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Allison is a registered nurse and senior health policy adviser with some 25 years experience. Prior to launching CPD Nurse Escapes, Allison worked as a private consultant for a diverse range of clients in the government and non-government, health, community and education sectors. Allison has an extensive background in regulation, governance and professional practice and applies this in education, policy development and project management. Allison was the Principal Advisor, Professional Practice at the Nursing & Midwifery Board of South Australia, for 10 years where she was responsible for developing nursing and midwifery policy and standards and advising and educating nurses and midwives on professional practice issues.

Wednesday, 23 November 2011

Nursing Autonomy Part 2: How can Nurses Enhance their Autonomy?

Nurses can promote and expand their autonomy and the control over their own practice by publicly identifying their unique expertise in health and client care in easily understandable terms in a way that shows the value of their nursing expertise.  

Nurses need to communicate that their work involves an exclusive knowledge base and skill set that is different from and even unknown by physicians. Nurses must to be able to articulate nursing practice and fully understand their scope of practice to show nursing as a distinct and critical profession.

But how do we enhance our autonomy?

Encouraging continuous examination of practice allows nurses to reflect on the degree of autonomy in their decision making. By creating and fostering environments that support continuing educational opportunities and learning provides for autonomous clinical practice (through establishing and ensuring an evidence-based practice approach).

Supportive management, education, and experience are the three most important factors in enhancing autonomy over client care. Part of the dilemma is that most nurses practice as employees, the result being that nurses must structure their work within imposed rules, at the discretion of their employer rather than based on the critical judgement of the nurse. Unlike other health professions nurses do not usually have a discrete client base and it is therefore, more difficult to establish control over decision-making and determining client care. This of course has a profound effect on nursing practice.

Nurses need to foster understanding with other professions, with employers and the public, that nursing practice involves both direct clinical care and management of the context in which care is delivered. 

Nurses are not merely automatons, performing the tasks delegated to them by the physician in rote response. Nurses are autonomous yet interdependent practitioners who case manage complex care by; providing direct care, by collaborating with and seeking advice from other key health professionals and by negotiating components of that care that are the purview of other practitioners. 

Nurses are ground zero, from which all care occurs.

 Further, nurses are often under-represented on management and/or governance issues (issues that determine autonomy) and therefore their Influence on cultural change limited.Clinical nurses more likely to participate in clinical care decisions/policies but not organisational decisions/policy. Nurses must understand and engage with health service policy beyond clinical practice as decisions about autonomy and control over professional decision making are made at  level organisational governance and operational management levels. Nurses need to demand clarification of the rationale behind policy decisions affecting their practice and expose assumptions made in relation to their scope of practice.

Developing autonomy in nursing practice also requires a shift in communication styles and practice. Development of skills related to communication, interdisciplinary teamwork, and negotiation can assist nurses to master the skills necessary to advocate for their clients and demonstrate their autonomy. Our communication skills and the information and way we communicate can help articulate our autonomy to other professions. This may require a level of professional confidence to seek out feedback and critical review without being defensive.

Nurse Leaders

There is no one linear leader/ship. Leaders operate at all levels and evenly distributed throughout the whole organisation. They are characterised by being strong, visible and influential across the whole of the workforce, and may not hold management positions but lead through their this strength and their ability to engage with and address issues.  

Nurses should actively seek out and support nursing leaders who role model promoting autonomy and control over their own practice.This acts to create and shape culture and 
influence change in practice and policy.

Nurse Managers are well positioned to promote conditions to promote nurse autonomy and influence decision-making that supports control over nursing practice. There is evidence to support that Nurse Managers who are (1) informed about current nursing practice,  
(2) support staff to develop autonomy, and (3) communicate effectively with executive management about this practice, enhance professional autonomy. (Kramer & Schmalenberg, 2002;Upenicks, 2003).

Nursing Executive to need to promote and represent nursing staff/practice. A Nursing Executive who (1) advocates for a strong, influential nursing presence in the organisation, (2) is open and communicative and (3) supports participative management,is associated with a professional environment that includes autonomous clinical practice and nursing control over
practice (Hinshaw, 2002). Our Nursing Executive is our direct link to rest of executive team and nurses should expect and demand that nursing management and executive accurately and proactively represent current nursing best practice and advocate for professional autonomy.

Each and every nurse can:
  • Clarify expectations about clinical autonomy – expected practice
  • Enhance competence in practice – foster clinical case analysis and critiquing
  • Establish participative decision making – within policy and governance structure
  • Enhance competence in decision making – educate nurses about policy/decision making and how to contribute effectively
  • Identify, foster and support nurse leaders – engage with nurse leaders at all levels
  • Work upstream – seek to influence social, politician and economic factors in practice
  • Articulate nursing practice – to other nurses, other health professionals clients and the public

My advice...
Tell everybody what you do and how you do it....without you there is no care.

See Nursing Autonomy Part 3


Kramer, M., & Schmalenberg, C. (2004). Essentials of a magnetic work environment: Part 2. Nursing, 34(7), 44–47.

Upenieks, V. V. (2003). The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager, 22(2), 83–98.

Hinshaw, A.S. (2002). Chapter 4. Building magnetism in health organizations. In M.L. McClure & A.S. Hinshaw (Eds.), Magnet hospitals revisited: Attraction and retention of professional nurses (pp. 83–102). Washington, DC: American Nurses Association.


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  2. I like your blog a lot. Its informative and full of information. Thank you for sharing.