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Empowered professionals

A new model of responsible autonomy 

Command and control methods do not work well in complex environments. Staff that have limited discretion will be less able to solve problems, identify improvements or exercise initiative: worse, low levels of autonomy have been found to have a negative impact on patient mortality and the retention and recruitment of staff.

Daniel Pink’s summary of the research in this area has found some surprising results.


For simple tasks, standard monetary motivators work, but they may not work at all for complex and cognitively demanding tasks. Staff need pay that meets their needs and feels fair but once this is in place, three additional factors are required:


  • Autonomy – the ability to direct the course of one’s own work.
  • Mastery and self-challenge – The overarching desire for people to improve themselves, gain experience and get better at what they enjoy.
  • Purpose – The reasons staff do what they do. Doing tasks merely for money and profit is not very motivating, but doing tasks to make someone’s life better, to make the world better, to have a well defined purpose to work and to make money – that is motivating.

This is why the first habit is so important.


There are some additional steps to ensure that empowerment is effective. Firstly, if professionals are to be in the lead they will need to learn leadership and team working skills and be coached and supported as they learn.


This needs to include improvement skills and the time to use them. Secondly, as the Virginia Mason case study shows there often needs to be an explicit discussion about what is expected from staff and how they will be held to account. There needs to be a change in the traditional relationship between physicians and their organization. In the past there has been little accountability and autonomy was interpreted as the freedom to practise medicine in a wide variety of different ways unconstrained by cost considerations. A new model of responsible autonomy needs to be negotiated in which professionals are held to account for outcomes and where decisions to depart from evidence based pathways of care are recorded and discussed. For nurses and other staff more autonomy and control, supported by high quality front line leaders is important. Thirdly, empowerment is supported by improved team working which is also associated with fewer errors, lower nurse burnout and higher quality care – including possibly reduced mortality. Team working does not just happen and needs to be developed and nurtured.

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