Do ICU nurses really have more autonomy?

Coffee Nurse, BSN, RN · Jan 18, 2010

Does adult ICU generally have more standing orders than NICU? I only have experience with the latter, and it surprises me to hear that some places allow nurses to titrate inotropes within a range, decide when to give K boluses, etc. In my unit, those actions are definitely strictly by specific MD order only. Does it vary by facility, or is it just that I'm working with the tiniest patients?

FlyingScot, RN · Jan 18, 2010

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

No not really. As Elkpark stated we really don't work autonomously anywhere. If you are working by protocol, standing orders, etc. you are still working under a physician's order. That decision to titrate a pressor up or down is based on parameters given to us by the doctor. Standing orders are okayed by a doctor. Even when I was flying we worked under protocol. I had the ability to independently apply it in the order I saw fit but the order still originated from my MCP.It might have looked to a bystander as if I was functioning autonomously but I really wasn't. In the ICU and ER settings a seasoned nurse can anticipate what the orders are going to be and get started on them (IV for kidney stone patient for example, labs for a r/o sepsis patient, O2 for a SOB patient you get my drift) but truthfully we walk a very fine line when doing these things.That is a collegial relationship but certainly not an example of an autonomous nursing role.It's a matter of trusting your medical colleagues to back you up with an order because if they don't then you have the potential to be hung out to dry if something goes wrong. In my experience NICU is probably the most restrictive as far as nursing practice which is completely understandable. The margin for error is very, very small. That said, even if we don't function autonomously in its purest definition that still doesn't mean our critical thinking skills, assessment,nursing judgement and ideas for plan of care (both nursing and medical) are without value.

Virgo_RN, BSN, RN · Jan 18, 2010

Agree with the above.

XingtheBBB, BSN, RN · Jan 18, 2010

Does adult ICU generally have more standing orders than NICU? I only have experience with the latter, and it surprises me to hear that some places allow nurses to titrate inotropes within a range, decide when to give K boluses, etc. In my unit, those actions are definitely strictly by specific MD order only. Does it vary by facility, or is it just that I'm working with the tiniest patients?

And I've only worked in level II "NICU" (no drips) so I can't really compare. But yes. We have a goal for all of our titratable drips- nitro, most inotropes, pressors, sedation and we titrate to that goal. Nursing judgment is key as rarely do we have "start at XX rate" orders or standing protocols to "increase by XX mcg". We just learn how big of a change is too much and how little of a change is a waste of time. And we do have regular and renal sliding scales for K, Mag, Ca, Phos.

CASTLEGATES · Jan 18, 2010

Regarding the study; it's perceived autonomy. It's the nurses digression whether or not to alert the doc and flexible sliding scale orders may be classified as dependent but the orders are open to your professional assessment. In that respect, ICU over ER for my experience had it hands down. I was following orders but making more critical judgments of what and how much to follow. My ER days, doc says do it, it's done then they move on. ICU it's up to you what pressor to use (sometimes the orders give you a choice of pressors and choices of drips and you match to what the UO, CO and swan are reading...all depends on the facility and trust of their staff.). Wean to extubate...how much peep to drop? What settings? We did all the vents, too so it was wide open. We did call resp to extubate once we had em on blow by though. We'd call the doc (per orders) to remove CT's once output reached X or less, etc. It was a lot of work, lots of thinking but fun. I think it all depends on your sliding scale orders and if they depend on them. I'd say it's impossible to do a study since facilities vary and states vary so vastly with what you can and cannot do. The state I'm in, we can't do squat...a couple states out west, you ran most of it.

IHeartPeds87 · Jan 18, 2010

In my experience NICU is probably the most restrictive as far as nursing practice which is completely understandable. The margin for error is very, very small. That said, even if we don't function autonomously in its purest definition that still doesn't mean our critical thinking skills, assessment,nursing judgement and ideas for plan of care (both nursing and medical) are without value.

It surprises me to see someone saying that! I always was under the impression that the NICU nurses felt they were very autonomous....?

JulieCVICURN, BSN, RN · Jan 18, 2010

To me, autonomy is about not having to call the doctors for every little thing. In our ICU we have lots of standing orders and sliding scales, etc., but we also have more authority with the doctors. It's not fair, but they seem to be less condescending to our unit than they are to others. I didn't realize this until my friend who works at the same hospital in Peds/Med-Surg told me that the doctors often don't even call them back when they're paged! I've never had a doc not return my call, not in 3 years! (Which is the entire span of my nursing career).

elkpark · Jan 18, 2010

It surprises me to see someone saying that! I always was under the impression that the NICU nurses felt they were very autonomous....?

Again, in nursing, "autonomy" is largely self-defined -- lots of people feel their role is more or less autonomous, but someone else with a slightly different perspective may see it entirely differently (as we've seen just in this short discussion :)).

Music in My Heart · Jan 18, 2010

Everyone states that ICU nurses tend to have more autonomy than nurses on other floors. Can someone elaborate? In what ways are ICU nurses more autonomous?
Just curious...I have been interested in working with babies and am considering the NICU...i have a ways to go lol im only a prenursing student right now!

From what I've observed, NICU nurses don't have much autonomy because (a) the babies are soooo dang fragile and (b) there's often a neonatologist in the house (and often an NP and/or CNS).

That's based on one small NICU and two large level III regional facilities.

FlyingScot, RN · Jan 19, 2010

Again, in nursing, "autonomy" is largely self-defined -- lots of people feel their role is more or less autonomous, but someone else with a slightly different perspective may see it entirely differently (as we've seen just in this short discussion :)).

You're absolutely right IMHO. I believe that the examples of "autonomy" given in this thread are really examples of nursing judgement and critical thinking rather than true autonomy. I say this because the decisions are based on guidelines/orders given by a physician. A more accurate example of autonomy in nursing is our various state boards. We are nurses governed by nurses, not by doctors or politicians but by nurses. It's a great thing. This is autonomy at its purest. We decide the scope of practice, educational standards, licensing and discipline of our fellow nurses. Another example would be (this might have been mentioned earlier) those hospitals that utilize shared governance. I think we often interchange the words autonomy and independence, treating them as synonymous when really they are not. I really value institutions that allow me to think independently and have been really frustrated with those jobs that require me to "check my brain at the door".

allnurses Guide · Jan 19, 2010

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

Please don't put words in my mouth. I NEVER said "psych nurses don't practice real nursing, they just sit around", and that's not what I think. I do think psych nursing involves a lot of one on one talking, and that's half the point of it. God bless psych nurses, I absolutely couldn't do it. As I clearly said THAT'S JUST ME and what I prefer to do. My point was that the definition of "nursing autonomy" is irrelevant - what you and I feel is "more" or "less" independence in practice isn't the same. If you think critical care nurses "stand around and fiddle with stopcocks and follow orders all day" I hope you never need one.

PostOpPrincess, BSN, RN · Jan 19, 2010

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 ...
I do not understand this one-up-man-ship that people display.

Extremely UNNECESSARY.