Clinical nurse perceptions of who governs their work environment including control over practice in provincial hospitals in Saskatchewan

Organizational restructuring and reform in the health care system has impacted the ability of Clinical Nurses (CNs) to participate in and influence decision making that affects the delivery of patient care. Clinical nurses maintain and advocate a professional responsibility to practice according to specific standards, policies and procedures, and to meet the needs of the patient and family members. Clinical nurses’ participation in decision making at the patient, unit and administrative levels recognizes their abilities and skills as professionals; however, CNs continue to experience a limited role in the decision making and control over nursing practice at all of these levels. The literature overview examines control over nursing practice including how this complex concept is difficult to define and undervalued within the CNs’ professional practice environment. It is evident in the literature that control over nursing practice is important to the CNs’ professional practice environment ultimately affecting job satisfaction, recruitment/retention, and patient outcomes. Control over nursing practice is explored in relation to internal and external factors that affect the professionalism of the CN. Internal factors are those that are more closely related to the CNs’ scope of practice and include professionalism (influence in decision making including policies and procedures, collegial relations, and professional development), CN satisfaction (workload, scheduling, health, safety and security concerns, supportive management, and opportunities for leadership), safe quality patient care (staffing, education, and specialization), empowerment, and autonomy. The external factors are outside the immediate scope of the CN yet directly and indirectly affect the CNs’ control over nursing practice including health care restructuring, organizational influence, work environment models (shared governance and magnet hospital environments), and nursing leadership. This study provided CNs employed in the provincial hospitals in Saskatchewan an opportunity and a “voice” to share their perceptions of who governs their professional practice environment including control over nursing practice. This mixed method descriptive survey design used Hess’ Index of Professional Nursing Governance ([IPNG], 1998) along with five questions geared to elicit qualitative responses to study the perceptions of who governs CNs’ professional practice environment including control over nursing practice in provincial hospitals in Saskatchewan. Section one of the IPNG contains a demographic section including information on age, gender, nursing education, and employment information. The second section of IPNG consists of 86 questions that are further divided into six subscales asking respondents to indicate who has control over nursing practice in a number of areas within their particular health facility. The six subscales include Subscale I – Professional control relating to who has control over professional practice in the organization, Subscale II – Organizational influence examining who participates in governance activities within the organization, Subscale III – Organizational recognition identifying who controls nursing personnel and related structures, Subscale IV – Facilitating structures indicating who determines and participates in governance decisions within the organization, Subscale V – Liaison exploring who influences the resources that support professional practice, and Subscale VI – Alignment identifying who sets and negotiates conflict within the organization. These questions are rated on a 5 point Likert scale according to the following response possibilities: 5 = staff nurses only; 4 = primarily staff nurses with some nursing management/administration input; 3 = equally shared by staff nurses and nursing management/administration; 2 = primarily nursing management/administration with some staff nurse input; 1 = nursing management/administration only. Section three – the qualitative questions, contained one closed ended and four open ended questions that provided CNs an opportunity to share a more personal perspective regarding their perceptions of control over nursing practice in their work environment. These questions included: 1. What does control over nursing practice mean to you? 2. How could control over your practice be changed significantly? 3. Do you feel you have enough control over practice in your work environment? 4. What limits your control over practice in an area that interests you? and What enables your control over practice in an area that interests you? The total population of 1804 CNs in provincial hospitals in Saskatchewan was invited to participate in this study. One hundred and seventy two CNs (9.53%) responded to this study, including 118 from Saskatoon (11.8%) and 54 from Regina (6.7%). The descriptive data provides data on gender and average age of CNs that is similar to Canadian Institute for Health Information ([CIHI], 2006) and Health Canada (2006a). A greater number of CN respondents indicated their basic nursing education was a diploma and more CNs had attained a baccalaureate degree as their highest level of education when compared to the CIHI data. Twice as many CNs indicated having specialty certification and a higher number were working full time in comparison to the CIHI data. The quantitative data obtained from the IPNG subscales indicates CNs perceive limited control over nursing practice and this is by in large held mainly by nursing management/administration (1) and nursing management with some staff nurse input (2). The subscale results include Professional control (M = 1.72), Organizational influence (m = 2.13), Organizational recognition (M = 1.73), Facilitating structures (M = 1.82), Liaison (M = 2.1), and Alignment (M = 2.1). Overall, the results from the IPNG subscales provide scores of less than “3” on the Likert scale indicating CNs perceive limited control over nursing practice in their professional practice environment. There were no significant differences within the provincial hospitals or between the health regions regarding CNs’ perceptions of control over nursing practice. In their qualitative responses, CNs provided information related to both the internal and external factors as discussed in Chapter Two. Clinical nurses indicate they face many challenges regarding control over practice including lack of influence in decision making in issues related to policy and procedure, quality patient care, staffing ratios, self-scheduling, and educational opportunities. They also identified external factors affecting their control over nursing practice including a lack of support by management in relation to decision making, a lack of provision of and access to an adequacy of resources, and a lack of communication and collaboration. Many CNs indicated their only influence in decision making was related to direct patient care. Clinical nurses described that being valued, supported, and recognized for their experience and education in decision making positively affects control over nursing practice and more specifically, quality patient care. Study results offer government officials, practitioners, regulatory bodies, researchers, administrators, educators, nurses, the public, professional association, employers, unions, and any other stakeholders information that provides an opportunity to increase their awareness and understanding of the impact that control over nursing practice has for CNs in their practice environment. If stakeholders are serious in their attempts to recognize CNs’ concerns regarding control over nursing practice in their work environment, the results from this study will provide information facilitating change in the CNs’ control over nursing practice. Ultimately, this affects the CNs’ professionalism and ability to provide quality patient care