Do ICU nurses really have more autonomy?

RNperdiem, RN · Jan 18, 2010

We do have more control over visitors. Nurses can tell families to leave at shift change and limit the number of visitors.

We used to pick our own assignments after a quick report, but that changed when we moved to a bigger unit. I miss that small piece of autonomy sometimes.

shoegalRN, RN · Jan 18, 2010

Yes, in ICU the nurse can determine if a visitor can stay or leave after visitor hours. If it's a new admit from ER, I will allow the pt to have a visitor at the bedside.

If it's a withdrawal of pt care, I will allow family to stay at the bedside and I will be at the desk to give that family whatever they need, in addition to caring for my other pt.

Also, nurses can swap assignments and orientees as well.

allnurses Guide · Jan 18, 2010

God, I don't care about being able to let visitors come and go!!

I do think there is more clinical autonomy - a lot of things are able to be titrated according to your nursing judgement ie. changing critical drips and watching the vital signs and invasive hemodynamics to see how the wean is going. Many things have standard orders or ranges which allow you to make decisions within those ranges before calling a doc. You also after time, and with experience, get that "sense" of when things are going well or badly, and the doctors tend to listen to you a lot more when you tell them the patient is circling the drain, because they know you've been standing there watching them for 12 hrs straight.

netglow, ASN, RN · Jan 18, 2010

Well, during college clinicals I had quite a lot of ICU time, did my management rotation in ICU as well. I had the opportunity to look at two facility ICUs (not NICU).

I'd say that "level" of autonomy comes from the nurse. How do I explain. One facility only hired nursing staff with (5yr) cardiac experience at minimum much preferred if they were going to be new to the ICU. This facility does open hearts, level one trauma etc. on a regular basis. I sensed confidence in these nurses and felt secure working with them. Also, these nurses could at times, pretty much lay out what they wanted for a patient, brief the intensivist or other physicians, turnaround and implement as the MD pushed paper. That is autonomy. But realize that you better know your stuff. This kind of "knowing your stuff", is on a different level than your typical nurse knowing her stuff. Lots of extra education on their part. Its almost like they are entrepreneurs, very self motivated. The other ICU, had very infrequent open hearts, and hardly any real trauma. I noticed the majority of staff were young, some new grads :eek: you could palpate the stress of the place without seasoned mentorship. I did not witness the same caliber of autonomy at this site. I also felt jittery due to a lack of very experienced staff.

If I were you, I'd try to get every opportunity to be in a longer clinical rotation in NICU if you have management (at least 5 weeks, while in school). The only way to really understand is to work there in an RN capacity as a student. This is a way to see if you feel you still want to work towards that one future goal.... or not. I feel that you have to step back and look at things how they really are, and get away from fantasy thinking as much as possible. "I always wanted to be a nurse since I was a little girl" and "I only want to work in ICU" as some people soapbox, can really throw your potential out the window, and lead to a serious case of "crap, this isn't all I dreamed it to be."

XingtheBBB, BSN, RN · Jan 18, 2010

We have a lot of protocols that seem to give us autonomy. For instance, if a K level is low, we write for oral or IV replacement according to our protocol and give it. No phone calls unless the patient is an exception. Our insulin protocols are also broader.

The doctors ask us a lot what we want ordered and if we think we should intubate or not.

We can also run our own codes... occasionally things happen fast and we get the pt back fast and realize we never called a doc.

CASTLEGATES · Jan 18, 2010

Depends on the facility. One where I was, our standing orders were "Versed 1-4 q1-4 prn, Morphine sulfate 1-8q 1-4 prn, K and Mg standing orders, wean to extubate, titrate for cardiac output of xxx, titrate for map of xxx titrate for xxx to xxx. Some private hospitals are more controlling where teaching institutions, it's a collaborative effort and everyone's pitching in leaving you a well educated, well informed competent nurse. I prefer teaching places cause you get to help the residents get through their rotation and in turn they help you giving you the flexibility you need in order to get your patient outta there and onto the floor.

We also were self governed and had open visiting hours 24/7. Studies show complaints and lawsuits plummet when visiting is not restricted. We'd just ask them not to awaken the Pt but they could stay as long as they like and to step out for a minute if something needed to be done. We found visits were shorter and less often when hours were open. It was a progressive thinking unit and everything worked great. We had nothing to hide and we were not self conscious about our competence so visiting was not a threat.

elkpark · Jan 18, 2010

I'm not trying to start an argument or anything, but I read a study years ago that someone had done of autonomy/independence within the different nursing specialties (sorry I don't have a link -- it was years ago) -- the authors looked at what percentage of a typical day at work consisted of performing "dependent" functions, those things that consisted of following physician orders, protocols, standing orders, etc. or other things that you were told to do by other people/disciplines, and what percentage consisted of performing "independent" functions -- things that were exclusively nursing actions and that you didn't need anyone else's direction or permission to do. The study looked at all the different specialties and arranged them on a continuum from "least independent" to "most independent," and the results were that ICU nursing was the least independent specialty (because nearly everything that's done is done in accord with physician orders, protocols, etc.) and psychiatric nursing was the most independent specialty (I don't recall where other specialties fell on the continuum -- I just remember the two "ends").

Of course, that doesn't mean that ICU nurses don't feel that they have a lot of independence or autonomy in their practice -- a lot of that depends on how you're treated by physicians and your bosses in a particular facility, how the unit is operated, and your own attitude toward your practice.

XingtheBBB, BSN, RN · Jan 18, 2010

I'm not trying to start an argument or anything, but I read a study years ago that someone had done of autonomy/independence within the different nursing specialties (sorry I don't have a link -- it was years ago) -- the authors looked at what percentage of a typical day at work consisted of performing "dependent" functions, those things that consisted of following physician orders, protocols, standing orders, etc. or other things that you were told to do by other people/disciplines, and what percentage consisted of performing "independent" functions -- things that were exclusively nursing actions and that you didn't need anyone else's direction or permission to do. The study looked at all the different specialties and arranged them on a continuum from "least independent" to "most independent," and the results were that ICU nursing was the least independent specialty (because nearly everything that's done is done in accord with physician orders, protocols, etc.) and psychiatric nursing was the most independent specialty (I don't recall where other specialties fell on the continuum -- I just remember the two "ends").
Of course, that doesn't mean that ICU nurses don't feel that they have a lot of independence or autonomy in their practice -- a lot of that depends on how you're treated by physicians and your bosses in a particular facility, how the unit is operated, and your own attitude toward your practice.

That makes sense. Really, I think it's how people define autonomy. Strictly speaking there is NO autonomy in ICU. Not for anyone. The residents order according to protocols and are very much accountable to the attendings. The intensivists are accountable to their partners and the best practices they have defines and accountable to their consults... renal, cardio, ID, neuro, etc. ICU is hugely collaborative. But you use your critical thinking in an way that is consistent with the way nursing schools and theorists define autonomy.

allnurses Guide · Jan 18, 2010

I'm not trying to start an argument or anything, but I read a study years ago that someone had done of autonomy/independence within the different nursing specialties (sorry I don't have a link -- it was years ago) -- the authors looked at what percentage of a typical day at work consisted of performing "dependent" functions, those things that consisted of following physician orders, protocols, standing orders, etc. or other things that you were told to do by other people/disciplines, and what percentage consisted of performing "independent" functions -- things that were exclusively nursing actions and that you didn't need anyone else's direction or permission to do. The study looked at all the different specialties and arranged them on a continuum from "least independent" to "most independent," and the results were that ICU nursing was the least independent specialty (because nearly everything that's done is done in accord with physician orders, protocols, etc.) and psychiatric nursing was the most independent specialty (I don't recall where other specialties fell on the continuum -- I just remember the two "ends").
Of course, that doesn't mean that ICU nurses don't feel that they have a lot of independence or autonomy in their practice -- a lot of that depends on how you're treated by physicians and your bosses in a particular facility, how the unit is operated, and your own attitude toward your practice.

I'd rather be "less independent" and titrate an inotrope infusion using critical thinking and hemodynamic knowledge than be "more independent" and instigate "nursing" interventions by chatting to a psych patient.. but that's just me!! :) Nursing loves to measure their wishy washy "nursing" interventions and call that autonomy. I call being able to keep someone alive autonomy.

elkpark · Jan 18, 2010

I'd rather be "less independent" and titrate an inotrope infusion using critical thinking and hemodynamic knowledge than be "more independent" and instigate "nursing" interventions by chatting to a psych patient.. but that's just me!! :) Nursing loves to measure their wishy washy "nursing" interventions and call that autonomy. I call being able to keep someone alive autonomy.

Ah, yes, the ol' "psych nurses don't practice real nursing, they just sit around and chat with people all day" hoohah ... You don't think psychiatric nursing ever involves "keeping someone alive"?? What about all the acutely suicidal people we deal with on a day-in-day-out basis? I'd rather use my critical thinking skills and extensive knowledge of psychology, psychiatric nursing, and human development and behavior to make significant changes in people's lives than stand around and fiddle with stopcocks and follow orders all day, but that's just me ... :cool:

Good thing there's room for all of us in nursing, huh?

Otessa, BSN, RN · Jan 18, 2010

To OP-yes, they have more autonomy than a med-surg nurse but less than an ER nurse