NURSING AND HEALTHCARE MANAGEMENT AND POLICY

Nurses autonomy: influence of nurse managers actions

Majd T. Mrayyan PhD RN
Assistant Professor, College of Nursing, The Hashemite University, Zarqa, Jordan

Submitted for publication 31 October 2002

Accepted for publication 24 July 2003

Correspondence: M R A Y Y A N M . T . ( 2 0 0 4 ) Journal of Advanced Nursing 45(3), 326336

Majd T. Mrayyan, Nurses autonomy: influence of nurse managers actions
College of Nursing, Background. Autonomy plays an important part in nurses job satisfaction and
The Hashemite University,
retention, but the literature shows that they are often dissatisfied with this aspect
P.O. Box 13133,
and want better working conditions and greater autonomy in decision-making.
Zarqa,
Jordan.
Aims. The aim of this study was to examine the role that nurse managers have in
E-mail: mmrayyan@hu.edu.jo enhancing hospital staff nurses autonomy.
Methods. The study used a comparative descriptive survey design. Data collection
took place over the Internet through the use of selective listservs in the United States
of America (USA), Canada, and the United Kingdom. Of the 317 hospital nurses
participating, 264 (833%) were from the USA. Differences relating to nurses, nurse
managers, and hospital settings were controlled in the analysis.
Results. Nurses were more autonomous in making patient care decisions than unit
operational decisions, and they perceived their autonomy to be at a moderate level.
Those who were autonomous in patient care decision-making were also likely to be
autonomous in unit operation decision-making. Nurse managers actions had a
strong relationship with nurses autonomy in deciding on patient care and unit
operation decisions, and with total autonomy. The three important variables that
were reported by staff nurses to increase their autonomy were supportive man-
agement, education and experience. The three most important factors that were
reported to decrease nurses autonomy were autocratic management, doctors and
workload.
Discussion. Technical issues such as the availability of listservs, valid e-mails, vir-
uses, and familiarity with the Internet and its applications were the major limita-
tions of this study. Nurses autonomy over patient care and unit operations
decisions needs to be enhanced, and nurse managers should promote this. Similarly,
there is a role for nurse education, both in preregistration programmes and in
continuing education for managers. Further research needs to explore the barriers
that nurses face in autonomous decision-making and how nurses participation in
unit operational decisions can be promoted.
Conclusions. Hospital staff nurses have moderate autonomy which could be in-
creased by more effective support from nurse managers. The use of electronic
questionnaires is a promising data collection method.

Keywords: hospital staff nurses, autonomy, nurse managers, decision-making

sibilities. Major changes have taken place in health care

Introduction
systems globally. These changes include, but are not limited
In todays health care environment, the role of the nurse has to, a shortage of nurses, shortened lengths of stay in hospitals,
become more complicated, and is linked to multiple respon- an increasing emphasis on cost effectiveness, downsizing of

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2004 Blackwell Publishing Ltd

Nursing and healthcare management and policy
health facilities, and an increase in patients with acute and
chronic diseases (Davidson et al. 1997, Baker et al. 2000,
Curtin 2000). These changes increase the need for autonom-
ous nursing practice.
Enhancing nurses autonomy has been of interest to those
who wish to maintain nursing standards and promote the
professionalism of nursing. Autonomy is viewed as a
positive concept for nurses (Ballou 1998, Nietsche &
Backes 2000), influencing job satisfaction, retention and
quality of care. Today, when staffing levels are reduced in
hospitals, there are concerns about a decline in the quality
of care because of the increased demands of workload and
patient acuity (Davidson et al. 1997, Curtin 2000, Blegen
2001). These demands may also influence the autonomy of
nurses.
The purpose of this research was to examine the percep-
tions of hospital staff nurses about: their autonomy in
practice; the roles that nurse managers have in enhancing
their autonomy; and actions that nurse managers could use to
enhance their autonomy. This is one of only a few studies to
link reported nurse managers actions with staff nurses
autonomy. It is also one of only a few studies that has used an
electronic questionnaire for data collection.
Literature review
Nurses autonomy is an important factor in their job
satisfaction and in staff retention. Effective nurse managers
could be the link between nurses autonomy, job satisfaction,
and retention. A review of literature showed numerous
studies that reported that nurses were dissatisfied in their
work, and desired better working conditions and increased
autonomy in their work environments (Chaboyer et al. 1999,
Chaboyer et al. 2001, Finn 2001).
Autonomy is not always clearly defined and operational-
ized in nurses daily professional lives (McParland et al.
2000). Research findings suggest that autonomy is the
strongest predictor of nurses job satisfaction, which in turn
reflects positively on and influences retention of nurses (Boyle
et al. 1999, Burnard et al. 1999, Chaboyer et al. 1999, 2001,
Nolan et al. 1999, Richard 1999, Wade 1999, ORourke
et al. 2000, Upenieks 2000, Finn 2001). Of equal importance
is the exploration of how nurse managers can enhance the
autonomy of nurses.
Nurses autonomy is a phenomenon of international rele-
vance that is linked to work environment. Varjus et al. (2003)
describe the autonomy of Finnish intensive care unit nurses as
being a part of empowerment. The majority of nurses reported
that they had more autonomy in decision-making about patient
care than about unit operations. The autonomy of nurses is

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
Nurses autonomy
linked to their managers leadership style; leaders are recog-
nized as central to nursing teams (Kosinska & Niebroj 2003)
and clinical supervision can promote autonomous behaviours
in nursing professionals (Berggren & Severinsson 2003).
Nurse managers who enhance staff nurses autonomy are
also likely to enhance their job satisfaction and decisions to
stay in their jobs (Huff 1997, Seguin 2003). In addition, a
manager who is considerate to staff, values their input, and
supports personal development has a direct effect on retent-
ion (Boyle et al. 1999). Also, managers leadership behav-
iours can influence staff retention indirectly, through the
utilization of their work experience, individual decision-
making, communication of essential information, and rela-
tionships with co-workers (Nolan et al. 1999).
Research findings have accentuated the vital role of nurse
managers in influencing staff nurses autonomy, work envi-
ronment and quality of working life, and in facilitating
patient care (Kennerly 2000, Margall & Duquette 2000,
Gould et al. 2001, Kerfoot 2001). Work environment is
linked to leadership and management styles (Boyle et al.
1999, Davidhizar & Cathon 2001), and Lucas (1991) reports
a strong positive relationship between participative leader-
ship and job satisfaction.
The study
Research questions
This study was conducted to examine the roles of nurse
managers in enhancing hospital staff nurses autonomy, and
was aimed at answering the following research questions:
1 What aspects of autonomy do nurses perceive that they
have in patient care and operational decisions about their
units?
2 What are the actions of nurse managers that enhance staff
nurses autonomy?
3 What is the relationship between the perceived actions of
nurse managers and nurse autonomy?
4 What are the three most important factors that hospital
staff nurses perceive to encourage their work autonomy?
5 What are the three most important factors that hospital
staff nurses perceive to hinder their autonomy?
Participants
A convenience sample of nurses was obtained from hospital-
employed nurses who participated in 23 nursing listservs in the
United States of America (USA), Canada and the United
Kingdom (UK). From these listservs, a total of 6000 addresses
were collected from 8 November 2001 to 17 December 2001,
327
M.T. Mrayyan
giving 3615 potential participants. One listserv was cancelled,
which resulted in failure of delivery for 532 e-mail addresses.
One Internet provider stopped its free delivery and another
one was sold, which resulted in some changes in participants
e-mail addresses. These changes resulted in 607 returned
e-mails because of invalid addresses (23% of the e-mails were
non-deliverable). Nine hundred and ninety-seven e-mails were
not sent because it was determined from their e-mail addresses
that they were educators or researchers (tested through 50
individual contacts who responded that they were not eligible
because they were working in nursing schools), and another
249 people e-mailed back that they were not eligible either
because they were not nurses or had not worked in hospitals
settings in the past 5 years. However, these study limitations
were similar to what Sheehan and Hoy (1999) experienced in
their electronic data collection. They sent 5000 e-mails to
collect their studys data, but 255% were non-deliverable and
it was difficult to compute an accurate response rate.
Our sample was one of convenience, based on the
accessibility of hospital staff nurses from different countries.
In this type of sampling bias is great, as is the threat to
validity. The fact that nurses who subscribe to listservs might
not be representative of the whole region should be taken into
consideration. Also, our study was directed toward hospital
staff nurses representing one occupational group. Use of the
Internet limits the sample to those who have access and the
knowledge to use the Internet. However, unless some
researchers take the risk of conducting electronic data
collection, the promises of web-based research will remain
unfulfilled.
An eligibility criterion ensured that nurses were familiar
with hospital environments, by requiring that they had
worked in a hospital for at least 1 year within the last
5 years. Contact was made with the potential participants,
and they were requested to indicate if they met the criterion
and would be willing to participate in the study.
Questionnaire
Following the method used by Hayajneh (2000), an elec-
tronic questionnaire was used. The questionnaire had four
parts:
Part I Autonomy scale. The autonomy scale of Blegen et al.
(1993) was used to measure nurses autonomy. The
questionnaire was a self-report tool consisting of 42 items;
21 items related to decisions about patient care and the other
21 items related to decisions about unit operations. Blegen
et al. used an expert panel to review the 42 items. Panel
members grouped items into four sections for both the patient
care subscale and the unit operations subscale:
328
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
Decisions related to patient care:
defining patient care provision
enhancing staff collaboration
handling patient and physician complaints
resolving diagnosis and discharge-related issues.
Decisions related to unit operations:
organizing their own work
planning to deliver high quality care
developing and revising patient care procedures
managing unit resources.
Blegen et al.s scale is a Likert scale with responses ranging
from 1 to 5 as follows: 1 nurses have no authority and
accountability; 2 nurses assume authority and account-
ability when asked; 3 nurses share authority and account-
ability with others; 4 nurses consult with others and
participate in group decisions; 5 nurses have full inde-
pendent authority and accountability. Blegen et al. obtained
Cronbachs alpha coefficients of 078 for the patient care
decisions subscale and 092 for the unit operation subscale.
Content validity of the entire scale was determined through
the expert panel and found to be satisfactory.
Part II Nurse managers actions scale. A scale (initially nine
items) was developed specifically for this study, based on the
literature (Hersey & Blanchard 1988, Taunton et al. 1989a,
1989b, 1997, Weaver et al. 1991, Blegen et al. 1993, McGillis
& Donner 1997). Staff nurses were asked how often the nurse
manager performed certain actions, such as: supports nurses
to resolve conflicts with physicians, patients, and colleagues
and supports staff nurses autonomous decision-making. A
five-point Likert scale was designed, as follows: 1 does not
do; 2 seldom; 3 sometimes; 4 usually; 5 always.
Part III Characteristics/demographic data. Demographic
data were collected on both nurses and managers. Nurses
characteristics related to: gender, marital status, shift worked,
time commitment, country where nurses currently worked,
education, age, years of experience in nursing, and years of
experience in the current area of work. Nurse managers
characteristics related to: gender, education, age, years of
experience in nursing, and years of experience in management.
Part IV Open-ended questions. In order to cover all aspects
of nurses autonomy, two open-ended questions asked the
staff nurses to list: (a) three factors that they considered
important to enhancing their autonomy, and (b) three factors
that they considered hindered their autonomy.
Reliability and validity
The study used a descriptive comparative design. Ten nurse
managers in the USA were used as an expert panel to
establish the content validity of the nurse mangers actions
Nursing and healthcare management and policy
scale (initially consisting of nine items), and found it to be
satisfactory. The internal consistency of scale items (reliab-
ility) was addressed by correlating each of the nine items with
the total item score. The acceptable level of coefficient alpha
was set at not <070 (Thorndike 1982). However, because
the total number of items was small, the concept of negative
correlation vs. positive correlation was used. Positive corre-
lation indicated the internal consistency of scale items, and
negative correlation indicated that items were not related to
each other and that they were not measuring the same
phenomenon (Pedhazur & Schmelkin 1991, Norusis 1993).
One item showed negative correlation (r 019) and was,
therefore, eliminated. Itemtotal correlation of the other
eight items ranged from 012 to 084, and the reliability
coefficient was 066. The nurse managers were asked for
recommendations on the content of a second (eight-item)
draft of the scale. Four of the 10 respondents thought that
nurse managers should encourage autonomous decision-
making, self scheduling, and participation in planning capital
expenditures. Three items were added to capture these ideas.
The revised scale, following the pilot test, consisted of
11 items. The reliability coefficient of the 11 items was 088,
which is satisfactory for a newly established scale.
Pilot study
The electronic questionnaire was piloted with five graduate
nursing students who were requested to estimate the time
required to complete the questionnaire and to identify any
technical difficulties or any defects in the data inputting
process. Based on the pilot study, the time required to fill and
submit the electronic questionnaire was estimated to be
20 minutes. Data were imported accurately into the database
file; this was confirmed by comparing the answers in the
submitted electronic questionnaire with those in a hard copy
of the questionnaire. The pilot study was also intended to
detect any issues relating to the web server on which the
electronic questionnaire was hosted.
Main study
An attempt was made to send each nurse an invitation and an
electronic questionnaire link via their e-mail addresses. A
reminder to participate in the study was sent to 13 clinical
listservs, because of an initial low response rate. Four
hundred and fifty questionnaires were returned, and data
cleaning resulted in 317 usable questionnaires, of which 264
(833%) were from the USA and 53 (167%) from Canada
and the UK. With web-based data collection, it is very
difficult to calculate an accurate response rate because of

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
Nurses autonomy
non-deliverable e-mails (Sheehan & Hoy 1999). Also, it is not
known how many people who received the request to
participate were not eligible. However, sampling a large
and diverse population from different countries resulted in an
estimated response rate of nearly 10%.
After consulting a statistician, samples from Canada and
the UK were combined to form a non-USA sample, as data
from these samples showed similar standard deviations with
regard to nurses and managers demographic details and
organizational characteristics. This made comparisons and
meaningful data interpretation possible, although some
differences between the health care systems of these countries
had to be borne in mind.
Ethical considerations
The university institutional review board approved the
implementation of the study. Returned questionnaires did
not include the names of respondents, as they were imported
directly into a database file that was created through
Microsoft Access, thus assuring anonymity and confidential-
ity.
Data analysis
For all statistical data analysis, alpha was set at 001, as the
study had many variables. Thus, significant results that were
due to chance were minimized. The research questions were
addressed by using data analysis procedures and statistics such
as mean, standard deviations, frequencies, Pearson product
moment correlations, regression analyses, and content analy-
sis for the two open-ended questions. T-tests and chi-squared
tests were used to compare between the USA and non-USA
samples. The t-test was used with continuous variables such as
the autonomy items and nurse managers actions, while the
chi-squared test was used with categorical variables such as
sample demographics (Agresti & Finlay 1999).
Results
Significant differences in participants demographic details
are displayed in Tables 13. Comparisons of the demographic
variables of the two groups of USA and non-USA nurses and
nurse managers were performed using chi-square analysis, as
all variables were treated as categorical. Nurses selected their
categories by marking checkboxes in the electronic question-
naire. Unequal sample sizes between USA and non-USA
nurses were taken into consideration during data analysis by
looking for any extreme differences in the standard deviations
of variables before data interpretation.
329
M.T. Mrayyan

There were some differences between countries in terms of
nurses demographic details (Table 1) such as gender
(P 0001): the non-USA part of the sample was 245%
(n 13) male, while the USA part was only 8% (n 21)
male. There were differences between countries in shifts
worked (P < 0001): 212% (n 56) of USA nurses worked
night shifts vs. 38% (n 2) in other countries, and only
182% (n 48) of USA nurses worked rotating shifts vs.
472% (n 25) of non-USA nurses.
Comparisons between USA and non-USA nurse managers
demographic details (Table 2) indicated there were significant
differences in terms of the level of education (P < 0001).
Over 85% (n 211) of USA nurse managers held bacca-
laureate or masters degrees vs. 568% (n 25) in other
countries. In other countries, more nurse managers held a
diploma than in the USA (432%, n 19 vs. 149%, n 37).
There were significant differences between nurse managers in
term of age (P 0004): 157% (n 8) non-USA nurse
managers were 2534 years old vs. 55% (n 14) in the
USA, and 176% (n 9) non-USA nurse managers were
55 years old or more vs. 74% (n 19) in the USA. The
majority of USA nurse managers were 3554 years old

Table 1 Nurses demographics

Whole Other
sample USA countries

Variable n* % n* % n* % Chi-square Significance

Gender 1266, 1 d.f. 0001

Male 34 107 21 80 13 245
Female 283 893 243 920 40 755
Shift worked 2497, 3 d.f. <0001
Day 163 514 139 527 24 452
Evening 23 73 21 79 2 38
Night 58 183 56 212 2 38
Rotating 73 230 48 182 25 472
Type of unit 7365, 5 d.f. <0001
General medicine 64 213 46 186 18 339
Intensive care 71 237 66 267 5 94
Obstetrics 63 210 58 234 5 94
Psychiatric 21 70 5 21 16 303
Operating room 36 120 32 130 4 76
Emergency room 45 150 40 162 5 94

*The total of some categories do not equal 317 because of missing data.

Table 2 Nurse managers demographics (as

Whole Other
reported by nurses)
sample USA countries

Variable n* % n* % n* % Chi-square Significance

Level of education 1927, 2 d.f. <0001

Diploma 56 192 37 149 19 432
Baccalaureate 116 397 104 420 12 272
Master 120 411 107 431 13 296
Age (years) 1330, 3 d.f. 0004
2534 22 72 14 55 8 157
3544 143 464 124 482 19 373
4554 115 373 100 389 15 294
55 or more 28 91 19 74 9 176
Years of experience 1503, 2 d.f. 0001
in nursing
<1 7 25 2 09 5 104
59 36 130 29 127 7 146
10 or more 234 845 198 865 36 750

*The totals for some categories do not equal 317 because of missing data.

330
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
Nursing and healthcare management and policy Nurses autonomy

Table 3 Mean values and standard deviations of autonomy scores decisions. Alpha reliability of the autonomy scale was 094
 for the 42 items.
Score n X SD
Patient care decisions and unit operation decisions were
Total autonomy 317 314 068 ranked in ascending order, based on their reported means.
Patient care decisions autonomy 316 374 074
Nurses reported that they had the most autonomy when
Unit operation decisions autonomy 316 256 086
making decisions about the following areas of patient care:
serving as patient advocates, questioning physician orders,
(871%) (n 224) vs. 667% (n 34) in the non-USA teaching about patient medication, consulting with medical
sample. Nurse managers in the USA were more experienced doctors (MDs) and other professionals, and preventing skin
(P 0001). Only 09% (n 2) of nurse managers had breakdown (Table 4). On the contrary, nurses reported low
<1 year of experience in nursing in the USA compared with autonomy in relation to informing patients about surgical
104% (n 5) in other countries, and 865% (n 198) of risks, ordering diagnostic tests, and determining the day of
USA nurse managers had more than 10 years of experience discharge.
compared with 75% (n 36) of nurse managers in other With regard to unit operational decisions (Table 5),
countries. nurses were most autonomous when trading hours with
To answer research question 1, a mean score for each of each other (replacing each other on the schedule), deciding
the subscales relating to autonomy was calculated by adding their own breaks and lunch times, making patient assign-
the items and dividing the total by 21, as each subscale had ments, serving on departmental committees, and presenting
21 items. On a 5-point Likert scale, the sample mean for unit in-service programmes. Nurses reported low autonomy
total autonomy was 314. The mean for patient care in respect of interviewing and selecting new staff, identifying
decisions autonomy was 374 and the mean for unit causes of unit budget variance, and planning the yearly unit
operation decisions was 256 (Table 3). These results budget.
indicate that nurses perceived they had more autonomy To answer research question 2, a mean score for the nurse
over patient care decisions than over unit operation managers actions scale was calculated by adding the items
and dividing the total by 11, as this scale had 11 items. The
mean score for nurse managers actions was 303 (Table 6),
Table 4 Mean values and standard deviations of patient care deci-
sions autonomy subscale Table 5 Mean values and standard deviations of unitoperation
decisions autonomy subscale
n 317
 n 317
Patient care decisions X SD

Unit operation decisions 

X SD
1. Serve as patient advocate 458 093
2. Question physician orders 439 103 1. Arrange for trading hours 358 141
3. Teach about patient medication 436 111 2. Decide own break and lunch time 357 134
4. Consult with MD and other professionals 432 109 3. Make patient assignments 324 146
5. Prevent skin breakdown 432 109 4. Serve on department committee 311 140
6. Teach self care activities 428 112 5. Present unit in service 307 147
7. Discuss alternatives with physician 426 112 6. Determine delivery of care method 301 142
8. Prevent patient falls 422 109 7. Implement new ideas 298 133
9. Teach heath care promotion activities 415 114 8. Schedule own hours 266 144
10. Refuse to carry out physicians orders 403 106 9. Develop unit goals 262 117
11. Decide time to administer care 402 121 10. Develop and revise unit procedures 258 118
12. Plan care with patient 396 118 11. Develop and revise standards of care 248 123
13. Advance PRN orders 378 143 12. Develop and revise unit policies 245 117
14. Refer to other health care professionals 368 130 13. Initiate research activities 244 137
15. Make decision for pain management 363 123 14. Determine quality assurance indicators 232 129
16. Handle individual patients complaints 349 113 15. Choose new equipment and supplies 232 114
17. Develop patient education material 314 130 16. Determine staff meeting agendas 221 122
18. Handle physician complaints 310 130 17. Develop peer review evaluation 208 121
19. Inform patient of surgery risks 288 143 18. Staff nurse job description 206 123
20. Order diagnostic test 204 127 19. Interview and select new staff 174 108
21. Determine day of discharge 178 107 20. Identify causes for unit budget variance 164 107
21. Plan yearly unit budget 136 087
PRN, pro re nata (when necessary).

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336 331
M.T. Mrayyan
Table 6 Mean values and standard deviations of nurse managers
actions (n 317)
Nurse managers actions
Encourages nurses to communicate openly with all
members of the health care team
Supports nurses to resolve conflicts with physicians,
patients, and colleagues
Encourages leadership among nurses
Supports staff nurses autonomous decision-making
Consults nurses while establishing standards of care
Allows staff nurses to self-schedule
Delegates to nurses 24-hour responsibility about their
units decisions
Helps nurses to develop plans to meet their educational
needs
Stimulates nurses intellectual discussions about work
Encourages nurses to participate in research projects
and use research
Involves staff nurses in planning the capital expenditure
Mean
indicating that nurses felt that their managers sometimes
encouraged them to enhance their autonomy.
Nurses reported that their nurse managers enhanced their
autonomy through the following managerial actions:
encouraging nurses to communicate openly with all mem-
bers of the health care team; supporting nurses to resolve
conflicts with physicians, patients, and colleagues; and
encouraging leadership among nurses. On the contrary,
nurses reported that their nurse managers did less to
encourage them to participate in research projects and use
research results, and also did less to involve them in
planning capital expenditures.
To answer research question 3, the total score for nurse
managers actions was correlated with the total scores
relating to autonomy in patient care decisions, autonomy in
unit operational decisions,and autonomy as a whole
(Table 7). The correlation of 058 indicated a positive
relationship between total autonomy and nurse managers
actions. The significant and moderate correlation between
autonomy in patient care decisions and nurse managers
actions was 034, and the correlation between autonomy in
unit operation decisions autonomy and nurse managers
actions was 062. These correlations indicate that nurse
managers actions may positively influence nurses autonomy.
Also, it appears that nurse managers actions have a strong
relationship with nurses autonomy in certain areas of unit
operational decisions.
In answering questions 4 and 5, nurses indicated that the
three important factors that increased their autonomy were:
332
Table 7 Comparisons of correlations of autonomy scores and nurse
managers actions (n 317)

X SD Autonomy scores Nurse managers
action
379 130
Total autonomy 058*
343 137 Autonomy on patient care decisions 034*
Autonomy on unit operation decisions 062*
332 145
327 147 *Correlation is significant at 001 level (one-tailed).
319 140
295 152
295 146
supportive management (n 52, 164%), education (n 20,
63%), and experience (n 21, 66%). The three most
291 138 important factors that staff nurses indicated hindered their
autonomy were: autocratic/non-participative management
290 148 (n 67, 211%), physicians (n 28, 88%), and workload
254 150
(n 14, 44%). Poor communication between physicians
213 126 and nurses was perceived to be a hindrance to nurse
autonomy. Shortage of nurses, with resulting increases in
303 111
workload, was identified by nurses as decreasing or hindering
their autonomy.
Discussion
Limitations of the study
Web-based research is reported to have a lower response
rate than traditional mailed surveys (Duffy 2002). In this
study, 23% of the e-mails were non-deliverable. Data
collection took place at a time of massive increases in new
computer viruses, which is documented in a recent study as
one problem that may affect electronic data collection
(Duffy 2002). The web server on which the electronic
questionnaire was hosted went down for 6 hours during the
time that a reminder was being sent to the 13 clinical
listservs. Data collection was initiated following the polit-
ical and emotional event of the 11 September 2001. Also,
some nurses might not have an Internet connection at
home. The majority of responses were sent during the day
and rarely arrived in the evening or at weekends; most of
nurses responded while they were working in the hospital.
Nurse managers actions as reported by nurses were
studied; nurse mangers themselves should be studied in
future research.
Enhancing staff nurses autonomy
The purpose of this study was to examine the perceptions
of hospital staff nurses about their autonomy in practice
and the role that nurse managers have in enhancing
autonomy.

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
Nursing and healthcare management and policy
Nurses reported that they had more autonomy in making
patient care decisions than unit operation decisions. This
finding is consistent with the results of other studies
(Ferguson-Pare 1996, Cook et al. 2001, Krairiksh & Anthony
2001).
Nurses also reported that their managers sometimes
encouraged them to enhance their autonomy. Studies have
shown that nurses who work in hospitals desire autonomy
and responsibility and usually like to be led by a leader with a
participative leadership style (Allen 2000, Margall &
Duquette 2000). These managers are open-minded, and
facilitate team communication, conflict handling, and shared
decision-making. The findings about nurse managers actions
that promote nurses autonomy are supported by those of
other studies (Adams et al. 1996, McGillis & Donner 1997,
Taunton et al. 1997).
Nurses reported that the three important variables that
increased nurses autonomy were supportive management,
education and experience. On the contrary, the three most
important variables that were reported to decrease autonomy
were autocratic/non-supportive management, physicians and
workload. Education enhances nurses autonomy, and those
who had taken university-based undergraduate nursing
courses demonstrated a more positive attitude toward pro-
fessional autonomy than those who had hospital-based
training (Williams & McGowan 1995). Experienced staff
nurses had more authority and autonomy in their work.
Professional autonomy in nursing has been found to increase
with increases in grade of post and years of experience
(Kikuchi & Harada 1997, Hooi et al. 2000).
Nurses lack of autonomy has been related to hospital rules
and physicians traditional mode of supervision and control
(Carmel et al. 1988). Medical decisions were reported to be
given higher priority than nursing decisions. Autonomy has
been viewed by others as an important factor in the power
imbalance between nurses and physicians (McParland et al.
2000). Unfortunately, in this power struggle patient care,
which is supposed to be the major goal of a health care
system, is often relegated to a lower priority. Increased
workload (related to patient acuity) has also been associated
with registered nurse perceptions of lower autonomy
(Ferguson-Pare 1996). In these situations, nurse mangers
have vital roles to play. Practising a participative manage-
ment and decision-making style could enhance autonomy.
Implications for practice
The findings indicate that nurses have more autonomy over
patient care decisions than over unit operation decisions.
Nurses reported a high level of autonomy in response to the

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
Nurses autonomy
majority of patient care decision items. However, there was low
autonomy in relation to some aspects of patient care decisions,
such as determining day of discharge, which may reflect
negatively on the quality and cost of nursing care. Patients who
are discharged prematurely may be rehospitalized with more
complicated conditions. Nurses should become more involved
in discharge-related decisions as they have the knowledge to
assess patients readiness to care for themselves. This informa-
tion must be used in team decisions about discharge.
Autonomy relating to unit operational decisions was
reported to be lower than that relating to patient care
decisions. In only two of the 21 unit operation decisions, was
the mean above 35 on a 5-point scale; these related to
arrangements for trading hours and deciding own break
and lunch time. Blegen et al. (1993) report that staff nurses
would welcome making more decisions that are related to
unit operations. Discussion has to take place between nurses
and nurse managers on strategies to increase the involvement
of nurses in unit operation decisions. They should explore
how to increase nurse involvement in research activities and
how to facilitate input into planning the unit budget. A
participative management style on the part of the nurse
manager can assist in these initiatives.
In response to the items inviting comments, participative
management was identified as the main factor that enhanced
nurses autonomy and autocratic/non-participative manage-
ment was the main factor that hindered it. Increasingly, as
researchers explore the attributes of professional practice
environments, participative management is highlighted as a
factor in enhancing nurse autonomy, a main attribute of
professional practice. In my study, nurse managers were
perceived by staff nurses as sometimes engaging in actions
that enhanced their autonomy. Staff nurses and their man-
agers need to engage in dialogue to determine which
managers actions are likely to enhance staff nurse autonomy.
Nurses reported physicians as the second factor that
hindered their autonomy. To achieve optimum patient care,
nursephysician collaboration is needed, based on trust,
respect, and joint contributions of knowledge, skills and
values.
Implications for education
The findings suggest that education enhances autonomy.
Nursing students at undergraduate and graduate levels can be
offered extensive coursework in leadership, communication,
conflict resolution, and decision-making. Moreover, nurse
managers have to be educationally prepared to assume their
roles and responsibilities and to fulfill organizational goals.
Nurses who plan to be in administrative positions should take
333
M.T. Mrayyan
What is already known about this topic
Nurses autonomy is an important factor in their job
satisfaction and retention.
Nurses have limited autonomy in the work environment
and they are dissatisfied in their work.
The role of nurse managers has rarely been studied, but
their leadership styles are important in promoting staff
retention and job satisfaction, which are the conse-
quences of autonomy.
What this paper adds
A link between the reported actions of nurse managers
and hospital staff nurses autonomy.
Managerial actions, as perceived by staff, that nurse
managers can use to increase the autonomy of nurses.
An example of use of the Internet for data collection.
core courses in nursing administration, especially in their
graduate curriculum. Nurse educators can prepare nurses in a
way that enhances their clinical autonomy, based on realistic
expectations about the practice environment.
Education of managers in participative management strat-
egies has become critical, as we struggle to enhance the
practice environment and improve recruitment and retention
strategies. Courses could include material on shared govern-
ance initiatives, a central theme of which is participative
management
Implications for research
This study is considered to be a baseline for further research
that could explore in more depth the role of the nurse
manager in enhancing nurse autonomy. The instrument for
measuring nurse managers actions could be expanded to
involve a wider range of managerial activities. Further
research is needed to examine the barriers to autonomy that
nurses face in relation to unit operational decisions and what
actions nurse managers can take to increase nurses partici-
pation in these decisions. In addition, intervention studies
should be conducted to determine the impact of nurse
managers actions on staff nurses perceived autonomy over
nursing care decisions and unit operation decisions.
Summary and conclusions
This is a descriptive study of a convenience sample of hospital
staff nurses, with data collection taking place over the Internet.
334
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 326336
The perceptions of staff nurses about the influence of nurse
managers actions on nurses autonomy are described.
Nurses reported their autonomy to be at a moderate level.
Changes in health care systems demand new nursing roles
and autonomous decision-making. The roles of nurse
managers are becoming increasingly important in todays
complex and changing health care environment. The study
results highlight the importance of nurse managers actions
on nurses autonomy. Given the complexity of todays
health care environment, it is a challenge to encourage and
maintain nurse autonomy. Nurse managers have significant
roles to play in enhancing staff nurses autonomy. This can
be accomplished by practicing participative management,
trusting nurses ability to make decisions, and delegating
authority and responsibility for decision-making to staff
nurses.
Staff nurses and their nurse managers can do much to
manipulate the environment to enhance nurses autonomy in
making both patient care decisions and unit operational
decisions. As a long-term investment, managers and admin-
istrators need to pay close attention to nurse autonomy as it
enhances nurse retention. The presence of autonomous and
long-serving nurses would have a positive effect on the
quality and cost-effectiveness of patient care. As a long term
investment, nurses autonomy should commence at recruit-
ment; the organization should advertise and promote itself as
an autonomous work environment to attract nurses. How-
ever, this promotional strategy must be translated into action
after nurses are recruited.
Acknowledgements
Special thanks are due to Prof. Joanne McCloskey Dochterman
at the University of Iowa College of Nursing for her help during
my doctoral study and Prof. Sonia Acorn at the University of
British Columbia College of Nursing for her help in preparing
this manuscript.
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