Background Discretionary autonomy is a key factor in enhanced patient outcomes and nurses' work satisfaction. Among nurses, insufficient autonomy can result in moral distress. Objectives To explore levels of autonomy among European critical care nurses and potential associations of autonomy with nurse-physician collaboration, moral distress, and nurses' characteristics. Methods Descriptive correlational study of a convenience sample of 255 delegates attending a major European critical care conference in 2009. Respondents completed a selfadministered questionnaire with validated scales for nurses' autonomy, nurse-physician collaboration, and moral distress. Results The mean autonomy score (84.26; SD, 11.7; range, and the mean composite (frequency and intensity) moral distress score (73.67; SD, 39.19; range, were both moderate. The mean collaboration score was 47.85 (SD, 11.63; range,. Italian and Greek nurses reported significantly lower nurse-physician collaboration than did other nurses (P < .001). Greek and German nurses reported significantly higher moral distress (P < .001). Autonomy scores were associated with nurse-physician collaboration scores (P < .001) and with a higher frequency of moral distress (P = .04). Associations were noted between autonomy and work satisfaction (P = .001). Frequency of moral distress was associated inversely with collaboration (r = -0.339; P < .001) and autonomy (r = -0.210; P = .01) and positively with intention to quit (r = 0.257; P = .004). Autonomy is defined as the freedom to make decisions within the domain of an individual's profession and to act accordingly. 10,11 The ability to make discretionary and autonomous decisions based on comprehensive knowledge, clinical expertise, and evidence-based findings is a hallmark of professionalism. In general, ICU nurses make 1 care decision every 30 seconds 12 and approximately 9 important patient-care decisions per hour, 13 suggesting that exercising judgment is a core nursing activity and influences the quality of care provided. Previous studies 11,[14][15][16] in European ICUs indicated that the levels of nurse autonomy differ between countries and that the decision-making capacity of these clinicians needs to be developed and strengthened. However, factors that may be associated with low autonomy among European ICU nurses have not been systematically studied. Although, presumably, poor nursephysician collaboration may limit a nurse's ability to implement care-and unit-related decisions, associations between these 2 constructs have not been investigated. Evidence of the association between nurse-physician collaboration and ICU nurses' moral distress is likewise scant. Although the design of the study we report here was unsuitable for exploring either causative factors or antecedents of autonomy-and inferences may be limited by differences in responders' context of practice-we wished to address autonomy, nurse-physician collaboration, and moral distress simultaneously in a sample of European ICU nurses to gain preliminary insigh...

Enhancement of nurse-physician collaboration and nurses' participation in end-of-life decisions seems to be a managerial task that could lead to the alleviation of nurses' moral distress and their retention in the profession.

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The ICS shows promise as a tool for evaluating individualized care in European cultures. The international expansion of an existing instrument developed for one country facilitates comparative studies across countries. There is a need to further test the construct validity and appropriateness of the ICS in different settings in European and nonwestern cultures.

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