Main Points

• Professional autonomy is one of the essential elements in the professionalization of nursing.

• The high level of autonomy of nurses increases their job satisfaction of nurses.

• It was found that the nurses’ autonomy levels and job satisfaction were above average.

Introduction

The concept of professionalism is defined as a service carried out by experts trained in the field, supported by relevant professional organizations, and provided by considering the interest of society (1). Having theoretical knowledge of a profession, a standard education process, and having experts in the field are among the criteria for professionalization (2).

Miller et al. (3) first explained the concept of professionalism in nursing. According to Miller et al. (3), a professional nurse; integrating theoretical knowledge with practice in line with intellectual knowledge, skills, and attitudes, benefiting from professional knowledge while providing health protective, improving and curative health services; nurses is a member of the profession who can get to the root of problems, can think critically, make decisions and solve problems, can provide quality care to individuals in need, and can fulfill the roles of educator, researcher and manager. The lack of education in the first years of nursing, the fact that only women are in the profession, and education at different education levels are considered obstacles to professionalism. However, in recent years, it has gained importance in professionalism in nursing, especially with the standardization of education. The members of the nursing profession need to know the criteria of professionalism to fulfill their requirements and to conduct research on this subject (4).

The meaning of nursing autonomy is multidimensional, but it is generally explained by definitions such as independence, self-management, and clinical decision-making (5). Autonomy in nursing is examined in two dimensions: Professional autonomy and professional autonomy. According to Oshodi et al. (6) refers to the autonomy of nurses who provide direct patient care, their ability to act beyond standard practice and make decisions about individual patient care. Autonomy in nursing is defined as making independent decisions regarding patient care, developing care processes to ensure patient safety, the ability to make decisions regarding the profession, and having and using independent roles (7).

Autonomy is one of the essential and basic building blocks in the professionalization of the nursing profession. To strengthen the nursing profession, clinical autonomy is required. The professional autonomy of nursing is the ability to have the right and responsibility to make clinical decisions and implement decisions according to the needs of patients (8,9). Although the importance of autonomy in patient care is known, it is stated that the clinical decision-making status of nurses for patients is uncertain (10,11). In the studies in the literature, it is stated that nurses have a significant level of autonomy (12,13). It has also been reported that autocratic leadership styles and the effect of physician leadership in management are obstacles to autonomy and negatively affect autonomy in nursing by reducing nurses’ self-esteem (14). In the literature, it is stated that the high level of autonomy of nurses increases the quality of care given to patients (15,16). A higher level of autonomy among nurses is considered to be a significant predictor of increased job satisfaction (14), safety performance (17), and nurses’ increased attendance (18). It has also been reported that nurses’ low level of autonomy causes depression, job change, burnout, and decreased job satisfaction (18-20).

Job satisfaction is defined as evaluating the work environment and giving emotional reactions, which can affect the employees’ physical and mental health, work performance, happiness, productivity, and work-related behaviors (5). The satisfaction of nurses from their work and the environment they work in can be achieved by determining the institution’s needs of the managers, taking the necessary precautions, and improving the employees’ motivation and quality of life (21,22). Employees’ positive and negative situations in business life affect job satisfaction (5). Nurses’ high workload and low autonomy negatively affect job satisfaction and cause it to decrease gradually (23). On the other hand, the decrease in job satisfaction causes nurses to be negatively affected physically and mentally by the emergence of various diseases, decreases work efficiency, and affects human relations negatively (24). It is stated that nurses get efficiency from their workplace, have high job satisfaction, and increase their performance, patient satisfaction, and quality of care (25).

In the literature, it is stated that nurses’ having a say in patient care, being independent in the clinical decision-making process and having high autonomy provide a positive working environment and accordingly, the job satisfaction of nurses increases (10). In a study, it was stated that as the occupational autonomy levels of nurses increased, their job satisfaction levels increased (14). At the same time, it is stated that nurses’ receiving administrative support for autonomy and working in cooperation increases their job satisfaction (7,26).

Aims: One of the factors affecting autonomy, which is one of the foundations of professionalization, is the level of job satisfaction of nurses. Increasing the professional autonomy of nurses increases their job satisfaction and patient care quality. For this reason, it is necessary to determine the relationship between nurses’ attitudes toward professional autonomy and job satisfaction and to make improvements accordingly. Therefore, the aim of the study is to determine the attitudes of nurses toward professional autonomy and job satisfaction. There are not enough studies in the literature examining the relationship between nurses’ professional autonomy and job satisfaction. Especially in Turkey, there is no study on the subject. Therefore, the results of our study will contribute to the literature. For this reason, our study will make important contributions to the literature on this subject and will pioneer future research.

Material and Methods

This descriptive and cross-sectional study was conducted between December 2022 and March 2023.

Research population and sample: The research population comprises nurses working in Turkey. In determining the sample, the open epi program was used for calculating the sample of 204,969 nurses. According to the sample calculation, 302 nurses were reached for 90% power.

Data Collection Tools of the Research

Individual identification form: It consists of 6 questions questioning the socio-demographic characteristics and working experiences of nurses, such as age, gender, marital status, clinic worked, duration of work, and educational status.

Attitudes towards professional autonomy scale for nurses: It was developed by Asakura et al. (27) in Japan. Turkish validity and reliability were performed by Şimşek and Ceylan (28). The scale consists of three sub-dimensions, namely “work-related independence,” “autonomous clinical decisions,” and “control over working conditions,” and 18 items. The items of the scale were scored using a 5-point Likert system ranked from “I strongly disagree’’ to “I strongly agree’’. “Strongly agree” indicates the most liberal attitude towards professional autonomy for nurses, while “strongly disagree” indicates the most conservative attitude. The lowest score that can be obtained from the scale is 18, and the highest score is 90. In the study of Şimşek and Ceylan (28), the Cronbach alpha value was found to be 0.81. In our study, the Cronbach alpha value of the scale was found to be 0.76.

Job satisfaction scale: The scale consists of 10 questions. The answers given to the questions on the scale are scored between 1 and 4 in the direction of dissatisfaction-satisfaction. The lowest score that can be obtained from the scale is 10, and the highest score is 40. A high score from the scale indicates a high level of job satisfaction. Cronbach’s alpha value of the scale was determined as 0.81 (29). the study, Cronbach’s alpha value was found to be 0.78.

Data collection: Data for this study were collected online. The web-based questionnaire was sent to the nurses after ethical approvals were obtained. The survey form was prepared in Google forms. The questionnaire link was sent to the nurses via e-mail and online messaging applications. An informed consent form has been added to the first page of the questionnaire. In addition, nurses were informed about the research. In this way, permission was obtained from the nurses to participate in the study. Nurses who agreed to participate in the study answered the questionnaire. For nurses who did not fill out the questionnaire, a reminder e-mail was sent once a week. Filling out the questionnaire took an average of 15 minutes. Research data were collected between 19 December 2022-4 March 2023.

Statistical Analysis

The data obtained from the research were analyzed in the SPSS (Statistical Package for Social Science) 23.0 package program. Numerical and percentile distribution, Kruskal-Wallis-H, and correlation analyses were used to analyze the data. Statistical significance was determined as p<0.05.

Ethical Consideration

Permission was obtained from Kayseri University Ethics Committee for this study (date: 02.12.2022, no: 78). Necessary explanations about the study were made in the online form sent to the nurses, and the nurses were given the option of accepting or not participating in the research.

Results

It was found that the mean age of the nurses was 38.6±7.48. Of them 73.5% (n=222) were female, 86.1% (n=260) had the “a bachelor’s degree’’, and 34.8% (n=105) had been working in the clinic for 4-6 years (Table 1).

The mean scores the nurses obtained from the the attitude scale towards professional autonomy was 69.07±4.63, the work-related independence sub-dimension mean score was 21.61±2.65, the control over working conditions sub-dimension 29.68±2.45, and the autonomous clinical decisions sub-dimension 19.70±2.22. The mean scores the nurses obtained from the job satisfaction scale was 22.27±3.81 (Table 2).

Comparisons were made between the nurses’ educational levels, the total score means of the job satisfaction scale, and the mean scores of the autonomy scale. There was a significant difference between the education level and the total score means of nurses obtained from the autonomy scale. In this study found that the mean total score of the undergraduate nurses was higher than the other education groups (KW=9.536, p=0.008). Similarly, there was a significant difference between the educational status and the mean scores of the job satisfaction scale. In the study, it was determined that the mean scores of the job satisfaction of the nurses with a bachelor’s degree were higher than those from other education levels (KW=8.930, p=0.012) (Table 3).

When the working years of the nurses and the scale total score and sub-dimension scores were compared; it was determined that there was a significant difference between the total mean scores of the job satisfaction scale and the years of employment, and that the job satisfaction of the nurses who worked between 1-3 years was higher (KW=9.060, p=0.049). It was determined that there was no significant difference between the years of employment and the total and sub-dimension mean scores of the attitude scale toward professional autonomy (p>0.05) (Table 3).

Correlation analysis was performed between the total and sub-dimension scores of the attitude scale towards professional autonomy and the total scores of the job satisfaction scale. According to the results of the analysis, it was determined that there was a positive and significant correlation between the autonomic clinical decisions sub-dimension scores and the job satisfaction scale total score (r=0.221, p=0.031). It was determined that there was a positive and significant correlation between the attitude towards professional autonomy total scale score and the job satisfaction scale total score (r=0.384, p=0.044) (Table 4).

Discussion

Autonomy increases the professionalism of the nursing profession. In particular, the increase in the autonomy of nurses in clinical practices and professional roles also increases professional autonomy. Autonomy in nursing enables nurses to increase their clinical decision-making ability and independent roles. At the same time, it increases the independence of nurses in their roles and responsibilities and enables them to defend their rights (24,25).

Professionalism in nursing is an important multidimensional concept that includes individual and professional conditions, structures suitable for the profession, sociological and individual factors. Professionalism in nursing includes a wide range of personal characteristics, self-regulation and competence, professional values, professional expertise and development effort, professional interactions, social, professional and legal responsibility, and the creation of a sense of belonging and professionalism (30). The formation of professional identity and professionalism in nursing is a dynamic process that starts with nursing education and continues to develop throughout the professional career. This process contributes to nurses’ reflection of their competencies in their professional practices and thus positively affects their social interactions with patients, relatives and colleagues (31).

Professional autonomy is an important factor in ensuring patient safety and improving the quality of care. In addition, the autonomy of nurses affects professional satisfaction, motivation and performance positively (3). Professional autonomy is defined “as the practice of one’s occupation by one’s education, with members of that occupation governing, defining, and controlling their activities in the absence of external controls” (32). At the same time, in the literature, professional autonomy is defined as an increase in the level of decision-making in patient care, an increase in the independent roles of nurses and clinical decision-making ability (33,34). A higher level of autonomy among nurses has been recognized as a critical determinant of job satisfaction, safety performance, and staff nurse retention (14,17,35,36). But, nurses cannot be autonomous if their authority over patient care and clinic operations is not substantially increased (14). The results of this study demonstrated that the total score obtained by the nurses from the scale of attitude toward professional autonomy was at a above average level (69.07±4.63). This is similar to the results of studies evaluating nurses’ professional autonomy in many countries, including Turkey (10,12,37,38). However, in a study conducted by Dorgham and Al-Mahmoud in Egypt, nurses’ autonomy levels were found to be low (33). A study conducted in Turkey reported that the lowest score among the professionalism criteria was the professional autonomy score of nurses (34). In another study, it was stated that only 6.7% of nurses had professional autonomy (35). According to these results, we can say that the autonomy levels of nurses differ. These differences may be due to the countries where the research was conducted, the working conditions of nurses and the number of samples. Autonomy is one of the foundations of the nursing profession. For this reason, nurses’ high level of autonomy will increase professional independence. In order to increase the autonomy level of nurses, training programs should be organized, and information should be given about the importance of autonomy in the nursing profession. In addition, it may be recommended to conduct multicenter studies with larger sample groups to determine the autonomy levels of nurses.

Studies have found that work experience increases nurses’ ability to make clinical decisions, act independently, and have professional autonomy. However, an increase in the retirement rates of nurses with work experience is observed today. Therefore, clinics employ more newly graduated nurses. At the same time, with the increase of newly graduated nurses, the educational status of nurses is also increasing. For this reason, nurses’ work experience and educational status affect professional autonomy (34-37). The results of this study demonstrated that that there was a significant relationship between educational status and attitude towards professional autonomy, and nurses with a bachelor’s degree had higher professional autonomy compared to other education groups (p=0.008). It has been reported that nurses with higher education levels have higher occupational autonomy (39,40). In the study of Lapeña et al. (41) with newly graduated nurses, it was found that nurses’ autonomy levels were high. In addition, it was stated in the study that nurses’ autonomy level is high because they have less clinical experience and are still adapting to their nursing roles. In other studies, it was stated that the level of education is effective in increasing professional autonomy (10,42). In this study, it was found that most of the nurses have a bachelor’s degree. Especially in our country, nursing education is no longer given at the high school level. For this reason, as the number of undergraduate graduates working in the clinic increases, the autonomy level of nurses will also increase. At the same time, these results show that nursing education significantly impacts professional autonomy.

Nurses’ autonomy over their roles allows them to act independently and increase their clinical decision-making rates, and thus their job satisfaction increases (7). It is stated that when nurses plan and prioritize their practices, they are more satisfied with their jobs and their adaptation to work increases (14,43). Thus, the quality of care given to patients increases (44,45). The results of this study demonstrated that found that the job satisfaction of the nurses was above the average level (22.27±3.81). Similarly, another study reported that nurses’ job satisfaction was at an average level (46). When the working years of the nurses were compared with their job satisfaction, it was determined that the job satisfaction of the nurses who had a working life of 1-3 years was higher than the nurses who worked for long years (p=0.049). In a study, it was found that nurses who worked for two years or less had higher job satisfaction than nurses with higher work experience. In addition, in the study, it was stated that as the working years of the nurses increased, their job satisfaction decreased (47). According to these results, we think that as the working years of nurses increase, their workload increases, and burnout may develop due to this. Increasing burnout in nurses may negatively affect job satisfaction. Therefore, we can say that job satisfaction is higher in nurses who have just started working.

In the literature, it has been stated that the autonomy levels of nurses cause different results related to work (8,29,44,45). A study conducted in Brazil stated that as nurses’ occupational autonomy level increased, their job satisfaction also increased (29,44). In other studies, occupational autonomy was determined as the main predictor of job satisfaction (8). Another study found that as nurses’ attitudes toward professional autonomy increased, job satisfaction, job performance, and professional commitment increased (45). At the same time, it has been determined in other studies that it causes negative results such as depression, leaving work, and increased burnout levels in nurses with low autonomy levels (44). The results of this study demonstrated that there was a positive and significant relationship between the participants’ attitudes toward professional autonomy and their job satisfaction (p=0.044). It has been reported that professional autonomy is positively associated with job satisfaction, nurses with a bachelor’s degree have a greater sense of professional autonomy, and this situation is positively associated with job satisfaction (48). Nurses are the largest part of healthcare providers and their professional skills play an important role in the fulfillment of the healthcare system. Therefore, the professional competence of nurses is extremely important for healthcare providers (49). Work engagement in professional nursing practice is critically important to consider when addressing key challenges of health systems, including the global nursing shortage, pressures to reduce healthcare spending, and increasing demands for quality care and positive outcomes for patients (50). Our research findings are consistent with the literature. According to the study’s results, as the autonomy levels of nurses increase, their job satisfaction increases. Especially with the increase in autonomy, the job satisfaction of nurses may increase due to greater control and compliance with the job.

Conclusion

Our study examined the relationship between nurses’ attitudes toward professional autonomy and job satisfaction. Our study results determined that nurses’ attitudes toward professional autonomy were high, and their job satisfaction was above average. The results of this study demonstrated that there is a significant correlation between nurses’ attitudes toward professional autonomy and job satisfaction. As nurses’ attitudes towards autonomy increase, their job satisfaction also increases. Nurses should be able to advocate for their patients and make appropriate patient care decisions in clinical settings involving the collaboration of various healthcare professionals. Educators and administrators should be encouraged to develop professional autonomy and provide stress management as part of the primary nursing curriculum to increase nurses’ professional autonomy. There are very few studies in the literature examining the relationship between nurses’ attitudes towards professional autonomy and their job satisfaction. Especially in Turkey, there is no study on the subject. Therefore, the results of our study will contribute to the literature. At the same time, autonomy is examined in two different ways as professional autonomy and professional autonomy. Today, there are mostly studies on occupational autonomy in the literature. However, a holistic examination of the nursing profession is very important. For this reason, it is also important to determine the attitudes of nurses about professional autonomy. In future studies, we can suggest examining nurses’ attitudes towards both professional autonomy and professional autonomy with a larger sample group.

Ethics Committee Approval: Permission was obtained from Kayseri University Ethics Committee for this study (date: 02.12.2022, no: 78).

Informed Consent: An informed consent form has been added to the first page of the questionnaire

Peer-review: Internally and externally peer-reviewed.

Author Contributions: Surgical and Medical Practices – S.Ş., C.Ö.; Concept – S.Ş., C.Ö.; Design – S.Ş.; Data Collection and/or Processing – S.Ş., C.Ö.; Analysis or Interpretation – S.Ş.; Literature Search – S.Ş., C.Ö.; Writing – S.Ş., C.Ö.

Declaration of Interests: No conflict of interest was declared by the authors.

Funding: The authors declared that this study received no financial support.