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ROFESSIONAL AUTONOMY,
COLLABORATION WITH
PHYSICIANS, AND MORAL
DISTRESS AMONG EUROPEAN
INTENSIVE CARE NURSES
By Elizabeth D.E. Papathanassoglou, RN, MSc, PhD, Maria N. K. Karanikola, RN,
MSc, PhD, Maria Kalafati, RN, MSc, PhD, Margarita Giannakopoulou, RN, PhD,
Chrysoula Lemonidou, RN, MSc, PhD, and John W. Albarran, RN, MSc, DPhil
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mong nurses, the association between being able to exercise autonomy and job
dissatisfaction, burnout, and intention to leave the profession is well established.1-3
In intensive care units (ICUs), increased nursing autonomy is strongly linked with
improved outcomes for patients1,4,5 and nurses health and well-being.6,7 Exercising
autonomy is a factor in supporting application of evidence-based practice8 and
in enhancing nurses satisfaction and retention.9
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potential associations among the 3 constructs. Associations with employee (sex, educational background,
clinical experience, level of work satisfaction, significance of job independence), organizational (type
of unit, health care staff ratios) and professional
(perceived status of ICU nursing)
factors, and nurses intention to quit
were also explored.
Discrepancies
in the levels of
nurse autonomy
exist between
countries.
Methods
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Some variables, including autonomy and nursephysician collaboration scores, did not fit the criteria
for normality and were fairly resistant to transformation because they originated from different
populations. For variables for which normality
transformation was not sufficient, nonparametric
tests were used. Parametric (t test, analysis of variance) and nonparametric (Mann-Whitney test,
Kruskal-Wallis test) comparisons between country,
education, and type of unit groups were performed.
Because of the small number of respondents from
specific countries, nonparametric analyses (KruskalWallis test) were performed, and the results were
confirmed with the exclusion of countries with
fewer than 10 respondents. Spearman r and partial
correlation coefficients were reported for bivariate
associations and partial associations to control for
the effect of background variables. Scale scores were
calculated according to the instructions provided
by the developers of the respective scales.
Ethical Issues
Ethics review approval was obtained from the
EfCCNa research and development review board and
the University of Athens, School of Nursing, scientific
review board. Questionnaires were returned anonymously in sealed envelopes. Return of a completed
questionnaire was considered equivalent to a participants consent to have the data included in the study
and used in publications and conference presentations.
Results
Internal consistency was sufficient for the autonomy scale (a = 0.878); the subscales of knowledge
base (a = 0.698), action base (a = 0.75), and value
base (a = 0.818); moral distress frequency (a = 0.87)
and intensity (a = 0.87) subscales and composite
moral distress subscale (a = 0.86); and the collaboration scale (a = 0.91).
Background and Demographic Data
The highest percentage of respondents was from
Italy (21.3%; Figure 1). Among the entire sample,
respondents had a mean of 12.07 (SD, 7.9) years of
nursing experience in intensive care, and 83.1%
were women (Table 1). Participants were rather satisfied with their ICU position (mean job satisfaction
score, 7.66; SD, 1.27; scale range, 1-10). They regarded
their job independence as very important (mean
score, 8.2; SD, 1.04; scale range, 1-10), but they did
not think that people understood the importance
of critical care nursing (mean score, 6.8; SD, 2.15;
scale range, 1-10). The typical patient to nurse ratio
was approximately 2.5, with larger standard deviations
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Other
12.4%
Croatia
2.1%
United
Kingdom
4.3%
Italy
21.3%
Belgium
2.1%
Cyprus
2.8%
Netherlands
2.5%
Norway
15.2%
Sweden
9.2%
Slovenia
3.5%
Denmark
7.8%
Finland
6.7%
Greece
9.9%
Moderate levels of
collaboration and
satisfaction about
care decisions
were found.
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Table 1
Demographic and background characteristics
and differences among participants (n = 255)
from different countries
Characteristic
Experience in intensive care
unit nursing, mean (SD), y
Valuea
P for differences
12.07 (7.9)
<.001
NS
Position
Head nurse
Staff nurse
60 (23.5)
195 (76.5)
Sex
Female
Male
212 (83.1)
43 (16.9)
Type of hospital
Public
University
Private
149 (58.4)
89 (34.9)
17 (6.7)
Type of unit
Medical/surgical
Cardiac surgery
Coronary
Neurosurgical/burn
Other
190 (74.5)
33 (12.9)
17 (6.7)
9 (3.5)
6 (2.4)
NS
NS
NS
.001
Educational background
Diploma
Bachelors degree
Masters degree
Doctoral degree
Other/missing data
84 (32.9)
87 (34.1)
50 (19.6)
10 (3.9)
24 (9.4)
7.66 (1.27)
NS
Importance of job
independence,b mean (SD)
8.2 (1.04)
NS
Participants perception of
the public appraisal of the
importance of intensive
care unit nursing,b mean (SD)
6.8 (2.15)
<.001
2.02 (1.60)
2.25 (1.70)
2.58 (2.18)
<.001
<.001
<.001
4.66 (2.87)
7.46 (4.18)
9.05 (7.03)
A few times
a year
<.001
<.001
.002
<.001
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Table 2
Most and least frequent morally distressing situations, and items with
highest composite moral distress scores (accounting for both frequency
and level of disturbance) and autonomy scale items with the highest
and lowest scores
Score,a mean (SD)
2.43 (1.05)
2.21 (1.17)
2.035 (1.22)
1.91 (0.96)
1.82 (1.17)
0.22 (0.57)
0.54 (0.92)
0.56 (0.90)
Items with highest composite moral distress scores (frequency x level of disturbance)
Initiating extensive life-saving actions when they only prolonged death
Carrying out a physicians orders for futile care
Working with colleagues who are not as competent as the patient care requires
Continuing to participate in the care of a hopelessly injured person
Assisting a physician who is providing incompetent care
Following the familys wishes to continue life support even though it is not in the best interest of the patient
Providing less than optimal care due to pressures to reduce costs
7.68
6.90
6.38
6.25
5.58
5.16
4.72
(4.54)
(4.79)
(4.05)
(4.66)
(4.14)
(4.28)
(4.59)
5.54 (0.72)
5.56 (0.70)
5.48 (0.79)
3.51 (1.84)
3.63 (1.29)
a Scores for most and least frequent morally distressing situations are on a Likert scale of 0 to 4; scores for items with highest composite moral distress
scores are from 0 to 16; and scores for the autonomy scale items are on a Likert scale of 1 to 6.
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A
70.00
65.00
60.00
55.00
50.00
45.00
40.00
35.00
30.00
25.00
Iceland
Switzerland
Estonia
Cyprus
Croatia
Germany
Spain
Sweden
Netherlands
Slovenia
Denmark
Greece
Finland
Norway
Belgium
Italy
United Kingdom
20.00
Intention to Quit
Intention to resign a post because of morally
distressing situations was associated positively with
composite moral distress scores (r = 0.229; P = .01)
and frequency of morally distressing situations
(r = 0.257; P = .004) and inversely with autonomy
(r = -0.142; P = .03) and collaboration scores (r =
-0.337; P < .001). Significant associations were noted
between intention to quit and patient to nurse ratios
per shift (r = 0.160 to 0.165; P = .02). Significant
inverse associations were noted between intention to
quit and respondents educational level, years of ICU
experience, and job satisfaction (Table 4).
Country
160.00
*
*
120.00
100.00
80.00
Discussion
60.00
40.00
Iceland
Switzerland
Estonia
Croatia
Cyprus
Germany
Spain
Netherlands
Sweden
Slovenia
Denmark
Finland
Greece
Norway
Belgium
Italy
20.00
United Kingdom
140.00
Country
status appraisal (r = 0.284). Significant inverse associations were noted with nurse-physician collaboration and patient to nurse ratios per shift (r = -0.151
to 0.224; P < .001).
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Table 3
Correlation matrix with Spearman r correlation coefficients and
P values reported (A) and partial correlation procedure results
with partial correlation coefficients and P values reported (B)a
A
Autonomy score
P
Composite
cumulative
distress score
Distress
frequency
Collaboration
score
1.000
.
-0.159
.07
-0.174b
.04
0.319c
<.001
0.903c
<.001
-0.337c
<.001
-0.116
.19
-0.208c
.02
-0.168
.05
1.000
-0.339c
<.001
-0.120
.16
-0.210b
.01
-0.207b
.01
0.336c
<.001
0.236c
.003
0.253c
.001
1.000
0.666c
<.001
0.540c
<.001
1.000
0.650c
<.001
Composite distress
score
P
Distress frequency
P
Knowledge base
of autonomy
score
1.000
Collaboration score
P
Knowledge base
of autonomy score
P
0.843c
<.001
Action base of
autonomy score
P value
Action base
of autonomy
score
Value base
of autonomy
score
Autonomy
score
0.884c
<.001
Value base of
autonomy score
0.850c
<.001
1.000
-0.2104b
.04
Autonomy score
P
-0.2476b
.01
0.9059b
<.001
Educational level, length of experience in intensive care units, and morning patient to nurse ratio were controlled for.
Significant at the .05 level.
c Significant after Bonferroni adjustment at the .01 level.
b
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Table 4
Correlation analysis results with Spearman r correlation coefficients and P values
Knowledge
base of
autonomy
Knowledge base of autonomy
P
1.000
Intention to quit
P
Intention
to quit
Composite
distress
score
Distress
frequency
-0.149
.08
-0.116
.19
-0.120
.16
1.000
Collaboration
0.336a
<.001
0.229b
.01
0.257b
.004
-0.207b
.01
1.000
0.903a
<.001
-0.337a
<.001
1.000
-0.339a
<.001
1.000
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ICU
working
experience
Educational
level
0.168b
.04
0.225b
.004
Continuing
education
Work
satisfaction
-0.246a
.002
0.325a
<.001
-0.167b
.04
Job
independence
Status
appraisal
0.187b
.02
0.167b
.03
-0.092
.27
-0.039
.64
0.011
.90
-0.007
.94
0.060
.50
-0.015
.86
-0.054
.54
0.038
.67
-0.278a
.001
-0.065
.45
0.018
.83
0.007
.94
-0.080
.35
0.013
.88
-0.325a
<.001
0.081
.31
-0.087
.28
0.274a
.001
-0.099
.21
0.284a
<.001
-0.006
.94
-0.127
.11
0.217b
.005
0.189b
.02
0.017
.83
1.000
-0.092
.24
0.144
.07
0.110
.16
0.066
.40
-0.312a
<.001
0.138
.08
0.184b
.02
0.021
.79
1.000
-0.053
.50
0.164b
.04
1.000
1.000
-0.028
.74
-0.092
.24
0.228a
.003
1.000
-0.076
.36
-0.011
.89
0.187b
.02
-0.011
.89
1.000
among Finnish ICU nurses in which the investigators used the same instrument we did, trends of
autonomy were similar to those in our study.
Moral distress is equally a problem and is
increasingly prevalent, especially among ICU nurses,
because the ICU itself is a stressful environment.39
In a recent European survey of ICU nurses,40 the
majority of nurses reported that participating in
end-of-life decision making was often associated
with moral distress. Moral distress not only is linked
with burnout and job stress but also may adversely
affect provision of quality care when nurses become
emotionally drained and disengaged.41,42 Previous
US reports,24,43,44 provide accounts of situations associated with increased moral distress. The situations
typically involve having to work with unskilled colleagues and the provision of futile or inappropriately
aggressive care. Similar to findings in previous studies,24,26 levels of moral distress in our study were moderate. However, the nurses in our study identified
activities such as initiating extraordinary life-saving
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Absence of
nurse-physician
collaboration is a
main source of
moral distress.
Collaboration in
and satisfaction
with care
decisions were
associated with
lower levels of
moral distress.
Conclusions and
Implications
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SEE ALSO
For more about moral distress, visit the Critical Care
Nurse Web site, www.ccnonline.org, and read the article by Martin and Koesel, Nurses Role in Clarifying
Goals in the Intensive Care Unit (June 2010).
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