158 J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 158–163 Original Barriers of Professional Autonomy among Arab-Speaking Countries during Covid-19 Pandemic Zahra Abbas Abdulnabi1,* and Sadeq AL-Fayyadh2 1Department of Adult Nursing, College of Nursing, University of Basrah, Basrah, Iraq. 2Chairman, Department of the Adult Nursing, College of Nursing, University of Baghdad, Baghdad, Iraq. Corresponding Author: Zahra Abbas Abdulnabi (E-mail: zahraa.abbas1202a@conursing.uobaghdad.edu.iq) (Submitted: 05 April 2021 – Revised version received: 18 April 2021 – Accepted: 22 May 2021 – Published online: 26 June 2021) Introduction Independence in decision-making is synonymous with clinical autonomy. Clinical autonomy is defined as the right of nurses to conduct clinical decisions and professional judgment on the basis of their own clinical competence to support the wide spectrum of nursing practices, as distinguished by law enforce- ment agencies, guidelines, and moral values.1 Understanding the idea of clinical decision-making practice in healthcare settings gives vision into clinical decision- making practice and gives t h e nurses an opportunity to choose the best options for problem-solving and to develop the best care plan to evalu a te and select nursing interven- tions. Clinical educators f a ced challenges to find out how best to develop nurses’ cap a bilities in clinical decision-making.2–4 Globally, 19 million nurses are using clinical judgment before decision-making. 11% of the patients in the United Kingdom are suffering from complication due drugs abuse. 34% of these situations that are critical, 6% lead to lifelong dis- abilities and 8% of patients die. Half of these incidences are avoidable. In absolute terms, healthcare spends 1 billion every year on avoidable incidents. Similarly, in Canada, with 7.5% of patients experience complications in hospital, 36.9% of these refereed as avoidable and 20.8% leading to premature death. Therefore, significant factors behind these statistics are clinical decisions making and professional judgment of health care practitioners, especially by nurses.5 Autonomy in clinical decision-making increasing the nurse’s responsibility. Nurses who have high level of autonomy provide the best level of care to patients to save their lives and protect them, and this leads to enhanced patient outcomes.6–8 In critical care units, the role of nursing is significant, because it varies from other hospital settings. In such chal- lenging settings nurses deal with perplexing and life-threat- ening conditions, aiming for achieving high quality care.9, 10 Nurses who work in critical care units and emergency depart- ment spend a lot of time with the patient and monitor changes in health status, so the decision of the nurses actually affects the survival of the patient and decides the potential quality of life. For a nurse to practice clinical roles, the standard of deci- sion-making is necessary and is affected by the nature of the surrounding environment.11–13 Barriers to nursing autonomy, include however not lim- ited to the fact that the nursing profession has previously depended on the medical profession because of the domina- tion of the health care system by the physician, the disparity between male and female influence, and the style of top-down management. These factors are coupled with the lack of finan- cial, governmental, social and cultural organizational support. In addition, nurses’ schooling, regulation, organizational cul- ture, and work-related socialization, which varies across nations, may have an enormous impact on the perception of professional autonomy of nurses, their motivation and ability to achieve professional autonomy in different nursing prac- tices settings; such as critical care, emergency, and traditional care arenas.14–16 The current study is the first that covers many Arabic countries. This study will contribute to development of nursing autonomy in clinical decision-making in critical care units, emergency and medical surgical departments, not only in Iraq but also in Arab countries and worldwide. This autonomy is Abstract Objectives The aims of the study are to determine barriers of nursing autonomy among Arab-Speaking countries during Covid-19 pandemic and to determine difference in professional autonomy levels among Arab-Speaking countries and work place. Methods Data collected from December 12 2020 to March 15 2021 by Google form survey. Cross-sectional design was used in the present study. A purposive sample of 708 nurses who had met the study’s inclusion criteria were targeted. Data were analyzed through the use of IBM-Statistical Package for Social Sciences (SPSS) version 17, in which descriptive and inferential statistical measures were employed. Results The results of the study showed no deference in professional autonomy among Arab speaking countries P = 0.826 and work place (P = 0.826). Most common barriers of professional autonomy are absence of law protecting professional duties (35.6%) which was perceived by of the study subjects, followed by the policy of health (30.4%), followed by hospital administration style (26.4%) and domination or physicians authority (29.9%). Conclusion Most common barriers of professional autonomy are absence of law protecting professional duties, the policy of health care sector, domination of physician’s authority and hospital administration style. This result reflects highlights the importance of removing all obstacles to upgrade nurse’s professional autonomy in the covered Arab-speaking counties. Keyword Professional Autonomy, Nursing, Nurses, COVID-19, Arabs ISSN 2413-0516 159J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 158–163 Z. A. Abdulnabi and S. AL-Fayyadh Original Barriers of professional autonomy among Arab-speaking countries during covid-19 pandemic considered important to nursing becoming completely inde- pendent professional. Materials and Methods Ethical consideration The researchers pledge to keep the details of the participants privately, using the collected data without causing any possible harm to the study subjects. The study tool was designed to pre- serve the right of subject’s anonymity. Subjects were given the right to freely participate in the study by signing the electronic consent form of the study. Design and setting of study Cross-sectional design .The study was conducted virtually tar- geting Arab-speaking nurses who were practicing in critical care units, emergency and medical surgical departments. Beside Iraq, the covered countries were the Hashemite Kingdom of Jordan, Egypt, Palestine and Kingdom of Saudi Arabia. Instrument of study Study instrument consist of two part, first part consist of socio-demographic and professional characteristic, second part consist of Nursing Activity Scale (NAS) which contains 30 items, that explains conditions in which a degree of profes- sional nursing autonomy must be exercised by a nurse. Statistical analysis Data were entered into the IBM-Statistical Package for the Social Sciences (SPSS) version 17 software program and ana- lyzed using descriptive and inferential statistics. Results and Discussion The findings in Table 1 showed that the majority of study par- ticipants age group was 26–31 years representing (39.4%) of the study sample. This result is supported by Maharmeh17 a descriptive correlational design aimed to describe Jordanian critical care nurses experience of autonomy in their clinical practice, which indicated that (62%) of sample were in age group of 22–30 years. Another study was done by Keshk et al.,18 found in their study that the highest percent of study partici- pant (50%) within age group (26–34). Data were collected by using Google form survey whereas young individuals were the most common persons who responded. These result agreed with other study, which showed that young individuals are spending a significant amount of their time using social media.19 Regarding to level of education, findings of the study indi- cated that more than half of study sample were holding Bach- elor’s degree (57.6%). Another study conducted among nurses in the southeast of Iran, found that most of nurses were holding Bachelor’s degree (97%) too.20 Another study con- ducted in Intensive Care Unit (ICU) of Islamic republic of Iran, showed that more than half (85%) of nurses who were participants in the study were holding Bachelor’s degree.21 In the present study (55.4%) of study sample were male. Another study indicated that the highest percentage of study respondents were male (54.2%).22 Furthermore, the chal- lenging nature of nursing profession has hindered females from joining nursing, which created a critical imbalance as shown in Iraqi Nursing Syndicate (INS)’s statistics as male:fe- male nurse ratio is 75:25.23 This ratio was reflected by the descriptive statistics of sample demographics, which were, more male nurses (55.4%) participated in this study than females (44.6%). The study findings showed that most study sample (68.1%) were from Iraq due to the fact that this research was conducted in Iraq and Iraqi nurses were the most respon- sive subjects to the online questionnaire than other Arab- speaking countries. According to Table 2 that is related to professional charac- teristics, represents highest percent of study participants (75.4%) were working in governmental sector. Another study was conducted to examining the level of professional autonomy as well as its predictor and outcomes among practicing nurses in the Phillippins, found that (73.5%) of study participants were working in public sector.24 These results were not sur- prising due to the fact that Arab-speaking countries health sector is public service sector, unlike Western countries, where the majority are capital institutions. About working place, the majority of the study sample were working in critical care units (37.7%). In contrast, Amini et al.,25 nurses’ autonomy level in teaching hospitals and its relationship with the underlying factors showed that more than half of their study samples (49.2%) were working in Table 1. Frequencies and percentages of socio-demographic characteristics of study participants. (N708) Co un tr ie s Characteristics F Percent Valid % Iraq 482 68.1 68.1 Egypt 113 16.0 16.0 Jordon 39 5.5 5.5 KSA 39 5.5 5.5 Palestine 35 4.9 4.9 Ge nd er Male 392 55.4 55.4 Female 316 44.6 44.6 Ag e/ Ye ar s 20 – 25 224 31.6 31.6 26 – 31 279 39.4 39.4 32 – 37 116 16.4 16.4 38 – 44 71 10.0 10.0 45 – 51 16 2.3 2.3 52 – 58 2 0.3 0.3 Ed uc at io na l at ta in m en t Diploma in Nursing 190 26.8 26.8 Bachelor’s in nursing 408 57.6 57.6 Master in nursing 102 14.4 14.4 Doctorate in nursing 8 1.1 1.1 Total 708 100.0 100.0 The underlined numbers in Table 1, represent the highest percentag- es of the selected variables. In which, more than half (55.4 %) of the study sample were males. More than quarters (39.4%) of the study sample were classified as adult individuals within age range of 26 – 31 years. Furthermore, most of them (57.6%) were holding Bachelor’s degree. Concerning the nurses’ country, the highest percentage (68.1%) of the study participants were from Iraq. 160 J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 158–163 Barriers of professional autonomy among Arab-speaking countries during covid-19 pandemic Original Z. A. Abdulnabi and S. AL-Fayyadh Table 2. Frequencies and Percentages of Professional Characteristics Professional Characteristics F % Working sector Governmental Sector 534 75.4 Private Sector 74 10.5 Both Sectors 100 14.1 Working place Emergency Department 215 30.4 Medical Department 110 15.5 Surgical Department 107 15.1 Critical Care Units 267 37.7 Burns Care Department 9 1.3 Years of Experience in Hospital 1 - 5 Years 429 60.6 6 - 10 Years 155 21.9 11 - 15 Years 67 9.5 16 - 20 Years 42 5.9 21 - 25 Years 12 1.7 26 - 30 Years 3 .4 Years of Experience in Recent Unit 1 - 5 Years 520 73.4 6 - 10 Years 133 18.8 11 - 15 Years 30 4.2 16 - 20 Years 17 2.4 21 - 25 Years 7 1.0 26 - 30 Years 1 .1 Working Shift Morning Shift 453 64.0 Evening Shift 255 36.0 Professional Roles Nurse Executing an Administrative Role 166 23.4 Bedside Nurse 542 76.6 Experience development Yes 680 96.0 No 28 4.0 Source of Knowledge Social Media Platforms 146 20.6 Scientific Websites 43 6.1 Audiovisual media 12 1.7 Books & scientific journals 89 12.6 Professional colleagues 59 8.3 All of the Above 330 46.6 Not Apply to me 29 4.1 Participation in training program of professional autonomy Yes 350 49.4 No 358 50.6 No. of Beds in Unit 1 – 5 156 22.0 5 – 10 217 30.6 >10 beds 335 47.3 No. of the patient in work shift one Patients 49 6.9 Two Patients 105 14.8 >3 patients 554 78.2 Table 2. Frequencies and Percentages of Professional Characteristics Professional Characteristics F % No. of nurses in work shift 1 - 5 Nurses 427 60.3 5 - 10 Nurses 190 26.8 > 10 nurses 91 12.9 Having Nursing Association Yes 372 52.5 No 181 25.6 Not Sure 155 21.9 Nursing Association Membership Yes 178 25.1 No 366 51.7 Not Apply to me 164 23.2 Have Job Description Yes 360 50.8 No 348 49.2 Applying Job Description Yes 247 34.9 No 297 41.9 Not Apply to me 164 23.2 Awareness of Job Description Yes 550 77.7 No 158 22.3 Professional Autonomy in Curriculum Yes 484 68.4 No 224 31.6 Total 708 100.0 The underlined numbers in Table 2, represent the highest percentag- es of the selected variables. In which, the majority of the respondents were working in governmental sector (75.4%) at the time of data collection. About (37.7%) were practicing nursing in critical care units. Furthermore, most of them were working in morning shift (64.0%). 1–5 years’ experience in recent unit was the dominant choice of the study subjects, representing (73.4%). Most nurses were employed as bedside nurses (76.6%). The highest percentage of subject’s experi- ence in the hospital was spotted as (6-10 years) representing (60.6%). Of equal importance, (96.0%) of study participants were actively working on developing their professional autonomy experience. Social media (20.6%), books and scientific journals (12.6%) were the most common sources of knowledge, by which nurses were working to develop their competencies about professional autonomy. More than half (50.6%) of the study respondents were not previously par- ticipated in training programs of professional autonomy. The highest percentages of the served bed in the targeted units were more than ten, representing (47.3%). On the other hand, the highest percentage (78.2%), representing the number of the patient in work shift, which is more than three for each nurse. About (60.3%), representing 1-5 nurses, was the highest percentage of nurse’s number during work shift. The majority of respondents indicated having an active nursing association membership (51.7%), and (50.8%) indicated having a job description. However, only (41.9%) of them were able to apply job description. About three quarters of the study sample (77.7%) indicated having job description awareness. Surprisingly, only (68.4%) of respondents reported that professional autonomy was covered during their academic preparation curriculum. non-critical care units. The findings of this study have indi- cated that the majority of study sample were practicing in critical care units due to the fact that data collection phase was conducted during Covid-19 pandemic, in which most units in the hospital were transformed to be critical care units to accommodate the increasing numbers of patient. Concerning working shift, most of study subjects were work during morning shift (64.0%). Another study conducted (Continued) 161J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 158–163 Z. A. Abdulnabi and S. AL-Fayyadh Original Barriers of professional autonomy among Arab-speaking countries during covid-19 pandemic to assess nurse’s work autonomy on patient care and unit oper- ation which stated that (59.8%) of sample were working in day shift.26 This result is not surprising due to the fact that the number of the nurses who work in morning shift is more than night shift. This can be explained by the fact that most nurses preferred working in morning more than night shift, due to administrative and duties nature factors. Morning shift pro- vide opportunities for sleeping, learning and developing team- work skill from other health care providers that are available. Furthermore, competent nurse peers provided reassurance and direction in making important patient decisions. Indeed, nurses made patient decisions based on facts derived by their own skill or knowledgeable peers rather than data or hospital procedures.27–29 The study found that the highest percentage in terms of years of experience in hospital and recent unit of study partic- ipants between 1–5 years (73.4%). These findings agreed with30, which indicated that the highest percentage of experi- ence years was less than ten years (51.0%). These results were not surprising due to the fact that the majority of study partic- ipants were within age group 26–30 years (39.4%). Professional role is another variable that this study has highlighted, whereas the majority of the study participants were bedside nurses (76.6%). This finding is congruent with Labrague et al.,24 in which the highest percent of study sample were practicing nursing as a staff nurse position (84.7%). This result was not surprising due to the fact that staff nurses form the majority of heath care system when compared with nurses who hold managerial positions. The results of the present study indicated that more than half (50.6%) of study respondents were not previously partici- pated in training programs of professional autonomy. This result is similar to Allahkhshian et al.21 in which they found that there was not any training program about the concept of professional autonomy offered to nurses. This highlights the huge gab and emphasizes the extreme necessity of conducting such educational program to enhance nurse’s awareness about their standard professional role autonomy boundaries. Unfor- tunately, these results were not surprising due to the fact that the majority of study respondents are from Iraq, which do not emphasize an importance of the professional independence of nursing and the necessity of training programs that clarify the limits of professional independence and the role of the nurse in order to provide the best care to the patient. Surprisingly, only (68.4%) of respondents reported that professional autonomy was covered during their academic preparation as a topic in the nursing curriculum. In contrast, (Allahkhshian et al.21 indicated that nursing autonomy and professionalism in the nursing were not emphasized in the nursing core curriculum. Most study participants (96.0%) had indicated that they work on developing their knowledge & experience about nursing professional autonomy. They highlighted many sources to seek development including, social media plat- form (20.6%), books and scientific journal (12.6%). These were most common source of knowledge seeking platforms. The highest percentage of the bed in unit was more than ten, representing (47.3%). On the other hand, the highest per- centage (78.2%), representing the number of the patient in work shift, which is more than three for each nurse, while global nurses patients ratio 1:1 as recommended in critical care units. About (60.3%), representing 1–5 nurses is the highest percentage of nurse’s number during work shift. Having high numbers of admitted clients, nursing staff shortage, is not sur- prising because of data collected phase was conducted during Covid-19 pandemic. That lead to increase work load and decreasing number of health care providers in the world due to the fact that nurses being the front line of fighting the pandemic has led to high morbidity and mortality rate among them. Unfortunately, no reliable statistics about number of nurse’s death rate due to coronavirus are available to be reported. The majority of respondents indicated having a nursing association membership (51.7%), have nursing association (52.5%) and (50.8%) indicated having a job description. How- ever, only (41.9%) of them were able to apply job description. About three quarters of the study sample (77.7%) indicated having job description awareness. At the end of this section, it is important to notice that the present study is the first that deals with the aforementioned variables, which makes its find- ings unique in terms of highlighting new gaps that need to be addressed effectively. As presented in Table 3, the highest percentages of the perceived barriers of nursing professional autonomy according to the subjects of the current study were the absence of law(s), describing and protecting professional duties (35.6%), fol- lowed by hospital administration style (26.4%), followed by the policy of the health institution (30.4%), followed by domi- nation of physician’s authority (29.9%). These were the domi- nant barriers that may have prevented nurses from authenticating professional autonomy. These findings are sup- ported by a study which found that physician-dominated of the health care system and autocratic hospital management were the most common obstacles of nursing autonomy.21 Other studies indicated that intra-professional conflict such as Table 3. Barriers of applying professional autonomy Perceived barriers f % Hospital administration 187 26.4 Unit Manager 78 11.0 Work Load 121 17.1 Absence of legislations protecting professional duties 252 35.6 Colleagues 52 7.3 Low confidence in abilities to execute professional duty independently 6 0.8 Awareness lack of nursing authority & professional responsibilities limit 64 9.0 Health care institution dominant policy 215 30.4 Domination of physician’s authority 212 29.9 All of the aforementioned barriers 91 12.9 Not apply to me 182 25.7 The underlined numbers in Table 3, represent the highest percent- ages of the perceived barriers according to nurses’ choices. In which, absence of law protecting professional duties (35.6%), hospital administration style (26.4%), the applied policy of the health institu- tion (30.4%) and the domination or authority of physicians (29.9%), were the prevailing barriers that may have prevent nurses from authenticating professional autonomy. 162 J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 158–163 Barriers of professional autonomy among Arab-speaking countries during covid-19 pandemic Original Z. A. Abdulnabi and S. AL-Fayyadh absence of respect, trust and collaboration between physicians and nurses were barriers that must be addressed to upgrade nurse’s professional autonomy. Nurses will be empowered when having the confidence to step forward embracing their professional and ethical authority through creating collabora- tive relationships with physicians.31–34 These study findings also supported by structural element of empowerment theory which suggested that an organization must provide authority, support and resources to employees that are required for achieving the organizational objectives.35 Analysis of variance (ANOVA) test in Table 4 indicated that there was no statistically significant difference in nurses professional autonomy between Arab-speaking countries (mean = 0.106, F = 0.543, P = 0.704), and working place (mean = 0.074, F = 0.376, P = 0.826).These results may explained by the fact that Covid-19 pandemic had a global impact on health care systems of the covered countries such as increase number of patient admitted to hospital and decline number of health care professionals; especially nurses, increase work load, and economic impact, which lead decrease resources and neces- sary supply. Conclusions Most common barriers of professional autonomy are absence of law protecting professional duties, the policy of health care sector, domination of physician’s authority and hospital administration style. This result reflects highlights the impor- tance of removing all obstacles to upgrade nurse’s professional autonomy in the covered Arab-speaking counties. Recommendation Support and encourage nurses to exercises autonomy in clin- ical practice by providing law that protects them, standard and policy to apply their practice in work field. Improve collabora- tive relationship between nurses and physicians to enhance patient outcomes, decrease physicians’ domination and improve nursing autonomy. Strong united nursing groups and professional associations are also required to drive forward in self-government in nursing. Limitations Limited access to the internet services was one of the major obstacles that have limited the participation rate. Of equal importance, a significant percentage of medical-surgical nurses were affected by the Covid-19 pandemic during data collection phase, which also limited the participation rate in the study. Funding Information The budget of this research work was not support by any gov- ernmental or non‐governmental organization. The author of this manuscript covered all the research work‐related expenses. Conflicts of Interest None. Table 4. Differences in the professional autonomy levels in respect to nurses’ countries Professional Autonomy* Country Character- istics Sum of Squares df Mean Square F Sig. 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