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Barriers to ICU Nurses’ Autonomy in Iran: A qualitative study
Maryam AllahBakhshian, PhD, Nasrollah Alimohammadi, PhD, Fariba Taleghani, PhD, Ahmadreza Yazdan Nik, PhD, Saeed Abbasi, PhD, Leila Gholizadeh, PhD
Abstract
Background: The acute nature of the ICU environmentnecessitatesthat urgent clinical decisions are frequently made by the health care team. Therefore, it is important that critical care nurses have the authority to make decisions about their patient care.
Objective:To explore perceived barriers to the practice of professional autonomy from the perspectives of ICU nurses in Iran.
Design: In this qualitative study, 28 critical care nurses were interviewed using a semi structured in-depth interview method. The interviews were recorded, transcribed verbatim and analyzed using content analysis.
Results:Data analysis led to identification of 2 main themes and 5 sub themes: 1) the profession-related barriers with two associated subthemes of ‘lack of capacity to exercise autonomy’ and ‘lack of strong professions bodies’;2) organizational barriers with the associated sub themes of ‘role ambiguity’, ‘a directive rather than supportive workplace’, and ‘lack of motivation’.
Conclusion:ICU nurses in Iran may face many challenges in gaining professional autonomy.The identified inter and intra professional barriers to the exercise of autonomy need to be addressed to promote critical thinking, job satisfaction, and motivation of ICU nurses, which can in turn lead to improved patient outcomes.
Key words: Nursing autonomy, professionalism, qualitative study, content analysis, ICU
Introduction
Autonomyis a key element in attaining full professional status and career recognition(Baykara & Şahinoğlu, 2013; Traynor, Boland, & Buus, 2010; Weston, 2010). The degree of autonomy varies across disciplines, yet, some level of independence is necessary in any profession to stimulate critical thinking and enhance job satisfaction(Mastekaasa, 2011).Professional autonomy in nursing is a complex issue andcontinues to be debated and discussed in the 21st century(Gagnon, 2008).Overall, the concept of autonomy is poorly defined and understood in the nursing literature,particularly inthe context of intensive care nursing(Lakanmaa, Suominen, Ritmala-Castrén, Vahlberg, & Leino-Kilpi, 2015).Weston (2008) defines nursing autonomy as ‘the ability of nurses to act according to their knowledge and clinical judgment which reflects and encourages the full scope of nursing practice, as defined by regulating bodies and ethical codes and values[u1]’.Overall, evidence from many countries including Iran suggests that nurses report low to moderate autonomy scores (Mrayyan, 2004; IliopoulouKK, 2010; Papathanassoglou, Karanikola et al. 2012, Amini, Negarandeh et al. 2015).
As an important member of the health care team, nurses have a fundamental duty to act in the best interests of their patients. A meaningful level of autonomy would empower nurses to practice within a self-regulating professional environment, to make clinical decisions based on a their professional judgment, and act based upon these decisions within their full scope of practice(Watson, 2009).Autonomy in nursing practice has been found to improve patient outcomes. Nurses who have a higher degree of autonomy in their practice provide high quality patient care,maintain patient safety, anddecrease mortality, as autonomy fosters an increased sense of engagement and accountability (Keith & Cianelli, 2014; Rafferty, Ball, & Aiken, 2001; Watson, 2009).When nurses are empowered with the authority, they begin to think critically and independently, the processes that facilitate effective planning and provision of nursing care (Bys, 2016; Miyashita et al., 2007).Increased professional autonomy,particularly in the context of professional collaborations with equal authority to contribute,creates a healthy work environment for nurses through reducing work pressure, depression, and burnout and improving job satisfaction and workforce retention (Ballou, 1998; Bys, 2016; Enns, Currie, & Wang, 2015; Karago¨zog˘lu, 2009 ; Karasek Jr, 1979; Kramer & Schmalenberg, 2003; Papathanassoglou et al., 2012; Rafferty et al., 2001; Watson, 2009).
ICU is a high pressure environment, where expensive care is delivered to critically ill patients and intensive care nurses frequently experience the need for urgent decision makings aboutdeteriorating patients (Hartog & Benbenishty, 2015). In such clinical environments,nurses feel the need for autonomy to make clinical decision making on a daily basis(Paganini & Bousso, 2014).Health care organizations should, therefore, support and empower ICU nurses with authority so that they can apprpraietly fulfil their caring responsibilities and deliver an evidence based patient-centeredhigh quality patient care(Mrayyan, 2004; Skår, 2010). Nevertheless,nurses find autonomous decision making in clinical situations to be challenging and view the exercise of autonomy as ‘complex’ (Iliopoulou KK, 2010). This is partially due to the fact that the profession has been historically dependent on the medical profession because of the dominance of medicine, power imbalance between genders, and autocratic management styles(Traynor et al., 2010).These factors coupled with lack of institutional support and economic, political, social, and cultural barriers pose significant challenge to nursing autonomy (Baykara & Şahinoğlu, 2013).In addition, education, legislation, organizational culture and professional socialization of nurses, which vary across countries, may have positive impact on nurses’ perception of professional autonomy and their desire and capacity to gain professional independence (Iliopoulou KK, 2010).
In Iran, the health care system is physician dominated, and due to an inappropriate distribution of power in hospitals, nurses commonly experience powerlessness (Asad Zandi M & Gholami M, 2007). This hierarchical structure between physicians and nurses originates from differences in educational backgrounds, the historical dominance of men over women, and the historical role of nurses and physicians(Alireza Nikbakht Nasrabadi & Emami, 2006). Many physicians view nurses as their ‘helpers’ only and not as ‘professional care providers’. The social portrait of nursing as a profession is also poor (Nikbakht Nasrabadi, Emami, & Parsa Yekta, 2003). These factors affect self-esteem and self-confidence of Iranian nurses (Nikbakht Nasrabadi & Emami, 2006). In summary, evidence from Iran indicates that nurses receive limited career support, and mutual collaborations between nurses and physicians are at a low level(Sodeify, Vanaki, & Mohammadi, 2014).The current study sought to explore the influence of contextual factors that influence the exercise of authority among Iranian nurses.
Design and sample
This study is part of a larger project which aims to improve professional autonomy among critical care nurses in Iran. The current paper presents the results of the exploratory phase which aimed to probe barriers to the exercise of professional autonomy from Iranian nurses’ perspectives. A qualitative descriptive methodology was applied and data collected through semistructured in-depth interviews (Hsieh & Shannon, 2005).Descriptivequalitative studies allow for description or exploration a phenomenon, problem or issue, and can encompass abroad range of questions relating to people’s experiences, knowledge, attitudes, feeling,perceptions and views. Qualitative descriptive studiesare less interpretive than other qualitative approaches such as a phenomenological study or grounded theory)Sandelowski,2000).
The sample consisted of 28 ICU nurses considered as key informants. The participants worked in different clinical roles including bedside nurse, head nurse ornurse supervisor. Purposeful maximum variation sampling was used to ensure diversity withrespect to job roles and positions, age, gender, education, and work experience. Table 1 summarizes the main characteristics of the study participants.
The informants were invited to share their experiences of situations where they felt independent as well as situations where they found it difficult to exercise professional authority.An interview guide was developed including the following questions:How do you experience professional autonomy in your daily work?, How do you evaluate the professional autonomy among critical care nurses?, and What factors impede autonomous practice? “Probing questions were asked, when needed, to clarify the participants’ responses and re-direct discussions.
Table 1. Characteristics of the study participants
variable / no/%Age
20-30
31-40
41-50 / 5/17
14/50
9/32
Education
Bachelor degree
Postgraduate qualification / 24/85
4/14
Marital status
Single
Married / 8/18
20/71
Nursing experience
Less than 1 year
1- 2 years
More than 2 years / 3/10
5/17
20/71
Employment position
Nurse
Head nurse
Nurse supervisor / 24/85
1/3
3/10
Ethical considerations
Approval to perform the study was granted by the Ethics Committee of Isfahan University of Medical Sciences. All the participants were informed about the purpose of the study. The voluntary basis of the study was explained to the participants and they were assured of the confidentiality and anonymity of the research data.
Data collection
The data were collected from April to June 2015 through semi structured interviews. The interviews took place in aprivate roommainly at thehospital where the participants were working and were conducted in Persian language. The time and place of interviews were determined bythe participants.All the interviews were conducted by one researcher in order to assure consistency across the interviewsand the lengthofinterviews varied between 30to 90minutes.Four participants needed time to reflect upon the research questions and to think more deeply about our questions, thus, a second interview was carried out with these participants. The interviews were all recorded and transcribed verbatim. Observational notes were also taken immediately after each interview.
Data analysis
Data collected from the interviews were analyzed using manifest and latent content analysis, which led to identification of main study themes and sub-themes. Two researchers, (MA) and (NA), read all the transcriptions several times to immerse themselves in the data and achieve a sense of the whole. The researchers independently selected the meaning units andcondensed meaning units for the first two interview transcripts, and they then discussed and resolved any discrepancies. The principle author (MA) then extracted the meaning units and condensed meaning units for the remaining interview transcripts, assigned codes to the condensed meaning units to reflecttheexperiences of the participants in a more abstract way. Finally, similar codes were next groupedintomorecomprehensive subcategories and categories through an inductiveprocessbyconstantcomparison, reflection and interpretation. The process and findings were discussed with the other researchers.
The peer debriefing or reviewing of the data, codes, subcategories andcategoriesstrengthened thecredibility of the findings. Recruiting participants whovariedondemographic characteristics, experience and employment position helped transferability of the results.
Findings
Analysis of the interview data led to identification of 2 main themes and 5 sub-themes reflectingthe experience of ICU nurses of professional autonomy and the perceived barriers.[table 2]Overall, the participants expressed positive attitudesabout nursing autonomy and acknowledged the growth of professional identity and integrity as an importantelement of professionalism and job satisfaction. Yet, they believed there were significant barriers to the exercise of autonomy in the nursing profession. Although, an array of individual, educational and organizational issues wasdiscussed during the interviews, the most frequent discussions revolved around organizational barriers. Since there were found no significant differences in the perceived barriers to nursing authority from the perspectives of bedside nurses, head nurses and, nurse supervisors, data were combined for analysis.
Table. 2 themes and subthemesProfession-related barriers /
- lack of capacity to exercise autonomy’
- lack of strong professional bodies
Organizational barriers /
- role ambiguity
- a directive rather than supportive workplace
- lack of motivation
Profession-related barriers
Lack of capacity to exercise autonomy, poor self- confidence and low self-esteem emerged as significant internal barriers to the exercise of professional autonomy among ICU nurses. The participants linkedtheirsense of a lack of internal aptitude to practice autonomyto the prevailing view that nursing is a dependent practice. They believed that the dominance of female nurses in the profession, the gender that has historically and culturally been reliant on men, impeded nursing autonomy.
“Perhaps, a major reason for not willing to be independent relates tothe gender issues and the presence of greater numbers of women in nursing….because women are fearful, more cowardly and lack self-assertion. We (nurses) are indeed way behind getting (professional) independence." (p7)
Nurses’ lack of self-confidence to exercise autonomous practice was also related to thelack of education and training on the concept of professional autonomy and its important role in development of nursing identity. Some participants pointed to the lack of capacityamong nurses, in terms of knowledge and confidence, to make autonomous clinical decisions. However, it was viewed important that nurses shouldappreciate the significance of their role as a nurse and their unique contribution to patient care and to the health care system broadly. It is through this awareness and appreciation that they will acquire the necessary knowledge and skills to empower them to act independently.
"We have little courage to contribute to the discussions in the medical ward rounds because we don’t have the skills. We should participate in decisions about the patients’ care with knowledge and confidence.... The (health care) team must know that as the coordinator of patient care, I can give advice too." (p8)
“I think we better not to make some clinical decisions individualistically, as we don’t have adequate knowledge in some specialized areas as well as the confidence. So, personally I prefer to avoid it (autonomous practice) ..” (p11)
The participants believed that due to theirlow self-esteem, nurseslackedthe confidence to trust themselves, think critically, and act independently to improve patient care. They were also reluctant to trust their nursing colleagues in issues related to patient care and preferred to seek for the opinion of a physician. The lack of autonomous decisions and critical thinking as an important part of professionalism was perceived by the participants as leaving nurses with the feeling of working as a machine operator and routine careprovider, and having negative effect on nurses’ sense of usefulness and job satisfaction.
"My colleagues don’t trust in me. If they ask my opinion on patient care, but the doctor tells them something else, they accept the doctor’s opinion… We don’t treat ourselves, patients, or others properly… we are like set to do certain things, like machines without feelings...."(p26)
Lack of strong professional bodies
Participants acknowledged the importance of professionalism and the role that powerful professional bodies and nursing associations can play in achieving nursing autonomy and professional growth.
"There's no unity in nursing; we don't have strong professional alliances so as to gain autonomy. In medicine discipline, the medical association protects doctors. They (doctors) are supported through training to prevent the recurrence of similar mistakes, but what about us?" (p10)
Organizational barriers
Role ambiguity
The participants commonly expressed concerns about the role ambiguity and role conflicts in nursing profession. They claimed that there was no clear nursing job description and transparent scope of practice leading to confusion in the accountabilities and expectations.
"We have to ensure that doctors complete all the required paperwork, otherwise weget critiqued for the shortcomings. We have nothing to do with these paperwork, yet these responsibilities have been imposed on us” (p2)
According to the statements of many participants, due to financial savings and lack of adequate staff recruitment, tasks outside the scope of their dutywere imposed on nurses. This was resulted in the experience of role conflict in the workplace and perceived as adding significantly to nursing workload, reducing nurses’ time to think critically, plan, and provide quality nursing care.
"We've been exploited; we have to do what others should be doing, varying from medical practice to lab operation and etc. These are wasting nurses’ time. We're so much involved in many tasks that we are not able to provide a quality nursing care." (p7)
Participants made certain that there should be a balance between the power or right to act and expectations. There was a belief that expectations of the nurse were unrealistic, and did not match nurses’ scope of practice. Participants believed that the current policies and nursing workload did not support the development of professionalism and autonomy in nursing.
“Nurses bear too much liability; compared to their power and work rights, expectations are too much, there is no balance between them. One should first have job integrity to be accountable for, isn’t that right? We don’t have that integrity and freedom but are expected to be accountable. Clearly, there is no balance between these two!” (p3)
The majority of the participants exclaimed that nurses spend significant amounts of their time completing indirect patient care activities such as unnecessary documentation and performing routine care activities. These activities were believed to have taken away nurses’ valuable time which could have been otherwise spent on better assessment of the patient, planning and delivery of safe, effective, and comprehensive care, and promoting critical thinking skills of nurses and autonomous practice.
A directive rather supportive work place
Most of the participants in this research stated that the development of professional autonomy required a support-based organization. They believed in the physician- dominated health care system, there limited intra- and inter-professional support for nursing autonomy.. The existing top-down management style precluded participation of nurses in decision making at both micro and macro levels, opportunities that could empower nurses and promote professionalism and autonomous practice.
“Many times we have not been given the chance to make a decision. For example, when I identify the need for specific would dressing, there should be the doctor’s approval so that the insurancecompany can reimburse the costs.” (p18)
From the perspective of the participants, the nature of inter-and intra-professional relationships played an important role in shaping the legal authority and intellectual independence of nurses. Participants claimed that in general there was lack of mutual respect, trust and cooperative relationships between doctors and nurses, posing a barrier to development of nursing autonomy.
"Sometimes there is a poor relationship between doctors and nurses, let alone trust nurses and want to use their experiences. In such top-down oriented systems, benevolence fades away… There will be no autonomy (for nurses) if the relationships are not supportive.” (p9)–