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Strategies for Enhancing Autonomy and Control Over Nursing Practice

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Marla J. Weston, PhD, RN

Abstract

Clinical nurse autonomy and control over nursing practice (CONP) have been associated with increased nurse satisfaction and improved patient outcomes - both elements of a healthy work environment. This article outlines strategies for enhancing autonomy as well as strategies for enhancing CONP and describes the importance of articulating expectations for autonomous practice, enhancing competence in clinical expertise, establishing participative decision making, and developing nurses' skills in making decisions. In addition, the critical role of nurse leaders and the need to work upstream to influence the social, political, and economic factors affecting nursing practice are discussed.

Citation: Weston, M.J., (Jan. 31, 2010) "Strategies for Enhancing Autonomy and Control Over Nursing Practice" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 2.

DOI: 10.3912/OJIN.Vol15No01Man02

Key words: autonomy, control over nursing practice, decision making, empowerment, healthy work environment, leadership, nurse satisfaction, nursing practice participative decision making, professional practice, professionalism

A healthy work environment is one that is invigorating, robust, flourishing, and able to flexibly adapt to a constantly changing set of circumstances. Much like health in a person represents more than the absence of disease, a healthy work environment encompasses more than absence of malfunction. Like a healthy person who is active and contributing to the world, a healthy work environment garners employee engagement and energy toward collectively producing desired results. A healthy work environment not only establishes a desirable workplace, but also provides the infrastructure to positively impact the effectiveness of the work itself. A healthy work environment is one that is invigorating, robust, flourishing, and able to flexibly adapt to a constantly changing set of circumstances.

The value and contribution of nurse autonomy and control over nursing practice (CONP) in creating a healthy work environment—both in terms of nurse satisfaction and the quality and safety of patient outcomes—have been consistently demonstrated (Aiken, Clark, Sloane, Lake & Cheney, 2008; Lake & Friese, 2006). Moreover, recent research has reported that a positive work environment, including higher levels of autonomy and CONP, is not associated with increased nursing costs (Mark, Lindley, & Jones, 2009).

Autonomy refers to the ability to act according to one’s knowledge and judgment, providing nursing care within the full scope of practice as defined by existing professional, regulatory, and organizational rules (Weston, 2008). Nurses in Magnet facilities have described their culture as supporting autonomous practice, expecting and encouraging them to utilize their nursing expertise to deliver the best in patient care (Kramer & Schmalenberg, 2003a). They perceived that the organization supported their nursing actions and clinical judgment.

CONP refers to the nurses’ ability to shape departmental and organizational policies and practices related to nursing care (Weston, 2008). Nurses with high levels of CONP have the responsibility and opportunity to provide input and make decisions related to their practice, including policies and personnel issues affecting the context of the care they deliver (Kramer & Schmalenberg, 2003b).

From the very first research on Magnet hospitals, the concepts of both autonomy and CONP were associated with a healthy work environment and professional practice (McClure, Poulin, Sovie, & Wandelt, 1983). Subsequently, autonomy and CONP have been suggested as intervening variables to explain the relationship between magnet hospitals and positive patient outcomes (Aiken, Smith, & Lake, 1994).

Both autonomy and CONP have been associated with job satisfaction and nurse retention (Kramer & Schmalenberg, 2004). In addition, they have been associated with increased respect, status, and recognition for nurses (Hinshaw, 2002). CONP has been positively correlated with nurse autonomy and job satisfaction; and negatively associated with personal and situational job stress (Forbes, Bott, & Taunton, 1997). Not surprisingly then, work environments where nurses report high levels of autonomy and CONP have been associated with lower staff turnover rates and less nurse burnout (McClure, Poulin, Sovie, & Wandelt, 2002; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). McGilton and Pringle (1999) reported that nurses’ perceived control over organizational issues appears to more strongly predict job satisfaction than nurses’ perceived control only in the clinical domain. In other words, while both autonomy and CONP impact job satisfaction, CONP appeared to have the stronger influence. Findings that autonomy and CONP impact employee satisfaction are consistent with the literature in other industries (Cotton, Vollrath, Froggatt, Lengnick-Hall, & Jennings, 1998; Sagie, 1994). Within management literature, the degree of worker participation in decision making has been found to relate positively to satisfaction with work (Black & Gregersen, 1997).

Nursing work environments with higher levels of autonomy and CONP have also been associated with increased performance and improved patient outcomes. Autonomy and CONP have been identified as important work environment attributes for enhancing patient safety (Institute of Medicine, 2004). In addition, even when controlling for nurse staffing and education, hospitals with better care environments, i.e. those having more nurse autonomy and CONP, were found to be associated with significantly lower mortality rates (Aiken et al. 2008). Laschinger and Havens (1996) found that CONP strongly predicted nurses’ perceptions of effectiveness of patient care. In addition, higher reported levels of CONP were positively associated with nurse executives’ perceptions of the quality of patient care delivered (Havens, 2001). Similarly, in the management literature, employee autonomy and control have been associated with improved outcomes. A positive, but weak, relationship has been demonstrated between participation in decision making and performance (Black & Gregersen, 1997; Sagie, 1994).

In light of the importance of autonomy and CONP, understanding these concepts and their applicability in practice can support the development and sustainability of a healthy work environment. This article will provide strategies that nurses can use to strengthen nurse autonomy and CONP in the healthcare setting. In addition the critical role of nurse leaders and the need to work upstream to influence the social, political, and economic factors affecting nursing practice will be discussed. The Table offers a concise summary of these strategies.

Strategies for Enhancing Autonomy

While a nurse’s scope of practice is legally defined based on educational qualifications and specific experiences, professional and organizational expectations determine the degree to which autonomous practice occurs. As described in the following section, strategies for enhancing autonomy are based on setting clear expectations for autonomous decision making and providing support for increasing the knowledge and expertise of nurses.

Clarify Expectations about Clinical Autonomy

Professionally and organizationally sanctioning and supporting the application of nursing knowledge and expertise in the care of patients has been associated with enhancing autonomous nursing practice (Kramer & Schmalenberg, 2003a). Nurses can enhance autonomy by clearly communicating and organizing their work to ensure that they have the freedom to act on nursing decisions using sound clinical judgment. Describing expected behaviors involves communicating that nurses are expected and encouraged to make decisions about clinical patient care that are based on the science and art of nursing. This involves setting an expectation of independent nursing action and supporting decision making within the scope of nursing practice. In addition, because nursing practice involves both independent and interdependent actions, clearly identifying acceptable responses to situations that are at the edge of nurses’ commonly accepted scope of practice is helpful in this process (Stewart, Stansfield, & Tapp, 2004). Examples of such identifications include outlining expectations related to verbal physician orders and establishing protocols for over-the-counter medications. Behavioral expectations can be formally outlined in orientation programs, demonstrated by preceptors, and highlighted through ongoing discussions about clinical practice.

...patient care rounds can be organized in a way that ensures that nurses contribute to decision making about the treatment plan of patients. In addition to clearly defining expectations for autonomous clinical practice, incorporating nursing knowledge and expertise into clinical practice embeds autonomous practice into patient care. For example, patient care rounds can be organized in a way that ensures that nurses contribute to decision making about the treatment plan of patients. The nurse is positioned to discern subtle trends and changes in a patient’s condition, to know the unique personality and strengths of the patient, and to have established a caring relationship with the patient (Manojlovich, 2007). Including nurses in clinical rounds maximizes the valuable contribution of their unique perspective and information in the care of patients. With nursing input, more diverse solutions can be explored, patient care planning is more robust, interdisciplinary communication is improved, and care coordination can provide for more effective implementation of plans.

Recognizing autonomous practice can reinforce verbally communicated expectations. For example, acknowledging exemplary performance by having nurses share clinical examples that highlight autonomous practice provides a venue for displaying sanctioned autonomous practice. Nursing grand rounds, poster sessions on clinical case studies, and/or situations shared during staff meetings can all be used to illustrate examples of autonomous nursing practice. In addition, emphasizing expected behaviors through recognitions and rewards outlines for nurses the realm of autonomous actions. Clinical ladder programs formally reward and recognize clinical practice, further delineating expected autonomous actions.

Novice nurses quickly observe the nature of clinical judgment and autonomous nurse actions demonstrated by more senior colleagues... Role modeling expected behaviors also reinforces autonomous clinical practice. Novice nurses quickly observe the nature of clinical judgment and autonomous nurse actions demonstrated by more senior colleagues and use these observations to identify accepted levels of independent and interdependent decision making. Clinical nurse leaders and clinical nurse specialists in the practice setting can engage in behaviors reflective of autonomy and serve as an ongoing resource for role modeling, coaching, and mentoring excellence in clinical practice.

A component of coaching for autonomous behavior includes addressing when behaviors are not within the range of expected actions. For example, if nurses are not making the expected autonomous decisions, coaches can compare actual with expected actions to show how to make the expected nursing contributions and behaviors more explicit. Addressing inappropriate actions using constructive feedback can guide autonomous nursing practice. If nurses take clinical actions that are not appropriate or not successful, constructive feedback can redirect their practice patterns.

Studies have suggested that creating a climate that is supportive of nursing practice will augment the level of autonomous practice. For example, nurses working in Magnet hospitals perceived that managers were more supportive of their independent clinical decision making than did nurses working in non-Magnet hospitals (Upenieks, 2003). Because of perceptions of support, nurses in Magnet hospitals may be more willing to assume the risk for making autonomous patient care decisions. Building trust in the clinical setting by supporting nursing actions that may be risky, yet are safe, encourages innovative practice and enhances autonomy.

Enhance Competence in Practice

The establishment of the sound clinical judgment needed for autonomous practice requires a foundation of nursing expertise. Although difficult to define, nursing expertise is a combination of knowledge and skill along with extensive experience (Jasper 1994). Thus, implementing strategies to increase the competence of nurses by creating a learning environment can foster autonomy. Stewart, Stansfield, and Tapp (2004) reported that autonomy can be fostered by enhancing competence and confidence through strategies such as teaching rounds, formal continuing education, and a climate of inquiry in everyday practice. Also during staff meetings, clinicians can share complicated patient scenarios that have challenged their autonomous decision making to both exemplify excellence in practice and receive feedback on how to further enhance patient care. Promoting evaluation of autonomous practice in this way allows for unique variation in culture and norms between units.

...implementing strategies to increase the competence of nurses by creating a learning environment can foster autonomy. Encouraging the continuous examination of practice allows nurses to reflect on the degree of autonomy present in their decision making. In addition, establishing an evidence-based practice approach may develop and enhance autonomy. By identifying and evaluating relevant research while simultaneously assessing and incorporating information about patient preferences into their plans, nurses have the opportunity to make autonomous patient care decisions. Further, development of skills related to communication, interdisciplinary teamwork, and negotiation can assist nurses to master the skills necessary to advocate for their patients.

Creating an environment that supports both formal and informal continuing educational opportunities and learning provides for autonomous clinical practice. Baccalaureate-prepared nurses have reported a higher preference for both clinical autonomy and CONP (Blegen et al., 1993). In addition, master’s-prepared nurses have reported significantly higher professional autonomy in clinical nursing situations compared to nurses prepared with a diploma or associate degree (Schutzenhofer & Musser, 1994). Further, Ericsson, Whyte, and Ward (2007) found that nurses with specialty nurse certification and specific clinical training demonstrated higher levels of expertise. Tuition reimbursement and support for returning to school can enhance the development of skills and competence needed to support autonomous practice.

The importance of the culture of learning cannot be stressed enough. For example, while nurse managers at non-Magnet hospitals focused on adequate staffing as a critical element, managers at Magnet hospitals emphasized educational opportunities and an autonomous climate as being a vital factor for nurse satisfaction (Upenieks, 2003). In the Mrayyan study (2004) supportive management, education, and experience were identified as the three most important factors in enhancing autonomy over patient care and unit operations.

In summary, autonomy can be increased by strategies that incorporate the unique knowledge and expertise of nurses into clinical patient care. Clarifying the expectation that valuable nursing knowledge should be applied in the practice setting provides the framework for enhancing clinical autonomy. Professional enrichment and education build the clinical knowledge and competence that is a necessary foundation for nurse autonomy.

Strategies for Enhancing Control over Nursing Practice

Most nurses practice as employees, and as a result must structure their work within imposed rules that have a profound effect on their practice (Hess, 2004). To truly control their practice, nurses must have both the right and the power to make decisions affecting the rules surrounding their practice. Nurses must create and use decision-making structures at the workgroup, organizational, and professional levels of practice.

Establish Participative Decision Making

Historically the concepts of empowerment and participatory management have been laden with a paternalistic tone of people in positions of authority allowing staff to provide input and participate in some operations. The structure of an organization or profession operationalizes goals and values in support of achieving desired outcomes (Wolf, Triolo, & Ponte, 2008). An organized structure for nurse participation in decisions, along with an explicit communication processes contribute to enhancing CONP. Kramer and Schmalenberg (2003b) have shared that nurses in organizations with high levels of CONP describe an operative structure that is in place, one that is recognized as authoritative by others. The representatives in the structure are known and some input is sought and expected from all nurses. In addition, staff nurses have responsibility and accountability for the issues and solutions discussed within the structure. The classic example of such a structure is a shared governance council with nurses actively managing decisions related to their practice.

The importance of nurses having responsibility and accountability for professional and practice issues cannot be stressed enough. The structure for CONP is one in which the responsibility for nursing care of patients is placed with staff nurses (Hinshaw, 2002). Historically the concepts of empowerment and participatory management have been laden with a paternalistic tone of people in positions of authority allowing staff to provide input and participate in some operations. Fundamentally, this is where many shared governance programs go awry. In these situations, although an organizational structure is established and nurses are permitted to provide input into key decisions, the ultimate authority for the decision making continues to reside with managers and administrators. In contrast, autonomy and CONP need to be founded on a process of engagement where nurses, as knowledge workers, are expected to make and own decisions (Porter-O’Grady, 1997).

...nurses should be included along with physicians and administrators on key organizational committees that establish patient care policies and procedures. Because nurses typically work as employees within a larger structure and within the healthcare system itself, nurses must have a formal structure for participating in organizational and system decisions. For example, within employment settings, nurses should be included along with physicians and administrators on key organizational committees that establish patient care policies and procedures. The expectation should be set that nurses will share a full and equal voice in, and responsibility for making patient care decisions (McKay, 1983). Not only does this foster strong, productive nurse-physician and nurse-administrator relationships, it also contributes to necessary interdisciplinary richness (Hinshaw, 2002; Ponte, 2004).

Whatever organizational structure is used, nurses should be able to make program and resource decisions without going through layers of bureaucracy that stifle innovation and implementation. In addition, to be involved, nurses must be active on hospital and professional committees. Organizing an “involvement-friendly environment” where it is easy for nurses to participate in meetings will increase CONP (Forum for Shared Governance, n.d.). Nurses can maximize the opportunity for colleagues to attend meetings or complete committee work by adequately staffing for patient care. Fundamentally, nurses need to foster the understanding that their work involves both the direct clinical care of patients as well as the management of the context in which that care is delivered. As a result, both clinical patient care and organizational and committee work are within the realm of nursing practice. Nurses cannot effectively practice without the right resources (including an appropriate amount and mix of caregivers, supplies, and supporting systems) or without the necessary evidence-based policies and practices. To control practice, nurses must have some influence over necessary resources and policies for their practice (Hess, 2004). To do so, nurses must ensure that they and their colleagues are well-represented and able to be influential whenever and wherever key decisions are being made that will impact the nature, scope, and context of their practice.

Enhance Competence in Decision Making

...nurses need to foster the understanding that their work involves both the direct clinical care of patients as well as the management of the context in which that care is delivered. Although it is important that clinical nurses serve on committees, they are generally underprepared to do so; hence they are challenged in representing their needs. Studies find that clinical nurses participate to a greater extent in decisions related to clinical patient care decisions than to unit or organizational decisions (Anthony, 1999; Blegen et al., 1993; Krairiksh & Anthony, 2001). Consequently, clinical nurses’ experience and competence in participating in group decision making, influencing organizational processes, and impacting policy is somewhat limited. More frequently nurses are invited to provide input into the decision but are not involved in making the selection or final choice in the decision that is made (Anthony, 1999; Issel & Anderson, 2001). Generating alternatives, as well as choosing alternatives, planning implementation, and evaluating results, have been found to be  significantly related to satisfaction and influence (Black & Gregersen, 1997; Issel & Anderson, 2001). Clinical nurses working in Magnet hospitals distinguish between participative management, which they articulate as providing input or sharing an opinion, and CONP, which they articulate as actually selecting among the available options regarding practice policies, practice issues, and personnel issues affecting nurses (Kramer & Schmalenberg, 2003b). In other words, developing skill in generating alternatives and selecting a final choice, coupled with ensuring that there is a structure for both input and decision making enhances nurses’ satisfaction and influence.

As a result, investing in teaching nurses about the decision-making process, coaching them through early decision making, and supporting both successful and unsuccessful decisions will foster an environment for increasing autonomy and also CONP. Expecting nurses to participate without allowing opportunities to acquire prerequisite skills will result in either frustration or apathy (Hess, 2004). Ensuring that nurses develop the skills to manage meetings, gather and analyze existing evidence, explore alternatives, and make sound decisions will support CONP. In this way, nurses will have the knowledge and ability to not only make recommendations but also be empowered to enact decisions.

Nurse leaders, whether in management, clinical, educational, or research positions, can be taught facilitation skills to enhance their ability to garner discussion that leads to identification of group expertise without dominating the discussion or decision making. Naturally, during decision making, creative tensions will emerge by exposing differences in perspectives and gaps between organizational visions and current realities (Burns 2001). Teaching leaders to pose questions that expose assumptions and challenge sacred cows can help to illuminate tensions and paradoxes, thus ultimately fostering creative new solutions.

In summary, CONP can be increased by strategies that ensure nurse participation in key decisions within the organizational and professional structure. Establishing the structures and processes for active nurse input and decision making provides the framework for enhancing CONP. Because many nurses have little such experience, investing in teaching and supporting decision making related to the context of nursing care is necessary to build competence for CONP.

Role of Nurse Leaders

Nurse managers in particular are instrumental in producing the conditions for autonomy and CONP. Although leadership can come from any nurse, designated leaders remain extremely influential for enhancing both autonomy and CONP. Consistently the recommendation is made to create strong, visible nursing leadership in the nursing department and at the unit level to increase autonomy and CONP (Hinshaw, 2002). Nurse managers in particular are instrumental in producing the conditions for autonomy and CONP. Manager leadership behaviors have been shown to influence staff decision-making patterns (Taunton, Boyle, Woods, Hansen, & Bott, 1997). In studies comparing Magnet and non-Magnet hospitals, greater accessibility of nurse leaders, support of autonomous decision making by leaders, and access to work empowerment structures were found to be the most significant elements accounting for differences in empowerment and job satisfaction (Kramer & Schmalenberg, 2002; Upenicks, 2003). In a qualitative study, seven staff-nurse focus groups identified and rank ordered the skills needed by a nurse manager to effectively manage a patient care unit. The top three management skills in descending order were effective communication, remaining available to staff, and involving staff in decision making (Maceri, 2006). Supervisor support was positively correlated with nurses reporting more control over their work and higher satisfaction (Hall, 2007). Nurse manager actions, specifically those encouraging nurses to communicate openly with other healthcare team members, supporting nurses to resolve conflicts, and encouraging leadership, were associated with increased nurse participation in patient care and conditions of work decisions (Mrayyan, 2004).

In addition to the critical role of the nurse manager, executive leadership is critical to creating an environment that is supportive of autonomy and CONP. Organizationally, a visionary nurse executive who trusts and values nursing staff is essential for creating the context for high levels of autonomy and CONP. A chief nurse executive who (a) advocates for a strong, influential nursing presence in the organization; (b) is open and communicative; and (c) supports participative management is associated with a professional environment that includes autonomous clinical practice and nursing control over practice (Hinshaw, 2002). Upenieks (2003) reported that when the entire executive team, and not just the nurse executive, offered support of nursing, a climate was established that endorsed autonomous nursing practice.

Thus, the role of formal nurse leaders is powerful in establishing the context for autonomy and CONP. In contrast to the traditional command-and-control management style that results in stabilization of practices, enhancing autonomy and CONP involves leadership that encourages and fosters new ideas and innovation. This sort of ‘controlled destabilization’ has been found to be a characteristic of Magnet facilities (Wolf, Triolo, & Ponte, 2008). These situations require nurse managers and nurse leaders who value and support their colleagues’ input and decision making.

Work Upstream

In addition to addressing autonomy and CONP at the individual and organizational levels, nurses have real opportunities to shape the social, political, and economic factors that influence their practice within the healthcare system. Whereas nurses describe autonomy in terms of clinical practice, sociologists describe autonomy as the right of a profession to control its own work free from the influence or power of others (Freidson, 1988). In other words, nurses use the word autonomy to describe the freedom to make decisions about an individual patient, while sociologists use the word autonomy to describe the freedom of a profession, such as nursing, to make independent decisions about its body of knowledge and its work.

Nurses today have the opportunity, even the obligation, to ensure and enhance both autonomy and CONP by influencing social, political, and economic factors related to their practice. Nurses today have the opportunity, even the obligation, to ensure and enhance both autonomy and CONP by influencing social, political, and economic factors related to their practice. Even as the importance of nurses’ contributions have become increasingly clear through studies demonstrating that nursing practice impacts the quality of patient outcomes in hospitals, the underlying technical expertise and unique knowledge needed to influence these outcomes is largely unclear to the public and even to nurses themselves. In spite of years of desire and demonstration to the contrary, the public’s perception of nursing practice is still largely that of a handmaiden to the physician (Buresh & Gordon, 2001). Although the public highly regards nurses, they do not highly value nurses in terms of believing that nursing care is equally as important as medical care in contributing to health (Gordon, 2005). Nurses can promote and expand their autonomy and CONP by publicly identifying their unique expertise in health and patient care in easily understandable terms in a way that shows the value of their nursing expertise. Nurses need to communicate that their work involves an exclusive knowledge base and skill set that is different from and even unknown by physicians. This knowledge/skill set includes monitoring of patient and public health status (surveillance); managing complex, highly technical interventions; integrating and coordinating healthcare services; and providing relevant education and emotional support in furthering health (Institute of Medicine, 2004).

Lack of clarity about the contribution of nursing may be related to the multiple educational levels and diversity of roles within the profession. Nurses earning diplomas or associate degrees often do not have content in their curriculum to prepare them to advocate in the social or political context. Further, the lack of acknowledgement, even within the profession, of the wide range of roles and expertise that constitute nursing contributes to the devaluing of the work. Although nurses conceptually describe the profession as caring for the individual, family, and community, nurses often discount colleagues not providing direct patient care by describing them as “not real nurses.” This negating of nurses’ contribution to the managerial, policy, educational, and research components of professional practice diminishes the recognition of the full contribution of nursing knowledge and expertise (Truth about Nursing, 2006). None-the-less, all nurses have a contribution to make upstream in the social and political process. For example, novice nurses with entry level degrees can communicate about the role and responsibility of registered nurses with their individual patients. Colleagues with advanced degrees can serve as primary investigators to conduct research to demonstrate the impact of nursing practice. All nurses can acknowledge their colleagues’ contributions in various roles and practice settings, and thereby assist the public to value the depth and range of the nursing profession in healthcare.

Nurses need to communicate that their work involves an exclusive knowledge base and skill set that is different from and even unknown by physicians. Similarly, nurses can influence the economic and political factors that enable or constrain nurse autonomy and CONP. Conversations about reforming the United States (U.S.) healthcare system have placed U.S. nurses in a desirable position of having enormous influence in the dialogue (see the American Nurses Association [2009] webpage health system reform). Certainly decisions about the economics of healthcare influence the practice environment and degree of autonomy and CONP of nurses. Just as the transition from fee-for-service to prospective payment influenced the context of nursing practice, decisions on future payment structures for healthcare will impact the practice of nursing. In this climate, nurses need members of their profession to have economic and political prowess to proclaim what is unique to nursing and negotiate for their professional role (Turkel & Ray, 2000). In this venue, professional nursing associations can have a powerful impact on promoting autonomy and CONP both by enhancing the skills of nurses and by leveraging a collective response in the political arena. In addition, appointing and electing nurses to positions with political influence on local, state, and national levels can ensure that nurses’ unique expertise is included when decisions that will influence nursing practice are made.

Conclusion

The publication of the original research on Magnet hospitals concluded with a section on the overarching importance of autonomy and CONP (McClure, Poulin, Sovie, & Wandelt, 1983). Inherent in autonomy and CONP is nurse power—not power to dominate, but power to contribute uniquely nursing knowledge and expertise to patients and the organization. This power both enriches the practice of nursing and positively impacts the quality of patient care. Establishing strong structures and processes to enhance nurse autonomy and CONP provides for the engagement, inclusion, and ownership of nurses over their clinical practice, and thereby enhances the health of the work environment.

Table. Strategies for Enhancing Autonomy and Control Over Nursing Practice

  1. Strategies for Enhancing Autonomy
    1. Clarify expectations about clinical autonomy
      1. Describe expected behaviors
      2. Embed nursing knowledge into clinical practice processes
      3. Recognize and reward autonomous practice
      4. Role model expected behaviors
      5. Coach nurses not demonstrating expected behaviors
      6. Provide manager support for autonomous practice
    2. Enhance competence in practice
      1. Create a learning environment
      2. Enable formal and informal educational opportunities
  2. Strategies for Enhancing Control Over Nursing Practice
    1. Establish participative decision making
      1. Use an organized structure for nurse participation in decision making
      2. Ensure authority for clinical decision making resides with direct care nurses
      3. Include nurses on organizational committees
      4. Minimize bureaucracy
      5. Support involvement by nurses on committees and workgroups
    2. Enhance competence in decision making
      1. Teach nurses about the decision-making process
      2. Coach and support nurses through early decisions
      3. Teach facilitation skills to leaders
  3. Strategies for both autonomy and CONP
    1. Ensure strong nurse leaders
      1. Create strong, visible, nurse leaders
      2. Ensure that nurses in supervisory positions are encouraging autonomy and CONP
      3. Have executives advocate for influential nursing practice
      4. Encourage new and innovative ideas
    2. Work upstream
      1. Influence social, political, and economic factors
      2. Publicly describe nursing’s unique expertise and contribution
      3. Acknowledge nurses’ contributions in all roles and practice settings
      4. Use political clout of professional organizations and nurses in leadership roles

Author

Marla J. Weston, PhD, RN
E-mail: Marla.weston@ana.org

Marla J. Weston, a nurse leader with nearly 30 years of diverse management experience in healthcare operations, is the Chief Executive Officer of the American Nurses Association and the American Nurses Foundation. Dr. Weston graduated with a bachelor of science degree in nursing from Indiana University of Pennsylvania, a master of science degree in nursing from Arizona State University, and a doctoral degree in nursing from the University of Arizona, where she received an outstanding dissertation award. For years, her practice, research, and writing have centered on enhancing autonomy and control over practice in nursing.

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© 2010 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2010


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