Beatrice Dorothy Wade: Philosopher, Administrator, and Advocate

Occupational therapist, Beatrice D. Wade, contributed to occupational therapy through her interest in the philosophy of professional autonomy, in educational program administration and curriculum design, in mental health advocacy and in service to the profession as an office holder during her occupational therapy career spanning the years 1925-1971. The purpose of this article is to document her life, work, and contributions and to summarize her impact on current professional autonomy, and philosophy of education and practice.

Physician-nurse collaboration in the relationship between professional autonomy and practice behaviors

BACKGROUND

Nurses and physicians are key members of healthcare teams. While physicians are responsible for the diagnosis and treatment of patients, nurses are part of the treatment and the primary practitioners of patient care. Nurses' professional autonomy, collaboration with physicians, and practice behaviors in treatment and patient care practices are interrelated.

OBJECTIVES

In the present study, we examined the mediating effect of physician-nurse collaboration on the relationship between nurses' practice behaviors and their professional autonomy.

DESIGN

The present study utilized a cross-sectional survey design following quantitative methods.

METHODS

This study was conducted in the Istanbul Province of Turkiye from September to October 2022. The sampling method used was a convenience sampling strategy to provide easier access to participants when selecting nurses from different health institutions. The mean age of the 295 nurses was 31.23 years, with ages ranging from 21 to 59 years. The data analysis was conducted using IBM's SPSS 24.0 software package and the Process Macro 4.0 plug-in.

ETHICAL CONSIDERATION

Research ethics approval was obtained from the researcher's university.

RESULTS

Physician-nurse collaboration is positively associated with practice behaviors and professional autonomy. Nurses' professional autonomy in practice behaviors through physician-nurse collaboration is significant (95% CI [0.043, 0.135]).

DISCUSSION

Our results revealed the relationships among physician‒nurse collaboration, professional autonomy, and practice behaviors among nurses.

CONCLUSION

Our results provide evidence on the underlying factors of nurses' practice behaviors in patient care and guide the development of an intervention program to enhance this collaboration. Hospital managers can contribute to a collaborative physician‒nurse working environment.

Professional autonomy among Registered Nurses-Validation of the translation of the Dempster Practice Behaviour Scale and survey results

AIM

To test the psychometric properties of the Finnish version of the Dempster Practice Behaviour Scale and explore nurses' professional autonomy along with which characteristics are related to it.

DESIGN

An instrument validation and a descriptive cross-sectional study.

METHODS

The web-based survey was conducted in September 2021 at two university hospitals in Finland. Exploratory factor analysis (EFA) was used to explore the factor structure of the modified instrument, while Cronbach's α coefficients were calculated to determine the reliability of the scale. Descriptive univariate and multivariate analyses were conducted to examine Registered Nurses' professional autonomy. The study followed STROBE guidelines.

RESULTS

During the validation process, the 30 items of the Dempster Practice Behaviour Scale were reduced to 25 items. The S-CVI/Ave for the translated scale was 0.94. When one additional item was omitted from the EFA, the results supported five factors, which explained 45.9% of the total variance. The mean overall autonomy score was 3.63 out of 5, with readiness and empowerment the subscales with the highest and lowest, respectively, mean values. The linear regression models showed that age, nursing experience, unit type, education, shift, and perceptions of the importance of professional autonomy were related to the subscales describing professional autonomy.

CONCLUSION

The psychometric testing provided evidence that the translated instrument was reliable. Nurses assessed that they are skilled professionals who are accountable for their actions. However, they experienced rather low levels of professional autonomy in empowerment and valuation. Health care organizations should consider this through authentic leadership and, thus, possibly strengthen professional autonomy.

The effect of sex, age, work experience, education, shift, and ward on nursing autonomy perceptions

BACKGROUND

In Italy, cultural and professional nursing improvements are reached thanks to the university-based education which marks the clinical competency and the professional autonomy in nursing decision-making.

OBJECTIVE

To highlight how Italian nurses perceived their nursing autonomy level in the main action-points highlighted in the Italian regulation law according to sex, age, work experience, education, shift and ward.

METHODS

A cohort explorative study was carried out from September 2022 to January 2023 to highlight how Italian nurses perceived their nursing autonomy levels in the main action-points highlighted in the Italian regulation law for the nursing profession according to demographic characteristics, like: gender, age, work of experience, education, shift, ward employment.

RESULTS

A total of 403 nurses were enrolled. Significant differences were recorded in: decision-making authority in patient care and shift (p≤0.001) and ward employment (p = 0.045); ability to initiate nursing interventions and education (p < 0.001) and ward employment (p = 0.011); collaboration and communication with healthcare team members and education (p < 0.001) and ward employment (p = 0.010); independence in clinical judgment and critical thinking and shift (p < 0.001); responsibility for the planning and evaluation of nursing care and education (p = 0.005) and shift (p = 0.002) and ward employment (p = 0.013); autonomy in professional development and continuing education and shift (p < 0.001) and ward employment (p < 0.001).

CONCLUSIONS

The results highlighted the intricate world both of the healthcare surrounding and the abilities to act autonomously within the multiprofessional staff. Future studies will develop qualitative and phenomenological designs in order to better define in which fields nurses will act their professional autonomy.

Intensive Care Unit Nurses' Professional Autonomy: A Scoping Review

Intensive care unit (ICU) nurses' professional autonomy is a critical factor affecting their ability to sustainably provide high-quality care to patients who are critically ill and to their families. However, in the absence of a systematic or scoping review of ICU nurses' professional autonomy, limited information and evidence are available on this topic. The aim of this scoping review was to clarify the extent and type of evidence on ICU nurses' professional autonomy. This scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The following research questions were addressed: (1) Which areas of interest and trends regarding ICU nurses' professional autonomy have been explored in studies published in scientific journals? And (2) What is known about ICU nurses' professional autonomy? The data sources included MEDLINE, CINAHL Ultimate, PsycINFO, Cochrane Library, and Ichushi-Web of the Japan Medical Abstracts Society databases. Identified studies were mapped based on their aim, design, methodology, and key findings and categorized according to their focus areas. Of the 734 identified studies, 16 were analyzed. The identified categories were as follows: "relationship between professional autonomy and mental issues," "experiences and processes of exercising professional autonomy," "relationship between professional autonomy and nurse-physician collaboration," "relationship between professional autonomy and demographic characteristics," "concept of professional autonomy," "barriers to professional autonomy," and "team approach to improve professional autonomy." Most studies have focused on the relationship between professional autonomy and mental health issues and nurse-physician collaboration and few included interventions to enable or promote the exercise of professional autonomy, highlighting a research gap. Future research should identify factors that inhibit the professional autonomy of ICU nurses and that can be changed through interventions and should develop educational and organizational change-based interventions to modify the factors.

Nurse autonomy expressed in Portuguese and Brazilian professional legislation: a documentary study (1986-2022)

OBJECTIVE

To analyze the convergence of nurse's autonomy expressed in Brazilian and Portuguese professional practice legislation.

METHOD

Qualitative, social-historical documentary study on the normalization of Brazilian and Portuguese professional standards for nursing practice, materials socialized in the digital collection of the profession's organizational and disciplinary entities. Qualitative analysis from the perspective of Eliot Freidson's sociology of professions.

RESULTS

Ten standards were analyzed, five from each country, which establish legislation for the nurses' professional practice. The following categories emerged: autonomy of knowledge and specific competence of the profession, in the ethical limits of the multi-professional relationship and in the disciplining of training for professional practice.

CONCLUSION

The professional autonomy under analysis implies providing access to services and to multi-professionality for the availability of health to society.

How artificial intelligence is reshaping the autonomy and boundary work of radiologists. A qualitative study

The application of artificial intelligence (AI) in medical practice is spreading, especially in technologically dense fields such as radiology, which could consequently undergo profound transformations in the near future. This article aims to qualitatively explore the potential influence of AI technologies on the professional identity of radiologists. Drawing on 12 in-depth interviews with a subgroup of radiologists who participated in a larger study, this article investigated (1) whether radiologists perceived AI as a threat to their decision-making autonomy; and (2) how radiologists perceived the future of their profession compared to other health-care professions. The findings revealed that while AI did not generally affect radiologists' decision-making autonomy, it threatened their professional and epistemic authority. Two discursive strategies were identified to explain these findings. The first strategy emphasised radiologists' specific expertise and knowledge that extends beyond interpreting images, a task performed with high accuracy by AI machines. The second strategy underscored the fostering of radiologists' professional prestige through developing expertise in using AI technologies, a skill that would distinguish them from other clinicians who did not pose this knowledge. This study identifies AI machines as status objects and useful tools in performing boundary work in and around the radiological profession.

Nurse managers' perceptions of nurses' professional autonomy-A qualitative interview study

AIMS

To describe nurse managers' perceptions of nurses' professional autonomy in hospitals and their role in promoting it.

DESIGN

A qualitative descriptive approach.

METHODS

Fifteen nurse managers participated in semi-structured focus group interviews in two university hospitals in Finland between May and June 2022. The data were analysed using inductive content analysis.

RESULTS

Nurses' professional autonomy in hospitals is perceived according to three themes: individual qualities behind independent actions, limited influencing opportunities in the organization and physicians' central effect. The nurse managers perceive that they enhance nurses' professional autonomy by promoting the nurses' independence at work, their sufficient and up-to-date competence, their expert role in multi-professional cooperation and joint decision-making and an open and appreciative work community.

CONCLUSIONS

Nurse managers can enhance nurses' professional autonomy with shared leadership. However, there are still gaps in nurses' equal possibilities to influence multi-professional work, especially outside of patient care. Promoting their autonomy requires commitment and support from leadership at all levels of the organization. The results advise nurse managers and the administration of the organization to maximize the potential of nurses' expertise, along with encouraging nurses towards self-leadership.

IMPACT

This study provides an innovative approach to nurses' roles through their professional autonomy from the perspective of nurse managers. These managers have an important role in enhancing nurses' professional autonomy, empowering and supporting them in their expertise, enabling necessary advanced training, and maintaining an appreciative work community where all have equal participation opportunities. Thus, nurse managers have the opportunity to strengthen high-quality multi-professional teams' ability to jointly develop the patient's care for better outcomes through their leadership.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Autonomy of Nursing Students: Methodological Study of Validation of the PALOP Scale Portuguese Short Version

The cultivation of critical thinking and decision-making skills promotes student autonomy. Only a few instruments measure nursing students' autonomy, and the PALOP® Scale is one of them. This study aimed to semantically and culturally adapt the PALOP® Scale to European Portuguese and assess the psychometric properties of a short version. A methodological study was conducted with 530 second and fourth-year undergraduate nursing students. Content validity was assessed using exploratory and discriminant factor analysis, and reliability was determined through analyses of internal consistency, temporal stability, and floor and ceiling effects. The analysis of the psychometric properties of a short version of the PALOP®-PT Scale revealed complete agreement (100%) among panel members for content validity. The scale also showed discriminative capacity among second- and fourth-year students (t (528) = -7.907, p < 0.001) with a five-factor structure, with a total explained variance of 57.2%. Reliability analysis showed excellent internal consistency (α = 0.935) and moderate temporal stability (95% ICC (3.1) = 0.520 [0.290-0.693], p < 0.01). The short version of the PALOP®-PT Scale is a promising tool to assess nursing students' perceived autonomy and identify necessary adjustments to their professional identity.

"I didn't know anything, but I learned over time": The process of nurses attaining autonomy in Intensive Care Units

Objective

Understand the social processes experienced by nursing professionals and the meanings underlying autonomy in adult Intensive Care Units in the city of Cartagena (Colombia).

Methods

A qualitative study with a grounded theory approach was conducted. Fifteen semi-structured interviews were carried out with nursing professionals, and the analysis was based on the coding technique proposed by Strauss & Corbin.

Results

Of the respondents, fourteen were female and one was male, with ages ranging from 23 to 57 years. Experience in intensive care units ranged from 1 to 28 years, and none had postgraduate studies. After thematic analysis, the central category was obtained from four categories: adaptation process, applicability of autonomy exercise, building autonomous competence, and limitations to the exercise of autonomy.

Conclusion

Nursing professionals achieve their autonomy through a social process, based on different stages of learning when facing the environment of the units. It is grounded in decision-making and the power to act freely. However, barriers continue to hinder it, including limitations imposed by institutions, protocol-based interventions, social status, and individual differences among professionals.

Autonomy in entrustable professional activities after the COVID-19 pandemic: the perspectives of residents and teachers

Introduction. The entrustable professional activities (EPAs) are 13 activities that new medical graduates should be able to perform without direct supervision. Our objective was to assess the perceptions of residents and teachers regarding their autonomy to perform the EPAs 2 years after the onset of the COVID-19 pandemic. Materials and methods. Cross-sectional study of first-year residents of clinical and surgical specialties and their teachers. Electronic, anonymous questionnaires were used. Results. Subjects were 31 residents and 20 teachers. Most residents believed that they were able to perform 8 of the 13 EPAs independently. According to most teachers, residents required direct supervision to perform 11 of the 13 EPAs. Significant differences were observed between residents' and teachers' perceptions in 8 of the 13 EPAs. Conclusion. The perception of autonomy to perform the EPAs in the beginning of the residency program was considerably better among residents than their teachers.

The effect of cognitive flexibility in nurses on attitudes to professional autonomy

BACKGROUND

Professional autonomy, which directly affects the quality of professional nursing in patient care, and cognitive flexibility, which is an important factor for adaptation to change and developing nursing roles, are important concepts for nursing.

RESEARCH OBJECTIVES

This research was carried out to determine the effect of cognitive flexibility on attitudes towards professional autonomy in nurses.

RESEARCH DESIGN

This was a descriptive study.

PARTICIPANTS AND RESEARCH CONTEXT

The research was conducted with 415 nurses working in a city hospital of a province, meeting the inclusion criteria and agreeing to participate in the study. A questionnaire form, The Cognitive Flexibility Inventory (CFI), and the Attitude Toward Professional Autonomy Scale for Nurses (APASN) were used to collect data.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the university ethics committee before starting the study. Institutional permission was obtained from the city hospital where the study was conducted. Electronic informed consent was obtained from the nurses included in the study.

FINDINGS

In the study, the mean CFI score was 80.62 ± 11.55 and the mean APASN score was 70.42 ± 18.79. There was a weak positive correlation (r = 0.270; p < 0.05) between CFI and APASN scores. Moreover, the effect of the CFI mean score on the APASN mean score was found to be statistically significant (β = 0.278; p < 0.001). Furthermore, CFI explains 7.7% of APASN.

CONCLUSION

In the study, nurses' attitudes towards professional autonomy and cognitive flexibility scores were found to be at a good level. Cognitive flexibility has a positive effect on attitudes towards professional autonomy. Interventional studies that will increase the level of cognitive flexibility are recommended in the development of nurses' attitudes towards professional autonomy.

Development and validation of a professional autonomy scale for Japanese midwives

Japanese midwives are required to autonomously perform midwifery diagnosis and maternity care. However, education to promote the professional autonomy of midwives is inadequate, and previous studies have not been able to identify a measure for it. This study aimed to develop a professional autonomy scale for midwives, to be used for the education and career advancement of Japanese midwives. The Midwives Professional Autonomy Scale extracted items from the midwives' "autonomy" and "specialty" literature, and 10 professionals verified the surface and content validity of the scale. Overall, 695 Japanese midwives participated in a survey, of which a sample of 399 was recovered. Exploratory factor analysis was performed using the sample to confirm the validity of the construct and internal consistency of the scale (Cronbach's alpha value 0.95). Additionally, the validity of the criteria was confirmed using the self-efficacy scale, self-esteem scale, and job satisfaction, and the stability was confirmed by test-retest reliability. Consequently, the professional autonomy scale for Japanese midwives comprised 24 items and 5 factors. This scale can thus be used to evaluate the professional autonomy of Japanese midwives and for midwifery education.

Analysis of the concept of nurses' autonomy in intensive care units: A hybrid model

Objective

To analyze the concept of autonomy of nurses in Intensive Care Units (ICU).

Methods

The hybrid model approach proposed by Schwartz-Barcott and Kim, which includes theoretical, fieldwork and analytical phases, was used for this study. For the theoretical and fieldwork phases, the Graneheim and Lundman stages and the CORE-Q checklist were used, and the results were combined in the final analysis phase. For the theoretical phase, 46 related articles, two instruments and four books were identified after using a search strategy in 7 bibliographic databases in English and one in Persian with the terms MESH: 'nursing', 'autonomy' and 'intensive care'. The information extracted in the theoretical phase served as the basis for the design of the questions used in the semi-structured interviews in the fieldwork phase. Eight nurses with ICU experience working in hospitals affiliated to Isfahan University of Medical Sciences (Iran) participated in the fieldwork phase.

Results

The antecedents of the concept of nurse autonomy in ICUs were: empowerment of the workforce, organizational platform, and social and individual views of the profession. Its attributes were professionalism and high personal capabilities. Finally, increased personal competencies, promotion of quality of care, improved attitudes towards the profession and professional outcomes were noted as consequences.

Conclusion

The autonomy of nurses in the ICU can facilitate their empowerment, which translates into the promotion of their caring behaviours, followed by the improvement of patient outcomes and quality of care.

Key Maternity Care Stakeholders' Views on Midwives' Professional Autonomy

Advancement towards the professionalism of midwifery is closely linked to midwives' professional autonomy. Although the perspectives of Belgian midwives on their professional autonomy have been studied, the views of other maternity care stakeholders are a blind spot. The aim of this study, therefore, was to explore maternity care stakeholders' views on Belgian midwives' professional autonomy. A qualitative exploratory study was performed using focus group interviews. A heterogenous group of 27 maternity care stakeholders participated. The variation between midwives, with different levels of autonomy, was reported. The analysis of the data resulted in five themes: (1) The autonomous midwife is adequately educated and committed to continuous professional further education, (2) The autonomous midwife is competent, (3) The autonomous midwife is experienced, (4) The autonomous midwife assures safe and qualitative care, and (5) The autonomous midwife collaborates with all stakeholders in maternity care. A maternity collaborative framework, where all maternity care professionals respect each other's competences and autonomy, is crucial for providing safe and quality care. To achieve this, it is recommended to implement interprofessional education to establish strong foundations for interprofessional collaboration. Additionally, a regulatory body with supervisory powers can help ensure safe and quality care, while also supporting midwives' professional autonomy and professionalisation.

Italian midwives in Europe: a qualitative study on the experiences of professional migration

Aim

To explore the reasons for Italian midwives' decision to migrate, and their lived professional and emotional experiences.

Methods

A descriptive phenomenological study was conducted recruiting Italian midwives who were working abroad in European countries. We offered a telephone or web interview. Two researchers conducted, audio-recorded, and fully transcribed the interviews and other two researchers, independently, performed a content analysis.

Results

Thirty-two midwives having professional experiences in the UK, Ireland, Germany, Switzerland, and Spain were interviewed. Five themes emerged: 1) Education, 2) Migration decision-making, 3) Professional experience abroad, 4) Midwives' perceptions of their role, 5) Satisfaction versus desire to return. Our findings show a general dissatisfaction with Italian job opportunities in terms both of access to employment and work conditions. This scenario is complicated by the status of the professional midwifery in Italy.

Conclusion

Stakeholders should ensure that the migration of Italian midwives is not synonymous with dispersion but is a channel of professional growth and mutual exchange.

Do policies affect management? Evidence from a survey of clinicians of the Italian National Health Service

Since the early 1990s, New Public Management ideas have deeply influenced reforms and their implementation in the Italian NHS. We compare doctors' perceptions about management systems in two Italian regions which differ in the dominant values of the regional political environment. In total 220 doctors, orthopaedists and cardiologists, working in public hospitals in Lombardy and Emilia-Romagna, were surveyed. Doctors in Emilia-Romagna perceived their organization to be more managerially driven in comparison to their colleagues in Lombardy. Doctors from Lombardy perceived their professional freedom to be higher, regardless of their specialization. The divergence of professionals' perception between these two Italian regions, which operate within the same Beveridge model, shows that dominant values of regional politics may have tangible effects on hospital management.

To be or not to be stressed: Designing autonomy to reduce stress at work

BACKGROUND

Many organizations are undertaking efforts to reduce the stress of (oftentimes overworked) employees. Information Technology (IT) (e.g., smartphones) has the potential to be a key instrument for reducing stress. One design-relevant factor considered to reduce stress is the concept of autonomy. Unfortunately, little research exists using autonomy as a characteristic of technology design.

OBJECTIVE

Against this background, this study aimed to investigate specific autonomy-related design options with the potential to prevent stress.

METHODS

In a factorial survey, this experimental study tested three design options in an overwork scenario: 1) autonomy (no intervention by design), 2) nudge ("nudging" by design), and 3) enforcement (hard stop by design). 51 participants (mean age 38 years, 50% women, mean work experience 18 years) from the Netherlands, United Kingdom, United States of America, and Germany participated in the experiment for 330 seconds on average. To test our hypothesis, we used a two-step approach. First, a multiple linear regression was applied. Second, we carried out a one-way ANCOVA comparing the effects of our design options.

RESULTS

Our results indicate that autonomy can be manipulated through technology design and is negatively correlated with stress. Additionally, the design options autonomy and nudge were associated with lower levels of perceived stress than was enforcement.

CONCLUSION

The study proposes a careful use of IT and policies that limit the perceived autonomy of employees. Overall, this study offers a set of design recommendations arguing that organizations should implement technology that helps employees prevent overwork and maintain their autonomy.

The Impact of the COVID-19 Pandemic on the Professional Autonomy of Anesthesiological Nurses and Trust in the Therapeutic Team of Intensive Therapy Units-Polish Multicentre Study

INTRODUCTION

The COVID-19 pandemic as well as the rate of spread of this particular pathogen around the world have caused the number of patients requiring medical attention and intensive care to exceed the capacity of even the best organized health care systems. This resulted in the need to hire employees who had not previously worked in intensive care units. Experience and knowledge have become particularly important in the context of mutual trust in the ICU team. At the same time, it could affect the level of professional autonomy of nurses, understood as the freedom to perform work based on knowledge, skills and competence without the need to submit to other medical professions. The pandemic status has required that nurses are always involved in their work by participating in training. Faced with the dangers of COVID-19, there is no doubt that by the end of the pandemic, both nursing and healthcare will be better equipped to face future challenges.

METHODS

The study lasted from July to September 2021. The data collection procedure started with the consent of the heads of the institutions where the data was collected. The study was conducted using the Dempster Practice Behavior Scale (DPBS), which examines work autonomy. The survey using the proprietary questionnaire was conducted among 225 nurses working in eleven ICUs in five voivodeships in Poland.

RESULTS

The autonomy of nurses during the COVID-19 pandemic was assessed at a high level. Younger respondents rated autonomy as being higher. Almost half of the respondents assessed the level of professional independence as high, including 52% of nurses, and significantly less, including 34% of doctors. A group of 47% of respondents assessed that trust had decreased and 28% said that trust had improved slightly.

CONCLUSIONS

Professional independence allows you to perform work independently on others, taking responsibility for decisions and actions. The COVID-19 pandemic, through the influx of new staff members into treatment teams, had an impact on both nursing autonomy and the level of trust in a team, as shown in this study.

The contribution of professional autonomy in advancing ethical behaviour: A narrative review of studies in nursing

AIM

This article explores moral disagreements between nurses and physicians; specifically, we aim to analyse professional nurses' practice in navigating these conflicts.

BACKGROUND

Nurses face morally challenging situations while caring for patients when their views on treatments and care may contradict those of physicians. It is important that nurses represent patients' perspectives and are partners in the care decision-making process.

METHOD

The narrative review method was used in this study.

RESULTS

A total of 27 articles published between 2009 and 2021 were included in the analysis. The following themes were explored in this article: areas in which moral disagreements occur and how these disagreements shape physician-nurse relationships, differences in the status of professional autonomy in nursing in the Baltic states and Nordic countries, and potential directions for nurses' involvement in the decision-making process regarding moral disagreements in nursing practice.

CONCLUSION(S)

Moral disagreements between nurses and physicians most often occur in situations related to treatment and/or care strategies as well as end-of-life decisions. Nurses' participation in the decision-making process and physicians' willingness to consider nurses' perspectives play a fundamental role in navigating moral conflicts because nurses possess a body of knowledge about their patients that differs from that of physicians. This knowledge is just as worthy as physician knowledge. Considering the level of professional autonomy in specific regions, nurses' involvement in decision-making regarding particular patients' care in the Baltic states seems to be relatively low compared to that in the Scandinavian countries, where nurses have a much wider space for independent decision-making.

IMPLICATIONS FOR NURSING MANAGEMENT

Complex moral situations that require the input of both physicians and nurses must be examined and addressed. Several processes may assist in fostering nurses' contributions to decision-making, among which training to effectively deal with morally complex situations and creating an atmosphere conducive to collaboration between physicians and nurses are particularly important.

Using self-determination theory in research and evaluation in primary care

BACKGROUND

Multimorbidity (the co-existence of two or more long-term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions.

OBJECTIVE

This article proposes self-determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity.

METHODS

We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework.

RESULTS

SDT-based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care-based complex intervention for patients with multimorbidity in deprived areas of Scotland).

CONCLUSIONS

SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories.

PATIENT OR PUBLIC CONTRIBUTION

Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long-term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

The Effect of Role Conflict and Professional Autonomy on the Role Performance of Patient Safety Coordinators in Small and Medium-Sized Hospitals in Korea

This study aimed to investigate the effects of role conflict and professional autonomy on the role performance of patient safety coordinators in small and medium-sized hospitals in Korea. The participants in this cross-sectional study were 121 patient safety coordinators in general hospitals or hospitals with more than 100−300 beds. Data were collected through an online survey for about three weeks in February 2022. The variables were role conflict, professional autonomy, and role performance. In the data analysis, we employed the t-test, ANOVA, correlation, and multiple regression methods. Almost all (99.2%) of the participants were nurses. The lower the role conflict and the higher the professional autonomy, the better the role performance shown. As a result of analyzing the factors affecting role performance, the regression model was found to be significant (F = 6.988, p < 0.001). The most influential factor in role performance was professional autonomy (β = 0.279, p = 0.002). In conclusion, it is thought that systematic education and legal and institutional arrangements for independent roles and work regulations are needed to strengthen patient safety coordinators’ competency in small and medium-sized hospitals in Korea. This will improve the role performance of patient safety coordinators and create a better patient safety culture.

The Relationship Between Professional Autonomy and Job Stress Among Intensive Care Unit Nurses: A Descriptive Correlational Study

BACKGROUND

Autonomy is an essential factor in the nursing profession. Nurses' autonomy can improve care quality, decrease mortality in patients, and attenuate job stress. This study aimed to investigate professional autonomy and its relationship with job stress among nurses working in Intensive Care Units (ICUs).

MATERIALS AND METHODS

This descriptive correlational study was conducted at Urmia nursing school in Iran in 2020. Three hundred ninety-eight nurses working at the ICUs entered the study. Data was collected using the Dempster Practice Behavior Scale (DPBS) and the Health and Safety Executive (HSE) questionnaire. Independent t-test and analysis of variance (ANOVA) were used to examine the relationship between demographics and study variables. Pearson's correlation coefficient was used to investigate the relationship between professional autonomy and job stress of nurses.

RESULTS

The mean (SD) of total professional autonomy and job stress score of nurses was, respectively, 102. 11(91. 88), and 115. 53(12. 42), indicating moderate autonomy and job stress. Professional autonomy had a significant positive correlation with job stress (r = 0.51, p < 0.001). It also had a significant positive correlation with work experience in ICU (r = 0.12, p = 0.014).

CONCLUSIONS

ICU nurses have moderate autonomy and job stress, and their autonomy is a significant positive predictor of their job stress. University authorities are recommended to develop practical strategies to enhance nurses' autonomy and eliminate factors that cause job stress in ICU nurses in order to preserve nurses' health, improve the quality of nursing care, and increase patient safety.

"Physician Advocates": a novel strategy for improving the value of hospital care by employing hospitalists part time to support non-hospitalist physicians

BACKGROUND AND OBJECTIVE

At many hospitals, private-practice physicians still admit their own patients and are accustomed to autonomy in clinical practice. This creates challenges for hospital's efforts to improve the efficiency, quality, and value of care. Experienced inpatient-focused physicians-"Physician Advocates"-could act as liaisons between private practitioners and the fast-paced inpatient microsystem.

METHODS

We conducted a controlled pre-post ("differences-in-differences") analysis at an academic medical center where private-practice physicians care for about 40% of medical inpatients and hospitalist groups care for 60%. In the intervention, "Physician Advocates" participated in daily multidisciplinary "Progression of Care Rounds," offering suggestions to increase care quality for private-practice physicians' patients. Controls were cared for by a large, well-established hospitalist group, which convened separate, unchanged multidisciplinary rounds. Outcomes were length of stay (LOS; primary outcome), 30-day readmissions, and inpatient mortality.

RESULTS

In a risk-adjusted analysis of 31,632 medical inpatients, LOS declined by 4 hours more from the baseline period to the post-intervention period in the intervention group relative to the control group (ratio: 0.96, 95% CI: 0.93-0.99, p=0.004). Readmissions declined 22% more in the intervention group (OR: 0.78, 95% CI: 0.63-0.97, p=0.023). Mortality was unchanged (OR: 1.23, 95% CI: 0.78-1.93 p-value=0.378).

CONCLUSION

Among inpatients cared for by private practitioners, adding Physician Advocates to multidisciplinary rounds was associated with improved LOS and reduced readmissions-measures of efficiency and value. The Physician Advocates approach should be tested in diverse health systems because it allows hospitals to leverage the expertise of on-site clinicians while respecting the traditional private-practice care model, in which primary care physicians manage their hospitalized patients.

The Ethics of Algorithms in Healthcare

The amount of data available to healthcare practitioners is growing, and the rapid increase in available patient data is becoming a problem for healthcare practitioners, as they are often unable to fully survey and process the data relevant for the treatment or care of a patient. Consequently, there are currently several efforts to develop systems that can aid healthcare practitioners with reading and processing patient data and, in this way, provide them with a better foundation for decision-making about the treatment and care of patients. There are also efforts to develop algorithms that provide suggestions for such decisions. However, the development of these systems and algorithms raises several concerns related to the privacy of patients, the patient-practitioner relationship, and the autonomy of healthcare practitioners. The aim of this article is to provide a foundation for understanding the ethical challenges related to the development of a specific form of data-processing systems, namely clinical algorithms.

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study

BACKGROUND

Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed.

OBJECTIVE

To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'.

METHODS

A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation.

RESULTS

The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities.

CONCLUSION

Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.

Impact of Nurse-Physician Collaboration, Moral Distress, and Professional Autonomy on Job Satisfaction among Nurses Acting as Physician Assistants

Although there is considerable literature on job satisfaction among nurses in various settings, there is little research about contributing factors, including moral distress to job satisfaction among a certain group of nurses, such as nurses acting as physician assistants. The purpose of this study was to verify the impact of nurse-physician collaboration, moral distress, and professional autonomy on job satisfaction among nurses acting as physician assistants. Descriptive and correlational research was conducted on a convenience sample of 130 nurses from five general hospitals in South Korea. In the final regression model, the adjusted R square was significant, explaining 38.2% of the variance of job satisfaction (F = 8.303, p < 0.001), where 'cooperativeness' (β = 0.469, p = 0.001) from nurse-physician collaboration, 'institutional and contextual factor' from moral distress (β = -0.292, p = 0.014), and professional autonomy (β = 0.247, p = 0.015) were included. In hospital environments, a more cooperative inter-professional relationship between nurses and physicians led to less moral distress caused by organisational constraints. A higher level of professional autonomy among nurses acting as physician assistants is required to increase their job satisfaction.

Development and Validation of the Turkish Version of the Attitude Toward Professional Autonomy Scale for Nurses

Autonomy in nursing practice is one of the recurring fields in literature of research. For nurses to be autonomous is considered to have a great importance on the quality of healthcare services. This study aimed to examine the validity and reliability of the Turkish version of the Attitude Toward Professional Autonomy Scale for Nurses. This methodological study adopted a descriptive cross-sectional design. The study was done in a secondary care hospital. Sample group includes 199 nurses that work at a secondary care hospitals. It was carried out while culturally adjusted and it also included two-way translations of English version of the Attitude Toward Professional Autonomy Scale for Nurses. To evaluate its validity, LISREL statistics software was used to make confirmatory factor analysis. Internal consistency was evaluated by using Cronbach's α and total-item correlations. Average age of the sample group was found 28.35 ± 6.16. Confirmatory factor analysis yielded t-scores, which were significant for all the 18 items (p < .05). Fit indices of the model, resemblance rate chi-square statistics were identified as 𝜒 2/df = 198.01/132 = 1.50. The Cronbach's alpha of the scale (.918) was indicative of strong internal consistency. The scale demonstrated strong validity and internal consistency. This scale can be used to assess perceptions of nursing practices that enhance the quality of nursing care.

Creating Empowering Conditions for Nurses with Workplace Autonomy and Agency: How Healthcare Leaders Could Be Guided by Strengths-Based Nursing and Healthcare Leadership (SBNH-L)

The COVID-19 pandemic had the unintended consequence of placing nurses in the spotlight because their knowledge and skills were in desperate need. While it will be years until we fully understand the impact that this pandemic has exacted on the nursing workforce, early studies have found that nurses have been traumatized by this event and many intend to leave the profession This seismic event only further exacerbated an already vulnerable and strained nursing workforce that pre-existed worldwide prior to COVID-19. The pandemic also highlighted the many challenges facing nursing leadership, in particular, how to create conditions to maintain and sustain a healthy nursing workforce. Nurses’ job satisfaction has emerged as an important predictor of whether nurses remain in an organization and stay in the profession. When examined more closely, job satisfaction has been related to nurses feeling empowered to exercise autonomy over their own practice and having agency. Autonomy and agency, in turn, are affected by their managers' leadership styles. Leaders are instrumental in setting the tone and creating the climate and culture that either values or devalues autonomy and agency. To help leaders create empowering conditions, we have developed a guide for leaders. This guide, based on the value-driven philosophy of leadership called Strengths-Based Nursing and Healthcare Leadership (SBNH-L), is founded on principles of person-centered, empowerment, relationship-focused, and innate capacities (ie, strengths) that are operationalized in eight core values. This guide can be used by leaders as their roadmap to create empowering workplace conditions that value and facilitate nurses’ autonomy and agency.

Job stress and its relationship with nurses' autonomy and nurse-physician collaboration in intensive care unit

AIMS

To determine nurses' job stress and its relationship with professional autonomy and nurse-physician collaboration in intensive care unit (ICU).

BACKGROUND

Low professional autonomy, high job stress and lack of nurse-physician collaboration can affect nursing care in ICU and the main reasons ICU nurses leave the occupation or transfer to other clinical units.

METHODS

A cross-sectional, correlational study was conducted on 398 nurses in teaching hospitals in Urmia, Iran, in 2020. Data were collected using the Dempster Practice Behaviors Scale, the Health and Safety Executive tool and the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration.

RESULTS

The mean job stress (115.53 ± 12.42) and professional autonomy (102.19 ± 11.88) of ICU nurses were 'moderate', and nurse-physician collaboration (74.25 ± 5.10) was 'good'. There was a positive relationship between professional autonomy and job stress (r = .506) and nurse-physician collaboration (r = .242). Professional autonomy was a predictor of job stress in nurses (p < .000), and work experience in ICU can cause job stress in nurses (p = .024).

CONCLUSION

Increasing nurses' professional autonomy causes an increase in job stress and improves nurse-physician collaboration in ICU.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should implement practical strategies to improve nurses' autonomy, enhance nurse-physician collaboration and decrease their job stress.

[Factors related to plateauing among Yogo teachers]

Objectives　The purpose of this study was to identify the factors related to plateaus to support the career development of Yogo teachers (school nurses).Methods　In March 2017, 1,000 elementary, junior high, and high schools in Tokyo, Kanagawa, Saitama, and Chiba prefectures were stratified and randomized. Questionnaires were sent to 1,000 Yogo teachers in each school. Plateaus among Yogo teachers were analyzed by hierarchical multiple regression analysis and path analysis by creating a conceptual framework that leads to plateauing through work engagement from professional autonomy (innovative behavior), social support in the workplace, and work-related stressors.Results　Data from 335 Yogo teachers were included in the analysis. The path analysis indicated that the factors that influenced content plateau among Yogo teachers were work engagement, self-learning of professional autonomy (innovative behavior), and years of experience. Work engagement was influenced by self-learning, pursuit of better practice, informational support, instrumental support, emotional support, role ambiguity, and job position. The developed model was a substantial fit to the data: CFI=1.00, RMSEA=0.00, SRMR=0.01. The coefficient of determination was R²=0.41 for the content plateau phenomenon and R²=0.45 for work engagement. Factors that influenced hierarchical plateau among Yogo teachers were work engagement, self-learning, education, job position, and the absence of a school counselor. Work engagement was influenced by self-learning, pursuit of better practice, informational support, instrumental support, emotional support, role ambiguity, and job position. The model was a substantial fit to the data: CFI=1.00, RMSEA=0.00, SRMR=0.01. The coefficient of determination was R²=0.25 for the hierarchical plateau phenomenon and R²=0.45 for work engagement.Conclusions　This study found that the low plateau phenomenon among Yogo teachers was associated with high self-learning of professional autonomy (innovative behavior) and work engagement. To prevent the plateau phenomenon, it is necessary to support them to enhance self-learning, create a conducive work environment, and consider training for Yogo teachers that takes into account their years of experience.

Nurses Working in Nursing Homes: A Mediation Model for Work Engagement Based on Job Demands-Resources Theory

This study examined the impact that the attractiveness of working in nursing homes and autonomous clinical judgment have on affective occupational commitment, and whether work engagement mediates these relationships. This analysis was based on the job demands-resources theory. The study setting was 1200 nursing homes (including long-term care welfare facilities and long-term care health facilities) in eastern Japan. An anonymous, self-report questionnaire survey was administered to two nurses from each facility, resulting in a prospective sample of 2400 participants. Overall, 552 questionnaires were analyzed, in which structural equation modeling and mediation analysis using the bootstrap method were performed. The results showed that the attractiveness of working in nursing homes does not directly affect affective occupational commitment; work engagement fully mediates the impact of attractiveness of working in nursing homes on affective occupational commitment. Additionally, autonomous clinical judgment showed a direct impact on both work engagement and affective occupational commitment, indicating that work engagement partially mediates the impact on affective occupational commitment. To increase the affective occupational commitment of nurses working in nursing homes, managers should help nurses recognize the attractiveness of working in nursing homes, and then provide appropriate support to help such nurses work in a motivated manner.

Professional autonomy in nursing: An integrative review

AIM

To summarize knowledge of professional autonomy in nursing.

BACKGROUND

Professional autonomy is associated with experienced meaningfulness of the work. This refers to participation in decision-making and the ability to influence working practices.

EVALUATION

In an integrative review, relevant studies were retrieved from four databases. Quality was systematically evaluated using critical appraisal tools. PRISMA guidelines were followed. Inductive content analysis was used to analyse current knowledge of the focal subject.

KEY ISSUES

The search identified 27 relevant studies published between 2000 and 2019. Elements describing nurses' professional autonomy were independence in decision-making and ability to utilize one's own competence. Themes relating to nurses' professional autonomy were shared leadership, professional skills, inter- and intra-professional collaboration and healthy work environment.

CONCLUSION

Understanding the multidimensional nature of professional autonomy is essential to create attractive work environments. It is important to enable nurses to participate in decision-making and develop nursing through shared leadership to enhance the recruitment and retention of a skilled workforce.

IMPLICATIONS FOR NURSING MANAGEMENT

The findings have anticipated utility for supporting nursing practice and nurse leaders' understanding of approaches to foster nurses' professional autonomy.

Patient-Centered Appointment Scheduling: a Call for Autonomy, Continuity, and Creativity

When making an appointment, patients are generally unaware of how much clinician time is available to address their concerns. Similarly, the primary care clinician is often unaware of what the patient expects to accomplish during the visit, leading to uncertainty about how much time they can allot to each sequentially appearing concern, and whether they can reasonably expect to address necessary preventive services and chronic disease management. Neither patient nor clinician expectations can be adequately managed through standardized scheduling templates, which assign a fixed appointment length based on a single stated reason for the visit. As such, standardized appointment scheduling may contribute to inefficient use of valuable face-to-face time, patient and clinician dissatisfaction, and low-value care. Herein, we suggest several potential mechanisms for improving the scheduling process, including (1) entrusting scheduling to the primary care team; (2) advance visit planning; (3) pro-active engagement of ancillary team members including behavioral health, nursing, social work, and pharmacy; and (4) application of innovative, technologically advanced solutions such as telehealth and artificial intelligence to the scheduling process. These changes have the potential to improve efficiency, patient and clinician satisfaction, and health outcomes, while decreasing low-value testing and return visits for unaddressed concerns.

Quality improvement and antimicrobial stewardship in general practice - the role of the municipality chief medical officer. A qualitative study

AIMS

This study aimed to explore the conditions for the Municipal Chief Medical Officers' (MCMOs) involvement in quality improvement in general practice, specifically concerning antibiotic prescribing practices.

METHODS

This qualitative study consisted of semi-structured in-depth telephone interviews and group interviews with MCMOs (n = 12). The interview guide aimed to explore the MCMOs' views on their role and responsibilities regarding the quality of care in general practice. The data were analysed using systematic text condensation.

RESULTS

Three main themes were identified: 1) the relationship between the municipality and the general practitioner (GP), with the MCMO acting as an intermediary, 2) influencing the GPs' work and 3) antibiotic use and infection control. The MCMOs perceived themselves as liaisons between the municipalities and the GPs. They emphasized building trust, showing respect and sharing common values in their interactions with the GPs, upholding the GPs' professional autonomy. Working for quality improvement was considered a priority; however, MCMOs expressed a need for external support to establish a permanent quality improvement framework. The informants were positive about engaging in improving antibiotic prescribing practices because this combined the municipality's responsibilities for quality improvement and communicable disease control.

CONCLUSIONS

The MCMOs considered themselves as well-suited agents for quality improvement in general practice, as liaisons between the municipalities and the GPs. Quality improvement in general practice would benefit from a clearer structure in terms of the MCMOs' roles and responsibilities. Within communicable diseases control, the MCMOs have a clear mandate, which places antimicrobial stewardship initiatives in a favourable position amongst other areas of quality improvement.

The Engaged Patient: The Relevance of Patient-Physician Communication for Twenty-First-Century Health

The patient-doctor interaction has changed profoundly in the past decades. In reaction to paternalistic communication patterns, health policy makers have advocated for patient-centered care and shared decision-making. Although these models of medical communication remain still aspirational, patients have become more engaged in advocating for their own health in encounters with physicians. I argue that the engaged patient is a more accurate conceptualization of the changing role of the patient than patient consumerism, the empowered, or expert patient. I examine how the emergence of engaged patients influences the autonomy of health professionals, relates to the rise of the internet as an alternative source of medical information, centers the role of the patient-doctor interaction in public health epidemics, and contributes to health inequities.

The Impact of Changes in Professional Autonomy and Occupational Commitment on Nurses' Intention to Leave: A Two-Wave Longitudinal Study in Japan

This study aimed to investigate changes in nurses’ attitudes toward professional autonomy and occupational commitment over time, and their effect on nurses’ intentions to leave, using a two-wave longitudinal design. Anonymous, self-report questionnaires were distributed to all nurses working at 28 hospitals in western Japan on two separate occasions (n = 1778). Multivariate analysis using a generalized estimation equation was conducted, with the intention to leave at Time 2 as the dependent variable, and the changing secular trends in all subscales of attitudes toward professional autonomy and occupational commitment as the independent variables. Age, sex, education, and intention to leave at Time 1 were control variables. Results showed that increasing changing secular trends in control over work conditions, which is a subscale of attitudes toward professional autonomy, increased intention to leave at Time 2, while increasing changing secular trends in all subscales of occupational commitment decreased intention to leave at Time 2. Nurses with a progressive attitude toward discretion of control over work conditions may have higher intentions to leave. Therefore, increasing control over their work conditions may reduce this intention. Additionally, it is necessary to continually enhance nurses’ occupational commitment by offering professional development programs.

Professional Autonomy of Nurses: A Qualitative Meta-Synthesis Study

Background:

Autonomy is the main element of professional practice in nursing. However, despite the many studies conducted on nursing autonomy, this concept is not fully understood and a comprehensive explanation of this concept in nursing is necessary. Meta-synthesis offers a way to increase the understanding of this concept using existing research findings. Thus, the present study aimed to explain the concept of professional nursing autonomy.

Materials and Methods:

This qualitative meta-synthesis was conducted based on a modified version of Noblit and Hare's meta-ethnography approach and qualitative studies on the concept of nursing autonomy published in databases such as PubMed, Scopus, Web of Science, Cochrane, SID, IranMedex, Magiran, and ScienceDirect in the past 15 years (2003–2018).

Results:

Thirteen articles that reported the experiences of nurses regarding professional autonomy were included in the research. Based on the meta-synthesis of findings, the final interpretation of the professional autonomy of clinical nurses was presented in the three themes of professional competence, professional decision making, and professional interactions.

Conclusions:

According to the results, the concept of professional autonomy is a developmental achievement based on patient-based professional competence along with self-reliance to provide the best care plan for the promotion of patients' health through the professional decision making and professional interactions with other professional team members.

Correlation of happiness and professional autonomy in Iranian nurses

BACKGROUND

Happiness and professional autonomy in nurses increase job satisfaction, reduce turnover and improve the quality of healthcare services.

AIMS

The present study aimed to examine the correlation between happiness and professional autonomy in Iranian nurses.

METHODS

This descriptive-correlational study was conducted on 371 nurses in 2017. The participants were selected via two-step random sampling. Data were collected using the Oxford Happiness Inventory and Dempster Practice Behaviors Scale within the score ranges of 0-87 and 30-150, respectively. Data analysis was performed in SPSS version 16.

RESULTS

Mean score of happiness among nurses was 43.1 ± 13.3 and the mean score of professional autonomy was 96.4 ± 13.5. According to Pearson's correlation coefficient, professional autonomy had a positive, significant correlation with happiness (r = 0.481; p < 0.001). In addition, the results of regression analysis indicated that professional autonomy could predict 23% of the happiness variance in the nurses (p < 0.001).

CONCLUSIONS

According to the results, the level of happiness in Iranian nurses was favourable, whereas the level of professional autonomy was moderate. Considering the significant correlation between happiness and professional autonomy, attention should be paid to the simultaneous enhancement of these variables to improve the efficiency of nursing care.

[On the need for supervision of the entrants to medical residences]

According to the Association of American Medical Colleges, there are thirteen core Entrustable Professional Activities (EPAs) that medical graduates should be able to perform in their first day of residency, without direct supervision. In Argentina EPAs are not clearly defined. Moreover, there is no local data about the need of supervision regarding these activities. The aim of this study was to assess residents' and teaching physicians' estimations about the level of supervision that physicians in their first month of residency needed in order to perform EPAs. A cross-section study was conducted. First-year medical residents and teaching physicians were included. Electronic or paper surveys were sent, asking the level of supervision the participants estimated that residents needed to perform the 13 core EPAs, during their first month of residency. Participation was voluntary and anonymous. There were significant differences between the opinion of residents (n = 71) and teaching physicians (n = 39), for 11 out of 13 EPAs. More than half of the teaching physicians considered that residents needed direct supervision when performing EPAs, except for asking clinical questions and looking for evidence. Most residents thought that they required direct supervision in 6 EPAs. In conclusion, medical residents perceived the need of lower levels of supervision when compared to teaching physicians, who considered that medical graduates were not capable of performing most EPAs without direct supervision upon entering residency. Thus, it would be important to improve the procedures to evaluate the competences of medical graduates in order to establish more accurate supervision levels.

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.

Exploring the Impact of Group Size on Medical Students' Perception of Learning and Professional Development During Clinical Rotations

INTRODUCTION

Research assessing the size of learning groups in medical education and how that affects the learner's experience is limited. The main goals of the study were to (1) assess the effect of varying group size on medical students' subjective experiences during clinical years. We hypothesized that students in smaller groups were more likely to have better experiences during clinical rotation than those in larger groups, and (2) determine if medical students have desirable experiences working with other medical learners (fellows, residents, osteopathic students, physician assistants, and nurse practitioners) during clinical rotations.

METHODS

The study utilized a mixed method approach where 153 medical students in their clinical years were asked to complete a 10-item survey. A linear-by-linear association test of trend and Mann-Whitney U test were used to evaluate the students' quantitative data. A multidisciplinary team used an immersion-crystallization approach to analyze the content of the students' qualitative data.

RESULTS

There was a 90% (137/153) response rate. Most students (80%) reported desirable experiences during clinical rotations because of supportive learning environments, engaging preceptors, willingness of residents to teach, as well as the opportunity to participate in patient care. There were significant differences in students' perceived clinical experiences as a function of group size, where groups of two students were preferable over groups of four or more.

CONCLUSIONS

Varying group size appears to affect students' clinical experiences.

Conscientious Non-objection in Intensive Care

Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

Turkish adaptation and psychometric characteristics of the Nursing Authority and Autonomy Scale

AIM

To adapt the Nursing Authority and Autonomy Scale (NAAS) into Turkish the Nursing Authority and Autonomy Scale (NAAS) to Turkish and assess its psychometric properties for Turkish nurses and nurse managers.

BACKGROUND

The NAAS is a tool that specifically measures nursing authority and autonomy from the perspectives of nurses and nurse managers.

METHODS

The study sample consisted of 160 nurse managers and 266 staff nurses. Content validity was assessed using expert approval. Construct validity was assessed using confirmatory factor analysis. Internal consistency was assessed using Cronbach's α, and the test-retest reliability was assessed using Pearson's correlation coefficients.

RESULTS

The model achieved a good fit. The internal reliability of the NAAS' authority and autonomy in nursing practice and importance of nursing practice subscales were .84. The Cronbach's α of the instrument was .88. The test-retest scores within an interval of 3 weeks were statistically not significant.

CONCLUSIONS

The Turkish version of the NAAS has good psychometric properties and this scale can be employed to measure nurses' authority and autonomy.

IMPLICATION FOR NURSING MANAGEMENT

Nurse managers and educators should use an appropriate scale such as NAAS in order to assess nurses' clinical authority and autonomy to improve patient outcomes and develop nurses.

State governance versus dentists' autonomy - the case of Swedish dental care

OBJECTIVE

A trend towards the state governance of healthcare through quality indicators and national clinical guidelines has been observed, and it is argued that this trend can be a challenge to the autonomy of healthcare professionals. In Sweden, these regulatory tools have been implemented in combination with subsidies for adult dental care that are based on guideline recommendations which serve to ensure that dental care is evidence-based and cost-effective. This paper aims to analyse the implications of these changes regarding dentists' autonomy and whether the government's political intentions can be fulfilled.

MATERIAL AND METHODS

The paper is based on documents from government authorities and professional theories.

RESULTS

The financial control over Swedish dental care has been strengthened, and it can be argued that this is a step in the right direction from a societal point of view, as public resources are limited. Dentists' professional autonomy with their patients is not affected, which is appropriate, as patients should be treated according to their individual needs and expectations.

CONCLUSIONS

This article shows that the state's governance does not directly detail dentists' work, which indicates a balance between state governance and dentists' autonomy. However, further research is required to get knowledge on Swedish dentists' view of the governance.

Job autonomy in relation to work engagement and workaholism: Mediation of autonomous and controlled work motivation

OBJECTIVES

This study integrates the Self Determination Theory and the Job Demands-Resource model in explaining motivational antecedents of 2 forms of excessive work: work engagement and workaholism. It specifically examines the relationship between job autonomy, situational work motivation, work engagement, and workaholism.

MATERIAL AND METHODS

The sample comprised 318 full-time employees of an international outsourcing company located in Poland. The mediation analysis was used for testing hypotheses about the mediation of autonomous and controlled motivation in the relationship between job autonomy, work engagement, and workaholism.

RESULTS

The results have confirmed that autonomous motivation mediates the relationship between job autonomy and work engagement. The assumption about the mediation role of controlled motivation in the relationship between job autonomy and workaholism has not been confirmed; however, external regulation (i.e., controlled motivation) is a significant predictor of workaholism.

CONCLUSIONS

Giving employees more job autonomy might increase their intrinsic and identified regulation and may therefore lead to more energetic, enthusiastic, and dedicated engagement with their jobs. Workaholism may be predicted by external regulation, and work characteristics other than job autonomy may play an important role in enhancing this controlled type of motivation. Int J Occup Med Environ Health 2018;31(4):445-458.

Electronic Health Records and the Disappearing Patient

With rapid consolidation of American medicine into large-scale corporations, corporate strategies are coming to the forefront in health care delivery, requiring a dramatic increase in the amount and detail of documentation, implemented through use of electronic health records (EHRs). EHRs are structured to prioritize the interests of a myriad of political and corporate stakeholders, resulting in a complex, multi-layered, and cumbersome health records system, largely not directly relevant to clinical care. Drawing on observations conducted in outpatient specialty clinics, we consider how EHRs prioritize institutional needs manifested as a long list of requisites that must be documented with each consultation. We argue that the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician's role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative.

[Reflection around the code of ethics for nurses]

The code of ethics for nurses highlights the values, principles and obligations which characterise our profession. It also emphasises the conditions required to enable nurses to perform their professional practice with the autonomy granted to them by the Public Health Code.