Are Nurses REALLY Autonomous?

[pagandeva2000, LPN]

I am posting this question because my hospital is applying for Magnet Status. I work as an LPN, so, actually, this does not fit us because we work under the auspice of the RNs, but from what I have witnessed at my place of work, I do not witness autonomy with our RNs. Each time orders are questioned, the nurses are disrespected and ignored by the physicians. For example, on the med-surg units, a nursing judgement may be made for a patient to be on what is called a 'nursing one on one'. But, the supervisor will not provide staff because there is no order by the physician. I can think of many other situations, but can't think of them, now. I see the limitations placed on the nurses at my hospital and think that magnet is a joke because of this. So, I am asking the nurses of this forum if they are practicing with autonomy and if so, how? I am hoping to hear that there are some that are actually working with automony, and vents from those that feel they are not.

Thanks in advance for sharing!

[LightningRN]

Of course no nurse practices with absolute autonomy, thats not our job. Autonomy in nursing to me means that the physicians we work with respect us as professionals to take care of our patients to the best of our ability and trust our judgement when they are not around. In my specific situation I feel that the nurses I work with are allowed a great deal of autonomy in caring for our patients. I realize that it is not that way everywhere. Its one of the things I love the most about my job.

[pagandeva2000, LPN]

What gets my drawers in a bunch is that when I question the orders of a physician, I am not questioning his judgment...I am using this as a learning tool for myself. Obviously, the physician has more education than I do and learned differently than I, so, when I ask, it is so I can better comprehend for myself as well as teach the patient when they question me. The answer 'because I said so' is disrespectful, because in most cases, the patient will approach the NURSE rather than the almightly physician about why things are done. Thanks for sharing.

[LightningRN]

If you are questioning because you don't understand why a physician is doing something specific maybe just the way you word it will make a big difference. Instead of saying "why?" and getting a response like "because I said so" .. you might try something like ... "will you explain the rationale of this for me?".

I have never ever asked a physician the rationale of something and gotten blown off or "because I said so". Either you work with some really disrespectful physicians or perhaps you aren't making yourself clear that you are honestly trying to learn something and it may come off as "questioning" orders in a disrespectful manner.

[pagandeva2000, LPN]

If you are questioning because you don't understand why a physician is doing something specific maybe just the way you word it will make a big difference. Instead of saying "why?" and getting a response like "because I said so" .. you might try something like ... "will you explain the rationale of this for me?".

I have never ever asked a physician the rationale of something and gotten blown off or "because I said so". Either you work with some really disrespectful physicians or perhaps you aren't making yourself clear that you are honestly trying to learn something and it may come off as "questioning" orders in a disrespectful manner.

Thanks for the input. I don't walk to them with an accusing voice or challenging their authority; I have asked them if they can clarify a question or clear something up for me. Here is an example; an order came in to our clinic for a client to take kaxeolayte one dose at the clinic and the patient to take the second dose at home. Did not order the route. No follow up appointment to monitor the potassium level. The potassium was 5.9. While I 'knew' that in a clinic setting, the order was probably by mouth, but I make no assumptions and the route is supposed to be there, no matter what. I pick up the med from the pharmacy and see that that same bottle can be administered by mouth and by enema. I checked the physician's note and didn't see why the patient would need to take this drug with no follow up. I take it to the RN, she is afraid to page him because he is a creep. I page the man, and he tells me that he is on his way home, is not coming back and that I should assume that the order is to be by mouth. I then asked if the patient was to be followed up and also wanted to know who can I contact to add to the order that it was in fact, to be adminstered by mouth. He says he does not know and hangs up on me. I then get the RN and tell her I am not comfortable administering this medication to the patient with vague orders. I checked my drug book, nothing made sense to me. I wanted to give this patient the right information and support, so, I call the physician back and had the RN speak to him. She gave the meds without receiving an adequate answer, either.

It came up in a meeting later who we should contact if we have such issues, but I felt that this should have been discussed during orientation what to do when the clinic closes and the physicians are gone. Basically, I know that the approach is extremely important. I think I do that, and it seems that most of the nurses have a similar approach. This is one of many examples that make me say that we are advertising false information to receive magnet, because each discipine seems to work against us. We have no input on things done to support patient services. Another one is that we have late clinic and they closed the pharmacy after 5 pm, but clinic lasts until 9 pm. We sell prescriptions for $10 each in our community hospital; so, those with no insurance can pay for their medications. How can we administer vaccines, clonidine, or tell patients that they can pick up their meds the same day when there is suddenly no pharmacy available for us? I can go on and on...sorry...:angryfire

[kcalohagirl]

I work in a hospital that just got Magnet status.

I don't know about nursing on the other units, but I can speak a bit about the unit I work on.:)

Our unit is a specialty unit. In other words, unless every other telemetry bed in the hospital is full, we rarely get patients that aren't from the Cardiothoracic Surgery service. Occasionally we will get Cardiology patients, but not really very often. So we know our docs and the docs know us pretty well. Our CTS surgeons are absolutely AMAZING to work with! The 3 surgeons have a staff of 4 PAs, and 1 resident per rotation. The PAs are awesome, and most of the residents aren't too bad either. In the time I have been on this unit, there have probably only been 2 residents that just made the nurses cringe.

Usually we contact the PAs or the Resident. Attendings are rarely on call. I work night shift, and even when there is something slightly emergent (bp, falling O2, etc) the person on-call will often ask us for feedback on what we would like to try, what may have worked in the past for that person, and are also more than willing to tell us why they think a course of action we suggest might not be the right one. There is hardly ever any friction between the nurses and PAs, and usually the only friction seen between the nurses and the Resident is when the nurses feel the Resident isn't being aggressive enough with treatment. The attendings have also made it very clear that we are to feel free to call them at any time of the day or night if we feel that to be the case.

I think this is one of the most awesome environments I could possibly work in! It really fosters an "environment of care" (as the catchphrase goes.) Caring for the patients seems to be a team effort, and it's really common to see the nurses and PAs collaborating during morning rounds to try to come up with what will best serve the patient.

Yes it occasionally has it's days, but what place doesn't?

[RNontheroad]

Being a traveler, I get to experience a variety of hospitals and units. It is my humble opinion, that nurses seem to have more autonomy in teaching hospitals. My guess is because we are not the lowest ones on the "food chain"...the residents are. They often look to the nursing staff for guidance. The attending physcians put a certain amount of trust in us as well, to help keep an eye on the residents and help teach and answer their questions.

Some of it seems to depend on the type of unit as well. Specialized units (ie: cardio-thoracic, neuro-trauma, etc) seem to have a bit more autonomy as well because they work very closely with a specific group of docs and they get to know each other well. There seems to be a real trust that is established and in turn, the nurses have a bit more leadway.

I have not seen much difference in Magnet vs. Non-Magnet as far as autonomy (unless you consider self scheduling and and the clinical ladder to be part of the equation).

[one breath at a time]

I worked at a teaching hospital in a medical respiratory icu where we had a lot of automony. I agree with RNontheroad in a specialized unit of a teaching hospital the residents and sometimes even the interns ask and even rely on nursing to point out what labs might be needed, meds or interventions that may be useful. This unit had great attendings who always took the time to explain interventions.

I now live in a small community (thanks us army) where the dr want to make all the calls and some dont even want to speak to nursing. I think it is that the doctors here have long standing relationships with the patients, may have been treating them for years before they ever come to the hospital where I finally meet them.

There are always those who have "the complex."

[LightningRN]

Thanks for the input. I don't walk to them with an accusing voice or challenging their authority; I have asked them if they can clarify a question or clear something up for me. Here is an example; an order came in to our clinic for a client to take kaxeolayte one dose at the clinic and the patient to take the second dose at home. Did not order the route. No follow up appointment to monitor the potassium level. The potassium was 5.9. While I 'knew' that in a clinic setting, the order was probably by mouth, but I make no assumptions and the route is supposed to be there, no matter what. I pick up the med from the pharmacy and see that that same bottle can be administered by mouth and by enema. I checked the physician's note and didn't see why the patient would need to take this drug with no follow up. I take it to the RN, she is afraid to page him because he is a creep. I page the man, and he tells me that he is on his way home, is not coming back and that I should assume that the order is to be by mouth. I then asked if the patient was to be followed up and also wanted to know who can I contact to add to the order that it was in fact, to be adminstered by mouth. He says he does not know and hangs up on me. I then get the RN and tell her I am not comfortable administering this medication to the patient with vague orders. I checked my drug book, nothing made sense to me. I wanted to give this patient the right information and support, so, I call the physician back and had the RN speak to him. She gave the meds without receiving an adequate answer, either.

It came up in a meeting later who we should contact if we have such issues, but I felt that this should have been discussed during orientation what to do when the clinic closes and the physicians are gone. Basically, I know that the approach is extremely important. I think I do that, and it seems that most of the nurses have a similar approach. This is one of many examples that make me say that we are advertising false information to receive magnet, because each discipine seems to work against us. We have no input on things done to support patient services. Another one is that we have late clinic and they closed the pharmacy after 5 pm, but clinic lasts until 9 pm. We sell prescriptions for $10 each in our community hospital; so, those with no insurance can pay for their medications. How can we administer vaccines, clonidine, or tell patients that they can pick up their meds the same day when there is suddenly no pharmacy available for us? I can go on and on...sorry...:angryfire

I honestly don't know how things work at your place of business, but if the same situation had happened to me I would have written a verbal order to administer the medication PO as per the phone conversation with the MD.

[pagandeva2000, LPN]

I honestly don't know how things work at your place of business, but if the same situation had happened to me I would have written a verbal order to administer the medication PO as per the phone conversation with the MD.

Since I wasn't sure, the RN handled it although she was clearly uncomfortable afterwards. That is a question that needs to be addressed with Staff Education. I'll ask them next week. I wasn't even sure if LPNs are allowed to take phone orders alone. I really appreciate the input that everyone gave thus far and look forward to hearing more. At least some places are demonstrating autonomy.

[pagandeva2000, LPN]

I work in a hospital that just got Magnet status.

I don't know about nursing on the other units, but I can speak a bit about the unit I work on.:)

Our unit is a specialty unit. In other words, unless every other telemetry bed in the hospital is full, we rarely get patients that aren't from the Cardiothoracic Surgery service. Occasionally we will get Cardiology patients, but not really very often. So we know our docs and the docs know us pretty well. Our CTS surgeons are absolutely AMAZING to work with! The 3 surgeons have a staff of 4 PAs, and 1 resident per rotation. The PAs are awesome, and most of the residents aren't too bad either. In the time I have been on this unit, there have probably only been 2 residents that just made the nurses cringe.

Usually we contact the PAs or the Resident. Attendings are rarely on call. I work night shift, and even when there is something slightly emergent (bp, falling O2, etc) the person on-call will often ask us for feedback on what we would like to try, what may have worked in the past for that person, and are also more than willing to tell us why they think a course of action we suggest might not be the right one. There is hardly ever any friction between the nurses and PAs, and usually the only friction seen between the nurses and the Resident is when the nurses feel the Resident isn't being aggressive enough with treatment. The attendings have also made it very clear that we are to feel free to call them at any time of the day or night if we feel that to be the case.

I think this is one of the most awesome environments I could possibly work in! It really fosters an "environment of care" (as the catchphrase goes.) Caring for the patients seems to be a team effort, and it's really common to see the nurses and PAs collaborating during morning rounds to try to come up with what will best serve the patient.

Yes it occasionally has it's days, but what place doesn't?

When Magnet came to your hospital, what was the experience? Did they ask you questions, and did they check charts and statistics of their best practice? They are on their way to us on 9/5-9/7 of this year. In fact, I may post this as a new thread. Thanks for sharing.