Abstract
The achievement of autonomous practice has been a clearly and consistently stated aim in nursing for many years. It is one which has driven significant changes in the education and preparation of student nurses, and one which continues to shape developments in clinical practice. This near universal, and perhaps uncritical, pursuit and endorsement of autonomy as a desirable attainment for nurses has its roots in commonly held beliefs about the status and influence enjoyed by more 'traditional' professions. Yet little is understood about the relationship between autonomy and nursing in the acute sector of the National Health Service (NHS). One of the key aims of this research is to explore whether nurses perceive themselves to be autonomous, and to identify conditions within nurses' work environment which either constrain or facilitate the development of autonomy. A second aim is to elucidate the relationship between the concepts of autonomy and influence. Having influence over managerial and resource decisions made within the hospital may be more important than having autonomy vis-a-vis nurses' ability to control their practice. Empirical measures of autonomy and influence were developed from data collected from 825 nurses working in 119 acute hospital wards in 7 RHAs, related to nurses' perceptions of the ward organisational environment. Three influence scales were developed associated with distinct managerial functions: influence over ward management, influence over the timing of ward and patient events, and influence over ward human and financial resources; and an autonomy scale. These scales were analysed in conjunction with scales measuring nurses' perceptions of other features of the ward organisational environment, and objective ward data about organisational practice, staffing characteristics and clinical specialty. Nurses' perceptions of autonomy were enhanced where care organisation was characterised by a high degree of individual nurse responsibility, and where the ward ethos of care was innovative. Social aspects of the ward environment and staffing resources were also important: nurses' perceived themselves to be more autonomous when they had a cohesive working relationship with ward nursing colleagues, and when there was a high degree of collaboration with medical staff. In addition, a high nurse/bed ratio and ward staff stability enhanced perceived autonomy. Perceptions of influence were particularly associated with a high ward grade mix, and individual nurses' clinical grades however. In general, nurses perceived themselves to be autonomous in their clinical practice, but to lack influence over managerial and resource decisions affecting the care they provide. This suggests that nurses have a narrow conceptualisation of autonomy, i.e. clinical autonomy, which is derived from the work organisation process at the micro, ward level. This type of autonomy is limited in scope and value however, because it makes little difference to nurses' ability to influence higher level hospital management decisions. The researcher argues that influence represents a missing, more enigmatic aspect of autonomy, and that consideration of both are vital to developing an understanding of nurses' position within acute NHS Trust hospitals, and to enhance nursing's professional development.