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. Copyright:

Introduction

Among the members of the healthcare team, nurses have a significant role in care provision; thus, the quality of care depends, to a large extent, on their service provision.[1] Moreover, professionalism and professional behavior in the medical sciences is very important today.[2] Therefore, it is essential that the nursing profession adapts to these changes and continually updates itself. Hence, the nurse is expected to become a person who thinks, makes decisions, and takes responsibility for his/her decisions, not just someone who takes orders. The most basic way for nurses to fulfill this expectation is to have individual and professional autonomy.[345] Autonomy is the main element of professional practice in nursing.[467] Therefore, the nursing profession values autonomy greatly.[2]

In general, the concept of autonomyis defined in many ways as a general term, and there are different opinions about it due to its complex structure.[8] A review of concept analysis papers on the concept of professional autonomy identified some features of nursing including lack of dependence on others, knowledge, competence, self-governance, decision-making, freedom, supporting patients and forming a friendly relationship with them, judgment, self-control, and responsiveness.[8910] For nurses, autonomy is defined as the ability to apply professional knowledge to patient care and clinical decision-making.[6] Furthermore, in a review study conducted to examine the challenges of autonomy in nursing, the ambiguity in the definition of autonomy was identified as one of the challenges in reaching autonomy in the nursing profession.[5] Indeed, despite many studies on nursing autonomy, this concept is not fully understood. Thus, a comprehensive explanation of the concept of professional autonomy in nursing seems necessary due to the important role of autonomy in improving the quality of patient care through timely decision-making at the patient's bedside, as well as reducing stress, and increasing job satisfaction, and attracting and retaining nurses.[4511121314] Besides, one of the outcomes of autonomy is the promotion of professional socialization.[115] Independence can lead to improved quality of nursing services for patients in general.

Despite the numerous qualitative studies conducted on the concept of professional autonomy of nurses,[341012] most of these studies have only discovered one aspect of the phenomenon, and they are incapable of offering a comprehensive and integrated explanation. To present a comprehensive picture of professional autonomy, meta-synthesis seems the most appropriate approach.[16] Meta-synthesis offers us a way to increase our understanding of this concept using existing research findings. Thus, the purpose of the current study was to explain the concept of nurses' professional autonomy.

Materials and Methods

This qualitative meta-synthesis was conducted to explain the concept of the professional autonomy of nurses. This article is a meta-synthesis extracted from a nursing doctoral dissertation.The study was conducted from July 2018–February 2019.

Qualitative meta-synthesis is a way of examining that which is known and attempting to develop it. The data analyzed in this method are the findings of the naturalistic studies conducted previously.[17] Finally, meta-synthesis involves a comprehensive analysis of a phenomenon based on the synthesis of qualitative findings.[18] The resulting interpretations are conclusions and inferences derived from reviewing all the articles related to that specific phenomenon. Therefore, a meta-synthesis study presents novel findings and interpretations which are not mentioned in any of the primary papers.[16] Meta-synthesis provides researchers with a way to discover new and fundamental themes and metaphors using a systematic approach. The result of this approach is the development of knowledge and presentation of a comprehensive picture of the construct.[19]

This study investigates qualitative articles, with different qualitative methodologies, on the concept of nursing autonomy, which has been published during the last 15 years (2003–2018). To use all available references and eliminate the risk of losing valuable data, gray literature, the references of the selected articles, and the articles published in peer-reviewed journals were also searched. In this meta-synthesis, many studies were reviewed to expand individuals' perspective and create new knowledge. Therefore, the researchers studied all articles in relevant fields, and not only a sample of them. Therefore, a comprehensive search was undertaken based on the study aim, similar to measures taken in the early stages of a systematic review. Later, to search for articles, a review of the published qualitative studies on the concept of nursing autonomy in international databases including PubMed, Scopus, Web of Science, Cochrane, and ScienceDirect as well as national databases such as SID, IranMedex, and Magiran was undertaken. The keywords “professional autonomy,” “clinical autonomy,” “professionalism,” “nurse,” “hospital nursing staff,” “clinical nurse,” “nurse*”, and “nursing” were used according to Medical Subject Headings (MeSH). The inclusion criteria included qualitative methodology, accessibility of the full text of the article, and Persian or English language articles.

In the initial search in the above databases, 2096 abstracts were found among the qualitative studies conducted on the professional autonomy of clinical nurses from 2003 to 2018. After reviewing the titles and abstracts, 2054 of these articles were excluded from the study due to the lack of relevance to the subject of the research or being repetitive. Finally, two members of the research team reviewed the full texts of the remaining articles, and 13 articles were included in the study.[4810132021222324252627] Stages of database searching and study selection are provided in Figure 1.

Figure 1

Searching databases and selecting relevant studies

The Critical Appraisal Skills Program (CASP) was used to evaluate and validate qualitative studies. This scale consists of 10 items regarding research objectives, method logic, research plan, and sampling method, data collection, reflectivity (including the relationship between the researcher and participants), ethical considerations, data analysis accuracy, a clear expression of findings, and research significance.[19] In this study, the three members of the research team reviewed the selected articles to examine them in terms of meeting the inclusion criteria, and to resolve any uncertainties and disagreements through consultation with the research team. Then, with the agreement of the research team, the articles that received 60% of the overall scale score (to prevent the loss of valuable data) were included in the study. It is worth noting that although several studies have considered scoring systems for this scale, the original version has not suggested any scoring systems.

Synthesis of the included findings in this study was conducted using Noblit and Hare's seven-step process for the meta-synthesis of qualitative researches.[18] In this method, the articles were analyzed in comparison with other studies using a continuous comparison approach. First, the key concepts of each study were extracted, and the inter-study and intra-study similarities and differences in the concepts and the themes were analyzed. Each article was read several times to ensure that all the concepts were integrated and the relations between the key concepts of each study were discovered. In fact, in the present study, a three-level analysis was used. At the first level, all the citations made by participants were translated by the original researchers and then were extracted and interpreted. The second-order constructs consisted of interpretive themes developed by the original researchers using first-order constructs. The themes explained by the authors of each original study were listed, and the number of studies that generated each of the themes was determined. The third-order constructs were obtained by the synthesis of studies. The third-order constructs were developed through the analysis of second-order constructs to identify new and similar themes.[2829]

To assess the validity of the findings, we used peer check; the results obtained from the meta-synthesis study were presented to 3 nursing faculty members, who were familiar with the qualitative research methodology and there was consensus about the findings.

Ethical considerations

The present study was approved by the Institutional Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Iran (IR.AJUMS.REC.1397.286).

Results

Based on the search, 13 articles were included in the study. The main results and the features of the investigated studies are presented systematically in Table 1. In this study, first, all codes were extracted from qualitative articles. Then, considering the concept of each code and based on their similarities and differences, these codes were categorized into similar concepts. Thus, the themes of the study were formed. Ultimately, the final interpretation of the professional autonomy of clinical nurses was presented in the 3 themes of professional competence, professional decision making, and professional interactions, and 12 categories [Table 2].

Table 1

Features of the reviewed studies about the concept of professional autonomy in clinical nurses

Code	Author, year of publication, city	Study objectives	Study type	Samples	Interviews/focus groups	Results
1	Ruelens-Trinkaus[10] 2017 Pennsylvania	To explore the meaning and experiences of professional autonomy in novice registered nurses in their clinical practice	Van Manen’s phenomenological method	11 novice registered nurses from a variety of acute clinical care settings	Interviews	Revealed four essential themes:1- The Journey Toward Developing Confidence: Can I speak up/Should I speak Up, Feeling Overwhelmed, I am not sure I am ready to be on my own2- Role Modeling3- Advocating4- Starting to Put the Pieces TogetherThe participants defined professional autonomy using phrases such as (a) “confidence,” (b) “advocating for your patient,” (c) “independent decision-making,” (d) “skill,” and (e) “knowing what you are talking about”
2	Nouri et al.[4] 2017 Iran	To discover the perceptions of nurses about professional autonomy in nursing	Content-analysis approach	8 clinical nurses in Golestan Province in Iran	Interviews	The themes:1- Individual factors: Decision-making power, Trust, Physician-nurse interaction, Nurse’s knowledge2- Organizational factors: Nurses’ motivation, nursing managers’ powers, Nursing education, Organizational support3- Health policy factors: Limitation of the job description, Professional immunity, Field specialization
3	Dos Santos, and Grativol Aguiar Dias de Oliveira 2016[20] Brazil	To identify the social representations of nurses regarding professional autonomy in the care of patients with wounds and analyze their interfaces with the constant incorporation of technologies in this care	Thematic content analysis	31 nurses working ina municipal hospital in the Lakes Region of thestate of Rio de Janeiro	Semi-structured interview	Category 1- Definitions: professional autonomy in the context of treating and preventing woundsCategory 2- Facilities and difficulties in establishing professional autonomyCategory 3- Image and vocational training for professional autonomyCategory 4- technologies and their relationship with the professional autonomy of the nurseIt is concluded that the representational content on autonomy is linked mainly to the level of knowledge, power of decision, vocational training, and institutional factors
4	Paganini and Bousso[13] 2015 Brazil	To understand the process by which nurses exercise autonomy in making end-of-life decisions in intensive care units	Grounded theory	14 critical care nurses	Interview	Phenomenon 1: ICU nurses work in a high-pressure environment (cause).Phenomenon 2: They empower themselves to make decisions (strategies).Phenomenon 3: They review the spaces in which they can exercise autonomy (consequence)
5	Weiland[21] 2015 Oklahoma	To understand the meaning of autonomy as interpreted by nurse practitioners	Gadamerian hermeneutic study	9 nurse practitioners ‎practicing in primary health care	Interviews	The major theme: Having genuine nurse practitioners practiceFour subthemes: relationships, self-reliance, self-empowerment, and defending the nurse practitioner role
6	Taghinejad et al.[8] 2013 Iran	Concept Analysis of Autonomy in nursing	Walker and Avant Concept Analysis	-	-	Extracted themes: self-governance, ability, capacity, competence, self-controlling, freedom, critical reflection, and decision-making
7	Gagnon et al.[22] 2010 Canada	To explore the concept of autonomy from the perspective of oncology primary nurses	Leininger’s ethno-nursing method	15 registered nurses who were employed full-time in the ambulatory cancer program or had previously functioned in the role of a primary nurse	Semi-structured Interviews/observation	-Autonomy is an unspoken opportunity in the workplace.-Autonomy is developed through professional and personal growth acquired over time.-Demonstrating autonomous behaviors is a conscious choice
8	Skar[23] 2010 Norway	To illuminate the meaning of nurses’ experiences of autonomy in work situations	Qualitative hermeneutic approach	11 Norwegian nurses, each with 2-3 years of work experience since graduation	In-depthinterviews and focus group interviews	-To have a holistic view-To know the patient-To know that you know-To dare
9	Keys[24] 2008 the United States	To understand how chief nursing officers perceive and experience autonomy within a magnet hospital framework	Phenomenological study	9 female chief nursing officers of a magnet hospital	Unstructured telephone interviews	Three broad categories emerged from the data:1- Effective relationships: person fit, team, and organizational/business focus2- Nursing representation: advocacy, and role modeling3- Chief nursing officers’ attributes: credibility and influence
10	Berti et al.[25] 2008 Brazil	Newly graduated nurses’ perception of their professional autonomy and patient’s decision-making process	Grounded theory	15 newly graduated nurses performing in different sectors of a medium-sized public state hospital	Focal-group	A -Nurse autonomy:A1- Understanding professional autonomy as an attribute as well as a conquestA2- Perceiving the existence of some professional autonomy conditionersA3- Making use of professional autonomyA4- Pointing out the perception of risks of autonomyA5- Pointing out conflicts in the physician/nurse relationshipA6- Pointing out conflicts in the nurse/nursing auxiliary relationshipA7- Pointing out conflicts in the nurse/nurse relationship
11	Kramer and Schmalenberg[27] 2003 the United States	To identify structures supporting autonomy	Grounded Theory	279 volunteer staff nurses from 2 magnet hospitals	Interview	A grounded theory of autonomy was formulated: Autonomy is the freedom to act on what you know in the best interests of the patient and to make independent clinical decisions in the nursing sphere of practice and interdependent decisions in those spheres where nursing overlaps with other disciplines. Autonomy is facilitated through evidence-based practice, being held accountable in a positive, constructive manner, nurse manager support, and it often exceeds standard practice
12	Stewart et al.[26] 2004 Canada	To explore clinical nurses’ understandings of autonomy	Qualitative hermeneutic approach	43 nurses who had been working in heart health departments for at least a year	Focus groups	Nurses described autonomy as their ability to accomplish patient care goals promptly by using their knowledge and skills to understand and contribute to the overall plan of care and assess patient needs and conditions, effectively communicate concerns and priorities regarding patient care, and access and coordinate the resources of the multidisciplinary teamA distinguishing feature of nurses’ descriptions of autonomy was that they viewed patient outcomes as being accomplished through their interdependent work with nurses and other members of the healthcare team. Nurses emphasized the interdependent and relational character of autonomy. These nurses experienced autonomy when they were able to accomplish patient care goals promptly through their nursing knowledge and skills
13	Kramer and Schmalenberg 2003 the United States	To ascertain staff nurses’ concept of autonomy, to empirically quantify nurse autonomy, and to determine the relationship between the degree of autonomy and staff nurses’ rankings of quality care on their units and their job satisfaction	Constant-comparative method and thematic, categorical analysis	279 volunteer staff nurses from 14 magnet hospitals	Interview (also quantitative data collection including job satisfaction and quality care rating scales)	When these staff nurses talked of autonomy, they meant (1) clinical, not professional autonomy, and (2) that the action was beyond the usual standard of nursing practice.Besides, based on the results, a 5-category-ranked scale was developed, with No. 1 indicating the highest degree of autonomy and No. 5 the lowest

Table 2

The process of developing the themes of professional autonomy in clinical nursing, extracted from the studied qualitative articles

Codes of selected articles	Sub-categories	Categories	Theme
10-7	Nursing autonomy as an acquired trait	A consciously acquired trait	professional competence
	Developing autonomy through professional experience
	Developing autonomy through living experiences
	The emergence of autonomy as an informed choice
1-2-3-8-12	Acquiring practical and technical knowledge as a necessity for autonomy	Having technical competence
	Knowing what you know
	Using your knowledge and skills to understand and help care plans
	Knowing what you are talking about
	Skill
	Application of professional knowledge at the patient’s bedside
	The ability to achieve the goals of timely (proper) care
	Capability
6-7-11	Freedom from others’ control	Freedom of action
	Freedom in taking action in the patients’ best interest
11-13	Acting beyond common nursing standards	Going beyond standards
1-7-8	Defending patients	Supportive nurse
	Knowing patients
	Supporting patients
8	Comprehensive outlook	Being comprehensive
5	Self-empowerment	Self-reliance
1-13	Role-modeling
1-2-5-8-9	Self-expression
	Having courage
	Self-confidence
6	Self-governance
6	Self-control
10	Having control over everything that happens in their unit
7-11-4-1-6-2	Using nursing knowledge to make decisions	The power of independent clinical decision-making by applying nursing knowledge	Professional decision making
	Independent clinical decision-making in the field of nursing
	Making mutual (interactive) interdisciplinary decisions
	Self-empowerment in decision-making
	Independent decision-making
	Decision-making power
2	-	Bedside judgment
6	-	Critical rethinking
7-9-12-5	Trust	Effective relations and influence on others	Professional interactions
	Influencing others
	Credit including trust, respect, and extensive experiences
	An effective dialogue about concerns and priorities in patient care
	Relations
1-2-10-12	Knowing how to work in a team	Coordination with other professional team members
	Access to and coordination with resources in a multi-professional team
	Putting parts together
	Interactions between physicians and nurses

Discussion

This meta-synthesis study was conducted to combine the results of qualitative articles on the concept of nursing autonomy to achieve a better understanding of this concept and a comprehensive definition of nursing autonomy. Therefore, based on the results of the current meta-synthesis study, it can be claimed that the concept of professional autonomy is a developing trait which is achieved based on patient-based competence and self-reliance to develop the best care plan for improving patients' health through the professional decision making and professional interactions with other professional team members. In reviewing other texts, some definitions of professional nursing autonomy were found. In a study, based on the experiences of nurses, having awareness, self-confidence, and complete control while providing care, having the power to make decisions for the patient, and having freedom in clinical judgments were associated with the concept of autonomy in nursing practice.[23] Another study showed that autonomy is an unspoken opportunity at the workplace, achieved through individual and professional development over time, and the representation of autonomous behaviors of a consciously-made choice.[22] In a concept analysis study, Taghinejad et al. also stated that autonomy is the quality or state in which one is self-governing, and in particular autonomy is the capacity through which one can determine one's actions through independently made choices, among a set of principles and rules to which one adheres.[8] Moreover, based on the meta-synthesis study by Wang-Romjue, the nurses' perception of autonomy was being a self-sufficient sole provider of patient care that includes the 2 subthemes of independent practice and self-empowerment.[30] Given these differences in the definitions of nursing autonomy, it can be seen that autonomy is a complex construct about which there are various opinions. In the present study, a more comprehensive representation of the concept of autonomy was presented by combining the findings of the selected studies, which would not be available in any of the studies alone.

Autonomy is the main element of professional nursing practice and is an important aspect of professionalism.[47] In this regard, in the study by Nikbakht Nasrabadi et al., the concept of professionalism was defined as having sufficient knowledge in the relevant field along with experience and autonomy in practice, as well as providing principled and comprehensive care for patients.[31] Moreover, autonomy is one of the factors affecting the professional socialization of nursing. In this regard, in a study conducted to explain the concept of professional socialization of clinical nurses, practical autonomy was identified as an element of the concept of professional socialization.[15]

Professional autonomy can create strength and capability in nurses. As a result, nurses should be considered as one of the main members of the treatment team, and the importance of care provision, its value, and the risks involved must be made clear. Hence, if nurses have the power to act autonomously, they will act and make decisions based on their judgments, and thus, they can decide and choose their course of action quickly.[13]

Finally, it is recommended that qualitative studies be carried out in the future to develop and evaluate the constructs obtained in meta-synthesis studies. Besides, considering the importance of the concept of professional autonomy in nursing, investigating the extent of nurses' autonomy seems necessary. This requires a comprehensive tool developed based on the main themes of this concept. Therefore, the results of this study can be used to design a comprehensive and valid tool for the assessment of the concept of autonomy in nurses.

One of the strengths of the present study was its qualitative meta-synthesis methodology, including the comprehensive search and the screening of articles based on inclusion and exclusion criteria. The limitations of this study were the lack of access to some databases and the use of only English and Persian papers.

Conclusion

The results of the present meta-synthesis study could be used to apply some strategies to enhance the professional autonomy of nurses based on the examples extracted by reviewing studies. Consequently, practical solutions can be proposed to overcome the deficiencies in professional autonomy by the implementation, evaluation, and improvement of the programs that enhance the mentioned traits in nurses including professional competence, self-reliance, clinical reasoning, and professional interactions from the beginning of training courses until they are appointed professional employees. The promotion of professional autonomy can directly affect the Quality of Working Life (QWL) of nurses, prevent work abandonment, and increase their job satisfaction, which ultimately leads to improved quality of care. Due to the importance of autonomy for the nursing community, it seems necessary to investigate the status of nursing professional autonomy and determine its advantages and weaknesses.

Financial support and sponsorship

Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Conflicts of interest

Nothing to declare.