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

Abstract

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.

Keywords

cognitive flexibility care nursing nursing care professional autonomy

Introduction

Nursing is a critical, evidence-based, human-centered professional group with advanced clinical, technical, and communication skills.^1–3 Nursing is a profession that always supports people in health and illness from birth to death and also plays a role in end-of-life care.^4,5 In recent years, social, cultural, scientific, and technological developments in the field of health care have given nurses important responsibilities and roles.⁶ Today, nursing has many roles such as caregiver, educator, researcher, manager, decision maker, patient advocate, communication provider, coordinator, therapeutic, and consultant. Within the scope of these roles and responsibilities, the transition of nursing roles from traditional to modern has led to an increase in the activities carried out by the nurses with their own decision, thus, it has necessitated the implementation of autonomy in nursing and increasing the level of autonomy of nurses.^4,6

Background

The concept of autonomy is defined as the independence of individuals, the ability to protect and increase their personal rights, and it is stated as the need to achieve the determined goals. Autonomy provides the individual with self-knowledge, power sharing and independence and is one of the primary criteria of professionalism.^6–8 Professional autonomy means that the member of the profession has control over professional practices and decisions. Professional autonomy in nursing is the ability of nurses to perform their professional practices in accordance with professional practice standards, ethical declarations, professional rules and laws.⁹ The foremost condition of professional autonomy in nursing is to reflect the evidence-based practices of the profession by understanding science and scientific method adequately.⁶ At this point, cognitive flexibility is thought to be another important concept for nurses to make evidence-based decisions in multiple complex problems they encounter in line with their professional autonomy. Cognitive flexibility can also be considered as a person’s ability to adapt to certain situations, the ability to quickly restructure the mind, the ability to switch from one thought to another, or the capacity to approach different problems with multifaceted strategies.^10,11

It has been reported that individuals with cognitive flexibility are individuals who are aware of their individual potential and can struggle with the feeling of discomfort when faced with difficult situations, have their own unique coping strategies, and as the level of cognitive flexibility increases, their creative thinking tendencies also increase.^12,13 In the literature, it has stated that cognitive flexibility can help people understand other people’s emotions and increase their own awareness by enabling people to realize different alternatives.^14–16 When all these are taken into account, it can be thought that nurses with high cognitive flexibility can produce alternatives in the face of problems, adapt more easily to the different characteristics of their patients, and collaborate more easily with their caregivers and/or families. Considering the difficulties faced by nurses, we think that cognitive flexibility is an important component in providing professional care in challenging conditions. Determining the attitudes of nurses towards the concept of professional autonomy, which is one of the key concepts of professional nursing and directly affects the quality of patient care, and determining the level of cognitive flexibility, which is an important factor in adapting to changing and developing nursing roles, will shed light on the importance of the subject.

Research hypotheses

H1: There is a statistically significant positive correlation between cognitive flexibility and attitudes towards professional autonomy in nurses.

H2: Cognitive flexibility in nurses has an effect on attitudes towards professional autonomy.

Material and Methods

Purpose and Type of the Research

This research was conducted as a descriptive study to determine the effect of cognitive flexibility on nurses’ attitudes towards professional autonomy by using structural equation modeling.

Population Sample

The population of the research consisted of 480 nurses working in the City Hospital of a province. No sample selection was made in the study. Moreover, nurses working in a city hospital of a city in the Central Anatolian Region of Turkey between 10.06.2022 and 20.08.2022 and who agreed to participate in the study were included in the study. At the end of the study, 415 nurses were reached with a 1.77% acceptable error and 95% confidence level. There is no clear consensus about the sample size in structural equation modeling. In line with the recommendation of the literature, the sample of the study was between 10 and 20 times the number of variables in the model and not less than 200.^17,18

Data Collection Tools

The data of the study were collected by using a questionnaire prepared by the researchers using the literature ^13,19,20 to determine some socio-demographic characteristics of the nurses, the Cognitive Flexibility Inventory and Attitude Toward Professional Autonomy Scale for Nurses.

Questionnaire form

The first six questions of the survey form include socio-demographic characteristics such as age, gender, and educational status, and questions 7–11 include information about their employment status in the profession.

The attitude toward professional autonomy scale for nurses

It was developed by Asakura, Satoh and Watanabe in 2016 in Japan.²¹ The Turkish validity and reliability of the scale were made by Şimşek and Ceylan (2021).²⁰ This scale focuses on the cognitive aspects of professional autonomy. The scale consists of three sub-dimensions, “job-related independence,” “autonomous clinical judgments,” and “control over working conditions,” and 18 items. The items of the scale were scored using a 5-point Likert system ranked from 1 (I strongly disagree) to 5 (I strongly agree). “Strongly agree” indicates the most liberal attitude towards professional autonomy for nurses, while “strongly disagree” indicates the most conservative attitude. The lowest score that can be obtained from the scale is 18, and the highest score is 90. Low scores indicate low autonomy and high scores indicate high levels of autonomy. The total Cronbach’s alpha coefficient of the original scale is 0.85, while it was found to be 0.97 in the present study.

The cognitive flexibility inventory (CFI)

The CFI, which was developed by Dennis and Vander Wal (2010),²² was prepared to measure the ability of individuals to produce alternative, harmonious, appropriate, and balanced thoughts in difficult situations.²³ The scale consists of 20 items and two subscales: alternatives and control. As the score obtained from the scale increases, cognitive flexibility increases. The total Cronbach’s alpha coefficient of the CFI was found to be 0.90,²³ while it was found to be 0.85 in the present study.

Data Collection

Data were collected online from nurses working in a city hospital of a province via Google Forms. The informed consent page was presented to the nurses on the entrance page of the data collection form submitted online, and the nurses who agreed to participate in the study filled out the data collection forms.

Evaluation of Data

AMOS 26.0, SPSS 25.0 package program and PROCESS macro, which is an add-on of this program, were used in the analysis of the data (IBM Corp., Armonk, New York, USA). In the study, the upper limit of the error value for statistical significance was determined as 0.05. Personal information of nurses is given as frequency and percentage. It has been examined whether the variables, which are the hypothetical criteria for the use of parametric techniques in examining the relationships between the variables, meet the normality assumption. According to the kurtosis and skewness coefficients of the variables and the coefficient of variation, it was observed that the variables showed a normal distribution. The relationship between the variables was examined with the Pearson correlation coefficient. For the use of regression analysis, linear scattering was observed between the variables. For the main purpose of the research, structural equation modeling was established and Maximum Likelihood (ML) was applied as an estimation method in the model. Secondly, since the Chi-square (X²) value is very quickly affected by the sample size in the evaluation of fit indices, instead of CMIN/DF, p < 0.05 for regression weights, Goodness of Fit Index (GFI) > 90, which shows how much the model measures the covariance matrix in the sample, Adjusted Goodness of Fit Index (AGFI) > 90 to compensate for the lack of GFI in the high sample, Comparative Fit Index (CFI) > 90, which differentiates the established model from the absence model, and Root Mean Square Error of Approximation (RMSEA) < 0.05, which is the measure of approximate fit in the population, were used.^24,25

Ethical consideration

In order to conduct the research, approval (2021-09-157) from the Clinical Research Ethics Committee of a university and institutional permission from the City Hospital were obtained. Electronic informed consent was obtained from the nurses included in the study.

Results

The distribution of nurses according to their descriptive characteristics is given in Table 1

Table 1.

Distribution of nurses by descriptive characteristics (n = 415).

Characteristics
Age (mean±SD)		30.99±6.98
Working time in the profession (mean±SD)		8.32±7.31 (years)
	n	%
Gender
Female	324	78.1
Male	91	21.9
Education status
Health vocational high school	18	4.3
Associate degree	32	7.7
Bachelor’s degree	323	77.8
Master degree	42	10.1
Marital status
Married	233	56.1
Single	182	43.9
Status of having a child
No child	20	4.8
One child	102	24.6
Two children	83	20.0
Three children and more	28	6.7
Spouse’s profession
Other public institution	116	28.0
Health personnel	79	19.0
Private sector	20	4.8
Housewife	18	4.3
Weekly working time
45 h or less	170	41.0
46 h or more	245	59.0
Way of working
Day	98	23.6
Night	10	2.4
Day and night	307	74.0
Working unit
Outpatient clinic, outpatient unit	71	17.1
Risky units	190	45.8
Inpatient unit	154	37.1
Mission in the hospital
Service nurse	280	67.5
Other	98	23.6
Responsible nurse	27	6.5
Training nurse	10	2.4

. According to the table, the average age of the nurses is 30.99 ± 6.98, and the working time in the profession is 8.32 ± 7.31 (years). Moreover, 78.1% of the nurses are women, 77.8% are undergraduate graduates, 56.1% are married, 24.6% have a child, 28% spouses work in other public institutions other than health, 59% of them work 46 h or more, 74% of them work day-night shifts, 45.8% of them work in risky units, and 67.5% of them work as service nurses. Table 2

Table 2.

Cognitive Flexibility Inventory, Attitude Toward Professional Autonomy Scale for Nurses and its sub-dimensions and mean, standard deviation and correlation values of other variables (n = 415).

Variables	Mean±SD	1	2	3	4	5	6	7	8	9
1. Age	30.99±6.98
2. Working time in the profession	8.32±7.31	0.928**
3. CFI	80.62±11.55	−0.012	0.001
4. Control	26.75±5.41	0.065	0.075	0.705**
5. Alternatives	53.87±8.64	−0.057	−0.046	0.896**	0.316**
6. APASN	70.42±18.79	−0.118*	−0.096	0.270**	0.053	0.328**
7. JRI	19.64±5.59	−0.062	−0.052	0.247**	0.032	0.310**	0.945**
8. CWC	27.65±7.74	−0.158**	−0.125*	0.241**	0.037	0.299**	0.955**	0.854**
9. ACJ	23.13±6.46	−0.101*	−0.083	0.284**	0.081	0.328**	0.946**	0.860**	0.840**	-

Pearson correlation coefficient was used.

CFI: The Cognitive Flexibility Inventory; APASN: Attitude toward Professional Autonomy Scale for Nurses; JRI: Job-Related Independence; ACJ: Autonomous Clinical Judgment; CWC: Control Over Work Conditions.

*p < 0.05, **p < 0.01.

shows the Nurses’ Cognitive Flexibility Scale, Nurses’ Attitudes towards Professional Autonomy Scale and its sub-dimensions, and mean, standard deviation, and correlation values of other variables. A statistically significant and positive correlation was found between CFI and sub-dimension mean scores (p < 0.05). A statistically significant and positive correlation was found between APASN and sub-dimension mean scores (p < 0.05). A statistically significant and positive correlation was found between CFI and APASN at a weak level (r = 0.270; p < 0.05). There was a statistically significant and negative correlation between age and APASN mean score at a very weak level (r = −0.118; p < 0.05), between age and CWC mean score at a very weak level (r = −0.158; p < 0.05), between age and ACJ mean score at a very weak level (r = −0.101; p < 0.05), and between working time in the profession and CWC mean score at a very weak level (r = −0.125; p < 0.05). The structural equation modeling created between the Cognitive Flexibility Inventory and the Attitude Toward Professional Autonomy Scale for Nurses is given in Figure 1

Figure 1.

Structural equation modeling between the Cognitive Flexibility Inventory and the Attitude Toward Professional Autonomy Scale for Nurses. CFI: The Cognitive Flexibility Inventory; APASN: Attitude Toward Professional Autonomy Scale for Nurses; JRI: Job-Related İndependence; ACJ: Autonomous Clinical Judgment; CWC: Control Over Work Conditions.

. Besides, the analysis results of the Cognitive Flexibility Inventory, the Attitude Toward Professional Autonomy Scale for Nurses and its sub-dimensions are given in Table 3. First of all, it was examined whether the measurement model was meaningful for each sub-dimension. The effect of the Cognitive Flexibility Inventory on the Attitude Toward Professional Autonomy Scale for Nurses was found to be statistically significant (β = 0.278; p < 0.001). At the same time, the path coefficients belonging to all the items under each dimension were found to be statistically significant. When the fit values were examined as a result of the analysis, CMIN = 3.339, DF = 2, CMIN/DF = 1.67, RMSEA = 0.040, CFI = 0.999, and GFI = 0.996. All of the compliance criteria were obtained within the desired limits. Moreover, CFI explains 7.7% of APASN, 87.3% of APASN JRI, 83.4% of APASN CWC, and 84.8% of APASN ACJ.

Table 3.

Analysis results of the cognitive flexibility inventory, the attitude toward professional autonomy scale for nurses and its sub-dimensions (n = 415).

			β⁰	β¹	SH	Test stat	p	R ²
APASN	<---	CFI	0.278	0.126	0.022	5.696	<0.001	0.077
JRI	<---	APASN	0.934	1				0.873
CWC	<---	APASN	0.913	1.353	0.042	31.94	<0.001	0.834
ACJ	<---	APASN	0.921	1.139	0.035	32.625	<0.001	0.848

β⁰: Standardized Coefficient; β¹: Non-standardized Coefficient; SE: Standard Error; R²: Explained variance; CFI: The Cognitive Flexibility Inventory; APASN: Attitude Toward Professional Autonomy Scale for Nurses; JRI: Job-Related Independence; ACJ: Autonomous Clinical Judgment; CWC: Control over Work Conditions.

Discussion

In order for nurses to carry out their professional practices in accordance with professional practice standards, rules, and laws related to the profession and ethical declaration, it is necessary to recognize sufficient autonomy in practices and support the professional autonomy of nurses.^26,27 In this study, in which nurses’ attitudes towards professional autonomy and cognitive flexibility levels were determined and the effect of cognitive flexibility on their attitudes towards professional autonomy was evaluated, it was determined that the mean APASN of nurses was 70.42 ± 18.79. Considering that the lowest score that can be obtained from the scale is 18 and the highest score is 90, it can be stated that nurses' attitudes towards professional autonomy were at a good level. In previous studies, the attitudes of nurses towards professional autonomy varied from moderate ^28–31 to high levels.³² These differences may be attributed to factors such as nurses' working conditions, educational level, or cultural environment. The fact that the nurses in this study had good attitudes towards autonomy shows their tendency to act autonomously in caregiving and it is predicted that supporting this attitude will have positive effects on patient care outcomes. Moreover, the fact that nurses are both a health care team that spends more time with the patient and provide care with a holistic care approach requires ethical decision-making in practices.^33–35 It is thought that professional autonomy is important for nurses to make decisions in accordance with nursing ethics while fulfilling all these duties and responsibilities.

It was reported that in the development and maintenance of professionalism in nursing, it is necessary to move away from routines, undertake tasks by using creative power and fulfill them appropriately.⁶ For this requirement, the development of the cognitive flexibility of the nurse is important in providing the opportunity to find appropriate solutions to changing conditions.¹⁵ In the present study, the mean score of nurses’ cognitive flexibility level was observed to be 80.62 ± 11.55. Considering that the highest score that can be obtained from the scale is 100 points and the lowest score is 20 points, it can be said that the cognitive flexibility of nurses was at a good level. In the literature, studies related to the cognitive flexibility level of nurses are limited.^19,36 In studies conducted with nurses and nursing students, cognitive flexibility was determined at a medium level.^19,37

In the present study, as the cognitive flexibility level of nurses increased, their attitudes towards professional autonomy also increased. Furthermore, cognitive flexibility explained 7.7% of nurses’ attitudes towards professional autonomy. In the literature, there is no study evaluating the effect of cognitive flexibility on professional autonomy in nurses and this study provides the first data related to the subject. The higher the level of cognitive flexibility, the easier it is for nurses to adapt to changing situations, make autonomous clinical decisions, and generate alternatives. Furthermore, it can be thought that nurses with a high level of cognitive flexibility during the provision of care to individuals from different cultures can provide respectful and appropriate care to the integrity and culture of the individual they care for, and at this point, the level of cognitive flexibility is important for nursing ethics.

As a result, it can be stated that the attitudes towards professional autonomy and cognitive flexibility scores of the nurses in the study were at a good level. In the study, it was determined that there was a positive relationship between nurses’ cognitive flexibility levels and their attitudes towards professional autonomy. It was also observed that cognitive flexibility had an effect on the attitude towards professional autonomy. It is thought that it is important to strengthen nurses’ attitudes towards professional autonomy in their work environments and to improve cognitive flexibility in improving care. It is recommended to implement psychoeducation programs to improve cognitive flexibility levels in nurses and to conduct intervention studies to evaluate the effects on attitudes towards professional autonomy.

Limitations

This study was conducted in a city hospital of a province and the results of the study cannot be generalized to the population.

Footnotes

Acknowledgements

We thank the nurses who participated in our study.

Author Contributions

Z. Kılıç, N. Uzdil, and Y.Günaydın were jointly responsible for conceptualizing the study. Z. Kılıç; literature search, study design, manuscript preparation. N. Uzdil; methodology and statistical analysis. Y.Günaydın; data collection and review of manuscript. All listed authors meet the authorship criteria, and all authors are in agreement with the content of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Züleyha Kılıç

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