Not Convinced Nursing is an Autonomous Profession

[Inspired By Silence]

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.

[jjjoy, LPN]

If autonomous means working without constant, direct supervision and having the ability to, within certain parameters, structure their own workflow then as well making decisions throughout the day then, yes, nursing is generally autonomous. The degree of autonomy varies a lot, though, depending on the type of nursing one does.

If it is to be able to set one's own work hours and choose which projects to take on, then generally no, nursing *in general* is not incredibly autonomous. In practice, msot nurses are employed by organizations who set the employment conditions that the nurse either agrees to or doesn't (by not accepting the job).

If autonomous means the right to practice one's trade independently (that is, set up shop and forego working for an intermediary that contracts with payors and brings in patients), only a very small percentage of nurses attempt that, and they are generally private duty nurses and primary care NPs.

[tewdles, RN]

I think that part of the difficulty of this thread is the definition of autonomous or autonomy. We seem to differ in the way that we define the word itself and then how we might apply that definition to nursing. Whether or not nurses (as individual professionals) are treated as or allowed to function as autonomous professionals is more related to their employer model than it is related to the nurses' ability to function autonomously. In other words, nurses can generally function more autonomously than their practice environments allow...and that is okay for most.

Clearly nursing is governed and directed by nurses, that makes the profession autonomous. Nurses, by and large, are given an assignment, or area of responsibility and then the individual nurses determine independently how to accomplish the tasks and duties involved and in which order to accomplish them...this is professional autonomy. The care the nurse provides is individual, distinct, and generally self-directed, all of which would apply to an autonomous profession.

Autonomy in nursing is not limited to one's ability to own or operate their own health care business (as a physician might) although that can be a component of autonomy. It is not about taking direction or orders from someone else, few autonomous professionals function without input or direction from other interested professionals.

I am an autonomous professional. I was while working in PICU, in L&D, in community health, and I am in hospice. There has ALWAYS been the expectation that I will use my professional judgement to act on behalf of my patients. In my mind, that is an expectation of professional autonomy.

I welcome enthusiastically further discussion on this subject.

[jjjoy, LPN]

Clearly nursing is governed and directed by nurses, that makes the profession autonomous. Nurses, by and large, are given an assignment, or area of responsibility and then the individual nurses determine independently how to accomplish the tasks and duties involved and in which order to accomplish them...this is professional autonomy. The care the nurse provides is individual, distinct, and generally self-directed, all of which would apply to an autonomous profession.

I don't see how having a board of nursing that issues & can revoke licenses would make the profession more or less autonomous than a profession without that.

What you describe could also describe teachers, police officers, administrators, managers, and more. Assistive personnel from offices to hospitals also have similar autonomy (though not the same level of responsibility). Secretaries usually need to use their own discretion in how to handle things and in prioritizing, and nursing assistants often have their own patient assignments and are to independently accomplish their goals (bathing, grooming, etc) using problem-solving skills, getting assistance when needed and referring to another when something is beyond their 'scope'. I'm not sure how I feel about what 'autonomy' can mean and what gets labelled as such.

And I'm wondering if it's even really possible to define a profession as 'autonomous' as that implies that many other professions are 'not autonomous.' Most jobs have some degree of autonomy, though it may be relatively small. Often times, workers are obstructed from acting autonomously simply because the employer doesn't allow it, even though it would be possible to have more leeway without the strict dictates of an employers.

[sharonlu]

I was in a situation more than once where I felt I had to refuse the doctor's order and did so. One time the MD became angry and took the syringe and administered the too high dose himself and the patient (7yr old) died. I was glad I refused. Nurses get stuck in some pretty bad situations - like you feel you are not able to take the huge assignment given you and that it would be dangerous for the patient if you try to get by but if you walk out you are "abandoning" the patient. What do you do?

[RyanSofie]

OK moderator have had enough of this discussion. I have worked hard to be who and what I am ...a Registered Nurse and I love what I do. Please Please close this subject...

[t2krookie]

It sounds to me like you equate professional autonomy with ability to make medical diagnosis and prescribe medications.(Correct if overly simplified) If I understand your post, nurses can only be considered autonomous if we are practicing in more of a advanced practice role.(True autonomy correct ) It makes me sad that, assuming you are a nurse, you feel that your education and position does not allow you to implement meaningful nursing processes which improve the quality of life of your patients.(Now you're putting words into another's mouth) It is most unfortunate, IMHO, that you apparently do not value the nursing process and plans of care.(Again with assumptions. Never made a value judgment on nursing process. I only reflected that it was not "autonomous" which was the subject line of the thread) I wonder why you minimize the importance of the fact that we DO impact pt outcomes...that is HUGELY important...and frankly, continuous nursing care is the primary reason that people remain in the hospital(Repeat of last comment. Your extrapolation is increasingly speculative and off target)...they need OUR assessment, support, and intervention 24/7.(nice obvious patronizing platitude that no one would contend)

My suggestion would be that you pursue an APN for yourself.

(Good suggestion. I already am and learning a wonderful new world of nursing.)

Look , if you can step away from the personal observations based on speculation and address my comments in a more impersonal nature, it would be easier to have a substantive discussion. I'm not here trolling RN boards looking for a fight. I saw a thread that I was interested in and I gave my "2 cents" being as it is an issue I had given thought to many times. The issue of "autonomy" of nursing is something I ardently support.

Our "science" or skill has a far more extensive history of success than many disciplines and actually is the root of several different allied health professions. That being in mind, we can sit on the sidelines as doctors and "why can't you just be happy being a nurse" types try to decide our professional development or marginalize us, OR we can in power ourselves by starting to think of nursing as a path towards health promotion that incrementally can resume the primary care spot and respect it had prior to the white coats co opting the definition of healthcare pathways.

I stand by my definition of "autonomy". If someone wants to call standing orders they carry out autonomy ,then so be it. It is not my definition. Do I dislike standing orders? Heck no. They are usually the right thing to do, but not always. It is the "not always" part that we as nurses have to rigorously defend to our Docs and our managers/clinical coordinators ect.. This would be less so were we identified more as "autonomous" practitioners of our nursing arts. I am advocating for an educational model that supports this effort. Not trying to have a ******* contest.

[tewdles, RN]

(Good suggestion. I already am and learning a wonderful new world of nursing.)

Look , if you can step away from the personal observations based on speculation and address my comments in a more impersonal nature, it would be easier to have a substantive discussion. I'm not here trolling RN boards looking for a fight. I saw a thread that I was interested in and I gave my "2 cents" being as it is an issue I had given thought to many times. The issue of "autonomy" of nursing is something I ardently support.

Our "science" or skill has a far more extensive history of success than many disciplines and actually is the root of several different allied health professions. That being in mind, we can sit on the sidelines as doctors and "why can't you just be happy being a nurse" types try to decide our professional development or marginalize us, OR we can in power ourselves by starting to think of nursing as a path towards health promotion that incrementally can resume the primary care spot and respect it had prior to the white coats co opting the definition of healthcare pathways.

I stand by my definition of "autonomy". If someone wants to call standing orders they carry out autonomy ,then so be it. It is not my definition. Do I dislike standing orders? Heck no. They are usually the right thing to do, but not always. It is the "not always" part that we as nurses have to rigorously defend to our Docs and our managers/clinical coordinators ect.. This would be less so were we identified more as "autonomous" practitioners of our nursing arts. I am advocating for an educational model that supports this effort. Not trying to have a ******* contest.

I am sorry if I offended you. I simply tried to respond to the character of your post.

I am unclear as to a couple of your points but I will say this in response. Most of what I do as a nurse is unrelated to physician orders. Standing orders are nice so that I can quickly carry out medical orders...but I function to a very large degree upon my own professional nursing judgment and plan of care. Many nurses in many settings function in professionally autonomous capacities. Others, not so much...sometimes by choice.

It is because we are autonomous professionals that we rigorously defend our judgment when a standing order is ill-advised. I believe that credibility is earned to a very large degree and thoughtful, proactive, and effective nurses often have much credibility in professional relationships.

I would be interested on your thoughts about what educational changes might improve the autonomy of our profession.

As a female, I would likely lose a pi***** contest.

[t2krookie]

after much discussion with fellow nurses (i am a rn with a cardiology / icu / ed background , currently pursuing fnp) we generally agree that clinical graduate programs would benefit immensely from an addendum curriculum that involves internships or dare i say "residencies" of a more formal nature that are geared to preparing them for real world practice. the difference as i understand it , (corrections would be appreciated) being that residencies and fellowships are paid positions that offer financial support for the student that is so necessary to support their efforts as well as being a situation in which they are expected to be still learning while being productive at the same time. the "main "core curriculum changes i would like to see would be more extensive assessment/treatment didactics with both md/do and cns/nps.

there is alot i am leaving out(i'm busy running a business and watching kids at the moment). in "my" ideal world, the graduate programs would incorporate these changes while the dnp structure would expand upon them but not being an educator i can only guess at what hardships this would cause the institutions who offer these programs. the leaderships courses are something i feel personally could have been incorporated piecemeal into the other subjects thus freeing up time to add these additions, but my bias is probably due to my military experience where we did so.

these changes obviously need funding and that has always been the main voiced barrier to such a change. md/do residencies are government funded , while no such program exists outside of military programs / civil service programs that i know of for nps.(again corrections would be appreciated).

in the recently published ama opinion on scope of practice of midlevel providers , you can see the innate disdain for rn's and pa's readiness for assuming primary care/ independent roles. they continue to assault our quest for autonomy and give the opinion that we should be supervised by a md/do at all times to one degree or another and constantly cite our lack of residency and didactic education.

these changes would require a change in gestalt for what nursing is imo. i stand by my affirmation that nursing is the oldest form of healthcare in existence and should in fact be a pathway for greater incremental responsibility leading to true autonomous care for our patients within a well established scope of practice. this takes advocacy by nurses and for nurses, not naysayers. many threads along this line had persons stating an opinion that the person should consider medical school. i challenge such a view because of my deep faith and opinion that medical school is but one way to approach independence and historically was never the only way.

my apologies for the unfocussed direction of this post , but it is off the cuff and i have many distractions at the moment.

[RyanSofie]

"I challenge such a view because of my deep faith and opinion that medical school is but one way to approach independence and historically was never the only way." Nurses !!!! Pave the way...Join our colleagues and unite to change . We need to use a united voice .

[tewdles, RN]

I agree that we would benefit from a unified voice.