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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 102-111

Relationship between leadership styles and clinical decision-making autonomy among critical care nurses


Department of Nursing Administration, Faculty of Nursing, Cairo University, Cairo, Egypt

Date of Submission16-Jan-2018
Date of Acceptance09-May-2018
Date of Web Publication12-Nov-2018

Correspondence Address:
Nadia T Mohamed
Department of Nursing Administration, Faculty of Nursing, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_4_1

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  Abstract 


Background Participation of nurses in an organization’s decision making varies depending on many factors, including the influence of nurse managers, head nurses, leadership, and collaboration with physicians.
Aim The aim of the present study was to explore the relationship between leadership style and decision-making autonomy among critical care nurses at New Kasr Al-Aini Teaching Hospital.
Participants and methods A descriptive exploratory research design was utilized. The study was conducted at New Kasr Al-Aini Teaching Hospital which is affiliated to Cairo University Hospital. The study was done on a convenient sample of 200 staff nurses who are working in critical care units. Data were collected using the Clinical Decision-Making Questionnaire which contains two main parts: the first part was demographic data and the second part was a Clinical Decision-Making questionnaire, adopted from Fareed (2016), and a Leadership Styles Questionnaire, which was designed by the researcher based on an extensive review of the related literature to measure three common styles of leadership.
Results There was high agreement on total perception of respondents about clinical decision-making autonomy; the highest mean percentage of respondents’ perception was on arranging patient investigations and supervising junior staff dimensions, followed by providing health education and making decisions to change patient medication dimensions. The least mean percentage was on work environment dimension. Regarding dominant leadership style the majority of staff nurses’ perceive their leader on democratic, followed by authoritarian, and lastly laissez-faire leadership style.
Conclusion There was no statistically significant relationship between nurses’ clinical decision-making autonomy and leadership styles.
Recommendation Critical care nurses’ managers should foster nurses’ autonomy by enabling them to exercise clinical decision-making autonomy, and by actively supporting nurses’ decisions and accountability.

Keywords: autonomy, critical care nurses, decision making, leadership styles


How to cite this article:
Mohamed NT. Relationship between leadership styles and clinical decision-making autonomy among critical care nurses. Egypt Nurs J 2018;15:102-11

How to cite this URL:
Mohamed NT. Relationship between leadership styles and clinical decision-making autonomy among critical care nurses. Egypt Nurs J [serial online] 2018 [cited 2018 Dec 14];15:102-11. Available from: http://www.enj.eg.net/text.asp?2018/15/2/102/245117




  Introduction Top


The dynamic and uncertain nature of healthcare environment requires nurses to be competent decision makers in order to respond to clients’ needs. Changes in patient needs, medical technology, and financial resources create uncertainty in healthcare organizations and require redesign of its structure and its process of care. As a result, nurses require greater autonomy and participation in decision making, which results in better outcomes. However, nurses’ participation in organizational decision making varies depending on many factors, including the influence of nurse manager leadership and collaboration with physicians (Krairiksh and Anthony, 2001; Liu, 2008).

The role and influence of first-line nurse managers are becoming increasingly important in today’s complex and continually changing healthcare organizations. Thus, the function and scope of their practice have evolved, increasing their accountability, authority, and responsibility for unit management, patient care, and staff development. In light of these changing roles, nurse managers need to continue to provide leadership to their staff to achieve patient, nurse, and unit goals, involving staff in decisions that directly or indirectly affect patient care. It is one of the leadership strategies used by nurse managers to achieve goals (College of Nurses of Ontario, 2011).

Leadership occurs at all levels within an organization. It is the process of supporting others to improve client care and services by promoting professional practice. Effective leadership is demonstrated by staff participation in decision making, the philosophy of the organization, and by the style of individual leaders within the organization (College of Nurses of Ontario, 2011). Leadership competencies influencing staff and stimulating growth and development of staff are the most important factors that increase staff participation in decision making. Influencing staff by developing a trust relationship between nurse managers and their staff encourages the staff to talk about their ideas and concerns (Janney et al., 2001; Krairiksh and Anthony, 2001).

The collaboration between nurses and physicians is an organizational component that may also affect the staff nurses’ participation in decision making. In collaborative practice, nurses and physicians share responsibilities for patient care and respect each other’s ability. Nurses share their knowledge, thoughts, and abilities with physicians to provide effective patient care planning and implementation (Krairiksh and Anthony, 2001).

One important aspect of the professional role of nurses is the belief in autonomous nursing practice that can be expressed as greater participation in clinical decision making. University-educated nurses also appear to be socialized to value autonomy and, in turn, expect a high level of involvement in clinical decision making (Hoffman et al., 2004). Many research studies have focused on nurses’ clinical functioning; most of these studies have linked the problem to the nurses’ knowledge and skills (McCaughan et al., 2002). Hence, the healthcare professional who provides direct care has to possess the autonomy and decision-making skills needed to provide quality, cost-effective care. Autonomy is commonly associated with the nurse’s ability to make decisions and with her professional knowledge base; an autonomous nurse is one who practices within a self-regulating professional environment; makes decisions based on professional judgment, and is able to act on these decisions within her own sphere of practice (Scott and Caress, 2005).

The amount of autonomy that nurses have varies from hospital to hospital and unit to unit, as does the extent to which nurses can make decisions. Clinical autonomy is a role characteristic that is socially constituted and the nurse’s position in a ward may act to constrain their clinical autonomy and decision making (Varjus et al., 2011). Much variability exists in the decisions nurses can make and the extent to which nurses want to make decisions; there may be barriers to nurses’ clinical decision making as a result of the type of hospital or ward in which they work. Nurses working in areas such as community health, critical care, and mental health are more independent decision makers than others. Nursing accountability for critically ill patients’ outcomes increases, along with the complexity of critical care. The rising severity of a critically ill individual need nurses to respond to increasingly complex and acute patient problems (Dematte et al., 2003).

A good leader will move easily between the styles depending on the context. Accordingly, organizations and managers are increasingly aware that they face a future of rapid and complex change. Leaderships who used a variety of styles achieved the best results which they adopted to the situation (Cheryl, 2012). Managers with leadership styles that seek and value contributions from the staff promote a climate in which information is shared effectively, promote decision making at the staff nurse level, exert positional power, and influence coordination of work. Historically, creating a climate that is supportive of nursing practice will augment the level of autonomous practice (College of Nurses of Ontario, 2011).

The concepts of empowerment and participatory management have been laden with a paternalistic tone of people in positions of authority allowing the staff to provide input and participate in some operations. In addition to the critical role of the nurse manager, executive leadership is critical to creating an environment that is supportive of autonomy and control over nursing practice (CONP). Organizationally, a visionary nurse executive who trusts and values the nursing staff is essential for creating the context for high levels of autonomy and CONP. Thus, the role of formal nurse leaders is powerful in establishing the context for autonomy and CONP (Scott and Caress, 2005).

Significance of the study

Reviewing researches and observation while practicing in different hospitals showed that the main reason for nurses leaving work areas is unsatisfactory work conditions. These work conditions include lack of autonomy, inability to make clinical decisions, heavy patient loads, leadership styles, and nonsupportive management (Strachota et al., 2003). Not all leaders exhibit the same leadership traits. Leadership style affects the entire unit, including nurses’ participation in decision making, morale, skills, and ultimately can affect the quality of patient care (Frankel, 2008).

In Egypt, there were very few studies valuing decision making in the nursing profession. Hamdy (2002) reported that nurses constitute the largest professional group in the healthcare system and make up about half the workforce in the healthcare area; only 4.3% of the staff nurses agreed that the nurses’ job allows them to make their own decisions. Therefore, nurses work within a climate of uncertainty and disempowerment along with high organizational demands; this condition threatens the physical and emotional well-being of nurses and the profession itself (Hart and Eli, 2005). Practice and clinical decision-making autonomy are preconditions for supporting critical care nurses (CCNs) in fulfilling their caring responsibilities (Dorgham, 2013). Lack of decision making among nurses in a clinical setting is the chief cause of nurses’ job dissatisfaction, lose their motivation, and resistance to change (Ahmed, 2013).


  Participants and methods Top


Design

A descriptive exploratory research design was utilized in this study.


  Aim Top


This study aimed to explore the relationship between leadership styles and decision-making autonomy among CCNs at New Kasr Al-Aini Teaching Hospital.

Research question

The current study had a main question:
  1. What is the relationship between leadership styles and clinical decision-making autonomy among CCNs?


Participants

A convenient sample of 200 staff nurses who are working in critical care units in New Kasr Al-Aini Teaching Hospital.

Setting

The study was conducted at New Kasr Al-Aini Teaching Hospital which is affiliated to the Cairo University Hospital. The hospital bed capacity is 920 beds with a total of 800 nurses from different categories of staff nurses (bachelor of nursing, graduates of technical nursing institute and diploma nurses).This hospital consists of 12 floors. The study was conducted in nine critical care units which provide paid healthcare services. The surgical ICU is located in the ground floor. It contains 16 beds, an open heart ICU located in the first floor and divided into two parts; adults with eight beds and infants with four beds. Cardiac CCUs are located in the second floor (2A) and consists of eight beds; Dr ShriefMokhtar unit (CCU1) consists of 12 beds; Dr Mohamed ElGendy unit (CCU2) consists of eight beds; and a hepatic ICU (6B) is located in the sixth floor and consists of eight beds, chest ICU is located in the seventh floor and consists of eight beds, Neurology ICU (7B) which is located in the seventh floor consists of four beds and neonatal ICU (7D) which is located in the seventh floor consists of 12 critical care beds and four intermediate beds.

Tools

To achieve the aim of the present study, data were collected using the following two tools:
  1. A Clinical Decision-Making Questionnaire (CDMQ) which contains two main parts:
    1. The first part was demographic data which was designed to collect the characteristics of the respondents such as age, sex, working department, educational level, and years of experience.
    2. The second part was the CDMQ, it was adopted from Fareed (2016). It covered 14 dimensions and contains 67 items as follows: diagnosing patient’s problems (four items), managing the work environment (six items), providing basic nursing care (five items), providing psychological support (four items), acting in an emergency situation (six items), teaching the patient or family (three items), informing patients about their prognosis (four items), arranging patient investigations (four items), supervising junior staff (three items), mentoring nursing students (four items), making decisions to change patient medication (three items), providing discharge information for the patient or family (six items), organizing the work of others (three items), and autonomy in nursing clinical decisions (12 items).
      • The scoring system: three-point Likert scale: always=(2); sometimes=(1); never=(0). This questionnaire was estimated by the total number of responses by the participants, the higher the score, the higher the clinical decision-making autonomy.
  2. Leadership Styles Questionnaire which was developed by the researcher based on extensive review of the related literature. It is designed to assess three common styles of leadership: authoritarian, democratic, and laissez-faire. It composed of 18 items. Five-point Likert scales were used; the number of responses on each item indicates the degree to which the respondents agree or disagree (5-1), and the sum of the responses on items 1, 4, 7, 10, 13, and 16 will indicate an authoritarian leadership style. The sum of the responses on items 2, 5, 8, 11, 14, and 17 indicates democratic leadership style, whereas the sum of responses on items 3, 6, 9, 12, 15, and 18 indicate laissez-faire leadership style.


Tool validity

Both tools were submitted to six experts in nursing administration from the Faculty of Nursing Cairo University for testing the content, coverage, clarity, wording, length, format, and overall appearance.

Pilot study

A pilot study was carried out on 10 head nurses and 10 CCNs (excluded from the main study’s sample) from the previously mentioned setting to assess and ensure the applicability and suitability of the statements and the time required to complete the questionnaire; therefore, the rewording or rephrasing of statements was done in three items.

Reliability

Cronbach’s α coefficient was used to measure internal consistency reliability of the CDMQ (0.69), which was satisfactory and regarding Leadership Styles Questionnaire, the calculated reliability was 0.74.

Procedures

The study protocol and tools were approved by the Research Ethics Committee in Faculty of Nursing, Cairo University then approval from authoritative staff at New Kasr Al-Aini Teaching Hospital to conduct the current study. Nurses were informed that participation in the study was completely voluntarily and they had the right to withdraw at any time. The nurses were assured that data are confidential and used only for research purposes. During data collection the researcher handed the questionnaire sheets individually to the participant nurses in their units and asked them to fill it and return back. If the nurses return back the questionnaire that is means their acceptance. The time spent to fill the questionnaire ranged from 15 to 20 min The researcher was ready to answer any question during filling the questionnaire. Data was collected in a period of 3 months from June to March 2016.

Statistical analysis

All data was collected, tabulated, and subjected to statistical analysis. SPSS version 20 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics such as frequency, percentage distribution, mean score, and SD were utilized in analyzing data pretended in this study. Relative statistical tests of significance were used to identify the relationships among the study variables. Threshold of significances is fixed (P≤0.05).

Ethical considerations

The research was approved by research ethical committee in the Faculty of Nursing, Cairo University. The data was collected after obtaining the approval from the hospital responsible authorities. Prior to the data collection, informed consents of all nurses were obtained. The nurses were informed about the purpose of the research study. Return back the questionnaire that is means nurses’ acceptance.


  Results Top


[Table 1] showed that, the most of the study participants (91.5%) were female, (18%) of study participants were working in surgical ICU, (12.5%) was working in chest ICU, the same percentage in Neonate, and ShreefMokhtar CCU the least percentage (7%) was working in hepatic ICU, the majority (71.0%) of study participants were graduated from secondary nursing school and the rest were graduated from technical nursing institute. Regarding to years of experience more than half of study participants (51.0%) had experience less than 10 years.
Table 1 Frequency distribution of staff nurses demographic data (n=200)

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[Figure 1] showed that, high agreement (mean %=81.36) about total perception of respondents about clinical decision-making autonomy. The highest mean percentage of respondents’ perception was on arranging patient’s investigation and supervising junior staff dimensions (92.83 and 90.67), respectively. Followed by 89.33 and 89.11 were on health education and making decision to change patient’s medication dimensions, respectively. The least mean percentage (64.39) was on managing work environment dimension.
Figure 1 Staff nurses’ perception regarding clinical decision making autonomy dimensions (n=200).

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[Table 2] showed that, staff nurses perceived their leader on democratic leadership style (mean %=78.57), followed by authoritarian leadership style (mean %=75.3), and lastly laissez-faire leadership style (mean %=62.37).
Table 2 Staff nurses’ perception about leadership styles (n=200)

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[Table 3] showed that, there was no statistically significant relationship between nurses’ clinical decision-making autonomy and leadership styles.
Table 3 Relationship between leadership styles and staff nurses’ clinical decision-making autonomy (n=200)

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[Table 4] showed that there was a highly significant statistical difference (f=4.34, P=0.00) in the participants total perception according to their work department, there was significant statistical difference (t=−1.61, P=0.02) in the participants total perception according to their scientific degree, there was no significant statistically difference (f=1.48, P=0.22) in the participants total perception according to their level of experience and there was no significant statistically difference (t=−2.23, P=0.05) in the participants total perception according to their sex.
Table 4 Relationship between staff nurses’ perception about clinical decision-making autonomy and their demographic data (n=200)

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  Discussion Top


Nurses place a high value on their autonomy in clinical settings. Autonomy in general and autonomous decision making in particular can be influenced by managerial interventions. Nurse managers can initiate interventions at the unit level to promote nurses’ autonomy, which will influence job satisfaction and retention as well as patients’ satisfaction and the quality of nursing care.

Regarding demographic data the result of the current study revealed that, the majority of study sample was females, this due to the fact that most of the working staff was female in the selected units. The majority of study participants were graduated from secondary nursing school because the majority of the hired staff was nursing diploma. As regard to years of experience more than half of study participants had experience less than 10 years.

The present study revealed that, high agreement about total perception of respondents about clinical decision-making autonomy. The highest mean percentage of respondents’ perception was on arranging patient’s investigations and supervising junior staff dimensions followed by health education and making decision to change patient’s medication dimensions. The least mean percentage was on managing work environment dimension. This finding is consistent with Varjus et al. (2003) who found that, the majority of nurses reported more autonomy in relations to actions and decision-making concerning patient care than regarding issue related to unit operations.

The current study showed that, the majority of nurses arranging patient’s investigations as obtain the patient investigation results and discuss them with the physician and arrange for more investigations if needed at the same time which went in line with a study done by van Keer (2015) showed that, good care from the families’ point of view included seeking exhaustive information, and participating in end-of-life decision making, provide complete information about patient conditions (investigation, health education, preparation for discharge, etc.) from nurses and healthcare professionals. Bucknall (2000) stated that, in critical care, nurses must exercise high levels of responsibility and discretional decision making due to the urgency in treating life threatening illnesses. Thus, it might be anticipated that CCNs would possess high levels of decision-making autonomy to experience job fulfillment (Cronqvist et al., 2006).

The current study revealed that the majority of nurses supervising junior staff and mentoring nursing students. On the contrary, a study by Sharon (2010) revealed that, staff nurses experience a great deal of stress during their shift when asked to mentor a nursing student in addition to their workload. Also, Wilson and Carol (2012) who showed that, at some time nurses had experienced clinical supervision on novice nurses, but on occasions is understood as an extra responsibility within their daily work and therefore perceived negatively. In addition to a study by MacKusick (2010) showed that, from the reasons of the nurses turnover were taking the responsibilities of the new nursing graduates in their working units. The current study results may relate to the restricted organization policies concerning medication errors and mistakes punishments which make the experienced nurses have many responsibilities and try to avoid the mistakes during their shifts, also they may consider mentoring junior staff as over responsibilities for them.

The current study revealed that the majority of nurses give health education to patients and their families. In congruent with this finding Keltner (2013) who approved that, nurses who have educated patient and families about treatment and illness prognosis can serve as a support to them in both treating and promoting mental health problems which was opposite to the study result of Kemppainen and Tossavainen (2013) who approved that, nurses have not yet demonstrated a clear and obvious role in implementing health related activities (patients’ knowledge of their illness and self-management). Also, Reinke and Sarah (2011) showed that, most behaviors related to meeting patients’ and families’ needs regarding prognostic information are completed collaboratively with physicians with no nurses’ intervention. Moreover, Hoffman et al. (2004) identified a significant difference between the scores for perceived and normative decision making. Nurses reported that, they wanted more decision-making authority than they currently have and they feel they cannot make decisions to the extent they want.

In the present study, the majority of the study sample can diagnose the patient’s problem in different situations from deterioration and improvement, when to ask for help if they have no information and close to the patient also to diagnose his fears and worries. Odell (2015) supported this finding in his study found that, nurses had the skills needed to assess patient’s problems and perform accurate physical assessment. Studies (Silva and Galvão, 2007; Brady and Cummings, 2010) found similar results in several hospital units. In the emergency room, it was observed that sharing ideas and the decision-making process was the most common style among nurses, as well as in the operating room. Styles sharing and delegate ‘passes on the responsibility for the decisions and the implementation’ were the most frequently used in the surgery hospitalization unit. Also, Kristi (2013) found that, in critical sittings, the nurses need to own much experience to be able to deliver clinical decision making in an emergency situation.

In congruent with the finding that, The least mean percentage was on managing work environment dimension, Hughes (2008) found that, nurses shoulder much of responsibilities when there is workforce shortage and lack of needed medical equipment or lack of appropriate policies and standards which leads to low standard nursing care. Also, Kalliopi (2011) showed that, workplace facilities affect positively on nurse’s clinical decision making. In addition to a study done by Shariff (2014) showed that, lack of resources considered a great barrier towards improving all spheres of healthcare that nurses can make.

On the other hands Scholes (2006) stated that, although CCNs are required continually to develop new skills and expand their role, their autonomy appears to be restricted by medical dominance, their perceived lack of knowledge and the limited responsibility afforded to them (Cornock, 2002). Unit nurse managers not listening to staff nurse ideas or including staff nurses in the decision-making process, they may not have been demonstrating the leadership skills sought by staff nurses (Robert, 2012).

The present study founded that, staff nurses perceive their leader on democratic leadership style, followed by authoritarian leadership style, and lastly laissez-faire leadership style. These findings are in accordance with Davidson et al. (2003) who claimed that, the ways that leaders function vary and can be located along a continuum from authoritative to participatory in leadership styles. Moreover, literature mentioned that nurse managers had many leadership styles, but normally they had one that they used more than the others. In addition, the nurse managers should consider their leadership style from the point of view of employees, situation factors, and goals of the organization (Vesterinen et al., 2012). That nurses who work in hospitals desire autonomy and responsibility and usually like to be led by a leader with a participative leadership style (Allen, 2000; Margall and Duquette, 2000).

These results proved the findings of Mills (2007) which reported that, situational leadership is centered on the premise that, there is no such thing as a single appropriate leadership style for each and every situation. In this approach, the leader’s behavior in relation to subordinates in a specific task is emphasized. It is founded interrelation between the leader’s task behavior, his/her relationship behavior, and the subordinates’ maturity.

The present study showed that, there was no statistically significant relationship between nurses’ clinical decision-making and leadership styles. This result was consistent with a study on the benefits and outcomes of staff nurses’ participation in decision making. Krairikish and Anthony (2001) reported that nurse managers’ leadership had little effects on staff nurses’ participation in decisions. Furthermore, nurses reported that, the three important variables that increased nurses’ autonomy were supportive management, education, and experience. On the contrary, the three most important variables that were reported to decrease autonomy were autocratic/nonsupportive management, physicians, and workload (McParland et al., 2000).

The present study concluded that, there was a highly significant statistical difference in the participants total perception according to their work department, there was a significant statistical difference in the participants total perception according to their level of education, there was no significant statistically difference in the participants total perception according to their level of experience and there was no significant statistically difference in the participants total perception according to their sex.

In consistence with the study findings, Iliopoulou and While (2010) found that, the CCNs often encounter difficulties associated with clinical decision making. Their autonomy as decision makers has been reported to be affected by their perceived lack of knowledge, by medical control on a regular basis and by the mismatch between their high level of training in critical care and the low level of responsibility afforded to them. In addition, Bucknall (2000) in Australia which proved that lack of time as well as inadequate knowledge base and personnel conflicts were the more frequent barriers to decision making among CCNs.

On the other side, Al-Enezi et al. (2009) asserted that, professionals mature age-wise and gather more experience; they tend to make a better adjustment to the work environment when compared with younger peers. Benner (2001) study of decision making by CCNs identified that knowledge and experience were important to clinical decision making. Also, Papathanassogloue et al. (2005) reported the positive association between the length of ICU experience and decision-making autonomy may be understandable on the basis of both increased knowledge and psychomotor skills, and the ability to handle more efficiently the hierarchical relationships of the unit.

In addition to these findings, Papathanassogloue et al. (2005) showed differences between those who worked in coronary and cardiothoracic care units and those working in general and pediatric units. These results are in consistent with several other studies of autonomy of nurses working in different clinical settings and countries, including Australia (Bucknall, 2000), Finland (Varjus et al., 2003), the USA, Canada, and the UK (Mrayyan, 2006), the USA (Mrayyan, 2005), and the UK and Greece (Bakalis et al., 2003; Papathanassogloue et al., 2005) which concluded that, nurses with more than 12 years of experience reported higher levels of autonomy. Also, these results supported by Hooi et al. (2000) study which stated that, experienced staff nurses had more authority and autonomy in their work. Professional autonomy in nursing has been found to increase with increases in grade of post and years of experience.


  Conclusion Top


It can be concluded that dominant leadership styles among head nurses were democratic and authoritarian styles as well as laissez-faire leadership style. Findings demonstrates that high staff nurses agreement about total perception of clinical decision-making autonomy. The majority of staff nurses’ perception was on democratic leadership style, followed by authoritarian leadership style, and lastly laissez-faire leadership style. There was no statistically significant relationship between nurses’ clinical decision making and total of leadership styles. Also, there was no statistically significant relationship between nurses’ clinical decision-making autonomy and leadership styles. There was a highly significant statistical difference in the participants total perception according to their work department, there was significant statistical difference in the participants total perception according to their scientific degree, there was no significant statistically difference in the participants total perception according to their level of experience and there was no significant statistically difference in the participants total perception according to their sex.

Recommendation

Based on findings of the current study:
  1. The nurse manager have to ensure a nursing contribution to decision making at all levels of policy development and implementation, and to address the obstacles in particular medical dominance for actualizing nursing autonomy.
  2. The nurse manager actively supporting nursing decisions and nursing accountability.
  3. Providing continuous in-service education to increase nurses’ knowledge base. Further research should be conducted to determine more closely at what kind of decisions and actions at the patient care level and at the unit level CCN’s can practice autonomy decision making.
  4. Nursing leaders must focus on the needs of individual staff and use motivational and empowering strategies appropriate to each person and situation.
  5. Nursing leaders should encourage professional growth through effective role modeling.
  6. Nursing leaders should build the leadership capacity in the nursing workforce.
  7. Nursing leaders should encourage nurses to test new skills in a safe and supportive environment.
  8. Further research is needed to examine the barriers to decision-making autonomy that nurses face in relation to unit operational decisions.
  9. This study may be needed to be replicated with larger sample size.
[51]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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