Educational Management Program on Enforcement Autonomous Decision Making Among Novice Graduate Nurses

Tanta Scientific Nursing Journal

Educational Management Program on Enforcement Autonomous Decision Making among Novice Graduate Nurses

Walaa Mostafa Abd El Haliem Eid: Assistant lecturer in Nursing Administration, Faculty of Nursing, Tanta University Fouada Mohamed Shaban Prof. of Nursing Administration Faculty of Nursing, Tanta University Safaa Abd Al moneim Zahran Assistant prof. of Nursing Administration, Faculty of Nursing, Tanta University Karima Ahmed El Said Assistant prof. of Nursing Administration, Faculty of Nursing, Tanta University Abstract Background: autonomous decision making (DM) is a positive concept for novice graduate nurses (NGNs) influencing job satisfaction, retention and quality of care. They have to exercise judgments and DM skills through learning DM process to act independently and autonomously. Aim: to assess, design, implement, and evaluate an enforcement educational management program on autonomous clinical and managerial decision making for novice graduate nurses. Setting: study was conducted at Tanta University and El Menshawy Hospital. Subjects: all (90) novice graduate nurses working in above mentioned setting. Tools: Three tools were used including decision making autonomy assessment scale, decision making and principles of autonomy knowledge test and educational enforcement program on decision making and autonomy principles. Results: Pre programs, all NGNs have low level of DM autonomy in clinical and managerial decisions and had poor level of knowledge about DM autonomy principles. Post program, (95.5%) of NGNs had good level of knowledge. NGNs (12.3% and 24.4%) had moderate level of managerial and clinical DM autonomy respectively. Conclusion: NGNs at two hospitals not having the authority and autonomy for making clinical and managerial decisions. Additionally, had lacking knowledge about decision making autonomy principles and facing organizational obstacles that limit their autonomy in DM. Post program, NGNs' knowledge and skills about autonomous DM improved. Recommendations: updating the structure of NGNs' job description including their involvement in decision making. Stress active managerial support to NGNs to improve their decision-making skills and become independent in clinical and managerial decisions.

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Introduction decisions that govern nursing practice and Novice graduate nurses (NGNs) are practice environment. Absence of baccalaureate prepared registered nurses educational program to support their with less than three full years of decision making skills was the first experience in the profession (1,2). managerial barriers for their decisional Technology and research advances, greater involvement. workloads, diminishing resources, and Autonomous decision making considered complexity of nursing care requirement an important element for novice nurses' overwhelm novice graduate nurses (3,4). All professional identity and source of power of these phenomena increased the in their clinical practice (11-13). challenge for decision making by nurses Autonomous decision making not involve (5). For novices, this challenge is even the exercise of routine tasks or the greater and call for effective, independent, unquestioning enactment of physician and competent decision maker (6) .To orders (14). For novice nurses, autonomous assume new and independent roles in their decision making means acting and decide practice NGNs need to develop their independently without being restricted by abilities to problem solving, making bureaucratic rules of hospitals and decisions, acting independently to function receiving orders or permission from others and decide safely (7). based on complex body of knowledge and Basically, novice graduate nurses (NGNs) skills (15,16). Autonomy is an essential as professionals are accountable for attribute for achieving professional status patients with more complex care require by using the power to determine what close observation and specialized needs to be done in providing patient care, treatment (8). They face legal, complex, to act on assessments and to accept and educational problems dictate the accountability for independent decisions demand for professionally prepared (17). It manifested through communication autonomous nurses to fulfill their of mutual respect and trust both intra and professional role and move the profession interprofessionally in clinical settings (18). forward (9). Although nurse specialists Autonomy in clinical and managerial expected to make independent clinical and decisions is required by NGNs when managerial decisions, Eid (2009) (10) assessing the information about patient revealed that nurses specialist not have the needs, putting nursing diagnose and authority and autonomy in making judgment about the patient's health

Vol. 11 No. 2 November, 2016 125 Tanta Scientific Nursing Journal problems. Adding that, when deriving the To deal with these concerns NGNs need to outcomes of nursing care provided, be enforced to be autonomous decision developing and planning the nursing maker (28). They need to be trained to procedures, implementing the plan of care incorporate an educational framework that and evaluating the care provided against supports their development. Prerequisite the standard of care (19-21). Variety of intellectual and cognitive skills are needed independent managerial decisions needed in order to manage complex information about resources affecting patient care and to make judgments (29). In addition, including staffing, budgeting, equipment, they need to be trained to exercise supplies, time, and patient assignment to discretionary decision making by using the staff. Moreover, planning, organizing, critical concise to select a course of action collaboration, and quality of professional consistent with client and unit needs. Self practice decisions (22, 23). direction and intellectual flexibility are The nature of novice nurses' clinical required to negotiate and compromise (18). decision making is linear, based on limited Enforcement of educational management knowledge and experience in the program on autonomous decision making profession and focused on single tasks or for NGNs is very important to teach them problems (5,24,25). They tend to view how to make effective decisions by decision making as responding to patient investing their knowledge about decision complaints, and following protocols or making process and supporting them in documented care plans. As they make both successful and unsuccessful decisions decisions; their focus leans toward doing, for increasing their autonomy and control rather than on thinking and reflecting, over nursing practice. Designing and make them rely excessively on more implementing program for novice graduate experienced nurses and avoid situations nurses they will become autonomous, they that require them to make decisions (26). will able to choose a specific course to Consequently, the Institute of Medicine respond to both the problem and the (2008) (27) stressed that a higher level of opportunities that confront them, make clinical decision making autonomy have to judgments about the care that they provide be given to NGNs and that they be trusted to patients and management issues (30). and supported to make autonomous Aim of the study: Assess, design, decisions about patient's care and unit implement, and evaluate an enforcement operations. educational management program on

Vol. 11 No. 2 November, 2016 126 Tanta Scientific Nursing Journal autonomous clinical and managerial clinical decisions, it consisted of 34 items decision making for novice nurses. divided into clinical decision in patient Research hypothesis: Improvement of assessment, nursing diagnosis outcome knowledge and skills of autonomous identification, care planning, care decision making among novice graduate implementation and care evaluation. b) nurses. Managerial decisions subscale was used to Materials and Method assess novice gradate nurses' autonomy in Material managerial decisions. It consisted of 38 Study design: Quasi experimental items divided into managerial decisions research design was used to achieve the related to quality of professional practice, aim of present study. Such design fits the quality of support staff practice, nature of the problem under investigation. professional nursing staff development, Setting: The study was conducted at Tanta collaboration, unit governance and University Hospitals and El Menshawy leadership decisions, unit staffing Hospital. Subject: The study subjects decisions, planning, and organizing the consisted of all (90) novice graduate nurses up work unit decisions. The response for to 3 years of experience at Tanta University questionnaire was measured by 3 points Hospital and El Menshawy Hospital. The scaling as follows:- subject was 25 novice graduate nurses at Tanta Never =1 Rarely =2 Always =3 University Hospital and 65 at El Menshawy Part (3): Modified organizational obstacles Hospital. for autonomy in making clinical and Tools: To achieve the aim of the study the managerial decision making (19) questions following tools were used. related to general organizational and Tool I: Decision making autonomy managerial support obstacles affect novice assessment scale consisted of three parts: graduate nurses autonomy in making their Part (1): Characteristics of subject such decisions. The responses for questionnaire hospital name, age, years of experience, was measured on three points likert scaling unit name and marital status. ranging from (3) strongly agree to (1) Part (2): Decision making autonomy disagree. Levels of response were high, assessment questionnaire contained moderate and low. clinical and managerial decisions subscale. Tool II: Decision making and principles a) Clinical decisions subscale was used to of autonomy knowledge test. It consisted assess novice gradate nurses' autonomy in

Vol. 11 No. 2 November, 2016 127 Tanta Scientific Nursing Journal of 66 questions in forms of true &false (32 content validity of its items. The experts items), multiple choice (28 items) and responses were represented in four points apply (6 items). These questions were rating score ranging from (4-1); 4= classified into 5 categories. Items related strongly relevant, 3= relevant, 2= not to decision making basic concepts and relevant, and 1= strongly not relevant. IDEALS model, items related to autonomy Necessary modifications were done, principles and its dimensions, items related included clarification, omissions of certain to autonomous nursing practice and questions and adding others. The content characteristics of autonomous nurse, items validity was 94% for novice graduate related to implementation of decision nurses' decision making autonomy in making process, and items related to clinical and managerial decisions and organizational obstacles for novice 95.5% for decision making autonomy graduate nurses' decision making obstacles. autonomy. Each item of the knowledge * Ethical consideration: Nurses consent test was allotted score of (1) for correct to participate in the study was obtained answer and (0) for wrong answer. Level of (nurses were informed about the privacy of novice graduate nurses' knowledge was as information obtained from them, nature of follows: the study, their rights to withdraw, and the - Low level knowledge < 60% of total confidentiality of their names). scores. * A pilot study was conducted on ten - Fair level knowledge = 60% -<80% novice graduate nurses. They are randomly of total scores selected from the two hospitals and - High level knowledge >80% of total excluded from the sample. The first time scores. implemented after the development of the Method: tools and second time implemented before * An official permission was sent for starting the actual data collection to test responsible authorities at two hospitals the clarity of its items, applicability, and (Tanta University Hospitals and El relevance of the questions. The Menshawy Hospital) to obtain the administration time for filling approval and assistance in data collection. questionnaire sheet was approximately 30 * Tool I & II were presented to a jury of 7 minutes for assessment tool (I) and experts in nursing administration to check approximately 45 minute for knowledge

Vol. 11 No. 2 November, 2016 128 Tanta Scientific Nursing Journal test tool (II). Reliability of tools was to make clinical and managerial 0.824 for clinical and managerial decision autonomous decisions. making autonomy, and .816 for obstacles Selection and organization of program for novice nurses' decision making content autonomy. After determining the objectives of * Data collection phase: assessment sheet program, the content was specifically was distributed by researcher to all novice designed, method of teaching, and nurses in two hospitals to assess novice evaluation was identified. Simple scientific gradate nurses' autonomy in clinical and language was used. The content designed managerial decisions and assess to provide knowledge and skills related to obstacles affect their autonomy in making decision making and autonomy principles. their decisions. The appropriate time for The program contents included 5 sessions data collection was according to workload about: of each unit. ……….. 1- Decision making basic concepts and * Development of the enforcement IDEALS model developed by Facione educational program. (2006) (31). Educational enforcement program on 2- Autonomy principles and dimensions. decision making and autonomy principles 3- Autonomous nursing practice and was developed by the researcher based on characteristics of autonomous nurse. review of relevant recent literature and 4- Examples of clinical situations to train results of novice graduate nurses' the novice graduate nurses how to knowledge test scores on decision making implement the decision making process and autonomy principles and decision and make better clinical and making autonomy scale responses. managerial decision. The first step in the construction of this 5- Organizational obstacles for novice program was the statement of general and decision making autonomy. specific instructional objectives. Teaching- learning g strategies General instructional objectives Selection of teaching method was The main objectives of the program is to governed by studying the subjects enforce novice graduate nurses with themselves and content of the program. knowledge and skills about decision The methods used were lecture, group making and autonomy principles to be able discussion, case study and examples from

Vol. 11 No. 2 November, 2016 129 Tanta Scientific Nursing Journal work situations. a- Pre implementation of the program pre- Teaching aids testing of novice nurses' level of The teaching aids used in the program knowledge. were data show, flow sheet handouts, pen b- Post testing novice graduate nurses and papers. level of knowledge immediately after Implementation of the program implementation of the program. - The study was carried on 90 novice c- Difference in level of autonomy of graduate nurses. Novice graduate decision making using tool (1). nurses will be divided into ten groups. * The duration of data collection about 12 The program time was 10 hours for months. each group. One session every day for 5 Statistical analysis days, every session2 hours. They The collected data were organized, preferred to start the session after tabulated and statistically analyzed using finishing necessary work at 11 a.m -1 SPSS software version 16. p.m. For quantitative data, the range, mean and - The program theoretical sessions were standard deviation were calculated. For held in the conference room and head qualitative data, comparison between two nurse room at El Menshawy Hospital groups and more was done using Chi- and in wards at Tanta University square test (2) and Fisher Exact test (FE). Hospitals. Results - The novice graduate nurses were Table (1) shows characteristics of novice informed about the general instructional graduate nurses (NGNs). The age of objectives of program and of each novice graduate nurses were ranged from session. The researcher builds good 24-27 years, with mean age 25.10+0.90. relationship and gave a simple form of High percent (67.8%) of novice graduate motivation to enhance their nurses were in the age group 24-25 years, participation and more involvement in and the rest (32.2%) were in the age group the program activities. 26-27 years. Evaluation of the program High percent (72.22%) of NGNs were The program was evaluated using the worked in El Menshawy Hospital and decision making and autonomy principles knowledge test as follows;

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(27.78%) worked at Tanta University NGNs' autonomy in making clinical and Hospitals. managerial decisions at (P=0.0001). Equal percent (47.8%) of NGNs were Figure (1) shows levels of novice nurses' married and single. Their mean years of total knowledge pre and post program experience were 1.46+0.86. Over forty implementation. Pre program, no one of percent (46.7%) of NGNs get very good in novice nurses had good level of graduation level, (37.8%) their grades knowledge compared to post program, were good, and (15.6%) their grades were most of them were at good level of excellent. No one of them attend any knowledge. educational programs about decision Table (3) represent difference between making. mean percent of improvement of novice Table (2) represents correlation between graduate nurses' knowledge about decision scores of clinical and managerial decision making and principles of autonomy at making autonomy, scores of organizational Tanta University and El Menshawy obstacles of decision making autonomy hospitals post than pre program and total knowledge score of novice implementation. The table shows nurses' pre program implementation. Total significant improvement of novice nurses' scores of autonomy in making clinical & knowledge at two hospitals post than pre managerial decisions differ statistically program implementation at (p=0.018). significant according to NGNs' age and Mean percent of improvement was years of experience at (P=0.0001), 250.26%±76.67 at Tanta university Moreover, statistical significant correlation hospitals while 208.41%±58.85 at El found between total scores of autonomy in Menshawy hospital. clinical & managerial decisions and scores Figure (2) shows novice graduate nurses' of general organizational obstacles of level of actual managerial decision making decision making autonomy at (P=0.0001). autonomy pre and post program Statistical significant correlation between implementation. Pre program, none of total scores of autonomy in managerial novice nurses had high or moderate level decisions and scores of managerial support compared to few of them post program obstacles of decision making autonomy at had moderate level of managerial decision (P=0.0001), Besides that, total knowledge making autonomy. scores have statistical significant effect on Figure (3) shows novice nurses' levels of

Vol. 11 No. 2 November, 2016 131 Tanta Scientific Nursing Journal actual total clinical decision making responsibility for decision making", and autonomy pre and post program "no support from nurse manager when any implementation. Pre program, none of problem happen" were ranked 1,2,3,4 novice nurses had high or moderate level organizational obstacles that limit NGNs' of clinical decision making autonomy decision making autonomy with mean compared to about quarter of them post score >2. However, item of "nurse program had moderate level of clinical manager transfer you suddenly without decision making autonomy. preparation" was the least obstacle for Table (4) represents mean scores of NGNs' decision making autonomy with organizational obstacles for novice nurses' mean score =1. decision making autonomy at Tanta Post program, item of "physician only take University hospitals pre and post program decision making" was the first general implementation. Pre program, item of organizational obstacle for novice nurses' ""physician only take decision making" decision making autonomy with mean was ranked the first general organizational score 2.80+0.41, while item of "increase obstacle for NGNs' decision making in non nursing duties" was the least autonomy with mean score 2.80+0.41 obstacle with mean score 1.20+0.41. Item while the item of "increase in non nursing of "nurse manager only retain the duties" was ranked the least obstacle with responsibility for decision making" was mean score 1.20+0.41. Item of "absence the first managerial support obstacle for of educational program to support decision NGNs' decision making autonomy post making skills" was ranked the first program with mean score 2.80+0.41. managerial support obstacle for NGNs' While, item of "absence of educational decision making autonomy with mean program to support decision making skills" score 2.84+ 0.41 while the item of "nurse was the least obstacle with mean score =1. manager transfer you suddenly without Total rank post program showed that items preparation" was ranked the least obstacle of "physician only take decision making" , with mean score 1.00+0.00. "nurse manager only retain the Total rank pre program showed that responsibility for decision making", "no items of "absence of educational program support from nurse manager when any to support decision making skills " , problem happen", and "no response from "physician only take decision making" , nurse manager to NGNs' problems" "nurse manager only retain the ranked1,2,3,4 organizational obstacles that

Vol. 11 No. 2 November, 2016 132 Tanta Scientific Nursing Journal limit NGNs' decision making autonomy obstacles that limit NGNs' decision with mean score >2. However, item of making autonomy with mean score >2. "absence of educational program to However, item of "the nurse manager support decision making skills" become insist to heart novice nurses" was the least the least obstacle for NGNs' decision obstacle for NGNs' decision making making autonomy with mean score =1. autonomy with mean score =1. Table (5) represents mean scores of Post program, item of "absence of rules organizational obstacles for novice nurses' that indicate the freedom in unit decision decision making autonomy at El making" was the first general Menshawy hospitals pre and post program organizational obstacle for novice nurses' implementation. Pre program, item of decision making autonomy with mean "lack of supplies and equipment in unit" score 2.31+0.75, while item of "increase in was ranked the first general organizational non nursing duties" was the least obstacle obstacle for NGNs' decision making with mean score 1.23+0.42. Item of "nurse autonomy with mean score 2.31+ 0.75. manager only retain the responsibility for While item of "increase in non-nursing decision making" was the first managerial duties" was ranked the least obstacle with support obstacle for NGNs' decision mean score 1.23+0.42. Item of "absence making autonomy post program with mean of educational program to support decision score 2.54+0.50. While, item of "nurse making skills" was ranked the first manager insist to heart you" was the least managerial support obstacles for NGNs' obstacle with mean score =1. decision making autonomy with mean Total rank post program showed that items score 2.54+ 0.50. While item of "nurse of "nurse manager only retain the manager insist to heart you" ranked the responsibility for decision making", "no least obstacle with mean score 1.00+0.00. response from nurse manager to NGNs' Total rank pre program showed that items problems", " the way of nurse manager in of "absence of educational program to conflict resolution is in equity" and support decision making skills ", "nurse "absence of rules that indicate the freedom manager only retain the responsibility for in unit decisions " were ranked 1,2,3,4 decision making", " the way of nurse organizational obstacles that limit NGNs' manager in conflict resolution is in equity" decision making autonomy with mean and "lack of supplies and equipment in the score >2. However, items of "nurse unit" were ranked 1,2,3,4 organizational manager insist to heart you" and "absence

Vol. 11 No. 2 November, 2016 133 Tanta Scientific Nursing Journal of educational program to support decision making skills" become the least obstacles for NGNs' decision making autonomy with mean score 1.00+0.00, 1.18+0.39 respectively. Table (6) shows correlation between scores of clinical & managerial decision making autonomy and scores of organizational obstacles of decision making autonomy of novice nurses post program implementation. Significant correlation found between age & years of experience of novice nurses and total scores of autonomy in clinical & managerial decisions post program at (p<0.05). Also, significant correlation found between total scores of clinical decision making autonomy and total score of organizational obstacles to decision making autonomy at (p<0.05). Furthermore, the table shows significant effect of general organizational obstacles on clinical and managerial decision making autonomy. While, significant correlation found between total scores of managerial support obstacles and total scores of managerial decision making autonomy. Where managerial support obstacles had an effect on NGNs' managerial decision making autonomy

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Table (1): Characteristics of novice graduate nurses (n=90).

The novice graduate nurses Characteristics No % Age 24-25 61 67.8 26-27 29 32.2 Mean +SD 25.10+0.90 Hospital Tanta university hospitals 25 27.78 El Menshawy hospital 65 72.22 Department Anesthesia ICU 15 16.7 Neurology ICU 10 11.1 Medical ICU 15 16.7 Neonatal ICU Cardiology ICU 20 22.2 Pediatric ICU 11 12.2 Renal Dialysis 9 10.0 10 11.1 Marital status Single 43 47.8 Married 43 47.8 widowed 4 4.4 Years of experience 0.5-<2 67 74.4 2 8 8.9 3 15 16.7 Mean +SD 1.46+0.86 Graduation level Excellent 14 15.6 Very good 42 46.7 Good 34 37.8 Attendance of training programs about decision making Attend 0 - Not attend 90 100

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Table (2): Correlation between scores of clinical and managerial decision making autonomy and scores of organizational obstacles of decision making autonomy of novice nurses pre program implementation (n=90).

Novice graduate nurses (n=90)

Total scores of Total scores of Total scores of Total Variables autonomy in autonomy in Obstacles to knowledge making clinical making autonomy of scores decision managerial decision decision making r p R p r p r p Age 0.749 0.0001* 0.591 0.0001* 0.143 0.180 0.017 0.875

Experience years 0.825 0.0001* 0.614 0.0001* 0.186 0.079 -0.030 0.777

Total scores of autonomy in - - - - 0.285 0.006* - - making clinical decision Total scores of autonomy in making managerial 0.063 0.557 - - -0.173 0.102 - - decision Total scores of general 0.628 0.0001* 0.237 0.024* - - -0.086 0.418 organizational obstacles Total scores of managerial support 0.163 0.125 -0.488 0.0001* - - -0.145 0.172 obstacles Total knowledge 0.606 0.0001* 0.327 0.0001* -0.150 0.158 - - scores *Significant (P<0.05)

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Pre Post

100 100% 95.5% 90

10 4.4% 0 0% 0% 0%

Poor Fair Good

Figure (1): Levels of novice nurses' total knowledge pre and post program implementation (n=90).

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Table (3): Difference between mean Percent of improvement of novice graduate nurses' knowledge about decision making and principles of autonomy at Tanta University and El Menshawy hospitals post than pre program implementation (n=90).

Mean % of improvement of novice nurses' knowledge Knowledge subitems about (n=90) Z test decision making and Tanta University El Menshawy Total P principles of autonomy hospital hospital (n=25) (n=65) (n=90) Basic concepts and IDEALS 211.03%±120.63 156.92%±90.49 172.12%±102.12 2.237 model of decision making. 0.025* Decision making autonomy 190.83%±136.17 163.62%±114.73 171.18%±120.89 0.913 principles and dimensions 0.361 Autonomous nursing practice 216.88%±139.17 134.44%±69.6 157.34%±100.44 2.839 and characteristics of 0.005* autonomous nurse IDEALS model application in 240.00%±73.54 615.33%±311.90 427.66±186.22 6.000 clinical practice of decision 0.0001* making Organizational obstacles for 190.70%±138.80 256.63%±292.26 238.31%±259.80 0.641 novice decision making 0.522 autonomy:

Total Knowledge 250.26%±76.67 208.41%±58.85 220.04%±66.56 2.374 0.018* *Significant (P<0.05) Z test =Test of proportions

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Pre Post

100 100% 90 87.7% 80 70 60 50 40 30 20 10 12.3% 0 0 0 0

Low Moderate High

Figure (2): Novice nurses' levels of actual total managerial decision making autonomy pre and post program implementation (n= 90).

Pre Post

100 100%

80 75.5% 60

20 24.4%

0 0 0 0

Low Moderate High

Figure ( 3): Novice nurses' levels of actual total clinical decision making autonomy pre and post- program implementation (n=90).

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Table (4): Mean scores of organizational obstacles for novice nurses' decision making autonomy at Tanta University hospitals pre and post program implementation (n=25).

Mean score of organizational obstacles Organizational obstacles of decision making autonomy items Total Total Mean +SD Rank rank rank pre post Absence of rules that indicate the freedom in Pre 1.40+0.50 6 15 13 unit decision making, Post 1.56+0.51 5 Increasing the numbers of critical patients in the Pre 1.56+0.51 5 13 11 unit Post 1.64+0.86 3 Unclear work responsibilities to you Pre 1.56+0.77 4 14 14 Post 1.56+0.77 4 Lack of supplies and equipment to do the work Pre 1.80+1.00 2 8 8 Post 1.80+1.00 2 Shortage in nursing staff in the unit Pre 1.64+0.86 3 11 15 Post 1.40+0.50 6 Increase in non nursing duties Pre 1.20+0.41 7 17 17

Post 1.20+0.41 7 General organizational obstacles organizational General

Physician only take decisions without your Pre 2.80+0.41 1 2 1 involvement Post 2.80+0.41 1 4 No response from nurse manager to novice Pre 2.32+0.48 5 6 graduate nurses problems. Post 2.44+0.92 3 Absence of educational programs to support Pre 2.80+0.41 1 1 19 decision making skills. Post 1.00+0.00 12 Nurse manager transfer you suddenly from unit Pre 1.00+0.00 12 19 18 to unit without preparation. Post 1.12+0.33 11 Nurse manager only retains the responsibility Pre 2.76+0.43 2 3 2 for decision making. Post 2.80+0.41 1 Nurse manager refuses the head nurse decisions. Pre 1.68+0.90 8 10 6 Post 2.32+0.48 5 No support from nurse manager when any Pre 2.44+0.92 3 4 3 problems happen. Post 2.76+0.43 2 Nurse manager biased to some of you than Pre 1.60+0.50 9 12 10 others. Post 1.68+0.90 8 Nurse manager insist to heart you. Pre 1.12+0.33 11 18 16

Post 1.40+0.50 10 Managerial support obstacles support Managerial

No encouragement of excellent nurses in the Pre 2.00+0.76 6 7 7 unit. Post 2.00+0.76 6 Nurse manager biased to guilty physician. Pre 1.76+0.66 7 9 9 Post 1.76+0.66 7 Nurse manager refuse to give your vacations Pre 1.40+0.50 10 16 12 when you need it. Post 1.60+0.50 9 The way of nurse manager in conflict resolution Pre 2.40+0.50 4 5 5 is inequity Post 2.40+0.50 4

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Table (5): Mean scores of organizational obstacles for novice nurses' decision making autonomy at El Menshawy hospital pre and post program implementation (n=65).

Mean score of organizational obstacles Organizational obstacles of decision making autonomy items Total Total Mean +SD Rank rank rank pre post Absence of rules that indicate the freedom in Pre 1.35+0.48 5 15 4 unit decision making, post 2.31+0.75 1 Increasing the numbers of critical patients in Pre 1.35+0.48 4 14 15 the unit post 1.35+0.48 5 Unclear work responsibilities to you Pre 1.29+0.46 6 16 7 post 1.66+0.75 2 Lack of supplies and equipment to do the Pre 2.31+0.75 1 4 14 work post 1.35+0.48 4 Shortage in nursing staff in the unit Pre 1.37+0.72 3 13 16 post 1.29+0.46 6 Increase in non nursing duties Pre 1.23+0.42 7 17 17

post 1.23+0.42 7 General organizational obstacles organizational General

Physician only take decisions without your Pre 1.66+0.75 2 7 13 involvement post 1.37+0.72 3

No response from nurse manager to novice Pre 2.23+0.55 4 5 2 graduate nurses problems. post 2.48+0.50 2 Absence of educational programs to support Pre 2.54+0.50 1 1 18 decision making skills. post 1.18+0.39 11 Nurse manager transfer you suddenly from Pre 1.37+0.60 10 12 12 unit to unit without preparation. post 1.37+0.60 10 Nurse manager only retains the responsibility Pre 2.48+0.50 2 2 1 for decision making. post 2.54+0.50 1 Nurse manager refuses the head nurse Pre 1.38+0.49 9 11 6 decisions. post 2.09+0.76 5 No support from nurse manager when any Pre 2.09+0.76 5 6 5 problems happen. post 2.23+0.55 4 Nurse manager biased to some of you than Pre 1.55+0.50 7 9 9 others. post 1.55+0.50 7 Nurse manager insist to heart you. Pre 1.00+0.00 12 19 19

post 1.00+0.00 12 Managerial support obstacles support Managerial

No encouragement of excellent nurses in the Pre 1.58+0.50 6 8 8 unit. post 1.58+0.50 6 Nurse manager biased to guilty physician. Pre 1.18+0.39 11 18 11 post 1.38+0.49 9 Nurse manager refuse to give your vacations Pre 1.43+0.75 8 10 10 when you need it. post 1.43+0.75 8 The way of nurse manager in conflict Pre 2.40+0.49 3 3 3 resolution is inequity post 2.40+0.49 3

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Table (6): Correlation between scores of clinical and managerial decision making autonomy and scores of organizational obstacles of decision making autonomy of novice nurses post program implementation (n=90).

Novice nurses at Tanta University and El Menshawy hospitals post program implementation (n=90) Total scores of Total scores of Total scores of Total autonomy in autonomy in Obstacles to knowledge Variables making clinical making autonomy of scores decision managerial decision making decision r p r p r p r p Age 0.777 0.0001* 0.774 0.0001* 0.143 0.180 0.010 0.868

Experience years 0.706 0.0001* 0.595 0.0001* 0.186 0.079 -0.033 0.727

Total scores of - - - - 0.350 0.002* - - autonomy in making clinical decision Total scores of 0.676 0.0001* - - -0.173 0.102 - - autonomy in making managerial decision Total scores of 0.628 0.0001* 0.237 0.024* - - -0.089 0.421 general organizational obstacles Total scores of 0.180 0.146 -0.488 0.0001* - - -0.124 0.168 managerial support obstacles Total knowledge 0.074 0.615 0.1612 0.279 -0.141 0.161 - - scores *Significant (P<0.05)

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Discussion Analysis of present study novice graduate Decision making autonomy is a basic nurses poor level of knowledge pre benchmark of professionalism and tool for program revealed that they lack of protecting and reinforcing the novice sufficient knowledge about how to gather nurses' professional identity and status in information for patient assessment, lack nursing practice (32). Assessment of novice clinical judgment skills to expect potential graduate nurses' level of performance and health problems to make actual nursing knowledge about autonomy in clinical and diagnosis. They don't know how to decide managerial decisions making revealed that plan of action to implement and evaluate pre program , all novice nurses showed the patient's status and can't evaluate the low level in making autonomous decisions effectiveness of nursing care provided. and poor level of knowledge about This result indicates that those novice principles of decision making autonomy. graduate nurses have minimum clinical This might be explained by the fact that all experiences; they are beginning practice novice nurses were young aged and not need training to increase their experience. attended training programs about decision Most probably the high professional making. As well as the high percent of registered nurse vacancy rates increased them their experience was less than two the pressure on novice nurse and induced years. Beside the high level of obstacles them to work as soon as possible while they were facing either for managerial still not prepared to handle patient care support or general organizational which situations. limit their autonomy in decision making. Amini et al (2015) (34) revealed that nurses Department for International Development in teaching hospitals have moderate (2010) (33) support present results and professional decision making autonomy revealed that nurses have not any because they don't perceive enough power autonomy in decision making and not nor receive an adequate amount of involved in any decisions affecting their managerial support and feel barriers in practice. Also, Eid (2009) (10) support obtaining their rights and have lower legal present study results and mentioned that authority in decision making as well as nursing experience had an effect on nurses' they clarified that decision making decision making autonomy and that nurses autonomy influenced by nurse's age and need more autonomy in decisional experience that makes their voice heard. involvement in their work setting.

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Shamsi and Akbari (2011) (35) support the delegating tasks. However, novice nurses' finding and discussed the barriers to experiences three main themes "functional inability of staff nurses to make patient disability" includes complex and assessment, nursing diagnosis, care specialized skills; "communicative planning, implementation and evaluation problems" includes communication with are related to lack of experience, lack of physician and colleagues, and "managerial trained nurses to do it, insufficient challenges". information and skills, lack of managerial Novice nurses in present study face support in implementing these decisions, general organizational obstacles that limit lack of enough time and excessive number their decision making autonomy and have of patients which make the nurses unable statistically significant effect in making to make these decisions independently. clinical and managerial decisions. At Novice graduate nurses are required to Tanta University hospital the first ranked have strong knowledge base and integrate obstacle was physicians make decisions available evidence, clinical judgment, without nurses' involvement. Physicians decision making and patient preference as often serve as a dean and medical faculty they plan, implement, and evaluate patient hold higher posts and nurses under care outcome (36). supervision of them. Furthermore, Rafi and Hezaveh (2014) (37) assumed that university hospitals are largest healthcare one of the major problems of novice systems and have hierarchies that promote nurses is the lack of the necessary ability a top-down management system with to act as administrator and coordinator of many levels and nursing considered a the care team in the various shifts. lower position within the bureaucratic According to the current status of sever structure which lead to feeling impaired nursing shortage, the novice nurse authority and powerless among nurses. forcefully became the shift manger and The same result found by Liu et al (2015) because of her lack of required (38) reported that physician centered competency and experience she involved atmosphere in decision making, lack of trouble. These deficiencies are in the area care facility, structure of rules that of monitoring and controlling tasks, determine limits of authority, unclear work decision making, planning and prioritizing, responsibilities, shortage of nursing staff coordination, accountability, unit and heavy workload are important factors governance, time management and affecting nurses decision making

Vol. 11 No. 2 November, 2016 144 Tanta Scientific Nursing Journal autonomy. Elizabeth and Maria et al achieving goals and health plan targets. (2015) (39) also support present study result Lack of care facilities caused novice and revealed lower level of nurse nurses stressed and frustrated because they autonomy associated with lower perceived unable to meet their patient needs, nurse - physician collaboration. indecisiveness which negatively affect Der (2011) (40) suggests that to improve the their autonomy in such decisions and relationships among novice nurses and giving the feeling of inability to have physician various approaches are control over the work (44). implemented. Unit based program to Novice nurses in present study showed improve communication and use of that the shortage of staff in ICU ranked multidisciplinary rounds. Team work high among obstacles for their decision training and open communication to making autonomy. They assumed that the reduce the differences to the point that nursing shortage considers from the both sides could work amicably for the highest obstacles for the novice nurses' benefit of the patients (41). While lack of clinical and managerial decision making communication and collaboration among autonomy. Yet critical care patients were novice nurses and physician has totally dependent on availability of significantly poor patient outcome, lower sufficient number of trained novice nurses perceived ability to meet patients' needs staff to ensure continuous care and and lower perceived technical quality of constant bedside attention. Novice nurses care exist in the unit (42). play vital role in provision of basic and At El Menshawy hospital the first ranked advanced life support. So there must be at obstacle was lack of supplies and least one trained novice nurse per patient equipment. This result means that those at all times (45). novice nurses can't make autonomous The fact that for novices, the actual decisions due to insufficient supplies or causes for nursing shortage, where the equipment needed in the intensive care. vacancy rate of professional registered Ministry of Health and Population (2012) nurse in the same time of high patient and (43) confirm this finding and reported that work acuity, lack of placement program most governmental hospitals have poor and support for newly trained nurse. physical facilities and lack supplies and Consequently, their responsibilities equipment that affect health care provider's increased and experience workload in their decision making and difficulty in

Vol. 11 No. 2 November, 2016 145 Tanta Scientific Nursing Journal job that affects their clinical and to plan and govern the unit, (35%) managerial decision making autonomy (46). reported high in nursing errors and Carayon and Gureses (2011) (47) reported expressed both tasks delayed and tasks not that lack of time and heavy workload completed. negatively affected decision making So, it is important for nurse manager to be autonomy because novice nurses can't good observer of the work situations, comprehend patient's requirements. direct management of the work Unclear work responsibility among novice environment and workstation and make nurses constituted as high rank obstacle for interviews, focus group, and survey of their decision making autonomy in present novice nurses to meet the challenges of study. The fact is that the over workload creating a patient driven healthcare system and increasing responsibility in ICU make and decrease their sense of stress caused the novice nurses have limited time to by workload in their job (49). perform tasks that have a direct effect on Finding of the current study showed patient care and limit their autonomy to correlation between total scores of make independent decisions to perform autonomy in managerial decisions and various procedures. About half of novice scores of managerial support obstacles of nurses implement care without assessment, decision making autonomy. This means planning, and evaluation of it . Workload that managerial support obstacles limit make those nurses have lack of time to novice nurses' decision making autonomy gather information about patient's needs in managerial decisions. Actually those and use physical technique as inspection, novice nurses lack managerial support that palpation when making patient assessment. ruling over them and lead them reluctant to Moreover, less time to analyze patient' assume responsibility of independent assessment data and not to establish decision making. They never make priorities for nursing diagnosis and managerial decisions because there is no document it. Consequently, they can't educational program to support their make effective care planning. decision making skills and knowledge and Present result consistent with the result of nurse manager retain to her self the Kumari and De (2015) (48) they revealed responsibility of decision making. that (65%) have less time available to Lack of managerial support make the deliver care and to interact with their novice nurses ignored about certain issues patients and other healthcare professionals and decisions that are essential to their

Vol. 11 No. 2 November, 2016 146 Tanta Scientific Nursing Journal practice because they are separated from mean for improving present study novice making these decisions. They were not nurses' knowledge and skills. involved to set and evaluate standards of Really the present study program nursing practice and ignored to decide maximized the novice nurses' knowledge when developing nursing staff. Adding and skills about autonomous decision that they were overlooked about how to making because it was the first educational make scheduling, planning and organizing program about decision making they their units. attend in their employment. The program This result consistent with the result of Eid was planned and implemented according (2009) (10) who revealed that staff nurses to their pre assessed needs. Furthermore in intensive care units at Tanta university the simplification of educational matter of hospitals perceived lack of managerial the autonomous decision making program support and reported absence of and the well-presented information by educational programs was the highest suitable educational aids increase novice managerial support barrier for nurses' nurses' interest and desire to acquire decisional involvement. needed principles and knowledge as well The same result was found by Dorgham as try to apply it. and Al Mahmoud (2013) (28) reported low The result revealed significant level of decision making autonomy as a improvement of novice nurses' knowledge result of leadership style and centralized at Tanta University Hospital than El decision making. Menshawy Hospitals . This may be due to Result of present study post program that the experienced novice nurses (25%) implementation revealed that there was who had two years of experience or more significant improvement in novice nurses' were working at Tanta university hospitals level of knowledge about principles of in which experience in work place increase decision making and autonomy. The fact is the ability to integrate knowledge and that the knowledge and skills level were reaching to the reasoning level . Bakr et al poor pre program implementation at two (2013) (50) implies that clinical experience hospitals , but it was significantly prepares novice nurses to be able of increased to become at good level post "doing" as well as "knowing" the program. This could direct the attention clinical principles of decision making. that the implementation of current In fact, statistical significant improvement educational program was succeed as a found post program between total levels of

Vol. 11 No. 2 November, 2016 147 Tanta Scientific Nursing Journal actual managerial decision making Present study post program result revealed autonomy as well as autonomy regarding that there was still significant correlation professional nursing staff development between age & years of experience of decisions, unit governance and leadership, novice nurses and their total scores of unit staffing, and organizing the work unit autonomy in clinical & managerial decisions . decisions. This means that practicing About one third of them post program decision making is more than the simple become always monitor of support staff application of theoretical knowledge or performance against standards, identify performing technical skills but it requires nurses' educational needs, recognize integrating knowledge, skills and appropriate and available services to experience to make a deep understanding address patient's health care, and group the of surrounded environment and make activities to be done in the unit. Moreover, effective independent autonomous more than half always delegate some decisions. aspects of work to others and evaluate the Current study result also showed effectiveness of the current mode of significant correlation between total scores patient care delivery. of clinical decision making autonomy and Beside managerial decisions, quarter of total score of organizational obstacles to novice nurses had moderate level of novice nurses' decision making autonomy clinical decision making autonomy post program . It means that novice nurses compared to none of them had high or still face general organizational obstacles moderate level pre program. Statistical that limit their decision making autonomy significant improvement found between all in spite of improving their level of items of clinical decisions post program. knowledge about principles of decision Also about half of novice nurses always making and autonomy. Novice nurses as a make decision making about care health care professional provides direct implementation and nursing diagnosis care need to be trusted and valued for compared to low percent pre program. creating the context for high level of Moreover, considerable percent of them autonomy and control over nursing become always make decisions about care practice (10). They have to possess the planning, patient assessment and outcome autonomy and decision making skills identification compared to low percent pre needed to provide quality and cost program . effective care (18).

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Dorgham and Al Mahmoud (2013) (28) autonomy. At El Menshawy hospitals support the finding and reported that novice nurses reported that items of "nurse despite nurses being equipped with the manager retain the responsibility for necessary knowledge and skills to make decision making", "no response from nurse decisions regarding patient care, they still manager to novice nurses problems", "the feel their autonomy in clinical decision way of nurse manager in conflict making is being constrained as a result of resolution is in equity", and "absence of restricted organizational structure and rules that indicate the freedom in unit support from physician. decisions" are the highest organizational Present study revealed significant obstacles for their decision making correlation between total scores of autonomy. But, "absence of educational managerial support obstacles and total program to support decision making skills" scores of managerial decision making become the least obstacles for novice autonomy post program . This means that nurses' decision making autonomy at two managerial support obstacles still had an hospitals because the knowledge level effect on novice nurses' managerial about decision making were improved decision making autonomy. Actually, post through the educational program . program novice nurses at the two Therefore, novice nurses have to be hospitals understudy ranked high supported and encouraged from both the organizational obstacles for limiting their structure itself by given authority for decision making autonomy and make high decision making and their nurse manager percent of them had low level of decision in their setting to use relational autonomy making autonomy and unable to make the to be independent when making decisions. other clinical and managerial decisions. Managerial support to novice nurses Novice nurses at Tanta University through interviewing them to determine hospitals post program reported that items their needs and verbalize their problems of "physician only take decisions", "nurse that are being ignored or frustrated and manager retain the responsibility for make recognition (44). decision making", "no support from nurse So, novice nurses at Tanta university manager in problems" and "no response hospitals and El Menshawy hospitals need from nurse manager to novice nurses to be provided and enforced with problems" are the highest organizational periodical autonomous decision making obstacles for their decision making program to assist them to develop their

Vol. 11 No. 2 November, 2016 149 Tanta Scientific Nursing Journal personal and professional decision making 2- Prim importance the existence of skills, use decision making structures at rules support NGNs autonomy in the workgroup, organizational and decision making. professional level of practice, increase 3- Improve team working relationships their professional profile which facilitate and collaborate of NGNs and development of new knowledge and skills physicians by gently sharing their that needed for making autonomous knowledge, thoughts, abilities and decisions. active participation in decision Conclusion making. Novice graduate nurses at Tanta 4- Prim importance the availability of University Hospitals and El Menshawy sufficient supplies and equipment for Hospitals had low decision making carrying out different process to give autonomy for clinical and managerial NGNs the feeling of ability to have decisions and they were lacking control over nursing practice. knowledge about decision making and 5- Prim importance the availability of autonomy principles as well as their adequate number of professional ranked high organizational obstacles registered nurse to decrease NGNs' aggravated to limit their autonomy in workload and to have enough time not clinical and managerial decisions. only for concentration in solving Those nurses have great need to attend patient's problems but involve with educational to enforce them to be administration to make efficient autonomous decision maker in their effective critical decisions. professional role. 6- Provide learning environment for Recommendation novice nurses that support both formal Based on the finding of the current study and informal continuing education the following recommendations are programs and learning provides for suggested for: autonomous clinical practice. 1- Decision making should be facilitated 7- Orient novice nurses about their job with decentralization of control and description. non hierarchical structure to support NGNs autonomy in decision making.

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