Q: Are you sure nurses are autonomous? Based on what I've seen, it sure looks like physicians are calling the shots.
A: Nursing is an autonomous, self-governing profession, a distinct scientific discipline with many autonomous practice features. Despite what the media may portray, nursing is not directed by physicians, even though nurses have less practical power than physicians do. In addition to extensive medical expertise, nurses have a unique, holistic patient advocacy focus, a unique scope of practice, and a unique body of knowledge, including special expertise in areas such as patient education, wound care and pain management.
Nursing is clearly an autonomous and distinct scientific discipline. For entry into practice, nurses are educated by nursing scholars typically in nursing degree programs lasting two or four years at universities and colleges, using textbooks authored by those scholars, many of whom are at the forefront of health care research. About 10,000 U.S. nurses have PhD's in nursing (another 10,000 nurses have Ph.D.'s in other health-related fields and work in nursing), and close to 380,000 U.S. nurses have master's degrees in nursing. These nurses--not physicians--are the theoretical and practical leaders of the nursing profession.
The profession also has many of the hallmarks of autonomous practice, though that issue is more complex because of the social, legal and economic limits under which nurses have traditionally operated. Current state laws typically define nursing practice in broad terms that do not depend on physicians, nurse-controlled state boards administer rigorous licensing examinations, and nurses have independent malpractice liability and codes of ethics. Though there is clearly a significant overlap with medicine, nursing is not a subset of or dependent on medicine.
Even in the managed care era, nurses have significant autonomy in clinical settings. Nurses typically are hired, fired and managed by other nurses. In hospitals, where most U.S. nurses work, registered nurses are managed by other nurses in a chain of command reaching up to a chief of nursing (or sometimes, patient care services). Contrary to the great majority of popular media depictions, nurses do not report to physicians in hospital care settings. Indeed, physicians do not have expertise in many areas of nursing practice, and even where they do, nurses' patient advocacy duties require that they actively resist any care plan that they believe is not in the patient's best interest. This is also the basic structure in nursing homes and other assistive care facilities, where many other nurses work. And in public schools and other public health positions, nurses are effectively autonomous within the scope of their professional duties. Even the nurses who work in what are commonly called "physicians' offices" are operating autonomously within the scope of their nursing practice, though they may be employees of the practice. Since today such offices often include Advanced Practice Registered Nurses (APRNs), it would be more accurate to call them "advanced practitioners' offices," or even better, "outpatient health offices," which would not ignore the contributions of registered nurses and other health workers in such outpatient settings.
There are a number of reasons for the common misperception that nurses report to physicians. Of course, nurses and physicians collaborate as members of the health care team. But historically, nurses have deferred to physicians, for reasons including the imbalance of power among the genders. Today, physicians' combination of economic power and social status is unmatched. Physicians still have more years of formal education than most (but not all) nurses. And over 90% of nurses are still female, at a time when women have a much wider range of career choices. Most physicians are not well-informed about nursing, and many refer to anyone working in the health care setting who is not a physician as a "nurse." Many physicians regard themselves as being essentially in charge of patient care. Consistent with this authoritarian vision, physician disrespect and disruptive behavior, including verbal and even physical abuse, remain issues in many care settings. (See Suzanne Gordon, Nursing Against the Odds, 2005.) As a result of these and other factors, many nurses remain reluctant to challenge physicians or assert themselves generally. (See Buresh and Gordon, From Silence to Voice, 2nd ed. 2006.) In addition, recent developments in health care have led to some confusion as to professional identity among patients and others. In many care settings, registered nurses are now visually indistinguishable from a range of other caregivers who may not be highly trained members of autonomous professions. Not even all nurses agree that they are members of an autonomous profession, in our view mistaking a lower level of practical power for a conceptually subordinate practice role, and maintaining that physicians have final authority over all patient care decisions. And some scholars and nursing advocates who are sympathetic to nursing and aware of its importance are susceptible to this way of thinking. (See, e.g., Dana Beth Weinberg, Code Green: Money-Driven Hospitals and the Dismantling of Nursing (2003), at 16, 80, 112, 115, 133, 177-78; Gordon, Nursing Against the Odds.) In reaching such flawed conclusions, these nursing supporters often seem to rely on the views of workplace sociologists, rather than nursing leaders and scholars, who are presumably too close to their own subordination to see it clearly.
Despite these obstacles, nurses' unique scope of practice is finally gaining recognition from some influential government institutions. Many state nurse practice acts now define nursing in broad and independent terms that do not depend on physicians or any other practitioners. For instance, California's Nursing Practice Act defines nursing practice as care that promotes health and requires significant scientific knowledge or skill, including patient care, disease prevention, the administration of medications and other procedures "ordered" by physicians or other advanced practitioners, testing procedures, health assessment and intervention. Cal. Bus. & Prof. Code § 2725. The comparable Massachusetts law defines nursing as services to "assist individuals or groups to maintain or attain optimal health," and contains details similar to the California law, including the administration of procedures "prescribed" by advanced practitioners, "clinical decision making" based on nursing theory to develop and implement care strategies, evaluating responses to care and treatment, coordinating care delivery, collaborating with other members of the health care team, and "management, direction and supervision of the practice of nursing." Mass. Gen. Laws Ann. ch. 112 § 80B. The Massachusetts law further provides that "[e]ach individual licensed to practice nursing in the commonwealth shall be directly accountable for [the] safety of nursing care he delivers." Id. The Texas Nursing Practice Act defines professional (registered) nursing practice to include assessing, intervening, and teaching to help the ill, working to maintain health and prevent illness, supervising nursing practice and education, administering medications or treatments "ordered" by physicians or other advanced practitioners, and performing acts "delegated by a physician" under the Medical Practice Act. Texas Occ. Code Ann. § 301.002.
All of these state laws make clear that nursing is responsible for managing itself, and broadly define nursing practice to include a wide range of critical prevention and care functions that do not depend on physicians or anyone else. Obviously, all the statutes are also careful to note that one--ONE--aspect of nursing is to administer certain treatments prescribed by advanced practitioners, and certain language in the California and Texas laws ("ordered," "delegated") does suggest a subordinate relationship with regard to those tasks. However, even in administering treatment prescribed by these other practitioners, nurses have a professional and legal obligation in their patient advocacy role to assess the care prescribed, and if necessary to work for better options, even in the face of advanced practitioner opposition. Indeed, nurses are not relieved of malpractice liability simply because they are administering treatment prescribed by a advanced practitioner, even if they are doing so precisely as the advanced practitioner wished; nurses are subject to independent legal requirements. Nurses' patient advocacy may include persistent negotiation with advanced practitioners, obtaining interdisciplinary ethical consults, refusing to participate in care plans or practices nurses deem unsafe, removing inebriated surgeons from the OR, and if necessary going to the appropriate administrative or other authorities to stop such actions. Do nurses find any of that easy to do, given current power structures? No. But that does not make them subordinate to physicians.
Moreover, recently some courts have begun to recognize that nursing is in fact a distinct scientific profession with its own standards and scope of care. For decades U.S. courts have tended more or less unthinkingly to regard nursing as a subset of medicine, and accordingly permitted physicians to testify as to the standard of nursing care in malpractice actions. (See Ellen K. Murphy, Nov. 2004, "Judicial recognition of nursing as a unique profession," Association of periOperative Registered Nurses Journal.) However, the Illinois Supreme Court recently reviewed the evolving recognition of nurses' unique practice, and concluded that a physician was not qualified to testify as to a nursing standard of care because he was not a nurse. (See Sullivan v. Edward Hospital, 806 N.E.2d 645, 653-61 (Ill. 2004).) Although this decision was specific to the Illinois statutory and judicial context, it is fairly characterized as "judicial recognition [of] nurses' long-time assertion that nursing is an independent profession with a unique body of knowledge and not simply a subcategory of medicine." (Murphy.)
Indeed, one powerful argument that nurses are autonomous appears in a recent position paper by The American Association of Nurse Attorneys (TAANA) demonstrating that only nurses (not physicians) should be permitted to provide expert testimony as to the nursing standard of care in malpractice actions. (See TAANA Position Paper on Expert Testimony in Nursing Malpractice Actions, TAANA, September 23, 2004.) The TAANA piece cites many of the factors discussed above, including the distinct, self-directed nature of nursing theory and practice, the state nursing practice acts, and cases reflecting the growing judicial recognition of nursing as a distinct profession in the malpractice context. The paper concludes:
Based on the foregoing it is clear that nursing is a profession, unique, identifiable and autonomous. As a profession, nursing has the authority and responsibility to define its standards of practice. ... It is clear that the profession of nursing, though closely related to the practice of medicine, is, indeed, distinct with its own licensing scheme, educational requirements, areas of specialization, Code of Ethics, models, theories and contract with society. The standard of care for nurses arises from the very nature and scope of nursing and is derived from the nursing process. The nurse is not a "junior doctor" nor is the nurse a mere "underling" of the physician. To so hold would negate the existence of nursing as a profession and would render the Nurse Practice Acts of every state, commonwealth and territory meaningless. It is unlikely that any physician, unless he/she has completed a nursing program and has practiced as a nurse, can offer competent, reliable expert opinion on these nursing standards. ... The nursing profession and only the nursing profession has the right, duty and responsibility to determine the scope and nature of nursing practice including the standard of care for nurses.
Perhaps the most visible apparent examples of nursing autonomy are APRNs, who now number over 200,000 in the United States. Most APRNs are nurses with masters degrees or doctorates in nursing who perform "practitioner" tasks that have traditionally been associated with physicians. APRNs include Nurse Practitioners, Certified Registered Nurse Midwives, Certified Registered Nurse Anesthetists, Nurse Psychotherapists and Clinical Nurse Specialists, who work in a variety of fields including emergency care. (See The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses.) However, because many states have responded to physician pressure with statutes requiring that physicians "supervise" APRNs in some way in their expanded scope of practice, practitioner APRNs may not be the best example of nursing autonomy--they are moving into areas that have traditionally been the province of physicians, and physicians have responded in unsurprising ways. Of course, many of these restrictions are little more than a legal fiction, and numerous studies have shown APRN care to be at least as good as that of physicians. Unfortunately, it would be easy to conclude--as a major recent health report in U.S. News & World Report appeared to--that APRNs represent a kind of liberation of nurses from their former position as subordinate physician assistants. That fits with traditional beliefs, but as demonstrated above, it is incorrect.
What's that you say? Nurses have no real autonomy because the reality is that oppressive, greedy, patriarchal physicians, hospitals and other powerful health care system actors exercise so much practical control over nursing, to the detriment of public health and the future of the world? We know that the state of nursing can be immensely frustrating. There is no doubt that nurses generally have less practical power than physicians, and that social constructs tend to reflect that, and of course formal autonomy means less if it is not fully reflected in reality. 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.
We believe there is a difference between a relative lack of power, on the one hand, and subordination, which suggests that one party reports to another in a formal sense, i.e., a master-servant relationship. Physicians are no more the conceptual "masters" of nurses than the United States is of India. Code Green gave the impression that, while nurses at the peak of their potential power may have real influence on patient care decisions, the ultimate authority for all care rests with physicians; in bad times, nursing consists of blindly following physician orders. In other words, the book suggests that the physician role varies between benevolent monarch and ruthless authoritarian. But as explained above, we believe that nursing has many powerful hallmarks of autonomy despite its relative lack of power, and that it is in nurses' interests to push the idea that they are part of an autonomous profession as strongly as possible. Just as human rights do not cease to exist simply because they are not fully observed, nursing autonomy does not cease to exist simply because it is subject to daunting practical constraints. If nurses' influence on patient care is seen as merely a matter of physicians' grace and as confined to the boundaries of physicians' practice, then nurses' ability to protect themselves and their patients is accordingly limited. But if nurses are seen as autonomous professionals with a unique practice model and scope of care--if they are not a class of "physician subordinates"--then they have a far stronger base on which to build and advocate.
Career seekers who have the qualities skilled nursing requires--including intellect, courage, passion, interpersonal ability, and a strong work ethic--value autonomy greatly. It is not hard to see why they would find little to interest them in the mute, servile "nurses" they encounter in many mass media products, particularly on television. They must understand that no matter how weak nursing may at times appear to be, especially in the managed care era, it has been and remains a distinct, self-regulating profession like medicine and law. Nursing has its own scope of practice, its own knowledge base, its own leaders and scholars, and its own legal and ethical duties. Nurses' unique, autonomous practice has saved countless lives, despite the prevailing belief that it does not exist. In this respect, nursing has been a kind of shadowy superhero: the Dark Knight Nurse, perhaps. But that must change if the profession is to gain the strength it needs to meet the global health challenges ahead.
Q: But how are nurses autonomous? We do not prescribe. We have to work under the "guidance" of physicians or some healtcare facility.
Even though nurses collaborate with physicians and nurse practitioners who write prescriptions, that does not mean nurses are not autonomous! Every time nurses make an assessment of a patient, they are engaging in autonomous nursing work. Every time nurses make a decision about what to do with the findings of their assessments, they make autonomous professional decisions. Every time they educate a patient or advocate for a patient they are engaging in autonomous professional acts.
For instance, a nurse's patient is struggling to breathe a little bit, so the nurse listens to his lungs and finds them 3/4 full of rales. The nurse lays out the options for action in her head: apply oxygen, consider COPD status, evaluate medications, straighten him up in the bed, check the cardiovascular medications to make sure the heart is pumping adequately and a whole bunch of other things. Finding the patient in slight distress was one autonomous assessment a non-nurse would probably not have noticed. Listening to lungs in response to her initial assessment was something the nurse knew to do and nurses are empowered to do because of their nursing education and status as a nurse. Considering the myriad options about how to respond to the rales are more autonomous acts. The nurse educates the patient about his heart disease, fluid buildup, salt intake, positioning, exercise—autonomous acts built on nursing knowledge base. Maybe the patient is on 20 mg./day of furosemide, the nurse advocates for the patient by negotiating with the prescribing health partner for 40 mg./day. All autonomous acts. This autonomy, these thought processes, this decision-making--this is how nurses save lives all over each and every day. Just because nurses do not prescribe does not mean their assessments and interventions do not matter. Oh no, they matter a great deal. This power, this knowledge, these actions--they come from nurses as individuals and the profession of nursing. Nurses save lives and they should embrace the power they have and stand behind it with pride.
last updated: March 4, 2015
For more information on nursing autonomy see:
Lynda Carey and Mark Jones, "Autonomy in Practice Is it A Reality?" in
Elsevier Health Sciences, October 2000.