Marlene Kramer and Claudia SchmalenbergThe Practice of Clinical Autonomy in Hospitals: 20 000 Nurses Tell Their Story

Published online http://www.cconline.org © 2008 American Association of Critical-Care Nurses

2008, 28:58-71. Crit Care Nurse 

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58 CRITICALCARENURSE Vol 28, No. 6, DECEMBER 2008 http://ccn.aacnjournals.org

want it, but truthfully I’mnot sure what it is . . . nothaving to follow bureau-cratic rules and chain ofcommand? . . . Autonomyis making decisions—notalways having to ask? Auton-omy must have something todo with bureaucracy and sizebecause many nurses in thishospital said that as wemerged and got bigger, welost our autonomy.

In 2001, staff nurses in 14 magnethospitals identified 8 essentials of ahealthy (ie, job satisfying and pro-fessionally productive) work envi-ronment,2 1 of which is clinicalautonomy. Six studies related to the8 essentials of magnetism have beenconducted (Table 1). In both the2001 study2,4-7 on the dimensions ofmagnetism and the 3 studies1,10-16 toidentify structures, intervieweesprovided hundreds of examples anddescriptions in response to requestsand questions such as the following:

• Describe a situation in whichyou functioned autonomously.

• What does the concept “auton-omy” mean to you?

Marlene Kramer, RN, PhDClaudia Schmalenberg, RN, MSN

Healthy Work Environments

PRIME POINTS

• How can autonomouspractice affect nurses’professional job satisfac-tion?

• How do nurses defineautonomy in the work-place?

• How do we improvethe work environmentso that nurses can func-tion autonomously?

In a previous article,1 wedescribed how staff nurses,managers, and physiciansworking on units with con-firmed healthy work envi-

ronments judged “competentperformance of nurses.” Althoughrelated to all of the essentials of ahealthy work environment,2 compe-tent performance is a sine qua nonfor autonomous decision making,the essential professional workprocess we discuss in this article.

Autonomy has long been citedas 1 of the 3 cornerstones of excel-lent, magnetic work environments.3

Progress in identifying organiza-tional structures and best practicesthat enable clinical autonomy hasbeen inhibited by widespread con-fusion, lack of precise definition ofclinical autonomy, and failure todistinguish between organizationaland clinical autonomy. The follow-ing excerpt4 from groups of staffnurses illustrates this confusion:

What is autonomy? I wishI knew. I’ve been trying toget an answer to that sincenursing school. I know I’mfor it and am supposed to

The Practice of Clinical Autonomy in Hospitals:20 000 Nurses Tell Their Story

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• What do you consider beforemaking an autonomous deci-sion?

• What are the best leadershippractices that enable you tofunction autonomously?

Through constant comparativeanalysis,18 we generated grounded

theories from which we constructedthe magnet hospital staff nurses’definition of autonomy and the itemsfor the Clinical Autonomy subscaleof the Essentials of Magnetism (EOM)tool. In the 2 psychometric studies8,9,17

summarized in Table 1, respondentsfrom both magnet and comparison

hospitals completed the EOM; theconstruct validity of the EOM wasestablished by comparing the scoresof nurses in these 2 groups of hospi-tals. Nurses in magnet hospitalsconsistently reported healthier workenvironments, including opportu-nity and support for autonomousclinical practice, than did staffnurses in comparison hospitals.8,17

This article is not based on asingle research study. It is a synthe-sis of the results from 6 studies1,2,4-17

on the essentials of magnetism con-ducted from 2001 to 2007 as theypertain to clinical autonomy andthe results of an informal survey at

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Marlene Kramer is vice president, nursing, at Health Science Research Associates, ApacheJunction, Arizona.

Claudia Schmalenberg is president, nursing, at Health Science Research Associates, TahoeCity, California.Corresponding author: Marlene Kramer, RN, PhD, FAAN, PO Box 7667, Tahoe City, CA 96145 (e-mail: mcairzona@juno.com).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

Authors

Table 1 Overview of six research studies conducted on the essentials of magnetism

Year

2001

2003

2004

2005

2006

2007

Name of study(published reports)

Dimensions of magnetism 2 4-7

EOM psychometric 8,9

RN-MD structure-identification 10,11

Autonomy structure-identification 12,13

Six essentials structure-identification 1,14-16

EOMII psychometric 17

Data collection

Individual interviews withstaff nurses; group inter-view with NMs and nurseexecutives

Essentials of Magnetismtool (EOM)

Individual interviews; single-item indicators

3,510 SNs on EOM; individ-ual interviews; single-itemindicators

2,990 SNs on EOM; individ-ual interviews; single-itemindicators’ ParticipantObservations in Centraland Unit Council Meet-ings, unit staff meetings;evidence-based practiceteam meetings

EOMII

Sample

279 staff nurses (SNs) and132 managers (NMs) andleaders in 14 magnet hos-pitals

3602 staff nurses in 26magnet and comparisonhospitals, plus an addi-tional 1000 nursesnationwide on-line

67 SNs, 43 NMs and 31 MDson 44 units in 5 high RN-MD relationship-scoringhospitals

131 SNs, 81 NMs and 55MDs on 74 units in 8 highautonomy-scoring magnethospitals

244 SNs, 105 NMs and 97MDs on 101 units in 8hospitals with confirmedhealthy work environments;46 representatives fromother professional depart-ments

10,514 SNs in 34 magnetand comparison hospitals

Purpose

To ascertain the steps and components ofthe work processes that staff nursesidentified as essential to productivity ofquality patient care.

To test the construct validity of the Essen-tials of Magnetism tool (EOM), that is,that magnet hospital staff nurses willscore higher than their non-magnetcounterparts; and to establish the psy-chometrics of the tool

To identify structures and ‘best practices’that enable development of collegial/collaborative RN-MD relationships

To identify, through EOM scores, the clinicalunits with highest autonomous practice;and to identify structures and ‘bestpractices’ that support the practice ofclinical autonomy

To identify, through EOM scores, the clin-ical units with the healthiest, staff nurse-confirmed work environments; and toidentify structures and ‘best practices’that support 1) competent performance,2) education, 3) control of practice, 4) perceived adequacy of staffing, 5) apatient-centered culture; and that foster6) nurse manager support.

To test the construct validity and establishthe psychometrics properties of theEssentials of Magnetism II

Method

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the 2006 National Training Institutein Anaheim, California, of criticalcare nurses about their perceptionsof autonomous practice. Unlessnoted otherwise, all excerpts arefrom interviews with staff nurses inthe 2001 study2,4-7 or in the 2004 to2007 structure-identification stud-ies.1,10-16 All the speakers are staffnurses unless noted otherwise. Sug-gestions offered are specificallyaddressed to clinical nurses and whatthese nurses might do to improvetheir work environment with respectto autonomous practice.

Status of AutonomousPractice in Hospitals

Staff nurses perceive and reportthat they feel that they should prac-tice autonomously, that it is expectedof them, but that they receive littlesupport for doing so.19 In the 15 yearsfrom 1974 to 1991, nurses reportedonly low to moderate autonomyscores.19,20 Part of the problem maybe due to inadequate, faulty, incon-sistent measurement. When auton-omy is measured by means of itemssuch as “Nurses need more auton-omy in their daily practice,”21 it isimpossible to know which of the 34different definitions of autonomy inthe literature is being used as a ref-erent.12 Hence, the results cannot beinterpreted accurately. However,when results from 3 different stud-ies19,22,23 by 3 different investigatingteams of 3 different samples of staffnurses, some of whom were nursesin magnet hospitals, in which thesame instrument22 was used to meas-ure autonomy were compared, thelevel of autonomy was only moder-ate; there was little change in level ofautonomy during 20 years and littlesupport for autonomous practice.

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This moderate level and lack of sup-port for autonomous practice werealso evident in a 2001 interviewstudy2,4 of 279 staff nurses in 14magnet hospitals. When we askednurses to describe a situation in whichthey functioned autonomously, 39%provided examples and descriptionsindicating limited, unsanctioned,unsupported, or no autonomy.4 By2004, more than 100 hospitals, 80%of them magnet hospitals, had beentested by using the EOM containingthe Clinical Autonomy subscale.Although autonomy scores in mag-net hospitals were significantly higherthan those in comparison hospitals,the scores still were only moderatelyhigh.12 In 2003, the mean autonomyscore for magnet hospitals was 78.59,70% of the total possible score; in2006, the mean score was 76.38,68% of the total possible score.8,17

What Is Clinical Autonomy?Definition

No word engenders more misun-derstanding, confusion, and differ-ences in conceptualization thandoes the word autonomy. Six differ-ent descriptors—clinical, job/work,professional, individual, practice,and organizational—are used, and,to add to the confusion, autonomyis dynamic; it changes over time. Asan experienced nurse said, “In the1980s, refusing to give a patient acontraindicated drug was an act ofheroism; in the 1990s, it was anexample of autonomy; today, it’sstandard practice.”

Staff nurse interviewees had aclearer and more consistent under-standing of what constitutes clinicalautonomy than what is indicated bythe descriptions and definitions inthe literature.4,12 They demonstrated

this by their high similarity in exam-ples of autonomy, descriptions ofsteps and components of the auton-omy process, and illustrations ofimpediments to autonomous prac-tice. When staff nurses use the wordautonomy, they mean clinical auton-omy; sometimes, clinical autonomyis also termed practice or profes-sional practice autonomy. Staffnurses do not group clinical auton-omy with control of practice andability to self-govern as was done bydirectors of nursing in 1982 and hascontinued in much of the literaturetoday.24 Today’s magnet hospitalsstaff nurses and their Canadiancounterparts25 clearly distinguish theself-determination, self-regulation,control of practice characteristics ofa profession from the autonomycharacteristic, that is, “the freedomto make decisions about the serviceneeds of clients” as defined byFlexner.26(p3)

The following definition ofautonomy was constructed throughconstant comparative and thematicanalysis18 and from the groundedtheory of autonomy generated fromthe examples and descriptions pro-vided by staff nurses interviewed inhospitals all across the United States:

Autonomy is the freedomto act on what you know inthe best interests of thepatient . . . to make inde-pendent clinical decisionsin the nursing sphere ofpractice and interdepend-ent decisions in thosespheres where nursingoverlaps with other disci-plines. . . . It often exceedsstandard practice, is facili-tated through evidence-based practice, includes

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being held accountable in aconstructive, positive man-ner, and nurse managersupport.

Autonomous practice includes bothtypes of decision making—inde-pendent and interdependent.

Crucial ComponentsUnderstanding the concept of

unique and overlapping (U/O) spheresof practice and their relationship totype of decision making (indepen-dent or interdependent) is essentialfor safe, effective autonomous prac-tice. U/O spheres may also be termedseparate and combined. The knowl-edge and activities of nurses and theknowledge and activities of physi-cians or other health professionalscan be envisioned as 2 or more partlyintersecting spheres (see Figure). Themore discrete and separate knowledgeand activities of each professionalare indicated by the parts of the spherethat do not intersect. Those that areshared are indicated by the overlap-ping areas.27 Usually health mainte-nance, prevention, and caringdominate nurses’ unique sphere,whereas curative, diagnostic, andprescriptive functions dominate thephysicians’ unique sphere. Profes-sionals make independent, patient-centered decisions in their unique

spheres of practice. Nurses mayseek counsel and advice frompeers, but the decision making isindividual and independent, as isthe accountability for decisionsmade. Decision-making responsi-bility and accountability are inter-dependent and relational in theoverlapping sphere.

The first of the following excerptsillustrates autonomous action in thenursing-unique sphere; the secondexemplifies autonomous decisionmaking and action in the overlapsphere of practice.

From previous experienceand knowing this particularpatient, I decide whetheralternating pain meds isbetter than giving a singletype of pain med all thetime . . . deciding when toget the patient out ofbed—the patient maybecome tachycardiac vspossibly getting a deepvein thrombosis.

An elderly patient withadvanced Alzheimer’s anddecreased mental statuswas ordered to have mag-netic resonance imaging torule out brain metastasis?Stroke? There was no reason

for it. Itwasn’tgoing tochange histreatmentone bit.And itwould havebeen veryhard on thepatientbecause, at

best, he would have had tohave conscious sedation;at worst, a general anes-thetic. I talked to the resi-dent about it yesterday,and he said he wanted itdone because the familywanted to know. I took itto the team, and wedecided not to do it. Italked with the brotherand when I explained thatit would not make any dif-ference in care, he calledthe rest of the family andthey understood.

Adoption of the U/O ConceptInto Practice

Although U/O spheres of prac-tice and the corresponding types ofdecision making have long beenheralded in the literature,24,27-30 onlyrecently has adoption of the con-cept in nurses’ professional practicebecome evident. In a 1980 classicbook on autonomy, Mundinger28

emphasized that autonomous prac-tice is not a nurse providing medicalcare without medical supervision ora nurse practicing medicine withouta license; rather it is a nurse provid-ing nursing therapy that comple-ments and at times overlaps medicaltherapy. In the same year, the Amer-ican Nurses Association and theAmerican Medical Association com-bined commission on collaborativepractice recognized the U/O spheresof practice and called for “the formaldevelopment of Scope of Practicedocuments.”29 In their 1980 SocialPolicy Statement, the AmericanNurses Association emphasized thatclinical autonomy and collaborativerelationships between nurses andphysicians are true partnerships in

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Figure Spheres of autonomy.

Other professional disciplines, eg, respiratory therapy

Nursing Medicine

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which power is held and valued byboth participants with recognitionand acceptance of separate and com-bined spheres of activity, responsibil-ity, and accountability.30(p7) In the1983 original magnet hospital study,31

all of the autonomy examples citedwere in the nursing-unique sphereof practice, for example, preadmis-sion programs for children, counsel-ing for pregnant adolescents, andsupport services for senior citizens.The overlap sphere was alluded towhen it was noted that in settingswithout a house staff, nurses perceivethemselves as having greater auton-omy and responsibility in decisionmaking and in management ofpatient care. The current magnetprogram of the American NursesCredentialing Center defines auton-omy as “independent judgmentexercised within a multidisciplinaryapproach to patient care.”32 Thissomewhat contradictory definitiondoes not address U/O spheres ofpractice or corresponding types ofdecision making, nor are theseaddressed in either the Forces ofMagnetism or in the suggestedsources of evidence.32

Despite the overt approval bynational professional nursing andmedical organizations, no evidence

of widespread, consistent use of theconcept of U/O spheres of practicewas reported until 2001, when staffnurses in 14 magnet hospitals wereinterviewed.4 When asked to describea situation in which they practicedautonomously, many nurses inquired,“Do you want me to describe a patientcare or a nursing care decision?”Interviewees’ descriptions indicatedthat autonomous patient care actionswere decisions that “extend beyondthe usual parameters of nursing toother disciplines,”2,4 essentially thesame as decisions made in the over-lapping sphere of practice. Nursingcare decisions were independentactions focused in the nursing arenaonly, the same as the nursing-uniquesphere of practice. Scope of practiceemerged as 1 of the 3 dominantthemes when the examples anddescriptions of autonomy were cate-gorically analyzed; frequency ofaction and organizational sanctionfor autonomous practice were theother 2. A total of 43% (n=117) ofthe nurses cited autonomous patientcare actions; 17% (n=47) cited nurs-ing care actions.2

Tracking the performance of sev-eral research samples (Table 1) onthe U/O item of the Autonomy sub-scale of the EOM provides further

evidence of the power and use ofthis U/O spheres concept as a criticalelement in autonomous practice inmagnet work environments. TheAutonomy subscale of the EOM IIcontains this item: “On this unit,nurses make independent decisionswithin the practice sphere of nurs-ing and interdependent decisions inthose spheres of practice wherenursing overlaps with other disci-plines such as medicine and respira-tory therapy.” Not only do nurses inmagnet hospitals consistently scoresignificantly higher on the totalAutonomy scale than do their coun-terparts in nonmagnet hospitals,8,17

but the percentage of staff nursesin magnet hospitals who respondedaffirmatively to the U/O itemincreased from 83% of 279 nurses in200133 to 90.2% of 3602 nurses inthe 2003 study8 to 94% of 3510nurses in the 2006 autonomy structure-identification study.12,13

The percentage of positive responsesin comparison hospitals hasremained low, decreasing from 38%in 2003 to 29% in 2006.8,17

The results of the autonomystructure-identification study12,13

provide additional evidence ofincreased recognition and use of theconcept of U/O spheres of practice.

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Health maintenance, pre-vention, and caring pre-

dominate in nursing’s uniquesphere; curative, diagnostic,and prescriptive functionsdominate in the medicalsphere of practice.

Safe, quality patient care,professional job satisfac-

tion, and nurse retentiondemand autonomous decisionmaking from all professionalpractitioners. Nurses want tomake decisions that promotequality patient care.

OUnderstanding the conceptof unique and overlap-

ping spheres of practice andcorresponding types of deci-sion making is essential toautonomous practice.

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When presented with 8 of the 34definitions of autonomy found inthe literature, 60% of the 267 staffnurses, nurse managers, and physi-cians interviewed selected 1 of thefollowing 2 definitions as representa-tive of their understanding of theconcept of autonomy.12 Both defini-tions recognize the concept of U/Ospheres of practice.

1. Autonomy is the freedom toact on what you know; to makeresponsible, independent decisionsin the nursing sphere, and interde-pendent decisions in that sphere ofpractice where nursing overlaps withother disciplines.

2. Autonomy is responsible, dis-cretionary decision making, collegialinterdependence, proactive advocacyfor patients and affiliative relation-ships with clients.

A total of 31% of the 267 inter-viewees selected 1 of the 2 followingliterature definitions to representtheir understanding of autonomy.Both of these definitions acknowledgemainly or only the overlap sphere.

1. Autonomy is an environmentin which nurses are given commandof their expert knowledge and allowedauthority and accountability in deci-sion making; it is independent judg-ment within a multidisciplinarycontext.

2. Autonomy is the power,authority, and accountability toperform actions and skills in thepractice arena where nursing andmedicine overlap. It includes skillssuch as administering narcotics inan emergency without a medicationorder, altering a patient’s mechani-cal ventilation after arterial bloodgas results, and pulling back a pul-monary catheter after interpreta-tion of a chest radiograph.

Reasons for Differential Use ofthe U/O Concept and HighAutonomy Scores

The U/O concept and corre-sponding different types of decisionmaking are not included in theAmerican Nursing CredentialingCenter definition of autonomy formagnet designation.32 Not all mag-net hospitals score at the level notedin the previous samples, nor do allnonmagnet hospitals score low. Thepercentage of nurses in magnet hos-pitals who respond affirmatively tothe item on U/O spheres of practiceis sometimes as low as 37%, and insome comparison hospitals, as manyas 85% of nurses respond affirma-tively to this item.

The differences in scores occurbecause in some hospitals, approvaland sanction from the leadershipcreate the interest, excitement, andsecurity for clinical nurses to prac-tice autonomously. One staff nurseremarked as follows:

We’re caught between arock and hard place. Thestate board, regulatoryagencies, and the hospitalkeep our decision makingin a straitjacket. Yet weknow, and the doctorsknow and urge us to makethe decisions we need to, tosave patients, to reassess,to prevent complications,to provide quality care, andto advocate for the patient.

Several nurses from a single unitwho came to the 2006 interviews asa group had this to say:

Autonomous practice canbe scary. You might make amistake; of course, you mayalso save the patient’s lifeor avert harm. But face it;

it’s a risk. It’s safer for younot to take the chance, butnot so good for the patient.One time I persisted in get-ting something that Ithought my patient neededonly to be embarrassedwhen it was pointed outthat I had neglected toconsider some fact. But mynurse manager told me to“never doubt” myself.“Think it through andthen act. Together we’lldeal with the conse-quences.” You’ve got to havethat kind of support or elsefunctioning autonomouslyis just too risky.

Executive-level nurses, managers,and staff nurses in the 8 magnethospitals that participated in theautonomy structure-identificationstudy13 provided considerable evi-dence of the support present intheir hospitals for autonomouspractice. The following are examples:

• Nurses from 2 of these hospitalspresented papers on auton-omy at the 2006 NationalMagnet Hospital Conference.

• Four hospitals had hosted anational speaker or work-shops on clinical autonomyfor their staff within the pre-ceding 2 years.

• Many of these 8 hospitals hadactive evidence-based practiceteams, often interdisciplinary,that focused on knowledge andbest practices that formed thebasis for autonomous decisionsin both the U/O spheres ofpractice. In 1 hospital, an evi-dence-based practice team ofmanagement and staff nurseswas examining management

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be trusted and supported in usingthe outcomes of evidence-basedpractice initiatives to make decisionsabout patients’ care.

When Are Autonomous DecisionsNeeded?

Unmet patient needs and rapidlychanging conditions are the stimulifor autonomous actions. In theautonomy structure-identificationstudy,12,13 we inquired, “What situa-tions or patient needs most frequentlymotivate you (or staff nurses) toautonomous action?” Intervieweesdescribed examples that fit into 6domains. Table 2 presents each ofthese domains with its primarymotivating factor or patient need.Examples of the emergency domainwere often in the overlap or com-bined sphere of practice. Need torescue and patient advocacy tied forhighest frequency, with physiciansciting more need to rescue and nursesmore patient advocacy examples.12,13

We probably commentmore often on the firstexample I gave you. . . . Isuspect the nurses thinkwe see only their swift andproper decision making inemergency situations. Iwonder if they know howmuch we appreciate theirautonomous decisions in

preventing harm and com-plications and in the coor-dination and teaching theydo. (Physician)

Triage decisions varied by unitand tended to be unit specific; theseincluded referrals to the proper placeand person for care and the adequacyof preparation for treatments, pro-cedures, or surgery. Patients withmultiple comorbid conditions whohad several physicians orderingmultiple and sometimes conflictingtreatments gave rise to the coordina-tion and integration domain.12,13

These autonomy domains arenot pure; overlap occurs. Althoughall domains can be present on anyclinical unit, patients’ needs tend tovary by units. The emergency andneed to rescue domains are far morecommon in critical care units thanin other units. Coordination andintegration are predominate needsof patients in geriatric and rehabili-tation units but are also needed, per-haps to a lesser degree, in critical care.Each domain requires differentknowledge, assessment, competen-cies, and decision-making skills.12,13

Most likely autonomous practicewould increase, along with improvedquality of patient care and nurses’job satisfaction, if unit orientationsand meetings included discussionsof the frequently made autonomous

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practices for communicatingorganizational sanction ofautonomy to staff nurses.

• In 1 hospital, all new hirescompleted a computerizedcritical thinking course.Although autonomy is morethan critical thinking, suchthinking is an important andessential aspect.

• Most of the hospitals promotedcollaborative nurse-physicianand interdisciplinary relation-ships necessary for safe andeffective autonomous practice,particularly in the overlapsphere of practice. Several hos-pitals used the SBAR (situation-background-assessment-recommendation) situationalbriefing model1; 2 had long-standing, well-functioning col-laborative practice programs11

with collaborative practiceorders that allowed staff nurses’considerable autonomy indecision making.

Why Should Nurses PracticeAutonomously?

If the risk involved is so great,why should staff nurses makeautonomous decisions? Such deci-sions are essential for patients’ safety,nurses’ job satisfaction, and nurseretention.2,3,12,19,28,33 Nurses want tomake decisions that promote qualitypatient care. They perceive auton-omy as an, if not the, essential com-ponent of professional practice.12,15

Physicians rated autonomous deci-sion making as the highest indicationof competent performance of staffnurses.1 Most recently, the Instituteof Medicine34 recommended that ahigher level of clinical autonomy begiven to staff nurses and that they

Table 2 Autonomy domains, patient needs and motivating factors

Autonomy domains

Emergency

Need to rescue

Patient advocacy

Triage (when and where to send patients)

End of life

Coordination - integration

Patient needs and motivating factors

Save patient’s life

Patient safety, prevent harm or complications

Mental and physical well-being of patient

Effective and efficient patient care

Quality of life or quality of death

Holistic patient care

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decisions on the unit and the knowl-edge and competencies needed tomake those kinds of decisions.

Clinical Units Reporting the MostAutonomy

On which clinical units do nursesreport the most autonomous prac-tice? In the autonomy structure-identification study,12,13 we selectedour interviewees from those clinicalunits in the 8 magnet hospitals inwhich staff nurses had previouslyconfirmed that they could and didfunction autonomously. Every oncol-ogy unit (n=18) in the 8 hospitalsscored high enough on the Autonomysubscale of the EOM to be selectedfor individual interviews with staffnurses, managers, and physicians.All of the orthopedic units had simi-larly high scores, but only 7 of the 8hospitals had such units and thenusually only 1 unit. Procedural out-

patient clinics had the next highestscores. Intensive care units (ICUs)were markedly underrepresented inthe high-scoring unit sample; only 8of 34 units in the 8 hospitalsreported extensive autonomouspractice as measured by the Auton-omy score on the EOM.12,13

Data from the autonomy struc-ture-identification study12 is not theonly evidence for this ordering ofunits with respect to degree ofreported autonomous practice.Almost the same unit lineup wasfound in the 2006 six essentialsstructure-identification study1,14-16 on 101 unitsin 8 other magnet hospitals. Oncol-ogy units reported the highestscores for autonomous practice;next, in order, were procedural out-patient departments and orthope-dic units; combined ICUs werethird from the bottom.35

The placement of ICUs in the unitlineup is puzzling and counterintu-itive, particularly because ICU nursesusually report a greater need for andscore higher in autonomy than donurses in other specialty areas.36

Why did nurses in some ICUs (8 of34) report appreciably more auton-omy than did nurses in other ICUs?To explore this question, we con-ducted informal inquiries of individ-ual and groups of ICU nurses duringthe 2006 American Association ofCritical-Care Nurses NationalTraining Institute in Anaheim. Weexplained the counterintuitive find-ing and asked the nurses for theirideas, insights, and explanations asto why this finding might haveoccurred. A dominant explanationwas that the increased use of inten-sivists and having physicians presentalmost all the time preclude the needfor autonomous decision making in

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the overlap area. Another popularexplanation was that autonomy inthe nursing-unique sphere was somuch a part of everyday practice inthe ICU that ICU nurses did not con-sider it or report it as autonomy. Ina completely different study, Cana-dian nurses reported a similar expla-nation for why ICU nurses may havelow autonomy scores.25 The follow-ing incident related to us by anexperienced ICU nurse, describeswhat one nurse learned from a col-league about the importance ofautonomous, “caring” decisions andactions in the nursing-unique sphereof practice.

I was working in an ICUsome 8 to 10 years into mycareer. This unit had notonly very high acuity andintensity but many elderlypatients. The nursing andmedical staff (and I amongthem) were really committedto doing what was neededto treat these patients’ ill-nesses and failing bodies.One night I was caring foran elderly lady who hadbeen in the ICU for over aweek. I don’t recall herdiagnosis. She had severeanasarca and was barelyresponsive. She lookedmiserable, and I’m surethat in addition to the myr-iad of drips and tubes, Imanaged her pain. Wewere performing a proce-dure that involved inject-ing iced saline into(probably) a Swan-Ganzline to, somehow throughtemperature measure-ments, calculate cardiacoutputs. All this is really

just staging for the mostamazing autonomous actof “caring” that I have everseen . . . one that changedme as a nurse.A fellow nurse asked if Ineeded any help as therewas a break in his work-load (I don’t recall how orwhy . . . perhaps his patienthad coded and died). I feltthat although I was busy, Ihad things under controland so I declined his kindoffer. He stood there for amoment, didn’t say any-thing to me but then pro-ceeded to “nurse this lady.”He went to the foot of thebed, spoke kindly to her,something like “I bet yourfeet are really cold anduncomfortable,” and beganto gently rub and massageher feet. He did this on andoff for a couple of hours,stood there gently rubbingher feet, talking to her, whileI continued to regulatedrips, monitor physiologi-cal parameters, etc, etc,etc. And you wouldn’tbelieve the look of peace,of comfort, that came overthis lady’s face.I’ve remembered this inci-dent for more than 20years. Who was the nursewho cared for this patient?Who made the reallyimportant autonomousdecisions for this lady atthis time? What was thenursing action that thepatient really benefittedfrom? If I recall correctly,the lady died between this

night and when I was nextscheduled to work. Andneither my actions northose of my colleague’s rub-bing would have saved herlife but who provided hercomfort and caring whenshe needed it most? It wasamazing to me what I hadmissed. I’m forever gratefulto my colleague for provid-ing this lady what was trulyan autonomous nursingaction and for showing memuch more about the pro-fession that I had chosen.

What Can Clinical NursesDo to Secure Autonomy-Friendly Environments?

The 267 staff nurses, nurse man-agers, and physicians working onthe 74 units in 8 magnet hospitalswho had high scores in autonomy inthe autonomy structure-identificationstudy,12,13 described structures andbest practices that enabled staffnurses to make autonomous deci-sions. Three structures and bestpractices that have particular rele-vance for clinical nurses are discussedin the following sections.

Define What Clinical AutonomyMeans

Autonomy cannot be safely andeffectively pursued with appropri-ate accountability without anunderstanding of the U/O spheresof practice by staff nurses, manage-ment, administration, and otherdisciplines. This pursuit of autonomycannot be done without agreementabout what clinical autonomy is andhow it is to be interpreted, at leaston each unit and in each hospital.Staff nurses can exert leadership in

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this endeavor. They can bring theissue to a staff meeting. They canask their colleagues to describe theirunderstanding of the concept ofautonomy. They can discuss therisks and benefits involved. The 4definitions provided earlier may bea good place to start. Staff nursescan discuss the differences betweenindependent decision making andinterdependent decision making thatinvolves input from other disciplines.What can and should nurses do iftheir assessments and observationsindicate that patients’ needs are notcovered by current orders or requireaction outside nurses’ current scopeof practice? As a physician said,“Pretending that risks and impedi-ments to autonomous practice don’texist will not make them go away.”

As professionals, clinical nurses,particularly those in magnet hospitals,have the obligation and responsibility

“to do something about the auton-omy mess” not only in the placeswhere they work but also with theirschool alumni and faculty, with theAmerican Nurses CredentialingCenter, and with professional nurs-ing specialty organizations. Nursescan ask themselves, what were theytaught about clinical autonomy intheir nursing programs? What havethey learned since beginning profes-sional practice, and what would theylike to see incorporated into the cur-riculum in the schools of nursing theyattended? The original Forces ofMagnetism originated from inter-views with staff nurses and directorsof nursing in the original 41 magnethospitals. Who better than profes-sional nurses in currently designatedmagnet hospitals to advise the Amer-ican Nurses Credentialing Centerabout the current practice of clinicalautonomy and evidence to support

that practice?32 The American Asso-ciation of Critical-Care Nurses isthe only professional specialtyorganization that recognizes U/Ospheres of practice as essential forautonomous practice.37 If moreimpediments to autonomous prac-tice are perceived by critical carenurses than by nurses on other units,critical care nurses need to initiatediscussion of this issue, not only inICUs and in the employing hospi-tals but also in meetings of theirspecialty organization.

Participate in Periodic Renegoti-ation of the Scope of Practice

Since the 1970s, scope of practicehas been termed redefining domainboundaries, shifting limits on action,knowledge and responsibility to meetpatient needs, performance of skillsbeyond professional jurisdiction,role enlargement or expansion, and

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situational credentialing.13 Negotia-tion relative to scope of practice isparticularly necessary in the overlap-ping sphere of practice. Intervieweesin the autonomy structure-identifi-cation study12,13 identified 3 levels orpatterns of autonomous decisionmaking and action. The first, do andinform later, is based on a historyand mutual trust between physiciansand nurses and is probably the mostfrequent autonomous action in theoverlapping sphere of practice.

I had a patient go into res-piratory distress. I assessedthe patient—rapid respira-tions, anxiety, color, etc—gave him more oxygen,ordered a chest x-raybecause I thought it wasfluid overload. Then Icalled the doctor and gavehim a complete report. Itwas fluid overload and wegot him out of that fast.

The second level of autonomousaction, persist until the patient getswhat he or she needs, involves repeat-edly contacting the same physician,contacting other physicians, going“up the chain of command,” orelecting not to follow an order or aprotocol that the nurse judges to beinappropriate for this patient in thissituation. The second excerpt aboutthe elderly patient with Alzheimer’sdisease in the section “Crucial Com-ponents” is an example of this typeof autonomous action. The follow-ing is another.

The patient is on a monitorand strips are OK, but shejust wasn’t herself. I couldsee by her body languagethat something just wasn’tright. I bugged the residentstill they came. They left

without even talking to me,so I called the attendingdirectly. He came rightaway and just as he wasasking me: “Diane, putinto words what you’reseeing that tells you some-thing isn’t right,” thepatient blew. We wouldhave lost that baby if thedoc hadn’t been right there.

True interdependent decision mak-ing characterizes the third level ofautonomous practice. The followingexcerpt from an ICU nurse in anautonomy workshop illustrates thislevel.

The patient was in for abrain bleed, and I’d beencaring for him for severaldays. He had many comor-bidities and had to be suc-tioned frequently. I tried tokeep these to a minimumbecause of the increasedintracranial pressure, but Istill had to do it quite oftento keep him from chokingon his secretions. The doc-tor came in while I was tolunch and ordered that thepatient not be suctionedoftener than once an hour.Well, I knew that was a “nogo.” I contacted Dr ___,but he was tied up; I con-tacted Janie, the respiratorytherapist, and Dr Allan, theclinical pharmacist, andexplained the situation,and gave them a chance tothink about what theymight recommend andthen got back to the officenurse and we set up a con-ference call between Dr___ and the 3 of us to see

how we could take care ofthis problem, not increasethe pressure, but yet keepthe patient breathing andcomfortable.

Renegotiation of scope of practicealso takes place in unit operationsmeetings or as a part of interdisci-plinary rounds, such as are frequentin medical ICUs, neonatal ICUs,stroke units, and trauma units, or inregularly scheduled interdisciplinarymeetings to develop, assess, andevaluate nurse order sets, collabora-tive practice orders, critical pathways,protocols, and rapid response teamdirectives. It is through the processof developing, assessing, and evalu-ating the effectiveness of orders andprotocols that renegotiation of whatdecisions and activities are best forquality patient care takes place.Interviewees, both nurses and physi-cians, were concerned about “onesize fits all” protocols with requiredimplementation, such as restraintsor electrolyte replacement, for allpatients in a specific group. Theseprotocols were strongly criticized asconstrictive, restrictive, and of littlevalue in autonomous decision mak-ing because they provided littleroom for judgment and appropriate-ness for individual patients. Some-times a protocol does not fit thisparticular patient, at this particulartime, in this particular context.

The role of clinical nurses in allof this negotiation is to participate,lobby for clarification, and identifywhat is needed. In the nursing-uniquesphere of practice, renegotiatingscope of practice is dictated by bestpractices, new developments in thefield, or new technologies and islargely a matter of intraprofessionaldialogue. The overlap sphere

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requires interprofessional dialogueand negotiation.

Obtain the Administrative Sanction and Support Needed

In the 2006 autonomy structure-identification study,12,13 intervieweesidentified administrative sanction,approval, and support as a best prac-tice enabling staff nurses to makeautonomous decisions. This findingis not new. This same best practicewas 1 of the 3 themes that emergedfrom the analysis of the hundredsof examples and descriptions ofautonomous practice provided bythe 279 staff nurses interviewed in2001.2 “I can not and will not prac-tice autonomously if I don’t have atleast the support and approval ofmy nurse manager.” Intervieweesnoted that if a nurse did not havethis support, the only alternativewas do it “back stage,” or as theirCanadian counterparts said, “You’vegot to go in the ‘back door’25 and livewith the risk that you may get jumpedon for trying to do the best you canfor your patient.” Several intervie-wees remarked that the only sup-port they got for autonomousdecision making was from theirpeers or from physicians.13

Additional autonomy-enablingstructures and best practices wereidentified by interviewees or throughan in-depth analysis of operationaland evaluation data collected fromeach of the 8 hospitals as part of theautonomy structure-identificationstudy,12,13 The most extensively citedstructures were evidence-based prac-tice teams, activities, and initia-tives.13 To practice autonomously, anurse must know, must have up-to-date knowledge backed by researchand evidence: “Our evidence-based

practice teams generate the knowl-edge upon which protocols andcritical pathways are based.” Themost effective teams were interdisci-plinary evidence-based practice teamsof nurses, physicians, pharmacists,and therapists organized aroundpatient care problems.13

A second autonomy-enablingpractice signifying administrativesanction was the inclusion of autonomy-related concepts in thecriteria for career ladder programsor in the criteria for a similar bonusvalue-added program.13 All 8 hospi-tals in the autonomy structure-identification study12,13 had sometype of professional advancementprogram. Often, the criteria foradvancement centered on participa-tion or leadership in educational orresearch activities or on council orpractice improvement agendas. Ofthe 8 hospitals that had the highestautonomy scores of more 100 hospi-tals tested with the EOM, 2 basedall or a large part of their careerladder criteria on the steps andcomponents of autonomy, specifi-cally designating the type of decisionmaking, sphere of practice, and risktaking as advancement criteria.13 In6 of the 8 hospitals, spheres of prac-tice and related decision makingwere spelled out in documents enti-tled Scope of Practice, Definitionsof Nursing, and Models of Profes-sional Practice.13

A third structure that communi-cates administrative/organizationalsanction and support for autonomyis performance appraisal documents.Four of the 8 hospitals cited this typeof sanction.13 In 3 of the 4 hospitals,identification of practice spheres andtypes of decision making were listedas subbehaviors and competencies;

in 2, “negotiating scope of practicewith physicians and other disci-plines” was cited as an advancedstaff nurse competency; in all 4,independent and interdependentdecision making were defined andlisted as major competencies of aprofessional nurse. The fact thatonly 4 of these 8 magnet hospitalscited sphere of practice and type ofdecision making in their perform-ance appraisals, and that in none ofthe 8 hospitals were these compe-tencies expected of entry-level nurses,supports staff nurses’ contentionsthat autonomous decision makingis exceptional rather than beginningor standard nursing practice.13

Staff nurses can take action toobtain the administrative supportneeded for autonomous practice.Nurses must ask for the support;they have an obligation to maketheir expectations known.14,15 If anurse wants to practiceautonomously and feel that patientsneed and deserve the best that thenurse can give, he or she must askthat clinical autonomy be defined,discussed, and included in perform-ance appraisals and in clinicaladvancement criteria. Nurses mustbring the issue to practice councils.

Sometimes nurses are made tofeel that they do not have the supportof leadership and/or managementin making autonomous decisionsin the best interests of patients. Anexperienced nurse related the fol-lowing:

My patient’s BP suddenlydropped, and I gave her abolus of fluid, which, forthis patient at this time,was the right thing to do,but I didn’t have a specificorder. As soon as the

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blood pressure came backup, I put in a call, but it wasa while before the doctorgot back to me. Thepatient’s BP would havebottomed out if I had notdone that, but my nursemanager made me feel likeI was a criminal or at thevery least, walking on eggs.The doctor was pleased; Igot great thanks and sup-port from him.

Unless these issues are openly dis-cussed and brought to the attentionof management and leadership, clin-ical nurses will never really find outif they are or are not expected tofunction autonomously.

SummaryStaff nurses in magnet hospitals

describe autonomy as the freedomto act in the best interests of patients,to make independent decisions inthe nursing sphere of practice andinterdependent decisions in thosespheres in which other disciplinesoverlap with nursing. Autonomouspractice is essential for safe andquality patient care and for nurses’job satisfaction. Nurses on oncology,procedural outpatient, and orthope-dic units report more autonomouspractice than do nurses on otherunits. Six domains of autonomybased on patients’ needs were

described; many of these are unitspecific. Improving the work envi-ronment so that nurses can functionautonomously is a responsibility ofboth leadership and clinical nurses.Clinical nurses can exert leadershipby defining autonomy, at least fortheir unit or service. Periodicallyrenegotiating the scope of practiceand obtaining administrative sup-port and sanction will do much tosecure autonomy-friendly workenvironments. CCN

Financial DisclosuresThis research was funded in part by a grant fromthe American Association of Critical-Care Nurses.

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eLettersNow that you’ve read the article, create or con-tribute to an online discussion about this topicusing eLetters. Just visit ccn.aacnjournals.organd click “Respond to This Article” in either thefull-text or PDF view of the article.

d•tmoreTo learn more about clinical autonomy, read“Decisions Made by Critical Care NursesDuring Mechanical Ventilation and Weaningin an Australian Intensive Care Unit” byLouise Rose et al in the American Journal ofCritical Care, 2007;16:434-443. Availableonline at www.ajcconline.org.

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