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Discussion

Afraid of losing my autonomy

I am currently applying at various hospitals for a RN position. I am a critical care RN with 4 years experience and would like to stay in the ICU/ER environment. I have held the same one position since graduating so ICU is all I know....and love! I worked in a community, mid-sized hospital that was non-teaching and non-magnet status. That was one factor that I disliked...all of the interesting, complex or major trauma patients were immediately flown out to larger facilites capable of handling them. I felt like my skills were capped, in that I didn't often get a challenging case or the opportunity to see something new.

I have applied for various positions at a local health system that is a Level 1 trauma center, magnet status, teaching facility that has multiple specialized critical care units (neuro, surgical, pediatric, etc). I would be exposed to a higher acuity of patients and be able to expand my skill level.

My question for those who have worked in both types of systems is what are the major differences in how nursing care is delivered? A few former coworkers who had worked in the type of facilites I am looking to get a position in have said things such as the nurses were very limited in the decision making, critical thinking and clinical aspects of patient care. Apparently, the residents were responsible for many of the procedures and decisions that nurses where I worked handled.

I'm concerned at going from a position where I was granted a high level of autonomy and was able to develop relationships with the physicians in which they trusted my judgement when I told them of concerns I had regarding their patients. It made caring for the patients much easier when the physicians knew that I knew what I was talking about and would promptly order appropriate treatments. I also was responsible for (and became proficient at) doings things such as drawing blood gases and other interventions that at larger hospitals, I'm told the residents do (as of course, they are learning and need the experience).

I was told by one nurse that they would never be allowed to do things such as draw gases or increase O2 for a patient in respiratory distress without first calling and getting explicit orders to do so. If I would have called a pulmonologist reporting distress without ABG results in hand, they'd probably hang up on me and tell me not to bother them until I had the information they needed. It was just expected of us.

My fear is that I will overstep my boundaries or feel stifled in a new position as I am used to taking charge and not having to get permission for every little action I take (ahead of time). I understand nurses must have orders for everything we do and that we are not doctors or qualified to act as such. I just don't want to work in an environment where nurses are treated as monkeys who can perform tasks but lack the ability to critically think or make decisions.

Thanks for any input :)

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    I do not have your experience, but I do work in a large, magnet, teaching hospital. The residents that I see are usually 1st (maybe a few 2nd years) year residents who are brand spankin' new. They learn very quickly how to lean on the nurses that will help them. When I was precepting, I had to fight with them to get chances to do certain skills (i.e they come in not knowing how to put in an NG tube). Other than that, I LOVE it! The new residents will usually talk to you and share info and you build a relationship with them.

    Your skills will NOT be wasted in a large hospital. You still will have a lot of autonomy and you will still have the opportunity to build great relationships with the physicians.

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    I never had more autonomy in a patient care setting than when I worked in a hot-shot world-class ICU. We drew ABGs, adjusted FIO2s, did our own weans, and a hundred other things on our expert nursing judgment. We had great relationships with the residents and faculty docs, on a first-name basis with all but the chief of service, and even he didn't mind.

    This question sounds more like the student task-minded focus on "what a nurse can do"-- "Ooooo, you got to do a .....!" Tasks aren't that big a deal. If residents want practice in doing radial sticks, let 'em knock themselves out. If I needed an ABG, I'd draw it off the a-line or do my own stick (we had a competency check for it). You, too, will want to have the ABG results when you call the pulmonologist or intensivist. Never fear. You'll learn more than you can imagine, too. Go for it.

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    • Author

    Thank you both for your insights! Good to hear that nurses still provide high-level care and maintain their autonomy in teaching facilitites. Forgive my ignorance, as I mentioned, I've only worked in one hospital and was worried by the comments made to me from a few individuals. I'm glad their experiences are not the norm.

    I'm now even more excited to expand my horizons and gain new experiences!

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    Not ICU, but I understand - I came from a smaller community hospital in OB/L&D where the nurses had a LOT of responsibility and autonomy. The docs showed up when the baby was crowning, the nurse did everything else. Then I moved to a large, high acuity teaching hospital. What I lost for autonomy (we RARELY did lady partsl exams or fetal scalp electrode placement because, like what you describe, the residents need to do that) I more than made up for with the safety of having a provider in house, 24/7, literally 2 minutes away from being at the bedside at any time. As well, because it was a high acuity teaching hospital, we saw much higher risk stuff. While I missed some of the "tasks" I no longer did, I learned a TREMENDOUS amount, and I imagine you would too.

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    If you feel that you are ready for a move, then you are. You will be exposed to so much more that you will be learning different procedures, protocols etc. Your learning will not stop and if the residents interfere, just ask them if you can do. . . . . . . . You are there to learn as well!!! Everything is not all about them!!! You are going to be so very excited to learn new things and put your skills to the test as well as expand them!!! Great opportunity!!!!

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    It depends on the facility...I have worked at teaching institutions that I had amazing autonomy....and I have worked at one that severely limited the RN. The residence inserted NGT's and pulled Swans. They were NOT nursing duties in their eyes. I quit the one that limited my skills.

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    • Author
    It depends on the facility...I have worked at teaching institutions that I had amazing autonomy....and I have worked at one that severely limited the RN. The residence inserted NGT's and pulled Swans. They were NOT nursing duties in their eyes. I quit the one that limited my skills.

    It seems it must just depend on the system. There is a large, world renowned facility in my area (I am not applying here due to the commute) that I've heard invests the majority of it's time and resources into the physicians and the nurses opportunities are largely overlooked.

    Thanks for your input :)

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    • Expert
    It seems it must just depend on the system. There is a large, world renowned facility in my area (I am not applying here due to the commute) that I've heard invests the majority of it's time and resources into the physicians and the nurses opportunities are largely overlooked.

    Thanks for your input :)

    It really depends....I have worked for the University of Chicago and we had TONS of autonomy. I worked at the Lahey clinic in MA...a physician run facility and there was much less. It really depends.

    I say stay perdiem at one pace and take the new position you can always leave if it isn't what you want.

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    TASKS do not equal autonomy anyhow. ANYtime you expand your horizons and go to a larger (or smaller) facility, there is plenty to learn and your autonomy will likely remain very much intact. There is always plenty to do no matter where you wind up. Autonomy to me, equates trust in us. Not tasks we do.

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