Challenges in the Critical Care Workplace

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

2012 American Association of Critical-Care Nurses

doi: http://dx.doi.org/10.4037/ajcc2012205

e41

Background Discretionary autonomy is a key factor in enhanced

patient outcomes and nurses work satisfaction. Among nurses,
insufficient autonomy can result in moral distress.
Objectives To explore levels of autonomy among European
critical care nurses and potential associations of autonomy
with nurse-physician collaboration, moral distress, and nurses
characteristics.
Methods Descriptive correlational study of a convenience
sample of 255 delegates attending a major European critical
care conference in 2009. Respondents completed a selfadministered questionnaire with validated scales for nurses
autonomy, nurse-physician collaboration, and moral distress.
Results The mean autonomy score (84.26; SD, 11.7; range,
18-108) and the mean composite (frequency and intensity) moral
distress score (73.67; SD, 39.19; range, 0-336) were both moderate. The mean collaboration score was 47.85 (SD, 11.63; range,
7-70). Italian and Greek nurses reported significantly lower
nurse-physician collaboration than did other nurses (P < .001).
Greek and German nurses reported significantly higher moral
distress (P < .001). Autonomy scores were associated with
nurse-physician collaboration scores (P < .001) and with a
higher frequency of moral distress (P = .04). Associations were
noted between autonomy and work satisfaction (P = .001). Frequency of moral distress was associated inversely with collaboration (r = -0.339; P < .001) and autonomy (r = -0.210; P = .01)
and positively with intention to quit (r = 0.257; P = .004).
Conclusions In this sample of European intensive care nurses,
lower autonomy was associated with increased frequency and
intensity of moral distress and lower levels of nurse-physician
collaboration. (American Journal of Critical Care.
2012;21(2):e41-e52)

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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

Autonomy is defined as the freedom to make

decisions within the domain of an individuals profession and to act accordingly.10,11 The ability to make
discretionary and autonomous decisions based on
comprehensive knowledge, clinical expertise, and
evidence-based findings is a hallmark of professionalism. In general, ICU nurses make 1 care decision
every 30 seconds12 and approximately 9 important
patient-care decisions per hour,13 suggesting that
exercising judgment is a core nursing activity and
influences the quality of care provided. Previous
studies11,14-16 in European ICUs indicated that the levels of nurse autonomy differ between countries and
that the decision-making capacity of these clinicians
needs to be developed and strengthened. However,
factors that may be associated with low autonomy
among European ICU nurses have not been systematically studied. Although, presumably, poor nursephysician collaboration may limit a nurses ability
to implement care- and unit-related decisions, associations between these 2 constructs have not been
investigated. Evidence of the association between
nurse-physician collaboration and ICU nurses
moral distress is likewise scant. Although the design
of the study we report here was unsuitable for exploring either causative factors or antecedents of autonomyand inferences may be limited by differences
in responders context of practicewe wished to

About the Authors

Elizabeth D. E. Papathanassoglou is an associate professor
and Maria N. K. Karanikola is a lecturer at Cyprus University of Technology, Department of Nursing, Siakolas Centre for Health Studies, Nicosia, Cyprus. Maria Kalafati is
a clinical instructor, Margarita Giannakopoulou is an assistant professor, and Chrysoula Lemonidou is a professor
at University of Athens, School of Nursing, Athens, Greece.
John W. Albarran is an associate professor in cardiovascular critical care nursing, Department of Nursing and
Midwifery, Faculty of Health and Life Sciences, University of the West of England, Bristol, England.
Corresponding author: Elizabeth D. E. Papathanassoglou,
RN, MSc, PhD, Cyprus University of Technology, Department
of Nursing, Siakolas Centre for Health Studies, 2252 Latsia,
Nicosia, Cyprus (e-mail: e.papathanassoglou@cut.ac.cy).

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address autonomy, nurse-physician collaboration,

and moral distress simultaneously in a sample of
European ICU nurses to gain preliminary insight
into potential associations.
In traditionally medically driven health care
systems, because of an unequal power relationship,
nurses contributions are either unsanctioned or
ignored.17 Nurse-physician collaboration has been
identified as a way of redressing the power relationship and supporting nurses autonomy.18-20 For
example, Baggs et al18 reported that effective nursephysician collaboration was associated with significantly better clinical outcomes. Professional
collaboration, in particular, is a precondition and
an outcome of autonomy.18 Moreover,
autonomy, control over nursing
practice, and satisfactory interprofessional collaboration are deemed core
elements of nursing practice in Magnet hospitals21 and are linked to
improved outcomes for patients.22
In contrast, limited autonomy
and problematic interdisciplinary collaboration may inhibit nurses ability
to apply personal and professional
moral reasoning, a situation that may
lead to moral distress.23 ICU nurses encounter ethical,
professional, and patient-care situations that can
provoke moral distress and, if not managed, possibly
compromise job satisfaction and retention.24-26
Moral distress occurs when clinicians are unable to
translate their moral choices into moral action.23 In
a recent study27 on end-of-life decisions, nurses who
experienced high levels of moral distress were less
likely than nurses who experienced lower levels to be
satisfied with the level of care and with the ethical
environment and were more likely to report lower
levels of collaboration.
The purpose of our study was to explore professional autonomy, nurse-physician collaboration, and
moral distress among European ICU nurses. Objectives included the investigation of perceived levels
of autonomy, collaboration, and moral distress;
potential differences among national groups; and

Increased autonomy for intensive

care unit nurses
is strongly linked
with improved
patient outcomes.

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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

Design and Sample

The investigation was a descriptive, correlational, cross-sectional
study. A convenience sample of delegates attending the 2009 joint European Federation of Critical Care Nursing Associations
(EfCCNa) and Lassociazione Nazionale Infermieri
di Area Critica (Aniarti) international 3-day conference were invited to participate. Our aim was to
recruit practicing ICU nurses. During registration,
delegates received a letter of invitation, a participant
information and consent sheet, and a copy of the
questionnaire, which was available in English, Italian and Greek.

Data Collection Instruments

Autonomy was assessed by using the scale
developed by Varjus et al,11 with their permission.
This Likert 6-point scale includes 18 items on the
knowledge, action, and value bases of autonomy.
The knowledge base includes decision making as a
cognitive process. The items provide a measure of
nurses views on their independence in decision
making, right to participate in decisions, and responsibility for the decisions made and for development
of the knowledge base. The action base provides a
measure of nurses opinions of their
independence in nursing actions
and in actions to organize a units
operations. The value base is a
measure of whether nurses are able
to follow their own nursing values
in providing care and in the unit.
A modified Corley Moral Distress Scale25 also was used with permission. This scale consists of 21
items describing situations that
could engender moral distress. Respondents rate
both the frequency and the level of disturbance
(intensity) that the situation causes on a scale of 0
(never occurred/not disturbing) to 4 (occurred very
frequently/greatly disturbing). For measuring current level of moral distress, the frequency and intensity scores for each item are multiplied. Each item

Delegates attending an international conference

in Europe were
invited to participate in the study.

e43

product of frequency and intensity ranges from 0 to

16. These products are added to obtain a composite
score. This scoring scheme allows all items marked
as never experienced or not disturbing to be eliminated from the score, reflecting actual moral distress.
Permission was also granted to use the Collaboration and Satisfaction About Care Decisions Scale.28
This 10-item 7-point Likert scale is used to measure
nurses perceptions of the level of collaboration in
sharing responsibility for solving problems and
making decisions. In addition, participants completed a short questionnaire on demographics, educational background, and their ICU and answered
questions about the frequency of participation in
continuing education programs, clinician to patient
ratios, degree of job satisfaction (on a scale of 1-10),
importance of job independence for the participant
(on a scale of 1-10), and how much participants
thought people in their country valued the importance
of critical care nurses work (on a scale of 1-10).
Forward and back translations (English-Greek/EnglishItalian) were performed to ensure accuracy of translation. Face validity, feasibility, comprehensibility,
and test-retest reliability of the Greek questionnaire
and the internal consistency of the scales were
established during a pilot study with a random
sample of 160 ICU nurses. The Cronbach a coefficients for all scales were greater than 0.8. Test-retest
reliability was tested in a convenience sample of 20
ICU nurses (Kendall t = 0.989, P < .001 for 2 consecutive administrations of the scales 1 week apart).
The reliability of internal consistency for all scales
was also tested with the study sample from the conference. Participants were advised to complete the
survey independently.
Data Analysis
For sufficient power, a sample size of approximately 250 respondents was required. Respondents
returned 1197 completed valid questionnaires; among
these, 958 were from Italian delegates. In order to
avoid overrepresentation, 60 questionnaires from
Italian delegates were randomly selected by using
Excel software (Microsoft Office 2003, Microsoft
Corporation, Redmond, Washington). After outliers
and missing data were excluded, 255 questionnaires
representing 17 countries were available for analysis.
Data were analyzed by using SPSS software, version 17.00 (SPSS IBM Corporation, Armonk, New
York). Descriptive and inferential statistics were used.
A nominal significance level (a = .05) was used, and
Bonferroni adjustment (a = .01 to .001, corresponding to the number of simultaneous tests) was used
for multiple bivariate comparisons and associations.

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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%

Figure 1 Percentages of respondents from each country.

during night shifts and significant differences

between countries.
Descriptive Statistics of Main Variables
The mean autonomy score was greater than
moderate (84.26; SD, 11.7; scale range, 18-108), as
were subscale scores for knowledge, action, and
value bases of autonomy. The mean reported moral
distress frequency was low (25.46; SD, 11.89; scale
range, 0-84), and differences among national groups
were significant. The intensity of moral distress was
higher (mean, 56.99; SD, 16.76; scale range, 0-84),
and differences among national groups were not
significant. The mean composite moral distress
score was moderate but varied widely according to
the participants nationality (mean, 73.67; SD,
39.19; scale range, 0-336). The mean composite
moral distress score per item in the scale was 3.52
(range, 0.5-7.69).
The mean collaboration score
was 47.85 (SD, 11.63; scale range,
7-70), suggesting moderate levels
of collaboration and satisfaction
about care decisions. The most frequent morally distressing situations were related to futile care
(Table 2). Similarly, the highest
composite moral distress scores
were associated with futility of care, collaborating
with inappropriately skilled colleagues, and compromised care due to cost restraints. Differences in
mean frequencies of individual moral distress items
were evident between countries. As for autonomy,
respondents reported highest scores for decisions
about nursing care and pertinent skills and lowest
scores for decisions about unit organization (Table 2).

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

SD, 1.44; scale range, 1-7) were for how satisfied

are you with collaboration in this hospital overall?

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)

Job satisfaction,b mean (SD)

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

Patient to nurse ratio, mean (SD)

Morning
Evening
Night
Patient to physician ratio,
mean (SD)
Morning
Evening
Night
Participation in continuing
education

4.66 (2.87)
7.46 (4.18)
9.05 (7.03)
A few times
a year

<.001
<.001
.002
<.001

Abbreviations: NS, not significant.

a Unless otherwise indicated, values are number (percentage) of respondents.
Because of rounding, not all percentages total 100.
b Scores from a numeric rating scale from 1 to 10.

The highest collaboration scores (mean, 5.23; SD,

1.58; scale range, 1-7) were for open communication between physicians and nurses about patient
care always takes place. Lowest values (mean, 3.95;

e45

Differences in Autonomy, Moral Distress,

and Collaboration Among Participants From
Different Countries
Despite obvious trends in the data, including
higher scores for nurses from Northern Europe,
differences in autonomy scores between countries
were not significant.
Differences between individuals of participating
countries were significant for the severity and frequency of reported moral distress (P < .001; Figure 2)
and for nurse-physician collaboration (P < .001; Figure 2). Nurses from Italy and the United Kingdom
reported less severe moral distress than did nurses
from Greece (P = .003-.007) and Germany (P = .02-.04).
Nurses from Greece reported higher frequency of
morally distressing situations than did nurses from
other countries (P = .001-.005), except for participants from Belgium, Spain, Germany, and Croatia.
Additionally, Norwegian nurses reported significantly less frequent moral distress than did nurses
from Greece or Germany (P = .02-.03).
Nurses from Belgium, Slovenia, Spain, Germany,
and Greece had higher cumulative moral distress scores
than did nurses from other countries (P = .001-.007).
Nurses from Italy and the United Kingdom had low
scores for moral distress, but only when compared
with nurses from Greece (P = .004-.007). In contrast,
nurses from Norway had lower scores than did nurses
from several other countries (P < .001). The perceived
effectiveness of nurse-physician collaboration was
significantly lower among nurses from Italy and
Greece than among nurses from Norway, Denmark,
and Sweden (P < .001).
Bivariate Associations Among Main
Study Variables
Autonomy. Autonomy scores had a positive association with collaboration scores (r = 0.319; P < .001)
and an inverse association with scores of moral distress frequency (r = -0.174; P = .04; Table 3A). The
value of the correlation coefficient between autonomy and collaboration, between autonomy and
moral distress frequency, and between autonomy
and composite moral distress increased when the
effect of level of education, previous ICU experience,
and patient to nurse ratios were controlled for
(Table 3B). Likewise, scores corresponding to the
knowledge base of autonomy were positively associated with collaboration scores (Table 4).
Moral Distress. Composite moral distress
scores had significant moderate associations with

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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)

Moral distress scale items

Most frequent morally distressing situations
Initiating extensive life saving actions when they only prolonged death
Carrying out physicians orders for futile care
Continuing to participate in the care of a hopelessly injured person
Working with colleagues who are not as competent as the patient care requires
Following the familys wishes to continue life support even though it is not in the best interest of the patient

2.43 (1.05)
2.21 (1.17)
2.035 (1.22)
1.91 (0.96)
1.82 (1.17)

Least frequent morally distressing situations

Responding to a patients request for assistance with suicide
Following a physicians request not to discuss death with a dying patient
Ignoring situations of suspected patient abuse by caregivers

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)

Autonomy scale items

Items with the highest scores
I am responsible for my decisions concerning nursing care
I am responsible for developing my knowledge base
I am responsible for developing my nursing skills

5.54 (0.72)
5.56 (0.70)
5.48 (0.79)

Items with the lowest scores

I can make independent decisions concerning my units operation
I can take independent action to organize unit operations

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.

collaboration scores (r = -0.337; P < .001) and with

action base of autonomy scores (r = -0.208; P = .02).
The frequency of morally distressing situations
was inversely associated with collaboration scores
(r= -0.339; P < .001) and with value (r= -0.207; P = .01)
and action (r= -0.210; P = .01) base of autonomy scores.
Collaboration. Collaboration scores were positively associated with autonomy scores (r = 0.319;
P < .001) and with knowledge (r = 0.336; P < .001),
action (r = 0.236; P = .003), and value (r = 0.253;
P < .001) base of autonomy scores and inversely associated with composite moral distress scores (r= -0.337;
P < .001) and frequency of morally distressing situations (r = -0.339; P < .001).
Associations Between Autonomy, Moral
Distress and Collaboration and Employee,
Organizational, and Professional Factors
Significant moderate associations were noted
between autonomy scores and length of ICU nursing

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experience (r = 0.155; P = .01), frequency of attendance at continuing education programs (r = -0.230;

P = .001), level of work satisfaction (r = 0.369; P < .001),
significance of job independence (r = 0.159; P = .005),
and perceived status of intensive care nursing (r= 0.211;
P = .001). Scores corresponding to the knowledge
base of autonomy were positively associated with
the level of educational attainment, length of ICU
experience, frequency of attendance at continuing
education programs, level of work satisfaction, significance of job independence, and perceived status
of intensive care nursing (Table 4).
Significant associations were noted between
the frequency of morally distressing situations and
patient to nurse ratios (r = 0.262-0.312; P < .001),
and perceived job status (r = -0.300; P < .001).
Significant positive associations (P < .001) were
also noted between nurse-physician collaboration
and the level of respondents education (r = 0.164),
level of work satisfaction (r = 0.274), and perceived

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e46

A
70.00

Mean colaboration score

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

Mean cumulative composite distress score

140.00

Country

Figure 2 Differences between nurses from different countries

were significant for mean collaboration scores (A) and for mean
cumulative composite distress scores (B) at P < .001. Nurses from
Italy and Greece reported significantly poorer collaboration than
did nurses from Norway, Denmark, and Sweden (P < .001). Nurses
from Italy and the United Kingdom reported less severe moral
distress than did nurses from Greece (P = .003-.007) and Germany
(P = .02-.04). Asterisks indicate scores that were significantly
different from other scores.

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).

Overall, no differences were noted for sex,

except for higher perceived status appraisal among
female respondents (P = .02). The Kruskal Wallis test
revealed significant differences by type of unit with
respect to composite moral distress (P = .047), moral
distress frequency scores (P = .01; highest mean of
ranks at burn/neurosurgical units), collaboration
scores (P = .04, highest mean of ranks at medical/
surgical and burn/neurosurgical units), and patient
to nurse and patient to physician ratios (P = .001;
highest mean of ranks at burn/neurosurgical units).
Nurses who worked in medical/surgical ICUs reported
higher nurse-physician collaboration than did nurses
who worked in cardiac surgery units (P = .007).

We investigated specific indices of autonomy,

collaboration, moral distress, and job satisfaction
simultaneously in a sample of European intensive
care nurses. Our results indicated moderate practice
autonomy scores, with lower scores for issues of
control over unit organization and policy; moderate
moral distress; moderate nurse-physician collaboration and satisfaction with care decisions; and significant differences among participants from different
countries for moral distress and nurse-physician
collaboration scores. Although differences in autonomy scores among nurses from different countries
were not significant, lower levels of autonomy were
associated with increased episodes and intensity of
moral distress, lower perceived nurse-physician collaboration, and increased intention to resign. The
lack of significance despite obvious trends for autonomy in different national groups may be attributed
to statistical power limitations and to limitations of
the instrument due to the conceptual complexity
of autonomy in nursing. Additionally, respondents
who had increased levels of autonomy were more
likely to report higher levels of collaboration and

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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

Composite moral distress score

Moral distress frequency

-0.2104b
.04

Autonomy score
P

-0.2476b
.01
0.9059b
<.001

Composite moral distress score

P
a

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

satisfaction with care decisions and to describe fewer

morally distressing situations than were nurses with
less autonomy. These results are important in implicating autonomy as a factor associated with experiences of moral distress and the intricate relationship
between collaborative practices, nurses perceived
autonomy, and moral distress.
However, these findings on autonomy should
be viewed in the context of the limitations of the
methods we used in the study. We could not control
for several confounding variables, including patients
severity of illness, which may have had an impact
on the associations explored. Further, the country of
origin of participants may have influenced the results;
approximately one-third of the respondents were
from the United Kingdom, Greece, and Italy. Moreover, the use of a convenience sample and the high
percentage of head nurses (Table 1) might have
resulted in the overestimation of autonomy levels,
job satisfaction, and notions of collaborative practices.

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Lack of sample heterogeneity was also a limitation.

Additionally, the lack of established norms for assessing the level of the main study constructs leads to
difficulties in confirming whether the reported levels
of nurses autonomy and satisfaction are satisfactory
or not. Further, the results are limited by the selfreported data. Moreover, some ICU environments
closely regulate the work of nurses via well-defined
guidelines and protocols. In such circumstances,
nurses may perceive that the ability to exercise
autonomy is limited. Units that actively support
informed decision making by caregiving staff may
increase nurses expectations of autonomyand
therefore the nurses perceptions of the degree of
autonomy they experience. An additional limitation
is that many participants did not complete the
questionnaire in their mother language.
Seago29 noted that nurses assessment of their
ability to exercise autonomy may be exaggerated,
a situation typical of the behavior of an oppressed

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e48

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

Composite cumulative distress score

P

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

Cumulative distress frequency

P
Collaboration
P

1.000

Highest level of education

P
ICU working experience
P
Position type
P
Continuing education
P
Work satisfaction
P
Job independence
P
Status appraisal
a
b

Significant after Bonferroni adjustment at the .004 level.

Significant at the .05 level.

group. Preferences for being autonomous differ

among nurses. Nurses with little preference for
autonomy may be less satisfied when they gain
decision-making influence.30 Furthermore, differences
in the educational preparation of nurses may be
predictive of nurses perception of autonomy.31 Hence,
participants educational background may be a major
confounder in the interpretation of our results. In
addition, nurses may aspire to different types of
decisional authority than other health professionals
do. Qualitative inquiries into the meaning of autonomy among ICU nurses revealed that autonomy
means having a holistic view,32 acting as a patients
advocate, and ensuring patients quality of life.33
Thus, nurses may need legitimate authority to bring
forth the values of care and empathy, values that may
not receive equal priority within dominant biomedical health discourses.
Overall, the participants in our study perceived
that they had increased autonomy in decisions
about nursing care but not in decisions about unit

10

operation and management, suggesting that the

nurses thought they had limited control over their
practice. Control over nursing practice and autonomy are distinct concepts.34 The former refers to a
nurses ability to shape departmental and organizational policies,35 whereas the latter is related to decision making pertaining to patient care. Studies have
indicated that control over nursing practice is associated with increased job satisfaction and improved
patient outcomes1,34,36 and with decreased job-related
stress, burnout, and staff turnover.37,38 The association between less autonomy and increased nurses
intentions to resign, along with decreased job satisfaction, is in accordance with previous findings2
and emphasizes the importance of exercising autonomy in some aspects of nursing work. Although low
clinical decision-making autonomy has been reported
among Hellenic intensive care nurses,16 the levels of
autonomy in our study are difficult to compare
with the levels in previous studies because of differences in the instruments used. In a previous study11

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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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actions that prolonged the inevitability of death as

more distressing than did nurses in previous
reports.26,43,44 One item associated with increased
moral distress in our study was delivery of suboptimal care because of resource constraints. Differences
among countries for this item were significant, and
it warrants more study.
The higher levels of moral distress reported by
nurses from Greece and Germany are interesting
and merit further investigation because the findings
may reflect the inequality of power relations between
nurses and physicians.17 Factors including culturally
driven health care systems, the educational preparation of nurses, and professional empowerment may
be relevant. For example, in Greece and Germany,
the transition of nursing education from technically
oriented schools to universities is not yet complete,
and this situation may undermine the decisional
authority of nurses in these countries. Low clinical
decision-making autonomy16 and diminished perceived
public image of ICU nurses45 have been previously

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e50

reported among intensive care nurses in Greece. Low

appreciation of the importance of ICU nursing work
by a units interdisciplinary team may affect ICU
nurses professional status and the quality of professional interactions among the members of the team.
Our finding of a negative association between
the level of reported autonomy and
frequency of moral distress reveals
the importance of nursing autonomy as a factor in mediating moral
distress. When nurses lack decisional
authority over patient care, they
may experience moral incongruence.46 Because of the ongoing
advancements of life-support technology, nurses may regularly experience situations that trigger moral distress.26
However, creating opportunities for open dialogue
and debriefing may facilitate resolution of such situations and minimize escalation of further moral
challenges.
Addressing the quality of nurse-physician collaboration on care decisions may be part of the
overall strategy to reduce moral distress. Gutierriez42
identified the absence of nurse-physician collaboration as a main source of moral distress. In our sample,
mean collaboration scores were higher than the
scores in a previous investigation47 in nurses in the
United States in which researchers used the same
instrument that we used. The reasons for the discrepancy in scores are unclear, because the difference
may reflect changes in practice in the 15 years
between the US study and our study and/or differences in nurses expectations and in unit policies.
Moreover, in our study, increased perceived collaboration in and satisfaction with care decisions were
associated with lower levels of moral distress.
Although extensive empirical evidence is not available, the association between nurse-physician relationships and nurses moral distress
has been discussed.48,49

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

The importance of autonomy,

accountability, and collaboration in
critical care nursing cannot be overstressed. Enhancement of nurses
autonomy and control over nursing
practice is an intricate task because
of interconnected professional, sociological, educational, and personal
factors. Similar to recent findings,34,45 our results
suggest that nurses think that laypersons do not

e51

appreciate the importance of ICU nursing work. To

expand their autonomy, ICU nurses must publicly
communicate the nature of their unique expertise and
their role in promoting safety, preventing complications, and contributing to patients health outcomes.34
In conclusion, although rigorous testing is
needed to confirm our results, the findings provide
insight into the factors that may be associated with
the autonomy and moral distress of intensive care
nurses in Europe and highlight discrepancies among
nurses from different countries.
In order to improve autonomy, nurses contribution to clinical decision making and their input
to unit-level decisions and organization must be
specifically targeted. Educational practices that
empower and promote a critical approach50,51 and
engagement in continuous professional development52 can support recognition of professional
autonomy of nurses. However, developing, implementing, and sustaining effective nurse-physician
collaboration are also imperative. Various approaches
for the enhancement of collaboration have been
investigated. Unit-based programs to improve communication53 and use of multidisciplinary rounds54
appear to be effective and to result in improved
patient outcomes and economic gains.55 Moreover,
on the basis of our results, enhancement of collaboration and autonomy can be expected to translate
into fewer experiences of moral distress and improved
appreciation of nurses input in patients outcomes.
ACKNOWLEDGMENTS
We acknowledge the enthusiasm of the 3rd EfCCNa/22nd
Aniarti conference delegates who participated in the
study. We thank Dr Bronagh Blackwood, Mr Daniel Benlahous, and Mrs Mette Ring of the EfCCNa research and
development committee for support during development
of the study protocol. The Hellenic Association of Critical
Care Nurses provided help in collecting and entering
data. We thank Aniarti and Mr Elio Drigo, especially,
for their enthusiastic support throughout the study, for
translating the scales into Italian, and for participating
in data collection. The Cypriot Association of Critical
Care Nurses and E. Kletsiou and E. Tsafou also provided
help in data collection.
FINANCIAL DISCLOSURES
None reported.
eLetters
Now that youve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click Submit a response in either the full-text or
PDF view of the article.

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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e52

Professional Autonomy, Collaboration With Physicians, and Moral

Distress Among European Intensive Care Nurses
Elizabeth D.E. Papathanassoglou, Maria N. K. Karanikola, Maria Kalafati, Margarita
Giannakopoulou, Chrysoula Lemonidou and John W. Albarran
Am J Crit Care 2012;21:e41-e52 doi: 10.4037/ajcc2012205
2012 American Association of Critical-Care Nurses
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