Organizational Support as Perceived by Staff Nurses and its Relation to their Autonomy

Context: Nurses need support at all levels in the organization. When staff nurses perceive organizational support, this can promote their sense of well-being, raise positive work behaviors and enhance their autonomy in patient care and unit operational decisions through having the right to make decisions and do their best to increases productivity and achieve organizational goals. Aim: The current study aimed to assess organizational support as perceived by staff nurses and its relation to their autonomy. Methods: A descriptive cross-sectional analytical research design utilized to achieve the aim of the current study. This study conducted in all units of Benha University Hospital. Study subjects were301 out of 1224 staff nurses; their selection was based on a simple random sample. Two tools used for data collection namely perceived organizational support questionnaire and staff nurses' autonomy scale. Results: The result of the study yield that more than two-thirds (73.3%) of the studied staff nurses had low perception levels regarding organizational support, while less than half (45.8%) of them had moderate autonomy levels. Also, there was a highly statistically significant positive correlation (p-value <0.001) between organizational support as perceived by studied staff nurses and their autonomy. Conclusions: The study concluded that a positive, highly statistically significant correlation was found between organizational support as perceived by studied staff nurses and their autonomy. The study recommended that hospital as an organization should clarify available types of its organizational support for staff nurses and encourage them to express their needs and put strategies to increase needed support. Hospital administrators should enhance staff nurses’ autonomy regarding patients' care and the unit's operational decisions. A training program should be provided for staff nurses about how to be more autonomous to make independent, wise decisions. Future research is suggested regarding a broader cross-section replication of this study for diverse nurses from all over the country that may yield generalization of the results. Also, further research is needed to explore barriers that staff nurses face in autonomous decision making and how promote them in participation in unit operational decisions.


Introduction
Organizational support is the degree to which staff trust in their organization, which evaluates their facilities and considers their roles. Also, the extent; to which staff' wants are seen by the organization and recognizes their well-being (Samuel, 2014). Organizational support is the beliefs of nurses regarding how the organization responds to increased efforts at work and how the organization meets their socio-emotional needs (Mirzaei, & Hoseinbeigi, 2016). Perceived organizational support defined as the perception of the staff about how the organization acknowledges them, appraises their services, meets their needs, and cares about their well-being (Pourghaz, Toomaj & Yaghoubi, 2014;Abed, & Elewa, 2016).
Perceived organizational support has several antecedents that include fairness, which means the perceptions of procedural or distributive justice and organizational politics. Also, it includes job conditions such as autonomy and pays, supervisor support, human resource practices such as reward systems, decision-making opportunities, and growth opportunities (Burns, 2016). 1 Corresponding author: Ehsan Saad Soliman Saad Also, Peterson, (2015), appointed to various shapes for organizational support. It is the provision of opportunities, emotional support, encourages being autonomous and improving performing appropriate decisions. Specific organizational factors that support nurse include: supportive organizational climate, autonomous climate, adequate staffing, participatory management, and continuing education and the opportunity for nursing advancement in the organization (Registered Nurses Association of Ontario, 2013) The perceived organizational support is an essential factor in the effort to develop work within an organization. This construct is important because of the increasingly competitive environment that makes employees more worried about the extent to which organizations pay attention to their well-being (Eisenberger, Malone, & Presson, 2016). Creating effective organizational support leads to the improvement of one's self-esteem, hope, and personal growth of nurses, resulting in being of physical, mental, emotional, and spiritual wellbeing. Also, the perception of organizational support may aid in restoring the balance between the benefits awarded by the organization, and the contributions of the staff (Pourghaz et al., 2014).
Organizational support has an impact on nurses' behavioral outcomes (Ahmed & Nawaz, 2015). Strong organizational support can promote a sense of well-being and positive work behaviors in nurses (Labrague, McEnroe Petitte, Leocadio, Van Bogaert, & Tsaras, 2018). Nurses' behavioral outcomes of perceived organizational support would include decreases in withdrawal behaviors such as turnover intentions and absenteeism and increases in extrarole performance. When nurses perceive organizational support, they have more ownership of their organizations and more satisfaction with their jobs (Hamed, 2018). Nurses need support and acknowledgment at all levels in the organization to enhance their autonomy, which increases the productivity of the organization (Kumar, 2014).
Autonomy is a multidimensional phenomenon, and the term derived from the Greek words auto and nomos meaning (self) and (law) (Wade, 1999). Autonomy means the quality of having the ability to function independently (Curtin & Dempster, 2015). Autonomy refers to the freedom, power, and authority to make decisions related to professional nursing practice (Registered Nurses Association of Ontario, 2013). Autonomy is described as authority and accountability for patient care and unit operations and the right to make decisions that require responsibilities for the outcomes (Johari, Tan, & Tjik, 2017).
The concept of job autonomy applied to nurses both as a profession and as individuals (Steel, Schmidt, &Shultz, 2013). The profession of nursing means the privilege of self-governance. While, for the individual nurse, it means the ability of nurses to make critical decisions within their profession and their right and responsibility to act according to the shared standards of that profession (Jin & MacDonald, 2017). McDonald (2002) defined nurses' autonomy as the process of allowing nurses to have substantial judgment. The autonomy of nurses is the extent to which nurses could form and control how and when they did the particular tasks of their job. Autonomy includes independence, capacity for decision making, judgment, knowledge, and self-determination (Finn, 2015). Professional nurses' autonomy is the practice of one's occupation in accordance with one's education. Members of that occupation are governing, defining, and controlling their activities in the absence of external controls. So, they have the right to decide what health care they want, as well as when, how, and who will be involved in that care (Kumer, 2014).
Job autonomy plays a vital role in nurses' well-being as nurses can deal with work-related stress better when nurses have greater autonomy at work. Since job autonomy drives nurses to believe that nurses have the competence and capabilities required to achieve their assignments, it enhances job performance and job satisfaction (Abd el Aal, & Zein Eldin, 2013). A nursing job has a disorganized structure, requiring nurses to make judgments and decisions, be innovative, and take discretionary actions. Therefore, nurses who have discretion and control are likely to exercise more effective solutions in case of problems, having the liberty to decide how to handle the situation. Autonomy drives nurses to feel a sense of job-related pride (Thompson & Prottas, 2016).
Autonomy is a critical psychological need. It denotes the experience of volition and self-direction in thought, feeling, and action (Curtin, &Dempster, 2015). Autonomy refers to the perception of being self-governed rather than controlled by external forces that everyone needs to attain self-actualization (Legault, 2016). The autonomy of nurses is the freedom to make independent decisions on behalf of patients regarding their interests (Bhanji, 2013). Nurses who are not having a right to say anything in the decisions and not have much organizational support and appreciation, they have organizational cynicism (Bashir & Nasir, 2013).
Effective autonomy level among staff nurses can be enhanced through implementing various human resources management practices related to organizational support (Sharma, & Dhar, 2016). When nurses feel that the organization pays more attention to meet their needs and care about their wellbeing, they will do their best to achieve organizational goals (Farasat & Ziaaddini, 2013). The health care workplace that supports autonomy may help nurses progress in their work. The experience of autonomy in the workplace motivates the nurse to work harder and to stay loyal to the organization (Legault, 2016).

Significance of the study
One of the researchers during practical training supervision of nursing students at Benha university hospital noticed that most staff nurses during their working complained from lack of support inside the organization, and nurses want the freedom to decide how to handle the different work situations without blame. Organizational support can promote a sense of well-being and positive work behaviors in nurses (Labrague et al., 2018). Kumar (2014) concluded that nurses need support at all levels in the organization to enhance their autonomy, which increases the productivity of the organization. Also, Currie, Harvey, West, McKenna, & Keeney (2005) stated that for autonomous practice to flourish, it is necessary that a supportive work environment with flexible policies are provided. When nurses perceive more organizational support, they become likely to be more autonomous and payout extra time in providing nursing care to the patients. However, the importance of organizational support and autonomy for nurses, to the knowledge of the researchers, no study conducted at Benha university hospital, Egypt, for this topic. So, the current study conducted to assess organizational support as perceived by staff nurses and its relation to their autonomy at Benha University Hospital.

Aim of the study
The current study aimed to assess organizational support as perceived by staff nurses and its relation to their autonomy.

Research questions
-Is there a relationship between organizational support as perceived by staff nurses and their autonomy?

Research design
A descriptive, cross-sectional analytical research design was utilized to achieve the aim of the current study.

Research Setting
This study conducted in all units (surgical, medical, and critical care units) at Benha University Hospital located in Qalubia Governorate, Egypt. The hospital composed of three separate buildings, the medical building that includes 478 beds, surgical building that includes 384 beds, and an ophthalmology building that includes 18 beds.

Subjects
The study subjects were 301out from1224 staff nurses who were working in the setting mentioned above.
Sample size: The sample size was calculated based on the following equation: Where "n " was sample size n=301 N was the total number of nurses. N=1224 e was the coefficient factor =0.005 (Yamane, 1967).
Sampling technique was a simple random sample through blindness selection from staff nurses in every unit at Benha university hospital.

Tools of data collection
Two tools used for data collection namely perceived organizational support questionnaire and staff nurses' autonomy assessment scale.

4.4.1.
Perceived organizational support questionnaire This questionnaire developed by Eisenberger et al., (1986) and modified by Rhoades &Eisenberger, (2002), it was translated by the researchers from English to Arabic format, and it included the following two parts: The first part includes the socio-demographic characteristics of studied staff nurses, including; age, gender, marital status, nursing qualification, and years of experience. The second part consisted of 45 items that grouped under three main dimensions as the following: Supervisor support (19 items), fairness (14 items), and job conditions (12 items). Scoring system: Responses of staff nurses measured against a five-point Likert scale that ranged from 5=strongly agree, 4=Agree, 3=Uncertain, 2=Disagree, and 1=strongly disagree. The mean and standard deviation was calculated and then converted into percentages. The perception level considered high if the total score was more than 75%, while perception level considered moderate if the total score ranged from 60%-75% while low perception level if the total score was less than 60 %.
Reliability of perceived organizational support dimensions was done using Cronbach's Alpha test, and reliability results were as the following: Supervisor support was 0.956, fairness was 0.859, and job conditions were 0.798.

Staff Nurses' Autonomy (Self-Assessment) scale
This tool adopted from El Adly (2014) based on Blegen et al., (1993). It was used to assess staff nurses' autonomy level. It consists of 48 items that grouped under two main dimensions as the following: decisions related to patient care and decisions related to unit operations.
-Decisions related to patient care (28 items) classified into the following: Patient care provision (7 items), nurses collaboration with patients (7 items), patient education (5 items), handle patient complaints (3 items), nurses decided on diagnosis, discharge and related issues (6 items).
-Decisions related to unit operations (20 items) that classified into four subscales as the following: Arranging their work (5 items), planning to deliver high quality of care (5items), developing and revising patient care procedures (4 items), and managing unit resources (6 items). Scoring system: Responses of studied staff nurses measured on a fivepoint Likert scale. It ranged from 1 to 5 as follows: Nurses do not/ never have authority and accountability =1. Nurses exercise authority and accountability if asked =2. Nurses share authority and accountability with others =3. Nurses consult with others and then take the decision =4. Nurses have full authority and accountability =5.
The statements scored for each component, summedup, converted into a percentage, and the total divided by the number of the items, giving a mean score for each component. The level of autonomy considered high if the score was more than 75%, level of autonomy considered moderate if the score ranged from 60%-75% while low level of autonomy if the score was less than 60% Reliability of autonomy scale dimensions was done using Crohnbach's Alpha test, and the results were as the following: Decisions related to patient care (0.

Procedures
Content validity of the perceived organizational support questionnaire was ascertained by a jury group that consisted of five professors specialized in nursing administration from faculties of nursing inside Egypt, and their opinions elicited regarding the tool format layout, consistency, and scoring system. Contents of the tool tested for accuracy and relevance. Besides, validity was also done to test its consistency, applicability, and feasibility.
Official permission to conduct the study was secured. The researchers clarified to staff nurses that participation was voluntary, and anonymity was assured. Approval of the hospital director has taken first. Also, a suitable time for data collection determined with each head nurse of the participated units and informed consent was taken from each participant. The participants informed of their right to withdraw at any time and notified that data were collected for scientific research only.
A pilot study conducted on 30 staff nurses who represent 10% of total study subjects. The pilot study aimed to determine the feasibility of the research process, applicability, and clarity of the study tool. It also serves to estimate the time needed for filling tools of data collection by study subjects. The two tools took from 20 to 30minutes from every participant. The pilot sample was included in the primary study sample because no modification has done in the tools of data collection.
The fieldwork for this study extended through nine months. It was started at the beginning of June 2018 and completed by the end of February 2019. The data collection took one month (October 2018). The researchers have introduced themselves and explained the purpose of the study to the selected randomly studied staff nurses who agreed to participate in the study. Data was collected three days per week in the presence of the researchers. Filling the two tools took about 20-30 minutes from every participant. The researchers collected data through meeting the selected randomly studied staff nurses at their work during work hours in the morning and afternoon shifts. Each researcher collected data from12-15selected randomly studied staff nurses per day from different surgical or medical units.

Data analysis
Data entry and statistical analysis were done using the Microsoft Excel and Statistical Package for Social Sciences (SPSS) program version 22. Data presented in tables and figures using descriptive statistics in the form of frequencies and percentages for qualitative variables and means and standard deviations for quantitative variables.
T-Test, ANOVA (F) test was used to compare the mean score between two and more groups, respectively. The correlation coefficient (r) used to evaluate the association between studied variables. The p-value is the degree of significance. A significant level value considered when p-value ≤ 0.05 and a highly significant level value considered when p-value ≤ 0.001, while p-value > 0.05 indicates non-significant results.

Results
Table (1) reveals that more than one-third of studied staff nurses aged between 20-30 years (38.9%) and their mean age of (26.98±7.58), while the majority of staff nurses were females (93.0%), more than three-quarters of studied staff nurses were married (78.1%). Regarding their educational qualifications, more than one-third had secondary nursing education (37.9%), and more than onethird of studied staff nurses had more than ten years of experience with Mean ± SD of (9.97±4. 25). Table (2) shows that the highest mean percentage (56.05%) regarding organizational support dimension as perceived by studie1d staff nurses was job condition, while the lowest mean percentage (51.79%) was regarding supervisor support. The total mean percentage of organizational support as perceived by studied staff nurses was (53.81%). Figure (1) shows that more than two thirds (73.8%) of the studied staff nurses had a low perception level regarding organizational support. Table (3) clarifies the autonomy dimension of decisions related to patient care; the highest mean percentage (69.99%) was related to nurses' collaboration with patients while the lowest mean percentage (57.5%) was related to handling patient complaints with a total mean (66.33%). The table also shows the autonomy dimension of unit decisions, the highest mean percent (53.63%) was related to developing and revising patient care procedures, while the lowest mean percentage (48.04%) was regarding managing unit resources. Also, the total mean percentage of the autonomy dimension of unit decisions was (50.56%). Moreover, the table reveals the total mean percentage (59.76%) for the total autonomy dimensions. Figure (2) shows that near half (45.8%) of studied staff nurses had a moderate autonomy level.
Table (4) clarifies that there was a highly statistically significant correlation between total organizational support as perceived by studied staff nurses and total autonomy (p value<0.001).
Table (5) shows that there was a statistically significant relationship between organizational support and staff nurses' years of experience.
Table (6) shows that there was a highly statistically significant relation between autonomy and staff nurses' educational qualifications. Also, there was a significant statistical relation between studied staff nurses' marital status and autonomy.      Relation between perceived organizational support and studied staff nurses' socio-demographic characteristics (n=301).

Discussion
Perceived organizational support is one of the main concepts that have a considerable impact on any organization. It affects all organizational policies through creating appropriate work conditions, supervisor support, appropriate rewards and justice in the workplace, and enhancing staff nurses' autonomy (Kurtessis, Eisenberger, Ford, Buffardi, &Adis, 2015). The study aimed to assess organizational support as perceived by staff nurses and its relation to their autonomy.
Regarding the results of the dimensions and total organizational support as perceived by studied staff nurses, the result of the present study revealed that the highest mean score regarding organizational support dimensions was job condition. This result might be due to the university hospitals provide opportunities for their staff for development, promotion and make climate more initiative to work and nursing in nature is a human job that needs taking and giving support. This finding was supported by Labrague, et al., (2018)  opportunities for promotion, and the units of the hospital do not have a positive work climate. Also, this result was in the same line with Moustaka, (2010), who reported a lack of task autonomy and feedback, as well as reduced advancement opportunities, appear to be significant determinants of emotional exhaustion for nurses. While the result indicated that the lowest mean of studied staff nurses' perception of organizational support dimensions was regarding supervisor support. This result might be due to the concentration of supervisors on work productivity only without attention to staff nurses' interests and social needs. This result was incongruent with Othman and Nasurdin, (2013), who found that participants reported a high degree of supervisor support. Also, in this regard, Frederico (2015) stressed the importance of supervisor support that increases staff motivation, job satisfaction, and positive attitudes towards the organization.
Regarding the total level of organizational support as perceived by studied staff nurses, the result of the present study indicated that near three-quarters of the studied staff nurses had a low level of perceived organizational support. The result might be due to lack of recognition, lack of nursing advocacy about their rights, work overload, and lack of objectivity regarding available opportunities. The result of the present study was supported by Abed, & Elewa, (2016), who reported that nurses receive poor organizational support. Also, this result supported by Higazee, Khalil, Rayan, & Zeinhom (2016) they showed that the study sample perceived less organizational support. This result is also congruent with Labrague et al., (2018), who concluded that the perception of organizational support was low among Filipino nurses. This result was not in the same line with Adam, (2018), who found that the majority of staff nurses had a moderate level of organizational support. Also, Radwan, Alsayed, Gad, & Kassem (2018) reported that nurses had a moderate level of perceived organizational support.
Related to total and mean percentage of autonomy dimensions for studied staff nurses, the results of the current study showed that the highest mean percentage of decisions about patient care was regarding nurses' collaboration with patients. This finding might be due to nurses' collaboration with patients is very important, and the university's hospital supports and encourages nurses to help the patients in taking the accurate decision as needed and respect patients' needs in the context of their treatment. This result was supported by Stewart, Stansfield & Tapp, (2004), who concluded that autonomy as independent decision making and practice through nurses' contributions through patient care goals through knowledge of how to get things done within hospital systems and through interdisciplinary coordination and collaboration. While the lowest mean percentage was related to handling patient complaints, this finding might be due to nurses' wrong culture regarding patient complaints is the responsibility of physicians and then implement physicians' orders for patient care, might be afraid of making the wrong decision regarding patient complaints. This result was congruent with Stewart, et al., (2004), who found that studied nurses had a high autonomy level regarding providing psychological support to the patient and his family, while the lowest mean percentage of decisions related to patient care was handling patient complaints. This finding disagreed with El Adly, (2014), who reported that they had a high autonomy level dealing with patient complaints.
Regarding the autonomy dimension of unit decisions, the highest mean percentage was developing and revising patient care procedures, while the lowest mean percent was for managing unit resources. This result was incongruent with Abd el Aal, & Zein Eldin, (2013), who found that nurses had low autonomy in determining staff identifying causes for developing and revising patient care procedures, while the lowest mean percentage of autonomy dimension of unit decisions was regarding managing unit resources.
Around half of the studied staff nurses had a moderate autonomy level. This finding might be due to supervisors who did not care to share most staff nurses in making a decision related to their unit. This finding was supported by Labrague et al., (2018), who found that nurses demonstrated moderate levels of professional autonomy. This result was in the same line with Paganini & Bousso, (2015), who found that nurses had a moderate level of autonomy in intensive care units. Also, Varjus, Kilpi, & Suominen (2011) reported that the majority of nurses working in the intensive care unit in Finland have a moderate level of autonomy. Moreover, Enns (2013), found that the majority of nurses had a moderate level of professional autonomy. Also, Finn (2015) revealed that the majority of nurses had a moderate level of autonomy.
On the other hand, Laschinger, Finegan, Shamian & Wilk, (2011), found that more than half of nurses perceived a high autonomy level and emphasized that they affect nurses' sense regarding their self-worth, meaningfulness, job satisfaction and morale. Also, Plati, Lemonidou, & Priami (2010), revealed that the study nurses had a low level of autonomy because of work overload and the medically driven task-oriented care. This finding might be due to the culture of the supervisors only who were responsible for decision making and staff nurses as followers who should obey the orders of their supervisors.
Results related to the correlation between organizational support as perceived by studied staff nurses' and their autonomy, the result of the present study demonstrated that there was a high statistically significant correlation between total organizational support as perceived by studied staff nurses and total autonomy. This result might be due to staff nurses' perception of their organization's support. They could perceive the organizational support through satisfying their needs, provide them with needed resources, solve their problems with flexibility, and involve them in decision making related to their work. Hence, they would make extra efforts with high autonomy related to their decisions regarding the unit and patients care to satisfy the health organization goal and provide a high quality of patient care. While this result contraindicated with Labrague et al., (2018), who found that perceived organizational support did not influence autonomy of nurses, this result is congruent with Kumar, (2014), who appointed to nurses need support at all levels in the organization to enhance their autonomy which increases the productivity of the organization.
Related to the relationship between organizational support as perceived by studied staff nurses and their sociodemographic characteristics, the result showed that there is a statistically significant relationship between organizational support and years of experience. This finding might be due to when staff nurses had more years of work experience in their organization; they can understand more regarding the methods of support from their organization and how to use it. This support satisfied their needs. The present study finding contradicted with Farasat, & Ziaaddini, (2013), who found no significant relationship between organizational support and personal characteristics of staff nurses. Also, the present study contradicted with Abed & Elewa, (2016), who found a statistically significant difference between staff nurses' organizational support and their age and working unit.
Labrague et al., (2018), were in the same line with the result of this study, which revealed that there was a significant correlation between organizational support and demographic characteristics of nurses. The result contradicted with Robaee, Shoorideh, Ashktorab, Baghestani, & Sharifabad, (2018), who reported a none significant correlation with any of demographic characteristics The results showed that there was a highly statistically significant relation between autonomy and studied staff nurses' educational qualifications. This result might be due to education gives staff nurses power, confidence, and experience that reflect on their autonomy in dealing with situations. Also, there was a significant relationship between autonomy and marital status. This might due to marriage give nurses support and emotional stability that reflect on their autonomy in dealing with situations. The result was inconsistent with Taylor, Beradley, & Nguyen, (2003), who found that single workers were less satisfied with all aspects of their job autonomy than married workers.

Conclusion
The current study concluded that a positive, highly statistically significant correlation was found between organizational support as perceived by the studied staff nurses and their autonomy. Also, the study findings proved that more than two-thirds of the studied staff nurses had a low perception level regarding organizational support, while less than half of them had a moderate level of autonomy.

Recommendations
Based on the findings of this research, the following recommendations have been generated: -Hospital as an organization should clarify available types of its organizational support for staff nurses and encourage them to express their needs and put strategies to increase needed support.
-Hospital administrators should enhance staff nurse's autonomy regarding patients' care and unit's operational decisions and encourage staff nurses to suggest new and innovative ideas about patient care and try to apply these ideas in their workplace. -The hospital administrators should create strategies that promote a supportive work environment such as fairness in rewards distribution, active listening, safe working condition, needed training, motivation (better opportunities for promotion), problem solving, periodic meeting, and respect their rights in autonomy. -A training program should be provided for staff nurses about how to be more autonomous to make independent, wise decisions. -Future research: A broader cross-section replication of this study for diverse nurses from all over the country may yield generalization of the results. -Further research is needed to explore barriers that staff nurses face in autonomous decision making and how to promote them in participation in unit operational decisions -Further research to investigate the relationship between perceived organizational support and other variables as job satisfaction, turnover, and productivity.