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

Abstract

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.

Keywords

Age nursing professional autonomy sex shift work schedule ward work experience

1 Introduction

Bioethical debates often describe professional autonomy perception as a linkage to beneficence, non-maleficence and justice [1, 2]. In the nursing practice, the autonomy concept has been associated to an important issue for the future of the profession [3, 4].

Literature evidence how autonomy impacts on the nursing job gratification and its relating power in health care organizations, too. In this context, Varjus et al. [5] have just demonstrated how the nursing autonomy has been globally recognized as an important key-element that is directly connected to work environments. In fact, most of the Finnish intensive care unit nurses have recorded more autonomy ability in decision-making than in other wards.

The World Health Organization (WHO) encourages the nursing recruitment and the profession retaining by sustainable workforce in order to face up to about nine million of nurses and midwives that will be necessary by 2030 [6]. Several factors may be considered in the nursing profession recruitment, as well as: economic and no economic benefits, mostly connected to working environmental and organizational conditions, foremost among all the nursing professional autonomy [7, 8].

Globally, there is uncertainty on nursing autonomy according to educational requirements, permission and nursing practice [9 –11]. Independent practice may implicate both an individual and a professional dimension. Dworkin (1988) [11] mentions as achievable some autonomy aspects, such as: the capability to assume independent decisions without any influence and, at the same time, with reasonable and thoughtful approach, with also sufficient knowledge and competences. Freidson [12] affirms that skills achieved during a scholarly education path put the basis of nursing professional autonomy and prudence in practical plans. Therefore, the accountability level in the nursing profession determines possible autonomy actions between alternate ones.

The nursing autonomy has been also considered as a multidimensional concept by identifying several factors which can potentially confused with other overlapping images, like: independence, self- governance and accountability [13, 14]. Two specific sub dimensions of the nursing autonomy have been recognized, specifically: clinical and professional autonomy. Clinical autonomy covers all the nursing skills necessary to perform beyond standardized practical approach and made decisions on individual patients’ care [15]. Professional autonomy may be practiced to either the staffing or individual nurses and included participation in decision- making in individual patient’s care and in nursing care process improvement in order to ameliorate both the nursing quality and the patient safety perception [16]. Additional factors have been identified in the control working profession competence and its relating requirements [17], which have also been associated to significant independence in performing and organizing nursing activities, clinical decisions according to nurses’ own assessment [18]. The nursing autonomy seems to increase work gratification, nursing awareness and positive empowerment [19, 20], by also improving better quality of work [21] and consequential nursing outcomes [19]. However, very few assessment tool have been showed in the current literature to assess the nursing autonomy, both in its qualitative and quantitative dimensions, too [19]. 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. Yet, these decisions largely reside in socio-political and governmental forces as described below. Firstly, the Decree of the Ministry of Health 739/1994 namely “Professional Profile”, defines the first identification of professional autonomy for nurses in Italy [22, 23]. Successively, further laws defined confirm nursing professional autonomy [24] by also describing key-role attitudes. However, there is a lack of investigations on nursing autonomy perceptions, without considering any tool assessment, but simply to consider what nurses perceive according to their first recognition of professional autonomy.

Therefore, by considering all the above mentioned assumptions, the present study aimed 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 employment.

2 Materials and methods

2.1 Study design

A cohort explorative study was performed 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.

2.2 Participants

All Italian nurses employed in public or private healthcare facilities, in the territory and in home care, as an employee or as a freelancer both in public or private setting were potentially eligible to participate in the present study, as indicating in the Italian Ministerial Decree –14 September 1994, no.739, namely “Regulation concerning the identification of the figure and the related profile nurse professional” [25]. On the other hand, retired nurses were excluded. The minimum statistically significant sample size was assessed through the Cochran formula [26]. By considering that in Italy there were about 456,000 nurses and by fixing 95% as the confidence level and 5% as the confidence interval, and power as 0.80, the representative sample size of the Italian nursing population was 384.

2.3 The questionnaire administered

The questionnaire was administered on-line through the Google moduli platform and contained two main sections. The first section collected demographic characteristics (Table 1), including as follows:

The second part of the questionnaire consisted of 6 statements based on the main actions regulated by the Ministerial Decree 14 September 1994, no. 739 - “Regulation concerning the identification of the figure and the related profile nurse professional” [22 , 25]. Participants were asked to assess their own perception of nursing autonomy by choosing a value ranging from 1 to 5. A value of 1 indicated the lowest level of autonomy perception, while a value of 5 indicated the highest level of autonomy perception (Table 2).

Table 1
First section of the questionnaire

Demographic characteristic Options

Gender Female, Male

Age Up to 30 years, 31–40 years, 41–50 years, 51–60 years, Over 61 years

Work Experience Up to 10 years, 11–20 years, 21–30 years, Over 31 years

Education Degree, Post-degree, PhD

Shift Work One shift per day (morning only), Two shifts per day (morning and afternoon), Three shifts per day (morning, afternoon, and night)

Ward Employment Medicine, Surgery, Obstetrics, Psychiatry, Operating Room, Emergency Department

Demographic characteristic	Options
Gender	Female, Male
Age	Up to 30 years, 31–40 years, 41–50 years, 51–60 years, Over 61 years
Work Experience	Up to 10 years, 11–20 years, 21–30 years, Over 31 years
Education	Degree, Post-degree, PhD
Shift Work	One shift per day (morning only), Two shifts per day (morning and afternoon), Three shifts per day (morning, afternoon, and night)
Ward Employment	Medicine, Surgery, Obstetrics, Psychiatry, Operating Room, Emergency Department

Table 2

The key-factor concepts items proposed in the second part of the questionnaire

Key-Factor	Statement
Item no.1	Decision-making authority in patient care
Item no.2	Ability to initiate nursing interventions
Item no.3	Collaboration and communication with healthcare team members
Item no.4	Independence in clinical judgment and critical thinking
Item no.5	Responsibility for the planning and evaluation of nursing care
Item no.6	Autonomy in professional development and continuing education

2.4 Data analysis

All data were collected in an Excel data sheet and then, processed thanks to the SPSS, version 20, IBM. Demographic data were considered as categorical variables and showed as frequencies and percentages. Then, linear regressions were performed to assess how demographic characteristics impacted on the several nursing issues referring to the nursing autonomy perception. All p values less than 0.05 were considered as statistical significant.

2.5 Ethical approval

The protocol no. 0023278/09/03/2023 of the Ethical Committee of the XXX, expressed the opinion of “not within its competence”, as the present study focused on healthcare workers and not on patients. Therefore, it waived the requirement of ethical approval and also suggested that it was only necessary to guarantee compliance with European regulations on privacy. However, the protocol study was stated within the presentation of the questionnaire. It was emphasized that participation was voluntary and those interested in participating were presented with the opportunity to express informed consent and the confidentiality and anonymous nature of the information was guaranteed according to the Declaration of Helsinki principles.

3 Results

A total of 403 nurses were enrolled in this explorative study. Most of them (68%) were females, aged until 40 years (60%), had maximum 10 years of work experience with the lowest academic degree (47.4%) and were employed in three shifts per day (76%), (Table 3). Additionally, 37% of the participants were employed in medicine wards, 15% in surgery ones, 7% in obstetric wards, 14% in psychiatric ones, 10 in operating rooms and 18% in emergency departments. According to the items proposed on the nursing autonomy perception and their related sampling characteristics, significant differences were recorded as follows (Table 3):

Table 3
The Italian nurses’ professional autonomy perceptions according to their demographic characteristics (n = 403)

Demographic Item no.1 Item no.2 Item no.3 Item no.4 Item no.5 Item no.6

characteristics μ±s.d. μ±s.d. μ±s.d. μ±s.d. μ±s.d. μ±s.d.

n (%) p-value p-value p-value p-value p-value p-value

Sex

Female: 275(68) 4.22±0.73 3.94±0.80 3.95±0.82 4.30±0.54 3.85±0.78 3.66±1.15

Male: 128(32) 4.26±0.75 3.96±0.84 3.95±0.85 4.39±0.59 3.92±0.82 3.76±1.21

p-value 0.748 0.919 0.929 0.194 0.539 0.566

Age

>30years:121(30) 4.29±0.73 3.97±0.83 3.96±0.87 4.38±0.55 3.84±0.83 3.84±1.13

31–40 years:120(30) 4.13±0.70 3.90±0.80 3.93±0.82 4.32±0.55 3.83±0.71 3.64±1.13

41–50 years: 86(21) 4.30±0.75 3.96±0.85 3.97±0.84 4.29±0.55 4.00±0.84 3.64±1.23

51–60 years: 70(17) 4.18±0.77 3.97±0.76 3.97±0.76 4.31±0.60 3.88±0.77 3.56±1.22

<61 years: 6(2) 4.33±1.03 3.67±1.03 3.67±1.03 4.33±0.52 3.33±1.03 1.17±0.98

p-value 0.236 0.920 0.840 0.438 0.448 0.055

Work experience

>10 years: 199(49) 4.24±0.72 3.94±0.79 3.95±0.83 4.34±0.54 3.86±0.79 3.67±1.17

11–20 years: 95(24) 4.20±0.72 3.98±0.85 3.99±0.86 4.32±0.59 3.90±0.77 3.77±1.13

21–30 years: 58(14) 4.19±0.78 3.93±0.81 3.93±0.81 4.34±0.55 3.88±0.82 3.64±1.16

<31 years: 51(13) 4.31±0.76 3.92±0.84 3.92±0.84 4.27±0.57 3.84±0.81 3.72±1.25

p-value 0.249 0.972 0.811 0.756 0.541 0.065

Education

Degree: 191(47.4) 4.28±0.69 3.99±0.71 4.01±0.72 4.29±0.46 3.89±0.92 3.65±1.12

Post-degree78(19.4) 3.95±0.95 4.31±0.63 4.33±0.64 4.50±0.78 4.06±0.83 3.02±1.39

PhD: 134(33.3) 4.32±0.61 3.67±0.94 3.65±0.97 4.29±0.50 3.73±0.51 4.15±0.85

p-value 0.101 ≥0.001* 0.011* 0.162 0.003* 0.469

Shift

One shift: 54(13) 4.57±0.60 3.98±1.04 3.94±1.11 4.65±0.48 4.15±0.88 4.59±0.88

Two shift: 44(11) 4.36±0.61 4.11±0.69 4.11±0.69 4.29±0.51 3.93±0.40 4.04±0.71

Three shift: 305(76) 4.15±0.75 3.92±0.78 3.93±0.79 4.28±0.56 3.82±0.81 3.48±1.18

p-value ≥0.001* 0.250 0.457 ≥0.001* 0.002* ≥0.001*

Ward

Medicine: 147(37) 4.09±0.75 3.95±0.79 3.95±0.81 4.34±0.55 3.98±0.65 3.48±1.35

Surgery: 60(15) 4.18±0.47 4.28±0.71 4.30±0.72 4.070.25 3.88±0.69 3.18±1.05

Obstetric: 30(7) 4.13±0.94 3.80±0.66 3.80±0.66 4.73±0.45 3.80±0.96 4.03±0.93

Psychiatric: 55(14) 4.69±0.63 4.13±0.79 4.13±0.79 4.35±0.52 3.89±1.06 4.15±0.89

Operating room: 39(10) 4.31±0.52 3.64±0.49 3.67±0.48 4.33±0.48 3.69±1.17 4.00±0.32

Emergency Department: 72(18) 4.19±0.83 3.75±1.00 3.74±1.06 4.35±0.73 3.76±0.52 3.90±1.20

p-value 0.045* 0.011* 0.010* 0.601 0.013* ≥0.001*

Demographic	Item no.1	Item no.2	Item no.3	Item no.4	Item no.5	Item no.6
Sex
Female: 275(68)	4.22±0.73	3.94±0.80	3.95±0.82	4.30±0.54	3.85±0.78	3.66±1.15
Male: 128(32)	4.26±0.75	3.96±0.84	3.95±0.85	4.39±0.59	3.92±0.82	3.76±1.21
p-value	0.748	0.919	0.929	0.194	0.539	0.566
Age
>30years:121(30)	4.29±0.73	3.97±0.83	3.96±0.87	4.38±0.55	3.84±0.83	3.84±1.13
31–40 years:120(30)	4.13±0.70	3.90±0.80	3.93±0.82	4.32±0.55	3.83±0.71	3.64±1.13
41–50 years: 86(21)	4.30±0.75	3.96±0.85	3.97±0.84	4.29±0.55	4.00±0.84	3.64±1.23
51–60 years: 70(17)	4.18±0.77	3.97±0.76	3.97±0.76	4.31±0.60	3.88±0.77	3.56±1.22
<61 years: 6(2)	4.33±1.03	3.67±1.03	3.67±1.03	4.33±0.52	3.33±1.03	1.17±0.98
p-value	0.236	0.920	0.840	0.438	0.448	0.055
Work experience
>10 years: 199(49)	4.24±0.72	3.94±0.79	3.95±0.83	4.34±0.54	3.86±0.79	3.67±1.17
11–20 years: 95(24)	4.20±0.72	3.98±0.85	3.99±0.86	4.32±0.59	3.90±0.77	3.77±1.13
21–30 years: 58(14)	4.19±0.78	3.93±0.81	3.93±0.81	4.34±0.55	3.88±0.82	3.64±1.16
<31 years: 51(13)	4.31±0.76	3.92±0.84	3.92±0.84	4.27±0.57	3.84±0.81	3.72±1.25
p-value	0.249	0.972	0.811	0.756	0.541	0.065
Education
Degree: 191(47.4)	4.28±0.69	3.99±0.71	4.01±0.72	4.29±0.46	3.89±0.92	3.65±1.12
Post-degree78(19.4)	3.95±0.95	4.31±0.63	4.33±0.64	4.50±0.78	4.06±0.83	3.02±1.39
PhD: 134(33.3)	4.32±0.61	3.67±0.94	3.65±0.97	4.29±0.50	3.73±0.51	4.15±0.85
p-value	0.101	≥0.001*	0.011*	0.162	0.003*	0.469
Shift
One shift: 54(13)	4.57±0.60	3.98±1.04	3.94±1.11	4.65±0.48	4.15±0.88	4.59±0.88
Two shift: 44(11)	4.36±0.61	4.11±0.69	4.11±0.69	4.29±0.51	3.93±0.40	4.04±0.71
Three shift: 305(76)	4.15±0.75	3.92±0.78	3.93±0.79	4.28±0.56	3.82±0.81	3.48±1.18
p-value	≥0.001*	0.250	0.457	≥0.001*	0.002*	≥0.001*
Ward
Medicine: 147(37)	4.09±0.75	3.95±0.79	3.95±0.81	4.34±0.55	3.98±0.65	3.48±1.35
Surgery: 60(15)	4.18±0.47	4.28±0.71	4.30±0.72	4.070.25	3.88±0.69	3.18±1.05
Obstetric: 30(7)	4.13±0.94	3.80±0.66	3.80±0.66	4.73±0.45	3.80±0.96	4.03±0.93
Psychiatric: 55(14)	4.69±0.63	4.13±0.79	4.13±0.79	4.35±0.52	3.89±1.06	4.15±0.89
Operating room: 39(10)	4.31±0.52	3.64±0.49	3.67±0.48	4.33±0.48	3.69±1.17	4.00±0.32
Emergency Department: 72(18)	4.19±0.83	3.75±1.00	3.74±1.06	4.35±0.73	3.76±0.52	3.90±1.20
p-value	0.045*	0.011*	0.010*	0.601	0.013*	≥0.001*

Abbreviations: μ±s.d.: mean±standard deviation; n: frequency.

Decision-making authority in patient care (item no.1) and shift (p≤0.001) and ward employment (p = 0.045), as nurses employed only during the morning shift (4.57±0.060) and employed at psychiatric wards (4.6±0.63) registered significant higher autonomy levels in the individual and community health needs’ identification;

Ability to initiate nursing interventions (item no.2) and education (p < 0.001) and ward employment (p = 0.011), as nurses having post-degree training (4.31±0.61) and employed at surgery wards (4.28±0.71) reported significant higher levels to identify the nursing care needs of the person and the community and formulate the related ones’ goals;

Collaboration and communication with healthcare team members; (item no.3) and education (p < 0.001) and ward employment (p = 0.010): nurses having post-degree training (4.33±0.64) and nurses employed at surgery wards (4.30±0.72) reported significant higher autonomy levels to plan, manage and evaluate the nursing care intervention;

Independence in clinical judgment and critical thinking (item no.4) and shift (p < 0.001): nurses employed only during the morning shift (4.65±0.048) reported significant higher autonomy levels;

Responsibility for the planning and evaluation of nursing care (item no.5) and education (p = 0.005) and shift (p = 0.002) and ward employment (p = 0.013), as nurses having post-degree training (4.06±0.83), employed only during the morning shift (4.15±0.088) and assigned at medicine wards (3.98±0.65) acted both individually and in collaboration with other health and social workers;

Autonomy in professional development and continuing education (item no.6) and shift (p < 0.001) and ward employment (p < 0.001): nurses employed only during the morning shift (4.59±0.088) and assigned at psychiatric wards (4.15±0.89) registered significant higher autonomy levels than the others.

4 Discussion

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

By considering demographic characteristics of participants, no significant differences were recorded according to sex, age and work experience. In this regard data were in disagreement to the current literature, as several studies revealed that work experience improved nursing skills and professional autonomy, as well as competencies to make decisions, working independently and pursue their own nursing values [7, 27]. The capacity to use individual’ s own competences raised with work experience [7 , 24–28]. However, individual factors also impacted to individual skills, and some nurses were completely more independent than the others [29, 30]. In this regard, the Norwegian Nurses Organization (NNO) declared that there was an association between education, ability and accountability in nursing [31]. Professional autonomy should emerge from the detailed skill to explore into involvements, to improve and use several learning typologies and to adopt this understanding into practice in order to offer high quality in nursing to patients [32]. Therefore, autonomy stated for nurses, who showed adequate awareness, influenced authority to make a change in what the patient needed [32].

Among all the demographic characteristics, education, shift and ward seemed to be more impacting on the nursing autonomy. As regards education, nurses with post-degree training seemed to be more inclined to identify the nursing care needs of the person and the community and formulate the related ones’ goals (p < 0.001), by planning, managing and evaluating the nursing care intervention (p < 0.001) and acting both individually and in collaboration with other health and social workers (p = 0.005). Current literature explained how accountability to maintain competence was an essential part of professional autonomy. In addition, to use nursing knowledge and skills, both Varjus et al. (2003) [5] and Özturk et al. (2006) [33] concluded that nurses’ accountability to develop their knowledge and skills were considered as important factors. Specifically, it included: knowledge, clinical competences and the ability to make decisions and act [33, 34]. Therefore, education improved nurses’ professional autonomy and experience, too [35, 36].

By considering shift, nurses employed only during the morning shift autonomously identified individual and community health needs’ (p < 0.001), by acting both individually and in collaboration with other health and social workers (p = 0.002) and performing its functions with the personnel support. In this regard, an English study [37] identified a strong association between teamwork and autonomy attitudes and underlined that nurses, who were more intricate in staff working, reported higher levels of autonomy and were more involved in decision making, too. The present data were in disagreement to the current literature, as night shift nurses seemed to be more autonomous than the others, for everything during the night through their nursing absence of other staff members [38]. Finally, as regards, ward employment, participants who worked in psychiatric wards autonomously performed the individual and community health needs’ identification (p = 0.045); while nurses employed in surgery wards (p = 0.010) felt themselves autonomous to identify the nursing care needs of the person and the community and formulate the related ones’ goals. Nurses belonged to medicine wards acted both individually and in collaboration with other health and social workers (p = 0.013) and nurses employed at psychiatric wards (p < 0.001) carried out its functions, where necessary, thanks to the work of support personnel. In this regard literature explained how authority unfairness has been associated to physicians [39] and pecking order structures. The nurses appeared to need the management support in order to steady the patients’ autonomy [37]. Additionally, Mantzoukas & Watkinson’s [40] declared the importance to improve individual nurses to reach high level in professional autonomy, also through everyday duties implying. The concept of autonomy, as taking free decisions in critical conditions, such as during emergencies, highlighted that autonomy could be adopted ad-hoc, when it was really necessary. Maybe, the different wards considered might indicate different nursing actions relating to different autonomy level perceived. In this aspect literature confirmed the present data, as the independence to make patient care decisions and work was considered as essential, by allowing full employ of nursing knowledge and competences [41, 42]. Significant factors of autonomy in working tasks concerning the skills to take independent decisions in the best regards of patients [5, 42] interpreted difficulties without impositions, by taking nursing measures and managing wards [11, 43–44, 50].

4.1 Strength and limitations

The present study was one of the few Italian studies which investigated nurses’ autonomy perceptions. However, it had an important limit: data collection was a very weak point, as participants were recruited only by spreading the questionnaire on-line, and this approach might influence the selection bias and its relating answers given, since participants did not ask any questions to someone in order to better clarify any potential doubts. On the other hand, the sample reached was representative of the Italian nursing community and it represented a point of strength.

5 Conclusion

The results highlighted in the present study suggested an intricate world between 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.

Acknowledgments and declarations

Ethical approval: The protocol no. 0023278/09/03/2023 of the Ethical Committee of the General Hospital of Policlinic of Bari, Italy expressed the opinion of “not within its competence”, as the present study focused on healthcare workers and not on patients. Therefore, it waived the requirement of ethical approval and also suggested that it was only necessary to guarantee compliance with European regulations on privacy.

The confidentiality and anonymous nature of the information was guaranteed according to the Declaration of Helsinki principles. Informed consent was obtained from all study participants.

Informed consent: Each participant gave the consent to participate in the present study. Conflict of interest: None to declare. Acknowledgements: The authors thank all participants who voluntary agreed to participate in the present study. Funding: This research was partially supported by a grant received by YCC. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Authors’ contributions: Study conception and design: EV, RM; Data collection: EV, RM; Data analysis and interpretation: EV, YCC; Reviewed the initial analysis: EV, RM, YCC; Drafting of the article: EV, YCC; Critical revision of the article: EV, YCC.

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