RESEARCH
Level of autonomy of primary care nurse practitioners
Alex Bahadori, DNP, ARNP-C (Doctor of Nursing Practice)1 & Joyce J. Fitzpatrick, PhD, RN, FAAN (Elizabeth
Brooks Ford Professor of Nursing)2
1 Professional Dermatology Services, Gulf Coast Dermatology, Hudson, Florida
2 Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
Keywords
Autonomy; nurse practitioners; primary care;
Dempster Practice Behavior Scale.
Correspondence
Alex Bahadori, DNP, ARNP-C, 12482 Everard
Dr., Spring Hill, FL 34609.
Tel: 352-556-6228; Fax: 352-684-6578;
E-mail: [email protected]
Received: February 2008;
accepted: June 2008
doi:10.1111/j.1745-7599.2009.00437.x
Abstract
Purpose: The purpose of this descriptive study was to determine the level of
autonomy of nurse practitioners (NPs) providing care to patients in a primary
care setting.
Data sources: Data were collected from 48 primary care NPs (PCNPs) who
attended a state clinical conference. The Dempster Practice Behavior Scale
(DPBS) was used to measure the autonomy of the NPs.
Conclusions: The total mean score for the DPBS in this study was 127
(SD = 10.25), indicating a very high level of autonomy of the NPs. The
Empowerment subscale had the lowest overall mean score, and the Valuation
subscale had the highest. There was no statistically significant relationship
between level of autonomy and age, years worked as an RN, and years worked
as an NP.
Implications for practice: This study provided evidence that PCNPs are highly
autonomous professionals and continue to struggle with empowerment. NPs
educationally prepared with a better knowledge of legal and political issues
will be better suited to influence healthcare reform. NPs, as autonomous
professionals, will be more likely to impact and shape future healthcare policy.
Introduction
Autonomy in practice has been a dominant professional
issue for nurse practitioners’ (NPs) performance and
practice (Dempster, 1990, 1994). Professional autonomy
means allowing professionals to have substantial control
over professional practice, including significant room
for exercise of their judgment (MacDonald, 2002). NPs
working in restrictive practice environments may perceive
themselves as less autonomous. NPs working in managed
care systems, with excessive rules and regulations, have
reported lower levels of autonomy (Ulrich & Soeken,
2005). Legal and organizational restrictions have been
dominant barriers to optimal autonomous practice of
NPs (Timmons & Ridenour, 1994).
Thus far, many researchers have addressed autonomy
in the context of other variables, such as organizational
influences, prescribing patterns, decision making, and
role implementation. Researchers have also compared
the outcomes of primary care NP (PCNP) autonomy
to other types of providers. However, there is limited
information on the actual level of autonomy of PCNPs.
This study provides information on the level of autonomy
of PCNPs, and the findings may be used for future research
to understand the complex variables that influence the
autonomous practice of PCNPs.
Background
NPs working in primary care settings are also known as
PCNPs. PCNPs comprise the largest group of NPs. Rapid
changes in healthcare delivery, financial constraints,
and consumer demand have influenced the practice of
all healthcare providers and are critical factors in the
emergence in the role of the PCNP (Furlong & Smith,
2005). The majority of PCNPs practice in outpatient
areas providing care to the adult patient population.
Journal of the American Academy of Nurse Practitioners 21 (2009) 513–519 © 2009 The Author(s)
Journal compilation © 2009 American Academy of Nurse Practitioners
513
Autonomy of primary care NPs
Studies have shown that NPs have the knowledge and
expertise to meet the healthcare needs of the ambulatory
patient population (Daly & Carnwell, 2003; Mundinger
et al., 2000).
The rapidly evolving healthcare environment mandates
that PCNPs function at the highest level of professional
autonomy. Without increased autonomy, NPs in primary
care will not be able to use their skills to the fullest
extent and may have limited impact on healthcare
reform. Also, many view the relationships between NPs
and physicians as supervisory rather than collaborative.
Successful collaborative practice requires more than
just working in physical proximity to others (Almost &
Laschinger, 2002). In collaborative practice, an NP and
a physician provide primary health services to a group
of patients, and the two professionals share authority
equally for providing care within the scope of their
practice (Mundinger, 1994).
Chumbler et al. (2000) examined the impact of
demographic characteristics, practice attributes, and
primary practice settings on NP decision making and
the effects of decision making on clinical productivity.
The results indicated that having more years of practice as
an NP, treating patients according to clinical guidelines,
practicing in a multi-specialty group practice, practicing
with fewer numbers of physicians, and practicing in a
family specialty area are all associated with greater levels
of clinical decision making. Clinical decision-making
authority had a strong positive correlation with greater
outpatient clinical productivity (r = 0.265, p < .001).
Mundinger et al. (2000) compared clinical outcomes for
patients assigned to either NPs or physicians. This large
randomized trial sampled 1316 patients from primary
care clinics in urban locations in New York. There
were no significant differences in reported health status
between patients treated by NPs versus physicians at
6 months (p = .92). The authors of this study concluded
that in situations where NPs had the same authority
and responsibilities as primary care physicians, patient
outcomes in primary care do not differ.
Pan, Straub, and Geller (1997) conducted a descriptive
correlational study to analyze the impact of a restrictive
practice environment on an NP’s level of autonomy with
respect to prescribing certain medications. The study
results showed that a restrictive practice environment
lowered the prescribing autonomy of NPs.
Cajulis and Fitzpatrick (2007) conducted a descriptive
study to determine the level of autonomy of NPs in an
acute care setting. The researchers used the Dempster
Practice Behavior Scale (DPBS) to measure the level
of autonomy in acute care NPs. The overall results
showed that NPs in an acute care setting had high
levels of autonomy (M = 117; SD = 14.5). Additionally,
514
A. Bahadori & J.J. Fitzpatrick
demographic variables of age, years worked as an RN,
years worked as an NP, and basic nursing preparation
demonstrated no significant relationship with autonomy
scores.
Several studies have explored the role of NPs in various
settings. Irvine et al. (2000) explored the influence of
organizational factors on NPs’ role implementation in
acute care settings. The results showed that acute care
NPs perceived their role as not well formalized in
their working environment. Norris and Melby (2006)
used surveys and interviews to explore the opinions of
emergency room nurses and physicians toward the role
of the acute care NP. The researchers concluded that
the blurring of boundaries between NPs and physicians
can result in inter-professional conflict and decreased NP
autonomy. Offredy and Townsend (2000) examined the
role and practice of NPs in primary care. The results
indicated a wide range of NP practice patterns and roles
even within the same local area.
Although PCNPs comprise the largest group of NPs,
there is a gap in the research on the actual level of
autonomy of PCNPs. The current study addresses that
gap by exploring the level of autonomy of PCNPs using
a previously validated scale, the DPBS, to understand the
complex variables that influence the autonomous practice
of PCNPs.
Methods
The study was conducted at an annual state conference
associated with the Florida Nurse Practitioner Network
(FNPN). The conference was held in Florida in October of
2007. There were approximately 200 NPs in attendance.
The FNPN is a statewide organization with approximately
2000 members and was founded in 2002. The organization provides educational and professional developmental
opportunities for all types of NPs across the state of Florida.
The sample included 48 NPs who met the inclusion
criteria of licensed to practice as an NP, practicing in
a primary care outpatient setting and working with
an adult patient population. Also the participant must
have been educationally prepared as a family, adult, or
gerontological NP. NPs working in any work schedule
were included; however, NPs working in the specialty
areas of acute care, pediatrics, women’s health, and
psychiatric/mental health were excluded. Additionally,
NPs practicing in inpatient settings and specialty practices
were excluded. Although pediatric and women’s health
NPs may be considered primary care providers, they were
excluded because their practice is limited to a specific
patient population.
Autonomy of primary care NPs
A. Bahadori & J.J. Fitzpatrick
Instruments
The instruments used in this study were the DPBS questionnaire and the background data questionnaire. The
DPBS is a 30-item questionnaire measuring autonomy
in practice (Dempster, 1990). The DPBS was designed
to assess behaviors, actions, and conduct related to the
individual’s autonomy in a practice setting. The instrument uses a 5-point Likert scale with scores from each
item ranging from 1 (not at all true) to 5 (extremely true).
Total scores range from 30 to 150 and higher scores on the
DPBS indicate a greater extent of autonomy. The DPBS
takes approximately 15 min to complete. The instrument
is generalizable within nursing and outside of nursing.
The operational definition of autonomy in PCNPs was the
total score obtained on the DPBS. A higher score indicated
a greater amount of autonomy (Dempster, 1990).
Four subscale dimensions comprise the DPBS: Readiness, Empowerment, Actualization, and Valuation. The
Readiness scale measured elements of growth, skill, competence, and mastery. The dimension of Readiness also
included the progression from one level to another
related to autonomy in practice (Dempster, 1994). The
Empowerment scale measured the legitimacy of one’s
performance in a practice setting (Ulrich et al., 2003).
Empowerment included rights and privileges, sanction,
and legal status to use one’s knowledge and skills to
their fullest extent without restriction (Dempster, 1994).
The Actualization scale measured decision making and
involved the dimensions of determination, responsibility, and accountability (Dempster, 1994; Ulrich et al.).
The Valuation scale measured elements of value, worth,
merit, and usefulness related to autonomy in practice.
All together, these four dimensions and subscales of
autonomy provide a framework for elaborating insights
into the issue of NP autonomy (Dempster, 1990). Initial reliability analysis revealed a Cronbach’s alpha of
.95 (Dempster, 1990).
Background information about age, gender, race,
educational background, basic preparation in nursing,
NP certification, years worked as an NP, years worked
at current job, years worked as a RN, current NP
specialty area, and work status was collected. The NPs
were asked additional questions to rate the importance
of the domains of practice and the conceptual strands
from the Strong Model of Advanced Practice (Ackerman
et al., 1996). The Strong Model defined five domains of
practice, which comprise the Advanced Nursing Practice
role and conceptual strands that envelop and unify
each domain (see Table 3). NPs progress from novice
to expert in the provision of advanced care in the five
domains. Autonomy, as it related to empowerment, was
identified as an important concept within the Strong
Model (Ackerman et al.). The questions from the Strong
Model were included to describe the level of importance
of the Strong Model concepts in the NP’s practice.
Approval was obtained from the university Institutional
Review Board prior to data collection. A letter of
permission was also obtained from the FNPN. Data were
collected at the conference directly from the participants.
Questionnaire packets were given to eligible participants
at a table staffed by the investigator, and they were
returned directly to the investigator by the end of the day.
Results
There were 62 questionnaire packets given to potential
participants at the conference that met the inclusion
criteria for the study. Forty-eight participants (77.4%)
returned completed questionnaires.
Characteristics of the participants
Results revealed that 91.7% of participants were female
and 8.3% were male. The age of the participants ranged
from 29 to 64 years with the average being 48.7 years and
SD 8.48 years. The majority of the participants (43.5%;
n = 48) were between 51 and 60 years of age. The
majority (70.8%; n = 48) of participants self-identified
as Caucasian, followed by Black (16.6%; n = 48), and
Hispanic and Asian were equal at 6.3%. Statistical
demographics for gender, age, and race are shown in
Table 1.
The educational characteristics included the highest
education degree and the basic nursing education of
the NPs. The majority of the participants were educated
with a Master’s in Nursing (87.5%; n = 48). Only one
participant (2.1%; n = 48) reported a Master’s Degree
Table 1 Characteristics of the participants (N = 48)
Characteristics
Age (Years)a
< 31
31–40
41–50
51–60
> 60
Gender
Female
Male
Race/ethnicity
Caucasian
Black
Hispanic
Asian
Frequency
Percentage
2
6
16
20
2
4.3
13.0
34.8
43.5
4.3
44
4
91.7
8.3
34
8
3
3
70.8
16.7
6.3
6.3
a Two responses were missing.
515
Autonomy of primary care NPs
A. Bahadori & J.J. Fitzpatrick
Table 2 Professional Characteristics (N = 48)
Characteristics
Frequency
Table 3 Level of importance of Strong Model concepts
Percentage
Concept
NP certification
Family NP
Adult NP
Gerontology NP
NP certifying board
AANP
ANCC
Both
Not board certified
NP specialty practice
Family
Internal medicine
Gerontology
34
10
4
70.8
20.8
8.3
10
33
2
3
20.8
68.8
4.2
6.3
30
15
3
62.5
31.3
6.3
in another field as their highest education degree. Four
participants (8.3%; n = 48) were educated at the Doctoral
level and one participant (2.1%; n = 48) reported the
highest degree as a Bachelor’s in Nursing. Associate
Degree was the basic education in nursing for 47.9%
of the participants. Bachelor’s Degree was reported as the
basic nursing education for 43.8% of the participants.
Only four participants (8.3%; n = 48) reported a diploma
as their basic nursing education.
The majority (70.8%; n = 48) of the study participants
were certified as family NPs. Details for NP certification,
professional NP certifying board, and current NP specialty
practice are shown in Table 2.
With regard to work status, 89.6% worked full time
and 10.4% worked part time. Years worked at current
job ranged from 3 months to 17 years with a mean of
3.7 years and SD 4.04. Number of years worked as an RN
ranged from no experience to 37 years with a mean of
17.8 years and SD 9.07. Years of NP experience ranged
from 0.5 to 30 years with a mean of 7.0 years and SD 5.66.
A Likert scale was used to answer the additional
questions on the background data questionnaire. There
were five possible answers ranging from 1 (not at all
important) to 5 (extremely important). These additional
questions were included to describe the level of
importance of the Strong Model’s concepts in the
NP’s practice. The participants indicated higher average
scores for direct comprehensive care, support of systems,
education, collaboration, and empowerment, whereas
research, publication and professional leadership, and
scholarship received lower scores (see Table 3).
DPBS Results
Cronbach’s alpha coefficients were calculated to
determine the internal consistency for the total DBPS
and each of the subscales. There were a total of 30
516
Direct
comprehensive
care
Support of
systems
Education
Research
Publication and
professional
leadership
Collaboration
Scholarship
Empowerment
Minimum
score
Maximum
score
Mean
SD
1
5
4.54
1.18
1
5
4.23
1.21
2
1
1
5
5
5
4.48
3.42
3.33
0.80
1.24
1.30
2
1
1
5
5
5
4.38
3.63
4.19
0.87
1.23
1.23
items in the DPBS. The overall Cronbach’s alpha for the
DPBS in this study was .79. The Cronbach’s alpha for the
Readiness subscale was .72, for Empowerment subscale
.44, for Actualization subscale .66, and .57 for Valuation
subscale.
The DPBS used a 5-point Likert scale ranging from 1
(not at all true) to 5 (extremely true). All of the questions
pertained to the NP’s practice. Results indicated that the
total level of autonomy mean score for this sample was
127.19 (SD = 10.25). The scores ranged from 105 to 146.
The total score and the four subscale scores are shown in
Table 4.
The Readiness subscale had 11 item statements and
measured elements of competence, skills, and mastery.
The PCNPs in this study indicated high levels of readiness
with a total mean subscale score of 46 (SD = 4.85). The
Empowerment subscale had seven items and measured
the legitimacy of one’s performance in a practice setting.
The total mean score for the subscale was 25 (SD = 4.23).
The Actualization subscale included nine items and
measured decision making, and involved the dimensions
of determination, responsibility, and accountability. The
total mean score for the Actualization subscale was 42
Table 4 Dempster Practice Behavior Scale
DPBS
Total score
Subscale scores
Readiness
Empowermenta
Actualizationb
Valuationc
a One
response was missing.
b Two responses were missing.
c One
response was missing.
Mean
SD
127.19
10.25
46.42
25.08
41.60
14.08
4.85
4.23
3.11
1.41
A. Bahadori & J.J. Fitzpatrick
(SD = 3.11). The Valuation scale had three items and
measured elements of value, worth, merit, and usefulness
related to autonomy in practice. The total mean score for
the Valuation subscale was 14.08 (SD = 1.41). This was
the highest scored subscale.
Pearson’s product moment correlation was used to
determine the relationship between autonomy and the
NP’s age, number of years worked as an RN, and number
of years worked as an NP. There was no significant
relationship found between the total score on the DPBS
and the NP age (r = −.003; p = .98), years worked as
an RN (r = −.28; p = .06), and years worked as an NP
(r = .18; p = .24).
Discussion
The participants in this study were 92% female and
8% male, which is close to national trends of 95% female
and 5% male (American Academy of Nurse Practitioners
[AANP], 2004). The age of the participants ranged from
29 to 64 years with an average age of 49, slightly older
than the national average of 47 (AANP). The AANP also
reported that most NPs were white and had practiced as
an NP for an average of 9 years. The participants in this
study were also mostly white (71%), with an average of
7 years NP experience.
The highest level of educational attainment for NP
participants in this study was 90% Master’s Degree and
8% Doctorate. This was higher than the AANP survey
that showed only 85% Master’s Degree education and
4% Doctorate. Also 94% of NPs in this study were board
certified, which is close to the national average of 92%
(AANP). The majority of the NP participants in this study
were certified (71%) and practicing (63%) in Family
Practice, which is consistent with the national trend.
Bachelor’s Degree was the basic education in nursing for
44% of the NP participants, Associate Degree 48%, and
diploma 8%. The national population of RNs has been
reported at Bachelor’s Degree 31%, Associate Degree
42%, and diploma 25% (U.S. Department of Health and
Human Resources, n.d.).
The total mean score for the DPBS in this study was 127
(SD = 10.25). This indicated that the average response
of participants on each of the 30 items on the DPBS
was at least a 4. Therefore, the PCNPs in this study
had very high levels of autonomy. Dempster (1994)
claimed that the NP role was designed to incorporate
a greater level of autonomy and independence. This
claim is supported by this study’s results. It was also
found that NPs who practiced in the family specialty
practice area experienced greater clinical decision-making
authority (Chumbler et al., 2000). Cajulis and Fitzpatrick
(2007) found that acute care NPs had very high levels
Autonomy of primary care NPs
of autonomy also. According to Almost and Laschinger
(2002), the role of the acute care NP and the PCNP
parallel each other. Results in each subscale from the
DPBS showed that the NPs had very high average scores
with the exception of the Empowerment subscale, which
showed moderate average scores.
NPs increasingly exhibit readiness for autonomy
(Dempster, 1994). The findings in this study provided
evidence that PCNPs are skillful, masterful, competent,
and displayed traits of professional growth. PCNP
participants had a moderate level of empowerment.
The Empowerment subscale had the lowest mean score
of the four subscales in this study. NPs continue to
struggle with empowerment for autonomy (Dempster,
1994). In Florida, change to provide legal empowerment
from others has been slow. Currently, PCNPs have
limited hospital privileges, they face obstacles with
reimbursement for their services, and they have not
been given legal prescriptive authority for controlled
substances. They are also bound by a collaborative practice
agreement. These barriers to legal status and privileges
could contribute to lower empowerment levels.
NPs actualize and exercise autonomy in their practice
scope (Dempster, 1994). The results of this study indicated
that PCNPs had very high levels of decision making,
accountability, responsibility, and determination. These
findings are consistent with other studies on NP’s
decision making and responsibility (Chumbler et al.,
2000; Mundinger et al., 2000).
The Valuation subscale contained the highest average
score out of all four subscales. The PCNPs in this study
indicated very high to extremely high levels of value,
worth, merit, and usefulness related to autonomy in
practice. NPs value autonomy because it has worth and
merit (Dempster, 1994).
No statistically significant relationship was found
between the variables of age, years worked as an RN, years
worked as an NP, and level of autonomy. These findings
are consistent with another study (Cajulis & Fitzpatrick,
2007). Also, in a study on NPs’ prescription authority, it
was found that years of NP experience had no impact on
authority level (Pan et al., 1997). In contrast, a study with
293 NPs concluded that NPs with more years in practice
had greater clinical decision-making authority (Chumbler
et al., 2000). There are only two known studies (present
study included) that have examined the relationship
between age, years worked as an RN, and level of
autonomy. Both of these studies had sample sizes less
than 100. A study with a larger sample size may be
able to detect significant correlations between age and
RN experience and level of autonomy. It is also a distinct
possibility that there is no relationship between age, years
517
Autonomy of primary care NPs
worked as an RN, years worked as an NP, and level of
autonomy.
Limitations
Limitations in this study include the fact that this study
used a convenience sample of PCNPs drawn from a state
clinical conference in Florida. This study also had a small
sample (N = 48) and only one setting. The results of this
study may not be generalized to all NPs in a primary care
setting. Additionally, the reliability of the DPBS subscales
was low.
Implications for nursing
Nurse practitioners are an important part of the
healthcare system. As the NP profession continues
to change and expand, so do the threats to NP
autonomy. Legal and institutional restrictions on NP
practice hinder professional growth and professional
authority. These restrictions force NPs to struggle
with empowerment for autonomy. In order to attain
maximal autonomy, NPs must understand their current
level of autonomy and explore new ways to increase
empowerment. Higher levels of autonomy and decisionmaking authority will allow NPs to care for their patients
as competent professionals, and may improve patient care
outcomes.
Although this study was limited to the description of
PCNP autonomy, the findings could lead to changes in
all NP education programs. The concepts from the Strong
Model should be highlighted in NP education programs.
NP curriculum should increase focus on autonomy and
emphasize the value of empowerment. NPs educationally
prepared with a better knowledge of legal and political
issues will be better suited to influence healthcare reform.
NPs, as autonomous professionals, will be more likely to
impact and shape future healthcare policy.
Recommendations for future research
Recommendations for future research include replication of this study using a large national random sample to
ascertain the generalizability of the findings. More similar
studies of other types of NP providers would allow for
direct comparison of autonomy levels among the groups.
A study to evaluate the relationship between NP autonomy levels and patient care outcomes should be done.
Although the NPs in this study had very high levels of
autonomy, the Empowerment subscale had the lowest
scores. This suggests that other factors such as national,
state, and institutional regulations may be important to
518
A. Bahadori & J.J. Fitzpatrick
explore. Also, future research is needed for the DPBS
instrument and its subscales, particularly with smaller
sample studies.
Conclusions
The results of this study indicated that PCNPs had very
high levels of autonomy. They also had very high levels
of skill, competence, decision making, accountability, and
valued their autonomy. They had only moderate levels of
empowerment that included rights, privileges, and legal
status. No significant relationship was found between
age, number of years worked as an RN, number of years
worked as an NP, and level of autonomy. The findings of
this study reinforced the fact that PCNPs are autonomous
professionals.
Acknowledgments
Much appreciation goes to Sr. Rita McNulty, DNP,
RN, CNP, Assistant Professor, and Mary Quinn-Griffin,
PhD, RN, Assistant Professor, Frances Payne Bolton
School of Nursing, Case Western Reserve University,
Cleveland, OH.
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