-tailed test).

Analysis of the DPBS results

Table 1 Personal and educational characteristics

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

Table 3 Work experience characteristics

Frequency

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

Two responses were missing.

One respondent reported race as other.

One response was missing.

503

NP autonomy in acute care

C.B. Cajulis & J.J. Fitzpatrick

Table 4 DPBS results

Scale

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

(Readiness subscale), r = .619 (Empowerment subscale),

r = .806 (Actualization subscale), and r = .851 (Valuation
subscale). The mean (SD), median, and range of the subscale scores are found in Table 4.
NP participants indicated high levels of competence,
skills, and mastery (67.1%), high levels of empowerment
(55.7%), high levels of decision making, responsibility,
and accountability (87.2%), and high levels of self-respect,
achievement, and satisfaction (80.8%), respectively. The
overall result indicated a high level of autonomy in this
sample of NPs with the majority of the participants indicating very high (41%) and extremely high (31.5%) levels
of autonomy. These data are included in Table 5.
After the results of the subscales were obtained and
summarized, an overall total score for each participant
was calculated. From a possible score range of 30150, the
overall result indicated scores ranging from 79.5 to 145
with a median score of 118.35 and a mean score of 117.37
(SD = 14.55). Results indicated that NPs with national
board certification had a higher mean total score
(M = 118.64, SD = 15.15) than those NPs (M = 114.58,
SD = 13.36) without NP national board certification.
However, the results showed no statistically significant
correlation (r = .131, p = .354) between having NP board
certification and autonomy scores. Although, the ANPs
showed higher mean total score (M = 118.61, SD = 16.23)
than the ACNPs (M = 117, SD = 11.33), there was no
statistically significant relationship (r = 2.155, p = .284)
noted between autonomy scores and NP specialty preparation. The results also noted that NPs with a doctoral
degree (n = 1) and/or Post Masters NP certificate (n = 7)
had a greater mean score (M = 121.14, SD = 9.62) than

those NPs prepared at a masters level (M = 116.78, SD =

15.34); however, there was no statistically significant
correlation (r = .104, p = .455) noted between the autonomy scores and the educational level.
There was no statistically significant correlation noted
between the DPBS score totals and the demographic variables of age, years worked as an RN, years worked as an
NP, basic nursing preparation, or length of employment at
current job (see Table 6).

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

Table 6 Relationship between demographic variables and autonomy

scores
Table 5 Levels of autonomy
Scale/percent (n = 54)

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

NP autonomy in acute care

C.B. Cajulis & J.J. Fitzpatrick

31% had extremely high levels of autonomy. The study

results supported Laschinger et al.s (2003) assertion that
NPs in acute care settings enjoy greater autonomy over
their work because they are highly specialized in a particular area. Results from all the subscales indicated high
levels of autonomy, which were consistent with the overall result; however, the Empowerment subscale had the
lowest percentage with 28% (very high) and 27.7%
(extremely), respectively, in comparison with the other
subscales. The Valuation subscale had the highest percentage of responses with 47.5% (very high) and 33.3%
(extremely high), respectively.
The findings in this study provided preliminary evidence
that NPs in acute care settings were highly competent and
skillful to tackle advanced nursing functions as well as
medical functions and responsibilities as indicated by high
levels of competence, skills, and mastery. Twenty-eight
percent of the NPs responses indicated very high levels of
empowerment with 27.7% having extremely high levels
of empowerment. This finding in this subscale is consistent
with the findings of a study done by Irvine et al. (2000),
which showed that NPs had relatively high autonomy
on the job. To date, however, NPs in this institution do
not have admitting privileges. They are not reimbursed
for their services. They are also bound by a mandatory
collaborative practice agreement. This mandatory collaboration may have been perceived as a barrier to an independent practice (Lee & Pulcini, 1998).
The Actualization subscale results indicated 44% as very
high, 43.2% as extremely high, 10.6% as moderate, and
2% with none to slight levels of decision making, responsibility, and accountability. These results were consistent
with multiple studies on NPs decision making, accountability, and responsibility (Adams & Miller, 2001; Burman
et al., 2002; Chumbler et al., 2000; Mundinger, 2000).
Results of the Valuation subscale (M = 12.33, SD = 2.06)
indicated high levels of self-respect, achievement, and
satisfaction.
The demographic variable of years worked as an NP
showed no relationship to the total autonomy scores,
which was inconsistent with other studies (Chumbler
et al., 2000; Kleinpell-Nowell, 1999). A study on NPs
prescribing activities revealed that years of NP experience
had no significant impact on their authority level (Pan
et al., 1997). This finding may be possibly explained by
some intervening work characteristics, which would
require further investigation. It was also noted that age,
years worked as an RN, basic nursing preparation, national
board certification, length of employment at current job,
highest educational level, and the type of NP specialty
preparation did not have any relationship with the total
autonomy scores. The small sample size may possibly
explain these results, and future replication with a larger

and more diverse sample is needed. The higher mean score

of those NPs with a Post Masters certificate and/or doctoral
degree may suggest that these NPs were employed as
advanced practice nurses (other than as an NP) or had
held administrative positions prior to NP practice. This
result, however, supported some studies that showed that
education is positively correlated to autonomy (Chumbler
et al., 2000; Sheer, 1994).

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.

Recommendations for future research

Recommendations for future research include replication of this study with a larger sample in multiple sites. It
will be interesting to evaluate relationships between levels
of autonomy, patient outcomes, and clinical productivity.
Further evaluation of collaborative practice agreements
between NPs and physicians is also recommended.

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

NP autonomy in acute care

higher percentage response in the Valuation subscale,

which indicated that NPs had very high to extremely high
levels of self-respect, achievement, and satisfaction, was
possibly related to the opportunities for growth and
development and a favorable work environment in this
institution. Although the overall result showed that the
majority of the NPs had very high levels of autonomy,
there is more work to be done to maximize NPs autonomy in acute care settings.

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.

References
Adams, D., & Miller, B. K. (2001). Professionalism in nursing
behaviors of nurse practitioners. Journal of Professional
Nursing, 17(4), 203210.
Almost, J., & Laschinger, H. (2002). Workplace empowerment,
collaborative work relationship and job strain in nurse
practitioners. Journal of the American Academy of Nurse
Practitioners, 14, 408420.
American Academy of Nurse Practitioners. (2004). U.S. Nurse
practitioner workforce survey 2004. Retrieved March 15,
2006, from http://www.aanp.org/Education+and+Research/
AANP+Reports+about+NPs
Batey, M. V., & Lewis, F. M. (1982). Clarifying autonomy and
accountability in nursing service: Part 1. Journal of Nursing
Administration, 12(9), 1318.
Brown, M. A., & Draye, M. A. (2003). Experiences of pioneer
nurse practitioners in establishing advanced practice roles.
Journal of Nursing Scholarship, 35, 391397.
Burman, M. E., Stepans, M., Jansa, N., & Steiner, S. (2002).
How do NPs make clinical decisions? Nurse Practitioner,
27(5), 5764.
Chumbler, N. R., Geller, J. M., & Weier, A. W. (2000). The
effects of clinical decision-making on nurse practitioners
clinical productivity. Evaluation and the Health Professions, 23,
284304.
Cullen, C. (2000). Autonomy and the nurse practitioner.
Nursing Standard, 14(21), 5356.
Dempster, J. S. (1990). Autonomy in practice:
Conceptualization, construction, and psychometric
evaluation of an empirical instrument. Dissertation Abstract
International, 50(07), 3320A. (UMI No. 9030752)
Dempster, J. S. (1994). Autonomy: A professional issue of
concern for nurse practitioners. Nurse Practitioner Forum, 5,
227232.
506

C.B. Cajulis & J.J. Fitzpatrick

Dworkin, G. (1988). The theory and practice of autonomy.

New York: Cambridge University Press.
Griner, P. (1995). Residency overwork and changing paradigms
of service. Annals of Internal Medicine, 123, 547548.
Howie, J., & Erickson, M. (2002). Acute care nurse practitioners:
Creating and implementing a model of care for an inpatient
general medicine service. American Journal of Critical Care,
11(5), 448458.
Institute of Medicine Quality Initiative. (updated 1995).
Americas health in transition: Protecting and improving
quality of health and health care. Retrieved September 16,
2005, from http://www.nas.edu/qual/ahit.html
Irvine, D., Sidani, S., Porter, H., OBrien-Pallas, L., Simpson, B.,
Hall, L. M., et al. (2000). Organizational factors influencing
nurse practitioners role implementation in acute care
settings. Canadian Journal of Nursing Leadership, 13(3), 2835.
Joel, L. (2002). Reflection and projections on nursing.
Nursing Administration Quarterly, 26(5), 1117.
Kanter, R. M. (1977). Men and women of the corporation.
New York: Basic Books.
Keane, A., & Richmond, T. (1993). Tertiary nurse practitioners.
Image-Journal of Nursing Scholarship, 25(4), 281284.
Keenan, J. (1999). A concept analysis of autonomy. Journal
of Advanced Nursing, 29, 556562.
Kleinpell-Nowell, R. (1999). Longitudinal survey of acute care
nurse practitioner practice: Year 1. AACN Clinical Issues, 10,
515520.
Knaus, V., Felten, S., Burton, S., Fobes, P., & Davis, K. (1997).
The use of nurse practitioners in acute care settings. Journal
of Nursing Administration, 27(2), 2027.
Kramer, M., & Schmalenberg, C. (1993). Learning from success.
Nursing Management, 24(5), 5861.
Lamb, G. S. (1991). Two explanations of nurse
practitioner interactions and participatory decision
making with physicians. Research in Nursing and Health,
14, 379386.
Laschinger, H. K. S., Almost, J., & Tuer-Hodes, D. (2003).
Workplace empowerment and magnet hospital
characteristics. Journal of Nursing Administration,
33, 410422.
Laschinger, H. K. S., Finegan, J., Shamian, J., & Wilk, P. (2001).
Impact of structural and psychological empowerment on job
strain in nursing work settings. Journal of Nursing
Administration, 31, 260272.
Lee, M., & Pulcini, J. (1998). Barriers to independent
practice: Mandatory collaboration between nurses and
physicians. Clinical Excellence for Nurse Practitioners, 2(3),
172173.
MacDonald, C. (2002). Nurse autonomy as relational.
Nursing Ethics, 9, 194201.
McKay, P. S. (1983). Interdependent decision-making:
Redefining professional autonomy. Nursing Practitioners
Administrative Quarterly, 7(4), 2130.
Mick, D., & Ackerman, M. (2000). Advanced practice role
delineation in acute and critical care: Application of the strong

C.B. Cajulis & J.J. Fitzpatrick

model of advanced practice. Heart & Lung: The Journal of Acute

and Critical Care, 29, 210221.
Mundinger, M. (1994). Advanced-practice nursing-good
medicine for physicians? New England Journal of Medicine,
330, 211214.
Mundinger, M. (2000). Primary care outcomes in patients
treated by nurse practitioners or physicians. JAMA, 283,
5968.
Offredy, M., & Townsend, J. (2000). Nurse practitioners in
primary care. Family Practice, 17, 564569.
Pan, S., Straub, L., & Geller, J. (1997). Restrictive practice
environment and nurse practitioners prescriptive
authority. Journal of the American Academy of Nurse
Practitioners, 9, 915.
Pruitt, R. H., Wetsel, M. A., Smith, K. J., & Spitler, H. (2002).
How do we pass NP autonomy legislation? Nurse Practitioner,
27(3), 6165.
Rosenfeld, P., McEvoy, M., & Glassman, K. (2003).
Measuring practice patterns among acute care nurse
practitioners. Journal of Nursing Administration, 33,
159165.

NP autonomy in acute care

Safreit, B. J. (1992). Health care dollars and regulatory sense:

The role of advanced practice nursing. Yale Journal of
Regulation, 9, 417488.
Shapiro, D., & Rosenberg, N. (2002). Acute care nurse
practitioner collaborative practice negotiation. AACN
Clinical Issues, 13, 470478.
Sheer, B. (1994). Reshaping the nurse practitioner image
through socialization. Nurse Practitioner Forum, 5(4), 215219.
Sidani, S., & Irvine, D. (1999). A conceptual framework for
evaluating the nurse practitioner role in acute care settings.
Journal of Advanced Nursing, 30, 5866.
Ulrich, C., Soeken, K., & Miller, N. (2003). Predictors of nurse
practitioners autonomy: Effects of organizational, ethical
and market characteristics. Journal of the American Academy
of Nurse Practitioners, 15, 319325.
Wade, G. H. (1999). Professional nurse autonomy: Concept
analysis and application to nursing education. Journal of
Advanced Nursing, 30, 310318.
Wade, G. H. (2004). A model of the attitudinal component of
professional nurse autonomy. Journal of Nursing Education,
43(3), 116124.

507