Introduction
Patient care is an important part of the disease recovery process. Among the members of the treatment team, the role of nurses in providing patient care is very important and essential. The reasons can be the constant communication between nurses and patients, their presence in all departments and healthcare systems, and the higher number of nurses compared to other medical personnel. It seems that increasing the nursing quality can have a great effect on increasing the quality of care [1]. On the other hand, the quality of provided patient care can have an effect on the grading and accreditation of hospitals [2]. The World Health Organization (WHO) defines the quality of care as “the degree to which health services provided to individuals and populations increase the likelihood of desired health outcomes and is consistent with evidence-based professional knowledge.” [3].
Safe nursing care is defined as the use of knowledge and skills of nurses to provide high quality care and minimize the risk of injury to patients [5]. Nowadays, due to the rapid change and development of health care, providing quality care requires having up-to-date knowledge, professional competencies, management skills, and the capacity to provide ethical and safe services [7]. It is necessary for nurses to have professional autonomy for providing care for each patient according to their conditions [2]. Professional autonomy in nursing is defined as the ability of nurses to make independent decisions based on sufficient knowledge, clinical expertise and evidence-based practice. In fact, autonomy is an important component of professional identity and quality of care in clinical practice [10]. Professional autonomy in nurses can increase the feeling of trust and respect, improve professional skills and promote effective communication with coworkers and doctors [8, 13]. Research shows that the clinical autonomy of nurses is at a moderate level and little changes have occurred in the last 20 years, and there is little support for their independent activities [14]. Therefore, considering the importance of providing safe and high-quality care to patients and the importance of clinical autonomy in nurses working in emergency departments (EDs) to provide unique care to patients with acute and life-threatening conditions, this study aims to determine the relationship between professional autonomy and safe nursing care in newly graduated nurses working in the EDs.

Methods
In this analytical cross-sectional study, the study population consists of all newly graduated nurses (two years had passed since graduation) working in EDs of hospitals in Guilan, Iran. They all were included in the study using a census sampling method. The data collection tool was a questionnaire with three sections of demographic form (surveying age, gender, marital status, educational level, nursing work experience, work experience in the ED, and working hours per month), the safe nursing care scale, and the professional autonomy scale.
The professional autonomy scale was designed and psychometrically assessed in 2020 by Rouhi-Balasi et al. for clinical nurses in Iran. It contains 31 statements with a 5-point Likert scale (5=always, 4=often, 3=sometimes, 2=rarely, and 1=never). The total score ranges from 95 to 495. The internal consistency of this tool using Cronbach’s α is 0.885 and the intra-class correlation coefficient for its test re-test reliability is 0.84. Also, the S-CVI/Avg index of this questionnaire is 0.964 [11].
The safe nursing care scale was developed in 2017 by Rashvand et al. for clinical nurses in Iran. It contains 32 statements with a 5-point Likert scale (5=always, 4=often, 3=sometimes, 2=rarely, and 1=never). The total score ranges from 73 to 365. The internal consistency of this tool using Cronbach’s α is 0.92 and the intra-class correlation coefficient for its test re-test reliability is 0.78 [17].
Descriptive and inferential statistics (independent t-test, Spearman or Pearson correlation test, and linear regression analysis) were used to analyze the collected data.

Results
Most of the participants were female (75.4%) and single (69.6%), with a mean age of 25.84±2.399 years. The professional autonomy score of novice nurses was 369.75±52.73 (out of 495) and their mean score of safe nursing care was 307.85±41.91 (out of 365). Most of the nurses had good performance in providing safe nursing care. Based on the results of the independent t-test, gender and marital status had no significant relationship between with providing safe nursing care. Also, based on Pearson’s correlation test results, the variables of age, nursing work experience, work experience in the ED, and working hours per month had no significant relationship with providing safe nursing care. There was a significant relationship between professional autonomy and safe nursing care (r=0.483, P<0.001). After entering all the variables with P<0.05 into the linear regression model, it was observed that the only variable that predicted the provision of safe nursing care was professional autonomy. For every one unit increase in professional autonomy, the likelihood of providing safe nursing care increases by 0.133 (P=0.009).

Conclusion
The present results revealed that the increase in nurses’ professional autonomy can lead to safer nursing care. Therefore, if nurses have a greater control over their performance, decision-making ability, and autonomy to act based on patient safety, they can provide better quality care to patients. Therefore, empowering nurses by providing conditions to perform based on professional autonomy, can ultimately lead to better results for the patients and cause overall safety in the EDs. The managers should support nurses’ autonomy and allow them to use their knowledge and skills effectively to provide safe and high-quality care. This study had a small sample size. Therefore, it is recommended that future studies should use a larger sample size and investigate contextual factors affecting the relationship between safe nursing care and professional autonomy in the EDs. 

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1400.495).

Funding
This study was supported by the Student Research Committee of Deputy of Research and Technology, Guilan University of Medical Sciences.

Authors' contributions
Conceptualization, study design, data collection, analysis and interpretation: All authors; Initial draft preparation: Leila Rouhi Balasi, Hasan Shafaati Shama, Ali Alizadeh and Ahmad Gholami; Supervision and critical revision: Leila Rouhi Balasi and Ahmad Gholami; Funding acquisition: Leila Rouhi Balasi.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the Vice-chancellor of Research and Information Technology, and the Student Research Committee of Guilan University of Medical Science, and all nurses who accompanied them in this research.




References