Power in Practice: A Study of Nursing Authority and Autonomy Kathleen Cleary Blanchfield and Diana L. Biordi Power and politics need to be translated into practice through development of authority and autonomy within the staff nurse role, The purpose ofthe research described was to identify and compare aspects of ‘agreement or disagreement between nurse leaders and staff about staff nurses’ authority and autonomy to deliver patient care. Findings indicated that significant differences exist between staff nurses’ and nurse leaders’ sense of staff nurse autonomy, and importance of authority and autonomy, differences that can lead to serious misunderstandings and power struggles. These differences, especially concerning management support, can seriously hinder both nurse leaders and staff nurses! success in restructuring cost-effective quality care. Key words: authority, autonomy, empowerment, power, restructure EW DEMANDS for restructuring N= delivery of health care provide the nursing profession with oppor- tunities to change the practice of nursing and, in so doing, to increase its power bases. Nurse leaders are doing this by calling for staff nurse empowermentas a major strategy when restructuring to improve quality and cost of health care.'* As the role of staff nurse changes from the sole provider of care to manager and provider of care, empower- ment becomes a major issue. Empowerment refers to the ability to make goal-directed decisions and to implement actions to meet desired goals. Thus, for staff nurses to be effective they are empowered with sanc- tioned authority and autonomy to manage and deliver patient care. Without clear au- thority and autonomy, registered nurses face care inefficiencies and power struggles.25 Purpose The research described in this article pro- vides insight into a basic aspect of nurses’ empowerment as expressed through author- 42 ity and autonomy within the staff nurse role. Without agreement between leaders and staff, nurses will not have the power neces- sary to perform nursing role functions‘and responsibilities. Consequently, the purpose of this research was to identify and compare aspects of agreement or disagreement be- tween nurse leaders and staff nurses about staff nurses’ authority and autonomy to de- liver patient care and to investigate the im- portance placed by nurses and their leaders on authority and autonomy of staff nurses. Background Power theory and its critical, closely linked components, authority and autono- Kathleen Cleary Blanchfield, PhD, RN, is Assistant Professor of Nursing Administration, Loyola Univer- sity, Chicago, Illinois. Diana L. Biordi, PhD, RN, FAAN, isa fellow of the ‘American Academy of Nursing, a specialist in nursing administration and women’s health, and Professor and Dean, Research and Graduate Affairs, Kent State University School of Nursing, Kent, Ohio. ‘Murs Adin Q, 1996, 20° 42-49 : (© 1996 Aspen Publishers, Ine.my, provided the conceptual framework for this study. Mintzberg defines power as “the capacity to effect (or affect) organizational outcomes.” French and Raven’ theorize that there are five bases of power: coercive, legitimate, reward, referent, and expert. Of these power bases, the legitimate and expert power bases are sources of authority and autonomy most relevant to nursing. Author- ity is defined as sanctioned or legitimate power delegated to an individual within an organization.* This delegated authority al- lows the individual to make decisions and to perform role-related functions.6? Autonomy is defined as an individual's ability to independently carry out the respon- sibilities of the position without close super- vision. Autonomy is closely linked to au- thority. If individuals are given the authority to make decisions and to perform necessary role functions, they require autonomy to in- dependently implement their responsibili- ties." Another important link between authority and autonomy occurs when individuals have acquired a knowledge base that makes them professionals. Consequently, professionals acquire authority to make decisions over is- sues dealing in their area of expertise."’ Since they have this special knowledge base and the authority to make decisions, profes- sionals believe they have earned the right to work autonomously. Frequently, the concepts of authority and autonomy have been used interchangeably, negating the distinction between the two.'? This blurs the importance of authority and deprives nursing of a major source of legiti- mate power. Without authority, autonomy is Jacking a vital element of empowerment: sanctioned power. It is autonomy by default, Nursing Authority and Autonomy 43 not autonomy that is recognized because of knowledge and skill.'' ‘The concept of authority of staff nurses is anew focus of research. Consequently, only three ‘studies were found that examined au- thority in nursing." All found disagree- ment over perceptions of staff nurses’ authority when compared to nurse manag- ers’ and other professionals’ perceptions. In contrast, many studies have been con- ducted about staff nurses’ autonomy.'*!7 They have differed in terms of measurement and in findings, yet one outcome is consis- tent. When staff nurses are asked to rate the value they place on autonomy, it is consis- tently rated as very important both for job satisfaction and for carrying out effective patient care. Several studies have indirectly indicated the importance of staff nurses’ authority and autonomy. Research on redesign of health care delivery systems has shown that quality and cost of care can be improved by delegat- ing authority to make decisions to the nurses who are responsible for the delivery of care.''§20 No research was found that si- multaneously examined staff nurse authority and autonomy or correlated these findings with those from their nurse leaders. Study This study used a descriptive ex post facto research design to measure how staff nurses and nurse leaders perceive the former’s au- thority and autonomy to deliver patient care. ‘The Nursing Authority and Autonomy Scale (NAAS) was distributed to 1,048 nurses from four midwestern hospitals that are part of a large health care organization. Two hos- pitals were inner city and two suburban,44 NURSING ADMINISTRATION QUARTERLY/SPRING 1996 ranging in size from 120 to 350 beds. One hospital had implemented shared gover- nance as a decentralized nursing manage- ment system. All were undertaking restruc- turing of management and patient care delivery systems. Five hundred and ninety- nine surveys were completed and returned (leaders=88, staff=511). Five hundred and ninety were usable. This provided a 57 per- cent return rate. Staff nurses comprised 85 percent of the respondents, nurse managers 8 percent, with the remaining 7 percent composed of chief nurse executives, directors of nursing, su- pervisors, educators, and clinical specialists. ‘The latter two groups (nurse managers and other nonstaff nurses) were combined to comprise one group, which is referred to as nurse leaders (15 percent). Prior to this col- lapsing of groups, t-tests were conducted and no significant differences were found with regard to the four dependent variables (authority, autonomy, importance of author- ity, and importance of autonomy). Instrument The NAAS, a three-part instrument, was developed foruse in this study. The first part, with 28 items, measured nurses’ perceptions of staff nurses’ authority and autonomy. The second part, with 10 items, measured nurses’ perceptions of the importance of staff nurs- es’ authority and autonomy. The third sec tion with 12 items asked demographic information. Two existing instruments served as a basis for the NAAS. Katzman’s!? Authority in Nursing Roles Instrument (ANRI) and the subscale on autonomy from Stamps and Piedmonte’s Job Satisfaction Index,” were adapted and expanded for the NAAS. In a recent study of instruments for nurse admin- istration research, both received outstanding ratings based upon their reliability and valid- ity" ‘The adapted and expanded NAAS instru- ment was pretested with staff nurses, physi- cians, and nurse managers. Statements were followed by a Likert-type scale ranging from S=strongly agree to l=strongly disagree. Authority items included such statements as: “[ initiate teaching patients how to care for themselves while recovering from illness or surgery” and “I initiate interactions with oth- er departments to coordinate the care given to my patients.” The autonomy items includ- ed such statements as: “I feel that Iam super- vised more closely than is necessary”; “Iam sometimes frustrated because all of my ac- tivities seem programmed for me.” Nurse leader surveys were phrased by third person statements to indicate staff nurses’ authority and autonomy. Reliability was indicated by a Cronbach’s alpha of .86 for authority items, a .72 for autonomy items, a .84 for importance of authority items, and a .78 for importance of autonomy items. Content validity for the NAAS was estab- lished by refinements based upon experts’ review and findings from several pilot stud- ies. Validity was indicated by use with groups who had known differences. A group of critical care nurses and a group of new graduate nurses had scores on the NAAS that were significantly different at the p<.05 lev- el. Analysis and Results Means, standard deviations, and Cron- bach’s alpha for the dependent variables areNursing Authority and Autonomy 45 Table 1. Means, standard deviations, and reliabilities for authority, autonomy, importance of authority, and importance of autonomy (N= 590) Total Standard Cronbach’s Variable Mean possible deviation reliability Authority 74.12 100.00 13.59 86 Autonomy 26.99 40.00 5.68 72 Importance of authority 26.04 30.00 438 84 Importance of autonomy 16.89 20.00 2.80 78 presented in Table 1. Overall, the scores for perception of staff nurses’ authority and au- tonomy were moderately high. Additionally, the mean scores for belief in the importance of staff nurses’ authority and autonomy were high. Pearson correlation coefficients demon- strated significant and moderately positive relationships between the variables (see Ta- ble 2 for correlations). The highest correla- tion was between importance of authority and importance of autonomy. To test if there is a difference between staff nurses and nurse leaders, data were an- alyzed using descriptive and inferential sta- tistics, Whenever repeated testing was done, a Bonferroni’s correction factor was also done. Very little difference was found be- tween the demographic variables for the two groups. One difference was found regarding highest level of education. Nurse leaders had a higher level of education, with 60 percent having a bachelor’s or master’s degree. Only 41 percent of staff nurses had a bachelor’s or master’s degree. Significant differences between staff nurses and nurse leaders were found in sev- eral areas. Hotelling’s T? results indicated staff nurses had a significantly higher F(1,587) = 10.36, p=.001 perception of their autonomy to enact patient care (M=27.31, SD=5.76) as compared to nurse leaders’ per- ceptions of staff nurses’ autonomy (M=25.21, SD=5.03). In order to test for any potential interac- tions among the variables, several two-way analyses of variance (ANOVAS) were con- ducted. Results of these analyses yielded two significant interactions. The first was between type of position and shift on impor- tance of authority at F(2,583) = 4.03, p=.018. The second was between type of position and shift on importance of autono- my at F(2,583) = 4.53, p=.011. To test these interactions, post hoc comparisons were conducted using simple main effects tests that indicated several significant findings. Nurse leaders who worked the night shift had a significantly higher (p<.05) belief in the importance of staff nurses’ authority (M=28.40, SD=2.30) and autonomy (M=19.20, SD=1.30) than the staff nurses who worked nights (M=26.71, SD=2.97), (M=16.81, SD=2.33). Again, when grouped according to shift on the scores for importance of autonomy, nurse leaders on the night shift had signifi- cantly higher (p<.05) scores for perceptions of staff nurses’ importance of autonomy (M=19.20, SD=1.30) as compared to the scores for the nurse leaders on the day shift (M=16.53, SD=2.55) and the evening shift46 NURSING ADMINISTRATION QUARTERLY/SPRING 1996, Table 2. Correlation matrix for authority, autonomy, importance of authority, and importance of autonomy (N= 590) Importance Importance of of Variable Authority Autonomy authority autonomy Authority 1.00 ‘Autonomy 32¢ 1.00 Importance of authority 65" 29" 1.00 Importance of autonomy a 31" 68" 1.00 “p=.01 (M=14,00, SD=2.83). Caution needs to be taken with these results due to the small number (5) of night nurse leaders. To test if there is a difference between hospital affiliation and the nurses’ scores on the four variables, a multivariate analysis of variance (MANOVA) was conducted. The results demonstrated significant differences between the nurses’ scores for authority (F[3,585] = 3.95, p=.008), autonomy (F[3,585] = 7.25, p=.000), and importance of authority (F[3, 585] = 4.73, p=.003) and hospital affiliation. To further explore these differences, sev- eral one-way ANOVAs were conducted. Nurses affiliated with hospital number two had significantly higher scores on percep- tion of authority (M=78.79, SD=12.00) and importance of authority (M=27.39, SD= 3.75) as compared to nurses affiliated with hospital number one; perception of authority (M=72.68, SD=14.06), and importance of authority (M=25.38, SD= 5.05). Nurses’ scores on perception of autonomy also varied with hospital affiliation. Nurses affiliated with hospital number four (M= 28.12, SD=5.01) and hospital number one (M=27.21, SD=6.03) had significantly high- erscores on autonomy as compared to nurses, affiliated with hospital number three (M=24.98, SD=5.57). To examine the relationship between the four variables and the remaining demo- graphic variables, several one-way ANOVAs were conducted. Results of these analyses indicated a significant difference between the type of units worked and nurses” perception of authority at F(2,588) = 4.01, p=.02. Specifically, nurses who worked in intensive care units (ICUs) or emergency de- partments (EDs) had a significantly higher level of perceived authority (M=76.99, SD=12.48) as compared to the nurses who worked specialty units (operating, pediatric, obstetric, or psychiatric) (M=72.51, SD= 15.63). Conversely, no significant differ- ence was found between nurses who work medical-surgical units and nurses who work in ICUs or EDs. Discussion The results of the present study have pro- vided empirical support for a conceptual linkage between authority and autonomy and the importance of each. Significant and moderately positive correlations were found between all four variables. The highest cor-Significant differences were found between staff nurses’ and nurse leaders’ perceptions about staff nurses? autonomy and importance of authority and autonomy. relation was between the importance of au- thority and the importance of autonomy. Nurses in this study correlate authority with autonomy and highly value both. A more representative group of nursing leadership was studied by expanding the nurse leader group to include not only nurse managers, but also chief nurse executives, directors of nursing, nurse educators, and clinical nurse specialists. Past studies have segmented these groups with the assumption that each is different, resulting in limited study of nurse leaders as a whole, Results of this study indicated that nurse leaders share, among themselves, the same perceptions about staff nurses® authority, autonomy, and their importance. It is significant that nurse leaders, from clinical nurse specialist to chief nurse executive, share the same per- ception. The position of nurse leader, regard- less of the title, removes nurses from staff nursing and direct patient contact. This can be a significant variable in shaping nurse leaders’ perceptions of staff nurses’ authori- ty and autonomy and their importance. Significant differences were found be- tween staff nurses’ and nurse leaders’ per- ceptions about staff nurses’ autonomy and importance of authority and autonomy. Re- sults indicated that staff nurses had a signif- icantly higher perception of their autonomy to enact patient care than did nurse leaders. ‘This difference, in leader and staff nurse per- ceptions, indicates a potential for conflict Nursing Authority and Autonomy 47 over staff nurse prerogatives in care deliv- ery. To avoid conflict and possible repri- mand, staff nurses might covertly enact their autonomy, thus leaving the leaders out of touch with staff. When nurse leaders are not fully aware of their staffs’ autonomous work practices, their leadership abilities are di- minished and staff can be left unsupported by management. Inefficient care follows when the one closest to the patient is unsup- ported by management. Type of position and shift worked influ- enced importance of authority and autono- my. Notably, the nurse leaders who work nights held a. significantly higher belief in the importance of staff nurse authority and autonomy than the staff nurses and the other nurse leaders who work the day and evening shifts. Nurses who work nights have a much broader span of control because the organi- zation is almost flat, with staff nurses taking greater responsibility for the entire operation of patient care. Nurse leaders who work nights acknowledge this by rating highly the importance of staff nurse authority and au- tonomy. Night nurses must take on more re- sponsibility and, hence, need more authority and autonomy. These findings have implica- tions for hospitals undertaking redesign of management structure and patient care de- livery. The importance of staff nurse author- ity and autonomy can increase as the layers are removed between management and staff. Type of unit worked significantly impact- ed nurses’ perception of their authority. Those who worked in an ICU or an ED unit had a significantly higher level of perceived authority as compared to nurses who worked in other specialty units. Typically, ICU and ED units are smaller and better defined, with standing orders or protocols that foster nurse48 NURSING ADMINISTRATION QUARTERLY/SPRING 1996 authority. Consequently, it is not surprising that these nurses had significantly higher levels of perceived authority than those who work in other more broadly defined specialty units, Tt was surprising that there was no signif- icant difference in perceived authority be- tween nurses who worked in ICU or ED units and nurses who worked in medical— surgical units. This demonstrates the effect of rapid change. Due to dramatic changes, medical-surgical nurses are caring for in- creasingly complex, acutely ill patients with multiple problems. Yascol”* proposes that the most highly refined specialty in nursing is the previous generalist, medical-surgical nurse. Hospital affiliation was found to be a sig- nificant independent variable. This indicates the importance that organizational environ- ment and management have on nurses’ sense of being empowered to deliver patient care. ‘The nurses with significantly higher author- ity scores were affiliated with the smallest of the hospitals (120 beds), in an urban setting, compared to the largest hospital (350 beds), in a suburban setting. The smaller hospital has fewer layers of management and a more interactive management style where every- one knows each other and addresses each other by title and name. The larger hospital has.amore formal management structure and nurses do not necessarily know everyone or their leaders. Manthey’s? theory that hospi- tals’ bureaucratic structures are a major hin- drance in nurses acquiring authority is substantiated by this finding. Brooks® found that hospital size affects nurses’ perception of power, with nurses in smaller hospitals having greater perception of power than those working in larger hospitals, Nurses’ perception of autonomy was also significantly impacted by hospital affilia- tion. Nurses from the hospital with shared governance were the highest in their percep- tion of autonomy. It is possible that organi- zational variables such as size, governance, management style, organizational culture, policies, and professional collaboration might be predictors of authority and autono- my, rather than demographic variables. However, complete study of these variables was beyond the scope of this study. Recommendations Findings from this study have implica- tions fornurse administrators who are under- taking redesign of management structure and patient care delivery systems. Rapid change provides the opportunity to empower nurses by clearly identifying staff nurses’ authority and autonomy in the delivery of appropriate and timely care. Unfortunately, this can be difficult because nurse leaders may be a step removed from changes in patient care that demand changes in staff nurse empower- ment, Consequently, leaders need to collab- orate with staff nurses to structure staff nurses’ authority and autonomy. Authority for staff nurses needs to be structured first through the status of registered nurse titles,?* and second, through the development of nursing practice standards, accountability, reporting relationships, job descriptions, and expectations. Since nurses highly value and correlate the importance of autonomy with the importance of authority, autonomy needs to be linked to staff nurse authority. Without authority, autonomy is lacking a vital ele- ment of empowerment: sanctioned power. 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