Professional Documents
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Keywords Abstract
Autonomy; nurse practitioners; acute care
setting; Dempster Practice Behaviors Scale. Purpose: The purpose of this descriptive study was to determine the level of
autonomy of nurse practitioners (NPs) providing care to an adult patient
Correspondence population in an acute care setting.
Corazon B. Cajulis, 182-37, 80th Road, Data sources: Data were collected from 54 NPs in different specialty areas
Jamaica, NY 11432.
currently working in a large metropolitan hospital. The Dempster Practice
Tel: 917-470-8161;
Behaviors Scale was used to measure the autonomy of the NPs.
E-mail: cbcajulis@msn.com
Conclusions: The overall mean autonomy score of 117.37 (SD = 14.55)
Received: September 2006; indicates a high level of autonomy of the NPs in this study. Forty-one percent
accepted: February 2007 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
doi:10.1111/j.1745-7599.2007.00257.x 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.
500 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 NP autonomy in acute care
autonomously. According to Almost and Laschinger (2002), Studies have shown that NPs provide accessible cost-
NPs need autonomy to make timely care decisions. The effective, high-quality care (Keane & Richmond, 1993;
development of autonomy in medical diagnosing and deci- Mundinger, 1994, 2000; Safreit, 1992). Several studies had
sion making was vital in the provision of effective and timely indicated NPs have autonomy in primary care (Adams &
care (Mick & Ackerman, 2000). Kramer and Schmalenberg Miller, 2001; Chumbler, Geller, & Weier, 2000; Offredy &
(1993) asserted that competence is a necessary precursor Townsend, 2000; Pan, Straub, & Geller, 1997). A study
for autonomy and empowerment. Therefore, autonomous done by Adams and Miller showed that the majority of the
individuals have competence to think, decide, and act NP participants were accountable for direct client out-
independently (Dworkin, 1988; Keenan, 1999; MacDonald, comes and made clinical decisions autonomously. Studies
2002). Autonomy to practice ones skills is the exercise of done on NPs diagnostic and clinical decision making
considered independent judgment and the freedom to make indicate similarities to that of physicians; however, NPs
discretionary decisions, actions, and plans according to style of management tends to be holistic, interactive, and
ones scope of practice, which requires that practitioners inclusive of patients and colleagues (Burman, Stepans,
be self-directed, intellectually flexible, responsible, and Jansa, & Steiner, 2002; Lamb, 1991).
accountable for their own actions (Batey & Lewis, 1982; Irvine et al. (2000) explored the influence of organiza-
Cullen, 2000; Dempster, 1994; Keenan; McKay, 1983). tional factors on the ACNP role implementation in a lon-
gitudinal survey. The results revealed that ACNPs had
Autonomy a relatively high level of perception of autonomy on the
job (M = 4.81, SD = 0.62) with a moderate to high level in
Dempster (1990) defined autonomy as the state of being
practice in relation to physicians (M = 4.81, SD = 0.67).
independent, free, and self-directing. Kanter (1977) stated
A study done by Kleinpell-Nowell (1999) found that over
that power is similar to autonomy and freedom of action.
a period of 1 year, ACNPs demonstrated increased inde-
Autonomy was characterized as the exercise of considered
pendence, autonomy, and confidence in practice.
independent judgment and the freedom to make discre-
Pan et al. (1997) analyzed the impact of a restrictive
tionary decisions according to ones scope of practice
environment on NPs level of autonomy regarding pre-
(Batey & Lewis, 1982; Keenan, 1999). The development
scribing selected categories of medications. Restrictive
of professional nurse autonomy may exist on a continuum
environment was referred to as the imposed state laws
in different stages (Wade, 2004). The Dempster Practice
and regulations related to the NPs prescribing authority on
Behaviors Scale (DPBS) was used to measure the level of
selected categories of medication. The study results indi-
autonomy of NPs in this study. Autonomy was operation-
cated that a restrictive environment significantly reduces
ally defined as the total score obtained on the DPBS.
NPs level of autonomy in prescribing medications: NPs in
inpatient settings were 27% more autonomous than NPs
Nurse practitioners
in ambulatory settings (M = 47.51 vs. M = 37.39, respec-
This study focused on NPs working in acute care. These tively). NPs not working directly with a physician had the
NPs were educationally prepared and trained as adult highest level of prescriptive autonomy.
nurse practitioners (ANPs), acute care nurse practitioners Almost and Laschinger (2002) used a predictive, non-
(ACNPs), geriatric nurse practitioners (GNPs), or family experimental design to test Kanters theory of organiza-
nurse practitioners (FNPs). ACNPs have specialty educa- tional empowerment on NPs perceptions of workplace
tion, training, and certification to practice in acute care empowerment, collaboration with physicians and man-
settings; however, other NPs work in the acute care setting agers, and work strain. The results indicated that NPs
and function in roles based on their education, training, perceived themselves to be moderately empowered, had
and experience. The NPs extended scope of practice a moderately high level of collaboration with physicians,
included advanced nursing functions as well as medical and had a moderate collaboration with managers. The
functions and responsibilities (Sidani & Irvine, 1999). primary care NPs perception of workplace empowerment
Expanded advanced nursing functions included education (M = 14.71, SD = 1.95), collaboration with managers (M =
and counseling of patients and family members, discussion 4.03, SD = 0.76), and collaboration with physicians (M =
and coordination of the patient plan of care, admission, and 4.26, SD = 0.58) were higher than those of ACNPs
discharge. Medical function and responsibilities included (M = 12.89, SD = 2.53; M = 3.51, SD = 1.13; M = 4.20,
day-to-day medical management of patients (Sidani & SD = 0.80, respectively). Laschinger, Almost, and Tuer-
Irvine). NPs focus in acute care settings encompassed Hodes (2003) did a secondary analysis from three studies
specialized knowledge and skills to manage select patient (two studies pertaining to staff nurses and one study on
groups with acute and specialized healthcare needs ACNPs) to test the link between workplace empowerment
(Mick & Ackerman, 2000). and magnet hospital characteristics. The ACNPs reported
501
NP autonomy in acute care C.B. Cajulis & J.J. Fitzpatrick
502
C.B. Cajulis & J.J. Fitzpatrick NP autonomy in acute care
503
NP autonomy in acute care C.B. Cajulis & J.J. Fitzpatrick
504
C.B. Cajulis & J.J. Fitzpatrick NP autonomy in acute care
31% had extremely high levels of autonomy. The study and more diverse sample is needed. The higher mean score
results supported Laschinger et al.s (2003) assertion that of those NPs with a Post Masters certificate and/or doctoral
NPs in acute care settings enjoy greater autonomy over degree may suggest that these NPs were employed as
their work because they are highly specialized in a partic- advanced practice nurses (other than as an NP) or had
ular area. Results from all the subscales indicated high held administrative positions prior to NP practice. This
levels of autonomy, which were consistent with the over- result, however, supported some studies that showed that
all result; however, the Empowerment subscale had the education is positively correlated to autonomy (Chumbler
lowest percentage with 28% (very high) and 27.7% et al., 2000; Sheer, 1994).
(extremely), respectively, in comparison with the other
subscales. The Valuation subscale had the highest percent- Limitations
age of responses with 47.5% (very high) and 33.3%
Limitations for this study were a small sample size
(extremely high), respectively.
(n = 54) and only one setting, a magnet-designated medical
The findings in this study provided preliminary evidence
center. The setting was a favorable work environment to
that NPs in acute care settings were highly competent and
practice; thus, the study results may not represent the
skillful to tackle advanced nursing functions as well as
average NP workforce working in an acute care setting.
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 Nursing implications
empowerment with 27.7% having extremely high levels As more NPs are employed by hospitals, knowledge
of empowerment. This finding in this subscale is consistent and understanding of the levels of autonomy require
with the findings of a study done by Irvine et al. (2000), further examination. The higher the level of competence,
which showed that NPs had relatively high autonomy decision-making authority, and autonomy of NPs, the
on the job. To date, however, NPs in this institution do more likely patients are provided with the best possible
not have admitting privileges. They are not reimbursed care. In todays healthcare environment where health care
for their services. They are also bound by a mandatory is characterized by financial prudence with an expectation
collaborative practice agreement. This mandatory collab- of quality care, NPs are in the best position to meet this
oration may have been perceived as a barrier to an inde- expectation. As sicker patients are admitted for inpatient
pendent practice (Lee & Pulcini, 1998). care and management, it is logical that NPs should have
The Actualization subscale results indicated 44% as very high levels of competence as well decision-making skills
high, 43.2% as extremely high, 10.6% as moderate, and and autonomy to care for these patients. Although the
2% with none to slight levels of decision making, respon- results of this study were primarily descriptive of the levels
sibility, and accountability. These results were consistent of NP autonomy in an acute care setting, these findings
with multiple studies on NPs decision making, account- could generate research regarding the impact of NPs
ability, and responsibility (Adams & Miller, 2001; Burman services on patient outcomes and clinical productivity in
et al., 2002; Chumbler et al., 2000; Mundinger, 2000). acute care settings.
Results of the Valuation subscale (M = 12.33, SD = 2.06)
indicated high levels of self-respect, achievement, and Recommendations for future research
satisfaction.
The demographic variable of years worked as an NP Recommendations for future research include replica-
showed no relationship to the total autonomy scores, tion of this study with a larger sample in multiple sites. It
which was inconsistent with other studies (Chumbler will be interesting to evaluate relationships between levels
et al., 2000; Kleinpell-Nowell, 1999). A study on NPs of autonomy, patient outcomes, and clinical productivity.
prescribing activities revealed that years of NP experience Further evaluation of collaborative practice agreements
had no significant impact on their authority level (Pan between NPs and physicians is also recommended.
et al., 1997). This finding may be possibly explained by
some intervening work characteristics, which would
Conclusions
require further investigation. It was also noted that age,
years worked as an RN, basic nursing preparation, national Data generated from this study indicated that the
board certification, length of employment at current job, majority of the NPs had high levels of autonomy. NPs
highest educational level, and the type of NP specialty had high levels of competence, skills, and mastery. They
preparation did not have any relationship with the total were also highly empowered, accountable, and respon-
autonomy scores. The small sample size may possibly sible. In addition, they had high levels of decision-making
explain these results, and future replication with a larger skills, self-respect, achievement, and satisfaction. The
505
NP autonomy in acute care C.B. Cajulis & J.J. Fitzpatrick
higher percentage response in the Valuation subscale, Dworkin, G. (1988). The theory and practice of autonomy.
which indicated that NPs had very high to extremely high New York: Cambridge University Press.
levels of self-respect, achievement, and satisfaction, was Griner, P. (1995). Residency overwork and changing paradigms
possibly related to the opportunities for growth and of service. Annals of Internal Medicine, 123, 547548.
development and a favorable work environment in this Howie, J., & Erickson, M. (2002). Acute care nurse practitioners:
institution. Although the overall result showed that the Creating and implementing a model of care for an inpatient
majority of the NPs had very high levels of autonomy, general medicine service. American Journal of Critical Care,
there is more work to be done to maximize NPs auton- 11(5), 448458.
Institute of Medicine Quality Initiative. (updated 1995).
omy in acute care settings.
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
Acknowledgments
Irvine, D., Sidani, S., Porter, H., OBrien-Pallas, L., Simpson, B.,
Thank you to Maria Vezina, EdD, RN, Senior Director for Hall, L. M., et al. (2000). Organizational factors influencing
Nursing Education and Research, Mount Sinai Hospital, nurse practitioners role implementation in acute care
New York, NY, and Sr. Rita McNulty, DNP, RN, CNP, settings. Canadian Journal of Nursing Leadership, 13(3), 2835.
Assistant Professor, Frances Payne Bolton School of Nurs- Joel, L. (2002). Reflection and projections on nursing.
ing, Case Western Reserve University, Cleveland, OH. 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.
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