RESEARCH

Collaboration and autonomy: Perceptions among nursepractitionersMary Margaret Maylone, DNP, CRNP, AOCNP (Nurse Practitioner)1, LeeAnn Ranieri, DNP, FNP-BC (NursePractitioner)2, Mary T. Quinn Griffin, PhD, RN (Assistant Professor)3, Rita McNulty, DNP, RN, CNP (AssistantProfessor)3, & Joyce J. Fitzpatrick, PhD, RN, FAAN (Professor)3

1 Sewickley Medical Oncology Hematology, Moon Township, Pennsylvania2 Arizona Minimally Invasive Sinus Institute, Phoenix, Arizona3 Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio

KeywordsCollaboration; autonomy; nurse practitioners;

interprofessional relations; quantitative

research; Dempster Practice Behavior Scale.

CorrespondenceJoyce J. Fitzpatrick, PhD, RN, FAAN, Frances

Payne Bolton School of Nursing, Case Western

Reserve University, 10900 Euclid Avenue,

Cleveland, OH 44106.

Tel: 216 3682543;

Fax: 216 3686389;

E-mail: Joyce.fitzpatrick@case.edu

Received: June 2009;

accepted: October 2009

doi: 10.1111/j.1745-7599.2010.00576.x

Abstract

Purpose: This descriptive study was designed to investigate the relationshipbetween nurse practitioners’ (NPs) perceptions of collaboration with physiciancolleagues and level of autonomy NP practice.Data sources: A convenience sample of 99 NPs attending a national clinicalconference completed the Dempster Practice Behavior Scale (DPBS) and theCollaborative Practice Scale modified for advanced practice nurses.Conclusions: NPs rated both their perceptions of collaboration with physi-cian colleagues and levels of autonomy as high. Yet, there was no significantcorrelation between these variables.Implications for practice: Collaboration between NPs and physician col-leagues is said to improve the quality and cost of health outcomes and alsoleads to professional satisfaction. Further research into the relationships be-tween collaboration and autonomy are necessary to understand these complexconcepts.

As the role of the nurse practitioner (NP) develops, au-tonomy continues to be a major professional issue in theevolution of the role and scope of practice (SOP). Barriersto practice, such as prescriptive authority limitations anddecreased reimbursement, have impacted autonomouspractice. Although state legislation has broadened the au-thority of NPs over the years, the current healthcare en-vironment continues to challenge the autonomous roleof the NP. Pioneer NP research has suggested that au-tonomy combined with collaboration may be the key tomaximizing NP potential, strengthening NPs’ unique po-sition in health care, and making a difference for patients(Brown & Draye, 2003).

The ability to practice autonomously depends on addi-tional factors, including organizational constraints, pub-lic perceptions, and collaboration and support of otherhealthcare colleagues. Collaboration between healthcareprofessionals is imperative to provide safe, cost-effective,high-quality healthcare services (Coeling & Cukr, 2000).Further, there is evidence that collaboration among ad-

vanced practice nurses (APNs) and physician colleaguesimproves the quality and cost of health outcomes and canlead to professional satisfaction (Coeling & Cukr, 2000).Still, hierarchical structures are frequently experiencedby practicing NPs with the physician in a dominant posi-tion and the NP in a subordinate role. Understanding bothautonomous practice and collaboration are further com-plicated by individual state SOP definitions with somerequiring a supervisory rather than a collaborative rela-tionship and a few requiring no relationship at all. Thepurpose of this study was to describe NPs’ perceptionsof collaboration with physician colleagues and their levelof autonomy. Relationships between these two variableswere also explored.

Background

Studies regarding collaboration between APNs andphysicians have included those focused on attitudesregarding collaboration among graduate NP students

51Journal of the American Academy of Nurse Practitioners 23 (2011) 51–57 C©2010 The Author(s)Journal compilation C©2010 American Academy of Nurse Practitioners

Collaboration and autonomy M.M. Maylone et al.

and physicians (Coeling & Cukr, 2000), perceptions ofcollaborative practice of both NPs and medical doctors(MDs) (Moser & Armer, 2000), and effects of empow-erment and occupational stress on collaboration (Al-most & Laschinger, 2002). Specific communication styleswere found to enhance collaborative behavior along withwork place empowerment; those NPs with a greaterSOP perceived higher levels of collaboration (Almost &Laschinger, 2002; Moser & Armer, 2000). The conceptsof both professional autonomy and NP autonomy remainambiguous despite being essential elements in the at-tainment of full professional recognition of NPs (Demp-ster, 1991). Lyon (2005) stressed that autonomous prac-tice involves self-directed treatment and diagnosis, whichmeans self-determined and controlled action not requir-ing authorization.

Brown and Draye (2003) described NPs’ experiences inestablishing, building, and maintaining their roles. Ad-vancing autonomy was the central organizing theme andremained an essential and important concept in the im-plementation and development of their role over time.This group of NPs stressed that autonomy creates a col-legial rather than an adversarial relationship with physi-cians and creates professionals with autonomous controlover their practice. They collectively recognized mean-ingful relationships with patients were important for jobsatisfaction, but stressed increased autonomy was essen-tial for them to use their skills to improve the health andoverall quality of life for their patients.

Ulrich, Soeken, and Miller (2003) studied sustainingautonomy in a managed care environment when deci-sion making is curtailed and the use of NPs is varied. Twohundred and fifty-four certified NPs licensed to practicein their respective states were surveyed using the Demp-ster Practice Behavior Scale (DPBS; Dempster, 1990). Theresearchers found that NPs were concerned about theirautonomy and their relationship to ethical patient care.Higher ethical concern was associated with a lower per-ception of autonomy as well as a negative perception ofthe ethical care environment. The researchers concludedautonomy continues to be a crucial element in NP prac-tice. Subsequently, Ulrich and Soeken (2005) tested acausal model of autonomy and ethical conflict in practiceand developed a causal model for use in future researchrelating autonomy and ethical conflict targeting managedcare environments.

Adams and Miller (2001) explored the level of pro-fessionalism in relationship to autonomy. Five hundredand two NPs at a national conference were surveyed.More than half of the participants had less than 5 yearsof practice, were employed in physicians’ offices, andhad written or participated in research studies. The re-searchers found that NPs had expectations to practice au-

tonomously in their delivery of patient care, monitoredtheir own professionalism, and, in regard to autonomy,half of the study participants had written their own jobdescription.

In summary, the significance of autonomy in NP prac-tice and performance has been documented (Dempster,1990). Since the earliest development, nurses in the NProle have struggled in pursuit of autonomous practice.Autonomy has allowed NPs to use their expertise and de-velop a practice focused on improved health for patients(Brown & Draye, 2003). Autonomy has been found to bea satisfier in NP practice (Kacel, Millar, & Norris, 2005).Ulrich and colleagues (2003) found that in managed carepopulations, the higher the managed care penetration inthe samples studied, the higher the NPs’ ethical concerns,and the lower the perceived autonomy. NPs perceive au-tonomy as an essential component of clinical practice andnecessary for the ability to practice to the full extent oftheir skills and knowledge (Dempster, 1990).

Gaps in the literature

With the exception of the identification of autonomy asa tensive issue affecting collaboration between APNs andphysicians (Martin, O’Brien, Heyworth, & Meyer 2005),little is known about the relationship that exists betweenthese variables and how it may influence practice. Au-tonomy is viewed by NPs as either a negative or posi-tive outcome of collaboration and is perceived by someas essential for collaboration to take place. Perceptionsof NPs may vary based on background and demographicvariables such as age, gender, educational levels, state ofpractice location, specialty, and certification.

In summary, positive results of collaboration have beendemonstrated between APNs and physicians. Collabora-tion has been studied with variables of culture and gender(Hojat et al., 2001), empowerment (Almost & Laschinger,2002), occupational stress, SOP (Alves, 2005), com-munication style (Dechairco-Marino, Jordan-March,Traiger, & Saulo, 2001), cost of care (Vazirani, Hays,Shapiro, & Cowan, 2005), and among various practicesettings. Autonomy has been linked to professionalism(Adams & Miller, 2001) and job satisfaction (Kacel et al.,2005).

Methods

Design and sample

This was a descriptive cross-sectional study; data werecollected at one time point. The participants were re-cruited from approximately 1200 NPs attending a na-tional clinical conference of the American Academy of

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M.M. Maylone et al. Collaboration and autonomy

NPs (AANP). All NPs practicing in the United Stateswere eligible to participate, and represented a variety ofpractice settings, specialties, and geographic locations.Participants were solicited for participation by a signposted on the conference message board inviting partici-pation in the study. A five-dollar gift certificate for a na-tional coffee shop or book store was offered as an incen-tive to participate.

Instruments

The DPBS (Dempster, 1990) was used to measure theextent of the NPs’ perception of autonomous behaviorsof practice. The DPBS is a 30-item instrument that wasdeveloped with a five-point Likert scale. This tool iden-tifies four theoretical dimensions that are measured assubscales of readiness, empowerment, actualization, andvaluation related to autonomy in practice. Readiness forautonomy refers to elements of growth, development,competence, mastery, and movement from one level toanother. Empowerment includes sanctions, legal status,legitimacy, and having rights and privileges. Actualizationencompasses the exercise of autonomy and applying it inthe practice area. Valuation is defined as having merit,worth, and usefulness and without it autonomy wouldnot matter. The DPBS has demonstrated strong psycho-metric properties in previous studies (Dempster, 1990).Cronbach’s alpha was 0.95; the content validity index ofthe DPBS was reported to be the maximum of 1.00. Thetotal scores for the DPBS range from 30 to 150; a higherscore indicates a greater extent of autonomy.

The Collaborative Practice Scale APNs (CPS-APN), amodification of the original CPS tool (Weiss & Davis,1985), was used to measure NPs’ perceptions of collabo-ration. The original tool consisted of two subscales, CPS-RN and CPS-Physician, each measuring assertiveness andcooperativeness of either the practice of the nurse or thephysician. Each subscale measured two factors (for a to-tal of four factors). Factor one of the nurse scale wasthe nurses’ pursuit of active interchange to communicatewith physicians about what a nurse can contribute (clin-ical expertise). The second factor was the nurses’ clarifi-cation of mutual expectations regarding shared responsi-bilities (expectations). The physician CPS contained twofactors that measured the beliefs about nurses’ contribu-tions in planning care (mutual responsibilities) and levelsof acknowledgment of the importance of the nurse (nursecontributions). The NP operates from both the nurs-ing and medical model (Shuler & Davis, 1993a, 1993b);therefore, minor wording changes to reflect APN practicewere made to the CPS with permission of the author. As aresult of the wording revision, the 19-item tool was calledthe CPS-APN.

All items in the CPS-APN were measured on a six-point Likert scale with a range from “never” to “always.”A higher score indicates more use of collaboration by theNP. The total possible score was 114. Cronbach’s alphacoefficients for reliability of the original nurse and physi-cian scales were reported as 0.83 and 0.85, respectively.Construct validity was reported after an exploratory fac-tor analysis with eigenvalues ranging from 1.27 to 4.17(Weiss & Davis, 1985).

Demographic and background characteristics of theparticipants included personal, educational, and profes-sional characteristics along with practice setting, employ-ment status, and years working as an NP.

Procedures

Prior to data collection, the study was approved by theInstitutional Review Board (IRB) of Case Western Re-serve University. Interested NPs were invited to obtain aresearch packet from the investigators who were presentat a conference exhibit booth. Completing the question-naires indicated consent. Participants were instructed tocomplete the packet and return it to the investigators dur-ing the conference.

Results

One hundred surveys were distributed; 99 surveyswere completed and returned; one survey was not re-turned.

Personal characteristics

Participants ranged in age from 28 years (n = 2) to 62years (n = 3) with a mean of 46 years (SD ± 8.17). Par-ticipants were predominately female (n = 91; 91%) andWhite, non-Hispanic (n = 94, 94.9%) (Table 1).

Table 1 Sample characteristics (n = 99)

Characteristic Frequency (%)/mean ± SD

Age (years) 46 ± 8.17

<31 4 (4.0%)

31–40 20 (20.2%)

41–50 44 (44.5%)

51–60 27 (27.3%)

> 60 4 (4.0%)

Gender (female) 91 (91.0%)

Race/ethnicity

White, non-Hispanic 94 (94.9%)

Black, non-Hispanic 5 (5.1%)

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Table 2 Educational characteristics of study participants

Characteristic Frequency (n = 99) Percentage

Basic RN preparationa

Diploma 18 18.2%

Associate degree 20 20.2%

Baccalaureate degree 60 60.6%

NP preparation

Non-degree certificate 1 1%

Master’s degree 84 84.4%

Post master’s degree 14 14.4%

Highest earned degree

Master’s degree in nursing 86 86%

Master’s degree-other 9 9%

DNP 1 1%

Other doctorate 1 1%

PhD 2 2%

aOne missing response.

Educational characteristics

The majority (84.8%) of NPs (n = 84) were prepared atthe master’s degree level, 14.1% (n = 14) were preparedwith a post-master’s degree, and 1% (n = 1) was preparedwith a nondegree certificate. Specific details are found inTable 2.

Professional characteristics

The professional characteristics of NPs examined wereNP certification type and NP certifying organization. Fam-ily practice certification was the most frequently occur-ring with 57% (n = 57), followed by adult at 20%(n = 20), acute care at 16% (n = 16), with each ofgerontological, pediatric, psychiatric, and other APN at1% (n = 4). Seventy-two percent (n = 72) were certifiedby the American Nurses Credentialing Center (ANCC),24% (n = 24) by the American Academy of Nurse Prac-titioners (AANP), and other certifying organization was1% (n = 1). Two participants were not certified (2%).

Additional characteristics

Employment status revealed that 85% (n = 88) of theNPs were employed full-time and 14% (n = 14) part-time. The most common practice settings were privatephysician offices (n = 35; 35%) and hospital inpatientunits (n = 21; 21.2%). It is notable that 4% (n = 4) ofNPs practiced in private NP groups. Years working as anNP ranged from a minimum of 1 year to a maximum of25 years with a mean of 7.6 years.

NPs were also asked to rate their expertise in thefollowing domains as described by the Strong Model ofAdvanced Practice (Mick & Ackerman, 2000); direct com-

Table 3 Participants’ self-report of expertise based on the five domains

of the strong model of advanced practice (n = 99)

Domain Mean ± SD Actual range

Direct comprehensive care 4.50 ± .65 3–5

Support systems 4.04 ± .72 2–5

Publication/professional leadership 2.87 ± 1.17 1–5

Research 2.46 ± 1.12 1–5

Education 3.87 ± .89 1–5

prehensive care, support of systems, publication and pro-fessional leadership, research, and education. Results aredisplayed in Table 3.

Reliability analyses for the instruments

Reliability of the CPS-APN tool (19 items) was evalu-ated with a Cronbach’s alpha, which was for this studyr = 0.88. Subscales of assertiveness (nine items) and co-operativeness (10 items) demonstrated a Cronbach’s al-pha of 0.74 and 0.86, respectively. Reliability of the DPBStool (30 items) was Cronbach’s alpha of 0.90. Subscalesor dimensions of readiness (11 items), empowerment(seven items), actualization (nine items), and valuation(three items) demonstrated Cronbach’s alphas of 0.88,0.57, 0.82, and 0.85, respectively.

Findings related to research questions

NPs’ perceptions of collaboration. The total meanscore reported on the CPS-APN was 83.5 (SD = 14.41)out of a possible score of 114. The mean score for the firstsubscale of assertiveness was 38.9 of 54 possible points.The mean score for the second subscale of cooperative-ness was 44.7 of 60 possible points. Details of these resultsare found in Table 4.NPs’ perceptions of levels of autonomy. The to-tal mean score for the DPBS reported by NPs was 123(SD = 12.7) out of a possible score of 150. Results on all

Table 4 Nurse practitioners’ perceptions of collaboration with physician

colleagues (N = 99)

Perception Range Frequency (%) Mean ± SD

Total scale 83.5 ± 14.41

Assertiveness 38.9

Low 9–23 1 (1.0%)

Intermediate 24–39 51 (51.5%)

High 40–54 47 (47.5%)

Cooperativeness 44.7

Low 10–26 2 (2.07%)

Intermediate 27–42 34 (34.3%)

High 43–60 63 (63.6%)

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M.M. Maylone et al. Collaboration and autonomy

Table 5 Participants’ scores on the Dempster Practice Behavior Scale

(DPBS) (n = 99)

DPBS Range Frequency Percentage Mean ± SD

Total scale 123 ± 12.7

Readiness subscale 45.6

Moderate scores 26–40 19 19.2%

High scores 41–55 80 80.8%

Empowerment subscale 25.6

Low scores 7–16 1 1%

Moderate scores 17–26 58 58.6%

High scores 27–35 40 40.4%

Actualization subscale 40.5

Moderate scores 21–32 4 4%

High scores 33–45 95 96%

Valuation subscale 13.2

Low 3–7 1 1%

Moderate 8–11 14 14.1%

High scores 12–15 84 84.8%

the subscale scores for the DPBS reached the maximum ofthe range (see Table 5) with the majority of respondentsscoring in the high score range for all but the empower-ment subscale.

Pearson product moment correlation coefficient wasused to examine the relationship between collaborationand autonomy. On first examination of the results, a non-significant negative correlation (r = −0.03) was found. Q-Q plots indicated a normal distribution of the sample, butdid indicate extreme outliers. Subsequently the outlierswere eliminated and the Pearson’s r remained nonsignif-icant (r = −0.12).

Other analyses

A significant difference was found (F = 7.75; α = .001)between years as an NP and total autonomy scores. Nosignificant difference (F = 2.15; α = .12) was found be-tween years as an NP and total collaboration scores. Posthoc analysis demonstrated that significance only occurredin those NPs with less than10 years of experience

Discussion

Sample characteristics

Compared to the AANP National NP Sample Survey

(Goolsby, 2005), NPs in this study were alike and pre-dominantly female at 91% versus 95%, slightly youngerwith a mean age of 46 years versus 48 years, respec-tively. In this study, 94% reported race and ethnicityas White, non-Hispanic, while 97% reported as non-Hispanic and 89.4% reported race as White in the AANP

sample. The AANP survey reported race had 2.7% Blackparticipants, while this study had 5% Black participants.Other races reported by the AANP work force samplewere Asian (2.4%), American Indian (1.3%), and Na-tive Hawaiian/Pacific Islander (.03%). This study hadno participants self-described in those categories. Thisis concerning since the racial/ethnic mix of the UnitedStates is projected to continue to change over the nextfew decades (Evans, 2004). In order to be prepared tocare for a diverse population and reduce health dispar-ities, a reflective diversity among the NP workforce isessential.

The majority (84.4%) had master’s level education astheir NP preparation, with 14.4% having a post-master’spreparation as an NP. In contrast, the AANP survey re-ported that 88% of NPs had graduate degrees. Certifi-cation as a family NP (FNP) was most frequent at 57%followed by adult NP (ANP) at 20%, and acute careNP (ACNP) at 16%. This compares slightly higher forcertification to the AANP sample at rates of 36.4% (FNP),19% (ANP), and 4.3% for ACNP. Years worked as anNP had a mean of 7.6 years in this study as comparedto 9 years for the AANP survey. The largest group ofrespondents reported most common practice setting asprivate physician office (35%) followed by hospital in-patient units (21.2%), which were similar to the nationalsurvey with 33% and 22%, respectively.

CPS-APN results

The results of this study indicate that overall, NPs per-ceive collaboration with physician colleagues at moderateto high levels. Collaboration has both high degrees of as-sertiveness and cooperativeness, unlike modes of conflictresolution, where NPs may completely yield to anotherprofessional or may strive to meet their own concerns(Weiss & Davis, 1985). Collaboration integrates mutu-ally compatible solutions with recognition of the concernsof both groups of professionals. In the five mode prefer-ences of conflict resolution measured by the CPS-APN,the majority of NPs (n = 46) preferred the collaborationmode (high assertiveness + high cooperativeness) and 32preferred the compromise mode (intermediate assertive-ness + intermediate cooperativeness). Findings for col-laboration were different from those reported by Alves(2005), who found that certified registered nurse anes-thetists (CRNAs) most frequently used a compromisingmode. The avoidance mode (low assertiveness and co-operativeness) was reported as the next frequently usedcollaboration technique as opposed to the collaborationmode. The differences in the findings may be explainedby the fact that the CRNAs described themselves as partof an anesthesia care team that consisted of a CRNA

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and an anesthesiologist, while the participants of thisstudy reported a variety of practice settings. Alves alsoreported that SOP restrictions potentially played a role inthe CRNAs’ overall ability to collaborate as those practic-ing with more liberal SOPs reported higher collaborationscores.

DPBS results

Four subscales of readiness, empowerment, actualiza-tion, and valuation measured autonomy in NP practice(Dempster, 1990). Total reliability of the original toolwas reported as 0.95 by Dempster and remained reliablewith an alpha of 0.90 in this study. While barriers andconstraints in NP practice were reported by the partic-ipants, a high level of autonomy was indicated in thisstudy. Likewise, the results of each of the subscales in-dicated high levels of autonomy related to mastery, skills,competence, decision making, responsibility, account-ability, self-respect, achievement, and satisfaction. Ulrichet al. (2003) similarly reported that although NPs wereethically concerned about their autonomy in managedcare environments, their actual autonomy scores werehigh.Readiness. Similar to other studies (Kacel et al.,2005), this study revealed NPs have a higher level of con-fidence in their direct patient practice skills, mastery, andknowledge than their skills in the indirect roles of re-search and staff development. Similarly, additional sup-port can be found in the fact that the majority of partic-ipants (80.8%) reported a high perception of readiness,19.2% reported moderate readiness, and 0% reportedlow readiness.Empowerment. The results of this subscale revealedthe majority of NPs perceive that they have a moder-ate level of empowerment (58.6%) compared to highlevels of empowerment in previous studies (Almost &Laschinger, 2002). Among the four subscales, empow-erment was the lowest, which could indicate NPs con-tinue to have restrictions on rights and privileges impact-ing their ability to practice to the fullest extent of theirknowledge and skills as a licensed independent provider.Another indication for the moderate levels of empower-ment among the participants may be the subscale of theDPBS tool. The Cronbach’s alpha for this study was 0.57,which indicates the measurement of empowerment wasnot highly reliable. The lower empowerment score couldalso be indicative of the demographic characteristics ofthe study population. In Almost and Laschinger’s (2002)previous study, acute care NPs represented the majorityof participants. Conversely, FNPs represented the major-ity of participants in the current study. In addition, theDPBS was the last instrument completed in the packet

given to the participants and the empowerment items be-ing reverse scored. Therefore, fatigue could have playeda role in the resulting scores or the reverse scoring couldhave created confusion about how to respond.Actualization. The results of this subscale revealedvery high levels of decision making, responsibility, andaccountability (96%) similar to previously conductedstudies. Adams and Miller (2001) found high levels ofprofessionalism with a positive impact on autonomy.Valuation. Findings from this subscale indicate thesampled NPs have a high level (84.4%) of self-respect,satisfaction, and achievement. These results were contra-dictory to reported levels of satisfaction by Kacel et al.(2005), where NPs (n = 147) were minimally satisfiedto satisfied with their role. The differences could be ex-plained as NPs in this study represented multiple stateswhere in previous studies NPs were from one state.

Relationship between perceptions of collaborationand level of autonomy

Both scores for collaboration (M = 83.53; SD = 14.41)and autonomy (M = 123.07; SD = 12.65) were high, al-though no relationship between the concepts was found.Almost and Laschinger (2002) found a positive relation-ship between work place empowerment and collabora-tion, indicating similar studies exploring autonomy areneeded.

Limitations

The limitations to this study are recognized as a smallsample size (n = 99) and the nature of the participants.NPs motivated to go to a national conference may repre-sent a more highly motivated sample of professionals ascompared to those in the general NP population.

Conclusions

The findings of this study are significant to NPs asthey strive for a collaborative and autonomous profes-sion. Collaboration can be used as a tool to build workingrelationships to provide high-quality care for patients. NPpioneers were committed to developing the autonomousNP role and paved the way for the autonomy reported bytoday’s NPs. In the present study, NPs perceive high as-sertiveness and high cooperation in the relationship withphysician colleagues that could strengthen patient out-comes, increase safety, and efficacy of care.

NPs in this study were found to have high levels ofcollaboration. NPs use intermediate assertiveness and co-operativeness but more frequently use high assertive-ness with high cooperativeness while collaborating with

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physician colleagues. NPs were also found to have highlevels of autonomy as measured by the dimensions ofreadiness, empowerment, actualization, and valuation.The findings of this study indicate that further explo-ration of the concepts of collaboration and autonomy areneeded as relationships were not identified. Further re-search exploring the concepts of collaboration and au-tonomous practice is needed at the local and state levelsto identify barriers and to find effective tools to increasecollaboration and enhance access and provision of careand resources for our patients and their families.

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