The Development of the Attitude Toward Professional Autonomy Scale for Nurses in Japan

Abstract

This study’s aim was to develop and test the psychometric properties of the Attitude toward Professional Autonomy Scale for Nurses in Japan. In Study 1, the initial (26-item) version of the scale was pilot tested on 454 Japanese nurses; item analysis and exploratory factor analysis were performed. In Study 2, the revised version of the scale (19 items) was administered to 802 Japanese nurses. The scale had good internal consistency (α = .85). Correlations with the scale of the desire of self-determination supported its concurrent validity. The scale could facilitate the assessment of cognitive aspects of professional autonomy among nurses and contribute to assessment of the propensity to behave autonomously among nurses in various clinical settings.

Keywords

Attitude toward professional autonomy nurses Japan

Introduction

Autonomy is the core component of professionalism (Asakura, 2015; Friedson, 1970; Tokii, 2010). However, capturing the meaning of the concept of autonomy is difficult. Professional autonomy is characterized as a professional’s right to control the nature and scope of his or her duties and working conditions (Friedson, 1970). In other words, professional autonomy is defined as an individual’s freedom to make decisions within the domain of their profession and to act accordingly (Batey & Lewis, 1982; Varjus, Leino-Kilpi, & Suominen, 2011). Alternatively, professional autonomy is the freedom to practice independently and to exercise professional judgment in practice activities (Thompson, 2012). From a review of the literature, we confirmed that the core features of autonomy are one’s right or freedom to exercise control over one’s activities.

Researchers who have conceptualized autonomy in nursing have not reached agreement about how autonomy should be defined and understood (Varjus et al., 2011). Varjus et al. (2011) noted that the definitions used in previous studies do not specify which components are included in the concept of autonomy or how the concept is operationalized. Thus, professional autonomy has not been defined or measured adequately in the field of nursing (Varjus et al., 2011). However, various definitions of autonomy in nursing have similar elements or attributes. Varjus et al. (2011) found that all of the definitions of autonomy in nursing shared core components, such as ability, independence, control, responsibility, accountability, authority, and one’s own practice. Keenan (1999), who analyzed the concept of autonomy in nursing, concluded that its attributes are independence, capacity for decision making, judgment, knowledge, and self-determination. However, responsibility and accountability are compatible with independence, authority, and individual decision making. Nevertheless, autonomy does not mean that the nurse has total control; rather, the autonomous nurse chooses when control should be exerted or set aside (Weins, 1990). Thus, the rights to make independent decisions and exert control over nursing practice appear to be the core components of autonomy in nursing. Based on this literature review, the present study defined professional autonomy in nursing as the rights to make independent decisions and exert control over nursing practice.

Some previous empirical studies have indicated that it is difficult for Japanese nurses to behave autonomously in the course of their professional duties (Adams & Miller, 2001; Adams, Miller, & Beck, 1996; Yamamoto, 2003). A study of discretion comparing nurses in Japan and in the UK, France, Denmark, China, Singapore, Thailand, and the United States showed that nurses in Japan have limited discretion compared to their counterparts in other countries (Yamamoto, 2003). Studies in several countries have compared Japanese nurses with their United States and Turkish counterparts using the Professionalism in Nursing Behaviors’ Inventory (PNBI) (which has a possible range of 2–27). The following mean PNBI scores were found: 16.7 ± 3.6 for U.S. nurse practitioners (Adams & Miller, 2001), 14.68 ± 4.37 for U.S. nurse executives, 12.06 ± 3.65 for U.S. middle managers (Adams et al., 1996), 7.16 ± 3.48 for Turkish nurses, and 6.74 ± 3.89 for Japanese nurses. The mean score on the PNBI among Japanese nurses was lower than for U.S. and Turkish nurses.

Japanese nurses sometimes make judgments autonomously, but their decisions do not always connect with their behavior in clinical settings (Asakura & Kago, 2013). In these cases, for example, Japanese nurses try to “judge autonomously but they cannot conduct a medical intervention according to their own judgment, they then ask a physician to order them to conduct the intervention” (Asakura & Kago, 2013). Thus, compared to nurses in other countries, Japanese nurses seem to find it difficult to behave autonomously or seem to have conservative attitudes toward autonomy in the physician-dominated context. To enhance their professional and autonomous decision making and behaviors, and in turn to increase the quality of nursing care, it is necessary to foster more liberal attitudes regarding the importance of autonomy in professional nursing practice.

In Japan, nurses are legally not allowed to perform medical interventions without physicians’ orders; hence, nurses tend to find it easier to follow physicians and lose their autonomy. In other words, for nurses in Japan, behaving autonomously depends on the characteristics of the clinical situation they work in or the characteristics of the physician they work with. For instance, when there is a paternalistic physician in clinical settings requiring acute medical care, it is not possible for nurses to behave autonomously. On the other hand, when a physician has a liberal attitude towards delegation of authority to nurses in home care settings, nurses may have greater scope to behave autonomously. However, when nurses have an opportunity to behave autonomously, if their attitude toward professional autonomy is too conservative, they will lose the opportunity. Thus, a more liberal attitude toward professional autonomy for Japanese nurses is essential. This study deals with attitudes, focusing on cognitive aspects of professional nursing autonomy.

Table 1 shows measures of nursing autonomy that have been developed in English and Japanese in previous studies. These scales mostly focus on behavioral aspects of professional autonomy of nursing, and partially deal with cognitive aspects. There are no scales of professional autonomy among nurses focusing only on cognitive aspects of autonomy. Thus, the biggest limitation of previous scales is that they combine behavioral and cognitive aspects without differentiating between them. Translating the scales, which include nurses’ active behaviors developed in other countries, is inadequate for the assessment of professional autonomy in Japanese nurses. Nurses’ behaviors are constrained by the degree of discretion that they are allowed by the law in each country. Because there are large differences in nurses’ discretion between countries, for instance, professional autonomy scales for nurses developed in the United States are not appropriate to assess professional autonomy in Japanese nurses. The scales translated by Kaharu (1990) and Shijiki (1995), shown in Table 1, have this problem.

Table 1.

Scales for nurses’ autonomy developed in English or Japanese.

Citation, Scale used	Language of the scale	Construct or subscale	Number of items	Internal reliability (Cronbach’s alpha)	Scope of the scale	Notes
Pankratz and Pankratz (1974), Nursing Attitude Scale	English	Nursing autonomy and advocacy, Patients’ rights, rejection of traditional role limitations	47	.93	Behavior and cognition	The scale is biased to patients advocacy for nursing autonomy. The extent of discretion stated in items is broader than allowed for Japanese nurses.
Tao (1979), The Measurement of Autonomy	Japanese	The degree of freedom, independence and discretion among nurses when nurses’ schedule is fixed and procedures are determined.	36	.69,–.45	Behavior and cognition	The extent of discretion stated in items is broader than allowed for Japanese nurses.
Shutzenhofer, (1987), Nursing Activity Scale	English	Unknown	30	.92	Activity (behavior)
Kaharu (1995), Nursing Attitude Scale Japanese Revised Version	Japanese	Nursing autonomy and advocacy, Patients’ rights, rejection of traditional role limitations	46	.81	Behavior and cognition	The extent of discretion stated in items is broader than what is allowed for Japanese nurses. Also the scale ignores discretion of nurses in Japan.
Boughn (1995), Autonomy, the Caring Perspective Instrument	English	Regard for self, regard for women, regard for nurses, advocacy and activism for self, advocacy and activism for women, advocacy and activism for nurses, advocacy and activism for patients	50	.84	Emotion, cognition, and behavior	Female model (caring and affiliation) is adopted for the autonomy scale.
Kikuchi and Harada (1997), Professional autonomy in nursing	Japanese	Cognitive ability, practical ability, ability for specific judgment, ability for abstract judgment, ability for autonomous judgment	61	.93, −.79	Cognition of their ability	Measuring autonomy is substituted for measuring ability in the scale. The scale measures nurses’ cognition of clinical ability and does not measure cognition of autonomy.
Hirai et al. (2009), Nursing Activity Scale, Japanese Revised Version	Japanese	Starting and developing new activity as professional nurse. Judgment based on professional sense. Responsibility as professional nurses.	35	.84	Behavior	Items tend to describe specific clinical settings. The scale ignores discretion of nurses in Japan.
Papathanassoglou et al. (2005), Hellenic intensive care nursing autonomy	English	Three major categories: basic technical, advanced technical, clinical decision.	38	.86	Behavior	Items describe specific situations in critical care settings.

Another limitation of professional autonomy scales among nurses developed in the previous research is that they conflate professional autonomy with other domains. Therefore, these scales have conceptual limitations. For example, such scales equate autonomy with other concepts, such as ability. For instance, Kikuchi and Harada (1997), who developed one of the most popular scales of professional autonomy among nurses, regarded professional autonomy as equivalent to clinical ability. Although the clinical ability of nurses might be strongly related to professional autonomy, they are not equivalent. As noted previously, attempts to develop direct measures of nurses’ autonomy have not been successful.

The purpose of this study was to develop the Attitude toward Professional Autonomy Scale for Nurses in Japan. The primary significance of the study is its focus on cognitive aspects of professional autonomy. In this study, we operationally defined attitude toward professional autonomy as the attitude concerning the permissibility of nurses’ autonomous functioning as professionals. This attitude ranges along a liberal-conservative axis. Because of the limitations in Japanese nurses’ discretion, whether or not they are able to make a decision and then behave autonomously depends on the context, as mentioned previously. Hence, objectively monitoring behavioral aspects of nurses’ autonomy in Japan is difficult. In the items of the scale, we expressed attitude toward professional autonomy in terms of “desire” and how “desirable” is the permissibility of nurses’ autonomous functioning. If nurses in Japan have liberal attitudes toward professional autonomy, this would be equivalent to desiring to behave autonomously as a professional.

According to social-psychological perspectives, an attitude is a predisposition to react in a specific way to a certain stimulus (Rosenberg & Hovland, 1960). The varieties of reactions are classified as emotional, cognitive, and behavioral in the three-component model (Rosenberg & Hovland, 1960). In this model, attitude is considered as a hypothetical construct that mediates between an antecedent stimulus and a subsequent behavior (Hewstone, Stroebe, Codol, & Stephenson, 1988; Nolen-Hoeksema, Fredrickson, Atkinson, Loftus, & Lutz, 2014). Alternatively, cognitive aspects of attitudes are related to beliefs and values about a topic (Lam et al., 2014) that is based on one’s intention to behave. In this study, we intended to measure the cognitive aspects of professional autonomy that are related to beliefs and values concerning professional autonomy.

To further understanding of how the desire for professional autonomy may affect nurses’ performance, one must understand how the attitude toward professional autonomy differs from other related constructs. For example, it is important to distinguish between the attitude toward professional autonomy and clinical ability, competency, or discretion. The constructs of clinical ability or competency essentially include other aspects excluded from professional autonomy, like aptitude, skill, or role performance (e.g., Akamine, Uza, Shinjo, & Nakamori, 2013; Takase & Teraoka, 2011). Discretion depends on a context in medical settings where nurses work, so that it is difficult to measure individual nurse’s professional autonomy by questioning their discretion with scale items.

This research was divided into two studies. The purpose of Study 1 was to generate scale items and to conduct a pilot test of the scale on a sample of nurses in Japan. The purpose of Study 2 was to test the revised scale’s psychometric properties on a second sample of Japanese nurses and to examine its concurrent validity with an established measure related to autonomy.

Study 1

Method

Approval for Studies 1 and 2 was obtained from the ethics committee of the Tohoku University Graduate School of Medicine. Official permission was obtained from the hospitals in which the participants worked. The ethical issues concerned the participants’ confidentiality and anonymity during the study period and publication process. The participants were informed of the study’s purpose and design, and the voluntary nature of their participation. Final agreement to participate in this study was certified by individual participants returning the questionnaire.

Item generation

We reviewed the relevant literature on professional autonomy among nurses and discussed it deeply in order to develop items. Meetings were held once a week for three months regularly and the authors who were all PhD members of nursing faculties, were registered nurses, and had experience in developing psychometric scales were included. For the literature review, we reviewed empirical and theoretical literature in English and Japanese using the keywords “autonomy” and “nurses” in social science fields including nursing. Through this review and discussion, we agreed on three dimensions and developed a 26-item scale in Japanese: (1) autonomous clinical judgments (11 items: e g., “I desire to practice nursing according to my own judgment.”), (2) job-related independence (6 items: e.g., “I think that practicing independently in the community is desirable for nurses.”), and (3) control over working conditions (9 items: e.g., “I think that deciding by myself when I take night duty is desirable.”). The items were worded in such a way that they could apply to different organizational contexts. Responses were rated on a five-point Likert-type scale, ranging from 1 (Strongly disagree) to 5 (Strongly agree). “Strongly agree” indicated the most liberal attitude toward professional autonomy for nurses, and “strongly disagree” indicated the most conservative attitude. The instructions of the scale read, “How much do the items match your thoughts? Please choose any number from 1 (Strongly disagree) to 5 (Strongly agree).” We asked 10 Japanese nurses with Master’s or Doctoral degrees, or who had knowledge of the methodology for scale development and the concept of professional autonomy, to check the draft version for any problems with any of the items.

Sample and procedure

The scale was administered in 2012 to a convenience sample of 780 nurses working in a university hospital located in the eastern region of Japan. At the beginning of the study, we selected all registered nurses in the hospital, which has a total of 900 nurses. Then we omitted assistant nurses and nurses who were on maternity, childcare, or sick leave. This reduced the sample to 780 nurses. The questionnaire took approximately 15 minutes to complete, and participants’ anonymity was preserved. The nurses were instructed to complete the questionnaire and put it in a designated box. The questionnaires were then returned to the investigator.

Of the 454 questionnaires that were returned, 37 were not completed, and therefore, were excluded from the final sample, which consisted of 417 participants. Of the 417 nurses who completed the questionnaire, 55.2% (n = 230) were 20–29 years old (M = 31.9), 93.8% (n = 391) were female, 67.9% (n = 283) were single, and 46.3% (n = 193) had vocational school (three years) or junior college education (three years) for registered nurses (Table 2). We categorized vocational school (three years) and junior college education into the same educational group because vocational school (three years) and junior college both require three years of education and have the same curriculum in the Japanese nursing educational system.

Table 2.

Characteristics of the participants in Study 2 (n = 417).

Variable	n	%
Age
Under 29 years	230	55.2
30–39 years	97	23.3
40–49 years	57	13.7
50–59 years	29	7
≥60 years	4	1
Average age	31.94 (± 9.94, 20–63)
Sex
Male	26	6.2
Female	391	93.8
Marital status
Single	283	67.9
Married	125	30
Other	9	2.2
Educational background
Vocational school for nurses’ assistants followed by vocational school for registered nurses (two years)	43	10.3
Vocational school or junior college for registered nurses (three years)	193	46.3
Baccalaureate in nursing program (four years)	166	39.8
Master’s program in nursing	14	3.3
Other	1	0

Analysis

We checked for outliers and performed an item analysis to examine the items’ skewness, kurtosis, and distributions. We conducted the Kaiser-Meyer-Olkin test, Bartlett’s test of sphericity, and an exploratory factor analysis (maximum-likelihood estimation with Promax rotation) to identify meaningful factors. Then we computed the reliability coefficients for the overall measure and its subscales. Data analyses were performed using SPSS version 21.

Results

Descriptive statistics of scale items

The mean and standard deviation (SD) of the 26 questions on the Attitude toward Professional Autonomy Scale ranged from 2.6 (SD = 1.1) to 4.5 (SD = 0.6). The skewness and kurtosis values are shown in Table 3. Ceiling effects were found on Q6 and Q18. The correlation coefficients of the item-total correlation analysis ranged from .3 to .6, indicating that the score for each item was positively correlated with the total score. We excluded Q6 and Q18 based on ceiling effects.

Table 3.

Descriptive statistics for items in Study 1.

	M	SD	Skewness	Kurtosis
Item 1	4.00	0.84	−0.73	−0.70
Item 2	3.98	0.85	−0.70	−0.30
Item 3	4.11	0.80	−0.72	0.36
Item 4	3.58	0.97	−0.41	−0.11
Item 5	3.78	0.80	−0.16	−0.49
Item 6	4.47	0.55	−0.43	−0.35
Item 7	3.77	0.78	−0.27	−0.10
Item 8	3.61	0.87	−0.10	−0.45
Item 9	3.29	1.02	−0.02	−0.60
Item 10	2.71	1.15	0.48	−0.54
Item 11	3.06	1.20	0.09	−1.10
Item 12	3.65	0.90	−0.50	0.27
Item 13	3.97	0.78	−0.86	1.34
Item 14	4.31	0.76	−1.08	1.36
Item 15	3.84	0.96	−0.59	−0.14
Item 16	3.35	1.03	−0.04	−0.43
Item 17	3.88	0.96	−0.58	−0.27
Item 18	4.39	0.61	−0.59	0.10
Item 19	3.54	0.83	−0.08	−0.27
Item 20	2.64	1.11	0.25	−0.63
Item 21	2.55	1.00	0.29	−0.19
Item 22	3.04	1.07	−0.09	−0.60
Item 23	3.43	1.04	−0.51	−0.20
Item 24	3.56	1.03	−0.49	−0.29
Item 25	4.10	0.89	−1.03	1.11
Item 26	3.15	1.03	−0.04	−0.43

Exploratory factor analysis

The Kaiser-Meyer-Olkin test was 0.82, and Bartlett’s test was p < .001 (χ²= 3685.36, df = 276). Thus, this sample data were adequate for the use of factor analysis.

Exploratory factor analysis was performed on the 24 items (Table 4). The eigenvalues of the factors are as follows: Factor 1 = 6.06, Factor 2 = 2.97, Factor 3 = 1.79, Factor 4 = 1.53, Factor 5 = 1.12, Factor 6 = 1.02, Factor 7 = 0.92. The results indicated that a solution with six factors was possible. However, examination of the scree plot showed that a solution with three factors was also possible. Additionally, Factors 1, 2, and 3 accounted for 45% of the total variance. Consequently, we decided to perform a rotation with three factors because we thought this would provide a better solution.

Table 4.

Factor pattern matrix of exploratory factor analysis for 24 items.

	Item-total correlation	Factor 1	Factor 2	Factor 3	Communality
Item 23 (I think that practicing independently in the community is desirable for nurses)	.58	.87	−.02	−.01	.74
Item 22 (I think that becoming a director of a healthcare facility is desirable for nurses)	.60	.82	−.00	.08	.70
Item 24 (I think that it is desirable for nurses to independently manage clinics for primary care nursing)	.55	.74	.08	−.05	.60
Item 20 (I think that it is desirable for nurses to be allowed to have their own practice)	.49	.67	−.01	.04	.46
Item 21 (I think that practicing nursing without a medical doctors’ supervision is desirable)	.53	.48	.16	.12	.37
Item 25 (I think that increasing medical treatment fees for nursing interventions is desirable)	.57	.34	.31	.11	.36
Item 7 (I desire to practice nursing according to my own judgment)	.50	.01	.70	−.04	.47
Item 8 (I desire to decide how to care for patients according to my own judgment as a nurse)	.48	.04	.63	−.03	.42
Item 13 (I desire to decide how to arrange my duties independently while also considering the patient’s condition)	.42	−.22	.62	.22	.41
Item 4 (I think that it is desirable for nurses to make their own judgments without depending on a doctor)	.34	.08	.50	−.17	.27
Item 12 (I think that it is desirable for nurses to arrange their duties by themselves)	.41	−.16	.49	.28	.33
Item 19 (I think that expanding nurses’ scope of work is desirable)	.50	.17	.47	−.01	.33
Item 5 (I think that it is desirable for nurses to judge which professional should care for patients)	.36	.11	.45	−.11	.24
Item 2 (I desire to voice my opinion to medical doctors when I have a different opinion from them)	.48	.23	.40	−.04	.30
Item 3 (I desire to be able to voice my own opinion with the doctor when opinions differ)	.38	.14	.37	−.03	.20
Item 1 (I think that reflecting nurses’ judgment in the treatment policies of doctors is desirable)	.36	.19	.28	−.02	.17
Item 26 (I think that it is desirable for nurses to diagnose death and take responsibility for dealing with it)	.39	.24	.26	.02	.20
Item 16 (I think that deciding by myself when I will take night duty is desirable)	.42	.05	−.13	.88	.72
Item 15 (I think that deciding by myself when I will take a day off is desirable)	.34	−.09	−.05	.79	.60
Item 9 (I think that deciding my work shift by myself is desirable)	.40	−.00	.03	.67	.46
Item 17 (I think that working in my preferred duty zone is desirable)	.43	.13	.01	.53	.33
Item 10 (I think that it is desirable for nurses to select their own work clothing)	.39	.13	−.01	.47	.26
Item 11 (I think that it is desirable for nurses to wear any hair style they like during work as long as it does not interfere with their duties)	.30	.15	−.12	.44	.21
Item 14 (I desire to decide by myself whether to join a nursing research project)	.25	−.12	.18	.31	.14
Correlations between the factors
		Factor 1	Factor 2	Factor 3
Factor 1		–	.50	.18
Factor 2		–	–	.32

Maximum-likelihood estimation was used, along with Promax rotation. As Q1, Q3, Q14, Q25, and Q26 had factor loadings ≤ 4, we excluded these items, leaving 19 items belonging to the three factors that were extracted, each of which had an eigenvalue greater than 1.0. The variance accounted for by these factors was 25.9%, 12.2%, and 7.5%, respectively. These factors accounted for 45.6% of the overall variance between the items. It was determined that the three-factor model was the most interpretable model.

The three extracted factors were named based on their content: Factor 1, “job-related independence” (5 items); Factor 2, “autonomous clinical judgment” (8 items); and Factor 3, “control over work conditions” (6 items) (Table 4).

Examination of the scale’s reliability

Cronbach’s alpha coefficient for the total scale was .85. The alphas for Factors 1, 2, and 3 were .86, .77, and .80, respectively.

Study 2

Method

Sample and procedure

The Attitude toward Professional Autonomy Scale for Nurses and the Desire for Self-determination Scale (Sakurai, 1993) were administered in 2013 to a convenience sample of 1000 nurses working in a university hospital located in the eastern region of Japan. The hospital was different from that selected in Study 1. At the beginning of the study, we selected all registered nurses in the hospital, a total of 1100 nurses. Then we deleted assistant nurses and nurses who were on maternity, childcare, or sick leave. This reduced the sample to 1000 nurses. The questionnaire took approximately 15 minutes to complete, and participants’ anonymity was protected. The nurses were instructed to complete the questionnaire and put it in a designated box. The questionnaires were then returned to the investigator. Final agreement to participate in this study was certified by individual participants returning the questionnaire.

Measure to test concurrent validity

One of the subscales of the Scale of Self-determination and Competence, the Desire for Self-determination, developed by Sakurai (1993), was used as an external criterion to test the concurrent validity of the Attitude toward Professional Autonomy Scale for Nurses. The Scale of Self-determination and Competence is constructed with four subscales: the perception of competence, the desire for competence, the perception of having self-determination, and the desire for self-determination. Self-determination and Competence are theoretically derived from the concept of intrinsic motivation. Although it is expected that liberal attitudes towards autonomy will be moderately correlated with self-determination, because they are theoretically related, they are still different constructs. Therefore, the desire for self-determination would be positively correlated with attitude toward professional autonomy. The subscale of the desire for self-determination is a one-dimensional nine-item scale. Items are rated from 1 to 6, where higher scores show a greater need for self-determination and competence. The mean of the scale was 34.26 (SD = 3.36). Sakurai (1993) reported adequate internal consistency (Cronbach’s alpha = .75). The construct validity of the scale was supported by correlations with the need for achievement subscale (r = .29, p < .01) and need for autonomy subscale (r = .50, p < .01) of the Japanese version of the Edwards Personal Preference Scale.

Analysis

We checked for outliers and analyzed the skewness, kurtosis, and distributions of the items. Then we conducted confirmatory factor analysis for the Attitude toward Professional Autonomy Scale for Nurses to test its factorial validity. We computed the reliability coefficients for the overall scale and its subscales. We also calculated the correlations between the Attitude toward Professional Autonomy Scale for Nurses and the Scale for Self-determination and Competence. Data analyses were performed using SPSS Version 21 and Amos Version 21.

Descriptive statistics of scale items

The mean and standard deviation (SD) for the 19 questions on the Attitude toward Professional Autonomy Scale ranged from 2.6 (SD = 1.0) to 3.9 (SD = 0.7). The skewness and kurtosis values of the items were not greatly different from those in Study 1. Ceiling effects were not found for any of the items. The item-total correlations ranged from .20 to .53. We did not exclude any item from the scale based on these results.

Results

Descriptive statistics of scale items

Of the 802 questionnaires that were returned, 61 were not completed, and therefore, were excluded from the final sample, consisting of 741 participants. Of the 741 nurses who completed the questionnaire, 50.3% (n = 373) were 20–29 years old (M = 32.9), 94.1% (n = 697) were female, 69.0% (n = 511) were single, and 48.0% (n = 356) had a vocational school or junior college education (three years) for registered nurses (Table 5).

Table 5.

Characteristics of participants in Study 2 (n = 741).

Variable	n	%
Age
Under 29 years	373	50.3
30–39 years	192	25.9
40–49 years	104	14
50–59 years	70	9.4
≥60 years	2	0.2
Average	32.94 (±9.89, 20–60)
Sex
Male	44	5.9
Female	697	94.1
Marital status
Single	511	69
Married	223	30.1
Others	7	0.9
Educational background
Vocational school for assistant nurse training then vocational school for registered nurses for two years	51	6.9
Vocational school or junior college for registered nurses for three years	356	48
Baccalaureate program (four-year program in nursing)	315	42.5
Master’s program in nursing	19	2.5
Other	0	0

Confirmatory factor analysis of the conceptual model

First-order confirmatory factor analysis was performed on the three-factor, 19-item scale to validate the conceptual model. The model’s fitness indexes (comparative fit index (CFI) = .91, root mean square error of approximation (RMSEA) = .07, goodness of fit index (GFI) = .92, and adjusted goodness of fit index (AGFI) = .89) indicated a possibility that the model could be improved. The modification indexes indicated that the model could be improved if Q19 was deleted. In addition, the content of Q19 was different from that of other items in the factor. Then we conducted first-order confirmatory factor analysis again on the three-factor, 18-item scale, excluding Q19, to validate the conceptual model (Table 6). The indices of the model’s fit were more satisfactory (CFI = .90, RMSEA = .06, GFI = .93, and AGFI = .91).

Table 6.

The results of confirmatory factor analysis on cognitive professional autonomy among nurses.

	Factor loading	Covariance	Fitness index
Factor 1
Item 16	.88
Item 15	.75
Item 9	.73
Item 17	.78
Item 10	.48
Item 11	.41
Factor 2
Item 23	.83
Item 24	.82
Item 22	.77
Item 20	.61
Item 21	.49
Factor 3
Item 7	.74
Item 8	.66
Item 5	.62
Item 4	.53
Item 13	.42
Item 2	.40
Item 12	.32
Factor 1-Factor 2		.27
Factor 2-Factor 3		.47
Factor 1-Factor 3		.21
CFI			.90
RMSEA			.60
GFI			.93
AGFI			.91

CFI: comparative fit index; RMSEA: root mean square error of approximation; GFI: goodness of fit index; AGFI: adjusted goodness of fit index.

Examination of the scale’s reliability and concurrent validity

Cronbach’s alpha coefficient was used to evaluate the scale’s internal consistency. Cronbach’s alpha coefficient for the entire scale was .85. The alphas for Factors 1, 2, and 3 were .83, .83, and .74, respectively.

The Attitude toward Professional Autonomy for Nurses total scale had a weak, positive correlation with the Desire for Self-determination Scale, r = .33, p < .001. The three factor scales of the Attitude toward Professional Autonomy for Nurses also had weak positive correlations with the Desire for Self-determination Scale: Factor 1 (control over work conditions), r = .14, p < .01; Factor 2 (job-related independence), r = .25, p < .01; and Factor 3 (autonomous clinical judgment), r = .36, p < .01.

General discussion

Study 1 revealed three factors that were presumed theoretically in advance, and showed that the total scale and each subscale had good internal consistency. Study 2 confirmed the revised scale’s factor structure, verified its concurrent validity, and showed that its internal consistency was good. The results indicate that the Attitude toward Professional Autonomy Scale for Nurses may be a reliable and valid tool for measuring cognitive aspects of professional autonomy in the Japanese nursing population. The concurrent validity of the scale was confirmed for the most part: the “job-related independence” and “control over work conditions” subscales had significant but weak correlations with the Desire for Self-determination Scale, while the “autonomous clinical judgment” subscale had a significant but moderate correlation with this scale.

Although cognitive aspects of professional autonomy and desire for determination are conceptually related, they are still distinct constructs. Hence, only a moderate, rather than a strong correlation between them would be expected. If the correlations between the scale and the external criteria were very strong, the development of the scale would not have been considered successful because the scale and the external criterion would measure an almost identical construct. Thus, the present study’s results suggest that the Attitude toward Professional Autonomy Scale for Nurses has reasonable concurrent validity, although the correlation between one of the subscales and the external criterion was quite weak. The relationships among the decision-making items of the “control over work conditions” subscale may differ from those of the “job-related independence” or “autonomous clinical judgment” subscales. This may occur because “control over work conditions” includes making independent decisions about schedules for shift work and uniforms, which are basic rights of all workers, not only of professional workers. In Japan, most nurses have no authority to make decisions about their work schedules or attire (uniforms are common). Thus, providing Japanese nurses discretion in making choices about their working conditions could liberate them from the bureaucratic system, which hinders their professional development.

The three factors that were confirmed in the present study are original constructs that may be needed to develop professional autonomy among nurses. Specifically, one of the original concepts in this study is that the factors should capture elements of autonomy that were ignored in previous studies, such as whether Japanese nurses can act autonomously or not (Kaharu, 1990; Shijiki, 1995). Another original concept in this study is that the factors should address the domains where Japanese nurses can exert their autonomy. Thus, the Attitude toward Professional Autonomy Scale for Nurses has the potential to measure the degree of nurses’ intentions to control their situation. The scales of nursing autonomy used in previous studies tended to focus on whether nurses were permitted to initiate new nursing activities and new medical interventions independently (e.g., Hirai et al., 2009; Kaharu, 1990). However, the discretion of nurses in Japan is limited compared to that of nurses in other countries, especially the United States (Hanada & Yamamoto, 2003). Hence, nurses in Japan face severe obstacles to initiating necessary and often, lifesaving interventions by themselves.

The development of the Attitude toward Professional Autonomy Scale for Nurses is important because of the paucity of instruments that adequately measure adherence to the principles of autonomy. The scale has several advantages. It is relatively short and easy to administer, and it has adequate internal consistency. It may be used in a wide range of situations where autonomy among nurses is a matter of concern. As a result, the scale could facilitate the assessment of cognitive aspects of professional autonomy among nurses and contribute to the assessment of tendencies to behave autonomously among nurses in the various clinical settings. Because cognitive professional autonomy is an essential prerequisite for nursing practice, it might be useful as an independent or dependent variable for researchers investigating this concept.

Limitations and conclusions

The present study has several limitations. The design and methodology involved convenience samples and a cross-sectional design. Therefore, we were unable to confirm the scale’s generalizability to all Japanese nurses. The analysis did not use other variables related to professionalism in order to test the instrument’s concurrent validity, such as an objective evaluation of clinical ability or autonomous behavior.

In conclusion, the psychometric properties of the Attitude toward Professional Autonomy Scale for Nurses indicate that it may be a valid and reliable scale for measuring autonomy among Japanese nurses. Future studies using randomized samples and longitudinal designs to test repeatability and other aspects of its validity are needed to thoroughly evaluate this measure.

Footnotes

Acknowledgment

The authors thank the nurses who participated in this study.

Article Notes

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