The results indicated that the results of field work were mostly in line with those of the theoretical phase. In other words, the basic features of autonomy in ICUs were supported by the field work. The only difference was related to the participants’ expression of financial motivation, which was one of the sub-subcategories of the ‘mental and personality features’ subcategory and the ‘powerful human workforce’ category in the antecedents of the concept.
Overall, reviewing the related texts and instruments, interviews, and clinical observations revealed the attributes, antecedents, and consequences for identifying the concept of autonomy in ICU nurses, which have been described in details below. It is worth mentioning that this study aimed to explore the information about ICU nurses’ autonomy in texts, instruments, and articles in order to start field work.
Antecedents (based on the theoretical phase and field work)
Based on the theoretical stage and field work and integration of the obtained codes using an iterative process, three main themes were achieved from the antecedents(Table3).
1- Powerful human workforce
Powerful human workforce was one of the antecedents of the concept of ICU nurses’ autonomy, which consisted of three subcategories; i.e., demographic features, mental and personality features, and having professional competence.
a) Demographic features
This subcategory included such sub-subcategories as sex, age, education level, race, and job tenure.
“Men are more courageous. In my opinion, entrance of educated men in the nursing profession is highly effective. Women are calm, we always appease. If they tell me to do something tomorrow, I will do that. If they tell me to that again, I will. But men are not like this” (P2).
Considering the effective factors in the empowerment of human workforce, another participant maintained:
“Nurses are not independent, which can be associated with a variety of reasons, one of which being related to sex. A large number of nurses are female. They have a low self-confidence or they are not interested in working autonomously or like to be dependent on someone while working. Another reason is age. Those who are younger are inexperienced and do not even think about being autonomous” (P5).
The present study participants emphasized the role of demographic features such as age, sex, education level, and job tenure in ICU nurses’ autonomy. In the research carried out by Galbany-Estragues et al. also, participants referred to the impact of sex on nurses’ autonomy (15). Similarly, Katja Pursio mentioned knowledge and skills as the factors related to nurses’ professional autonomy (16), which represented the key role of demographic features in this concept.
b) Mental and personality features
The second subcategory of powerful human workforce was mental and personality features, which included the following sub-subcategories: having courage, expedition, personal desires, financial motivation, accuracy, interest in working in the ICU, correct interaction, personality growth and maturation, high stress tolerance, humanity, moral regulations, having self-confidence, and self-esteem. Considering the need for courage as an antecedent of autonomy, one of the participants stated:
“Lack of autonomy among nurses may be due to the lack of courage. For example, we have learned to say yes to everything physicians say. When a doctor comes for the clinical round, we are not able to express our opinions. Even when we know that we are right, we are afraid of making mistakes and being teased or considered a lowly educated person” (P1).
Another participant emphasized the necessity for prompt decision-making in interventions:
“Sometimes, we cannot wait for the resident to come due to the patient’s condition. We’re not responsible for intubation, but I saw several times that the head nurse did the intubation before the arrival of the anesthesia technician. We do this do save patients. However, if physicians come soon, they do their routine tasks” (P3).
Vicki D. Lachman introduced moral courage as a prerequisite for advance in the nursing profession (17). Additionally, Sung Mi-Hae conducted a study in 2011 and revealed a significant relationship between nurses’ self-confidence and professional autonomy (18), which confirmed the impact of mental and personality features on ICU nurses’ autonomy. However, financial motivation was only mentioned as an antecedent in the field work:
“I work in the ICU and I receive 100 tomans more than the nurse who works in other wards. This difference does not motivate me to work autonomously. If the payment is increased, we will work more efficiently” (P3).
“The nurses who work in private cardiac ICUs receive more. Besides, the system wants them to do a series of tasks, which leads them to feel more autonomous” (P5).
Ruth McDonald disclosed the impact of financial motivation on the quality of care provided by nurses and physicians, but not on nurses’ professional autonomy (19). In another research performed by Baljoon in 2018, autonomy was found to be a factor for increasing motivation and decreasing job quit amongst nurses. In other words, autonomy was mentioned as a factor for continuation of working in clinical settings, which was on the contrary to the results obtained in the present investigation (20).
c) Having professional competence
Having professional competence was the last subcategory of powerful human workforce, which included knowledge and performance competence, strong clinical reasoning, competence and skills, professional specialty and skills, ability to judge autonomously, unlimited use of one’s knowledge and skills, responsibility and accountability, decision-making capability, building relationships, problem-solving ability, perceived strength in clinical centers, necessity to make decisions and act quickly depending on patients’ conditions, interdisciplinary performance, maintenance of professional autonomy in teamwork, having authority for self-assessment, differentiation, and ability to apply knowledge.
One of the study participants discussed the unlimited utilization of knowledge and skills, having the ability to make decisions, expedition, and knowledge competence:
“In my opinion, autonomy implies that nurses have freedom of action and take responsibility for their activities. It means that nurses make decisions on the basis of the knowledge they have gained about their profession without worrying about the occurrence of legal problems” (P1).
Another participant considered the ability to forge effective relationships with colleagues as an influential factor in the maintenance of autonomy:
“I have seen that the nurses who have better relationships with physicians are more trusted by the system, of course if they have the required knowledge” (P1).
It was also found that quick clinical decision-making increased nurses’ autonomy in ICUs:
“Patients in ICUs are in worse conditions. Therefore, they need more autonomous, prompt decisions. Besides, the devices are complicated and nurses need some levels of autonomy to work with them” (P7).
The results also indicated that having a specific job description and acting accordingly would lead to professional competence.
“Some duties are mixed up. Nurses do some tasks due to their work conscience, but they will not be able to carry out their own responsibilities. Thus, they become tired and feel that they have to do everything or they have to do the tasks that other people don’t do. In fact, there is no clear job description and nurses have to do what they are not responsible for” (P2).
The necessity of teamwork was yet another subcategory of professional competence.
“This is our fault most of the time. We don’t believe in ourselves, we don’t do what we know is right, and we cause challenge for each other” (P8).
Particular specialties and skills were also found to enhance professional autonomy.
“The more specialist nurses such as respiratory nurses, wound specialists, ICU nurses, and gastroenterology nurses, the higher the professional autonomy will be” (P2).
Considering professional responsibility as a subcategory of professional competence, one of the participants said:
“Nurse should be aware that the patient’s life is in their hands. They shouldn’t say that care is useless and the patient is dead. I remember a man who was admitted in our ward. His consciousness level was 3, which reached 5 and he left here. Five months later, he came to the ward and said that he remembered our voices” (P3).
Based on the present study findings, ICU nurses have to strengthen their professional competence in order to achieve professional autonomy. In the same line, Weston et al. emphasized the necessity for increasing nurses’ clinical competence and developing their decision-making skills in order to promote professional autonomy (21). Katja Pursio also showed the necessity of nurses’ individual competencies for achieving autonomy (16).
2) Organizational platform
Considering the antecedents of autonomy among ICU nurses, the second theme was organizational platform that referred to organizational regulations and organizational culture. Organizational regulations and resources included professional support, liability insurance, legal authority, acceptance of nurses’ autonomy by insurance companies, opportunity for autonomous decision-making and function, freedom of action and thought, new job description for nurses, tariff setting for nursing services, limited payback, cooperation in policymaking and rule setting, institute’s policies, organizational and national laws, legal identification of professional performance boundaries, legal license for autonomy, existence and application of care scales and protocols, and sufficient equipment. The subcategories of organizational culture were overcoming medical sovereignty, leadership style, nursing managers’ behaviors, group adaptability, physicians’ view towards nurses’ autonomy, physicians’ trust in nurses, reduction of physicians’ monitoring, overcoming medical hegemony, existence of strong managers in the nursing profession, autonomous leadership and management, giving some managerial authorities to nurses without the interference of other treatment team members, defending nurses’ proper performance on the part of nursing managers in front of physicians, and other healthcare teams’ trust in nurses.
Regarding freedom of action and legal authority, one of the participants maintained:
“In my opinion, autonomy means that a nurse should have freedom of action and make decisions without worrying about the occurrence of legal problems” (P1).
Professional support was also found to enhance ICU nurses’ autonomy.
“Fear from the occurrence of legal problems may be a reason for the reduction of autonomy…I do my job accurately, but how much can I count on the head nurse or the matron? How much support will they provide? Will their support be effective?” (P7).
Generally, appropriate in-service training can increase nurses’ knowledge competence and, consequently, improve their autonomy. In this respect, one of the participants stated:
“In my opinion, active presence in in-service training and gaining information can be effective…” (P8).
In terms of tariff setting for nursing services, one of the participants said:
“When we don’t receive money for the tasks we do, we will not be autonomous” (P2).
“Medical dominance in clinical settings is highly effective in nurses’ autonomy. For instance, the hospital manager is a physician. Everything has been defined for physicians…Physicians are even paid for some procedures that have been done by nurses. Under these circumstances, physicians do not let us work autonomously. If financial issues were not a problem, nurses would be paid for what they did, which could consequently enhance their autonomy” (P4).
“Accreditation of nurses requires a defensive force” (P6).
Managers’ power was also reported to increase support for nurses, thereby enhancing autonomy in this profession.
“More powerful authorities may provide nurses with more support…” (P2).
In line with the present study, Ulrich revealed the direct impact of organizational factors and regulations on nurses’ autonomy (22).
3. Society’s sociocultural platform
This category included social and individual views towards the profession, equity among the treatment team members, valuing autonomous performance, workplace (urban/rural, clinic/hospital), and cultural, social, political, economic, religious, and traditional factors.
Considering the effect of workplace on nurses’ autonomy, one of the participants maintained:
“Nurses sometimes take tests for each other. They may not have sufficient motivation or the hospital environment may have convinced them that there is no difference between having and not having knowledge” (P1).
Regarding the social view and impact of culture, one of the participants said:
“Our major was long among the low-level occupations. Of course, people have a better view towards the profession nowadays, but they still consider us as mere service providers. Nothing more is expected from us and, as a result, we don’t try to be autonomous” (P6).
In the present study, the nurses discussed the negative effect of culture on autonomy. In contrast, Ingrid Hanssen mentioned autonomy and freedom as the inseparable elements of reasoning as well as the natural components of maturity in the western culture. In other words, the ideal western autonomy is a part of the cultural heritage.
Regarding the lack of equity between nurses and physicians, one of the study participants mentioned:
“We are not independent. There is not equity between us and physicians. If we were considered at an equal level to physicians and were valued as much, we could make decisions more easily and work autonomously” (P4).
The abovementioned participant referred to the lack of equity between physicians and nurses as a factor preventing nurses from achieving professional autonomy. Consistently, Evanthia Georgiou conducted a study in Cyprus and reported a low level of cooperation between nurses and physicians in terms of patient care as well as a moderate level of autonomy amongst nurses (23). Furthermore, Daniel Salhani pointed to the negative effects of political, economic, religious, and traditional factors, but none of the participants mentioned these factors in clinical settings (24).
Attributes (based on the theoretical phase and field work)
Based on the theoretical phase and field work, two main themes; i.e., professionalism and personal capabilities, were the attributes of the concept of autonomy in ICU nurses.
The subcategories of this attribute were professional autonomy, professional skills, scientific performance, knowledge, value, commitment, accountability for one’s responsibilities, adherence to moral issues, legal privileges, and controlling adherence to the regulations of the profession.
With respect to the importance of professional knowledge and attitude and the need for deep professional knowledge in this theme, one of the participants stated:
“From my perspective, the most important point is that we should learn and believe in our lessons. Sometimes, nurses have learned something, but they don’t believe in it or they may have memorized the lesson…” (P2).
Similarly, Marla J. Weston and Gail Holland Wade revealed the necessity of educational and skill competencies in nurses, which led to their professional autonomy (21, 25).
Accountability for one’s responsibilities was yet another category extracted from professionalism.
“If the physicians did the right task and received income and I did the right task and received income, they would be responsible for their tasks and I would be responsible for mine” (P2).
Gilmore, as cited by Nouri, also emphasized autonomy alongside accountability as the prerequisite for professional nursing performance (26).
2- Personal capabilities
This theme involved critical thinking, responsibility, decision-making, and autonomous performance. One of the participants believed that lack of decision-making and independent performance would be accompanied by the lack of autonomy:
“When I work in a place where I know that I have some authorities and I don’t have to obey others, I will have a higher level of motivation, I will feel more responsible, I will try to keep up-to-date, because I know that I have to make decisions. However, when the physician is the one who makes decisions, I say to myself that we will do whatever the physician says in case of problems; the physician is responsible in any event” (P2).
“Nurses should make decisions for patients irrespective of the routines and physicians’ orders. They should provide patients with the best healthcare depending on the conditions and take responsibility for what they have done. They should do this according to the knowledge they have gained” (P8).
The present study findings revealed responsibility as one of the attributes of autonomy amongst ICU nurses. Katerina also disclosed that a high level of accountability, responsibility, and autonomy was required in ICUs in order to optimize patients’ outcomes (27).
Consequences (based on the theoretical phase and field work)
Based on the theoretical stage and field work, four main themes were obtained regarding the consequences of ICU nurses’ autonomy.
1- Increased personal competency
The consequences of autonomy in ICUs included increased responsibility, credit, motivation to continue education, implementation of creative ideas, performance of research activities, promotion of clinical judgement, and critical thinking. In this regard, one of the participants stated:
“If we can act autonomously, we will definitely have a higher level of motivation to improve our information and even continue our education, because we know that we will be able to act autonomously in case of having a higher level of knowledge” (P6).
Increased motivation for continuing education and working in the profession has also been expressed in the book titled “Autonomy and Empowerment of Advanced Practice Nurses in New Mexico” as well as in the study carried out by Riitta-Liisa Lakanmaa (28, 29). Polly et al. also conducted a study in 2017 and indicated individual capabilities as a consequence of nurses’ autonomy (30). In the same vein, Motamed-Jahromi demonstrated that increased responsibility was one of the consequences of nurses’ autonomy (31). Increased decision-making power and critical thinking were other consequences mentioned by Stewart in 2004 (32).
2- Promotion of care quality
Autonomy was found to enhance the quality of patient care. In this regard, one of the participants said:
“If we are autonomous, we have our own care protocols and we know what to do with patients without waiting for the physician. This is good for patient safety, as well” (P2).
Promoted care quality was one of the basic consequences of autonomy among ICU nurses, which has been confirmed in numerous studies(25-28, 31-33). Moreover, autonomy was found to reduce the costs as well as the length of hospital stay.
“Hospital-acquired infections will decrease and lower costs will be imposed on patients. It will also be beneficial for patients in terms of safety. In my opinion, it will be most beneficial for patients” (P6).
“Experienced individuals do many tasks independently. They do something, which is exactly ordered by physicians. This accelerates the process of patient care. Overall, it increases patient safety and accelerates the care process” (P3).
Reduction of the length of hospital stay and costs was another important consequence, which was mentioned by Polly in 2012, as well (28).
3- Improvement of the view towards the profession
In this respect, one of the participants maintained:
“It is important to have approved protocols. I sometimes feel that even the protocols coming from the Treatment Deputy are old and that is why physicians do not accept them. If they know that our protocols are up-to-date, they will accept them to be used in clinical settings, which will be effective in improving the view towards the nursing profession” (P2).
Many researchers have also argued that professionalism, specialism, and socialism could promote the view towards the nursing profession (34-36).
4- Organizational consequences
This theme included the facilitation of healthcare provision, increased adherence to guidelines and protocols, increased knowledge-based performance, and effective leadership.
In terms of knowledge-based performance and adherence to protocols, one of the study participants said:
“If nurses are autonomous, they will be motivated to perform more efficiently based on protocols. In this way, they will try to learn accurately and will be able to provide more professional care services” (P7).
In agreement with the present study findings, Nouri, Tao, and Carolyn Elaine Disher indicated that commitment to the profession and the organization resulted in higher adherence to regulations, as a consequence of nurses’ autonomy (7, 26, 37). Tume also reported the increased adherence to guidelines and protocols as an important consequence of nurses’ autonomy (38). Increased knowledge and experience was yet another organizational consequence disclosed by Baykara in Turkey (39). On the other hand, Panunto introduced lack of autonomy as a factor in nurses’ non-adherence to the profession (40).
Analytical reflection (based on the analytical phase)
Comparison of the concept of autonomy in the articles to that described by the key informants in the experimental phase indicated that the only difference between the data obtained from the field work and the theoretical phase was related to financial motivation. This was related to the mental and personality features, as one of the attributes, which was mentioned in the clinical setting, but was not found to be among the antecedents of nurses’ autonomy in the explored articles and texts. Furthermore, the negative effects of political, economic, religious, and traditional factors related to the society’s sociocultural platform were among the antecedents expressed in the articles, while they were not emphasized in the clinical setting. The integrated overview of the antecedents, attributes, and consequences of this concept has been presented in Table 1.