Professional autonomy of nurses as an integral part of nursing practice

Introduction

Professional autonomy is one of the basic features of professionalism in nursing and represents a nurse's right and ability to independently decide on the scope and nature of her own work activities, assume responsibility for her decisions, and control the nursing care provided (Žiaková, 2023). In clinical practice, it is expressed through independent professional judgment, the use of competencies, and active participation of nurses in decision-making processes in patient care (Pursio et al., 2021; Rouhi-Balasi et al., 2020). Autonomy has a significant impact not only on individual professional performance but also on the quality of the work environment. It promotes a sense of professional empowerment, confidence, motivation, and job satisfaction, thereby contributing to a favorable organizational climate (Mabona et al., 2022). At the same time, it is linked to improving quality and patient safety, as it allows nurses to respond flexibly to clinical situations and make timely decisions (Clavelle et al., 2016; Yuk and Yu, 2023). Despite the demonstrated benefits, studies by Oshodi et al. (2019) and Labrague et al. (2019) indicate persistent differences in the level of autonomy between countries and workplaces, with nurses often having only a moderate or limited degree of independence. Nurses’ autonomy is mainly determined by hierarchical and organizational structures, power imbalances, and insufficient support from management, which can reduce nurses’ ability to independently decide on patient care (Parizad et al., 2021; Taleghani et al., 2023). Limited autonomy can therefore negatively affect job satisfaction, professional stability, and the quality of care provided.

Objective

Analyze the level of professional autonomy of nurses in individual dimensions of nursing practice.

Sample and Methodology

The sample included 143 nurses providing inpatient care from different regions of the Slovak Republic. Data were collected using a shortened version of the standardized Dempster Practice Behaviors Scale (DPBS), aimed at assessing nurses’ professional autonomy. The used version of the instrument contained 28 items divided into four dimensions (readiness, empowerment, actualization, appreciation) assessed via a five-point Likert scale. Data collection was conducted in February–March 2025 through an online questionnaire distributed electronically through professional databases and nurses’ professional contacts. Microsoft Excel was used for statistical processing of data. The data were analyzed using descriptive statistics (mean, standard deviation, and minimum-maximum ranges). The overall DPBS scale mean was calculated, as well as the means of the individual dimensions and items. The total score was the arithmetic mean of all 28 items, while dimension scores were the mean of items within the corresponding domain. Scale items were reverse-coded, with lower scores indicating a higher degree of professional autonomy.

Results

Table 1 Mean scores of DPBS professional autonomy dimensions (n = 143)

Legend: x̄ = arithmetic mean; SD = standard deviation; Min = minimum value; Max = maximum value;

Table 1 shows the mean scores of the individual dimensions of professional autonomy in the sample of 143 nurses. Due to reverse scoring, lower scores reflect a higher level of professional autonomy. The overall mean score of the DPBS reached 1.79 (SD = 0,36), indicating a generally favorable level of professional autonomy in the studied sample. The highest autonomy was observed in the Appreciation dimension (x̄ = 1,31), followed by the Readiness dimension (x̄ = 1,58). The Empowerment dimension achieved an average level (x̄ = 2,00). The lowest level of autonomy was identified in the Actualization dimension (x̄ = 2,08), which may indicate gaps mainly in applying decision-making authority and organizational conditions for nursing practice. The difference between the highest and lowest dimensions was 0,77 points, indicating practically meaningful variability across autonomy domains and suggesting uneven conditions for its exercise in clinical practice.

Table 2 Items indicating the highest level of professional autonomy (n = 143)

Legend: x̄ = arithmetic mean; SD = standard deviation; Min = minimum value; Max = maximum value;

A more detailed analysis of the DPBS scale focused on identifying areas where nurses achieved the lowest average scores, which, given this coding method, indicate the highest degree of professional autonomy (Table 2). This trend was most pronounced in the Actualization dimension, specifically in items “I am responsible for nursing procedures” (x̄ = 1,13), “I can take responsibility for nursing procedures” (x̄ = 1,14), and “I can accept consequences for my decisions” (x̄ = 1,20), reflecting a high level of personal responsibility and independent decision-making. Low scores were also recorded in Appreciation for the items “I can define my role” (x̄ = 1,24) and “I am confident in my abilities to practice my profession” (x̄ = 1,32), indicating a stable professional identity, self-confidence, and an internal belief in competence in nursing practice.

Table 3 Items indicating the lowest level of professional autonomy (n = 143)

Legend: x̄ = arithmetic mean; SD = standard deviation; Min = minimum value; Max = maximum value;

Areas with lower professional autonomy were identified based on items with the highest mean scores. Table 3 shows that increased scores were predominantly represented in the Actualization dimension, specifically for the items “I cannot function optimally because I do not have an autonomous position” (x̄ = 3,44), “I am limited only by bureaucracy” (x̄ = 2,79), “I have power to influence the decisions and actions of others” (x̄ = 2,68), and “I have too many autonomous interventions” (x̄ = 2,53). Elevated values were also identified in the Empowerment dimension in the item “I have legal basis provided for independent functioning” (x̄ = 2,33), indicating possible systemic limits of legislative and organizational support for autonomous professional practice. These results indicate persistent structural and organizational barriers that may limit full realization of professional autonomy in nursing practice. Higher SD values in these items point to heterogeneity in nurses’ work experiences, suggesting that the level of autonomy is significantly conditioned by local organizational conditions at individual workplaces.

Discussion

The aim of the research was to analyze the level of professional autonomy of nurses in individual dimensions of nursing practice, and the obtained results confirmed an overall favorable but unevenly distributed level of autonomy across personal and organizational aspects of professional performance. The overall DPBS scale score (x̄ = 1,79) indicates a favorable perception of nurses’ independence and professional responsibility, with the highest level of autonomy identified in the appreciation and readiness dimensions. Conversely, lower scores were found in domains related to organizational support and real opportunities to influence work processes. These findings correspond with international studies that define autonomy as the ability to control one's own practice, apply professional judgment, and manage care to improve its quality (Clavelle et al., 2016; Rouhi-Balasi et al., 2020). At the same time, it is confirmed that autonomy is not an isolated individual trait but is significantly influenced by organizational and systemic conditions of the workplace (Pursio, 2021; Van Oostveen, Vermeulen, 2017). In our sample, weaker ratings were mainly observed in organizational aspects of professional performance, especially the inability to function optimally, administrative burden, limited decision-making competencies, and insufficient managerial or legislative support. These factors represent barriers to the real implementation of autonomous practice, as also confirmed by AllahBakhshian et al. (2017). International comparisons indicate similar variability in autonomy. Amini (2015) found only a slight level of autonomy among critical care nurses (x̄ = 3,08), especially in the organizational dimension, suggesting a limitation of decision-making authority by workplace structural conditions. Yuk and Yu (2023) also identified autonomy as a significant predictor of patient safety, with working conditions having a greater impact than demographic variables. Autonomy also extends to staff attitudes and workforce stability. Higher work engagement and team collaboration significantly increase nurse satisfaction (Cayllahua Curiñaupa et al., 2022), while autonomy is strongly associated with job satisfaction and subsequent organizational commitment (Judi et al., 2025). Similarly, Labrague, McEnroe-Petitte, and Tsaras (2017) confirmed its relationship with higher performance and engagement. Scheepers et al. (2023) explained this mechanism, identifying autonomy as a job resource that supports engagement and individualized care delivery. Finally, the impact of autonomous practice is also reflected in clinical outcomes. Rao et al. (2017) demonstrated that hospitals supporting autonomous nursing decision-making achieve lower mortality and fewer complications. Strengthening professional autonomy therefore represents not only a factor in nurses’ satisfaction and professional stability, but also a key determinant of the safety and quality of care provided. This indicates a need for systemic interventions aimed at expanding competencies, reducing administrative burden, and fostering a supportive organizational culture that allows full realization of nurses’ professional potential.

Conclusion

Professional autonomy represents an important aspect of nursing practice. The study results characterized the level of nurses’ professional autonomy and highlighted its dependence on organizational and systemic factors of the work environment. Therefore, it is important to systematically create conditions that support independent decision-making, clearly delineate competencies, and reduce organizational and structural barriers that restrict autonomous professional practice. Strengthening professional autonomy should be an integral part of nursing management, workforce policy, and workplace design because it directly affects quality of care, patient safety, and stability of nursing staff.

Authors: prof. PhDr. Mária Kilíková, PhD.,MPH Vysoká škola zdravotníctva a sociálnej práce sv. Alžbety v Bratislave, n. o., Detašované pracovisko bl. Sáry Salkaháziovej, Rožňava PhDr. Tatiana Katriňáková Chirurgická jednotka intenzívnej starostlivosti, Nemocnica AGEL Levoča PhDr., Mgr. Mária Karafová Vysoká škola zdravotníctva a sociálnej práce sv. Alžbety v Bratislave, n. o.

List of Bibliographic References

ALLAHBAKHSHIAN, Maryam et al. 2017. Barriers to Intensive Care Unit Nurses’ Autonomy in Iran: A Qualitative Study. In Nursing Outlook. [online] 2017, vol. 65, no. 4. [cited 2026-01-29]. p. 392–399. Available online at: https://www.nursingoutlook.org/article/S0029-6554(16)30407-9/ ISSN 0029-6554.

AMINI, Kourosh et al. 2015. Nurses’ Autonomy Level in Teaching Hospitals and Its Relationship with the Underlying Factors. In International Journal of Nursing Practice. [online] 2015, vol. 21, no. 1. [cited 2026-01-29]. p. 52–59. Available online at: https://onlinelibrary.wiley.com/doi/10.1111/ijn.12210 ISSN 1440-172X.

CAYLLAHUA CURIÑAUPA, Ana J. et al. 2025. Attitude Toward Teamwork and Work Engagement as Predictors of Job Satisfaction in Nurses. In BMC Nursing. [online] 2025, vol. 24, no. 1. [cited 2026-01-30]. p. 791. Available online at: https://pubmed.ncbi.nlm.nih.gov/40598017/ ISSN 1472-6955.

CLAVELLE, Joanne T. et al. 2016. Evolution of Structural Empowerment: Moving From Shared to Professional Governance. In Journal of Nursing Administration. [online] 2016, vol. 46, no. 6. [cited to be added]. p. 308–312. Available online at: https://journals.lww.com/jonajournal/abstract/2016/06000/evolution_of_structural_empowerment__moving_from.6.aspx ISSN 0002-0443.

JUDI, Aysan et al. 2025. The Relationship Between Professional Autonomy and Job Performance Among Iranian ICU Nurses. In BMC Nursing. [online] 2025, vol. 24, no. 1. [cited 2026-01-30]. p. 20. Available online at: https://pubmed.ncbi.nlm.nih.gov/39773429/ ISSN 1472-6955.

LABRAGUE, Leodoro J. – McENROE-PETITTE, Denise M. – TSARAS, Konstantinos 2019. Predictors and Outcomes of Nurse Professional Autonomy: A Cross-Sectional Study. In International Journal of Nursing Practice. [online] 2019, vol. 25, no. 1. [cited 2026-01-29]. p. e12711. Available online at: https://onlinelibrary.wiley.com/doi/10.1111/ijn.12711 ISSN 1440-172X.

LABRAGUE, Leodoro J. et al. 2019. High-Fidelity Simulation and Nursing Students’ Anxiety and Self-Confidence: A Systematic Review. In Nursing Forum. [online] 2019, vol. 54, no. 3. [cited 2026-01-30]. p. 358–368. Available online at: https://pubmed.ncbi.nlm.nih.gov/30852844/ ISSN 1744-6198.

MABONA, Jean F. et al. 2022. Best Practice Recommendations for Healthy Work Environments for Nurses: An Integrative Literature Review. In Health SA Gesondheid. [online] 2022, vol. 27. [cited 2026-01-28]. p. 1788. Available online at: https://pubmed.ncbi.nlm.nih.gov/35548062/ ISSN 1025-9848.

OSHODI, Titilayo Olufunke et al. 2019. Registered Nurses’ Perceptions and Experiences of Autonomy: A Descriptive Phenomenological Study. In BMC Nursing. [online] 2019, vol. 18. [cited 2026-01-30]. p. 51. Available online at: https://pubmed.ncbi.nlm.nih.gov/31695577/ ISSN 1472-6955.

PARIZAD, Naser et al. 2021. Job Stress and Its Relationship with Nurses’ Autonomy and Nurse–Physician Collaboration in Intensive Care Unit. In Journal of Nursing Management. [online] 2021, vol. 29, no. 7. [cited 2026-01-30]. p. 2084–2091. Available online at: https://pubmed.ncbi.nlm.nih.gov/33894092/ ISSN 1365-2834.

PURSIO, Katja et al. 2021. Professional Autonomy in Nursing: An Integrative Review. In Journal of Nursing Management. [online] 2021, vol. 29, no. 6. [cited 2026-01-29]. p. 1565–1577. Available online at: https://pubmed.ncbi.nlm.nih.gov/33548098/ ISSN 1365-2834.

RAO, Aditi D. et al. 2017. Better Nurse Autonomy Decreases the Odds of 30-Day Mortality and Failure to Rescue. In Journal of Nursing Scholarship. [online] 2017, vol. 49. [cited 2026-01-29]. p. 73–79. Available online at: https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/jnu.12267 ISSN 1547-5069.

ROUHI-BALASI, Leila et al. 2020. Professional Autonomy of Nurses: A Qualitative Meta-Synthesis Study. In Iranian Journal of Nursing and Midwifery Research. [online] 2020, vol. 25, no. 4. [cited 2026-01-28]. p. 273–281. Available online at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7494166/ ISSN 2228-5504.

SCHEEPERS, R. A. et al. 2023. Empathic Nurses with Sufficient Job Resources Are Work-Engaged Professionals Who Deliver More Individualized Care. In Journal of Clinical Nursing. [online] 2023, vol. 32, no. 19–20. [cited 2026-01-30]. p. 7321–7329. Available online at: https://pubmed.ncbi.nlm.nih.gov/37469207/ ISSN 1365-2702.

TALEGHANI, Fariba et al. 2023. Analysis of the Concept of Nurses’ Autonomy in Intensive Care Units: A Hybrid Model. In Investigación y Educación en Enfermería. [online] 2023, vol. 41, no. 2. [cited 2026-01-28]. p. e17. Available online at: https://pubmed.ncbi.nlm.nih.gov/38589335/ ISSN 2216-0280.

VAN OOSTVEEN, Catharina – VERMEULEN, Hester 2017. Greater Nurse Autonomy Associated with Lower Mortality and Failure to Rescue Rates. In Evidence-Based Nursing. [online] 2017, vol. 20. [cited 2026-01-29]. p. 56. Available online at: https://ebn.bmj.com/content/20/2/56.long ISSN 1367-6539.

YUK, Songyi – YU, Soyoung 2023. The Effect of Professional Autonomy and Nursing Work Environment on Nurses’ Patient Safety Activities: A Perspective on Magnet Hospitals. In Journal of Nursing Management. [online] 2023, vol. 2023. [cited 2026-01-29]. p. 5587501. Available online at: https://onlinelibrary.wiley.com/doi/10.1155/2023/5587501 ISSN 1365-2834.

ŽIAKOVÁ, Katarína et al. 2023. Professionalism and Ethics in Nursing. Bratislava: Univerzita Komenského v Bratislave, 2023. ISBN 978-80-223-5714-2.