Learning culture strengthens hospital nurses’ professional autonomy, mixed methods study shows

Hospital nurses who took part in a structured, team-based learning programme built around participatory action research became measurably more autonomous, more proactive and more confident in applying evidence to their daily practice, according to a new mixed-methods study published in BMC Nursing. The research, led by Ria den Hertog of the Christian University of Applied Sciences Ede together with colleagues at Gelre Hospitals and Radboud University Medical Centre, examined how a participatory learning trajectory embedded in Evidence-Based Quality Improvement, or EBQI, could strengthen professional autonomy and nursing leadership development on the ward. The findings arrive at a time when health systems worldwide are grappling with nursing shortages, burnout and the persistent challenge of translating research evidence into bedside care. The study’s central message is strikingly simple: autonomy is not something nurses can simply be granted; it is something they develop collectively, through guided reflection, shared inquiry and the repeated enactment of leadership behaviours within the ordinary rhythm of clinical work.

Professional autonomy occupies a central place in nursing science and in quality improvement practice. It refers to a nurse’s capacity to make independent clinical judgements, act on them, and take responsibility for the outcomes, all within the boundaries of professional standards and organizational context. In EBQI programmes, in which frontline teams are expected to identify problems, consult evidence and implement changes, autonomy is a precondition for success. Yet previous research has shown that hospital nurses often struggle to enact autonomy in practice, constrained by hierarchical structures, time pressure, limited access to evidence, and a culture in which decision-making is perceived as the province of physicians and managers. The Dutch team set out to test whether a carefully facilitated learning culture could shift that dynamic, drawing on Self-Determination Theory, which holds that autonomy, competence and relatedness are fundamental psychological needs whose satisfaction fuels intrinsic motivation and engagement.

The study employed a convergent mixed-methods design that combined qualitative Participatory Action Research with a prospective pre-post comparative study. Two nursing teams in a Dutch hospital took part in the PAR trajectory, while two comparable teams served as non-PAR comparison wards. PAR is distinctive among research approaches because the participants are not subjects but co-researchers: nurses on the participating wards helped define the problems worth investigating, gathered and interpreted data about their own practice, and designed and tested changes themselves. In this study, each team developed a tailored learning trajectory that combined reflection sessions, knowledge development and the deliberate practice of nursing leadership behaviours, supported by four PAR-trained nurses who provided day-to-day facilitation. The researchers applied an appreciative approach, deliberately building on what teams already did well rather than concentrating on deficits. Qualitative and quantitative data were collected and analysed separately and then brought together at the interpretation stage through triangulation, allowing findings from the two strands to be compared and integrated into a comprehensive picture of the trajectory’s effects.

On the quantitative side, the researchers used established instruments to measure change over time. The Leadership Practice Inventory, or LPI, captured five domains of leadership behaviour, including the domain known as Challenge the Process, which reflects a willingness to seek opportunities, experiment and learn from setbacks. Evidence-based practice attitudes and skills were assessed with the Evidence-Based Practice Questionnaire, or EBPQ, and general confidence was measured with the Dutch General Self-Efficacy Scale, or DGSES. Analyses were conducted with the Statistical Package for the Social Sciences using mixed model analysis, a technique that accommodates repeated measures and between-group comparisons while accounting for the clustering of nurses within teams. The comparison design matters: by tracking non-PAR wards over the same period, the team could ask whether observed changes on the intervention wards exceeded the ordinary fluctuations of ward life.

The results were consistent across both strands of the study. Compared with the non-PAR comparison wards, nurses on the participating wards showed statistically significant improvements in three areas: aspects of professional leadership, specifically Challenge the Process (p = 0.014), attitudes and skills related to Evidence-Based Practice (p = 0.037), and self-efficacy (p = 0.038). The qualitative data explained how these statistical shifts came about. Four key outcomes emerged from the PAR trajectory. First, nurses reported increased professional autonomy, describing a growing sense that they were entitled and able to make and act on their own judgements. Second, work practices became more proactive: nurses initiated improvements rather than waiting for instructions. Third, psychological safety within the teams improved, so that raising doubts, admitting uncertainty and proposing experiments no longer felt risky. Fourth, the teams developed a shared vision of good care, which gave individual initiatives a common direction and made improvement a collective rather than individual project.

The mechanisms behind these gains, as reconstructed by the researchers, centred on ward-based learning, guided reflection and collective practice. Rather than sending individual nurses off to training courses and hoping the learning would transfer back to the ward, the trajectory anchored learning in the daily realities of the team. Reflection sessions, facilitated with an appreciative stance, allowed nurses to articulate tacit knowledge, examine routines and connect their experiences to research evidence. The enactment of leadership behaviours, such as challenging existing processes and modelling new practices, was treated not as an abstract competency but as something to be rehearsed in real situations and debriefed afterwards. In Self-Determination Theory terms, the trajectory satisfied the three basic psychological needs simultaneously: autonomy support, growth of competence through evidence-based practice skills, and relatedness through shared vision and psychological safety. This alignment, the authors suggest, explains why motivation and engagement increased alongside measurable skill gains.

The study’s implications for hospital management and nursing education are considerable. The authors conclude that nursing leadership development should be embedded in everyday clinical practice through structured action-reflection cycles, rather than confined to classrooms or one-off leadership programmes. PAR, they argue, can foster trust, engagement and team development, but only when organizational support makes meaningful participation possible: time away from the bedside, facilitation capacity and managerial backing are prerequisites, not luxuries. Equally important is their caution about sustainability. The improvements observed during the trajectory depended on intensive support, and the researchers emphasize that sustaining gains requires ongoing support for practice consolidation and innovation. Without continued investment, hard-won autonomy can erode back into routinized dependency, particularly in high-pressure hospital environments where staff turnover and workload leave little room for reflection.

The authors are also candid about the limits of generalizability. The study took place in the Dutch nursing context, where vocationally and bachelor-educated nurses work together in teams with a skill mix that differs from many other countries. In systems where the registered nurse workforce has a different educational composition, or where care assistants take on tasks performed by registered nurses in the Netherlands, the trajectory would need adaptation. The pre-post comparative design, while strengthened by comparison wards, involved a small number of teams, so the quantitative findings should be read as indicative rather than definitive. The article itself was shared early as a citable accepted version carrying a permanent DOI, subject to further editorial processing before the final Version of Record. These caveats notwithstanding, the convergence of significant quantitative effects and rich qualitative accounts lends the findings unusual credibility for a ward-level intervention study.

The research forms part of the ARMICA project, which focuses on strengthening the professional autonomy of hospital nurses in Evidence-Based Quality Improvement, and was funded by the Dutch Organisation for Health Research and Development, ZonMw. The study was conducted in accordance with the Declaration of Helsinki, received ethics approval from the institutional review board of Gelre Hospitals under approval number 2024.06, and all participants gave informed consent. The authors declare no competing interests. In a professional landscape where nurse burnout, attrition and voicelessness are widely documented, the study offers an evidence-based counter-narrative: when nurses are given the time, facilitation and psychological safety to learn as teams, they do not merely comply with quality improvement agendas, they begin to own them. For hospital leaders searching for levers that improve care without adding technological complexity, the answer suggested by this research may lie in an old-fashioned idea given new rigor: a genuine learning culture on the ward.