Collaboration & Organisational Influence Among Emergency Nurses - - PowerPoint PPT Presentation

Clinical Autonomy, Nurse/Physician Collaboration & Organisational Influence Among Emergency Nurses

• Dr. Patrick Cotter

DN, MSc, HDipN(A&E), BSc, DipMgt, RGN, RM, RNP, RANP

• Prof. Geraldine McCarthy

PhD, MSN, MEd., DipN, RGN, RNT

Study Background

• Nurses’ role in responding to healthcare challenges

recognised (Hanley, 2003; DOH&C, 2011)

• Suggestions usually around skills enhancement
• Nurses with greater skills/knowledge = Greater

contribution to patient care (?)

• High levels of perceived competence among ED nurses in

many skills (McCarthy, et al., 2013)

• Good education levels among ED nurses (McCarthy, et al.,

2013)

• Why repeated suggestions around skills enhancement??
• What about authority to utilise skills?

Background

• Nurse Autonomy and Collaboration between nurses and

physicians has positive influence on health outcomes for patients (Institute of Medicine, 2004; Zurmehly, 2008; Shang, et al., 2012)

• Some confusion - number of meanings in nursing mainly

professional, organisational and clinical

• Clinical Autonomy appears to be of most importance to

nurses (Mrayyan, 2004; Stewart, et al., 2004; Skar, 2009)

• Suggestion that collaboration with physicians has

positive influence on clinical autonomy

• The role of education, experience and gender unclear
• The role of the organisation highlighted in literature

“Clinical autonomy is evident where nurses have the authority to exercise their capacity for clinical judgement in the realm of clinical nursing care and collaboratively with other professions in overall patient care while practicing within a professional nursing context”. (Cotter, 2016)

Aims

• Primary aim – Investigate levels of Clinical

Autonomy & Nurse/Physician Collaboration among Emergency Nurses

• Secondary Aim – Establish if relationship

exists between Clinical Autonomy & Nurse/Physician Collaboration & Organisational Influences & Demographic Variables

Clinical Autonomy

(Dempster Practice Behaviours Scale (DPBS))

Nurse-Physician Collaboration

(Nurse-Physician Collaboration Scale (NPCS)

• Sharing of Patient Information
• Decision-making Process on the

Cure/Care

• The Relationship Between Nurse

and Physician (Cooperativeness)

Personal Factors (Demographics)

• Gender
• Age
• Education
• Qualifications/registrations
• Length of Experience

Organisational Influences

(Organisational Influences on Nursing Scale)

Conceptual Framework

Clinical Autonomy and Nurse/Physician Collaboration:

Applied to Staff Nurses Working in Emergency Departments

(Measures)

Instruments

• Instrument selection challenging: many instruments

used to measure autonomy in nursing: not always appropriately, poor validity (Weston, 2008)

• Issues relating to practice: instruments measuring

behaviours in practice sought

• Clinical Autonomy: DPBS(Dempster, 1990)
• Nurse/Physician Collaboration: NPCS (Ushiro, 2009)
• Organisational Influence on Nursing: New Scale
• Data on gender, age, experience, qualifications,

education level also gathered

Organisational Influence on Nursing Scale

• Based on items extracted from published

qualitative studies

• Items refined to 7 common items
• Extra item added following review
• Face validity from supervisors and external

advisor

• Content Validity established through CVI

based on 8 expert reviewers

Organisational Influences in Nursing Scale Expert Panel Rating – Content Validity Index Item The organisation in which I work.... Expert 1 Expert 2 Expert 3 Expert 4 Expert 5 Expert 6 Expert 7 Expert 8 No. Agree Item CVI ...values my nursing practice 4 4 3 4 4 4 4 3 8 1.00 ...gives me the opportunity to practice to my full capacity as a nurse 4 4 4 4 4 4 4 4 8 1.00 ...encourages me to communicate with all the members of the healthcare team 4 4 4 4 3 4 4 4 8 1.00 ...exerts too much control over my nursing practice 4 3 4 4 3 4 N/A 1 6 (of7) 0.86* ...encourages me to contribute to decisions about patient care 4 4 3 3 4 4 3 3 8 1.00 ...encourages trusting and supportive relationships within the healthcare team 4 4 4 3 4 4 3 4 8 1.00 ...has too many policies, procedures and routines involved in patient care 4 4 4 4 3 4 3 4 8 1.00 ...recognises my knowledge and ability as a nurse 4 4 4 4 4 4 3 3 8 1.00 Mean I-CVI 0.98 S-CVI/ Ave 0.98 Apparent Internal Consistency for Scale Yes Yes Yes Yes Yes Yes Yes Yes 8 100% (*Scored on basis of 7 experts – Data missing from rater no. 7)

Organisational Influences on Nursing Practice Scale

The organisation in which I work... Always Usually Sometimes Rarely Never ....values clinical nursing practice ....gives nurses the authority to practice to their full capacity as a nurse ....encourages nurses to communicate with all members of the healthcare team ....exerts control over clinical nursing practice ....allows nurses have a say in patient care ....develops trusting and supportive relationships within the healthcare team ....has too many policies, procedures and routines involved in patient care ....recognises the knowledge of nurses and their contribution to decisions about patient care

Scoring: each item scored 1 to 5 (always=5, usually=4, sometimes=3, rarely=2, never=1), items 4 and 7 reverse

• scored. Range 8 to 40. Higher score indicates more positive organisational influence.

Sample

• Inclusion

 Registered Nurses  Employed in Emergency Departments  Staff Nurse grade

• Exclusion

 Undergraduate student nurses  Advanced Nurse Practitioners  Nurse Managers  Agency or ‘relief nurses’

• Sample size calculated using G-Power 3.1
• N=84 required for medium correlation (Cohen’s r=0.3)

between clinical autonomy and nurse/physician collaboration (80% power, p=0.05)

• Non-randomised sample of 141 emergency nurses working in

3 Emergency Departments in the Rep. of Ireland Response 70.9% (n=100)

• Ethics

– Ethical approval sought and granted by Cork Teaching Hospitals Research Ethics Committee

• Access:

– Through hospital Directors of Nursing and relevant nursing managers

• Instrument

Reliability

– DPBS - α=0.86 – NPCS - α=0.918 – OINS – α=0.797

Participants

Age in years: mean 35.57 (SD 7.83)

Qualifications & Experience

Total Nursing – Median 10.17 (IQR=9.44) Emergency Nursing - Median 6.04 (IQR=6.37) Length of Experience

Level of Clinical Autonomy

• Mean DPBS score = 104.54 (SD=12.53)

Level of Nurse Physician Collaboration

• Mean NPCS score = 72.56 (SD 13.34)

Level of Organisational Influence on Nursing

• Mean Score 27.95 (SD=4.48).

Clinical Autonomy

• No relationship established between Clinical

Autonomy and – Gender (males M=109.46, SD=12.01; females M=103.81; t(98)=1.53, p=0.13) – Length of Nursing Experience (r=0.168, n=100, p=0.095) – Length of Emergency Nursing Experience (r=0.072, n=100, p=0.479)

Clinical Autonomy

• No relationship established between Clinical

Autonomy and

– Level of education (under grad M=104.70, SD=11.59, post grad M=104.19, SD=14.60; p=0.85) – Specialist emergency nursing qualification (Qualification M=105.74, SD=13.27; without qualification M=103.74, SD=12.05; t(98)=0.783, p=0.606)

Nurse Physician Collaboration

• No relationship established between Nurse

Physician Collaboration and

– Gender (males M=73, SD=13.51; females M=72.50; t(98)=0.126, p=0.90) – Level of Education (under grad M=73.00, SD=14.02; post grad M=73.58, SD=11.85; t(98)=0.492, p=0.62) – Specialist emergency nursing qualification (Qualification M=71.71, SD=13.68; without qualification M=73.13, SD=13.20; t(98)=-0.521, p=0.603)

Nurse Physician Collaboration

• No relationship established between Nurse

Physician Collaboration and

– Length of Nursing Experience (r=-0.056, n=100, p=0.577) – Length of Emergency Nursing Experience (r=- 0.140, n=100, p=0.166)

Clinical Autonomy and Nurse Physician Collaboration

• A significant negative relationship between

Clinical Autonomy and Nurse Physician Collaboration (r=-0.395, n=100, p<0.001)

Note: Low scores on NPCS = Higher levels of Nurse Physician Collaboration

Clinical Autonomy and Organisational Influence on Nursing Practice

• A significant positive relationship between

Clinical Autonomy and Organisational Influence on Nursing Practice (r=0.455, n=100, p<0.001)

Nurse Physician Collaboration and Organisational Influence on Nursing Practice

• A significant negative relationship between

Clinical Autonomy and Nurse Physician Collaboration (r=-0.413, n=100, p<0.001)

Note: Low scores on NPCS = Higher levels of Nurse Physician Collaboration

Discussion - Demographics

• Double national gender distribution of males in

Emergency Nursing (7.75% Vs 13%)

• Disproportionately young (75% < 40yrs Vs 34.6% in

UK (NMC, 2008) and 35% Australia (Turner et al., 2009)

• Median length of ED experience low (6.04years)
• Mixed EDs (adult and paeds) – 4% paeds trained, 3%

psych quals – issues for practice and education

• Only 40% have specialist qualification in Emergency

Nursing

• Demographics raise issues for service provision and

planning

Levels of Clinical Autonomy

• Moderate level
• Lower than found for Advanced Nurse Practitioners

(M=124.20(SD=14.3), Ulrich et al., 2003; M=127.19(SD=4.45), Bahadori and Fitzpatrick, 2009; M=123(SD=12.7) Maylone et al., 2010)

• Level of competence may be perceived as high

(McCarthy, et al., 2013) but autonomy appears

determined by practice level

• Supports the belief that level of practice determines

level of autonomy

Clinical Autonomy and Sample Characteristics

• No relationship between Clinical Autonomy sample

characteristics could be established

• Strategies to increase the involvement of nurses in care often

focus on education and skills development (Reconfiguration Forum for

Cork and Kerry, 2009; National Emergency Medicine Programme, 2012)

• Despite indicating high levels of competence (McCarthy, et al., 2013)

education in particular appears to have no significant influence over clinical autonomy

• Education and skills need to be coupled with strategies to

increase autonomy in practice to realise potential of nurses

Clinical Autonomy and Nurse Physician Collaboration

• A relationship between CA and NPC supported

(Hinno, et al., 2009; Gagnon, et al., 2010, Maylone, et al., 2010; Papathanassoglou, et al., 2012)

• Findings support belief that autonomy is

context based – involves interaction with wider society (MacDonald, 2002; Weston, 2009; Iliopoulou and

While, 2010)

• Strategies to increase involvement of nurses

should include building strong relationships between nurses and physicians

Recommendations

• A number of issues raised through demographics –

implications for recruitment and retention

• Strategies to increase the practice sphere of

emergency nurses should be cogniscent of the influences on Clinical Autonomy

• Clinical relationships between nurses and physicians

should be supported

• Organisational strategy to support nursing practice
• Influence of CA and NPC on patient care in ED

Acknowledgements

• Dr. Elaine Lehane
• Dr. Vicki Livingstone
• Prof. Joyce Fitzpatrick

Emergency Department Staff Nurses who participated

References

• Adriaenssens, J., et al. (2011) Exploring the burden of emergency care: predictors of stress-health outcomes

in emergency nurses. Journal of Advanced Nursing 67(6), 1317-1328.

• Bahadori, A. & Fitzpartick, J.J. (2009) Level of autonomy of primary care nurse practitioners. Journal of the American

Academy of Nurse Practitioners 21, 513-519.

• Browning, L., et al. (2007) Nursing specialty and burnout. Psychology, Medicine and Health 12(2), 248-254.
• Cotter , P. (2016) Clinical Autonomy, in, McCarthy, G. & Fitzpatrick, J. (eds) Nursing Concept Analysis: Applcations to

Research and Practice. Springer Publishing Company, New York.

• Dempster, J.S. (1990) Autonomy in practice: Conceptualization, construction and psychometric evaluation of an empirical
• instrument. Dissertation Abstract International, 50, 3320A.
• Department of Health & Children (2011) Strategic Framework for Role Expansion of Nurses and Midwives: Promoting Quality

Patient Care. Dublin: Government Stationary Office.

• Gagnon, L., et al.. (2010) Nurse autonomy in cancer care. Cancer Nursing 33(3), 21-28.
• Hanley, D. (2003). Report of the National Taskforce on Medical Staffing, The Stationary Office: Dublin.
• Hinno, S., Partanen, P., Vehvilainen-Julkunen, K. & Aaviksoo, A. (2009) Nurses’ perceptions of the organizational attributes of

their practice environment in acute care hospitals. Journal of Nursing Management 17, 965-974

• Iliopoulou, K.K. & While, A.E. (2010) Professional autonomy and job satisfaction: survey of critical care nurses in mainland
• Greece. Journal of Advanced Nursing 66(11), 2520-2531.
• Institute of Medicine (2004) Keeping patients safe: transforming the work environment of nurses. Washington, DC: National

Academy Press.

• Kramer, M. & Schmalenberg, C. (2008) The practice of Clinical Autonomy in hospitals: 20000 nurses tell their story. Critical

Care Nurse 28(6), 58-71.

• Maylone, M.M., Raneire, L.A., Griffin, M.T.Q., McNulty, R. & Fitzpatrick, J.J. (2010) Collaboration and autonomy: perceptions

among nurse practitioners. Journal of the American Academy of Nurse Practitioners 23, 51-57.

• Mrayyan, M.T. (2004) Nurses’ autonomy: influence of nurse managers’ actions. Journal of Advanced Nursing 45(3), 326-336.
• McCarthy, G., Tyrrell, M.P. & Lehane, E. (2003) Turnover rate in nursing and midwifery: the Irish experience. Nursing Times

Research 8(4), 249-263.

• McCarthy, G., et al., (2013) Emergency nurses: Procedures performed and competence in practice. International Emergency

Nursing 21(1), 50-57.

• Nursing & Midwifery Council (2008) Statistical Analysis of the Register 1 April 2007 to 31 March 2008. Nursing and Midwifery

Council, retrieved on 29/07/2013 from, http://www.nmc- uk.org/Documents/Statistical%20analysis%20of%20the%20register/NMC-Statistical-analysis-of-the-register-2007-2008.pdf

• Papathanassoglou, E.D.E., Karanikola, M.N.K., Kalafati, M., Giannakopoulou, M., Lemonidou, C. & Albarran, J.W. (2012)

Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. American Journal of Critical Care 21(2), e41-e52.

• Reconfiguration Forum for Cork and Kerry (2009) Review of Emergency Departments and Pre-hospital Emergency Care in Cork

and Kerry. Cork: Reconfiguration Forum for Cork and Kerry

• Shang, J., Friese, C.R.,Wu, E. & Aiken, L.H. (2012) Nursing Practice Environment and Outcomes for Oncology Nursing. Cancer

Nursing

• Skår, R. (2009) The meaning of autonomy in nursing practice. Journal of Clinical Nursing, 19, 2226-2234.
• Stewart, J., Stansfield, K. & Tapp, D. (2004) Clinical Nurses’ understanding of Clinical Autonomy: accomplishing patient goals

through interdependent practice. Journal of Nursing Administration 34(10), 443-450.

• The National Emergency Medicine Programme (2012) The National Emergency Medicine Programme: A strategy to improve

safety, quality, access and value in Emergency Medicine in Ireland. Dublin: Royal College of Surgeons in Ireland.

• Turner, C., et al. (2007) Spheres of influence or autonomy? A discourse analysis of the introduction of Nurse Practitioners in

rural and remote Australia. Journal of Advanced Nursing 59(1), 38-46.

• Ulrich, C., et al. (2003) Predictors of nurse practitioners’ autonomy: effects of organizational, ethical and market
• characteristics. Journal of the American Academy of Nurse Practitioners 15(7), 319-325.
• Ushiro, R. (2009) Nurse/Physician Collaboration Scale: development and psychometric testing. Journal of Advanced Nursing

35(7), 1497-1508.

• Weston, M.J. (2008) Defining control over nursing practice and autonomy. Journal of Nursing Administration 38(9), 404-408.
• Weston (2009) Validity of instruments for measuring autonomy and control over nursing practice. Journal of Nursing

Scholarship 41(1), 87-94.

• Zurmehly, J. (2008) The relationship of educational preparation, autonomy and critical thinking to nursing job satisfaction. The

Journal of Continuing Education in Nursing 39(10), 453-460.