Level of autonomy of primary care nurse practitioners
Alex Bahadori,DNP, ARNP-C (Doctor of Nursing Practice)1& Joyce J. Fitzpatrick,PhD, RN, FAAN (Elizabeth Brooks Ford Professor of Nursing)2
1 Professional Dermatology Services, Gulf Coast Dermatology, Hudson, Florida
2 Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
Keywords
Autonomy; nurse practitioners; primary care; Dempster Practice Behavior Scale.
Correspondence
Alex Bahadori, DNP, ARNP-C, 12482 Everard Dr., Spring Hill, FL 34609. Tel: 352-556-6228; Fax: 352-684-6578; E-mail: alex.bahadori@case.edu Received: February 2008; accepted: June 2008 doi:10.1111/j.1745-7599.2009.00437.x Abstract
Purpose: The purpose of this descriptive study was to determine the level of autonomy of nurse practitioners (NPs) providing care to patients in a primary care setting.
Data sources: Data were collected from 48 primary care NPs (PCNPs) who attended a state clinical conference. The Dempster Practice Behavior Scale (DPBS) was used to measure the autonomy of the NPs.
Conclusions: The total mean score for the DPBS in this study was 127 (SD=10.25), indicating a very high level of autonomy of the NPs. The Empowerment subscale had the lowest overall mean score, and the Valuation subscale had the highest. There was no statistically significant relationship between level of autonomy and age, years worked as an RN, and years worked as an NP.
Implications for practice: This study provided evidence that PCNPs are highly autonomous professionals and continue to struggle with empowerment. NPs educationally prepared with a better knowledge of legal and political issues will be better suited to influence healthcare reform. NPs, as autonomous professionals, will be more likely to impact and shape future healthcare policy.
Introduction
Autonomy in practice has been a dominant professional issue for nurse practitioners’ (NPs) performance and practice (Dempster, 1990, 1994). Professional autonomy means allowing professionals to have substantial control over professional practice, including significant room for exercise of their judgment (MacDonald, 2002). NPs working in restrictive practice environments may perceive themselves as less autonomous. NPs working in managed care systems, with excessive rules and regulations, have reported lower levels of autonomy (Ulrich & Soeken, 2005). Legal and organizational restrictions have been dominant barriers to optimal autonomous practice of NPs (Timmons & Ridenour, 1994).
Thus far, many researchers have addressed autonomy in the context of other variables, such as organizational influences, prescribing patterns, decision making, and role implementation. Researchers have also compared
the outcomes of primary care NP (PCNP) autonomy to other types of providers. However, there is limited information on the actual level of autonomy of PCNPs. This study provides information on the level of autonomy of PCNPs, and the findings may be used for future research to understand the complex variables that influence the autonomous practice of PCNPs.
Background
NPs working in primary care settings are also known as PCNPs. PCNPs comprise the largest group of NPs. Rapid changes in healthcare delivery, financial constraints, and consumer demand have influenced the practice of all healthcare providers and are critical factors in the emergence in the role of the PCNP (Furlong & Smith, 2005). The majority of PCNPs practice in outpatient areas providing care to the adult patient population. ©
Studies have shown that NPs have the knowledge and expertise to meet the healthcare needs of the ambulatory patient population (Daly & Carnwell, 2003; Mundinger et al., 2000).
The rapidly evolving healthcare environment mandates that PCNPs function at the highest level of professional autonomy. Without increased autonomy, NPs in primary care will not be able to use their skills to the fullest extent and may have limited impact on healthcare reform. Also, many view the relationships between NPs and physicians as supervisory rather than collaborative. Successful collaborative practice requires more than just working in physical proximity to others (Almost & Laschinger, 2002). In collaborative practice, an NP and a physician provide primary health services to a group of patients, and the two professionals share authority equally for providing care within the scope of their practice (Mundinger, 1994).
Chumbler et al. (2000) examined the impact of demographic characteristics, practice attributes, and primary practice settings on NP decision making and the effects of decision making on clinical productivity. The results indicated that having more years of practice as an NP, treating patients according to clinical guidelines, practicing in a multi-specialty group practice, practicing with fewer numbers of physicians, and practicing in a family specialty area are all associated with greater levels of clinical decision making. Clinical decision-making authority had a strong positive correlation with greater outpatient clinical productivity (r=0.265,p< .001).
Mundinger et al. (2000) compared clinical outcomes for patients assigned to either NPs or physicians. This large randomized trial sampled 1316 patients from primary care clinics in urban locations in New York. There were no significant differences in reported health status between patients treated by NPs versus physicians at 6 months (p=.92). The authors of this study concluded that in situations where NPs had the same authority and responsibilities as primary care physicians, patient outcomes in primary care do not differ.
Pan, Straub, and Geller (1997) conducted a descriptive correlational study to analyze the impact of a restrictive practice environment on an NP’s level of autonomy with respect to prescribing certain medications. The study results showed that a restrictive practice environment lowered the prescribing autonomy of NPs.
Cajulis and Fitzpatrick (2007) conducted a descriptive study to determine the level of autonomy of NPs in an acute care setting. The researchers used the Dempster Practice Behavior Scale (DPBS) to measure the level of autonomy in acute care NPs. The overall results showed that NPs in an acute care setting had high levels of autonomy (M=117; SD=14.5). Additionally,
demographic variables of age, years worked as an RN, years worked as an NP, and basic nursing preparation demonstrated no significant relationship with autonomy scores.
Several studies have explored the role of NPs in various settings. Irvine et al. (2000) explored the influence of organizational factors on NPs’ role implementation in acute care settings. The results showed that acute care NPs perceived their role as not well formalized in their working environment. Norris and Melby (2006) used surveys and interviews to explore the opinions of emergency room nurses and physicians toward the role of the acute care NP. The researchers concluded that the blurring of boundaries between NPs and physicians can result in inter-professional conflict and decreased NP autonomy. Offredy and Townsend (2000) examined the role and practice of NPs in primary care. The results indicated a wide range of NP practice patterns and roles even within the same local area.
Although PCNPs comprise the largest group of NPs, there is a gap in the research on the actual level of autonomy of PCNPs. The current study addresses that gap by exploring the level of autonomy of PCNPs using a previously validated scale, the DPBS, to understand the complex variables that influence the autonomous practice of PCNPs.
Methods
The study was conducted at an annual state conference associated with the Florida Nurse Practitioner Network (FNPN). The conference was held in Florida in October of 2007. There were approximately 200 NPs in attendance. The FNPN is a statewide organization with approximately 2000 members and was founded in 2002. The organiza-tion provides educaorganiza-tional and professional developmental opportunities for all types of NPs across the state of Florida. The sample included 48 NPs who met the inclusion criteria of licensed to practice as an NP, practicing in a primary care outpatient setting and working with an adult patient population. Also the participant must have been educationally prepared as a family, adult, or gerontological NP. NPs working in any work schedule were included; however, NPs working in the specialty areas of acute care, pediatrics, women’s health, and psychiatric/mental health were excluded. Additionally, NPs practicing in inpatient settings and specialty practices were excluded. Although pediatric and women’s health NPs may be considered primary care providers, they were excluded because their practice is limited to a specific patient population.
Instruments
The instruments used in this study were the DPBS ques-tionnaire and the background data quesques-tionnaire. The DPBS is a 30-item questionnaire measuring autonomy in practice (Dempster, 1990). The DPBS was designed to assess behaviors, actions, and conduct related to the individual’s autonomy in a practice setting. The instru-ment uses a 5-point Likert scale with scores from each item ranging from 1 (not at all true) to 5 (extremely true). Total scores range from 30 to 150 and higher scores on the DPBS indicate a greater extent of autonomy. The DPBS takes approximately 15 min to complete. The instrument is generalizable within nursing and outside of nursing. The operational definition of autonomy in PCNPs was the total score obtained on the DPBS. A higher score indicated a greater amount of autonomy (Dempster, 1990).
Four subscale dimensions comprise the DPBS: Readi-ness, Empowerment, Actualization, and Valuation. The Readiness scale measured elements of growth, skill, com-petence, and mastery. The dimension of Readiness also included the progression from one level to another related to autonomy in practice (Dempster, 1994). The Empowerment scale measured the legitimacy of one’s performance in a practice setting (Ulrich et al., 2003). Empowerment included rights and privileges, sanction, and legal status to use one’s knowledge and skills to their fullest extent without restriction (Dempster, 1994). The Actualization scale measured decision making and involved the dimensions of determination, responsibil-ity, and accountability (Dempster, 1994; Ulrich et al.). The Valuation scale measured elements of value, worth, merit, and usefulness related to autonomy in practice. All together, these four dimensions and subscales of autonomy provide a framework for elaborating insights into the issue of NP autonomy (Dempster, 1990). Ini-tial reliability analysis revealed a Cronbach’s alpha of .95 (Dempster, 1990).
Background information about age, gender, race, educational background, basic preparation in nursing, NP certification, years worked as an NP, years worked at current job, years worked as a RN, current NP specialty area, and work status was collected. The NPs were asked additional questions to rate the importance of the domains of practice and the conceptual strands from the Strong Model of Advanced Practice (Ackerman et al., 1996). The Strong Model defined five domains of practice, which comprise the Advanced Nursing Practice role and conceptual strands that envelop and unify each domain (see Table 3). NPs progress from novice to expert in the provision of advanced care in the five domains. Autonomy, as it related to empowerment, was identified as an important concept within the Strong
Model (Ackerman et al.). The questions from the Strong Model were included to describe the level of importance of the Strong Model concepts in the NP’s practice.
Approval was obtained from the university Institutional Review Board prior to data collection. A letter of permission was also obtained from the FNPN. Data were collected at the conference directly from the participants. Questionnaire packets were given to eligible participants at a table staffed by the investigator, and they were returned directly to the investigator by the end of the day.
Results
There were 62 questionnaire packets given to potential participants at the conference that met the inclusion criteria for the study. Forty-eight participants (77.4%) returned completed questionnaires.
Characteristics of the participants
Results revealed that 91.7% of participants were female and 8.3% were male. The age of the participants ranged from 29 to 64 years with the average being 48.7 years and SD 8.48 years. The majority of the participants (43.5%; n=48) were between 51 and 60 years of age. The majority (70.8%; n=48) of participants self-identified as Caucasian, followed by Black (16.6%; n=48), and Hispanic and Asian were equal at 6.3%. Statistical demographics for gender, age, and race are shown in Table 1.
The educational characteristics included the highest education degree and the basic nursing education of the NPs. The majority of the participants were educated with a Master’s in Nursing (87.5%; n=48). Only one participant (2.1%; n=48) reported a Master’s Degree
Table 1Characteristics of the participants (N=48)
Characteristics Frequency Percentage
Age (Years)a <31 2 4.3 31–40 6 13.0 41–50 16 34.8 51–60 20 43.5 >60 2 4.3 Gender Female 44 91.7 Male 4 8.3 Race/ethnicity Caucasian 34 70.8 Black 8 16.7 Hispanic 3 6.3 Asian 3 6.3
Table 2Professional Characteristics (N=48)
Characteristics Frequency Percentage
NP certification Family NP 34 70.8 Adult NP 10 20.8 Gerontology NP 4 8.3 NP certifying board AANP 10 20.8 ANCC 33 68.8 Both 2 4.2
Not board certified 3 6.3
NP specialty practice
Family 30 62.5
Internal medicine 15 31.3
Gerontology 3 6.3
in another field as their highest education degree. Four participants (8.3%;n=48) were educated at the Doctoral level and one participant (2.1%; n=48) reported the highest degree as a Bachelor’s in Nursing. Associate Degree was the basic education in nursing for 47.9% of the participants. Bachelor’s Degree was reported as the basic nursing education for 43.8% of the participants. Only four participants (8.3%;n=48) reported a diploma as their basic nursing education.
The majority (70.8%;n=48) of the study participants were certified as family NPs. Details for NP certification, professional NP certifying board, and current NP specialty practice are shown in Table 2.
With regard to work status, 89.6% worked full time and 10.4% worked part time. Years worked at current job ranged from 3 months to 17 years with a mean of 3.7 years and SD 4.04. Number of years worked as an RN ranged from no experience to 37 years with a mean of 17.8 years and SD 9.07. Years of NP experience ranged from 0.5 to 30 years with a mean of 7.0 years and SD 5.66. A Likert scale was used to answer the additional questions on the background data questionnaire. There were five possible answers ranging from 1 (not at all important) to 5 (extremely important). These additional questions were included to describe the level of importance of the Strong Model’s concepts in the NP’s practice. The participants indicated higher average scores for direct comprehensive care, support of systems, education, collaboration, and empowerment, whereas research, publication and professional leadership, and scholarship received lower scores (see Table 3).
DPBS Results
Cronbach’s alpha coefficients were calculated to determine the internal consistency for the total DBPS and each of the subscales. There were a total of 30
Table 3Level of importance of Strong Model concepts
Concept Minimum score Maximum score Mean SD Direct comprehensive care 1 5 4.54 1.18 Support of systems 1 5 4.23 1.21 Education 2 5 4.48 0.80 Research 1 5 3.42 1.24 Publication and professional leadership 1 5 3.33 1.30 Collaboration 2 5 4.38 0.87 Scholarship 1 5 3.63 1.23 Empowerment 1 5 4.19 1.23
items in the DPBS. The overall Cronbach’s alpha for the DPBS in this study was .79. The Cronbach’s alpha for the Readiness subscale was .72, for Empowerment subscale .44, for Actualization subscale .66, and .57 for Valuation subscale.
The DPBS used a 5-point Likert scale ranging from 1 (not at all true) to 5 (extremely true). All of the questions pertained to the NP’s practice. Results indicated that the total level of autonomy mean score for this sample was 127.19 (SD=10.25). The scores ranged from 105 to 146. The total score and the four subscale scores are shown in Table 4.
The Readiness subscale had 11 item statements and measured elements of competence, skills, and mastery. The PCNPs in this study indicated high levels of readiness with a total mean subscale score of 46 (SD=4.85). The Empowerment subscale had seven items and measured the legitimacy of one’s performance in a practice setting. The total mean score for the subscale was 25 (SD=4.23). The Actualization subscale included nine items and measured decision making, and involved the dimensions of determination, responsibility, and accountability. The total mean score for the Actualization subscale was 42
Table 4Dempster Practice Behavior Scale
DPBS Mean SD Total score 127.19 10.25 Subscale scores Readiness 46.42 4.85 Empowermenta 25.08 4.23 Actualizationb 41.60 3.11 Valuationc 14.08 1.41
aOne response was missing. bTwo responses were missing. cOne response was missing.
(SD=3.11). The Valuation scale had three items and measured elements of value, worth, merit, and usefulness related to autonomy in practice. The total mean score for the Valuation subscale was 14.08 (SD=1.41). This was the highest scored subscale.
Pearson’s product moment correlation was used to determine the relationship between autonomy and the NP’s age, number of years worked as an RN, and number of years worked as an NP. There was no significant relationship found between the total score on the DPBS and the NP age (r= −.003; p=.98), years worked as an RN (r= −.28;p=.06), and years worked as an NP (r=.18;p=.24).
Discussion
The participants in this study were 92% female and 8% male, which is close to national trends of 95% female and 5% male (American Academy of Nurse Practitioners [AANP], 2004). The age of the participants ranged from 29 to 64 years with an average age of 49, slightly older than the national average of 47 (AANP). The AANP also reported that most NPs were white and had practiced as an NP for an average of 9 years. The participants in this study were also mostly white (71%), with an average of 7 years NP experience.
The highest level of educational attainment for NP participants in this study was 90% Master’s Degree and 8% Doctorate. This was higher than the AANP survey that showed only 85% Master’s Degree education and 4% Doctorate. Also 94% of NPs in this study were board certified, which is close to the national average of 92% (AANP). The majority of the NP participants in this study were certified (71%) and practicing (63%) in Family Practice, which is consistent with the national trend. Bachelor’s Degree was the basic education in nursing for 44% of the NP participants, Associate Degree 48%, and diploma 8%. The national population of RNs has been reported at Bachelor’s Degree 31%, Associate Degree 42%, and diploma 25% (U.S. Department of Health and Human Resources, n.d.).
The total mean score for the DPBS in this study was 127 (SD=10.25). This indicated that the average response of participants on each of the 30 items on the DPBS was at least a 4. Therefore, the PCNPs in this study had very high levels of autonomy. Dempster (1994) claimed that the NP role was designed to incorporate a greater level of autonomy and independence. This claim is supported by this study’s results. It was also found that NPs who practiced in the family specialty practice area experienced greater clinical decision-making authority (Chumbler et al., 2000). Cajulis and Fitzpatrick (2007) found that acute care NPs had very high levels
of autonomy also. According to Almost and Laschinger (2002), the role of the acute care NP and the PCNP parallel each other. Results in each subscale from the DPBS showed that the NPs had very high average scores with the exception of the Empowerment subscale, which showed moderate average scores.
NPs increasingly exhibit readiness for autonomy (Dempster, 1994). The findings in this study provided evidence that PCNPs are skillful, masterful, competent, and displayed traits of professional growth. PCNP participants had a moderate level of empowerment.
The Empowerment subscale had the lowest mean score of the four subscales in this study. NPs continue to struggle with empowerment for autonomy (Dempster, 1994). In Florida, change to provide legal empowerment from others has been slow. Currently, PCNPs have limited hospital privileges, they face obstacles with reimbursement for their services, and they have not been given legal prescriptive authority for controlled substances. They are also bound by a collaborative practice agreement. These barriers to legal status and privileges could contribute to lower empowerment levels.
NPs actualize and exercise autonomy in their practice scope (Dempster, 1994). The results of this study indicated that PCNPs had very high levels of decision making, accountability, responsibility, and determination. These findings are consistent with other studies on NP’s decision making and responsibility (Chumbler et al., 2000; Mundinger et al., 2000).
The Valuation subscale contained the highest average score out of all four subscales. The PCNPs in this study indicated very high to extremely high levels of value, worth, merit, and usefulness related to autonomy in practice. NPs value autonomy because it has worth and merit (Dempster, 1994).
No statistically significant relationship was found between the variables of age, years worked as an RN, years worked as an NP, and level of autonomy. These findings are consistent with another study (Cajulis & Fitzpatrick, 2007). Also, in a study on NPs’ prescription authority, it was found that years of NP experience had no impact on authority level (Pan et al., 1997). In contrast, a study with 293 NPs concluded that NPs with more years in practice had greater clinical decision-making authority (Chumbler et al., 2000). There are only two known studies (present study included) that have examined the relationship between age, years worked as an RN, and level of autonomy. Both of these studies had sample sizes less than 100. A study with a larger sample size may be able to detect significant correlations between age and RN experience and level of autonomy. It is also a distinct possibility that there is no relationship between age, years
worked as an RN, years worked as an NP, and level of autonomy.
Limitations
Limitations in this study include the fact that this study used a convenience sample of PCNPs drawn from a state clinical conference in Florida. This study also had a small sample (N=48) and only one setting. The results of this study may not be generalized to all NPs in a primary care setting. Additionally, the reliability of the DPBS subscales was low.
Implications for nursing
Nurse practitioners are an important part of the healthcare system. As the NP profession continues to change and expand, so do the threats to NP autonomy. Legal and institutional restrictions on NP practice hinder professional growth and professional authority. These restrictions force NPs to struggle with empowerment for autonomy. In order to attain maximal autonomy, NPs must understand their current level of autonomy and explore new ways to increase empowerment. Higher levels of autonomy and decision-making authority will allow NPs to care for their patients as competent professionals, and may improve patient care outcomes.
Although this study was limited to the description of PCNP autonomy, the findings could lead to changes in all NP education programs. The concepts from the Strong Model should be highlighted in NP education programs. NP curriculum should increase focus on autonomy and emphasize the value of empowerment. NPs educationally prepared with a better knowledge of legal and political issues will be better suited to influence healthcare reform. NPs, as autonomous professionals, will be more likely to impact and shape future healthcare policy.
Recommendations for future research
Recommendations for future research include replica-tion of this study using a large nareplica-tional random sample to ascertain the generalizability of the findings. More similar studies of other types of NP providers would allow for direct comparison of autonomy levels among the groups. A study to evaluate the relationship between NP auton-omy levels and patient care outcomes should be done. Although the NPs in this study had very high levels of autonomy, the Empowerment subscale had the lowest scores. This suggests that other factors such as national, state, and institutional regulations may be important to
explore. Also, future research is needed for the DPBS instrument and its subscales, particularly with smaller sample studies.
Conclusions
The results of this study indicated that PCNPs had very high levels of autonomy. They also had very high levels of skill, competence, decision making, accountability, and valued their autonomy. They had only moderate levels of empowerment that included rights, privileges, and legal status. No significant relationship was found between age, number of years worked as an RN, number of years worked as an NP, and level of autonomy. The findings of this study reinforced the fact that PCNPs are autonomous professionals.
Acknowledgments
Much appreciation goes to Sr. Rita McNulty, DNP, RN, CNP, Assistant Professor, and Mary Quinn-Griffin, PhD, RN, Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
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