Introduction
Autonomy and self-care in the healthcare system are important principles of modern medicine and ethics. They received attention due to the complexities of health care and changes in the expectations of patients and their families. The knowledge of autonomy is needed to clarify and develop the nursing profession in rapidly changing care environments. there is a concern about how the core elements of nursing are taken care of when focusing on expansion and extension of specialist nursing roles. Autonomy provides a work environment for nurses that can improve their satisfaction in patient care. Autonomous nursing care occurs in large spectrums to provide the best patient care in the hospital. It includes nursing parameters such as training, planning, care and nursing care protocol. Since in hospitals there is an emphasis on teamwork between doctors and nurses to achieve optimal and quality care, professional interactions between doctors and nurses, and the autonomy of nurses according to their science and knowledge based on doctor’s prescription, this study aims investigate the autonomy of nurses in Imam Khomeini hospital of Arak, Iran based on Kramer and Schmalenberg’ autonomy model and its effect on the quality of patient care.
Materials and Methods
This is a causal-comparative study. Participants were 101 nurses of Imam Khomeini Hospital in Arak, Iran from the intensive care unit and internal medicine, surgery, pediatrics, gynecology, orthopedics, and emergency departments. Other departments were excluded from the study due to the difference in providing nursing services. The quality of patient care was measured using a questionnaire with 37 items developed by Moghimi and Ramazan. These items measure communication with the patients, patient education, patients’ vital signs evaluation, meeting the perceived needs of patients, patients’ easy access to the treatment staff, providing post-discharge care plan, patient participation in setting the care plan. The reliability of this questionnaire using Cronbach’s alpha is 0.85. The autonomy of nurses was measured using a questionnaire based on Kramer and Schmalenberg’ model. In this questionnaire, autonomy in nursing care is measured with four subscales including: Autonomous Patient Care Action, Autonomous Nursing Care Action, Limited Autonomy, Unsanctioned Autonomy, and No Autonomous Practice. The internal reliability of overall questionnaire using Cronbach’s alpha was obtained 0.83.
Results
Most of participants had age 39-46 years (59.4%), were female (68.3 %), and had a bachelor’s degree (92%). and a work experience of 15-20 years (46.5%). Based on the results, the regression models were as follows:
Predicted quality of care in the intensive care unit (Y) =3.02+0.253 (Limited Autonomy)
Predicted quality of care in the surgical department (Y)=2.78+0.187 (Autonomous nursing care)
Predicted quality of care in the pediatrics department (Y)=1.39+0.522 (Limited Autonomy)
Predicted quality of care in the gynecology department (Y)=3.12+0.205 (Limited Autonomy)
Predicted quality of care in the orthopedics department (Y)=2.18+0.466 (Limited Autonomy)
Predicted quality of care in the emergency department (Y)=4.58+0.129 (Limited Autonomy)
Based on the above regression models, it can be said that the regression model was significant for all departments except for the internal department. The predicting variables had a relatively high power such that with an increase of one unit in limited autonomy in the intensive care unit, autonomous nursing care in the surgical department, and limited autonomy in pediatrics, gynecology, orthopedics, and emergency departments among the nurses, the quality of care can be increased by 0.253, 0.187, 0.522, 0.205, 0.466 and 0.129, respectively.
Discussion
Our findings showed that the autonomy of nurses in Imam Khomeini Hospital was different based on the working departments. The results indicated the highest effect of limited autonomy on the quality of care, where the highest was in the pediatrics department and the lowest effect was in the emergency department.
In different studies, nurses’ autonomy is presented as an organizational factor that, along with other factors, plays a role in clinical care. This evidence shows that nurses’ autonomy affects patient outcomes. Nurses’ professional judgment in decision-making can lead to an increase in the quality of patient care. To achieve this goal, nursing managers should empower nurses and create an environment for them so that they can use their knowledge in training autonomy.
The effect of other factors such as nursing skills, educational level, type of patients, number of occupied beds, and the length of hospital stay were not evaluated in this study which can be considered as the study limitations. In general, based on the findings, it can be said that although Imam Khomeini Hospital in Arak has the potential to provide autonomy for nurses, but there is a need for organizational support, creating clinical autonomy by continuous learning and empowerment, supportive programs for clinical practices, and other educational programs.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Islamic Azad University of Arak Branch (Code: IR.IAU.ARAK.REC.1397.66).

Funding
This research has not received any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
The authors equally contributed to preparing this article.

Conflicts of interest
The authors declare no conflict of interest. 

Acknowledgements
The authors would like to thank all participants in this research.

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