Level of autonomy of primary care nurse practitioners

Autonomous competences and quality of professional life of paediatric nurses in primary care, their relationship and associated factors: A cross-sectional study

AIMS AND OBJECTIVES

To identify the autonomous competences and quality of professional life of paediatric nurses in primary care, their relationship and possible associated factors.

BACKGROUND

The autonomous competences of paediatric nurses vary among healthcare providers in Catalonia, Spain. Autonomy is related to quality of professional life, but little is known about autonomous competences and other factors contributing to paediatric nurses' quality of professional life.

DESIGN

A cross-sectional study following the STROBE statement.

METHODS

Data from 206 paediatric primary care nurses were analysed. A self-administered survey consisting of an ad hoc questionnaire and a validated instrument to measure quality of professional life (QPL-35 questionnaire) was conducted. Descriptive, bivariate and general multivariate regression analyses were used to identify the relationship between autonomous competences and quality of professional life, and its predicting factors.

RESULTS

47.6% nurses reported a medium level of autonomous competences, 46.6% a high level, and 5.8% a low level. Quality of professional life was medium-high for the domains perception of managerial support and global perception of workload and for the item disconnect from work after work shift, and very high and high values for the domain intrinsic motivation and for the item quality of work life, respectively. Autonomous competences and perceived autonomy were factors associated with quality of professional life. Other associated factors were academic background, specific training and being a paediatric nurse specialist.

CONCLUSIONS

Paediatric nurses in primary care have a medium-high level of autonomous competences and they perceive a high level of autonomy. Autonomous competences and level of perceived autonomy are predictors of quality of professional life.

RELEVANCE TO CLINICAL PRACTICE

Enhancing paediatric nurses' autonomous competences and academic background, receiving specific training and being paediatric nurse specialists might improve their quality of professional life, healthcare quality and outcomes for the child population.

The evolution of the role of nursing in primary health care using Bourdieu’s concept of habitus. A grounded theory study

Aims

To analyse the global process by which Spanish nurses have acquired a differentiated role in primary health care and to develop a theory that explains the evolution of this role.

Design

Grounded Theory was selected, as proposed by Glaser and Strauss, following the theoretical framework of Bourdieu’s habitus.

Methods

Thirteen in-depth interviews were conducted between 2012 and 2015, using theoretical sampling and seeking maximum variability. The analysis of the data included progressive coding and categorization, constant comparative analysis and memo writing.

Results

A core category emerged, “Autonomy”, composed of three categories: "Between illusion and ignorance. Genesis of a habitus", "The recognisable and recognised habitus" and "Habitus called into question", showing the genesis of the nursing role in primary health care and the elements that influence the autonomy of the role: the ability to decide their training, assume their own leadership, configure teams and acquire independent skills. “Seeking autonomy” was the substantive theory that emerged from the data.

Conclusion

The results reveal the elements that strengthen the autonomous professional role and that this role is legitimated when two elements are identified: the acquisition of a habitus, based on practices carried out regularly and the recognition of this habitus by the population and others professionals.

Impact

The results of this study identify the elements that guide and strengthen the professional role and redefine the concept of autonomy. These are operational findings and could potentially be used to define new strategies for advancing the role of nursing in primary health care.

The implementation of a professional practice model to improve the nurse work environment in a Dutch hospital: A quasi-experimental study

Aims

To evaluate the effects of the implementation of a professional practice model based on Magnet principles on the nurse work environment in a Dutch teaching hospital.

Design

A quasi‐experimental study.

Methods

Data were collected from registered nurses working on the clinical wards and outpatient clinics of the hospital in June/July 2016 (baseline) and in June/September 2019 (measurement of effects). Participants completed the Dutch Essentials of Magnetism II survey, which was used to measure their perception of their work environment. After baseline measurements were collected, interventions based on a professional practice model incorporating Magnet principles were implemented to improve the nurse work environment. Descriptive statistics and independent t‐tests were conducted to examine differences between survey outcomes in 2016 and 2019.

Results

Survey outcomes revealed significant changes in the nurse work environment between 2016 and 2019. Seven of the eight subscales (essentials of magnetism) improved significantly. Score for overall job satisfaction increased from 7.3 to 8.0 and score for quality of care increased from 7.0 to 7.6. On unit level, 17 of the 19 units showed improvement in the nurse work environment.

Conclusion

The implementation of a professional practice model positively affects the nurse work environment, job satisfaction and quality of care.

Impact

Nowadays, the quality of care is threatened by workload pressure and the low autonomy experienced by nurses. Considering the global shortage of nurses and growing complexity of healthcare, it is important to invest in improving the nurse work environment. The Magnet concept created a work environment in which nurses can deliver optimal quality of care. Knowledge of how Magnet principles affect the nurse work environment in the Netherlands is missing. These study results, including the description of how the interventions were implemented, will assist other hospitals to develop improvement strategies by focusing on the nurse work environment.

'An exploration of the levels of clinical autonomy of advanced nurse practitioners': A narrative literature review

AIMS AND OBJECTIVES

The aims of the review are to synthesise current evidence about advanced nurse practitioner clinical autonomy and consider how this may inform clinical practice and research.

BACKGROUND

Clinical autonomy is one of the cornerstones of advanced nursing practice globally, yet there is limited synthesis of clinical autonomy in the literature.

DESIGN

This is a narrative literature review.

DATA SOURCES

The databases Cumulative Index to Nursing and Allied Health Literature, EBSCO host, Cochrane Library, CINAHL and MEDLINE were searched for publications between 2005 and 2020 inclusive.

REVIEW METHODS

A systematic approach was used to analyse the literature reviewed. Two reviewers undertook quality appraisal.

RESULTS

Nineteen articles were selected. Four major themes emerged: (1) 'ANP Stepping Up'-moving into and accepting advanced nursing practice roles and clinical responsibilities; (2) 'ANP Living It'-ANPs' ability to act independently including an understanding of task mastery and self-determination; (3) 'ANP Bounce-back ability'-depicted in challenges that threaten their ability to practice clinically autonomously; (4) 'ANP Setting in Motion'-indirect care activities and service-level improvements.

CONCLUSION

A clearer understanding of advanced nurse practitioner clinical autonomy could help develop more in-depth knowledge. Research of advanced nurse practitioners' clinical autonomy would improve full utilisation in clinical practice.

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

A concept analysis of nurse practitioner autonomy

BACKGROUND

Nurse practitioner (NP) autonomy is often misunderstood and misconstrued. These misconceptions cause a confusing interplay of words that impedes advocating for policy change and ultimately hinders the profession.

OBJECTIVE

To develop a clear definition of NP autonomy to describe the professional role.

DATA SOURCES

Walker and Avant's method of concept analysis was used to undertake a concept analysis of NP autonomy. The terms used to search for possible uses and definitions of NP autonomy in electronic databases included NP, autonomy, and concept analysis. In addition, the websites for nursing organizations, Google, Google Scholar, and the Merriam-Webster dictionary were searched and included in this analysis. This search yielded 29 articles, consisting of literature reviews, meta-synthesis, position papers, and qualitative and quantitative studies.

CONCLUSIONS

Nurse practitioner autonomy should be defined as the NP's use of their experience, clinical judgment, and responsibility to practice without restriction in professional collaboration with other health care professionals. Autonomy allows NPs to practice to the maximum extent of their advanced education, participate in productive and voluntarily collaborations, and continue to positively influence health care discrepancies throughout the United States.

IMPLICATIONS FOR PRACTICE

This concept analysis provides a clear definition of NP autonomy. In addition, it explains the difference between the concepts of NP autonomy and full practice authority. Clear definitions of the concepts of NP autonomy and full practice authority will be beneficial in advocating and advancing policy on behalf of NPs.

Perspectives of Quebec Primary Health Care Nurse Practitioners on Their Role and Challenges in Chronic Disease Management: A Qualitative Study

BACKGROUND

Primary health care nurse practitioners (PHCNPs) can play a key role in chronic disease management. However, little is known about the challenges they face.

PURPOSE

The study aimed to describe PHCNPs' perspectives on their role for patients with chronic health conditions, the barriers they face, and facilitating factors.

METHODS

A qualitative descriptive exploratory study was conducted with 24 PHCNPs in the Canadian province of Quebec.

RESULTS

PHCNPs believe that they are in an optimal position to address the needs of patients with chronic health conditions, especially in providing self-management support. However, PHCNPs reported feeling pressured to practice according to a biomedical model and to constantly defend their role in chronic disease management. They feel that they are frequently being diverted from their role to compensate for the lack of family doctors. PHCNPs made concrete recommendations to optimize their autonomous practice and quality of care: promoting strong interprofessional communication skills, genuine mentoring relationships between PHCNPs and partner physicians, managers upholding the full scope of PHCNPs' practice, and a more flexible legislative framework.

CONCLUSIONS

The original conception of PHCNPs as health professionals with unique characteristics is at stake. The factors that should be targeted to support the autonomy of PHCNPs were identified.

Nurse-Physician Collaboration and the Professional Autonomy of Intensive Care Units Nurses

Background and aims

Poor collaboration between the physicians and the nurses may interfere with nursing performance in patient care. This study aimed to determine the nurse–physician collaboration and professional autonomy of intensive care nurses.

Subjects and methods

This descriptive correlational study was performed on 126 nurses working in the intensive care units (ICUs) of Ardabil, Iran. The data were collected using the Jefferson scale of attitudes toward physician–nurse collaboration’ (JSAPNC) and the Dempster Practice Behavior Scale (DPBS). The results were analyzed using descriptive statistics (mean, standard deviation, and frequency) and inferential statistics (t-test, ANOVA, and Pearson).

Results

The mean score of the nurse–physician collaboration was found to be 47.83 ± 3.9, which indicates good collaboration between physicians and nurses in the ICUs. The results showed that 73% of the nurses reported a moderate autonomy and 27% of them considered their autonomy to be high. There was no significant relationship between the nurse–physician collaboration and the professional autonomy of the nurses (p >0.05).

Conclusion

The nurses who participated in this study had a positive attitude toward collaboration with the physicians and a moderate level of professional autonomy. Interventions may be required to further enhance the level of nurse–physician collaboration and the professional autonomy of nurses.

How to cite this article

Aghamohammadi D, Dadkhah B, et al. Nurse-Physician Collaboration and the Professional Autonomy of Intensive Care Units Nurses. Indian J Crit Care Med 2019;23(4):178-181.

Predictors and outcomes of nurse professional autonomy: A cross-sectional study

AIMS

This paper is a report examining the level of professional autonomy as well as its predictors and outcomes among practicing nurses in the Philippines.

METHODS

This study adopted a descriptive, cross-sectional research design. One hundred sixty-six (n = 166) nurses participated in the study or a response rate of 83% during the months of January 2017 to May 2017. Seven self-reported scales were used for this study: the Nurse Autonomy Scale, Job Stress Scale, Burnout Measure Scale, Job Satisfaction Index, Organizational Commitment Questionnaire, Turnover Intention Inventory Scale, and the Six Dimension Scale of Nursing Performance. Inferential and descriptive statistics were used to analyse the collected data.

RESULTS

Nurses demonstrated moderate levels of professional autonomy with education and hospital bed capacity as strong predictors. Regression analysis showed positive effects of professional autonomy on nurses' job outcomes such as organizational commitment, job satisfaction, and work performance.

CONCLUSION

Consistent to international studies, nurses in the Philippines demonstrated moderate levels of professional autonomy. Nurses who had higher levels of autonomy tended to be high performing, satisfied, and committed in their jobs. Organizational efforts are critically important to foster autonomy in practicing nurses through adequate support, education, training, and developed policies.

Understanding critical care nurses' autonomy in Jordan

Purpose The aim of this study was to describe Jordanian critical care nurses' experiences of autonomy in their clinical practice. Design/methodology/approach A descriptive correlational design was applied using a self-reported cross-sectional survey. A total of 110 registered nurses who met the eligibility criteria participated in this study. The data were collected by a structured questionnaire. Findings A majority of critical care nurses were autonomous in their decision-making and participation in decisions to take action in their clinical settings. Also, they were independent to develop their own knowledge. The study identified that their autonomy in action and acquired knowledge were influenced by a number of factors such as gender and area of practice. Practical implications Nurse's autonomy could be increased if nurses are made aware of the current level of autonomy and explore new ways to increase empowerment. This could be offered through classroom lectures that concentrate on the concept of autonomy and its implication in practice. Nurses should demonstrate autonomous nursing care at the same time in the clinical practice. This could be done through collaboration between educators and clinical practice to help merge theory to practice. Originality/value Critical care nurses were more autonomous in action and knowledge base. This may negatively affect the quality of patient care and nurses' job satisfaction. Therefore, improving nurses' clinical decision-making autonomy could be done by the support of both hospital administrators and nurses themselves.

Meta-synthesis on nurse practitioner autonomy and roles in ambulatory care

BACKGROUND

Many healthcare stakeholders view nurse practitioners (NPs) as an important workforce resource to help fill the anticipated shortage of 20,400 ambulatory care physicians that is expected by 2020. Multiple quantitative studies revealed the attributes of NPs' practice autonomy and roles. However, there is no qualitative meta-synthesis that describes the experiences of NPs' practice autonomy and roles.

AIM

To describe and understand the experiences of NPs regarding their practice autonomy and roles in various ambulatory settings through the exploration of existing qualitative studies: meta-synthesis.

DESIGN

A qualitative meta-synthesis was conducted to gain insight into ambulatory NPs' practice autonomy and roles through content analysis and reciprocal translation.

METHODS

Articles published between 2000 and 2017 were retrieved by searching 7 databases using the following key words: U.S. qualitative studies, advance practice nurses, NP role in ambulatory care, NP autonomy, and outpatient care.

RESULTS

Autonomy, NPs' roles and responsibilities, practice relationships, and organizational work environment pressures are the four main themes that emerged from the content analysis of the nine selected qualitative studies.

CONCLUSION

Within and between states, NPs' experiences with autonomy and NPs' roles are multifaceted depending on state regulations, practice relationships, and organizational work environments.

Clarifying Clinical Nurse Consultant work in Australia: A phenomenological study

The Clinical Nurse Consultant role in Australia is an Advanced Practice Registered Nurse Role (APRN). This role has been conceptualized from the discrete pillars of research, education, practice, system support and leadership, articulated in the Strong Model of Advanced Practice. This conceptualization has been manifested in job descriptions, workforce. planning and course design. This paper explored whether there was a more refined way of conceptualizing the unique 'value add' of the role. A hermeneutic phenomenological approach was employed to explore the lived experience of the role. It was identified that the pillars of education, practice, leadership and research are interconnected and expressed in the system work of the Clinical Nurse Consultant. The findings have implications for education and workforce planning.

Following professional codes of practice and military orders in austere military environments: a controversial debate on ethical challenges

In 2004, the World Medical Association's International Code of Ethics claimed that 'medical ethics in armed conflict is identical to medical ethics in times of peace'. This paper challenges this notion and suggests that the hostile, austere and diverse environments in which military doctors and nurses serve are significantly more problematic and different to a civilian healthcare environment. It debates that there may be some incompatibility and challenges between following military orders such as the protocols written down in a Medical Rules of Eligibility matrix and professional codes of practice in these environments. This is either where fighting takes place or where the mission is for humanitarian purposes.

Nurse practitioner perceptions of the impact of physician oversight on quality and safety of nurse practitioner practice

PURPOSE

Nurse practitioner (NP) regulation and physician oversight (PO) of NP practice are inextricably intertwined. A flexible, well-prepared workforce is needed to meet consumer healthcare needs. All outcome studies have revealed that NPs provide safe, effective, quality care with outcomes equal to or better than that of physicians or physician assistants. Variability in state regulation of NP practice limits the full deployment of these proven healthcare providers, threatens the quality and safety of NP-delivered care, and limits consumer choice in healthcare access. The purpose of this study was to document NP perceptions of the impact of PO on the safety and quality of NP practice.

DATA SOURCES

A total of 1139 NP respondents completed an exploratory survey, Impact of Regulatory Requirements for Physician Oversight on Nurse Practitioner Practice. Participants were asked their perceptions of the impact of PO on patient care and NP practice. Descriptive statistics on the state of residence regulatory requirements and personal demographics were also collected.

CONCLUSIONS

NP perceptions of the impact of PO on the safety and quality of NP practice were predicted by NP experience and state regulatory environment ranking.

IMPLICATIONS FOR PRACTICE

The results of this study have implications for educators, policy makers, and nursing advocacy groups seeking to increase access to care in U.S.

POPULATIONS

Study participants perceived that requirements for PO impacted their practice and may jeopardize patient safety. An understanding of the impact of influences on regulatory processes is critical to ensuring full deployment of NPs as interprofessional leaders to meet current and future healthcare access.

Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: results from a national survey

The aims of this research study were to investigate moral distress among emergency department (ED) nurse practitioners (NPs) and examine relationships between moral distress and level of practice independence as well as intent to leave a position. Moral distress has been studied regarding registered nurses and physicians (MDs) but less so in NPs. It is important to explore moral distress in NPs because they tread a unique path between nursing and physician roles. Moral distress may play a significant role in staff nurses' intention to leave practice, and level of practice independence is found to have a relationship with NPs' intention to leave. A convenience sample of ED NPs was obtained from a mailing list of a national nursing specialty organization, the Emergency Nurses Association. Using a correlational design, survey methods assessed moral distress with the Moral Distress Scale-Revised (MDS-R), level of practice independence with the Dempster Practice Behavior Scale, and intent to leave with self-report. Correlational and regression analyses of data were conducted to characterize moral distress among ED NPs and associations between moral distress, level of practice independence, and intent to leave. Results found ED NPs do experience moral distress with poor patient care results from inadequate staff communication and working with incompetent coworkers in their practice. The MDS-R was a significant predictor of intention to leave among respondents. This study is the first of its kind to explore moral distress in ED NPs. Results suggest moral distress influences ED NPs' intent to leave their position. Further studies are needed to explore the findings from this research and to formulate interventions to alleviate moral distress in ED NPs and improve retention in the clinical setting.

Retail clinics versus traditional primary care: Employee satisfaction guaranteed?

PURPOSE

To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings.

DATA SOURCES

Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale.

CONCLUSIONS

Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings.

IMPLICATIONS FOR PRACTICE

The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs.

Nurses' autonomy level in teaching hospitals and its relationship with the underlying factors

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.

Nurse initiated reinsertion of nasogastric tubes in the emergency department: a randomised controlled trial

BACKGROUND

Patients sometimes present to the Emergency Department (ED) for reinsertion of nasogastric tubes (NGT) because of tube dislodgement. They usually need to wait for a long time to see a doctor before the NGT can be reinserted. This study aimed at investigating the feasibility of nurse initiated NGT insertion for these patients in order to improve patient outcome.

METHODS

This is a prospective randomised controlled trial. Patients requiring NGT reinsertion were randomised to receive treatment by either nurse initiated reinsertion of NGT (NIRNGT) or the standard NGT insertion protocol. Questionnaires were given to both groups of patients, relatives and ED nurses afterwards. Outcome measures included door-to-treatment time, total length of stay (LoS) in the ED and the satisfaction of patients, relatives and nurses.

RESULTS

Twenty-two patients were recruited to the study and randomised: 12 in the standard NGT insertion protocol and 10 in the NIRNGT protocol. The door-to-treatment time of the NIRNGT group (mean=45.6 min) was significantly shorter than the standard NGT insertion group (mean=123.08 min; p=0.003). No statistically significant difference was detected between the total ED LoS (p=0.575). Patients, relatives and nurses were generally satisfied with the new treatment protocol.

CONCLUSION

Patients can undergo NGT reinsertion significantly faster by adopting a nurse initiated reinsertion of NGT (NIRNGT) protocol.