I'm not trying to stir up a war. I realize I've just started a thread on a very controversial topic here. But I'm simply not convinced nurses have much autonomy. There are some aspects of nursing that appear independent, such as how nurses are governed by other nurses in terms of licenses, credentialing, certifying colleges, etc, but in the clinical setting, you do what the physician says. You can't giving a patient watered down nasal spray without a physician order. Catheterizing, wound dressing, dress removal, aside from taking vitals, recording the information, and advocating for the patient, you can't do anything a physician hasn't ordered in terms of providing care.
I understand I'm still young, and there are things about nursing I don't understand fully, so if you're willing to kindly explain how nurses can be considered autonomous health care providers, I'm more than willing to consider what you tell me.
I always thought autonomy more as being able to organize your day as you see fit. And I also thought that hospice nurses seem to have a lot of autonomy! My clincal experience with hospice was great. If you want autonomy, I think that is the way to go. But I'm just a student here. Any hospice nurses want to weigh in on this one?
Yup, compared to many other specialties, Hospice is much more autonomous.
Example: in hospital nursing (acute care vs. crit care)- you most often can't give ASA, Tylenol, etc w/o calling and getting an order.
In hospice nursing, there are 'standing orders' for pain meds, antiemetics, scop patches, etc for all pts, and you can give these at your own discretion.
Specializes in Community Health, Med-Surg, Home Health.
I can definitely agree that nurses feel the stress because we are there with the patients the entire time, possibly seeing them decompensate before our very eyes, and I am sure many nurses felt their hands were tied while waiting for a doctor to make a move.
However (at least from my personal observations and opinion), autonomy is as good as the doctor that supports that nurse if she has to act independently. Let that nurse make a mistake that is not deemed as prudent and see where that will land her. To me, this is what makes it stressful...you are damned if you do, damned if you don't. And, it seems to me that many times, the doctors have pushed their responsibilities on the nurses that really shouldn't be because they didn't want to respond. If an order is not signed, even after the fact, that nurse is left out there if the action taken is not deemed to be prudent and even that is subjective. This is one of the reasons why it is not safe to work in a place that has a high turnover of RNs. I see it as being a situation where a seasoned nurse cannot advise a nurse who doesn't have as much experience in how to navigate the system, the politics or personalities of their collagues, management and the physicians. It can be an accident waiting to happen.
I graduated from law school in 2002. I start my first semester of nursing school on Monday (it's a BSN program, so I've been taking re-reqs).
My advice would be to work as a nurse for a few years, then decide if you want to spend $100K on a law degree. You may be fortunate enough to have the means to pay for it outright. But cost would be a serious consideration. There are wonderful ways a nurse attorney can help people - so if you are serious about it, it very well may be worth the investment to you and your future patients/clients. Good luck in school!
well congratulations on getting into a program and I wish you lots of success!!!
Not a hospice nurse, but a home health nurse, and you don't get any more autonomous than us...most of our orders are made regarding dressings and wounds, nothing about medications, but while we are in the home we can't get the MD on the phone in the hour we are there, so we make our best judgment and then call the MD for the order. I did work in the hospital though prior to becoming a home care nurse, and I have to say that there was a lot of opportunity for autonomy there too--coming from a large teaching hospital, if you wanted it you could take it. Many nurses chose not to take it, either for fear, or lack of confidence, or purely just not caring; but we had the "power" to make a lot of decisions or to veto a lot of decisions as well. And as an advocate for your patient, I would think that would go without saying in many places. I can remember many a mornings where I would put orders in for a doctor for diet, activity, change the schedule of meds, d/c a foley, straight cath for retention, etc...and then tell the resident what I had done, never did they balk at it because it was all things that they would have done, but at 8AM when they are trying to catch up from post call and start rounding and multi-d rounds, they don't have the time to put in orders for 25 patients whose diet needs to be switched from clear liquid to regular because they are 1 day post op. I think if you have established the trust between the MD and the RN and the RN is willing and capable of taking on the "autonomous role" then he/she should take it...there were several nurses that would starve patients on our unit because their orders wouldn't get changed from clear liquid to regular until after breakfast was served when the docs were rounding...if you want the autonomy, take it...if you don't, leave it for someone else....
I haven't been a nurse for long but it seems to me that a huge problem with nursing is that no one wants to focus on providing basic care because it's perceived as lowly grunt work.
I think you hit on something essential there. People nowadays seem to have ideas that "grunt work" is bad, somehow. People seem to be allergic to poop, and have the idea that basic care is demeaning, and want to delegate everything but the meds and the charting to the CNA.
I diapered my little brother and sister, and helped potty train them, back before it was a mortal sin to potty train with candy. I babysat for ages as a teen and that was no picnic, lemme tell you. I worked fast food, phlebotomy (way bottom of the food chain there), raised my own kids, and had a whole slew of go-nowhere jobs. I would take wiping people's behinds with a nursing degree over any of those jobs. I am proud of having the knowledge, skill and willingness to do total patient care! Quite a few of the patients in our hospitals are utterly humiliated by having to have someone help them with basic bodily functions, and they need people who can do so with grace, and without making them feel worse about it. The profession of nursing is necessary and will never be unneccessary.
Okay I rambled a bit there. To me, autonomy means that my peers (nurses) oversee my department, and my license. It also means that me and my peers determine my workload, and if I don't like it I can go find another job with a different set of peers. It means that I get my assignment and for the rest of the shift, I determine how to go about having safe, well cared-for, live patients at the end of it. I determine if and when to call the family, the doctor, or the chaplain. Sometimes I am the chaplain, sometimes there is a code and the nurses who are ACLS certified, call the shots and the doc shows up later. (You can tell I work nights.) I make sure they are bathed, cleaned, assessed, dressings are good, etc. This means I work with people- I help the CNA's and check with them so they know what's expected, and pick up the slack if their workload is unreasonable. I work with the respiratory therapists and sedate people who fight the vent, etc. The thing is that I choose to do these things, nobody tells me to. The drugs are given by prescription from the doctor but I don't give drugs unless I know why and am comfortable that they are appropriate, and this requires education and training. I also play mediator between the patient, the family, the doctor, and god knows how many other departments. Sometimes patients are unable to communicate what they need, and I help with bringing problems to the attention of those who can help- whether the patient knows what I did or not.
I chose this profession, and I didn't choose it just to be autonomous. There is autonomy, but if you define autonomy as being god, you won't find that in a profession on this planet.
i have felt too autonomous in icu before. the following is a post i made in the critical care section two years ago. btw, i no longer work at this facility.
"ok, i feel kind of burned out after working four 13+ hour shifts in a row. too many admits and not enough admit orders being written. i work night shift.
do any of you feel that at times you have too much autonomy for your scope of practice? when i call a doctor for a problem i have to tell him what drug i want prescribed at what doses. i am waking them up and feel bad for that......but i am not a doctor and i am not a nurse practioner. i need to tell the primary physician what speciality consults the patient needs and write all the orders for it. sometimes i think, why should i even call the doctor? i am telling him what i need and he tells me ok.
so, now i have to do all the work, have no cna or unit clerk, and have to decide how to treat the patient too? do all of you feel like this? am i burnt out or are my icu hospitalists slacking off?
I'm starting nursing school in 12 days, so I have limited input on the nurses' autonomy subject, per se; I'm sure I'll have some strong opinions very soon. However, I have worked in other professions and have observed my husband's frustration with this for the 12 years he's been in the work force.
He has a PhD in electrical and computer engineering and designs software systems for robots. Even now, after 12 years of work plus 5 years of grad school, 4 years of college, and a lifetime of tinkering with robots at home, he still has to work under the requirements of other people, many with less robot experience than he has (and most without PhDs). He has long lamented the fact that he has always had a huge amount of responsibility with remarkably little authority. Now that he has an excellent team of younger engineers working under him, he is able to direct and teach them more and can spend more time on higher-level design decisions rather than writing all the code himself. Still, though, he's not a manager (tried it, hated it, went back to being a techie), he answers to managers (and even when he was a manager, there was always a manager above him), and someone else has the last word on what he does, even with all his expertise. The guy over him answers to a boss, and he answers to a boss as well. You'd think the buck stops with the CEO, but even he answers to the board, and they all answer to the stockholders!
I have also been thinking of the post above regarding why it's important to (most) nurses to have this autonomy, regardless of how you define it. Nursing attracts an increasingly well-educated, professional group of people these days, and these folks expect a certain level of independence in making decisions. I know I do. I want to feel that I'm using my mind and not having to wait around for someone else to rubber-stamp what I know is best before I can make a move. But I also know that no matter how many degrees and certifications I get, there will be someone above me that I have to answer to. I don't think that the need to answer to someone (accountability) is quite the same as having to have everything you do approved by someone (how I define a lack of autonomy). My husband's situation vacillates between the two; the former is to be expected, but the latter is where he (and many of those posting above) get frustrated. Either way, to quote Bob Dylan, "You're gonna have to serve somebody."
All that said, the day is going to come (again and again, most likely) that I have to wait for someone to okay a decision that could mean life or death to a patient, and that's going to require a measure of patience and fortitude I'm not sure I have...
You just now figuring this out??!!!!!!! Ever heard of PRN? Pee on RN!!!!!! Nurses are nothing more than sweat labor who are as disposable as yesterdays bath water. No respect from doctors and certainly no respect from management. It'll never change!!!!!!!!!
Specializes in PICU, NICU, L&D, Public Health, Hospice.
Yes, hospice nurses (particularly in the field) have a great deal of autonomy. The case nurse decides what the frequency of skilled nurse visits will be and what the focus of the visit will include. The nurse orders additional disciplines. The nurse educates and acts on the Plan of Care that is primarily created by the nurse. The RN case manager supervises the LPN and HHA working on the team. The nurse directs the family in care which does not require a physician order...so for instance...I can instruct the family to soak the feet, or increase oral fluids, elevate extremities, etc...things which are not contraindicated by diagnosis, drug list, or scope of practice. For the record...I could instruct in NONE of those things while in CHC, I could ONLY instruct in what the MD had ordered. The certified home care that I worked for allowed nurses only to carry out MD orders...period. They were not interested in nursing diagnosis unless there was a corresponding medical diagnosis and order set related.
Keep in mind that I do not need physician orders to carry out my daily job. For example, I visited a patient today who has an agitated dementia. She is ambulatory and falls occasionally. She bites her fingers and has an agitated echolalia. I visit, assess, develop a plan, and educate independently of other disciplines. I collaborated with the MD and NP today regarding a change in her meds. We do have standing medical orders which allow us a great deal of liberty in starting and increasing medications included in our formulary for specific symptom patterns. However, I also worked with pretty inclusive standing orders in the PICU, L&D, and in the outpatient setting.
I cannot order OTC meds for a patient, however, I can give them information which is factual and pertinent and then note that based upon our discussion they opted to initiate say...mucinex or milk of mag...you get my point. If the physician is not happy with the family's choice about that OTC med, I am accountable for the teaching I provided (accountability being a consequence of autonomy).
Honestly, what I do as a nurse is not limited to physician orders, rather, what I do is to identify where physician orders may be needed in addition to other interventions. I can see that a new med surg nurse may question his autonomy, feeling that all he does is carry out MD orders, however, it is the nurse that diagnoses the issue with skin integrity, or sleep disturbance, etc which may change the medical plan dramatically.
When you encounter nurses who are process and patient oriented rather than task oriented you are observing nurses who are functioning in an autonomous role.
Here is an excerpt from the link. It really is a great article IMHO.
To some extent this may depend on how you define autonomy--if it means having just as much power as physicians, or the legal and practical rights to do everything physicians do, such as prescribe narcotics, then nurses obviously do not have autonomy. However, in our view that would be an unduly narrow and physician-centric way to define autonomy, one that reflects the assumption that what physicians do is the most important part of health care. Nurses can't practice medicine, but neither can physicians practice nursing. If you're snickering, we suggest you examine your own understanding of and respect for what nurses do.
Dern straight...SaY it again LOUDER...:yeah::yeah: STANDING OVATION !!!!
Honestly, what I do as a nurse is not limited to physician orders, rather, what I do is to identify where physician orders may be needed in addition to other interventions. I can see that a new med surg nurse may question his autonomy, feeling that all he does is carry out MD orders, however, it is the nurse that diagnoses the issue with skin integrity, or sleep disturbance, etc which may change the medical plan dramatically.
When you encounter nurses who are process and patient oriented rather than task oriented you are observing nurses who are functioning in an autonomous role.
tewdles, it's funnt you posted this now.
I have been thinking about this since last week, when I posted. But this weekend I was supervisor, of a 120 facility with some very fragile residents. In that time we assessed a resident who fell and got her sent out to ER because we thought she broke something. She had. Called the on-call to get a PRN Ativan added for an agitated LOL with dementia who kept crashing her merry-walker into the doors. Talked a hysterical woman down from the edge when the hospital told her they were discharging her dying father back to us. Explained comfort care, soothed her....
And I ran the sucker, with the help of some excellent nurses and aides and physicians who trust us and give us what we ask for.
in terms of care the nurse has the right or the power to do what is right but in terms of treating the patient the doctors has the power....but yah you have a point there but as much as possible we dont really follow what the doctors saids unless its life threatening... i mean they are not there 24 hours like for example the doctor mistakenly ordered tramadol for pain reliever when the patient is post op for 6 days already.... are you still going to give it knowing that there is something fishy going on...? THATS WHERE AUTONOMY IN NURSING COMES IN!!nurses accepts orders from doctors because this is not about authority anymore but how two disciplines coordinate to work for a common cause to restore patient
:up: 
:yeah:
DLS_PMHNP, MSN, RN, NP
1,301 Posts
Yup, compared to many other specialties, Hospice is much more autonomous.
Example: in hospital nursing (acute care vs. crit care)- you most often can't give ASA, Tylenol, etc w/o calling and getting an order.
In hospice nursing, there are 'standing orders' for pain meds, antiemetics, scop patches, etc for all pts, and you can give these at your own discretion.
No calling physicians at 0200 to get orders.